**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 6) when Resident 6's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 6's care needs not met. Findings: During a review of Resident 6's admission Record (document with resident demographic and medical diagnosis information), dated 8/29/24, indicated Resident 6 was admitted in the facility on 8/30/23 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and end stage renal disease (terminal illness that occurs when kidneys can no longer function on their own). During a review of Resident 6's Minimum Data Set, assessment dated [DATE], indicated Resident 6's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 6 had no cognitive deficit. During a review of Resident 6's Order Summary, dated 8/29/24, the Order Summary Report indicated, . OLANZAPINE 10 MG [milligram-unit of measurement] TABLET. Give 1 (one) tablet by mouth at bedtime for UNSPECIFIED PSYCHOSIS . During a concurrent interview and record review on 8/29/24 at 3:39 p.m. Resident 6 annual MDS assessment dated [DATE], section N was reviewed by the Minimum Data Set Coordinator (MDSC). The MDSC stated Resident 6 received antipsychotic medication. MDSC stated Resident 6 use of antipsychotic medication was not coded on the annual MDS assessment. MDSC stated Resident 6 should have been coded as receiving antipsychotic medication. During an interview on 8/30/24 at 10:45 a.m. with the Director of Nursing (DON), the DON stated her expectation was for MDS assessments to be accurate. DON stated MDS nurses are responsible in making sure their assessments are accurate. During an interview on 8/30/24 at 2:20 p.m. with the administrator (ADM), the ADM stated her expectation was accurate documentation from MDS. ADM stated MDS nurse needed to accurately assess residents use of psychotropic medications. During a review of the facility document titled, RN MDS Coord-CSTCC Job Description, reviewed date 10/31/23, the Job Description indicated, . Responsible for accurate and timely completion and transmission of Minimum Data Set (MDS) assessment of all residents in the facility . During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment and Care Planning, dated 4/9/24, the P&P indicated, . The facility will complete resident assessments based on the most current Resident Assessment Instrument (RAI) guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy and procedures for one of two medication carts in Transitional Unit when medication cart contained Resident 53's (Fluticasone Propionate brand name- used to relieve allergic and non-allergic nasal symptoms) 50 mcg (microgram-unit of measurement) was found to not have an open date and beyond use date (BUD-the last date you can safely use a medication). This failure had the potential for Resident 53's medication to be administered past the discard date which could result in loss of effectiveness of medication leading to poor management of Resident 53's condition. Findings: During a concurrent observation and interview on [DATE] at 2:06 p.m. at the medication cart in Transitional Unit with Licensed Vocational Nurse (LVN) 1, Resident 53's (Fluticasone propionate brand name) was found with no open date and BUD. LVN 1 stated there was no open date and BUD because the facility followed the expiration date provided by pharmacy. During a review or Resident 53's admission Record, dated [DATE], the admission Record indicated, Resident 53 was admitted to the facility with diagnoses which included paraplegia (loss of muscle function in the lower half of the body, including both legs) and Chronic Obstructive Pulmonary Disease (COPD-lung disease causing restricted airflow and breathing problems). During an interview on [DATE] at 2:18 p.m. with LVN 1, LVN 1 stated, . They told me the policy was to label medication [Fluticasone-brand name] with the date it was opened as soon as the box was opened . LVN 1 stated open date should have been placed on the box when it was first opened and the used by date. During a concurrent interview and record review on [DATE] at 10:37 a.m. with the Director of Nursing (DON) the DON stated pharmacy labels the medication (Flonase-brand name). The DON stated the medication was given to Resident 53 daily so it will run out before the expiration date of 4/26. The DON reviewed facility policy and procedure titled Medication Administration Medication Guidelines and stated the facility will follow their policy and procedure and pharmacy recommendation. During a review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 1/2, the P&P indicated, . Multi-dose vials should be labeled to assure product integrity . Nursing staff should document the date opened on multi-dose vials . During a review of facility;s policy and procedure (P&P) titled, Medication Administration General Guidelines dated 1/23, the P&P indicated, . No expired medication will be administered to a resident . The nurse shall place a 'date opened' sticker on the medication . and enter the date opened . multi-dose vials and ophthalmic drops have shortened end-of-use dating, once opened, to ensure medication purity and potency . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for (Fluticasone propionate/ Salmeterol brand name) indicated, After removing from box and foil pouch, write the Pouch opened and Use by dates on the label on top of the device. The Use by date is 1 (one) month from date of opening the pouch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed provide one of 11 residents an accessible call system when Resident 43's call light (a device that is used by a resident to call staff for assistance) was out of reach and wrapped around the television arm behind the resident's bed. This failure resulted in Resident 43 being unable to call for assistance and had the potential to delay care during an emergency and cause adverse outcomes. Findings; During a review of Resident 43's admission Record (AR), dated 8/29/24, the AR indicated Resident 43 had been admitted on [DATE]. Resident 43's admitting diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), chronic obstructive pulmonary disease (COPD- lung disease that causes restricted airflow and makes it difficult to breathe) with acute exacerbation (a sudden worsening of respiratory symptoms), epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and schizophrenia (mental health condition that affects how people think, feel, and behave). During an observation on 8/26/24 at 3:25 p.m. in Resident 43's room, Resident 43's call light was out of reach and wrapped around the television arm behind the resident's bed. During an observation on 8/27/24 at 2:00 p.m. in resident 43's room, Resident 43's call light was was out of reach and wrapped around the television arm behind the resident's bed. During an interview on 8/28/24 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the resident had the ability to call for help. LVN 4 stated sometimes Resident 43 would yell out for help when someone walks by the room. LVN 4 stated Resident 43 would use his call light in the past. During an interview on 8/28/24 at 2:34 p.m. with Certified Nursing Assistant (CNA) 5, CNA5 stated all residents should have had their call light next to them so they could use it if needed. CNA 5 stated there was no instance where it would not be placed by a resident, it must always be within reach. During a concurrent observation and interview on 8/29/24 at 11:34 a.m. with CNA 6 outside of Resident 43's room, Resident 43's call light wire was laying on right side of the bed with call button on the floor. CNA 6 stated, [Resident 43] is very cooperative and aware . I reinforce call light education every time I am in the room. During interview on 8/29/24 at 1:54 p.m. with LVN 4, LVN 4 stated, It is important for [residents] to have a call light to tell us their needs even if unable to use one . No matter what their function is, it's important to have one. LVN 4 stated she was unsure why Resident 43's call light was wrapped around the base of the TV arm connected to the wall behind Resident 43. LVN 4 stated Resident 43 should have had his call light placed next to him. During interview on 8/30/24 at 9:43 a.m. with LVN 5, LVN 5 stated it is important for residents to have call light next to them. LVN 5 stated having a call light was important for safety and in case he needed help. LVN 5 stated every resident needs a call light because it was their right to have one even if they could not use it. During an interview on 8/30/24 at 10:53 a.m. with Director of Nursing (DON), when shown a photo of Resident 43's call light on the television arm connected to the wall behind the Resident's bed, DON stated I did not observe this. When asked if it were an acceptable practice to have call light away from patient, DON stated I did not observe this. DON stated, residents do have call light by them. Call lights should be placed next to residents. Important so call light is accessible. When asked if it were okay for Resident 43 to not have call light near them, DON stated she already answered the question. During an interview on 8/30/24 at 1:42 p.m. with Administrator (ADM), shown a photo of Resident 43's call light on television arm connected to the wall behind the Resident's bed. When asked if this is acceptable, ADM stated, resident will tell you if he needs help and will act based on his behavior. He's not a normal patient. When informed call light was like this all day on Monday and Tuesday, ADM stated Resident 43 may have placed it their himself. ADM stated, usually would like to have call light as close to resident as possible. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Residents, dated 9/2022, the P&P indicated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 8/26/24 at 3:29 p.m. in Resident 43's room, Resident 43's privacy curtain was tied in a knot, hanging near the door and out of reach. During an observation on 8/29/24 at 10:08 a.m. in Resident 43's room, Resident 43's privacy curtain was tied in a knot hanging on the left side of the Resident's bed. During a concurrent observation and interview on 8/29/24 at 11:36 a.m. with certified nursing assistant (CNA) 6 outside of Resident 43's room, Resident 43's privacy curtain was tied in a knot. CNA 6 stated Resident 43's curtain should not have been tied in a knot. CNA 6 stated having the curtain tied in a knot did not provide Resident 43 privacy or dignity. CNA 6 stated Resident 43 had the right to have his curtain in its intended condition and appearance. During an interview on 8/29/24 at 1:53 p.m. with licensed vocational nurse (LVN) 4, LVN 4 stated Resident 43's curtain was not supposed to be tied up in a knot. LVN 4 stated having the curtain tied up in a knot did not provide Resident 43 with privacy and dignity. LVN 4 stated every other resident in the facility has their curtains in a normal condition and Resident 43 had the right to have his curtains in the same condition as everybody else. During an interview on 8/29/24 at 2:45 p.m. with the environmental services manager (EVSM), the EVSM stated housekeeping staff would not tie curtains in a knot if they needed to clean the room. The EVSM stated all resident curtains should have been hanging freely towards the ground and not tied in a knot. During an interview on 8/29/24 at 3:11 p.m. with Director of Staff Development (DSD), the DSD stated, nursing staff should have untied the curtain if they saw it tied in a knot. The DSD stated having a proper hanging curtain was important to be able to provide privacy. During an interview on 8/30/24 at 8:41 a.m. with CNA 5, CNA 5 stated he was unsure why a curtain would be tied in a knot and no one else's curtain was like this. CNA 5 stated it was important to not have resident curtains tied in a knot because it helped provide privacy when used properly. During an interview on 8/30/24 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she did not know who would tied Resident's 43's curtain in a knot. LVN 5 stated she doubted the resident would be able to do it himself because he does not have control of his lower extremities. LVN 5 stated it was important to have the curtain untied and hanging down so it was easy to access in order to provide privacy. During an interview on 8/30/24 at 10:53 a.m. with the Director of Nursing (DON), when asked if it is acceptable to have curtain tied in a knot and hanging out of reach of the Resident, the DON stated Resident 43 could have done it himself and he can do more than we think. When asked if the DON's expectation was for curtains to be tied in a knot for any resident, DON stated Resident 43 probably did it himself. During an interview on 8/30/24 at 1:43 p.m. with Administrator (ADM), the ADM stated she expected staff to untie curtains if they saw them tied in a knot. During a review of the facility's Policy and Procedure (P&P) titled, Philosophy, dated 7/02/2024, the P&P indicated, It is the philosophy of CSTCC to provide resident care based on each resident's physical, psychosocial and clinical needs; focusing on each resident's overall well-being . 1. The facility will show respect for each resident's individuality, offering choices . 3. The facility will provide privacy and dignity when care is delivered. Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for three of 11 sampled residents (Resident 37, Resident 43, Resident 69) when: 1. Registered Nurse (RN) 1 administered medication to Resident 37's and did not provide privacy. This failure resulted in Resident 37 not being provided with respect and dignity while taking her medication. 2. RN 1 checked Resident 69's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. This failure resulted in Resident 69 not being provided with respect and dignity while her B/P was checked. 3. Resident 43's privacy curtain was tied in a knot. This failure resulted in Resident 43 not being provided his right for a respectful and dignified existence and denied Resident 43 the right to have an environment that promotes maintenance or enhancement of his quality of life. Findings: 1. During an observation on 8/29/24 at 8:59 a.m. in Transitional Unit, RN 1 prepared Resident 37's medications, walked in Resident 37's room and administered her (Resident 37) medications and did not provide privacy. RN 1 did not close the privacy curtain or closed the door, staff and other residents walking by. During a review of Resident 37's admission Record, dated 8/30/24, the admission Record indicated, Resident 37 was admitted to the facility with diagnoses which included heart failure, liver disease and hypertension (high blood pressure). During a review of Resident 37's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 37's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 13 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 37 had no cognitive deficit. During an interview on 8/29/24 at 10:05 a.m. with RN 1, she stated she administered medications to Resident 37 in her room and did not close the privacy curtain or the door. RN 1 stated it was Resident 37's right to have privacy when she took her medications. RN 1 stated she should have closed the privacy curtain and or the door because staff, residents and visitors were walking by. During an interview on 8/29/24 at 11:30a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated it was important to close the privacy curtain to provide privacy to residents when administering their medications because there are residents, staff and visitors walking by and could see what was going on inside resident's room. During an interview on 8/29/24 at 2:25 p.m. with LVN 1, she stated the practice was to always pull the privacy curtain when administering medications to residents in their room and never administer medication in the hallway. LVN 1 stated residents need to have their privacy respected including taking their medications. 2. During an observation on 8/29/24 at 9:18 a.m. in Resident 69's room, Resident 69 was lying in bed dressed appropriately. RN 1 approached Resident 69's bedside and checked Resident 69's blood pressure without closing the privacy curtain or the door. Staff, residents, and visitors walked by. During a review of Resident 69's admission Record, dated 8/30/24, the admission Record indicated, Resident 69 was admitted to the facility with diagnoses which included hypertension, hyperlipidemia (high cholesterol) and pain. During a review of Resident 69's Minimum Data Set, assessment dated [DATE], indicated Resident 69's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 9 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 69 had moderate cognitive deficit. During an interview on 8/29/24 at 10:10 a.m. with RN 1, RN 1 stated she checked Resident 69's blood pressure in her room and did not close the privacy curtain or the door. RN 1 stated Resident 69's bed was closest to the door and anyone walking by could see what was going on inside the room. RN 1 stated it was important to respect resident their rights to their privacy, RN 1 stated she did not realize she did not close the privacy curtain or the door. During an interview on 8/29/24 at 11:35 a.m. with LVN 2, she stated residents have rights to their privacy and that includes checking their blood pressure or administering medications. LVN 2 stated the facility practice was to ensure resident rights are respected. During an interview on 8/30/24 at 10:22 a.m. with the Director of Nursing (DON), The DON stated she did not see an issue of privacy when the nurse administered oral medications to Resident 37 and checked Resident 69's blood pressure and did not close privacy curtain. The DON stated she would be more worried if the nurse administered medication through a tube feeding and or checking the blood sugar because resident would have been exposed. DON stated residents have rights and facility staff must give their rights to their privacy. During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 3/20/24, the P&P indicated, . right to a dignified existence . be free of interference, coercion . right to be fully informed . right to personal privacy and confidentiality . During a review of facility's P&P titled, Medication Administration General Guidelines, dated 1/23, the P&P indicated, . Medications are administered in accordance with written orders . Provide for privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven sampled residents (Resident 6, Resident 55 and Resident 41) when Resident 6, Resident 41 and Resident 55's copy of Physician Orders for Life-Sustaining Treatment (POLST-a medical document which outlines a patient's preferences for end-of-life care) were incomplete and not readily available as part of Resident 6 and 55's current medical records. These failures had the potential risk for Resident 6, Resident 41 and 55's decision regarding their healthcare treatment options not being honored. Findings: During a review of Resident 6's admission Record, (AR-document containing resident profiles) dated 8/29/24, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (occurs when the kidneys are no longer able to function properly and filter waste from the blood) and heart failure. During a review of Resident 55's admission Record, dated 8/29/24, the AR indicated, Resident 55 was re-admitted to the facility on [DATE] with diagnoses which included Transient Ischemic Attack (TIA-occurs when there's a brief interruption in blood supply to the brain) and schizophrenia (chronic mental illness that affects a person's thoughts, feelings, and behaviors). During a concurrent interview and record review on 8/27/24 at 11:42 a.m. with Director of Staff Development (DS) Resident 41's Physician Orders for Life Sustaining Treatment (POLST [form is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness]) was reviewed. The POLST did not have the preparation date filled out on the form. DSD validated the date of preparation of the POLST form was missing. DSD stated the POLST must be totally filled out to be considered complete and accurate. During a concurrent interview and record review on 8/28/24 at 8:47 a.m. with Licensed Vocational Nurse (LVN 1), Resident 41's POLST form was reviewed. LVN 1 stated, the POLST form should have been filled out to ensure accuracy. During a concurrent interview and record review on 8/29/24 at 10:17 a.m. with Registered Nurse (RN) 1, Resident 6 and Resident 55's POLST form was reviewed, RN 1 stated the POLST forms of Resident 6 and Resident 55 was incomplete. RN 1 stated Resident 6 and Resident 55's POLST forms did not have dates when forms were prepared and completed. RN 1 stated POLST forms have to be completed, each column filled, signed and dated. During a concurrent interview and record review on 8/29/24 at 11:25 a.m. with LVN 2, LVN 2 stated POLST forms are completed on admission by the admission nurse. Resident 6 and Resident 55's POLST forms was reviewed. LVN 2 stated Resident 6 and Resident 55's POLST forms are incomplete, because there was no date when the POLST forms were prepared and there should have been. During a concurrent interview and record review on 8/30/24 at 10:50 a.m. with the Director of Nursing (DON), the DON reviewed Resident 6 and Resident 55's POLST forms and stated there was no date when POLST forms were prepared. DON stated Resident 6 and Resident 55's POLST forms are incomplete because it was missing the date when the forms were completed. During an interview and record review on 8/29/24 at 2:10 p.m. with the Director of Nursing (DON), Resident 41's POLST was reviewed. The DON stated, the POLST form needs to be filled out because it's part of the form. The DON stated, a complete form should have all areas that need to be filled out be completed. The DON stated, an incomplete form could have created uncertainty about the accuracy or validity of the from. During a review of facility's policy and procedure (P&P) titled, Physician Orders for Life-Sustaining Treatment (POST), dated 2/5/24, the P&P indicated, .Completion of a POLST form should reflect a process of careful decision making by the resident . Once the POLST form is completed, it must be signed by the resident, or . resident's legally recognized healthcare decision maker, and the attending physician . The POLST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference . During a review of the professional standards by the Centers for Medicare and Medicaid Services (CMS) titled, Standing Orders, dated, October 2008, the CMS Professional Standard indicated, .orders should be reviewed .all orders must be dated and authenticated promptly .All patient medical record entries must be .complete, dated .and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. The cook failed to follow the diet order for three of three residents (Residents 56, 69, and 88). 2. The facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. These failures had the potential to result in residents being exposed to contaminated food which could lead to food born illness for all residents who receive food prepared in the kitchen and had the potential for Resident 56, Resident 69 and Resident 88 to have weight gain or loss by diet orders not being followed. Findings: 1. During a concurrent observation and interview on 8/27/24 at 12:20 p.m. with the Dietary Manager (DM), in the facility's kitchen, the [NAME] (DA), did not follow the recipe for three residents with small portion diet orders during the lunch service tray line. The DA used the gray ½ cup serving scoop and not the blue ¼ cup serving scoop as indicated on the resident diet orders. The DM stated, the gray scoop was to be used for regular portions and the blue scoop was to be used for small portions. The DM stated, the DA should have switched scoops for the residents on with small portion diet orders. Not using the correct portions could lead to residents gaining undesired weight. During an interview on 8/27/24 at 2:15 p.m. with the Dietary Director (DD), the DD stated the expectation of the cook is to follow the diet orders exactly as ordered. The DA should have switched to the blue scoop for the small portion diets. During an interview on 8/30/24 at 2:50 p.m. with the Administrator (ADM), the ADM stated, the expectation for the DA is to follow diet orders as written. During a review of the facility's policy and procedure (P&P) titled, Meal Service dated 11/28/22, indicated, . Patient service parameters encourage accuracy of meal service within identified guidelines . During a review of the facility's P&P titled, Cook Job Description (undated), indicated, . follows standard recipes . During a review of Residents 56's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Section C assessment dated [DATE], indicated Resident 8's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 56 had no cognitive impairment. During a review of Resident 56's admission Record (AR), dated 8/29/24, the AR indicated, Resident 56 was admitted on [DATE] with diagnosis of Cardiomegaly (enlarged heart), Systematic Inflammatory Response Syndrome (SIRS - an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, lack of oxygen, or cancer), and Hyperglycemia (high blood sugar). During a review of Resident 56's Physician Order (PO), dated 8/12/24, the PO indicated . ease of chewing and promoting weight loss . small portion starch . During a review of Resident 69's AR dated 8/29/24, the AR indicated, Resident 69 was admitted on [DATE] with diagnosis of Aortic Aneurysm (a bulge or weakening in the aorta, the main artery that carries oxygenated blood from the heart to the body), Pain, and Hyperlipidemia (high levels of fat in the blood). During a review of Resident 69's MDS Section C dated 4/30/24, indicated Resident 69's BIMS score was 09. The BIMS assessment indicated severe cognitive impairment. During a review of Resident 69's PO, dated 5/8/24, the PO indicated . small portion starch . During a review of Resident 88's AR dated 8/29/24, the AR indicated, Resident 89 was admitted on [DATE] with diagnosis of Hypertension (high blood pressure), and Cerebrovascular Accident (CVA - a medical emergency that occurs when the blood flow to the brain is stopped). During a review of Resident 88's MDS Section C dated 6/28/24, indicated Resident 88's BIMS score was 15. The BIMS assessment indicated no cognitive impairment. 2. During an observation on 8/27/24 at 2:30 p.m. in the facility's kitchen, the food preparation sink was observed not having an air gap under the sink. During a concurrent observation and interview on 8/29/24 at 2:50 p.m. with the Building Maintenance Supervisor (BMS), in the facility's kitchen, the BMS stated the facility should have an air gap under the food preparation sink to prevent sewage back up into the sink and exposing food to contaminated water. During an interview on 8/30/24 at 10:10 a.m. with the ADM, the ADM stated the food prep sink should have had an air gap to prevent backup of sewer into food being prepared for residents. During a review of the FDA Food Code Section 5-402.11 Backflow Prevention dated 2022, the FDA Food Code indicated, . 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During a review of the Food and Drug Administration (FDA), Food Code Section 5-203.14 Backflow Prevention Device dated 2022, the FDA Food Code indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, .backflow prevention is required by LAW, by: (A) Providing an air gap .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of eight sample residents (Resident 80) when section I-Active Diagnosis and section N-Medication was not accurately coded on the admission and quarterly MDS assessment dated [DATE], 8/27/22, and 11/23/22. This failure had the potential for the facility not to be able to provide the necessary care and treatment appropriate for the resident needs. Findings: During a review of Resident 80's admission Record (document containing resident demographic information and medical diagnosis), dated 12/13/22, the admission record indicated Resident 80 was admitted to the facility on [DATE]. Resident's diagnoses included . SEPSIS SECONDARY TO URINARY TRACK INFECTION (infection spread throughout the body) . COMMUNICATING HYDROCEPHALUS (accumulation of fluid in the brain) . SEVERE MALNUTRITION (low body weight) . PRESSURE ULCER LEFT HEEL UNSTAGEABLE (a wound covered in a thick layer of tissue and yellow drainage) . During a review of Resident 80's past medical history, dated 12/5/22, the past medical history included Diabetes type II. During a review of Resident 80's Minimum Data Set(MDS), dated 11/23/22, the MDS indicated Resident 80's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 0 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 80 has severe cognitive impairment. During a review of Resident 80's Active Orders, dated 5/28/22, the Active Orders indicated, . [name brand of insulin] 10 units [standard amount of measurement] nightly for indication type 2 diabetes mellitus [High levels of sugar in the blood] . During review of Resident 80's admission MDS N-Medication (section N), dated 5/31/22, section N indicated, Resident 80 received insulin injections seven out of seven days during the assessment period. During a review of Resident 80's Quarterly MDS-Section N-Medication (section N), dated 8/27/22 and 11/23/22, section N indicated resident received insulin injections zero out of seven days during the assessment period. During review of Resident 80's quarterly MDS I-Active Diagnoses (section I), dated 5/31/22, 8/27/22, and 11/23/22 section I did not include an Active Diagnosis of Diabetes Mellitus. During a concurrent interview and record review, on 12/9/22, at 3:13 p.m., with the Minimum Data Set Nurse (MDSN), MDSN stated, Resident 80's use of insulin was not coded for MDS 8/27/22 and 11/23/22. MDSN stated, the MDS was inaccurate. During a concurrent interview and record review, on 12/9/22, at 3:15 p.m., with MDSN, Resident 80's MDS section I-Active Diagnosis (section I) dated 5/31/22, 8/27/22, and 11/23/22 was reviewed. MDSN stated, section I, did not include an Active Diagnosis of Diabetes Mellitus. MDSN stated, the use of insulin and Active Diagnosis of Diabetes Mellitus should have been coded on the MDS assessment and the MDS were inaccurate. MDSN stated Resident 80 was on weekly blood sugar checks and was monitored for hyper/hypoglycemia (high and low levels of sugar in the blood) daily. MDSN stated, it was important to ensure documentation was accurate in order to communicate Resident 80's healthcare needs. During a review of the facility's Resident Assessment Instrument/Minimum Data Set Manual (RAI/MDS- a comprehensive assessment and care planning procedure manual used by the nursing home), dated 10/2015, the RAI/MDS indicated, Section I: Active Diagnoses . Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment and Care Planning, dated 4/23/21, the P&P indicated, . Minimum Data Set (MDS) assessments are completed based on the most current Resident Assessment Instrument (RAI) guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed develop a baseline care plan within 48 hours of admission for one of eight sampled residents (Resident 60) when Resident 60 was admitted on [DATE] with a tracheostomy (trach- a surgical opening in the neck into the windpipe to allow direct access to the breathing tube; A tube is usually placed through the opening to provide an airway and to remove secretions from the lungs) and with a trach care plan developed on 8/23/21. This failure place Resident 60 at risk for his tracheostomy care needs not met. Findings: During an observation on 12/5/22, at 9:27 a.m., Resident 60 was seen laying in the middle bed with his head of bed elevated 30-40 degrees, turned slightly to the right, his left heel had a bandage on it and all four rails of the bed up. Resident 60 was asleep, had a with cool mist (used to prevent drying of secretions) attached to his trach, continuous pulse ox (machine monitoring his oxygen saturations and heart rate), stomach tube feeding (TF-a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, tube surgically place in abdomen directly to the stomach) running continuously, and a foley catheter (a thin flexible tube placed in the body to drain urine from the bladder) with a privacy bag hung off the side of his bed. During a review of Resident 60's Face Sheet, dated 12/8/22, the Face Sheet indicated, Resident 60 was last admitted on [DATE] with a diagnosis of Chronic Respiratory Failure (airways to the lungs become narrow and damaged causing difficulty breathing). During a concurrent interview and record review on 12/8/22, at 9:53 a.m., with the Director of Staff Development (DSD), Resident 60's care plans were reviewed for his admission dated 8/20/21. The DSD stated Resident 60 had a trach care plan developed on 8/23/21(past 48 hours). The DSD stated Resident 60 currently had a tracheostomy in place. During an interview on 12/16/22, at 3:17 p.m., with the Director of Nursing (DON), the DON stated a care plan should have been created upon admission. The DON stated having a trach care plan was important to direct the care of the trach. The DON stated if the trach was not being cared for properly there was the potential for infection and it was a life sustaining device for the resident. Review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team Duties in Team Conference, dated 7/19/22, the P&P indicated, . I. PURPOSE To review care of Resident's on a regular basis to ensure care meets their needs and meet regulatory requirements for care conferences for each resident. II. POLICY [name of facility] will hold team conference for each resident initially within 14 days of admission, for change of condition, quarterly and at any other time resident status warrants. Members may include the following interdisciplinary team members: A. 1. Attending Physician/ Medical Director 2. Director of Nurses, RN Clinical Manager 3. MDS Coordinator 4. Nursing representative (Supervisor of Charge Nurse) 5. Nutritional Service 6. Social Service 7. Respiratory Therapist 8. Activity Coordinator 9. Physical, Occupational, and Speech Therapists 10. Others providing care as deemed necessary B. Each professional assesses the resident within 48 hours of admission and completes their portion of the baseline care plan that pertains to their individual discipline. Patient care plans are initiated on admission, and when a new condition, order, or diagnosis in identified then reviewed in team conference and as needed by the resident's condition . Review of the facility's policy titled, Charting Guidelines, dated 4/18/22, the policy indicated, I. PURPOSE To provide guidelines to ensure appropriate documentation in the health record. II. POLICY It is the policy of [name of facility] that: A. All documentation is complete and accurate for each resident. B. Timely documentation of resident care will include: 1. Assessments of resident condition including any changes. 2. Care plan interventions 3. Recording of Activities of Daily Living, Vital Signs, Weights, Intake, and output 4. Medication Administration C. Documentation is to be completed as soon as possible after any type of resident intervention is provided . III. DOCUMENTATION A. All residents are assessed every shift with documentation in the EHR [Electronic Health Record]. B. Weekly summaries by the Licensed Nurse are required for all residents. Documentation must be focused on the resident's care plans including their progress towards goals and any changes to interventions. 1. Resident Care Plans are to be reviewed and updated as necessary at the time of the weekly summary or at any time an intervention requires changes. 2. Care plan review includes new problems or interventions, update of existing problems and discontinuation of resolved problems .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met for one of four sampled residents (Resident 9) when Resident 9 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) and monitoring for complications on multiple dates. This failure placed Resident 9 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites. Findings: During an observation on 12/5/22, at 3: 47 p.m., in Resident 9's room, Resident 9 was seated up in bed eating and dressed appropriately for the weather. Resident 9 was covered with a blanket and did not answer questions. During a record review of Resident 9's, admission Record, undated, indicated, Resident 9 was admitted on [DATE], with a diagnosis that include End-Stage kidney disease (final permanent stage of kidney disease when kidneys no longer function, needing dialysis). During a concurrent interview and record review on 12/14/22, at 3:03 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the licensed nurse on-duty was responsible to fill out the dialysis communication form and complete the assessment. LVN 5 stated the licensed nurse was responsible in assessing resident upon return from dialysis and complete the dialysis communication form which got filed in the resident's chart. LVN 5 reviewed the dialysis communication forms for Resident 9. LVN 5 stated there were incomplete dialysis communication forms for Resident 9. LVN 5 stated the incomplete dialysis communication forms were noted on the following dates: 9/8/22, 9/13/22, 9/27/22 and 11/3/22. During an interview on 12/15/22, at 8:53 a.m., with Unit Clerk (UC), the UC stated the licensed nurse on-duty completed the top portion of the dialysis communication form and gave the form to the resident to take to dialysis center. The UC stated the dialysis center nurse filled out the bottom portion of the dialysis form. The UC stated upon resident's return from dialysis center, the licensed nurse on-duty or the UC made sure the communication form was complete. The UC stated, if the dialysis form was incomplete the dialysis form was faxed back to the dialysis center. The UC stated the licensed nurse on-duty called the dialysis center and asked the nurse to complete the form. The UC stated the dialysis forms should be completed. During an interview on 12/15/22, at 9:38 a.m., with the Director of Staff Development (DSD), the DSD stated the licensed nurse on-duty filled out the top portion of the dialysis communication form and the dialysis center completed the lower portion. The DSD stated the licensed nurse or the UC made sure the dialysis communication form was completed. The DSD stated it was important for the dialysis communication form to be completed to know the resident status while at the dialysis center. During an interview on 12/15/22, at 2:50 p.m., with the Director of Nursing (DON), the DON stated, the UC filed the dialysis communication forms in resident's chart. The DON stated the UC notified the licensed nurse if the form was incomplete. The DON stated, . Nursing are responsible in making sure dialysis communication form are completed . During a review of the facility's policy and procedure (P&P) titled, Care of the resident on Hemodialysis, dated 12/05/22, the P&P indicated, . Communication with the outpatient Dialysis centers to be completed with the Hemodialysis communication tool, sent with resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from chemical restraints imposed for convenience for two of three residents (Resident 9, Resident 18, and Resident 42) when: 1. Resident 18 was prescribed quetiapine (a medication to reduce symptoms like hallucinations [see, hear, smell, taste, or feel, things that appear real but only exist in the mind], delusions [a belief that is clearly false and indicates an abnormality in thought], and disordered thinking, and other mental health problems), following behaviors of pulling on medical tubes and scratching herself. Licensed nursed did not attempt resident-centered, non-pharmacologic methods to address the behaviors prior to administering quetiapine. The physician did not consult with mental health professional prior to inaccurately diagnosing bipolar disorder (a mental illness that causes extreme mood swings). These failures placed Resident 18 at risk for unnecessary potential medication interactions, and quetiapine adverse effects that include, but are not limited to drowsiness, high cholesterol, high blood sugars (which increases the risk of diabetes, an illness that affects the ability to remove the sugar from the blood and convert it to energy used elsewhere on the body), weight gain, liver dysfunction, heartburn, dry mouth, and weakness. 2. Resident 42 was prescribed quetiapine, inaccurately diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally and impairs daily functioning), and no resident-centered interventions were attempted prior to the use of quetiapine, after Resident 42 attempted to elope the facility and made erroneous phone calls. Licensed nursed did not attempt resident-centered, non-pharmacologic methods to address the behaviors prior to administering quetiapine. The physician did not consult with mental health professional prior to inaccurately diagnosing. This failure resulted in Resident 42's weight gain and increased A1c level (a blood test for average blood sugar level was over the past two to three months), placed Resident 42 at risk for diabetes (a condition that alters the ability to remove sugar from the blood and use as energy in other parts of the body), as well as risk of liver dysfunction, heartburn, dry mouth, and weakness (adverse effects of quetiapine). Findings: 1. During a review of Resident 18's Minimum Data Set (MDS, an assessment and screening tool for long term care residents) dated 6/29/22, the MDS indicated, Resident 18 was a 74. year old female who was admitted from an acute care hospital on 6/23/22 to the facility, whose diagnoses included heart failure (heart muscle does not pump a well as it should), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), respiratory failure (serious condition the makes it difficult to breath), and unspecified dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without psychiatric or mood disorder or potential indicators of psychosis (when people lose some contact with reality). The MDS indicated, Resident 18 was severely impaired in the ability to make decisions regarding tasks of daily life. During a review of Resident 18's Medication Orders (MO), the MO indicated Resident 18 had an order for quetiapine 12.5 mg (milligrams, a unit of measure) via G-Tube (gastrostomy tube, a tube inserted through the belly, directly to the stomach with which to feed individuals who cannot eat by mouth) daily, initiated on 9/18/22. The MO indicated, Admin [administration] Instructions: agitation, pulling life sustaining tube, scratching skin raw . Indications of use: bipolar disorder [a psychotic mental health condition that causes extreme mood swings] in remission [decreased intensity of a disease] . The MO indicated Resident 18 was prescribed this order through 12/8/22. During a review of Resident 18's Hospital Discharge Summary (HDS), dated 6/23/22, the HDS indicated, Resident 18's diagnoses did not include bipolar disorder, and Resident 18's hospital medication orders did not include an order for quetiapine. During a concurrent interview and record review on 12/7/22, at 2:03 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 18's electronic medical record (EMR) was reviewed. RNS 1 stated, the EMR indicated, Resident 18 was admitted [DATE] from the acute care hospital with diagnoses of respiratory failure, tracheostomy (trach, a hole in the neck and into the windpipe in which a tube was placed to keep the hole open for breathing), ventilator (a machine that provides breathing in and out for a person that cannot breathe on their own) dependent, heart failure, dementia, hypertension (high blood pressure). RNS 1 stated, the EMR indicated the diagnosis of bipolar disorder was added on 9/22/22. RNS 1 stated, Resident 18 last left facility to an acute care hospital on 7/29/22 and was discharge back to the facility on 8/1/22. RNS 1 reviewed HDS, dated 8/1/22. RNS 1 stated, the HDS indicated, no antipsychotics were prescribed. During a concurrent interview and record review on 12/7/22, at 2:10 p.m., with RNS 1, RNS 1 reviewed Resident 18's History & Physical (H&P), dated 8/17/22, at 5:12 p.m., RN 1 stated the H&P indicated Resident 18 had no diagnosis of psychosis or bipolar disorder. During a concurrent interview and record review on 12/7/22, at 2:11 p.m., RNS 1 reviewed Physician's Progress Note (PPN), dated 9/21/22. RNS 1 stated, the PPN indicated no diagnosis of bipolar disorder. RNS 1 stated, the PPN indicated no documentation of quetiapine being prescribed. During a concurrent interview and record review on 12/7/22, at 2:14 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 8/21/22, at 6:45 a.m. RNS 1 stated the NN indicated, @ [at] 2330 [11:30 p.m.] assessment noted G Tube was dislodged Resident was holding in Right hand Replaced with G tube size # 16 . MD [medical doctor] 1 informed . During a concurrent interview and record review on 12/7/22, at 2:13 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 9/2/22, at 12:34 a.m. RNS 1 stated, the NN indicated, . Noticed resident itching and scratching self. [MD 1] was informed and ordered [hydroxyzine, a medication to treat itching] 25 mg TID [three times a day] as needed for 14 days. Order carried out . During a concurrent interview and record review on 12/7/22, at 2:15 p.m., RNS 1 reviewed Resident 18's Medication Administration Record (MAR), dated 8/1/22 to 10/5/22. RNS 1 stated, the MAR indicated, an original order for hydroxyzine 25 mg BID (twice a day) as needed for 7 day was initiated on 8/21/22. RNS 1 stated, the MAR indicated from 9/2/22 to 10/4/22 the order was changed to 25 mg TID as needed for scratching and given once a day on 9/15, 9/16, 9/19, 9/21, 9/22. 9/27, 9/28, 10/1, and 10/4. RNS 1 stated the MAR indicated order was changed to routine (around the clock) three times a day on 10/5/22. During a concurrent interview and record review on 12/7/22, at 2:17 p.m., RNS 1 reviewed Resident 18's NN, dated 9/18/22, at 1:42 p.m. the RNS 1 stated, the NN indicated, . Resident disconnected her trach from the ventilator at least twice during shift and began to desaturate [decreased saturation of oxygen in the blood] down to 91% prior to reconnecting ventilator. After being reconnected resident returned to 98% oxygen saturation. Resident also repeatedly scratching herself during shift. [MD 1] notified, new order received to start [quetiapine] 12.5 mg via PEG [G-Tube] daily . During a review of Resident 18's Behavioral Monitoring Flowsheet (BMF) dated 6/1/22 to 12/7/22, the BMF indicated, Resident 18 exhibited no behaviors of scratching self, pulling on tubes, or agitation in the month of 6/2022 or 7/2022. The BMF indicated, one episode of scratching in 8/2022; one episode of scratching and 6 other episodes without comments and indicating mood as calm in 9/2022; one episode of scratching and 2 other episodes without comments and indicating mood as calm in 10/2022; 4 episodes of scratching and 2 other episodes without comments and indicating mood as calm in 11/2022; and no episodes of behaviors of scratching, pulling tubes or agitation in 12/2022. During a concurrent interview and record review on 12/7/22, at 4:24 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 18's EMR. The DSD stated, the EMR indicated there were no non-pharmacological interventions scratching, pulling at tubes, or agitation prior to starting Resident 18 on quetiapine. During a concurrent interview and record review on 12/9/22, at 2:09 p.m., with the DSD, The DSD reviewed Resident 18' s' Care Plan (CP). The DSD stated the CP indicated, . Problem: Resident with psychotic disorder . The DSD stated, the first intervention is to administer medications as ordered. The DSD stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD .suicidal ideation, self harming threats . The DSD stated the CP had no non-pharmacological plan for monitoring scratching, pulling tubes, or agitation for a resident with a psychotic disorder. The DSD stated the CP was not specific to the resident. During a concurrent interview and record review on 12/9/22, at 2:15, the DSD and Licensed Vocational Nurse (LVN) 1, reviewed Resident 18's Problem List (PL). The DSD stated, the PL indicated bipolar disorder was added to Resident 18's PL on 9/22/22. The DSD stated Resident 18 did not have a history of delusions. LVN 1 stated she was unaware of Resident 18 had any disorganized speech or hallucinations because the resident was non-verbal. LVN 1 stated Resident 18 did not know what goes on around her. During an interview on 12/9/22, at 4:23 p.m., with the Director of Sub Acute Operations (DSAO), the DSAO stated there was no documentation in the corporation's record for Resident 18's diagnosis of bipolar disorder. During a review of Resident 18's MDS, dated 9/27/22, The MDS indicated, under potential indicators of psychosis the box was checked for none of the above. The MDS indicate, no physical verbal or other behaviors symptoms were exhibited. During an interview on 12/15/22, at 10:48 a.m., with Consultant Pharmacist (CP) 1, CP 1 stated, when Resident 18 came into the facility in June, the resident was not on quetiapine. CP 1 stated, she asked the facility where the diagnosis of bipolar came from because she had not seen it before being placed on quetiapine. CP 1 stated, the facility stated Resident 18 had a history of bipolar, they were adamant about the history. CP 1 stated, the facility told her the resident kept pulling tubes and I asked about using mittens. CP 1 stated the facility told her they tried mittens, but it didn't work. CP 1 stated, pulling of tubes was not an approved use for quetiapine. CP 1 stated, pulling at tubes was not a sign of bipolar disorder. CP 1 stated, if the resident had not exhibited behaviors, then the MD should have tapered the dose down. CP 1 stated, the 11/2022 was the first month she saw the facility monitoring behaviors. CP 1 stated, if someone had a trach and could not speak or communicate you cannot diagnose them as bipolar. CP 1 stated, Resident 18 cannot communicate, so it is even harder to tell if the resident was having side effects of the medication or if it is working or not. During an interview on 12/15/22, at 11:20 a.m., with Resident 18's daughter (Family Member, FM 2), FM 2 stated, Resident 18 has never been diagnosed with bipolar disorder but was made aware of her mother being place on a medication to help stop her itching and pulling. During an interview on 12/16/22, at 7:43 a.m., with Resident 18's son (Family Member, FM 1), FM 1, stated, the facility did contact him when his mother was started on quetiapine but did not mention anything about her being bipolar. FM 1 stated, Resident 18 is not bipolar but has a history of Parkinson's and some dementia. FM 1 stated, he has lived with his mother his whole life until she went into the hospital. During an interview on 12/16/22, 11:07 a.m., with MD 1, MD 1 stated, he did not recall Resident 18. MD 1 stated . I don't play with psychotropics. I don't walk in and start on [quetiapine] . When asked to define bipolar in remission, MD 1 stated . I can't answer unless I can see the record. I don't have access to the record now . MD 1 stated he would put a resident on quetiapine if they were on it in the emergency room or previously on quetiapine. During a concurrent interview and record review on 12/16/22, at 2:01 p.m., with the Director of Nursing (DON), the DON reviewed Resident 18's EMR. The DON stated the EMR indicated, Resident 18 was on quetiapine 12.5 mg daily, starting on 9/18/22 and the indication for use was pulling on life sustaining tubes and scratching. The DON stated he had never heard the term bipolar in remission. The DON stated, signs and symptoms of bipolar disorder would be hallucinations and delusions, so he does not know how the resident can be diagnosed with bipolar when she could not communicate. The DON acknowledged grabbing at a tube that is not naturally present would be normal. The DON validated there was no hallucination or delusions were noted on the MDS, dated 9/27/22. The DON validated the ability to monitor mood and behaviors was limited in July- November of 2022, due to limitations with [the electronic documentation system]. The DON acknowledged Resident 18' s' CP for psychotic disorder was generic and not specific to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Use, dated 7/19/22, indicated, . For all residents receiving antipsychotic or other psychotropic medication the nurse ensures . specific condition or diagnosis being treated, and the behaviors manifested are identified in the physician's order and physician's notes . Behaviors associated with use of the mediation are identified in the care plan . In each scheduled Interdisciplinary Team (IDT) meeting residents use of these type of medications will be evaluated for efficacy in controlling [sic] behavior, the advisability of attempting a gradual dose reduction (GDR) and any adverse drug reactions . Procedure . All residents are assessed upon admission and as needed during their stay for physical or behavioral triggers which may necessitate the use of medication to control resident's behavior . Alternate methods are attempted and documented in the resident's plan of care prior to the implementation of new psychoactive mediation treatment . During a review of the Manufacturer's Package Insert for Quetiapine (MPI), dated 1/1/22, the MPI indicated, . Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect size in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic adverse reaction . hyperglycemia [high blood sugar] . weight gain . changes in cholesterol . drowsiness . heartburn . constipation . dry mouth . 2. During a review of Resident 42's Face Sheet (FS, a one-page document with important information about the resident), dated, 1/31/22, the FS indicated, Resident 42 was a [AGE] year-old male and the reason for Resident 42's admit was a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a history of a traumatic brain injury (TBI, an injury that affects how the brain works). During a review of Resident 42's History & Physical (H&P), dated 12/17/19, the H&P indicated, diagnoses of TBI, subarachnoid hemorrhage, subdural hematoma (when a blood vessel in the space between the skull and the brain is damaged, blood leaks and forms a clot that places pressure on the brain and damages the brain), prostate mass (non-cancerous nodule), left inguinal hernia (a bulge in the groin area caused by fatty tissue or intestines pushes through a weak spot in the muscles surrounding the abdomen), intraventricular hemorrhage (bleeding into the fluid -filled areas, or ventricle, surrounding the brain), hypertension (HTN, high blood pressure), cardiac arrhythmia( irregular heart beat), dysphagia (difficulty swallowing), and a past history of arthritis (inflammation or swelling in one or more joints) & HTN. The H&P indicated, no history or diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally). During a review of Resident 42's MDS, dated 12/23/19, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, the active diagnosis box for schizophrenia was not checked. During a review of Resident 42's Medication Orders (MO), dated 1/30/20 to 1/31/22, the MO indicated, MD 1 prescribed quetiapine 50 mg two times daily from 1/30/20 to 2/15/20 and the indication for use was schizophrenia, manifested by episodes of delusions. The MO indicated, MD 2 altered the quetiapine order to 100 mg three times daily on 2/16/20 (three times the previous daily dose). The MO indicated, MD 1 altered the prescription to 200 mg 2 times a day with the indication for use as schizophrenia, manifested by episodes of delusions manifested by wanting to leave facility to drive his truck or wanting to get to his job. During a review of Resident 42's Nursing Progress Notes (NPN), dated 12/22/19, the NPN indicated, . Pt [patient] is alert and responsive, verbal, able to make needs know [sic], forgets limitations, tolerates meds [medications] well . During a review of Resident 42's NPN, dated 1/23/20, at 6:17 a.m., the NPN indicated, . At approximately 04:45 [4:45 a.m.] patient tried to elope, when he was scheduled for shower, still dressed exited at the door by PT [physical therapy] room, Staff nurse and CNA were with the patient trying to stop from leaving, resident didn't listen, called security and police dept [department] to Incident. , [sic] contacted supervisor by staff nurse, notified RP [responsible party] via phone . Patient was trying to enter property . while being accompanied by staff, security arrived and take [sic] the resident back to the facility. Patient is safe and went back to bed, remained in bed . During a review of Resident 42's NPN, dated 1/29/20, at 6:16 p.m., the NPN indicated, . Resident called 911 to ask for information on a friend who lives in [city name]. He is pacing up and down the hallways and opening the emergency exits. Resident wants to leave to go drive trucks in [nearby state]. RP to be contacted and MD to be informed . During a review of Resident 42's NPN, dated 1/29/20, at 7:17 p.m., the NPN indicated, . Resident called [nearby behavioral facility] 18 times. Resident was asked not to use the lobby phone anymore and to ask staff to dial for him from now on. Resident's sister (RP) was contacted and informed of behaviors of the resident. She asked if we could get him some medications to calm him down. MD contacted. Awaiting response . During a review of Resident 42's NPN, dated 1/29/20, at 7:34 p.m., the NPN indicated, . MD responded with new orders. Give 1mg [lorazepam, a medication to treat anxiety] STAT [immediately] and start him on [quetiapine] 50mg BID [twice daily] . During a review of Resident 42's NPN, dated 1/29/20, at 11:52 p.m., the NPN indicated, . After first administration of [lorazepam] 1mg IM [intramuscularly, a method of injecting medication into the muscle] Resident continued to attempt to run away. He ran out the front door and was brought back by staff he then went out the Emergency exit. Security responded and spoke with resident . He was still obsessing about leaving and wouldn't calm down. [MD 2] contacted and gave orders for additional 1mg [lorazepam] IM STAT. He also gave orders for [lorazepam] 1mg by mouth BID along with the [quetiapine] 50mg BID. [MD 2] stated we need to contact him every few days to increase [quetiapine] until it reaches 900mg. He also said we need to think about other types of psychotropics that work better for TBI patients . During a review of Resident 42's NPN, dated 1/30/21, at 6:38 a.m., the NPN indicated, . Pt. Slept [sic] good during the shift, no attempt to go outside the facility,randomly [sic] check patient, he get up to go bathroom twice and be able to go [sic]back to bed to sleep with no problem . During a review of Resident 42's NPN, dated 1/30/20, at 3:29 p.m., the NPN indicated, . Patient was seen walking out of building passing by at The [sic] activity area by the time we were out [sic] patient was already across the street. Patient ask why he [sic] went outside stated just wanted to go for a walk. Educate patient the danger [sic] of getting lost . During a review of Resident's NPN, dated 2/2/20, at 2:15 p.m., the NPN indicated, . Patient monitor for this shift patient in his room most of the time was on his phone ate in his room no attempt of going outside facility at this time he is in the activity likely to watch football [sic]. Supervisor made aware of night nurse endorsing about medication per supervisor [sic] will TX [text?] MD . During a review of Resident's NPN, dated 2/2/20, at 4:07 p.m., the NPN indicated, . Spoke with [MD 2] patient remained calm and cooperative, no signs of wandering at this time. Patient behaviors are currently controlled with current dose of [quetiapine] and [lorazepam]. Will continue to monitor . During a review of Resident's NPN, dated 2/2/20, at 9:33 p.m., the NPN indicated, . MD faxed back order to change diagnosis of [quetiapine] to schizophrenia M/B [manifested by] episodes of delusions . During a review of Resident's NPN, dated 2/14/20, at 10:34 p.m., the NPN indicated, . Patient eloped from facility at approximately 2145 [9:45 p.m.] this shift. Security, [city] PD [police department], RP and pt friend [name], MD, APS [adult protective services] and facility supervisor all made aware of patient elopement. Patient last seen asking a staff member if they could take him to [another town]. [city] PD said they would have officers out canvassing area . During a review of Resident's NPN, dated 2/15/20, at 1:41 a.m , the NPN indicated, . PD came back to facility and stated they still have not found patient out on the street . PD said . they will hand case to . PD missing persons . During a review of Resident's NPN, dated 2/16/20, at 10:42 p.m., the NPN indicated, . Patient seen pacing around facility and trying to exit the building through all doors. He is telling female staff they're 'his girl and they need to outside to his truck with him.' Multiple staff tried redirecting pt with TV, snacks offered, and that dinner would be in bedroom shortly but continued to say he needs change so he can find a ride to get to his job. Pt was reminded that he does not have work right now and that he lives here at the facility. Patient stated, 'No I don't, I need to get to my truck right now.' .RP called .he doesn't want to talk . call her tomorrow . [MD 2] notified . New MD orders to increase [quetiapine] 100mg TID, reinstate [lorazepam] 1mg by mouth BID, and to give [lorazepam] 1mg IM x1 [once] stat . All orders carried out . During a review of Resident 42's MDS, dated 3/20/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 6/18/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 9/16/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, verbal behavior directed toward other occurred 1 to 3 days. The MDS indicated, no physical or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 12/24/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, wandering behavior question was unanswered. During a review of Resident 42's MDS, dated 10/6/22, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a concurrent interview and record review on 12/8/22, at 10:47 a.m., with the DON, the DON reviewed the EMR for Resident 42. The DON stated he could not find any documentation of behavior monitoring prior to the administration of quetiapine, because there were no behaviors except for the elopement. During a concurrent interview and record review on 12/8/22, at 10:49 a.m., with the DON, the DON reviewed Resident 42's Physician Progress Notes (PPN), dated 2/28/20 to 12/21/20. The DON stated, the PPN did contain any documentation of a schizophrenia diagnosis or schizophrenia symptoms. During a review of Resident 42's Weights, dated 12/19/19 to 12/1/22, the Weights indicated, .12/19/19 . 216 pounds [lbs., a unit of measure] . 1/19/20 .205.3 lbs. 2/8/20 .210.3 lbs. [no weights between 2/8/20 and 6/13/20] . 6/13/20 . 226.4 lbs. 7/31/20 . 267.7 lbs. [+41.3 lbs. {18.2%} in one month] . 12/12/20 . 272.2 lbs. [+56.2 lbs. {26%} in one year] . 3/13/21 . 280.9 lbs. 6/18/21 . 284.8 lbs. 9/9/21 . 290 lbs. 11/02/22 . 296.3 lbs. During an interview on 12/9/22, at 10:40 p.m., with the RDFSD, the RDFSD reviewed Resident 42's EMR. The RDFSD stated, Resident 42 's diagnoses on admission included, arthritis, hypertension, hyperlipemia. The RDFSD stated, continued weight gain could worsen these diagnoses. The RDFSD stated, Resident 42 has been on a regular diet since at before 3/17/20. During a review of Resident 42's Hemoglobin A1C (HbA1c or A1C lab results, dated 3/6/20 to 10/12/22, The HbA1c indicated, . Ref [reference] Range & Units 4.8 - 5.6% . 3/6/20 . 5.4 . 3/5/21 . 5.7 . 6/18/21 . 6.0 . 12/16/21 . 6.1 . 2/2/22 . 6.3 . 10/12/22 .6.4 . During a review of Resident 42's Hemoglobin A1C results (A1C), dated 10/12/22, at 1:09 p.m., the A1C indicated, it was a fax and the result of 6.4 is circled and signed by [MD 1]. During a review of Resident 42's NPN, dated 10/12/22, at 10:17 p.m., the NPN indicated, . MD faxed back regarding patient's lab results: CBC [complete blood cell count], CMP [complete metabolic panel, electrolytes and minerals], Lipid [fats in the blood] Panel, Vitamin D, and HA1C [A1C]. No new orders at this time . During a concurrent interview and record review on 12/14/22, at 2:16 p.m., with LVN 8, LVN 8 reviewed Resident 42's EMR. LVN 8 stated, she could not locate any non-pharmacological (non-medication) interventions attempted prior to starting quetiapine and no targeted behavior to monitor on the flowsheet. LVN 8 stated, the EMR indicated, non-pharmacological interventions for behaviors documented in the flowsheet on 2/23/22. LVN 8 stated the expectation is to document on planned alternate to psychotropics every shift. LVN 8 stated the planned interventions do not show up in the EMR until the quetiapine is ordered. LVN 8 stated, the planned interventions were general, like noise and lighting reduction. During a concurrent interview and record review on 12/14/22, at 2:17 p.m., with LVN 8, LVN 8 reviewed the Psychotropic Medication Behavior Flowsheet (PMBF), dated 11/1/22 to 12/13/22. LVN 8 stated, the PMBF indicated, no target behaviors were observed. During a concurrent interview and record review on 12/14/22, at 2:18 p.m., with LVN 8, LVN 8 reviewed Resident 42's CP. LVN 8 stated, there was a care plan for quetiapine for history of wanting to leave the facility. LVN 8 stated, the CP indicated, the first intervention is to administer medications as ordered. LVN 8 stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD .suicidal ideation, self harming threats . LVN 8 stated, a lot of the interventions were general, not specific to resident. LVN 8 stated, it was important to have resident-centered non-pharmacological interventions so you can provide better care to the resident. During a concurrent interview and record review on 12/14/22, at 2:20 p.m., with LVN 8, LVN 8 stated she could not find a psychiatric consult nor an order for a psychiatric consult in Resident 42' medical record During a review of Resident 42's Behaviors and Moods (BM), dated 11/8/22 to 12/8/222, The BM indicated, all entries for physical behaviors observe are 'appropriate; all entries for verbal behaviors observed are appr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the State Long-Term Care (LTC) Ombudsman (OMB) of transfers and discharges for three of eight sampled residents (Resident 78, 82, and 83) when the OMB office was not notified for Resident 78, Resident 82 and Resident 83's hospitalizations. This failure resulted in Resident 78, Resident 82 and Resident 83 not having access to an advocate (the ombudsman) who could inform them their options and rights while being in the hospital. Findings: During a concurrent interview and record review on 12/8/22, at 9:01 a.m., with the Director of Staff Development (DSD), Resident 78's Electronic Health Records (EHR) for admission date 9/9/22 was reviewed. The DSD stated Resident 78 was sent to the hospital on 9/1/22 for a GI (gastrointestinal - stomach) bleed and again on 10/5/22 for sepsis (a serious infection that could lead to shock and or death). The DSD stated the nursing notes indicated the change in conditions and the responsible party being notified. The DSD stated she did not know where the documentation for Ombudsman notification for hospitalization was noted in the Resident 78's EHR. During a concurrent interview and record review on 12/8/22, at 10:49 a.m., with the DSD, Resident 82's EHR for admission date 9/7/22 was reviewed. The DSD stated Resident 82 was sent to the hospital on 8/28/22 for continuous fever and pneumonia (PNA - lung infection). The DSD showed the Nursing note that indicated the responsible party was notified of the resident going to the hospital. The DSD stated she did not know where the documentation for Ombudsman notification for hospitalization was noted in the Resident 82's EHR. During an interview on 12/9/22, at 11:22 a.m., with the DSD, the DSD stated, We send a list to the Ombudsman monthly of all the residents that are sent out for the previous month. The DSD provided a document indicating dates to send ombudsman notices. The DSD stated the Administrator (ADM) 1 informed her ombudsman notices were sent out monthly and was done by the social services staff. The DSD stated the facility was not able to send out ombudsman notices timely. During a review of facility documents (binder) titled, TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN (OMB) PROGRAM, indicated there was no transfer forms sent for Resident 78's hospitalizations on 9/1/22 and 10/5/22 and for Resident 82's hospitalization on 8/28/22. During an interview on 12/9/22, at 11:44 a.m., with Licensed Clinical Social Worker (LCSW) 2, LCSW 2 stated, Yesterday. I was told to send these forms [TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN PROGRAM] to the Ombudsman, and we have never had to do it before. We [Social Services] are not responsible for this; you would have to speak with [name of ADM 2]. During an interview on 12/9/22, at 11:48 a.m., with ADM)2, ADM 2 stated, The social workers [SW] are working on finding the binder [Transfer/ Discharge Binder]. ADM 2 stated it was the social workers responsibility to ask for the binder for the Ombudsman forms for tracking of discharges and transfers. ADM 2 stated they had a SW quit 2 months ago and she was responsible for the binder and faxing these forms to the OMB. ADM 2 stated the SW currently assigned to fax the transfers and discharges should have sent the notices to the OMB office. During a concurrent interview and record review on 12/15/22, at 4:15 p.m., with the Quality Registered Nurse (QRN), Resident 83's EHR for admission date 7/1/22 and 10/6/22 were reviewed. The QRN stated Resident 83 was sent to the hospital on [DATE] for GI bleed and on 10/6/22. The QRN stated Resident 83 was again sent to the hospital on [DATE] for bloody emesis (vomit). During a review of facility documents (binder) titled, TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN (OMB) PROGRAM, indicated Resident 83's transfer document for date 10/31/22 was missing the reason for transfer and the facility the resident was being transferred to. There was also no transfer form sent for Resident 83's hospitalizations on 10/4/22. During an interview on 12/9/22, at 12:15 p.m., with ADM 1, ADM 1 stated she was not aware of the issue with the transfer and discharge paperwork for the OMB office until yesterday when the DSD asked her about it. ADM 1 stated the Transfer and Discharge Fax Cover Sheet did not provide the needed information to for the OMB office. ADM 1 stated it did not provide the facility the resident was being transferred to and the reason for the transfer or discharge. ADM stated the transfer forms should have all the needed information. During an interview on 12/16/22, at 3:17 p.m., with the Director of Nursing (DON), the DON stated it was important to let the OMB know when there were transfers and discharges because they were the resident's advocate and could help to ensure the resident came back to the facility. The DON stated if the OMB was not informed of the resident going to the hospital they would not be able follow up on the resident to make sure their issues were being addressed. During a review of a professional reference titled, California Advocates for Nursing Home Reform [CANHR] Long Term Care Justice and Advocacy, dated 7/15/22, indicated, . Transfer and Discharge Rights . Written Notice Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand. 42 CFR 483.15(c)(3)(i). The facility must send a copy of the notice to the long-term care ombudsman program . The notice must contain all of the following information . The reason for the transfer or discharge . The effective date of transfer or discharge . The location to which the resident will be transferred or discharged . Retrieved from: http://www.canhr.org/factsheets/nh_fs/html/fs_transfer.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5a. During a review of Resident 80's admission Record (document containing resident demographic information and medical diagnosis), dated 5/25/22, the admission record indicated, Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnosis included Severe Malnutrition [low body weight], Pressure Ulcer unstageable [wound covered in a thick layer of tissue and yellow drainage], and a history of Venous Thrombosis and embolism [blood clots in blood vessels that reduces the flow of blood to vessels]. During a review of Resident 80's Care Plan, dated 6/14/22, the Care Plan indicated, . Turn and reposition every two hours . During a concurrent interview and record review on 12/15/22, at 12:00 p.m., with Quality Registered Nurse (QRN), Resident 80's, Activity and Daily Care Flowsheet (documentation for repositioning of resident) was reviewed. The Activity and Daily Care Flowsheet indicated, Resident 80 was turned on 12/6/22 at 0230, 0700, 0930, 1752 and 2215. The Activity and Daily Care Flowsheet indicated, Resident 80 was turned on 12/7/22 at 0700, 0730, 1600, and 1700. QRN stated the nurses were not documenting every time a resident's position is changed. QRN stated nurses should have documenting care to indicate it was done. During a review of the facility's policy and procedure (P&P) titled, CNA (Certified Nursing Assistant) Charting, dated 4/14/22, the P&P indicated, . I. PURPOSE To provide accurate and consistent documentation of resident status and care given by Certified Nursing Assistant staff . III. PROCEDURE A. Each Nurse Assistant completes the appropriate Flow Sheet/s for each resident assigned to their care . C. Documentation should include: . 2. Body Care: . f. Bed Mobility/ Positioning - Document level of assistance required to turn and reposition every two hours . 5b. During a review of Resident 80's Physician's order, dated 6/6/22, the Physician order indicated, . Restorative Nursing Assistance (help to maintain and regain physical, mental and emotional health) Once per day on Monday, Tuesday, Wednesday, Thursday and Friday . ROM (Range of Motion) exercises to prevent further contractures (tightening of muscle, tendons, ligaments or skin) . During a review of Resident 80's Restorative Nursing Assistance treatment notes, dated 9/2022-12/2022, RNA treatment notes indicated, RNA treatments were not consistent with physician orders of RNA Treatment 5 times per week as ordered. During a concurrent interview and record review, on 12/9/22, at 3:00 p.m., with Certified Nurse Assistant (CNA) 2, RNA treatment notes dated 9/1/22-12/1/22 was reviewed. CNA 2 stated she was not able to get to Resident 80's RNA treatments 5 times per week. CNA 2 stated her supervisors asked her to cover CNA duties when the facility was short staffed. CNA stated she 2 to not be able to complete RNA duties. During an interview on 12/16/22, at 10:13 a.m., with the Director of Nursing (DON), DON stated, he oversaw RNA services. DON stated, he was aware of the RNA's being pulled away from RNA duties to help in other areas of the facility. DON stated the RNA were not able to complete work duties. 5c. During a review of Resident 80's Physician Orders, dated 5/27/22, indicated Intake and Output-Measure (quantity of nutrition received) and record for patient on feeding tube (Intake Output) EVERY SHIFT . During a review of Resident 80's Care Plan, dated 5/31/22, indicated, . Tube feed to provide 100% of nutritional needs Risk for dehydration and malnutrition related . Monitor and encourage fluid intake, notify MD if inadequate fluids taken . During a review of Resident's 80's Input [intake] and Output [I&O] Flowsheet (documentation of nutrition going into the body and out), dated 10/1/22-12/5/22, the I&O Flowsheet indicated, 10/1/22-10/5/22, 10/22/22-10/26/22, 11/5/22-11/11/22, 11/14/22-11/15/22, 12/3/22-12/6/22 indicated no documented intake. During a concurrent interview and record review on 12/7/22 at 3:48 p.m., with Registered Nurse Supervisor (RNS), Resident 80's Input and Output Summary (Daily documentation of nutrition) dated 10/1/22 - 12/5/22 was reviewed. RNS stated, she was unable to locate where to document input and output or locate how much of the tube feeding was provided for Resident 80. RNS stated, the nurses went by how much formula was in each tube feeding hung. RNS stated nurses should have documented Resident 80's intake amount. RNS stated, input was not monitored or documented accurately. A concurrent interview and record review on 12/7/22, at 4:00 p.m., with Quality Registered Nurse (QRN), Input and Output Summary, dated 10/22-12/5/22 was reviewed. The input and output summary for dates 10/1/22-10/5/22, 10/22/22-10/26/22, 11/5/22-11/11/22, 11/14/22-11/15/22, 12/3/22-12/6/22 indicated no input was documented. QRN stated, input and output should have been completed. During a interview on 12/16/22, at 10:15 a.m., with Director of Nursing (DON), the DON stated the expectation was for nursing staff to document input and output. During a review of the facility's policy and procedure (P&P) titled, Charting Guidelines, dated 4/18/22, the P&P indicated, . All documentation is complete and accurate for each resident. B. Timely documentation of resident care will include: 1. Assessments of resident condition including any changes. 2. Care plan interventions 3. Recording of Activities of Daily Living, Vital Signs, Weights, Intake and output 4. Medication Administration C. Documentation is to be completed as soon as possible after any type of resident intervention is provided . III. DOCUMENTATION A. All residents are assessed every shift with documentation in the EHR. B. Weekly summaries by the Licensed Nurse are required for all residents. Documentation must be focused on the resident's care plans including their progress towards goals and any changes to interventions. 1. Resident Care Plans are to be reviewed and updated as necessary at the time of the weekly summary or at any time an intervention requires changes. 2. Care plan review includes new problems or interventions, update of existing problems and discontinuation of resolved problems . 3. During an observation on 12/5/22, at 10:07 a.m., Resident 78 was lying in bed with head elevated with all four bedrails up. Resident 78 was on tube feeding and had a foley catheter with a privacy bag on. During a review of Resident 78's Face Sheet (document that provided resident information), dated 12/8/22, the Face Sheet indicated, Resident 78 was admitted on [DATE] with an admitting diagnosis of Acute chronic respiratory failure (airways to the lungs become narrow and damaged causing difficulty breathing) with hypoxemia (abnormally low concentration of oxygen in the blood). During a concurrent interview and record review on 12/8/22, at 9:01 a.m., with the Director of Staff Development (DSD), Resident 78 's Electronic Health Care Records (EHR) for 9/1/22 were reviewed. The DSD stated Resident 78's Nursing Note dated 9/1/22 at 3:51 a.m. indicated, Resident has bleeding from rectum. Bright red and moderate amount. Will notify [name of doctor] in the morning. Will continue to monitor patient. Resident 78's nursing note dated 9/1/22, at 10:16 a.m., indicated, Resident PT/INR (Prothrombin Time Test and INR- lab that measures the time it takes for a clot to form in a blood sample) results faxed to MD (medical doctor), also notified regarding the previous NOC (night shift) shift x1 (once) bright red and moderate amount. NNO (no new orders) at this time. Resident 78's medication's was reviewed. The DSD stated Resident 78 was on (Warfarin brand name, blood thinner) 9 mg (milligrams- unit of measure) daily. Review of Resident 78's Care plan titled, Problem: Possible internal bleeding secondary indicated, . Date Start: 8/31/22 . Interventions: 1. Monitor output for blood and report to MD promptly . The DSD the care plan intervention was not done. The DSD stated, They [nursing staff] should have notified him [the doctor] as soon as possible. During a concurrent interview and record review on 12/15/22, at 11:40 a.m., with the Registered Nurse (RN) 9 (Charge Nurse), Resident 78's Nursing note dated 9/1/22 at 3:51 a.m. was reviewed. RN 9 stated she wrote the note. RN 9 stated, . We continued to monitor him (Resident 78), checked his vital signs and they were stable, and he did not have another bowel movement . RN 9 stated she felt it was safe to wait until later that morning to contact the doctor. RN 9 stated she was not sure if she contacted the doctor because she didn't make a note in the EHR. During an interview on 12/9/22, at 3:30 p.m., with the Director of Nursing (DON), the DON stated he would have expected the Charge nurse (RN 9) that night to call the doctor when Resident 78 had his first bowel movement that was described as having moderate amount of blood. During a review of Resident 78's Nursing Note, dated 9/1/22, at 3:42 p.m., the note indicated, Assigned LVN noted resident with large amount of rectal bleeding, assessment done by RN and NS (nursing supervisor), [doctors name] made aware with order to transfer to [name of hospital] ER (emergency room) for evaluation and management for rectal bleeding 15:40 called [name of ambulance company] ambulance 15:47 left message for RP [name and provided phone number] to call back 15:56 left for [name of hospital] ER, Picked up by 2 [name of ambulance company] ambulance paramedics via Gurney, resident alert and awake 16:15 received call back from RP . 4. During an observation on 12/5/22, at 9:27 a.m., Resident 82 was sleeping in his bed with the head of bed elevated and all four bed rails up. Resident 82 had a trach, oxygen saturation monitor (monitors heart rate and oxygen level for the resident) and a foley catheter with a privacy cover in place. During an observation on 12/5/22, at 12:18 p.m., Resident was coughing with trach site noted to have yellow sputum outside on the dressing. During a review of Resident 82's Face Sheet, dated 12/8/22, the Face Sheet indicated, Resident 82 was admitted on [DATE] with an admitting diagnosis of Acute Ischemic Left Posterior Cerebral artery Stroke (damage to the brain due to interrupted blood supply- a medical emergency). During a concurrent interview and record review on 12/8/22, at 11 a.m., with the DSD, Resident 82's care plans were reviewed. The DSD stated there was no care plan for Resident 82's trach. The DSD stated her expectation was that there should have been a care plan for his trach care and management. The DSD stated there was no care plan for Resident 82's Foley Catheter and her expectation was there should have been a care plan for Resident 82's foley catheter care. During an interview on 12/16/22, at 3:17 p.m., with the DON, the DON stated care plans were the instructional map to guide the care for the resident. The DON stated the orders given by the doctors were an integral part of the care provided to the resident. The DON stated the expectation was that staff follow the care plan and the orders for each resident and contact the doctor if there were any changes that need to be addressed for the resident. Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (A plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for five of eight sampled residents (Residents 62, 87, 78, 82 and 80) when: 1. Resident 62 did not have a care plan for the use of antibiotic (drug used to treat infections) to treat urinary (bladder) infection. This failure had the potential to result in Resident 62's antibiotic use to go unmet and could result in adverse effect of medication not being monitored by staff. 2. Resident 87 did not have a care plan for his dental issues. This failure had the potential to result in Resident 87's dental needs to go unmet and may lead to decline in appetite which could lead to weight loss. 3. Resident 78 had blood in his stool and the physician was not notified immediately. This failure resulted in a delay of care and treatment for 7 hours which led to Resident 78's hospitalization. 4. Resident 82 did not have a care plan for having a foley catheter (catheter made of rubber inserted into the bladder, via the urethra to drain urine from the bladder into a bag outside the body) and tracheostomy (trach- a surgical opening in the neck into the windpipe to allow direct access to the breathing tube. A tube is usually placed through the opening to provide an airway and to remove secretions from the lungs). This failure had the potential Resident 82's catheter care needs to go unmet. 5.(a) Turning and repositioning every two hours, (b) Restorative Nursing Assistance (RNA) services per physicians' orders, and (c) daily monitoring and evaluation of tube feeding (medical device used to provide nutrition) documentation and measurements for hydration was not done for Resident 80. These failures had the potential to result in Resident 80 to not receive individualized care consistent with his needs. Findings: 1. During a concurrent observation and interview on 12/5/22, at 12:35 p.m., in Resident 62's room, Resident 62 was sitting in his wheelchair eating lunch. Resident had a foley catheter and a catheter bag. Resident 62 stated he was happy with care and food. During a review of Resident 62's admission Record, dated 12/8/22, the admission Record indicated, Resident 62 was admitted in the facility on 11/8/22. Review of Resident 62's orders dated 12/8/22, indicated, . start date 12/6/22 . [Ciprofloxacin - antibiotic to treat infection] tablet 250 mg. [milligram-unit of measurement] Stop date 12/14/22 ORAL EVERY 12 HOURS SCHEDULED . DO NOT Remove Indwelling Catheter UNTIL DISCONTINUED . During a concurrent interview and record review on 12/8/22, at 8:34 a.m., with Registered Nurse Supervisor (RNS), RNS stated Resident 62 had an indwelling catheter for obstructive uropathy (flow of urine is blocked). RNS stated Resident 62 was initially started on antibiotic on 11/20/22. Care plans for Resident 62 was reviewed, RNS was unable to locate a care plan for antibiotic use on 11/20/22. RNS stated there should have been a care plan initiated on 11/20/22 when Resident 62 was started on antibiotic. 2. During a concurrent observation and interview on 12/5/22, at 10:12 a.m., with Resident 87's room, Resident 87 was laying in bed, some missing teeth observed. Resident stated he knew his teeth were in bad shape. Resident 87 stated, . I was seen by a dentist last month (November) and recommended to have all my teeth pulled out . Resident 87 stated he was just waiting for the appointment. During a review of Resident 87's admission Record, dated 12/8/22, the admission Record indicated, Resident 87 was admitted on [DATE]. During a concurrent interview and record review on 12/8/22, at 8:34 a.m., with RNS, RNS reviewed clinical record for Resident 87. RNS stated admission nursing assessments indicated dental issues. RNS stated, . There should have been a care plan started for the dental issues but I do not see a care plan . During an interview on 12/15/22, at 2:50 p.m., with the Director of Nursing (DON), the DON stated care plans were initiated upon admission. DON stated, . care plan is the driving plan and a map to care for the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 12/07/22, at 10:28 a.m., Resident 3 was supine (lying face upward) in bed with a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe). Resident 3 had stomach tube feeding (nutritional formula given from a plastic device through the abdomen). Resident 3 was not responsive and non-verbal (not using words or speech) to stimulation. During a review of Resident 3's History and Physical (H&P), dated 8/14/18, the H&P indicated, Resident 3 was a [AGE] year old male with Diabetes Mellitus Type II (high levels of sugar in the blood resistant insulin), Quadriplegia (paralyzed all four limbs), and persistent vegetative state (condition in which a patient was completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function). During a review of Resident 3's Glucose Timeline (GT), dated 9/12/22 - 10/10/22, the GT indicated, Resident 3's blood glucose levels were 121 - 224 mg/dL. The GT dated 10/12/22 - 11/7/22 indicated, Resident 3's blood glucose levels were 144 - 263 mg/dL. The GT dated 11/7/22 - 12/5/22 indicted, Resident 3's blood glucose levels were 151 - 289 mg/dL. During a review of Resident 3's Laboratory Values (VL), dated 10/7/22, at 5:17 a.m., the VL indicated, Resident 3's A1C (a blood test that shows the average blood sugar level over a three-month period) was 6.6% (normal levels 4.8 - 5.6%). The VL indicated, Resident 3's A1C was reviewed by the Medical Doctor (MD) on 10/7/22. During a review of Resident 3's Medication Orders (MO), dated 9/21/22, the MO indicated, Insulin regular (fast acting hormone used to treat high blood sugar) 10 Units (unit of measurement) subcutaneous (injection given in the fat tissue) 2 times daily. The MO dated, 9/21/22 indicated, Insulin (brand name - slow acting hormone used to treat high blood glucose) 22 Units Subcutaneous nightly. During a concurrent interview and record review on 12/8/22, at 4:25 p.m., with the Registered Dietician (RD), Resident 3's Electronic Health Records (EHR) was reviewed. RD stated, Resident 3 was on (Formula brand) 1.2 (a type of tube feeding formula) 60 ml (milliliters)/hr (hour) x 20 hours plus 50 ml free water flush (additional water provided to the resident daily) x 20 hours. RD stated, blood glucose level below 180 mg/dL was ideal for Resident 3. RD stated, Resident 3's blood glucose was not reviewed in the 11/10/22 care conference (quarterly meeting conducted by IDT [interdisciplinary team] members to decide treatment modalities for residents). RD stated, Resident 3's blood glucose should have been addressed during the IDT care conferences. RD stated, increased level of blood glucose could cause damage to the body such as kidney failure, blindness, and other medical complications. During a concurrent interview and record review on 12/9/22, at 9:18 a.m., with the Medical Doctor (MD), Resident 3's EHR was reviewed. MD stated, Resident 3 was diabetic, was on tube feeding, and in a persistent vegetative state. MD stated, blood glucose levels between 121 - 289 mg/dL for three consecutive months with Insulin treatment was not therapeutic (not treating or helping the disease). MD stated, MD expected the nursing staff to notify him of Resident 3's elevated blood glucose levels. MD stated, therapeutic blood glucose target for diabetic residents on tube feeding should be between 110 - 120 mg/dL. MD stated, MD did not provide nursing staff with a blood glucose parameter of when to notify him. MD stated, Resident 3 should have been on a blood glucose sliding scale (a set of orders for the treatment of blood glucose level with parameters to notify the MD). MD 1 stated, prolong elevated blood sugar can cause artery (blood vessel) disease, stroke, kidney failure, and wound complication. During a concurrent interview and record review on 12/9/22 9:39 a.m., with Licensed Vocational Nurse (LVN )1, Resident 3's EHR was reviewed. The EHR indicated, Resident 3's blood glucose levels were between 121 - 289 mg/dL from 9/12/22 - 12/12/22. The EHR indicated, Resident 3 received insulin as ordered on the Medication Administration Record (MAR) dated, 9/1/22 - 12/8/22. LVN 1 stated, blood glucose level was considered stable between 60 - 120 mg/dL. LVN 1 stated, no parameters was given to notify the MD of Resident 3's blood glucose levels. LVN 1 stated, generally the MD would be notified if blood sugar was below 60 and above 400 mg/dL. LVN 1 stated prolong elevated blood glucose can cause medical complications such as blindness, wound injuries, and kidney failure. LVN 1 stated, it was important to monitor blood glucose and notify the MD to get proper treatments. During an interview on 12/9/22 9:49 a.m., with the Director of Nursing (DON), DON stated blood glucose level of 60 - 120 mg/dL was considered therapeutic. DON stated, nurses were resident advocates who were required to use clinical judgment to notify the MD when blood glucose levels were outside of normal parameters. During a professional reference review retrieved from http://diabetesjournals.org/care/article-pdf/45/Supplement_1/S83/637560/dc22s006.pdf titled, . 6. Glycemic Targets: Standards of Medical Care in Diabetes-2022, dated 12/10/22, the professional reference review indicated, . Goals for Type 1 and Type 2 Diabetes Target (value) 70 - 180 mg/dL (milligram per deciliter - unit of measurement) . Based on observation, interview and record review the facility failed to ensure residents were provided treatment and care in accordance with professional standards for three of eight sampled residents (Resident 78, Resident 83 and Resident 3) when: 1. Resident 78 had blood in his stool and the physician was not notified promptly. This failure resulted in a delay of treatment and physician evaluation which led to Resident 78 being sent to the hospital. 2. Resident 83 had an order for dressing changes to be done every shift was not followed. This placed Resident 83 at risk for wound infection. 3. Resident 3's blood glucose levels were not properly managed (above 200 mg/dL, milligrams per deciliter - unit of measurement) from 9/12/22 through 12/5/22. This failure had the potential harm to cause permanent damage to parts of the body such as the eyes, nerves, kidneys, and blood vessels with prolong elevated levels of blood glucose to Resident 3. Findings: 1. During an observation on 12/5/22, at 10:07 a.m., Resident 78 was lying in bed with head elevated approximately 30-40 degrees with all four bedrails up. Resident 78 had a tracheostomy (trach- a surgical opening in the neck into the windpipe to allow direct access to the breathing tube to provide an airway and to remove secretions from the lungs) and was coughing. Resident 78 wad a stomach tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, tube surgically place in abdomen directly to the stomach) and had a foley catheter (a thin flexible tube placed in the body to drain urine from the bladder) with a privacy bag on. During a review of Resident 78's Face Sheet (a document that provided resident information) dated 12/8/22, the Face Sheet indicated Resident 78 was admitted on [DATE] with an admitting diagnosis of Acute on chronic respiratory failure (airways to the lungs become narrow and damaged causing difficulty breathing) with hypoxemia (low concentration of oxygen in the blood). During a concurrent interview and record review on 12/8/22, at 9:01 a.m., with the Director of Staff Development (DSD), Resident 78 's Electronic Health Care Records (EHR) for 9/1/22 were reviewed. The DSD stated Resident 78's Nursing Note dated 9/1/22 at 3:51 a.m. indicated, Resident has bleeding from rectum. Bright red and moderate amount. Will notify [name of doctor] in the morning. Will continue to monitor patient. A review of Resident 78's nursing note dated 9/1/22, at 10:16 a.m., indicated, . Resident PT/INR [prothrombin time test measures the time it takes for a clot to form in a blood sample] results faxed to MD, also notified regarding the previous NOC [night shift] shift x1 [once] bright red and moderate amount. NNO [no new orders] at this time. Resident 78's Medication list was reviewed. The DSD stated Resident 78 was on (Warfarin brand name, blood thinner) 9 mg (milligram- unit of measurement) daily. A Review of Resident 78's Care plan titled, Problem: Possible internal bleeding secondary indicated a Date Start: 8/31/22 Expected End: 11/30/22 Priority: High Description: Interventions: 1. Monitor output for blood and report to MD [Medical doctor] promptly . DSD stated the doctor was not called promptly. DSD stated, they [nursing staff] should have notified him [the doctor] as soon as possible. During a concurrent interview and record review on 12/15/22, at 11:40 a.m., with the Registered Nurse (RN 9), Resident 78's Nursing note dated 9/1/22 at 3:51 a.m. was reviewed. RN 9 stated she entered the nurses note. RN 9 stated she did not indicate in her note that she contacted the doctor. During an interview on 12/9/22, at 3:30 p.m., with the Director of Nursing (DON), the DON stated he would have expected the Charge nurse (RN 9) that night to call the doctor when Resident 78 first had blood in his stool. The DO stated the Charge Nurse would have been given new orders for Resident 78. During a review of Resident 78's Nursing Note, dated 9/1/22, at 3:42 p.m., the note indicated, Assigned LVN noted resident with large amount of rectal bleeding, assessment done by RN and NS [doctors name] made aware with order to transfer to [name of hospital] ER (emergency room) for evaluation and management for rectal bleeding 15:40 called [name of ambulance company] ambulance 15:47 left message for RP [name and provided phone number] to call back 15:56 left for [name of hospital] ER, Picked up by 2 [name of ambulance company] ambulance paramedics via Gurney, resident alert and awake 16:15 received call back from RP . Review of a professional reference titled, [Brand name] (Warfarin Tablets, USP), undated, indicated (Warfarin brand name) is an Anticoagulant (blood thinner) WARNING: BLEEDING RISK Warfarin sodium can cause major or fatal bleeding . Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding . Retrieved from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/009218s108lbl.pdf 2. During an observation on 12/5/22, at 10:04 a.m. Resident 83 was seen sleeping in his bed with the four rails up. Posted on the outside of the door to his room was a Contact Precautions sign (a sign posted to indicated specific protected garments are needed to enter and take care of this resident). Resident 83 had a personal blanket over him, presented with a trach and tube feeding currently running. Review of Resident 83's Face Sheet dated 12/16/22, the Face Sheet indicated Resident 83 was admitted on [DATE] with a diagnosis of Acute on Chronic Respiratory Failure with hypoxemia. Review of Resident 83's flow sheet for dressing changes dated from 11/1/22 -11/9/22 indicated no dressing changes were done on 11/2/22 and 11/3/22 and on 11/5/22-11/8/22 dressing changes were done only once each day. During a concurrent interview and record review on 12/16/22, at 8:31 a.m., with the Quality Registered Nurse (QRN), Resident 83's Electronic Health Care Record (EHR) for admission date 10/6/22 was reviewed. The QRN stated Resident 83's wound order dated 10/27/22 indicated dressing changes should be every shift and when needed. The QRN stated physician order for Resident 83 was not followed. Review of Resident 83's flow sheet for dressing changes dated from 11/1/22 -11/9/22 indicated no dressing changes were done on 11/2/22 and 11/3/22 and on 11/5/22-11/8/22 dressing changes were done only once each day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 12/5/22, at 10:15 a.m., in Resident 80's Room, Resident 80 was in bed wearing a clean gown and had tube feeding (a tube inserted into the stomach to assist with nutrition). Resident 80 was non-verbal and not able to be interviewed. During a review of Resident 80's admission Record (documented containing resident information and medical diagnosis), dated 5/25/22, the admission Record indicated, Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included . SEPSIS SECONDARY TO URINARY TRACK INFECTION [potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues] . SEVERE MALNUTRITION [low body weight] .PRESSURE ULCER LEFT HEEL UNSTAGEABLE [a wound covered in a thick layer of tissue and yellow drainage] . During a review of Resident 80's Minimum Data Set (MDS, a resident assessment tool used to identify resident cognitive and physical function.) Assessment, dated 11/23/22, the MDS indicated Resident 80's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 0 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 80 had severe cognitive impairment. During a review of Resident 80's Minimum Data Set (MDS), dated [DATE], the MDS Section G (functional status) indicated, Resident 80 needed extensive assistance (requires staff help) with bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 80's Braden Scale Risk Skin Assessment (BSA- tool used to assess resident's skin and help identify risk to prevent pressure ulcers), dated 12/15/22, the BSA indicated, the score was a 9 (Total score: 15-18 Mild risk, 13-14 Moderate Risk, 10-12 High Risk, 9-0 Severe Risk). Indicating Resident 80 was at a severe risk for developing pressure sores. During review of Resident 80's Care Plan, dated 12/13/22, the Care Plan indicated . start: 12/2/22 Resident [80] has pressure injury, this injury is unstageable [Full thickness tissue loss, depth of ulcer obscured by dead tissue] to LEFT HEEL . start 10/11/22 Has abrasions bilateral buttocks (self-inflected scratches), left foot and left heal (MASD-Moisture associated skin damage) . Start 10/21/22 Has MASD to the Right Posterior Thigh . Start 10/28/22 RESIDENT HAS STAGE 2 PRESSURE INJURY (Partial thickness skin loss) TO THE SACRUM (RE-OPENED) . start 10/21/22 RESIDENT HAS STAGE 2 PRESSURE INJURY TO THE LEFT INNER FOOT . During a review of Resident's 80's Wound Care Orders (WCO), dated 12/7/22, the WCO indicated, . Cleanse wounds to left lateral foot with wound cleanser or normal saline, pat dry, apply triple antibiotic to open areas and secure with [Brand name bandage] daily, or as needed for soilage or dislodgement, until healed . 12/5/22 Wound Care: Once every other day: Cleanse Stage 2 pressure injury to left inner foot (near the right great toe) with wound cleanser or normal saline, pat dry and apply calcium alginate secure with 4x4 gauze . change dressing ever 2 days and as needed for dislodgement or soilage, until healed . 12/3/22 Wound Care: Once every other day: Cleanse Unstageable pressure injury to left heel with wound cleanser or normal saline, pat dry . change dressing every 2 days and as needed 11/23/22 Wound Care: Daily: Cleanse re-opened stage 2 to sacrum with soap and water, pat dry, apply [Brand name bandage] and cover with silicone border [Brand name bandage] daily and as needed for episode of incontinence . 11/9/22 Wound Care: 2 times per day: Cleans MASD to the Right Posterior Thigh with soap and water, pat dry and apply Nystatin [treats fungal infections] ointment BID, until healed . During a review of Resident 80's Flowsheet LDAs (FLDA- Flowsheet Line, Drain and Airway, a flowsheet that documents wound care treatments), dated 12/9/22-12/11/22, the FLDA for Wound to the Left Heel indicated no treatment was documented. During review of Resident 80's FLDA, dated 11/24/22-11/26/22, 12/3/22-12/4/22 and 12/9/22-12/10/22, the FLDA for Wound to Sacrum indicated, no wound treatment was provided. During a review of Resident 80's FLDA, dated 11/25/22-11/29/22 and 12/9/22-12/10/22, the FLDA for Wound to Right posterior Thigh indicated no wound treatment was provided. During a concurrent interview and record review, on 12/15/22, at 12:00 p.m., with Quality Registered Nurse (QRN), and RNS, Resident 80's FLDA dated 11/1/22-12/7/22 was reviewed. The FLDA indicated wound treatment was not provided to Resident 80 for several days. RNS stated, wound nurse should be providing and documenting all treatments (as ordered). During an interview on 12/6/22, at 10:30 a.m., with Director of Nursing (DON), DON stated the nurses were to follow the wound treatment orders and document care and notify MD if there are any changes to a resident's wounds. and treatments . During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Risk Assessment, Prevention, Identification and Treatment, dated 11/15/22, the P&P indicated, . Purpose: D. To implement wound management strategies to optimize the healing potential and prevent deterioration of existing pressure injuries . C. Staging/Treatment 1. Stage all pressure injuries according to amount of tissue loss . Implement appropriate plan/strategies to retain intact skin, prevention complications . h. Document findings in the EHR. i. Initiate a Lines, Drains and Airways (LDA) for documentation of wound assessment and treatments . Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) and necessary treatment and services to promote healing, and prevent new pressure ulcers from developing for 2 of 8 sampled residents (Residents 44 and Resident 80) when Resident 44 and Resident 80 was not provided wound care according to physician order as indicated (no documentation) in the residents' Electronic Health Record (EHR). This failure resulted delay wound healing Resident 44 and Resident 80. Findings: During an observation on 12/9/22, at 8:16 a.m., in Resident 44's room, Resident 44 had a stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) bilateral (both sides) ischial (lower part of the buttock) pressure ulcers. Resident 44 was immobile (unable to move) and had a tracheostomy (a hole in the front of the neck to assist with breathing). During a review of Resident 44's Problem List (PL), undated, the PL indicated, Resident 44 had Anemia (low iron), Bed confinement status (immobile), Chronic pneumonia (ongoing infection of the lungs), Chronic respiratory failure (ongoing breathing difficulty), Quadriplegia (paralysis of all four limbs), and Traumatic brain injury (brain dysfunction caused by a motor vehicle accident). During a review of Resident 44's Wound Assessments (WA), dated 11/7/22 - 12/9/22, the WA indicated, Resident 44's left ischial stage 4 pressure ulcer wound was 12.5 cm³ (cubic centimeter - unit of measurement) on 11/7/22 and 30 cm³ (size increased) on 12/9/22. During a review of Resident 44's Wound Care Order (WCO), dated 11/11/22, the WCO indicated, Cleanse Bilateral ischial pressure injuries with NS (normal saline) moistened gauze. Start at center . pat dry . apply no sting skin prep . Apply [synthetic antimicrobial wound matrix, dressing] into wound base then apply [special foam dressing] to wound bed . Seal foam with drape and cut a dime-size hole in drape and use Y [shaped like letter Y] connector to bridge as needed . Check all tubing clamps are open and apply low, continuous suction at 125 mm Hg [millimeters of Mercury - unit of measurement] . Change dressing 3 times a week every Monday (DAY [day shift]), Wednesday (NOC [night shift]), and Saturday (NOC [night shift]) . During a review of Resident 44's Flowsheet LDAs [Lines, Drains and Airways] (FLDA), dated 11/7/22 through 12/9/22, the FLDA indicated no treatment was provided on 11/16/22, 11/19/22, and 11/26/22. During a concurrent interview and record review on 12/9/22 9:11 a.m., with LVN 12, Resident 44's FLDA dated 11/7/22 through 12/9/22 was reviewed. LVN 12 stated, LVN 12 worked the night shift on 11/16/22 and 11/26/22. LVN 12 stated, she was assigned to provide care to Resident 44 on 11/16/22 and 11/26/22. The FLDA indicated no wound treatment was provided to Resident 44 on 11/16/22 and 11/26/22. LVN 12 stated, it was important to document to indicate care was provided. During a concurrent interview and record review on 12/9/22, at 11:55 a.m., with Licensed Vocational Nurse (LVN) 13, Resident 44's FLDA dated 11/7/22 through 12/9/22 was reviewed. LVN 13 stated, LVN 13 worked the night shift on 11/19/22. LVN 13 stated, LVN 13 was assigned to provide care to Resident 44 on 11/19/22. The FLDA indicated no wound treatment was provided to Resident 44 on 11/19/22. LVN 13 stated, if treatment was not documented then the treatment was not provided. LVN 13 stated, if staff did not provide wound care as ordered, wounds could get worse or cause infection. During an interview on 12/8/22, at 2:33 p.m. with the Director of Nursing (DON), DON stated, missed treatment was unacceptable. DON stated, it was important to follow physician ordered wound care treatment for the healing of the residents wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services met the needs of one of eight sample residents (Resident 80) when tramadol (controlled substance used to treat moderate to severe pain) prescribed by a physician was not available for administration to Resident 80. This failure placed Resident 80 at risk of experiencing pain without medication. Findings: During a review of Resident 80's admission Record (documented containing resident demographic information and medical diagnosis), dated 5/25/22, the admission record indicated Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included .SEPSIS SECONDARY TO URINARY TRACK INFECTION (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) . COMMUNICATING HYDROCEPHALUS (accumulation of fluid in the brain) . DEPRESSION (persistent sadness and lack of interest) . (SEVERE MALNUTRITION (low body weight) . PRESSURE ULCER LEFT HEEL UNSTAGEABLE (a wound covered in a thick layer of tissue and yellow drainage) . During an interview on 12/15/22, at 12:30 p.m., with Pharmacy Manager (PM), PM stated on 9/13/22 at 4:30 am the pharmacy received a refill request for tramadol for Resident 80. PM stated, a physician needed to authorize the medication refill request. PM stated, on 9/15/22 at 10:54 a.m., Medical Doctor 1 (MD1) authorized the prescription. PM stated, an electronic shipping manifest (shipping verification) was signed and received by the facility on 9/15/22 at 20:30 (8:30 p.m.). During a review of Resident 80's Minimum Data Set (MDS- a tool used to identify resident care needs) assessment, dated 11/23/22, the MDS indicated Resident 80's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 0 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 80 had a severe cognitive impairment. During a review of Resident 80's Physician orders, dated 12/11/22, the Physicians orders indicated, Tramadol [medication used to treat pain] Tablet 50 mg [milligram, a dosage measurement] per G tube [administered through tube inserted into the stomach], 2 times daily. During a concurrent interview and record review, on 12/8/22 at 9:30 a.m, with Quality Registered Nurse(QRN), Resident 80's Medical Administration Record, dated 9/1/22 to 9/30/22 was reviewed. The Medical Administration Record indicated, Resident 80 was administered Tramadol 50 mg on 9/14/22 at 9:28 p.m. and the next does was administered on 9/15/22 at 9:38 p.m. QRN stated, Resident 80's scheduled 9/15/22 a.m dose was not administered due to tramadol not being available. QRN stated, the process for order refills is to complete a refill form and fax to pharmacy. During an interview on 12/8/22, at 10:00 a.m., with Director of Staff Development (DSD), DSD stated, the process for ordering refills was for a nurse to fax a pharmacy refill request before the medication runs out. DSD stated, then the pharmacy sends the refill. DSD stated, nurses are to call the physician if the medication was not on hand. During a review of Resident 80's Nurses Notes, dated 9/14/22 at 22:35 p.m., the Nurses notes indicated No Tramadol on hand. Pharmacy faxed. During an interview on 12/15/22, at 3:00 p.m., with Director of Nurses (DON), DON stated, if a resident ran out of pain medication was for nursing staff to call the physician and provide alternative pain medication as ordered. DON stated, nurses should have been aware of timely requesting needed pain medication refills. During a review of the facility's policy and procedure titled, Medications-Orders, Administration, Storage Documentation, dated 8/4/22, indicated, . Any orders for medications that are illegible, incomplete, and/or unclear will require clarification . Registered nurse (RN) or Licensed Vocational Nurse (LVN) will contact the ordering prescriber [physician] and clarify using the telephone/verbal order process (refer to Physician Orders policy) . If an illegible, incomplete, and/or unclear order is received in the Pharmacy, the Pharmacist will contact the facility and have the nurse obtain clarification of the order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications for two of four sampled residents (Resident 18 and Resident 42) when: 1. Resident 18's Quetiapine (an antipsychotic medication to reduce symptoms like hallucinations (see, hear smell taste or feel, thing that appear real but only exist in the mind), delusions (a belief that is clearly false and indicates an abnormality in thought), and disordered thinking, and other mental health problems) starting dose and indication was inappropriate; no resident-centered non-pharmacological interventions were attempted prior to and during use of Quetiapine, and inadequate side effect and behavior monitoring. These failures resulted in unnecessary medication use for Resident 18 and had the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that include but not limited to drowsiness, high cholesterol, high blood sugar (increasing risk for diabetes), liver dysfunction, weight gain, constipation, heartburn, dry mouth, akathisia (a state of agitation, distress, and restlessness) and weakness. 2. Resident 42's Quetiapine indication and dosage was inappropriate, inadequate side effect monitoring, no resident-centered non-pharmacological interventions were attempted prior to and during use of Quetiapine, inadequate side effect and behavior monitoring, and no physician-documented resident clinical justification rationale for not conducting the required (Gradual Dose Reduction (GDR- tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the Consultant Pharmacist (CP). These failures resulted in Resident 42 experiencing weight gain and increased A1C level (a blood test for diabetes or prediabetes that shows what your average blood sugar level was over the past two to three months), both are side effects of Quetiapine. Findings: 1. During a review of Resident 18's Minimum Data Set (MDS, an assessment and screening tool for long term care residents) dated 6/29/22, the MDS indicated, Resident 18 was a [AGE] year old female who was admitted on [DATE] to the facility with diagnoses which included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements) and unspecified dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without psychiatric or mood disorder or potential indicators of psychosis (when people lose some contact with reality). The MDS indicated, Resident 18 was severely impaired in the ability to make decisions regarding tasks of daily life. During a review of Resident 18's Medication Orders (MO), the MO indicated Resident 18 had an order for quetiapine 12.5 mg (milligrams, a unit of measure) via G-Tube (gastrostomy tube, a tube inserted through the belly, directly to the stomach with which to feed individuals who cannot eat by mouth) daily, initiated on 9/18/22. The MO indicated, Admin [administration] Instructions: agitation, pulling life sustaining tube, scratching skin raw . Indications of use: bipolar disorder [a psychotic mental health condition that causes extreme mood swings] in remission [decreased intensity of a disease] . The MO indicated Resident 18 was prescribed quetiapine 12.5 mg through 12/8/22. During a review of Resident 18's Hospital Discharge Summary (HDS), dated 6/23/22, the HDS indicated, Resident 18's diagnoses did not include bipolar disorder and there was no hospital medication orders for quetiapine. During a concurrent interview and record review on 12/7/22, at 2:03 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 18's electronic medical record (EMR) was reviewed. RNS 1 stated, the EMR indicated the diagnosis of bipolar disorder was added on 9/22/22. RNS 1 stated, Resident 18 went to the hospital on 7/29/22 and was discharge back to the facility on 8/1/22. RNS 1 reviewed HDS, dated 8/1/22. RNS 1 stated, the HDS indicated, no antipsychotics were prescribed. During a concurrent interview and record review on 12/7/22, at 2:10 p.m., with RNS 1, RNS 1 reviewed Resident 18's History & Physical (H&P), dated 8/17/22, at 5:12 p.m., RN 1 stated the H&P indicated Resident 18 had no diagnosis of psychosis or bipolar disorder. During a concurrent interview and record review on 12/7/22, at 2:11 p.m., RNS 1 reviewed Physician's Progress Note (PPN), dated 9/21/22. RNS 1 stated, the PPN indicated no diagnosis of bipolar disorder. RNS 1 stated, the PPN indicated no documentation of quetiapine being prescribed. During a concurrent interview and record review on 12/7/22, at 2:14 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 8/21/22, at 6:45 a.m. RNS 1 stated the NN indicated, @ [at] 2330 [11:30 p.m.] assessment noted G Tube was dislodged Resident was holding in Right hand Replaced with G tube size # 16 . MD [medical doctor] 1 informed . During a concurrent interview and record review on 12/7/22, at 2:13 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 9/2/22, at 12:34 a.m. RNS 1 stated, the NN indicated, . Noticed resident itching and scratching self. [MD 1] was informed and ordered [hydroxyzine, a medication to treat itching] 25 mg TID [three times a day] as needed for 14 days. Order carried out . During a concurrent interview and record review on 12/7/22, at 2:15 p.m., RNS 1 reviewed Resident 18's Medication Administration Record (MAR), dated 8/1/22 to 10/5/22. RNS 1 stated, the MAR indicated, an original order for hydroxyzine 25 mg BID (twice a day) as needed for 7 day was initiated on 8/21/22. RNS 1 stated, the MAR indicated from 9/2/22 to 10/4/22 the order was changed to 25 mg TID as needed for scratching and given once a day on 9/15, 9/16, 9/19, 9/21, 9/22. 9/27, 9/28, 10/1, and 10/4. RNS 1 stated the MAR indicated order was changed to routine (around the clock) three times a day on 10/5/22. During a concurrent interview and record review on 12/7/22, at 2:17 p.m., RNS 1 reviewed Resident 18's NN, dated 9/18/22, at 1:42 p.m. the RNS 1 stated, the NN indicated, . Resident disconnected her trach from the ventilator at least twice during shift and began to desaturate [decreased saturation of oxygen in the blood] down to 91% prior to reconnecting ventilator. After being reconnected resident returned to 98% oxygen saturation. Resident also repeatedly scratching herself during shift. [MD 1] notified, new order received to start [quetiapine] 12.5 mg via PEG [G-Tube] daily . During a review of Resident 18's Behavioral Monitoring Flowsheet (BMF) dated 6/1/22 to 12/7/22, the BMF indicated, Resident 18 exhibited no behaviors of scratching self, pulling on tubes, or agitation in the month of 6/2022 or 7/2022. The BMF indicated, one episode of scratching in 8/2022; one episode of scratching and 6 other episodes without comments and indicating mood as calm in 9/2022; one episode of scratching and 2 other episodes without comments and indicating mood as calm in 10/2022; 4 episodes of scratching and 2 other episodes without comments and indicating mood as calm in 11/2022; and no episodes of behaviors of scratching, pulling tubes or agitation in 12/2022. During a review of Resident 18's Side Effect Monitoring Flowsheet (SEMF), dated 9/19/22 to 10/31/22, the SEMF indicated, the planned alternatives to psychotropic medications documented was noise reduction. During a concurrent interview and record review on 12/7/22, at 4:24 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 18's EMR. The DSD stated, the EMR indicated there were no non-pharmacological interventions scratching, pulling at tubes, or agitation prior to starting Resident 18 on quetiapine. During a concurrent interview and record review on 12/9/22, at 2:09 p.m., with the DSD, The DSD reviewed Resident 18' s' Care Plan (CP). The DSD stated the CP indicated, . Problem: Resident with psychotic disorder . The DSD stated, the first intervention is to administer medications as ordered. The DSD stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD . suicidal ideation, self harming threats . The DSD stated the CP had no non-pharmacological plan for monitoring scratching, pulling tubes, or agitation for a resident with a psychotic disorder. The DSD stated the CP was not specific to the resident. During a concurrent interview and record review on 12/9/22, at 2:15, the DSD and Licensed Vocational Nurse (LVN) 1, reviewed Resident 18's EMR. The DSD stated, the EMR indicated bipolar disorder was added to Resident 18' s' problem list on 9/22/22. The DSD stated Resident 18 did not have a history of delusions. LVN 1 stated she was unaware of Resident 18 had any disorganized speech or hallucinations because the resident was non-verbal. LVN 1 stated Resident 18 did not know what goes on around her. During an interview on 12/9/22, at 4:23 p.m., with the Director of Sub Acute Operations (DSAO), the DSAO stated there was no documentation in the corporation's record for Resident 18's diagnosis of bipolar disorder. During a review of Resident 18's MDS, dated 9/27/22, The MDS indicated, under potential indicators of psychosis the box was checked for none of the above. The MDS indicate, no physical verbal or other behaviors symptoms were exhibited. During an interview on 12/15/22, at 10:48 a.m., with Consultant Pharmacist (CP) 1, CP 1 stated, when Resident 18 came into the facility in June, the resident was not on quetiapine. CP 1 stated, she asked the facility where the diagnosis of bipolar came from because she had not seen it before being placed on quetiapine. CP 1 stated, the facility stated Resident 18 had a history of bipolar, they were adamant about the history. CP 1 stated, the facility told her the resident kept pulling tubes . CP 1 stated, I asked about using mittens. CP 1 stated the facility told her they tried mittens, but it didn't work. CP 1 stated, pulling of tubes was not an approved use for quetiapine. CP 1 stated, pulling at tubes was not a sign of bipolar disorder. CP 1 stated, if the resident had not exhibited behaviors, the MD should have tapered the dose down. CP 1 stated, the facility started monitoring behaviors last month. CP 1 stated, If someone had a trach and could not speak or communicate you cannot diagnose them as bipolar . Resident 18 cannot communicate . so it is even harder to tell if the resident was having side effects of the medication or if it is working or not . During an interview on 12/15/22, at 11:20 a.m., with Resident 18's daughter (Family Member, FM 2), FM 2 stated, Resident 18 had never been diagnosed with bipolar disorder but was made aware of her mother (Resident 18) being place on a medication to help stop her itching and pulling. During an interview on 12/16/22, at 7:43 a.m., with Resident 18's son (Family Member, FM 1), FM 1, stated, the facility did contact him when his mother was started on quetiapine but did not mention anything about her being bipolar. FM 1 stated, Resident 18 was not bipolar but had a history of Parkinson's and some dementia. During a concurrent interview and record review on 12/16/22, at 2:01 p.m., with the Director of Nursing (DON), the DON reviewed Resident 18's EMR. The DON stated the EMR indicated, Resident 18 was on quetiapine 12.5 mg daily, starting on 9/18/22. DON stated the indication for medication use was pulling on life sustaining tubes and scratching. The DON stated he had never heard the term bipolar in remission. The DON stated, signs and symptoms of bipolar disorder would be hallucinations and delusions. The DON stated he did not know how the resident could be diagnosed with bipolar when Resident 18 could not communicate. The DON stated there was no hallucination or delusions noted on Resident 18's MDS, dated 9/27/22. The DON stated Resident 18' s' CP for psychotic disorder was not specific to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Use, dated 7/19/22, indicated, . For all residents receiving antipsychotic or other psychotropic medication the nurse ensures . specific condition or diagnosis being treated, and the behaviors manifested are identified in the physician's order and physician's notes . Behaviors associated with use of the mediation are identified in the care plan . In each scheduled Interdisciplinary Team (IDT) meeting residents use of these type of medications will be evaluated for efficacy in controlling [sic]behavior, the advisability of attempting a gradual dose reduction (GDR) and any adverse drug reactions . Procedure . All residents are assessed upon admission and as needed during their stay for physical or behavioral triggers which may necessitate the use of medication to control resident's behavior . Alternate methods are attempted and documented in the resident's plan of care prior to the implementation of new psychoactive mediation treatment . During a review of the Manufacturer's Package Insert for Quetiapine (MPI), dated 1/1/22, the MPI indicated, . Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect size in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic adverse reactions . hyperglycemia [high blood sugar] . weight gain . changes in cholesterol . drowsiness . heartburn . constipation .dry mouth . 2. During a review of Resident 42's Face Sheet (FS, a document containing resident's personal information), dated 1/31/22, the FS indicated, Resident 42 was a [AGE] year-old male. During a review of Resident 42's History & Physical (H&P), dated 12/17/19, the H&P indicated, diagnoses which included subdural hematoma (when a blood vessel in the space between the skull and the brain is damaged, blood leaks and forms a clot that places pressure on the brain and damages the brain), prostate mass (non-cancerous nodule), hypertension (HTN, high blood pressure), cardiac arrhythmia( irregular heart beat), and a past history of arthritis (inflammation or swelling in one or more joints). The H&P indicated, no history or diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally). During a review of Resident 42's MDS, dated 12/23/19, the MDS indicated, under potential indicators for psychosis,the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, the active diagnosis box for schizophrenia was not checked. During a review of Resident 42's Medication Orders, dated 1/30/20 to 1/31/22, the MO indicated, MD 1 prescribed quetiapine 50 mg two times daily from 1/30/20 to 2/15/20 and the indication for use was schizophrenia, manifested by episodes of delusions. The MO indicated, MD 2 altered the quetiapine order to 100 mg three times daily on 2/16/20 (three times the previous daily dose). The MO indicated, MD 1 altered the prescription to 200 mg 2 times a day with the indication for use as schizophrenia, manifested by episodes of delusions manifested by wanting to leave facility to drive his truck or wanting to get to his job. During a review of Resident 42's Nursing Progress Notes (NPN), dated 12/22/19, the NPN indicated, . Pt [patient] is alert and responsive, verbal, able to make needs know [sic], forgets limitations, tolerates meds [medications] well . During a review of Resident 42's Nursing Progress Notes, dated 1/23/20, at 6:17 a.m., the NPN indicated, . At approximately 04:45 [4:45 a.m.] patient tried to elope, when he was scheduled for shower, still dressed exited at the door by PT [physical therapy] room, Staff nurse and CNA were with the patient trying to stop from leaving, resident didn't listen, called security and police dept [department] to Incident, [sic] contacted supervisor by staff nurse, notified RP [responsible party] via phone . Patient was trying to enter property . while being accompanied by staff, security arrived and take [sic] the resident back to the facility. Patient is safe and went back to bed, remained in bed . During a review of Resident 42's Nursing Progress Notes, dated 1/29/20, at 6:16 p.m., the NPN indicated, . Resident called 911 to ask for information on a friend who lives in [city]. He is pacing up and down the hallways and opening the emergency exits. Resident wants to leave to go drive trucks in [nearby state]. RP to be contacted and MD to be informed . During a review of Resident 42's Nursing Progress Notes, dated 1/29/20, at 7:17 p.m., the NPN indicated, . Resident called [nearby behavioral facility] 18 times. Resident was asked not to use the lobby phone anymore and to ask staff to dial for him from now on. Resident's sister (RP) was contacted and informed of behaviors of the resident. She asked if we could get him some medications to calm him down. MD contacted. Awaiting response . During a review of Resident 42's Nursing Progress Notes, dated 1/29/20, at 7:34 p.m., the NPN indicated, . MD responded with new orders. Give 1 mg [lorazepam, a medication to treat anxiety] STAT [immediately] and start him on [quetiapine] 500mg BID [twice daily] . During a review of Resident 42's Nursing Progress Notes, dated 1/29/20, at 11:52 p.m., the NPN indicated, After first administration of [lorazepam] 1 mg IM [intramuscularly, a method of injecting medication into the muscle] Resident continued to attempt to run away. He ran out the front door and was brought back by staff he then went out the Emergency exit. Security responded and spoke with resident . He was still obsessing about leaving and wouldn't calm down. [MD 2] contacted and gave orders for additional 1mg [lorazepam] IM STAT. He also gave orders for [lorazepam] 1mg by mouth BID along with the [quetiapine] 500mg BID. [MD 2] stated we need to contact him every few days to increase [quetiapine] until it reaches 900 mg. He also said we need to think about other types of psychotropics that work better for TBI patients . During a review of Resident 42's Nursing Progress Notes, dated 1/30/21, at 6:38 a.m., the NPN indicated, . Pt. Slept [sic] good during the shift, no attempt to go outside the facility,randomly [sic] check patient, he get up to go bathroom twice and be able to go [sic]back to bed to sleep with no problem . During a review of Resident 42's Nursing Progress Notes, dated 1/30/20, at 3:29 p.m., the NPN indicated, . Patient was seen walking out of building passing by at The [sic] activity area by the time we were out [sic] patient was already across the street. Patient ask why he [sic] went outside stated just wanted to go for a walk. Educate patient the danger [sic] of getting lost . During a review of Resident 42's Nursing Progress Notes, dated 1/31/20, at 6:34 p.m., the NPN indicated, . [nearby behavioral facility] was calling [facility] regarding a pt named [Resident 42's first name] that is calling their office. Apparently [sic] it has happened several times today. Notified pt of concern, he is unaware of his actions. Called his friend [initials] with him [sic] and he seemed to dial the correct number. Will continue to monitor . During a review of Resident's Nursing Progress Notes, dated 2/2/20, at 2:15 p.m., the NPN indicated, . Patient monitor for this shift patient in his room most of the time was on his phone ate in his room no attempt of going outside facility at this time he is in the activity likely to watch football [sic]. Supervisor made aware of night nurse endorsing about medication per supervisor [sic] will TX [text?] MD . During a review of Resident's Nursing Progress Notes, dated 2/2/20, at 4:07 p.m., the NPN indicated, . Spoke with [MD 2] patient remained calm and cooperative, no signs of wandering at this time. Patient behaviors are currently controlled with current dose of [quetiapine] and [lorazepam]. Will continue to monitor . During a review of Resident's Nursing Progress Notes, dated 2/2/20, at 9:33 p.m., the NPN indicated, . MD faxed back order to change diagnosis of [quetiapine] to schizophrenia M/B [manifested by] episodes of delusions . During a review of Resident's Nursing Progress Notes, dated 2/14/20, at 10:34 p.m., the NPN indicated, . Patient eloped from facility at approximately 2145 [9:45 p.m.] this shift. Security, [city] PD [police department], RP and pt friend [name], MD, APS [adult protective services] and facility supervisor all made aware of patient elopement. Patient last seen asking a staff member if they could take him to [another town]. {city} PD said they would have officers out canvassing area . During a review of Resident's Nursing Progress Notes, dated 2/15/20, at 1:41 a.m , the NPN indicated, . PD came back to facility and stated they still have not found patient out on the street . PD said . they will hand case to . PD missing persons . During a review of Resident's Nursing Progress Notes, dated 2/16/20, at 10:42 p.m., the NPN indicated, . Patient seen pacing around facility and trying to exit the building through all doors. He is telling female staff they're 'his girl and they need to outside to his truck with him.' Multiple staff tried redirecting pt with TV, snacks offered, and that dinner would be in bedroom shortly but continued to say he needs change so he can find a ride to get to his job. Pt was reminded that he does not have work right now and that he lives here at the facility. Patient stated, 'No I don't, I need to get to my truck right now.' .RP called . he doesn't want to talk . call her tomorrow . [MD 2] notified . New MD orders to increase [quetiapine] 100 mg TID, reinstate [lorazepam] 1mg by mouth BID, and to give [lorazepam] 1mg IM x1 [once] stat . All orders carried out . During a review of Resident 42's MDS, dated 3/20/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 6/18/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 9/16/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, verbal behavior directed toward other occurred 1 to 3 days. The MDS indicated, no physical or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated 12/24/20, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, wandering behavior question was unanswered. During a review of Resident 42's MDS, dated 10/6/22, the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a concurrent interview and record review on 12/8/22, at 10:47 a.m., with the DON, the DON reviewed the EMR for Resident 42. The DON stated he could not find any documentation of behavior monitoring prior to the administration of quetiapine, because there were no behaviors except for the elopement. During a concurrent interview and record review on 12/8/22, at 10:49 a.m., with the DON, the DON reviewed Resident 42's Physician Progress Notes (PPN), dated 2/28/20 to 12/21/20. The DON stated, the PPN did contain any documentation of a schizophrenia diagnosis or schizophrenia symptoms. During a review of Resident 42's Weights, dated 12/19/19 to 12/1/22, the Weights indicated, .12/19/19 . 216 pounds [lbs., a unit of measure] . 1/19/20 . 205.3 lbs. 2/8/20 . 210.3 lbs. [no weights between 2/8/20 and 6/13/20] . 6/13/20 . 226.4 lbs. 7/31/20 . 267.7 lbs. [+41.3 lbs. {18.2%} in one month] . 12/12/20 . 272.2 lbs. [+56.2 lbs. {26%} in one year] . 3/13/21 . 280.9 lbs. 6/18/21 . 284.8 lbs. 9/9/21 . 290 lbs. 11/02/22 . 296.3 lbs. During an interview on 12/9/22, at 10:40 p.m., with the RDFSD, the RDFSD reviewed Resident 42's EMR. The RDFSD stated, Resident 42 's diagnoses on admission included, arthritis, hypertension, hyperlipemia. The RDFSD stated, continued weight gain could worsen these diagnoses. The RDFSD stated, Resident 42 had been on a regular diet since 3/17/20. During a review of Resident 42's Hemoglobin A1C (HbA1c or A1C lab results, dated 3/6/20 to 10/12/22, The HbA1c indicated, . Ref [reference] Range & Units 4.8 - 5.6% . 3/6/20 . 5.4 . 3/5/21 . 5.7 . 6/18/21 . 6.0 . 12/16/21 . 6.1 . 2/2/22 . 6.3 . 10/12/22 .6.4 . During a review of Resident 42's Hemoglobin A1C results (A1C), dated 10/12/22, at 1:09 p.m., the A1C indicated, a result of 6.4 is circled and signed by [MD 1]. During a review of Resident 42's Nursing Progress Notes, dated 10/12/22, at 10:17 p.m., the NPN indicated, . MD faxed back regarding patient's lab results: CBC [complete blood cell count], CMP [complete metabolic panel, electrolytes and minerals], Lipid [fats in the blood] Panel, Vitamin D, and HA1C [A1C]. No new orders at this time . During a concurrent interview and record review on 12/14/22, at 2:16 p.m., with LVN 8, LVN 8 reviewed Resident 42's EMR. LVN 8 stated, she could not locate any non-pharmacological (non-medication) interventions attempted prior to starting quetiapine and no targeted behavior to monitor on the flowsheet. LVN 8 stated, the EMR indicated, non-pharmacological interventions for behaviors documented in the flowsheet on 2/23/22. LVN 8 stated the expectation was to document on planned alternate to psychotropics every shift. LVN 8 stated the planned interventions do not show up in the EMR until the quetiapine was ordered. During a concurrent interview and record review on 12/14/22, at 2:17 p.m., with LVN 8, LVN 8 reviewed the Psychotropic Medication Behavior Flowsheet (PMBF), dated 11/1/22 to 12/13/22. LVN 8 stated, the PMBF indicated, no target behaviors were observed During a concurrent interview and record review on 12/14/22, at 2:18 p.m., with LVN 8, LVN 8 reviewed Resident 42's CP. LVN 8 stated, there was a care plan for quetiapine for history of wanting to leave the facility. LVN 8 stated, the CP indicated, the first intervention was to administer medications as ordered. LVN 8 stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD . suicidal ideation, self harming threats . LVN 8 stated, a lot of the interventions were general, not specific to resident. LVN 8 stated, it was important to have resident-centered non-pharmacological interventions so staff could provide better care to the resident. During a concurrent interview and record review on 12/14/22, at 2:20 p.m., with LVN 8, LVN 8 stated she could not find a psychiatric consult nor an order for a psychiatric consult in Resident 42's medial record. During a review of Resident 42's Behaviors and Moods (BM), dated 11/8/22 to 12/8/222, The BM indicated, all entries for physical behaviors observed were 'appropriate; all entries for verbal behaviors observed were appropriate; and all entries for emotion moods or behavior observed were calm or cooperative, or both, except one entry on 11/18/22 at 10:30 a.m., which indicated, calm; cooperative; anxious. During an interview on 12/15/22, at 10:10 a.m., with CP 1, CP 1 stated, she remembered Resident 42 because he had eloped and that was how he was started on quetiapine. CP 1 stated, she did not know if the facility documented behaviors prior to starting quetiapine. CP 1 stated, I review once a month and he [Resident 42] was already on quetiapine when I reviewed his record. CP 1 stated, the facility switched to electronic documentation system in 2019, and it was not made for long term care. CP 1 stated the facility got access to document behaviors in November of 2022. CP 1 stated, if the facility could not document behaviors, there would be nothing for the physician to assess for dose reduction. CP 1 stated non-pharmacological interventions were important and needed to be patient-specific because drugs were not the first line of treatment. CP 1 stated if a patient was schizophrenic, they need to see a psychiatrist. During an interview on 12/15/22, at 10:20 a.m., with CP 1 and DON, CP 1 stated, Resident 42 gained weight after starting quetiapine. CP 1 stated, I think quetiapine might have cause the gain (weight). CP 1 stated, weight and A1C we[TRUNCATED]

2. During an observation on 12/7/22, at 12:15 p.m., in the facility's kitchen, Resident 71's lunch tray was served by Dietary Aid (DA) 1 and 2. Steamed broccoli was served on a plate with a cheese-burger and mashed potatoes. During a review of Resident 71's Meal Ticket (MT), on 12/7/22, the MT indicated, Steamed Broccoli on side in bowl. During an interview on 12/8/22, at 11:54 a.m., with Resident 71, Resident 71 stated, I was served lasagna (an Italian pasta dish) last week and got itchy. I have a tomato allergy. There's a cook that puts raw tomatoes on everything . The doctor ordered [diphenhydramine brand name] for the itching. I took [diphenhydramine brand name] for three days. During a review of Resident 71's Meal Ticket, the MT indicated, Allergy: Tomato. During a review of Resident 71's Medication Order (MO), dated 12/2/22, the MO indicated [diphenhydramine brand name] 25 mg (milligrams - unit of measurement) every 6 hours as needed for itching. During a review of the facility's menu, dated 12/2/22, beef lasagna was on the menu. During a review of Resident's 71's Diet List (DL), dated 12/7/22, the DL indicated, Resident 71 was on a regular diet with allergy to tomato. During a concurrent interview and record review on 12/7/22, at 12:15 p.m., with the Food Service Director (FSD), Dietary Aid 1 and 2, Resident 71's MT and lunch plate was reviewed. DA 1 and 2 stated, the steamed broccoli should have been served in a bowl and not on the plate as indicated on Resident 71's MT. FSD stated, it was important to assemble food correctly to honor resident's preference. 3. During an interview on 12/8/22, at 8:48 a.m., with Resident 96, Resident 96 stated, I'm on a chopped diet but the facility puree (blended until smooth consistency) my food all the time. I am unable to cut meat due to weakness after contracting Covid (COVID-19, disease cause by the Coronavirus). The facility served me honeydew the last week of November and I'm allergic to honeydew, just touching the juice cause hives (a type of rash on the skin). During a review of Resident 96's Meal Ticket (MT), the MT indicated, Chopped per pref [preference] . Allergy: Honeydew. During a review of the facility's menu, dated 11/28/22, honeydew was on the menu. During a review of Resident's 96's Diet List (DL), dated 12/7/22, the DL indicated, Resident 96 was on a regular diet, chopped, with allergy to honeydew. During a review of the facility's rights notification titled, Resident admission Agreement. Resident Rights Under State Law, undated, the notification indicated, . c. The facility shall provide food of the quality and quantity to meet the Patient's needs in accordance with physician's orders . 33. The Resident has a right to reasonable accommodation of individual needs and preferences except where the health or safety of the Resident or other Residents would be endangered . Based on observation, interview and record review the facility failed to accommodate resident meal preferences, correct food consistency and allergies for three of ten residents (Resident 2, Resident 71, and Resident 96) when: 1. Resident 2 requested eggs over easy on several days and was not given the right food consistency and eggs not cooked to her preference an was served a pureed cantaloupe during lunch on 12/5/22. These failures had the potential to result in Resident 2's lack of pleasure in eating which could result in unplanned weight loss. 2. Resident 71's steamed broccoli was not served in a bowl as was her preference and had tomato allergy and was served beef lasagna. This failure resulted in an allergic reaction to Resident 71 causing her to be medicated. 3. Resident 96 was allergic to honeydew and was given honey dew with her meal. This failure placed Resident 96 at risk for an allergic reaction due to honeydew (a type of melon) being served with her food Findings: 1. During a concurrent observation and interview on 12/5/22, at 12:12 p.m., with Resident 2 in the dining room. Resident 2 was sitting in one of the round tables waiting for her lunch tray. Resident 2 stated her diet was a regular diet. Resident 2's food tray and had a orange colored pureed food in a clear container. Resident 2 stated it was a pureed cantaloupe. Resident 2 stated, the kitchen (staff) messed up her food almost every day. During an interview on 12/9/22, at 8:59 a.m., in Resident 2's room, Resident 2 stated, the kitchen sent out weekly menu selections and residents circled the food they wanted for the week which included a special request. Resident 2 stated her request was for eggs to be cooked over easy but she was always given eggs that was cooked hard (well done). Resident 2 stated she talked to the dietary staff about it but was always given the same hard eggs. Resident 2 stated she stopped ordering eggs completely because it was not cooked the way she wanted. During a review of Resident 2's Minimum Data Set (MDS-a standardized comprehensive assessment and care planning tool) assessment, Brief Interview for Mental Status (BIMS-assessment of mental status), dated 10/24/22, indicated, BIMS summary score of 15/15 which indicated Resident 2 was cognitively intact. During a review of Resident 2's clinical record titled, Diet Regular, undated, Resident 2's diet order of Regular was ordered on 4/27/22. Resident 2's food preferences included, . Eggs . During an interview on 12/9/22, at 10:37 a.m., with Nutrition Supervisor (NS) and [NAME] (CK), CK stated the dietary aide was responsible in checking the dietary slip to make sure residents were receiving the right consistency of food. The NS stated he was not made aware Resident 2 was served a pureed cantaloupe. The NS stated the dietary aide should have made sure residents received the right food consistency. The NS stated he was not made aware of Resident 2's problem with how she wanted her eggs cooked. During an interview on 12/9/22, at 11:19 a.m., with Dietary Aide (DA) 1, DA 1 stated he was responsible in putting the plates, fruits and drinks in the food trays for residents. DA 1 stated the diet slip contained resident's likes and dislikes. DA 1 stated he compared the diet slip with the foods he was putting in the food tray. DA 1 stated he checked the likes and dislikes and allergies when he placed the food in the tray and the supervisor double checked the food tray before the food cart was sent out on the floor. During a concurrent interview and record review on 12/8/22, at 11:25 a.m., with the Registered Dietitian/Food Service Director (RDFSD), the RDFSD stated the kitchen staff did the first and second check of the food trays to ensure residents were receiving the right food, right diet and right consistency. The RDFSD stated the Certified Nursing Assistants (CNAs) were responsible in doing the final check because they brought the food to the residents. The RDFSD stated the CNAs should have made sure residents received the right food consistency, right diet and notified the dietary staff if there were discrepancies. During an interview on 12/15/22, at 2:50 p.m., with the Director of Nursing (DON), the DON stated he was not aware Resident 2 was having issues how she wanted her eggs to be cooked. DON stated residents' food preferences had to be followed as much as possible to keep them happy. During a review of the facility's policy and procedure (P&P) titled, Nutrition/Dining Services, dated 11/18/22, the P&P indicated, . Diets, food allergies, food likes and dislikes, cultural and religious meal preferences, and special meal requests will be entered into an electronic Diet Spreadsheet. This information is used to personalized patients' meals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, & record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards and facility policy and procedure when: 1. Two boxes of over-the-counter bisacodyl (medication used for constipation) was expired in North 1 medication room and was not segregated from medications currently used by nursing staff. 2. Resident 82's punctured vial of Lantus (insulin medication for diabetes) was opened and did not have a sticker with a resident identifier or an open date on the medication. 3. Resident 45's Fluticasone propion-salmeterol (fluticasone-propionate salmeterol, a combination of drugs used to treat difficulty breathing) was labeled with the wrong expiration date. 4. Resident 8's Hydroxyzine (medication for itching) medication blister card (card used to individually store tablets) did not have a change of direction sticker to reflect current usage directions. 5. Discontinued medications for Residents 56, Resident 67, Resident 66, Resident 94, Resident 100, Resident 34, Resident 29, and Resident 1's were not disposed and was in the medication cart along with active (currently used) medications. These failures demonstrated a system of storing and labeling medications in an unsafe manner and did not follow acceptable professional standards for storing medications, placing the residents at risk for receiving the wrong medications, which could cause medication adverse reactions (harmful, unintended result caused by a medication), and had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications. 6. A medication cart in the transitional care unit was left unlocked and unattended by Licensed Vocation Nurse (LVN) 5. This failure resulted in the availability of medications to unauthorized residents, staff and visitors. Findings: 1. During a concurrent observation and interview on 12/5/22, at 9:31 a.m., at the Station 1 North Medication Room, Register Nurse (RN) 5 opened the stock medication drawer. There were 2 boxes of bisacodyl (a laxative) suppositories (a method of putting a medication in the body) with expiration date of 9/30/22 written on the boxes. One box contained 12 suppositories and the other box, 8 suppositories. RN 5 stated, the suppositories should have been discarded because they were expired. RN 5 stated, if the suppository was used on a resident the medication probably not going to work because it was expired. During an interview on 12/15/22, at 11:04 a.m., with Consultant Pharmacist (CP) 1, CP 1 stated, a medication used beyond the use by date would not be effective anymore. During an interview on 12/16/22, at 1:20 p.m., with the DON, the DON stated if the expired bisacodyl suppositories were given to a resident, the medication would not be effectiveness to the resident. The DON stated night shift nurses were responsible for checking for expired medications. The DON stated the expired medications were not being properly managed and disposed. 2. During a review of Resident 82's Minimum Data Set (MDS, an assessment and screening of residents), dated 12/9/22, the MDS indicated, Resident 82 had diagnoses including diabetes (a chronic condition that causes too much sugar in the blood). During a review of Resident 82's Order Listing Report (Order), dated 9/7/22, the Order indicated, . insulin glargine [a long-acting hormone that assists in moving sugar from the blood to other tissues where energy is needed] . 40 Units . Subcutaneous [injected under the skin] nightly . During a concurrent observation and interview on 12/6/22, at 3:46 p.m., with LVN 1, at South station Medication Cart 1, an insulin glargine pen [a pre-loaded, reusable injector, holding many doses] was not labeled with the date it was opened. LVN 1 stated, verified the pen had already been opened and was not labeled with the opened or discard date. LVN 1 stated, the policy was to label the pen with the date it was taken out of the refrigerator. LVN 1 stated the medication was less effective after 28 days. LVN 1 stated she did not know if it had been opened for 28 days since the medication was not dated. During an interview on 12/15/22, at 11:10 a.m., with CP 1, CP 1 stated if a resident received expired insulin glargine, the resident could have fluctuation in blood sugar, as the medication would not be effective. During an interview on 12/16/22, at 1:15 p.m., with the DON, the DON stated it was important for the insulin pen to be properly labeled with the correct dose. If the resident received the wrong dose, the resident's diabetes would be poorly managed. 3. During a review of Resident 45's admission Record (AR-a one page summary of important information about a patient), dated 11/9/22, the AR indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that make it hard to breathe and get worst over time). During a review of Resident 45's Order Listing Report (Order), dated 10/21/22, the Order indicated, . fluticasone propion-salmeterol [fluticasone-propionate salmeterol, a combination of drugs used to treat difficulty breathing] . 1 puff .every 12 hours . During a concurrent observation and interview on 12/6/22, at 3:13 p.m., with LVN 3, at North Station, Medication cart 3 Odd, Resident 45's fluticasone-propionate salmeterol inhalation power container found on medication cart. Container's hand-written label indicated, opened on 11/8/22 and discard on 12/11/22. LVN 3 stated, it was important to use the proper expiration date (12/8/22) so the medication will be effective for the resident. During an interview on 12/16/22, at 1:17 p.m., with the DON, the DON stated the facility should have followed the manufacturer's guidelines when the fluticasone-propionate salmeterol container was labeled for discard. The DON stated, if medication was used past expiration date, the resident's condition would not be properly managed. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for [Fluticasone and Salmeterol], the manufacturer for [Fluticasone and Salmeterol] indicated, . After removing from box and foil pouch, write the pouch opened and use by dates on the label on top of the device. The use by date is 1 month from date of opening the pouch. Discard device 1 month after you remove it from the foil pouch or when the dose counter reads '0' (whichever comes first) . 4. During a review of Resident 8's Order Listing Report (Order), dated 11/7/22, the Order indicated, . Hydroxyzine . 50 mg tablet . 3 TIMES DAILY PRN [as needed] for itching . Indication for Use . pruritus [itchy skin] of skin . During a review of Resident 8's Medication Administration Record (MAR), dated 12/3/22, the MAR indicated hydroxyzine had currently been administered to Resident 8. During a concurrent observation and interview on 12/06/22, at 4:30 p.m., with RN 5, at the South Station medication cart 5, medication card [a blister package of doses with prescription instructions] label indicated, hydroxyzine 50 mg tablet three times a day as needed for 14 days for itching medication was issued on 11/6/22. RN 5 stated the order was still active and had been made routine (around the clock) three times a day. RN 5 stated, pharmacy did not send a new medication card if the medication was still available for the resident. RN 5 stated, Usually we put a change of direction (administration directions) sticker on the medication card to prevent mistakes. RN 5 stated there was no change of direction sticker on the medication card. During an interview on 12/15/22, at 11:05 a.m., with CP 1, CP 1 stated, if directions for medication change and still have medication card, nursing should have placed a change of direction sticker on the blister card, if they don't a nurse could commit a medication error (mistake) by giving the wrong dosage or frequency. 5. During a concurrent observation and interview on 12/6/22, at 2:59 p.m., with LVN 2, on South Station at medication cart 3, found Resident 56's medication (med) card for ondansetron (a medication given for nausea) 4 mg 1 tablet by mouth three times a day for 14 days, issued on 7/2/22. LVN 2 stated, she was unable to locate current order in the MAR. LVN 2 stated, it was important to remove from discontinued medications from the med card so it would not be given accidentally. During a concurrent observation and interview on 12/6/22, at 3:13 p.m., with LVN 3, at North Station, med cart 3 odd, found Resident 67's med cards with 22 tablets for ondansetron 1 tablet by mouth three times daily for 10 days before meals, issued on 10/19/22. Found Resident 20's med card with 11 tablets for ondansetron 4 mg tablet by mouth three times daily as needed for up to 7 days for nausea, issued on 11/7/22. LVN 3 stated both orders were discontinued for the 2 residents. LVN 3 stated it was important to remove discontinued meds. LVN 3 stated, Because if we gave the meds when the resident does not have symptoms, the residents could have side effects of medication. During a concurrent observation and interview on 12/6/22, at 3:30 p.m., with LVN 4, on North Station at med cart 4 odd, found Resident 66's med card with ondansetron prescribed 4 mg tablet, give one tablet every eight hours as needed for up to 7 days for nausea/vomiting, issued 8/26/22. LVN 4 stated she did not see an active order in the MAR and the medication was discontinued and should have been put in the medication room for destruction. During a concurrent observation and interview on 12/6/22, at 3:46 p.m., with LVN 1, on South Station at med cart 1, found Resident 94's med card with 27 tablets of lorazepam (a controlled medication that can be easily abused and under strict government control, used for treating seizures) 0.5 mg, prescribed 0.5 tablet (0.25 mg) via G-Tube every 12 hours as needed for anxiety for 14 days, issued on 10/29/22. During a concurrent observation and interview on 12/6/22, at 3:56 p.m., with LVN 1, on South Station at med cart 1, found Resident 100's med card with 30 metoclopramide (a drug given for nausea and vomiting) tablets prescribed for one tablet by mouth every six hours as needed for up to 14 days for nausea/vomiting, issued on 11/16/22. Found Resident 100's med card with 2 tablets of sulfamethoxazole (a medication to treat infections) prescribed one tablet via G-Tube twice daily for 7 days, issued 11/24/22. LVN 1 unable to locate an active order in MAR. During a concurrent observation and interview on 12/6/22, at 4:05 p.m., with LVN 1, on South Station at med cart 1, found Resident 34's med card with four dicyclomine 20 mg tablets, prescribed one tablet by mouth three times a day as needed for 14 days for irritable bowel syndrome, issued 5/22/22. LVN 1 unable to locate an active order in the MAR. During a concurrent observation and interview on 12/6/22, at 4:10 p.m., with LVN 1, on South Station at med cart 1, found Resident 29's med card with 10 tablets of ondansetron 4 mg, prescribed one tablet via G-Tube every eight hours as needed for vomiting for up to 14 days, issued on 8/12/22. LVN 1 unable to locate an active order in the MAR. During a concurrent observation and interview on 12/6/22, at 4:21 p.m., with RN 5, on South Station at med cart 5, found Resident 1's med card with four - half tabs of quetiapine fumarate (medication used to treat mental mood disorders) 25 mg tabs, prescribed ½ tab twice a day via G-Tube for 27 doses, issued 9/27/22. Found Resident 1's med card with 11 tablets of ondansetron 4 mg tablets, prescribed one tablet viz G-Tube every 6 hours as needed for nausea/vomiting for up to 14 days, issued 5/31/22. RN 5 stated both medications were discontinued. During an interview on 12/7/22, at 10:59 a.m., with the DON, the DON stated Resident 94's lorazepam order from 10/29/22 was discontinued on 10/29/22. During an interview on 12/15/22, at 11:04 a.m., with CP 1, CP 1 stated, nursing needs to remove discontinued medications for the med carts so they don't make a mistake, if they accidentally give a discontinued medication to a resident, without an order it would be unnecessary and expose the resident to more side effects. During an interview on 12/16/22, at 1:25 p.m., with the DON, the DON stated discontinued medications should be separated from active medications, removed from the cart, and then destroyed, it is important to minimize errors and harmful to resident depending on the medication. During a review of the facility's policy and procedure (P&P) titled, Medications - Orders, Administration, Storage Documentation, dated 8/4/22, the P&P indicated, . Medications will be securely stored at all times and at the appropriate temperature . Nursing personnel shall remove any expired medication in a timely fashion from their med carts and place in the appropriate bin located in each nursing unit medication room. Discontinued medications will be held for 30 days, then destroyed . Controlled medications that are expired or discontinued shall be stored in the medication carts until they are collected by the Director of Nursing (DON) or DON designee for destruction . Obtain the medication from the medication room . refrigerator, as appropriate and verify the medication label matches the MAR or prescriber's [physician] order . Medications for discharged patients or those that are discontinued, will be removed immediately from the medication cart . Controlled substances for discharged residents or those that are discontinued, will be kept in the cart until the next day the DSD [Director of Staff Development] or designee is available to receive and catalog the medication for disposal . 6. During an observation on 12/7//22, at 2:57 p.m., in Transitional Care nursing station, there was an unlocked medication cart by the nursing station, unattended by staff. The unlocked medication cart was easily accessible to residents, staff and visitors. During an interview on 12/7/22, at 3 p.m., with LVN 5, LVN 5 stated another nurse borrowed her medication cart keys to unlocked the medication cart to put medications for a resident that was readmitted in the facility. LVN 5 stated the medication cart keys was returned to her but she did not ask if the medication cart was locked afterwards. LVN 5 stated she did not check if the the medication cart was locked. LVN 5 stated the medication cart should not have been left open and unattended. LVN 5 stated residents, staff and visitors could have accessed the medications inside the medication cart which could lead to self medication and or overuse of medication. During an interview on 12/7/22, at 3:05 p.m., with Registered Nurse (RN) 10, RN 10 stated she borrowed the medication cart keys from LVN 5 to put back the medications for a resident that was readmitted . RN 10 stated she returned the keys to LVN 5 and did not lock the medication cart. RN 10 stated, she should have locked the medication cart as soon as she turned her back. RN 10 stated . Residents, staff or other people could access the cart and take medications without our knowledge . During an interview on 12/15/22, at 2:50 p.m., with the Director of Nursing (DON), DON stated his expectation is for all the medication carts to be locked all the time anytime the nurse turned their back and not within their sight. The DON stated, . There are residents walking by all the time and sometimes visitors and staff may have access to the medications inside the medication cart that may lead to overdose and or allergic reactions . During a review of facility's policy and procedure (P&P) titled, Medications- Orders, Administration, Storage Documentation, dated 8/4/22. The P&P indicated, . D. Medication Storage . 3. Medication storage areas are to be locked when not in use . 4. Only authorized personnel will have access to medication storage areas .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the rights of one of four sampled residents (Resident 93) to be informed of their treatment prior to the administration of psychotropic (treatment of mental and behavioral disorders) medications when the Attending Physician (AP) did not obtain informed consent from a legal authorized resident representative prior to the administration of two psychotropic medications: lorazempam (medication to treat anxiety) and risperidone (medication to treat mental disorder). This failure resulted in Resident 93's respect and dignity being violated due to not being fully informed of the risks and benefits of the psychotropic medications being administered. Findings: During a review of Resident 93's clinical record titled, Record of Admission (document with personal identifiable information) undated, indicated Resident 93 was admitted to the facility on [DATE] with the medical diagnoses which included bipolar disorder (mental illness characterized by extreme mood swings) and anxiety disorder (characterized by feelings of apprehension, worry and uneasiness). During a review of the clinical record for Resident 93, the Minimum Data Set (MDS) assessment (an evaluation of memory, physical functions and care needs) dated 4/26/19, indicated Resident 93 was severely impaired with a Brief Interview for Mental Status (BIMS) (an assessment of temporal orientation and recall) score of 6 of 15 points. During a review of the clinical record for Resident 93, the Record of admission indicated Resident 93's Representative (RR) was the MD of the facility. During a review of the clinical record for Resident 93, the physician's orders dated 5/20/19, at 10:27 a.m., indicated, [lorazepam] (medication to treat anxiety) . 0.5 milligram (mg) (dry unit of measurement) TAB 1 tab .[at bedtime] .for Anxiety disorder .[risperidone] (medication to treat bipolar disorder) 1 TAB .Twice Daily .Bipolar disorder. During a review of the clinical record for Resident 93, the Verification of Resident [93's] Informed Consent For Psychotropic Drugs dated 3/10/19, indicated . [lorazepam] 0.5 mg 1 tab PO [by mouth] BID [twice per day]. Resident 93's informed consent did not indicate the reason for treatment and was not signed by the RR. During a review of the clinical record for Resident 93, the Verification of Resident [93's] Informed Consent For Psychotropic Drugs dated 10/30/18, indicated . Risperidone 1 mg 1 tab PO BID for Bipolar Disorder. Resident 93's informed consent was not signed by the RR. During a concurrent interview and record review with Director of Staff Development (DSD), on 5/20/19, at 4:17 p.m., he reviewed Resident 93's informed consents for lorazepam, and risperidone and was unable to locate Resident 93 RR's signature. The DSD was unable to find documentation to indicate consent was given for the use of the lorazepam and risperidone. The DSD stated the licensed nurses should have let Resident 93's RR sign the informed consents prior to initiation of psychotropic medications and the IDT should have reviewed Resident 93's psychotropic medications to ensure consent forms were obtained and signed. During an interview with the DSD, on 5/20/19, at 4:17 p.m., he stated, It [informed consents] was not caught in IDT [meeting]. The DSD stated the IDT did not document the reason for the use of psychotropic medication, the probable duration of improvement with or without treatment and the resident's right to refuse the proposed treatment. During a phone interview with Resident 93's Attending Physician (AP), on 5/20/19, at 5:46 p.m., he stated the attending physician would have to explain to the RR's of residents who did not have the mental capacity to make decisions, the risks and benefits of psychotropic medications. The AP stated Resident 93's informed consents for psychotropic medications should have been signed by the RR. The AP stated the facility's MD was Resident 93's RR. The AP stated there was no problem with the MD being Resident 93's RR. During a phone interview with Resident 93's RR [the facility's MD], on 5/20/19, at 6:06 p.m., he stated he was not related to Resident 93 and was appointed by the facility to be the RR for Resident 93. The RR stated Resident 93's informed consents should have been signed and communicated in Resident 93's IDT notes and were not. Resident 93's RR stated he was not court appointed to be Resident 93's RR and did not need to be. During a phone interview with DSD, on 5/21/19, at 12:35 p.m., he stated there were no IDT notes or documentation of Resident 93's informed consents that had been discussed by the RR and AP for Resident 93's psychotropic medications. During an interview with Registered Nurse (RN) 5, on 5/21/19, at 1:20 p.m., RN 5 stated Resident 93's informed consents for psychotropic medications should have been signed by the RR because Resident 93 did not have the capacity to make his own decisions prior to administration of medications. The facility policy and procedure titled, Consents dated 6/21/17, indicated, I. PURPOSE .B. To clarify the responsibilities of the hospital for consent to services and verification of informed consent and the physician responsibilities for obtaining and documenting informed consent .1.[facility] is responsible for obtaining the patient's or legal representative's consent for hospital services or activities .b. Consent for any other hospital activities which, without consent, would impinge on the patient's rights .D. Informed Consent for .Therapeutic Procedures 1. The physician has the legal and ethical duty to obtain the patient's informed consent, or the informed consent of the patient's legal representative, for medical treatment .vi. Documentation of informed consent shall include all the required elements listed above and the date/time completed by the physician or designee . Review of the document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities dated 5/2011, indicated, If you are, or become, incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment decisions on your behalf, such as a guardian, conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care .California Code of Regulations Title 22 Section 72527. Skilled Nursing Facilities (a) Patients have the rights enumerated in this section .(24) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time . Persons who may act as the patient's representative include a conservator, as authorized by Parts 3 and 4 of Division 4 of the Probate Code (commencing with Section 1800), a person designated as attorney in fact in the patient's valid Durable Power of Attorney for Health Care, patient's next of kin, other appropriate surrogate decision maker designated consistent with statutory and case law, a person appointed by a court authorizing treatment .(e) Patients' rights policies and procedures established under this section concerning consent, informed consent and refusal of treatments or procedures shall include, but not be limited to the following: (1) How the facility will verify that informed consent was obtained or a treatment or procedure was refused pertaining to the administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability of the patient to regain the use of a normal bodily function. (2) How the facility, in consultation with the patient's physician, will identify consistent with current statutory case law, who may serve as a patient's representative when an incapacitated patient has no conservator or attorney in fact under a valid Durable Power of Attorney for Health Care.

Based on observation, interview, and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of seven sampled Residents (Resident 62) when Resident 62's care plan for the refusal of medications was not reviewed or revised by the Interdisciplinary Team (IDT) (group composed of a physician, a nurse and appointed facility staff who meet and discuss the care of the residents). This failure had the potential to result in Resident 62's care needs going unmet. Findings: During a medication administration observation on 5/15/19, at 9:25 a.m., in station 3, Registered Nurse (RN) 1 prepared and administered medications for Resident 62. Resident 62 refused seven medications which included one tablet of ferrous sulfate (supplement to treat anemia) (low hemoglobin, lack of red blood cells in the body) 325 mg, one tablet of magnesium gluconate (supplement to treat low amounts of magnesium in the blood) 500 milligram (mg) (dry unit of measurement), one tablet of multivitamin (nutritional supplement) two tablets of senna docusate (medication to treat constipation) 50 mg-8.6 mg, one tablet of potassium chloride (medication to treat low potassium level (mineral and an electrolyte, which conducts electrical impulses throughout the body) 10 milliequivalent (mEq) (unit of measurement), one tablet of pentasa (medication to treat bowel disease) 500 mg, and one packet of juven (nutritional supplement drink). RN 1 marked the seven medications of Resident 62 in electronic medication administration record as refused medications. During an interview with RN 1, on 5/15/19, at 12:39 p.m., she stated Resident 62 did not want to swallow her medications and often refused certain medications. RN stated she did not notify Resident 62's attending physician on refusal of medications and she stated, I do not know how many days we need to contact the doctor on refusal of medications. During a review of the clinical record for Resident 62, the Medication Administration Record (MAR) dated 3/1/19 though 3/31/19, indicated Resident 62 had 89 medications refusals during the morning shift. During a review of the clinical record for Resident 62, the MAR dated 4/1/19 through 4/30/19, indicated Resident 62 had 208 medication refusals during the morning shift. During a review of the clinical record for Resident 62, the MAR dated 5/1/19 through 5/15/19, indicated Resident 62 had 83 medication refusals during the morning shift. During a concurrent interview and record review with MDS Coordinator (MDSC), on 5/15/19, at 3:50 p.m., she reviewed Resident 62's care plan which identified Resident 62's resistance of care dated 2/1/19 and stated the care plan was last reviewed on 2/1/19 and needed to be revised on 5/2/19. The MDS stated Resident 62's care plan should have been revised and updated by the licensed nurses and should have been followed by the IDT to address the frequent medication refusals. The MDSC stated, We missed it in IDT. During an interview with Director of Nursing (DON), 5/16/19, at 2:59 PM, he stated licensed nurses should have updated and revised Resident 62's care plan to reflect the frequent refusal of medications. The DON stated the IDT should have discussed new interventions and recommendations for Resident 63's medication refusals. The DON stated Resident 63's care plan needed to be accurate in order to implement a resident centered focused plan of care. The facility policy and procedure titled, Charting Guidelines dated 7/5/18, indicated, . Continue to chart on a resident as often as condition warrants until the condition is resolved . The facility policy and procedure titled, Minimum Data Set (MDS) Assessment and Care Planning dated 7/5/18, indicated, . 12. Care plans are updated and reviewed in team conference with resident, family, and the IDT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a hazard free environment for one of one sampled residents (Resident 697) when the facility knew Resident 697's did not have the mental capacity to make his own decisions and exhibited exit seeking behaviors; the facility did not assess and or implement interventions to prevent him from leaving the facility and aloud him to sign himself out of the facility against medical adivice (AMA) (the decision to discontinue medical care or treatment services despite the advice of medical professionals) on 11/19/18. This deficient practice had the potential to expose Resident 697 to harm, injury, or death. Findings: During a review of the clinical record for Resident 697, the discharge summaries dated 11/15/18, indicated Resident 697's diagnoses included cognitive dysfunction (mental condition affecting abilities to learn, memory, perception, and problem solving), alcoholism and homelessness. During an interview and record review with the Director of Staff Development (DSD), on 5/20/19, at 5:12 p.m., he stated according to the clinical record resident 697 was originally found wandering in traffic and taken to an acute hospital on [DATE]. During an interview with the DSD, on 5/20/19, at 4:17 p.m., he stated the medical director (MD) of the facility was Resident 697's Resident Representative (RR) and was assigned by the facility. The DSD stated Resident 697 did not have the capacity to make decisions. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 5/16/19, at 3:06 p.m., the MDSC reviewed Resident 697's clinical record and stated resident 697 was admitted to the facility on [DATE]. The MDSC stated resident 697 did not have the mental capacity to make his own decisions. The MDSC stated resident 697 was discharged AMA on 11/19/18. The MDSC stated resident 697's care plan dated 11/16/18 indicated resident had confusion, and alteration in thought process. During a review of resident 697's clinical record titled, RECORD OF ADMISSION, dated 11/15/18, indicated the RR was a Medical Director (MD) . During a review of resident 697's clinical record titled, NURSES NOTES dated 11/19/18, 12:00, indicated Patient [697] left the facility ambulating, took his money with him, AMA document in file, MD [Medical doctor] and RP [responsible party] made aware . During a review of resident 697's clinical record titled, LEAVING HOSPITAL AGAINST MEDICAL ADVICE, dated 11/19/18, indicated Resident [697] was allowed to sign himself out of long term care facility (LTCF), AMA. During an interview and record review with Licensed Vocational Nurse (LVN 2) on 5/21/19 at 2:20 p.m. Nurses notes dated 11/17/18 1120 indicated .pt was trying to exit the building staff was able to talk pt into staying, pt in bed resting at this time . The LVN 2 stated he [resident 697] has attempted to elope before, he [resident 697] just wanted to leave. During an interview and record review with Registered Nurse (RN 4) on 5/21/19 at 1:20 p.m. the RN 4 stated she was not aware of resident 697 not having the mental capacity to make decisions. The RN 4 stated she knew that the RR was MD according to resident 697's chart. The RN4 stated her supervisor had told her that the resident [resident 697] has been trying to leave facility for several days. The RN 4 stated she should not have allowed the resident to sign AMA since resident 697 did not have the mental capacity to do so. During a review of resident 697's clinical record titled, EMS (emergency medical service) Agency Incident Report dated 11/19/18, indicated, (name) Police Department (PD) called 20:05 (8:05) , non-emergency call .11/19/18 at 8:06 p.m., [1] Behind Macy's woman .[2] scene secure . [3] Law Enforcement At Scene . During a review of resident 697's clinical record titled, (name) EMS Ambulance report dated 11/19/18 20:22 (8:22 p.m.), indicated, Pt standing in parking lot, awake and alert, pink, warm, dry, c/o (complains of) left knee pain pt stated he has experienced gradually increasing left knee pain x 1 week . Pt presented with left knee pain with no obvious trauma or edema (accumulation of fluid), ambulatory, no obvious trauma, clear lung sounds, appeared to be gcs (scale used to assess level of consciousness)15, pt denied trauma . During a concurrent interview and record review with the MDCS, on 5/16/19 at 4:13 p.m., MDSC stated resident 697 should not have been discharged AMA. The MDSC stated the nurse should have notified his responsible party [MD] indicating it is not safe to allow the resident to leave. MDSC stated resident [697] should have been sent to the hospital for evaluation for resident safety. During an interview with the DSD, on 5/20/19, at 5:12 p.m., he stated we got couple phone calls that weekend that the resident was trying to leave. DSD stated the notes [nurses notes] are there to justify that he [resident 697] was an elopement risk, there should have been interventions such as activity, redirection, placing residents room closer to nurses station to observe resident more frequently, notifying ems, pd [police department] or security. DSD stated there could have been an environmental hazard since resident [697] eloped and was found on the street. The facility policy and procedure titled, Against Medical Advice (AMA) dated 3/18/19, indicated Purpose A. To provide guidelines to deal with a resident who desires to leave [name] against medical advice (AMA) . Definitions .C. Gravely disabled (unable to provide for self) D. Confused, disoriented, intoxicated or otherwise appearing ro lack mental capacity . Policy .C. Residents .are unable to make informed decisions, generally cannot leave the facility AMA. The resident can leave if the decision to leave AMA for such a resident is being made by an alternative consent giver.

Based on observation, interview, and record review, the facility failed to ensure medications were stored safe, secured, and not accessible to unauthorized individuals when Licensed Nurse (LN) 5 left one of 10 medication carts unlocked and unattended twice in one day. This failure resulted in the availability of medications to unauthorized residents, staff and visitors. Findings: During a concurrent observation and interview with LVN 5, on 5/16/19, at 10:40 AM., two medication carts [carts number three and four] were positioned in the hallway and in front of nurse's station. Medication cart number three was left unlocked without a nurse nearby and without supervision. Residents and non-licensed nursing staff were observed walking past the unlocked medication cart number three. LVN 5 returned to medication cart three from another area in the facility. LVN 5 pushed the button to lock medication cart three and stated she left medication cart three unattended and unlocked. LVN 5 stated the residents of the facility had access to medications from the unlocked medication cart she left unlocked and unattended. During a concurrent observation and interview with LVN 5, on 5/16/19 at 4:15 PM., medication cart three was against the wall near a resident room with the top drawer was left open and unattended. LVN 5 walked out of the resident room and stated she left the cart unlocked and unattended. LVN 5 stated she knew all medication carts needed to be locked when stepping away from the medication cart. LVN 5 stated an unattended and unlocked medication cart was not safe and residents could get into the medication stored. During an interview with the DSD, on 5/17/19, at 11:09 AM., he stated all medication carts needed to be locked when not in use. The DSD stated residents could have access to the medications from the unlocked medication cart and ingest medications not prescribed to them. The DSD stated unlocked medication carts needed to have a nurse directly with them at all times. The facility Policy and procedure titled, Medications - Orders, Administration, Storage Documentation dated 3/2018, indicated . D Medication Storage . 3. Medication storage areas are to be locked when not in use .

Based on interview and record review, the facility failed to maintain a complete and accurate medical record when the Physician Orders for Life-Sustaining Treatment (POLST) form (a document which describes patient wishes for end-of-life care), for two of six sampled residents (Resident 6 and Resident 81) were left incomplete. For Resident 6 this failure had the potential for error to occur related to the undated POLST form signed by his physician. For Resident 81 this failure placed him at risk to not have his end of life wishes met. Findings: 1. During a review of the clinical record for Resident 6, on 5/15/19, at 8:05 a.m., the POLST form was completed and reflected Resident 6's wishes. The POLST form signed by the physician and left undated. During an interview with the Medical Records Director (MRD), on 5/17/19, at 10:05 a.m., she stated she did not review the POLST forms for their completion. The MRD stated the nurses reviewed the POLST forms for their completion. During a concurrent interview and record review with the DSD, on 5/20/19, at 3:52 p.m., he reviewed the POLST form for Resident 6 and stated the POLST should have been dated when signed by the physician for it to be valid. 2. During a review of the clinical record for Resident 81, on 5/15/19, at 10:51 a.m., Resident 81's POLST dated 3/27/19, did not have his signature or the signature of his representative. During a concurrent interview and record review with Registered Nurse (RN) 6, on 5/15/19, at 11 a.m., RN 6 stated the POLST form for Resident 81 was not signed by Resident 81 or RP. RN 6 stated Resident 81's POLST form was not completely filled out and needed to be in order for it to be complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect in an environment that promoted and enhanced their self-esteem for seven of 51 sampled residents (Residents 94, Resident 88, Resident 74, Resident 57, Resident 4, Resident 45, and Resident 46) when: 1. The urinary catheter (a flexible tube inserted into the bladder to drain urine) bag for Resident 57, Resident 4, Resident 45 and Resident 46 was uncovered. 2. The facility celebrated a staff luncheon on 5/14/19 during resident meal time inside the dining room used by Resident 88 and 94 and interrupted access into the dining room used by both residents. 3. Bath towels were used instead of clothing protectors during meals for Resident 88 and Resident 74. These failures resulted in the infringement of the rights for Resident 94, Resident 88, Resident 74, Resident 57, Resident 4, Resident 45, and Resident 46. Findings: 1. During an observation on 5/14/19, at 8:46 a.m., in Resident 57's room, his urinary catheter bag was filled with urine and was visible to anyone who entered the room. During a review of the clinical record for Resident 57, the Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 3/23/19, indicated Resident 57 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) score of three of possible 15 points. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 4, on 5/14/19, at 11:02 a.m., she stated Resident 57's urinary catheter bag contained urine and was not covered. LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 57's privacy and dignity. During an observation on 5/14/19, at 9:26 a.m., in Resident 4's room, his urinary catheter bag was filled with urine and was visible to anyone who entered the room. During a review of the clinical record for Resident 4, the MDS assessment dated [DATE], indicated under section B of the MDS, Resident 4 was in a persistent vegetative state (absence of responsiveness and awareness due to brain injury) with no discernible consciousness. During a concurrent observation and interview with the Respiratory Therapist (RT), on 5/14/19, at 11:04 a.m., the RT stated Resident 4's catheter bag was not covered. During an interview with LVN 4, on 5/14/19, at 11:05 a.m., LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 4' s privacy and dignity. During an observation on 5/14/19, at 10:02 a.m., in Resident 45's room, her urinary catheter bag was filled with urine and was visible to anyone who entered the room. During a review of the clinical record for Resident 45, the MDS assessment dated [DATE], indicated Resident 45 was severely cognitively impaired with a BIMS score of three of possible 15 points. During a concurrent observation and interview with LVN 4, on 5/14/19, at 10:55 a.m., LVN 4 stated Resident 45's urinary catheter bag was not covered. LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 45' s privacy and dignity. During an observation on 5/14/19, at 10:05 a.m., in Resident 46's room, his urinary catheter bag containing urine was visible upon entering the room. During a review of the clinical record for Resident 46, Resident 46's MDS assessment dated [DATE], indicated a BIMS score of 9 points which indicated Resident 46's cognitive ability was moderately impaired. During a concurrent observation and interview with LVN 4, on 5/14/19, at 10:58 a.m., LVN 4 stated Resident 46's urinary catheter bag was not covered. LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 46' s privacy and dignity. During a concurrent interview and record review with the Director of Staff Development (DSD), on 5/21/19, at 12:23 p.m., he stated according to federal regulation the urinary catheter bags for the residents should be covered. The DSD stated it was not dignified to have the urine bag exposed for others to see. The facility admission agreement titled, Resident admission Agreement Resident Rights under Federal Law undated, indicated, The facility shall protect and promote the rights of each resident including each of the following rights: 1. The resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside the facility . To be treated with consideration, respect and full recognition of dignity and individuality . During an interview with the Director of Nursing (DON), on 5/15/19, at 2:25 p.m. the DON stated, We don't have a policy on dignity. The DON stated the resident admission packet had the resident rights listed. 2. During an observation on 5/14/19, at 12:09 p.m., staff were observed eating in the Transitional Resident dining room during the staff meal time and was not accessible to the residents. During an observation and interview with Resident 88, on 5/14/19, at 12:22 p.m., Resident 88 was eating lunch in bed. Resident 88 stated she would like to eat lunch with her friends and was not happy about eating lunch in her room. Resident 88 stated on special events the facility staff used the Resident dining room the residents were not allowed in the dining room for up to three hours. Resident 88 the facility stated staff did not offer an alternative area for residents to eat lunch. During a review of the clinical record for Resident 88, the MDS dated [DATE], indicated Resident 88 was not cognitively impaired with a BIMS score of 15 of 15 possible points. During an observation and interview with Resident 94, on 5/14/19, at 12:27 p.m., he stated, It's not right that we didn't go to the dining room because [the facility staff] were going to use [the dining room] for the staff [event]. They should have their own room to have meetings in. Resident 94 was eating his lunch in his room while sitting in a reclining chair. During a review of the clinical record for Resident 94, the MDS dated [DATE], indicated Resident 94 had no cognitive impairment with a BIMS score of 15 of 15 possible points. During an interview with the DSD, on 05/17/19, at 10:56 a.m., he stated the corporation was acknowledging the staff due to Hospital Week the dining room was closed off and an alternate dining room had been offered for the resident's noon meal in the subacute unit. The DSD stated hospital week happened once a year. The DSD stated the DON and managers which consisted of Activities Supervisor, Dietary Supervisor and DSD met and made the decision to close the resident dining room and make it available to the facility staff for the celebration of hospital week. The DSD stated the residents had an alternate dining area to eat lunch in. During an interview with the DSD, on 5/21/19, at 12:40 p.m., he stated the residents' right to eat in the Transitional dining room was taken away. The facility admission agreement titled Resident admission Agreement Resident Rights under Federal Law undated, indicated The facility shall protect and promote the rights of each Resident including each of the following rights:1. The resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside the facility . To be treated with consideration, respect and full recognition of dignity and individuality . 3. During a concurrent observation and interview with Resident 74, on 5/15/19, at 12:19 p.m., Resident 74 had a bath towel placed on his chest instead of a clothing protector (a piece of cloth to protect clothes from spilled food and drink). Resident 74 stated a clothing protector which tied around the neck would be comfortable and easier to keep in place instead of using the shower towel. Resident 74 adjusted the shower towel several times to keep it on in efforts to protect his clothes from spilled food and drinks. During a review of the clinical record for Resident 74, the MDS dated [DATE], indicated Resident 74 had no cognitive impairment with a BIMS score of 15 of 15 possible points. During an interview with Certified Nursing Assistant (CNA) 2, on 5/16/19, at 8:34 a.m., CNA 2 stated towels were being used to dry residents after showers and to protect resident clothes during shaving and grooming. CNA 2 stated there were no clothing protectors available in the facility to offer the facility residents. CNA 2 stated the facility provided towels to the residents in the place of clothing protector when eating. During an interview with DSD, on 5/21/19, at 12:42 p.m., he stated he would not use a bath towel as a clothing protector because the intended use of a towel were not the same as the clothing protector. The facility policy and procedure titled Resident Rights dated 7/5/18, indicated, Procedure A. The admissions coordinator and the social services coordinator inform and present the residents with their copy of the resident's rights at the time of admission .

Based on interview and record review, the facility violated the rights of three of three sampled Residents (Resident 86, Resident 93 and Resident 697) who were cognitively impaired and did not have a designated legal representative in accordance with applicable law and the facility's admission agreement to act on the Residents' behalf when: the Medical Director (MD) served as the Responsible Representative (RR) to make medical decisions and was not appointed by a court of law. These failures violated Resident 86, Resident 93's and Resident 697's rights to have a court appointed legal representative. Findings: During a review of the clinical record for Resident 86, the RECORD OF ADMISSION (a document with personal information) dated 9/29/09, indicated Resident 86 was admitted to the facility with the medical diagnoses of Anoxic brain damage (brain is completely deprived of oxygen), Respiratory failure, and a tracheotomy (opening into the airway in order to place a tube that allows assistance with breathing). The document listed the Medical Director (MD) of the facility as Resident 86's resident representative (RR). During a review of the clinical record for Resident 86, the Minimum Data Set (MDS) Assessment (an assessment of a resident's functional and cognitive status) dated 4/26/19, indicated Resident 86 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) score of three out of 15 possible points. During a review of the clinical record for Resident 93, the RECORD OF ADMISSION dated 10/22/18, indicated Resident 93 was admitted to the facility with the medical diagnoses of transient ischemic attacks (temporary blockage of blood flow to the brain), and epilepsy (neurological disorder that causes seizures). The document listed the MD of the facility as Resident 86's resident representative (RR). The document listed contact information for a Parole Agent to be contacted in case of an emergency or death. During a review of the clinical record for Resident 93, the MDS Assessment, dated 4/26/19, indicated Resident 93 was severely cognitively impaired with a BIMS assessment score of six out of 15 possible points. During a review of the clinical record for Resident 697, the RECORD OF ADMISSION dated 11/15/18, indicated Resident 697 was admitted with the medical diagnoses of hypertension (high blood pressure), nontraumatic subarachnoid hemorrhage (bleeding within area between brain and tissues that cover it), homelessness, dementia (long and short term memory loss which impair reasoning and functioning). The document listed the MD of the facility as Resident 86's resident representative (RR). During an interview with the Administrator (ADM), on 5/17/19, at 3:18 p.m., he stated he was not aware Resident 697's RR was the medical director of the facility. The ADM stated, I am not familiar with the details. I can't speak on the admission process. The ADM stated he counted on the Director of Nursing Services (DON) to follow up on matters involving residents who had cognitive impairment and who did not have a representative. During an interview with Social Worker (SW), on 5/20/19, at 8:53 a.m., she stated she had never gone into the process of looking for conservatorship (guardian appointed by a judge to manage the financial affairs due to physical or mental limitations residents) for residents who were unable to make decisions for it was pre-arranged by case management in [acute hospital]. The SW stated Resident 697's RR was the MD and it was discussed in the Interdisciplinary Team (IDT) (group of professionals who meet to discuss the care of the resident meeting) prior to Resident 697 admission to the facility. The SW stated the IDT received an email notification the MD was Resident 697's RR. During an interview with the Attending Physician (AP), on 5/20/19, at 5:49 p.m., AP stated he was aware Resident 697's RR was the MD. During an interview with the MD, on 5/20/19, at 6:06 p.m., he stated the resident's attending physician or the MD would be placed as the resident's RR to make medical decisions if the facility was not able to find a RR. He stated he usually received a call from the facility to notify him when he was designated as the RR. The MD stated, No, I don't need to be court appointed. The facility can assign designated person as an RR. During an interview with the admission Manager (AM), on 5/20/19, at 4:17 p.m., he stated residents who were evaluated by a psychiatrist and who lacked the capacity to make decisions were recommended by the IDT to have the MD designated as the RR. The AM stated there were no legal consultations done for the MD to be designated as the sole RR. During an interview with the AM on 5/21/19, at 12:35 p.m., he stated the facility did not have documentation the facility made an effort to reach out for legal consultations or locate a surrogate RR for Resident 697 since the time of admission. The facility document titled, Resident admission Agreement dated 3/1/16, indicated, . AGENT AND/OR LEGAL REPRESENTATIVE . If the Resident is unable to make decisions for himself or herself, an Agent and/or Legal representative may be available . Legal representative is defined as a person recognized under State Law as having the authority to make health care and/or financial decisions for the Resident . Durable Power of attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. The facility policy and procedure titled, Health Care Decision Making for Patients without Capacity and surrogates dated 2/5/18, indicated, . III. POLICY 4. No surrogate decision maker . Efforts to locate a surrogate should be diligent and may include contacting the facility from which the patient was referred, and contacting public health . provided treatment for the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of 10 sampled residents (Resident 57, Resident 4, Resident 45, Resident 46, Resident 77 and Resident 697) when: 1. Residents 57, 4, 45, and 46 care plan interventions for the use of urinary catheter (a flexible tube inserted into the bladder to drain urine) privacy bags were not implemented and exposed their urinary bags to staff and visitors. This failure violated Resident 57, Resident 4, Resident 45, and Resident 46. 2. Resident 77's care plan interventions for turning and repositioning every two hours was not implemented and Resident 77 was not turned for a period of four hours. This failure had the potential for resident 77 to develop or worsen current pressure ulcer's (localized damage to skin or underlying tissue over bony prominence as a result of pressure). 3. Resident 697's elopement risk care plan was not developed. This failure resulted in resident 697 eloping from the facility. Findings: 1. During an observation on 5/14/19, at 8:46 a.m., in Resident 57's room, his urinary catheter bag was filled with urine and was visible to anyone who entered the room. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 4, on 5/14/19, at 11:02 a.m., she stated Resident 57's urinary catheter bag contained urine and was not covered. LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 57's privacy and dignity. During a concurrent interview and record review with Registered Nurse (RN) 6, on 5/16/19, at 9:53 a.m., Resident 57's PLAN OF CARE dated 2/10/18, indicated, At risk for complications related to use of indwelling catheter. Resident needs catheter due to urinary retention .Keep drainage bag covered to promote dignity . RN 6 stated the purpose of a care plan was for staff to be aware of goals and interventions, and staff should have followed the care plan iterventions. During an observation on 5/14/19,at 9:26 a.m., in Resident 4's room, his urinary catheter bag was filled with urine and was visible to anyone who entered the room. During a concurrent observation and interview with the Respiratory Therapist (RT), on 5/14/19, at 11:04 a.m., the RT stated Resident 4's catheter bag was not covered. During an interview with LVN 4, on 5/14/19, at 11:05 a.m., LVN 4 stated the urinary catheter bag should have been covered and not been visible by others in efforts to maintain Resident 4' s privacy and dignity. During a concurrent interview and record review with RN 6, on 5/16/19, at 9:55 a.m., Resident 4's PLAN OF CARE dated PLAN OF CARE dated 10/31/18 indicated, At risk for complications related to use of indwelling catheter. Resident needs catheter due to neurogenic bladder (inability for bladder to control urine flow) . Keep drainage bag covered to promote dignity . RN 6 stated, the purpose of a care plan was for staff to be aware of goals and interventions, staff should follow the care plan. During an observation on 5/14/19 at 10:02 a.m. in resident 45's room, residents 45's urinary catheter bag containing urine was visibly seen upon entering the room. During a concurrent observation and interview with LVN 4 on 5/14/19 at 10:55 a.m. LVN 4 stated resident [45's] urinary catheter bag was not covered. LVN 4 stated it [urinary catheter bag] should be covered for privacy and dignity, so other patients and family members won't see it. During a concurrent interview and record review with RN 6 on 5/16/19 at 9:57 a.m., the clinical record for resident 45, the PLAN OF CARE dated 9/28/18 indicated, At risk for complications related to use of indwelling catheter. Resident needs catheter due to stage 4 pressure injury (deep injury reaching into muscle and bones) to sacrum . Keep drainage bag covered to promote dignity . RN 6 stated, the purpose of a care plan was for staff to be aware of goals and interventions, and staff should follow the care plan. During an observation on 5/14/19 at 10:05 a.m. in resident 46's room, residents 46's urinary catheter bag containing urine was visibly seen upon entering the room. During a concurrent observation and interview with LVN 4 on 5/14/19 at 10:58 a.m. LVN 4 stated resident [46's] urinary catheter bag was not covered. LVN 4 stated it [urinary catheter bag] should be covered for privacy and dignity, so other patients and family members won't see it. During a concurrent interview and record review with RN 6 on 5/16/19 at 9:57 a.m., the clinical record for resident 46, the PLAN OF CARE dated 2/14/19 indicated, At risk for complications related to use of indwelling catheter. Resident needs catheter due to neurogenic bladder . Keep drainage bag covered to promote dignity . RN 6 stated the purpose of a care plan was for staff to be aware of goals and interventions, and staff should follow the care plan. During an interview with the Director of Staff Development (DSD) on 05/17/19 at 8:14 a.m., the DSD stated the purpose of the care plan was to guide patient care. The DSD stated the care plan should be followed by nurses and Certified Nursing Assistants (CNA's) because it drove patient [resident] care. 2. During a review of the clinical record for Resident 77, the Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 4/17/19, indicated Resident 77's Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score was zero which indicated Resident 77 was rarely/never understood. The MDS assessment section G for functional status indicated, Resident 77 was totally dependent on staff members for bed mobility. Under section M for skin conditions, Resident 77 was coded at risk for pressure ulcers/injuries. During an observation on 5/16/19 at 8:40 a.m. in Resident 77's room, Resident 77 laid in bed on his back with the head of the bed elevated. During an observation on 5/16/19 at 11:06 a.m. in Resident 77's room, Resident 77 laid in bed on his back with the head of the bed elevated. During an observation on 5/16/19 at 12:54 a.m. in resident 77's room, Resident 77 laid in bed on his back with the head of the bed elevated. During a concurrent observation and interview with CNA 5 on 5/16/19 at 12:56 p.m. CNA 5 stated resident 77 was unable to turn and reposition himself. CNA 5 stated Resident 77 needed to be repositioned every two hours. CNA 5 stated she had not repositioned Resident 77 since morning. CNA 5 stated she should reposition Resident 77 to prevent pressure ulcer development and any existing pressure ulcers could get worse. During a review of the clinical record for resident 77, the PLAN OF CARE dated 1/13/19 indicated, Resident needs to be lifted mechanically using [brand name] lift with 2 person support due to Anoxic brain damage (brain deprived of oxygen) . Provide total Assist with bed mobility . Turn and reposition every 2 hours and as needed . During an interview with the DSD on 5/17/19 at 8:14 a.m. he stated it is our practice to turn or reposition residents every two hours. The DSD stated the care plan should be followed. The DSD stated when a resident was not repositioned it can lead to skin breakdown and existing pressure ulcers could get worse. 3. During a review of the clinical record for Resident 697, the Discharge summary dated [DATE], indicated Resident 697's diagnoses included cognitive dysfunction (mental condition affecting abilities to learn, memory, perception, and problem solving), alcoholism and homelessness. During an interview and record review with the DSD on 5/20/19 at 5:12 p.m., the DSD stated according to the clinical record titled Discharge Summaries resident 697 was originally found wandering in traffic and taken to the acute care hospital. During a concurrent interview and record review with the Minimum Data set Coordinator (MDSC), on 5/16/19, at 3:06 p.m., the MDSC reviewed Resident 697's clinical record and stated resident 697 was admitted to the facility on [DATE]. The MDSC stated resident 697 did not have the mental capacity to make his own decisions. The MDSC stated resident 697's care plan dated 11/16/18 indicated Resident 697 had confusion, and alteration in thought process. During an interview and record review with Licensed Vocational Nurse (LVN 2) on 5/21/19 at 2:20 p.m. the nurses notes dated 11/17/18 at 11:20 a.m., indicated . pt [patient] was trying to exit the building staff was able to talk pt into staying pt in bed resting at this time . LVN 2 stated he [resident 697] had attempted to elope before, he [resident 697] just wanted to leave. During a review of the clinical record for resident 697, the Nurses Notes dated 11/18/18 indicated, .Patient wanting his money to leave facility . During an interview and record review with Registered Nurse (RN 4) on 5/21/19 at 1:20 p.m. RN 4 stated she was not aware Resident 697 did not have the mental capacity to make decisions. RN 4 stated her supervisor had told her the resident [resident 697] had been trying to leave the facility for several days. RN 4 stated a care plan for elopement should have been developed since resident 697 was exit seeking. During a review of Resident 697's clinical record titled, NURSES NOTES dated 11/19/18 at 12:00 p.m., indicated, Patient [697] left the facility ambulating, took his money with him, AMA [against medical advice] document in file, MD [Medical doctor] and RP [responsible party] made aware . During an interview with the DSD on 5/20/19 at 4:17 p.m. the DSD stated, We got couple calls that weekend that the resident was trying to leave, obviously the notes are there to justify he is an elopement risk. The DSD stated a care plan for elopement should have been developed with interventions such as involvement in activity, redirection, room closer to nurses station for frequent observations and notifying security. The facility policy and procedure titled, Minimum Data Set Assessment and Care Planning dated 7/5/18, indicated, .The care plan is based on the individual needs of the resident . Document current care plan, changes in MDS assessment and any revision of care plan appropriately and on a timely fashion in the residents chart .

Based on observation, interview and record review the facility failed to ensure the medication error rate did not exceed five percent or greater when there were 30 medication pass opportunities for error and five errors resulting in a medication error rate of 16.67 percent. This failure resulted in the medication error for (Resident 33 and Resident 34) which placed them at risk of not receiving the full therapeutic effects of the medications administered. Findings: During a medication administration observation on 5/15/19, at 8 a.m., in the Transitional Unit, RN 3 prepared Resident 33's medications which included polyethylene glycol (laxative). RN 3 poured the polyethylene glycol powder from the packet into a medication cup filled with four ounces of water. RN 3 mixed the medication and administered to Resident 33. During a review of the clinical record for Resident 33, the Medication Administration Record (MAR) dated 5/1/19 through 5/31/19, indicated, [polyethylene glycol ]17 grams (GM) (dry unit of measurement) 1 Dose .give 1 dose in 8 ounces of water Oral Daily at 09:00 Every days . for constipation. During an interview with RN 3, on 5/15/19, at 8:15 a.m., LVN 1 stated, It [polyethylene glycol] should have been mixed with 8 ounces of water. I mixed it [polyethylene glycol] into 4 ounces of water. During a medication administration observation, on 5/15/19, at 9:51 a.m., in the Transitional Unit, RN 1 prepared Resident 34's medications to be taken via Gastrostomy tube (GT) (tube surgically inserted into stomach to administer medications, liquid hydration and nutrition) which included two tablets of docusate sodium (medication to treat constipation), one tablet of clonazepam (medication to prevent and control seizures), one tablet of oxycodone (medication to relieve pain), and one tablet of escitalopram (medication to treat depression). RN 1 placed the four medications in one plastic baggy; crushed the medications together and placed the crushed medications into a medication cup for administration. RN 1 proceeded to Resident 34's room and administered the mixed crushed medications to Resident 34 through the GT. During a medication administration observation on 5/15/19, at 9:51 a.m., in Transitional Unit, RN 1 stated she crushed all of Resident 34's four morning medications and administered them together through Resident 34's GT and not one at a time. During a review of the clinical record for Resident 34, the MAR dated 5/1/19 through 5/15/19, indicated, . DOCUSATE SODIUM AND SENNOSIDES (medications used to treat consitpation) 50 MG-8.6 MG TAB GIVE 2 TABS Gastrostomy Tube Twice Daily .for Constipation, CLONAZEPAM 1 MG TAB 1 Tablet Gastrostomy Tube Daily .OXYCODONE 5 MG TAB 1 tab Oral Twice Daily . [escitalopram] 10 MG TAB 1 tab Oral Daily . During an interview with RN 2, on 5/15/19, at 12:05 p.m., in the Transitional unit, RN 1 stated residents' medications could be crushed and be administered via GT all together. During an interview with RN 6, on 5/16/19, at 9:12 a.m., in Subacute Unit, she stated crushed medications should be administered separately in a feeding tube to minimize medication contraindications (an activity that would be bad for that condition) and adverse effects (harmful result) residents with a GT. During an interview with the Director of Nursing (DON), on 5/16/19, at 4:56 p.m., the DON stated the best practice in giving medications via GT was to crush resident's medications separately and to administer them one at a time through the GT. The DON stated the facility did not have the policy on crushed medication administration via feeding tube.

Based on observation, interview, and record review, the facility failed to ensure food was palatable and flavorful for five of five residents (Residents 6, 28, 30, 37, and 75) who were on pureed diets. This had the potential to result in disinterest of meals and decreased food consumption which could lead to weight loss and further compromise their medical status. (Cross reference 800 and 803). Findings: During an interview with Resident 6, on 5/15/19, at 4:41 p.m., she stated the pureed food was not good, it is gross and had no flavor. She stated she was served the same foods all the time and she begged to get off the pureed diet. Resident stated I can't stand it anymore. Review of the clinical record for Resident 6, the Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) dated 5/1/19, indicated Resident 6 had a BIMS of 12 which indicated mild cognitive impairment. During a record review of the Resident Dining Menu Week 4 dated 12/17/18, menu for Thursday 5/16/19, indicated indicated the following: pork carnitas, rice, beans, flour tortilla, sour cream, salsa, and Mexican rice pudding for the regular diet; and chicken mold (pureed food served in the shape of the food being served), pureed rice, pureed beans, a bread mold, sour cream, pureed salsa, and pureed Mexican rice pudding for the pureed diet. During a concurrent observation and interview with RD 1 and the NS, on 5/16/19, at 12:34 p.m., test trays (tray ordered to test for temperature and palatability) for regular and pureed foods were tasted. RD 1 stated the pureed rice was made with cream of rice cereal and water and she would rate it a one out of ten (one being the lowest rating and ten being the highest rating). NS refused to test the pureed food because he did not want to taste it. There was no pureed bread on the test tray. RD 1 stated the pureed food items were bland, not palatable, and lacked flavor. Record review of the facility Diet List dated 5/2/19, indicated there were five residents in the facility on a pureed diet (Resident 6, 28, 30, 37, and 75).

Based on observation, interview and record review, the facility failed to accommodate the residents food preferences and meal choices based on the policies and procedures titled, Food Provision for Patients by Family and Patient Food Services Patient Menu Selections for four of 52 sampled residents (Resident 88, 74, 29, and 91) when: 1. Resident 88's request for a baked potato and fried eggs were not granted. 2. Resident 74's food choices based on food likes and dislikes were not taken. 3. Resident 29's request for soup, bacon, pizza, regular beef burgers, and hot dogs were not granted. 4. Resident 91's request for fried eggs was not granted and his dislikes for turkey and tuna were not respected and was offered tuna and turkey sandwiches. 5. To act on and accommodate for the dislike of steamed scrambled eggs for breakfast for 13 of 28 days in the month of 5/19. These failures resulted in the decrease of residents' rights to self-determination and had the potential to result in decreased food consumption which could result in weight loss. (Cross reference 800, 801, 802, 803, and 813). Findings: 1. During a review of the facility's document titled Nutrition & Dining Resident Food Preference Record undated, indicated Circle dislikes, if any, if no dislikes, check box on lower right side of table. There was no area or directions to enter resident food likes. During an interview with Resident 88, on 5/14/19, at 9:57 a.m., Resident 88 stated she regularly attended resident council meetings. She stated she asked facility staff for a baked potato many times but was never served one following her request. Resident 88 stated food requests were made during the resident council meeting. Resident 88 stated she made request based on food preferences, and asked for baked potatoes and fried eggs instead of scrambled eggs. Resident 88 stated the facility did not grant her food requests. During a review of the clinical record for Resident 88 the Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) dated 4/21/19, indicated Resident 88 had a BIMS of 15 which indicated no cognitive impairment. During a review of the document titled Nutrition & Dining Resident Food Preference Record dated 5/16/19, indicated the Resident 88 disliked milk, cabbage, cauliflower, collard greens, corn, spinach, all juices, and orange juice. The document indicated Resident 88 liked soy and made no mention of her request or likes of baked potatoes. 2. During an interview with Resident 88 and Resident 74, on 5/14/19, at 4:05 p.m., both residents stated they were not asked about the foods they liked by the Registered Dietician (RD 2) when completing the food preferences form. Resident 88 stated the facility didn't make baked potatoes. Resident 88 stated she told both RD 2 and the Nutrition Supervisor (NS) she wanted a baked potato. Resident 88 stated she requested fried eggs in the past but the kitchen staff and the Activities Director (AD) informed her the facility did not make fried eggs. During a review of the clinical record for Resident 74 the BIMS dated 3/31/19, indicated resident 74 had a BIMS of 15 which indicated no cognitive impairment. Resident 74's Nutrition & Dining Resident Food Preference record dated 6/7/19, indicated Resident has no dislikes. A box checked indicated no cultural, religious, or ethnic preferences identified. There were no food likes recorded. During an interview with AD, on 5/15/19, at 4:33 p.m.,, he stated the facility was not allowed to make the residents fried eggs and he regularly told the residents this when they requested fried eggs. 3. During an interview with Resident 29, on 5/16/19, at 9:01 a.m., he stated he requested grilled cheese sandwiches but was told he could not have them. He stated he like soup to dip his sandwiches in, bacon, pizza, regular beef burgers, and hot dogs but was told by RD 2 the facility could not accommodate those requests. Review of the clinical record for Resident 29 the BIMS dated 2/21/19, indicated resident 29 had a BIMS of 15 which indicated no cognitive impairment. Resident 29's Nutrition & Dining Resident Food Preference Record dated 4/18/19, indicated the Resident 29 disliked scrambled eggs and quiche. There were no food likes recorded. 4. During an interview and observation with Resident 91, on 5/16/19, at 9:10 a.m., he stated he requested fried eggs many times and was told by facility staff he could not have them. Resident 91 stated he did not like turkey and did not like the tuna at this facility but was offered both types of sandwiches as alternates to the menu options. Resident 91 stated he did not like anything that was served for breakfast that morning on 5/16/19 and was not going to eat any of it. Observation of Resident 91's breakfast food tray was left uneaten. During a review of the clinical record for Resident 91, the BIMS dated 5/10/19, indicated Resident 91 had a BIMS of 9 which indicated moderate cognitive impairment. Resident 91's Initial Nutrition Assessment for Short-Term Stay dated 4/11/19, indicated Resident 91 was at risk for unintended weight loss, dehydration, and pressure ulcer due to intake less than 50 percent (%) of needs. The Nutrition & Dining Resident Food Preference Record dated 4/11/19, indicated Resident 91's food dislike was eggs. There were no food likes recorded on the food preference record. During an interview with the licensed vocational nurse (LVN) 1, on 5/20/19, at 4:52 p.m., he stated he remembered Resident 10 made a request to have grits for breakfast last week. LVN 1 stated the facility did not have grits and Resident 10 was given cream of wheat instead. LVN 1 stated he did not receive any training on what to do with residents' food requests or who to report them to. He stated he was unaware the facility policy and procedure titled Food Provision for Patients by Family dated 8/12/13, which indicated nutrition and dining service department were to be notified when a resident made requests for special food items; the dietary department would have to make every effort will be made to accommodate the patient's wishes or cultural/religious preferences. During an interview with the certified nurse assistant (CNA) 6, on 5/20/19, at 5:32 p.m., she stated Resident 10 expired two days earlier. CNA 6 stated the residents often requested other foods such as tacos, hamburgers, pizza, and omelets with vegetables but the residents were told they could order food to be delivered if they didn't like what was on the menu. CNA 6 she did not receive any training on what to do with residents' food requests or who to report them to. She stated she was unaware the facility policy and procedure titled Food Provision for Patients by Family dated 8/12/13, which indicated nutrition and dining service department were to be notified when a resident made requests for special food items; the dietary department would have to make every effort will be made to accommodate the patient's wishes or cultural/religious preferences. During a concurrent observation and interview with NS, on 5/14/19, at 9:03 a.m., in the kitchen, a package of 15 dozen raw eggs were observed with no indication they were pasteurized. NS stated he was unsure if they were pasteurized eggs or not. NS stated there were no other raw eggs in the facility. During an interview with the Registered Dietitian Director (RD 1) on 5/14/19 at 3:35 pm, RD 1 stated the raw eggs currently in the facility were not pasteurized. Review of the facility's invoices from egg purchases dated 5/2/18 through 5/15/19 indicated the facility had ordered unpasteurized eggs for five out of the 13 egg orders. During an interview with RD 1 and the NS, on 5/16/19, at 10:34 a.m.,, RD 1 stated RD 2 was responsible for assessing the resident's food preferences. NS stated the facility could not make baked potatoes or grilled cheese sandwiches because there was not enough staff. He stated he was aware the residents did not like the scrambled eggs and had substituted a sausage patty for the scrambled eggs on the menu for a few of the days scrambled eggs were offered. NS stated was told by management the facility could not offer the residents fried eggs for health reasons. NS acknowledged the facility was not accommodating resident food preferences. RD 1 stated they didn't allow residents to have regular coffee due to caffeine and she acknowledged they were limiting resident rights to have different foods at the facility. During an interview with the RD 2, on 5/16/19, at 3:54 p.m., she stated her main responsibility was to assess the residents when they were admitted and complete the food preference forms within 24 hours of admission. RD 2 he was responsible to handle all food related complaints. RD 2 did not attend resident council meetings. She stated if residents shared food complaints with her, she would usually share them with RD 1 or NS. RD 2 stated the residents requested their eggs sunny side up and were not accommodated with their request. During an interview with RD 1, on 5/17/19, at 2:38 p.m., she stated the facility never considered offering fried eggs or grilled cheese sandwiches because the idea was to limit additional choices to ones that the current dietary staff could manage. During an interview with the Director of Nursing (DON) and the Chief Operations Operator (COO), on 5/17/19, at 5:10 p.m., the DON stated RD 2 was responsible for completing resident nutrition assessments and quarterly food preferences. The DON stated RD 2 would report any concerns to him. The COO and DON stated they were unaware the residents requested grilled cheese sandwiches, fried eggs, or baked potatoes and were unaware the residents were being told the facility could not provide those requests. Both DON and COO agreed the policy and procedure titled Food Provision for Patients by Family dated 8/12/13, stated the facility was not doing there best to provide residents with their requests. DON stated he was unaware the facility's food preference assessment only addressed the residents' food dislikes and not their food likes. During an interview with RD 1, on 5/17/19, at 5:35 p.m., she stated the facility's food preference assessment did not address the resident's food likes or requests but only food dislikes and ethnic, cultural, or religious preferences. During an interview with the Senior Director of Nutrition and Dining (SDNF), on 5/20/19, at 8:49 am, she stated she was unaware the kitchen staff was not providing residents with requested food items. She stated any reasonable resident request should be provided such as a baked potato or grilled cheese sandwich. The facility policy and procedure titled Food Provision for Patients by Family dated 8/12/13, indicated Nutrition and Dining Services are to be notified if a patient requests a special food item(s). Every effort will be made to accommodate the patient's wishes or cultural/religious preferences. The facility policy and procedure titled Patient Food Services Patient Menu Selections dated 1/2018, indicated Nursing: Communicates food preferences that include strong likes/dislikes, ethnic food preferences and observance of cultural or religious dietary laws as requested by the patient and notes them in the electronic medical record. Review of the facility's resident council meeting minutes for the last eight months indicated very little documented about the residents' food concerns. Meeting minutes dated 9/4/18, indicated Old business .Not at this time and New Business .A. Informed residents how LOA (leave of absence) passes work, B. informed residents of where to report their issues with food and discharge, C. explained why food can't be served to rooms. Meeting minutes dated 10/2/18, indicated Old business .no old issues 5. The facility's policy and procedure titled Patient Food Services Patient Menu Selections dated 1/2018, indicated Patient food preferences are respected and appropriate dietary substitutions are made. Situations might include patients with strong likes/dislikes .ethnic food preferences and those observing cultural or religious dietary laws. During an interview with RD 1 and the NS, on 5/16/19, at 10:34 a.m., NS stated he was aware the residents did not like the scrambled eggs because they were liquid eggs steamed in the steamer per the recipe. NS stated the facility substituted a sausage patty for the scrambled eggs on the menu for a few of the days scrambled eggs had been offered. RD 1 stated the recipe for the scrambled eggs was not changed. During an interview with RD 2, on 5/20/19, at 8:31 a.m., she stated scrambled eggs were still on the menu and she had let the NS know the residents didn't like them. She stated she did not follow up to find out about the scrambled eggs. Review of the facility's current menu titled [Facility Name] Resident Dining Menu dated 12/17/18 indicated scrambled eggs were offered 13 of the 28 days of the revolving menu. Sausage patties were offered seven of the 28 days.

Based on observation, interview, and record review, the facility failed to ensure the results of the annual standard survey results were posted in a readily accessible location for the residents and the public when annual survey results for 2016, 2017 and abbreviated surveys of the facility were not in a readily accessible location for residents, families and visitors to view. This deficient practice posed the risk for the residents, their families, and visitors not to be fully informed of the facility's deficient practices and corrective actions taken by the facility. Findings: During a concurrent observation and interview with the Administrator (ADM), on 5/17/19, at 8:55 a.m., in the lobby, a facility survey binder titled, Consumer and Survey Info was located in an unlocked cabinet situated on the right side of the lobby entrance door. There were no results from the annual survey for 2016 and 20017. The binder contained no survey results from abbreviated surveys conducted in the facility during 2018 or 2019. The ADM confirmed the missing survey results from the binder. During an interview with the Director of Nursing (DON), on 5/17/19, at 9:25 a.m., he stated, I kept the 2567 [Statement of Deficiencies] complaints in a binder and I filed them in my office. During an interview with the Director of Staff Development, on 5/20/19, at 5:49 p.m., he stated the facility did not have the policy and procedure to ensure survey results were kept in a readily accessible area for residents, staff and visitors to view.

Based on observation, interview and record review, the facility failed to meet the dental needs for one of 51 sampled Residents (Resident 82) when Resident 82 was edentoulous (missing teeth), without dentures and the facility did not follow up with routine dental services to obtain experienced reduced nutritional intake due to being unable to chew food. This failure had the potential for Resident 82 to experience weight loss from reduced nutritional intake. Findings: During a concurrent observation and interview with Resident 82, on 5/15/19, at 2:49 p.m., he opened his mouth to point to the two remaining teeth inside his mouth. Resident 82 stated he did not understand why the dentist didn't pull them in order to receive a full plate of dentures. Resident 82 stated it was difficult for him to chew certain foods. Resident 82 stated he could not chew on meat because it was too tough for him. Resident 82 stated on several times he had no choice and had to eat sandwiches from the alternate menu instead of the tough meat. During a concurrent interview and record review with the Social Worker, on 5/16/19, at 11:40 a.m., she reviewed the assessment and recommendation by dental services dated 12/6/18 for Resident 82. The SW stated dental service provider documented have dentures made upon release [from the facility]. The SW stated it was difficult to understand dental assessments. The SW stated she did not know Resident 82 made a request for dentures and did not know of any pending discharge plans from the facility. During a concurrent interview and record review with the Registered Dietician (RD), on 5/17/19, at 11:06 a.m., she stated Resident 82 crossed out many of the food choices offered on the menu and had an average meal intake which ranged from 26 to 50 percent during the last quarterly review. The RD stated she was aware Resident 82 had one tooth and remained on a regular diet. The RD stated she would recommend a mechanical soft diet (food cut into smaller pieces). The RD stated she was unaware of the dental provider's recommendation made on 12/6/18 for dentures made upon release. The RD did not mention why the recommendation for a mechanical soft diet was not made earlier. During a concurrent interview and record review with the Director of Staff Development (DSD), on 5/20/19, at 3:52 p.m., he stated he was not aware of the dental recommendation which read, have dentures made upon release. The DSD reviewed Resident 82's interdisciplinary team (IDT) (a group made up of a physician, a nurse, a social worker and additional appointed facility staff who discuss resident care plan) note dated 4/16/19, and stated there were no documented discussions about Resident 82's need and request for dentures. During a review of the clinical record for Resident 82 titled, Interdisciplinary Team Conference dated 7/31/18, indicated New Admit 7/18/18 .BIMS [Brief Interview for Mental Status]= New Admit 15 [score which indicates cognitively intact] . Dentures: No .Dental Referral sent Diet order: Mechanical soft .D/C [discharge] potential: No .Resident is newly admitted .Dialysis pt [patient]. During a review of the clinical record for Resident 82, the IDT note dated 10/9/18, indicated Dental .2nd request submitted . 1st submitted on 7/20/18 . Diet order: Regular [with large portions] breakfast. During a review of the clinical record for Resident 82, the IDT note dated 1/22/19, indicated Dental: last visit 12/6/18 .Diet order: Regular [with large] portions .D/C Potential: No . During a review of the clinical record for Resident 82's IDT note dated 4/16/19, indicated Dentures: No .Dental: last visit 12/6/18 .Diet order: Regular diet .large portions . The facility documentation titled ADL [Activities of Daily Living] Flow Record dated 3/1/19 to 3/15/19, indicated Resident 82's percentage of each meal eaten. During this time period 30 meals were recorded by staff; 10 meals were refused, seven meals were 25 percent consumed and six meals were 50 percent consumed. For 3/16/19 to 3/31/19, there were 43 meals recorded, 12 meals were refused, eight meals were 25 percent consumed and eight meals were 50 percent consumed. Resident 82's documentation titled Initial Nutrition Assessment dated 7/19/18, indicated, Oral/Dental Condition .Edentulous [lacking teeth] only 1 tooth . Resident 82's documentation titled Quarterly Nutrition Review dated 10/23/18, indicated Oral /Dental Condition .[zero] . There were no boxes checked to document the condition of his teeth as the previous assessment indicated. Resident 82's documentation titled Quarterly Nutrition Review dated 1/18/19, indicated Oral /Dental Condition .Missing/Broken Teeth . Resident 82's documentation titled Resident Food Preference Record dated 7/19/18 indicated Diet: Regular, .Circle dislikes .[No] hard foods .Raw Vegetables [circled] .Resident has no dislikes [box checked .Difficulty chewing [circled] .Good appetite? Yes . Resident 82's documentation titled Resident Food Preference Record dated 10/17/18 indicated, Diet: Regular .[No] hard foods .Raw Vegetables .Difficulty Chewing/Swallowing? No. Resident 82's documentation titled Resident Food Preference Record dated 4/15/19, indicated, Diet: Regular .[No] hard foods .Raw Vegetables . Following these assessments, there was no indication marked for Difficulty Chewing as identified on the previous assessments dated 7/19/18 and 10/17/18. During a review of the clinical record for Resident 82, the Plan of Care dated 7/20/18, indicated, Problems .Weakness: Resident with history of unintended weight loss, only able to consume 1/3 of a meal, Risk for dehydration and fluid maintenance .Diet as ordered liberalized Regular diet to promote intake, large [portions] at breakfast [portion intervention dated 1/21/19] .Ensure Clear [supplemental liquid nutrition] at 10 am snack to promote po [by mouth] dated 1/21/19. There were no documented indications to reflect the dental recommendations made on 12/6/18.

Based on observation, interview, and record review, the facility failed to ensure there was a palatable, well balanced diet taking into consideration preferences of each resident when the regular diet was standardized as a heart healthy (no added salt or fat and cholesterol restricted) diet for 52 of 52 residents (Resident 2, 5, 6, 9, 10, 12, 13, 15, 17, 28, 29, 30, 32, 33, 34, 35, 37, 38, 44, 49, 50, 51, 52, 61, 62, 63, 64, 66, 67, 68, 74, 75, 76, 79, 80, 81, 82, 83, 88, 89, 90, 91, 92, 93, 94, 399, 447, 448, 501, 502, 503, and 504). This failure resulted in the decrease of residents' rights to self-determination and had the potential to result in decreased food consumption which could further complicate the medical conditions of the residents. (Cross reference 801, 802, 803, 804, 806 and 813). Findings: According to the Position of the American Dietetic Association: Liberalized diets for older adults in long-term care dated September 2002, It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet .A diet that is not palatable or acceptable to the individual can lead to poor food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. Often, a more liberalized nutrition intervention that allows an older adult to participate in his or her diet-related decisions can provide for the person's nutrient needs and allow alterations contingent on medical conditions while simultaneously increasing the desire to eat and enjoyment of food. This ultimately decreases the risks of weight loss, undernutrition, and other potential negative effects of poor nutrition and hydration. During an interview with Resident 88, on 5/14/19, at 9:57 a.m., Resident 88 stated she regularly attending resident council meetings. She stated she had asked facility staff for a baked potato many times but was never given one. Resident 88 stated she informed staff during resident council and would request and give her food preferences but would not get food requested. During an interview with Resident 88, and Resident 74, on 5/14/19, at 4:05 p.m., both residents stated they were not asked about the foods they liked when filling out the food preferences form. Both residents stated the scrambled eggs in the facility were not good and most residents would not eat them. Resident 88 stated the facility did not make baked potatoes. She stated she told both the Registered Dietician (RD) 2 and the Nutrition Supervisor (NS) her request for a baked potato. She stated she made requests for fried eggs in the past but the kitchen staff and the activities director (AD) told her the facility did not prepare fried eggs. During an interview with Resident 6, on 5/15/19, at 4:41 p.m., she stated the pureed food was not good, it was gross, and had no flavor. She stated she was served the same foods all the time and she begged to get off the pureed diet. Resident 6 stated, I can't stand it anymore. During an interview with Resident 29, on 5/16/19, at 9:01 a.m., he stated he attended resident council regularly. He stated the scrambled eggs in the facility tasted funny and made his complaint during the resident council many times. Resident 29 stated he made requests for grilled cheese sandwiches but was told by the time the facility made the sandwich and delivered it to him, it would be cold. He stated he also would like soup to dip his sandwiches in, bacon (with breakfast), pizza, regular (beef) burgers, and hot dogs but was told the facility could not accommodate those requests. During a concurrent observation and interview with Resident 91, on 5/16/19, at 8 a.m., Resident 91's breakfast food tray had food left untouched and not eaten. There was one hardboiled egg, one muffin, one orange slice, and two bowls of oatmeal. Resident 91 stated he liked oatmeal but he got burnt out on it. During an interview with Resident 91, on 5/16/19, at 9:10 a.m., he stated he made requests for fried eggs many times and was told he couldn't have them. Resident 91 stated he didn't like turkey and didn't like the tuna at this facility but was offered both kinds of sandwiches as alternates to the menu options. Review of the facility's diet manual titled [Facility name] Long Term Care Diet Manual dated 1/18/18, indicated the regular diet was restricted to 1857.6 calories, 282 grams (gm)(a unit of measurement) of carbohydrates (carbs), 58.6 gm of fat, and 2.3 gm of sodium (salt). The No Added Salt (NAS) diet (for heart failure), the Reduced Concentrated Sweets (RCS) diet (for diabetics), and the Low Fat, Low Cholesterol (LFLC) (for obesity) all indicated the same dietary restrictions of 1858 calories, 282 gm carbs, 58.6 gm fat, and 2.3 gm sodium. Review of the facility's diet manual titled [Facility name] Long Term Care Diet Manual dated 1/18/18 indicated Caffeine Restriction Guidelines: caffeine is contraindicated in certain conditions and diagnoses and is, therefore, limited on certain diets. The restricted amount of caffeine may vary depending on the diet. Therefore, all diets provided by within [Facility name] will be caffeine restricted. Review of the facility's policy and procedure titled Diet Orders Patient Menus dated 9/10/18 indicated Purpose: To standardize diet orders .to assure accuracy of menu items served to patients. Review of the facility's policy and procedure titled Food Provision for Patients by Family dated 8/12/13 indicated .food brought into the hospital by family/friends is to be discouraged .if a patient is on a restricted diet, a physician's order is required to allow the family to bring in food from the outside. The facility document titled Food from Home (used for resident and family education) dated March 2011, indicated .we encourage patients and their families to refrain from bringing in prepared foods from home .If you have been prescribed a special diet due to your medical condition, your nurse may need to obtain permission from your physician for you to bring in food from home. During an interview with RD 1, on 5/16/19, at 11:14 am, she stated the regular diet at the facility is standardized as a heart healthy diet. RD 1 stated the heart healthy diet was restrictive of salt, fat, and cholesterol. RD 1 stated she could not give the residents hot dogs or certain foods because they were higher salt and fat content then what the facility's diet manual allowed for a regular/heart healthy diet. RD 1 stated the facility did not allow residents to have regular coffee due to the caffeine. RD 1 confirmed the facility was restricting the diet for residents who were on a physician ordered regular diet. RD 1 stated they had a four-week menu cycle and the menu had not been changed for two years at the facility. During the concurrent test tray observation and interview with RD 1, and the NS, on 5/16/19, at 12:34 p.m.,the regular and pureed food meal served were tasted. RD 1 stated the pureed rice was made with cream of rice cereal and water and she would rate it a one out of ten (one being the lowest in flavor and ten being the highest best in flavor). NS refused to test the pureed food. The regular and puree food items tasted bland and were not palatable. RD 1 acknowledged that all food (regular and puree) tasted bland, not palatable and lacked flavor. RD 1 stated it was likely due to menus being restricted. Review of the facility's assessment (a tool used to determine the facility's residents' needs and appropriate staffing) which was undated, indicated under Nutrition: Individualized dietary requirements, liberalized diets, specialized diets, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions.

Based on interview and record review, the facility failed to ensure there was a full time qualified person responsible for food and nutrition services when the Registered Dietitian Director (RD 1) was not full time at the facility. The full time Registered Dietitian (RD 2), although qualified, and allowed to in her job description, did not perform as the director of food and nutrition services in the absence of RD 1. This failure resulted in a lack of oversight for food and nutrition services, insufficient staffing for the kitchen, unsatisfied residents, inaccurate facility assessment, and multiple deficiencies in the facility's food service. (Cross reference, 800, 802, 803, 804, 806, 812, 813, and 814) Findings: During an interview with RD 1, on 5/14/19, at 10:25 a.m., RD 1 stated she was the director of nutrition and dining for the facility and a sister facility in the same corporation. RD 1 stated there was a full time Registered Dietitian at this facility who was in charge of clinical nutrition services and could step to assist with food services if needed. During an interview with RD 1 and the Nutritional Supervisor (NS), on 5/16/19, at 10:34 a.m., RD 1 stated she was responsible to provide oversight to the kitchen staff. RD 1 stated she worked with the NS and RD 2 to make sure nutritional information was correct, policies were in place, the kitchen staff schedule was adequate, and the administrative work was completed. RD 1 stated she was in charge of completing evaluations, employee competencies, and was required to proved in-services (training) to staff, on average once every month. RD 1 stated she was required to spend 20 hours a week at the facility. During an interview with RD 2, on 5/16/19, at 3:54 p.m., RD 2 stated her main responsibility was to assess the residents when they were admitted to the facility. RD 2 stated she filled out resident food preference forms within 24 hours of admission, updated resident food preference forms on a quarterly basis, and informed NS or RD 1 of resident food complaints. RD 2 stated she did not provide oversight of the kitchen even though her job description stated she could do so. RD 2 stated she her time was taken up with the completion of resident clinical nutritional assessments. RD 2 stated the complexity of the nutritional assessments had increased in the facility residents over the last three years and her time was spent with her clinical obligations. RD 2 further stated she did not have time to provide oversight of the kitchen because of her involvement with the sister facility's dietary department and their insufficient staffing. During review of RD 1's job description titled Job Description/Competency Review [facility] Director dated 10/27/14, indicated .directs the operation of Food and Nutrition Services a [facility name] and [sister facility]. Performs a variety of duties including the planning and supervision of food purchasing and production, patient services, personnel management, and regulatory compliance .Supervisory Responsibilities; foodservice operation (clinical RD under supervision of the [clinical nutrition manager] CNM) with RD oversight of the entire operation. During review of RD 2's job description titled Job Description/Competency Review - Clinical Dietitian [facility name] dated 5/1/16, indicated Provides clinical nutrition services, including nutrition assessment, modified diet formulation, self-management training and nutrition intervention to patients/residents .Provides RD oversight to food service operations to ensure excellent compliance to policies and procedures and ensure safe food handling. Supervisory Responsibilities: RD oversight in the absence of the [facility name] Director. During review of NS's job description titled Job Description/Competency Review [facility name] Supervisor dated 11/17/14, indicated Responsible for the food service operations of Food and Nutrition Services at [facility name], under the supervision of the RD Director .Supervisory Responsibilities: food service staff. HSC 1265.4 states a) A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).

Based on interview and record review, the facility failed to evaluate and employ sufficient staff with the appropriate competencies to safely and effectively carry out the functions of food service taking into consideration resident needs when: 1. Kitchen staffing was not maintained to provide one dietary aide (DA) for AM shift, one cook for AM shift, one DA for PM shift, and one cook for PM shift for eight of the last 12 months. 2. Kitchen staffing for the facility was not properly assessed by the contracted food company, the Registered Dietitian Director (RD 1), or the Administrator (ADM) when one DA and one [NAME] for AM and PM shifts for this facility fell below the national average staffing benchmark and residents' preferences were not being provided. (Cross reference 801 and 835) 3. Kitchen staff did not demonstrate proper use of gloves in the tasks of food preparation and the serving of food. These failures resulted in the understaffing of qualified kitchen staff and the facility not being able to provide residents with requested menu options which had the potential to result in decreased food intake that could lead to weight loss and further compromise medical status. This finding further had the potential to result in foodborne illnesses from cross contamination or the growth of microorganisms for the 52 of 52 residents (Resident 2, 5, 6, 9, 10, 12, 13, 15, 17, 28, 29, 30, 32, 33, 34, 35, 37, 38, 44, 49, 50, 51, 52, 61, 62, 63, 64, 66, 67, 68, 74, 75, 76, 79, 80, 81, 82, 83, 88, 89, 90, 91, 92, 93, 94, 399, 447, 448, 501, 502, 503, and 504. (Cross reference 803, 806, and 812). Findings: 1. During a review of the facility's kitchen staffing schedule for May 2018 through April 2019 indicated the facility frequently scheduled three full time hourly kitchen employees in the kitchen. Two cooks (Cook 1 and [NAME] 3) were frequently scheduled to work double shifts, one new cook (Cook 2) was scheduled as the only cook on duty during his orientation, the Nutrition Supervisor (NS) was repeatedly scheduled as a fill in for DA and cook, and one DA (DA 1) was frequently scheduled to work double shifts as DA and was scheduled as the PM cook four times in one month. During a review of the undated facility's assessment (a tool used to determine the facility's residents' needs and appropriate staffing) indicated Food and nutrition services staff: two cooks, two aids. During a review of personnel files for DA 1, the file did not show a competency completion for the cook position. During an interview with RD 1, on 5/20/19, at 5:11 p.m., RD 1 stated DA 1 was not trained as a cook and did not have the competencies to be the cook. RD 1 was unable to provide documentation for DA 1's competencies for any of the job positions he completed in the facility dietary department. 2. During a review of the undated facility's assessment (a tool used to determine the facility's residents' needs and appropriate staffing) indicated under kitchen staffing the facility needed two cooks, two aides. During a review of the facility document titled, Hourly Staffing (document used to track employee hours worked and weekly pay) undated, inidcated the facility was allotted to employe a morning and evening cook, each for a total 112 weekly hours, one stocker for a total of eight hours per week, two dietary aides for a total of 112 hours per week and a detailed cleaner for a total of four hours per week. The combined total kitchen employee hours allotted to the facility's dietary department was 236 hours a week. During a review of the contract signed by the facility and the contracted food company titled Dietary Services Agreement dated 6/1/14, indicated [Name of contracted food company] will provide and pay for a sufficient number of hourly personnel who shall maintain, under [contracted food company managment] a safe, effective and efficient food and nutrition operation. The contract indicated the contracted food company would provide 6.57 full time hourly employees (not including management) based on their assessment of the facility's dietary production staff needs. During an interview with RD 1, on 5/16/19, at 11:36 a.m., RD 1 stated [contracted food company] allowed one cook and one DA to be on schedule at a time (for AM and PM shifts). RD 1 stated this was not sufficient staff to meet the residents' needs. During an interview with RD 1, on 5/17/19, at 2:38 p.m., RD 1 stated she did not make afor more cooks or DAs because the contracted food company determined the staffing needs for the facility and she had to make that work. RD 1 stated she had never considered offering fried eggs or grilled cheese sandwiches because the idea was to limit additional choices to ones the current staff could manage. During an interview with ADMIN on 5/17/19 at 3:17 pm, ADMIN stated he came to the facility two to three times a year. ADMIN stated the Director of Nursing (DON) and the Chief Nursing Officer (CNO) determined the facility's kitchen staffing needs along with the contracted food company. ADMIN stated the Board of Trustees for the Corporate Company signed the contract with the contracted food company. ADMIN stated he could not provide specific information about this facility. Admin stated he also held the role of CEO for the corporate company that owned this facility. During an interview with the CNO and the [NAME] President of Ambulatory and Post Acute (VPA) on 5/17/19 at 5:08 pm, both stated they did not know how kitchen staffing was evaluated and referred the interview to the DON and the Chief Operations Officer (COO). During an interview with CNO, VP, DON and the COO on 5/17/19 at 5:10 pm, COO stated the kitchen staffing was determined by an initial assessment and a quarterly review every year. COO stated the facility looked at quality measures, patient satisfaction measures, local leaders, and the contracted food company's leaders. COO stated no significant concerns about food service had been raised. COO stated the patient satisfaction measures used included resident council meeting minutes and filed grievances. COO stated no interviews or satisfaction surveys were done with the residents to determine satisfaction. DON stated RD 1 and the clinical Registered Dietician (RD 2) would report any concerns to them that the residents had. CNO, VP, COO, and DON were all unaware of the residents wanting fried eggs or grilled cheese sandwiches and being told the facility could not provide those requests. CNO, VP, COO, and DON were all unaware there was not enough kitchen staff to carry out residents' requests. CNO, VP, COO, and DON were all unaware of any resident complaints about food. COO stated he gave presentations to the Board of Trustees regarding the facility's kitchen staffing for evaluation and quarterly renewal evaluations. He stated when reviewing kitchen staffing needs, he looked at the number of meals served as relative to the number of staff and reviewed how this facility's staffing is compared to other facilities (through benchmarking by the ANFP) and he determined it was comparable. COO stated the last comparative evaluation was completed eight months ago. Review of RD 1's competency evaluation completed by the contracted food company titled 2018 Goal and Performance Management for [RD 1] dated 10/31/18 indicated management was aware of kitchen staffing issues (RD 1) continues to struggle with finding the right fit of employees that complete work tasks and are cohesive. Has had bad luck with re-hiring past employees. Teamwork is a struggle at [Facility Name]. During an interview with VPO and RD 1 on 5/20/19 at 4:03 pm, RD 1 stated she had informed DON the kitchen was short staffed. RD 1 stated she did not report any information to COO on kitchen staffing, staff satisfaction, or resident satisfaction for the kitchen staff assessment. She stated she was not part of that process but was available if management had questions for her. Review of the COO's most recent comparative evaluation titled Labor Hours Per Meal Served (undated) indicated the facility had four full time hourly kitchen employees with an average of 165 meals served which gave a Labor hours/Meals served of 0.19. The document indicated The 2016 ANFP Skilled Nursing Facility Benchmarking Program showed 0.19-0.39 average labor hours per meal. Review of the facility's kitchen staffing schedule for the last 12 months indicated the facility frequently had only three full time hourly kitchen employees in the kitchen and not four as indicated on the assessment. Through an email with the Foundation and Research Coordinator (FRC) for The Association of Nutrition & Foodservice Professionals (ANFP) on 5/21/19 at 1:49 pm, the FRC stated The median labor hours per resident across all facilities is 0.69 hours, while the labor hours per meal served is 0.25 hours. The facility's assessed labor hours per meal served of 0.19 hours was below the average benchmark according to the 2016 ANFP annual benchmarking survey. Review of the contract signed by the facility and the contracted food company titled Dietary Services Agreement dated 6/1/14 indicated [Name of contracted food company] .shall conduct employee satisfaction surveys for the staff .and maintain satisfactory staff survey scores for all hourly personnel. During an interview with the Senior Director of Food and Nutrition (SDNF) on 5/20/19 at 10:13 am, she stated the contracted food company performed annual employee satisfaction surveys and maintained satisfactory employee satisfaction survey scores for all hourly personnel within the corporation that owned this facility. SDNF stated the survey was anonymous and did not differentiate the employees at different facilities owned by the corporation. SDNF stated there was no way to determine the employee satisfaction at this facility from the survey. During an interview with DA 1 on 5/20/19 at 10:16 am, he stated he had worked for the contracted food company for just over one year, was unaware of any employee satisfaction survey, and had not participated in one. During an interview with [NAME] 3 on 5/20/19 at 10:17 am, she stated she had worked for the contracted food company for over ten years and had participated in the employee satisfaction survey two or three times during her employment. During an interview with [NAME] 1 on 5/20/19 at 10:22 am, he stated he had worked for the contracted food company for over eight years and had never participated in an employee satisfaction survey. He stated he had not ever been told there was a survey to take part in. During an interview with RD 1 on 5/20/19 at 10:23 am, she stated she verbally informed employees of the annual employee satisfaction survey and would allow them to use her computer to take the survey. She was unable to state how many employees had participated in the survey because it was done anonymously. RD 1 stated the survey would not help identify staffing issues at a particular facility because it was anonymous. During an interview with RD 2 on 5/20/19 at 10:27 am, she stated she participated in the employee satisfaction survey annually, it was anonymous, it did not ask what facility the employee worked at, and it would not help identify staffing issues at a particular facility. Review of the contracted food company's employee satisfaction survey results for the corporation owning this company dated 4/5/19 did not indicate any survey questions regarding the ability of staff to perform their jobs and further indicated (question #30) only 28% of management (salaried employees) agreed or strongly agreed that management would take action based on the results of the survey. 3. Multiple observations were conducted over the course of the recertification survey 5/14-5/16/19 that revealed food service staff (DA1, DA 2, [NAME] 1, and [NAME] 2) wore their gloves consistently while preforming multiple tasks without changing gloves between the tasks. During an observation on 5/14/19 at 8:45 am in the kitchen, Dietary Aide 1 (DA 1) was wearing gloves while rinsing dirty dishes from breakfast service. DA 1 moved to the clean side of the dishwasher and pulled a crate of clean dishes out of the dishwasher with his gloved hands then went back to the dirty side of the dishwasher and continued rinsing dirty dishes. DA 1 did not remove his gloves or wash his hands at any time during the observation. During an observation on 5/14/19 at 10:31 am in the kitchen, [NAME] 1 was wearing gloves while plating cottage cheese and fruit on salad greens. [NAME] 1 touched multiple non-food surfaces with his gloved hands while plating the food. [NAME] 1 did not remove his gloves or wash his hands at any time during the observation. During an observation on 5/15/19 at 12:18 pm in the kitchen, DA 2 was assisting in lunch service while wearing gloves and touching both non-food surfaces (including two refrigerator door handles, drink containers, and tray cart handles) as well as ready-to-eat foods (DA 2 retrieved fruit cups out of a refrigerator by placing his index finger inside the cup and his thumb and middle finger outside the cup). DA 2 repeated this for three resident's trays and did not remove his gloves or wash his hands at any time during the observation. During an interview with RD 1 on 5/16/19 at 12:48 pm, RD 1 stated her expectation was for the kitchen staff to remove gloves when going from touching food to touching the oven or tray carts. RD 1 stated staff were to wash their hands after removing gloves and before putting new gloves on. RD 1 stated staff did not need to wear gloves when they were opening the oven or pushing a tray cart. According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility's policy and procedure titled Personal Hygiene of Food Handlers dated 7/25/18 indicated E. Use of Gloves and Sanitized Utensils .3. When used, single-use gloves will be worn for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. During an interview with RD 1 on 5/20/19 at 5:11 pm, RD 1 had been asked to provide documentation of an in-service for proper glove use for kitchen staff. RD 1 provided a sign in sheet and in-service titled Bloodborne Pathogens with the objectives of: educated on what bloodborne pathogens are, review types of bloodborne pathogens, educate on routes of entry, educate on personal protective equipment, educate on exposure controls, and exercise; identifying good and bad practices. RD 1 stated that was the only in-service on glove use she had provided for the kitchen staff. There had not been any in-service regarding glove use in the kitchen for food services staff. RD 1 confirmed and was unable to provide documentation for DA 1's competencies for any of the job positions he worked.

Based on observation, interview, and record review, the facility failed to ensure: 1. Menus were updated periodically; 2. The regular diet menu for Resident 30 was followed on 5/14/19; the pureed diet menu was followed on 5/14/19; the mechanical soft diet for Resident 92 was followed on 5/15/19; and the large portion diet menu for ten of 53 residents (Resident 5, 6, 15, 29, 33, 35, 49, 76, 83, and 501) and pureed diet menu for five of 53 residents (Resident 6, 28, 30, 37, and 75) were followed on 5/16/19. This failure had the potential to result in disinterest of meals and decreased food consumption for 52 of 52 residents 52 of 52 residents (Resident 2, 5, 6, 9, 10, 12, 13, 15, 17, 28, 29, 30, 32, 33, 34, 35, 37, 38, 44, 49, 50, 51, 52, 61, 62, 63, 64, 66, 67, 68, 74, 75, 76, 79, 80, 81, 82, 83, 88, 89, 90, 91, 92, 93, 94, 399, 447, 448, 501, 502, 503, and 504) eating food from the kitchen which could lead to weight loss and further compromise their medical status. (Cross reference 800, 801, and 804). Findings: 1. During an interview with the Registered Dietitian Director (RD 1) on 5/16/19 at 10:34 am, she stated the menu is a four-week cycle (28 days) and has been repeated every 28 days for two years. RD 1 confirmed they have not updated the menu for two years and they received the menu from the contract food service company regional director. The facility's policy and procedure titled Patient Food Services Nutritional Adequacy/Approval dated 1/2018 indicated The menu is evaluated annually and updated as needed. During an interview with Resident 6, on 5/15/19, at 4:41 p.m., she stated she was served the same foods all the time and there was no variety. During a review of the clinical record for Resident 6 the Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) dated 5/1/19, indicated Resident 6 had a BIMS of 12 which indicated mild cognitive impairment. During a review of the clinical record for Resident 6 the Physician's Telephone Order dated 2/1/19, indicated Resident 6 was on a puree diet. During a concurrent observation and interview with Resident 91 on 5/16/19 at 9:10 am, he stated the residents were shown the menu once a month and were able to pick what they wanted to eat for the next month at that time. Resident 91 stated the foods offered did not have any variety month to month. Observation of Resident 91's breakfast tray indicated resident had not eaten any of the foods offered on his breakfast tray. Resident 91 stated he did not like what was offered for breakfast that day and was not going to eat any of it. During review of the clinical record for Resident 91 the BIMS dated 5/10/19 indicated Resident 91 had a BIMS of 9 which indicated moderate cognitive impairment. During review of the clinical record for Resident 91 the Physician's Telephone Order dated 4/11/19, indicated Resident 91 was on a regular diet. During review of the clinical record for Resident 91 the Initial Nutrition Assessment for Short-Term Stay dated 4/11/19, indicated Resident 91 was at risk for unintended weight loss, dehydration, and pressure ulcer due to intake less than 50% of needs. During review of the [Facility Name] Resident Dining Menu signed and dated 12/17/18, by RD 1 for all 28 days indicated residents were served food repetitively. Further review showed for breakfast the main dish offered was scrambled eggs 13 days, sausage patties seven days (sometimes offered as the main dish with oatmeal as a side and twice offered with french toast), french toast four days, pancakes three days, quiche one day, and waffles one day of the 28 days. Breakfast sides or alternates offered included oatmeal 16 days, cream of wheat 12 days, muffins seven days, and biscuits two days of the 28 days. During review of the [Facility Name] Resident Dining Menu signed and dated 12/17/18 by RD 1 for all 28 days indicated residents on pureed diets were given mashed potatoes 26 times (often two or three times in the same day), bread mold 22 times, chicken mold (a premade, pureed food, placed into a plastic mold that resembles the shape of the food it is) 20 times, turkey mold 18 times, beef mold 10 times, and pork mold four times. Further review indicated for breakfast, residents on pureed diets were offered omelet molds 17 times, pureed scrambled eggs three times, and french toast mold eight times. When residents on a regular diet were given pancakes, waffles, or french toast, residents on a pureed diet were given french toast mold. When residents on a regular diet were given sausage, residents on a pureed diet were given a regular turkey mold. During an interview with RD 1 and the NS, on 5/16/19, at 10:34 a.m., RD 1 the puree food was served in molds of the shape of the food being served. RD 1 stated the puree molds used did not give much variety to the menu. NS stated they swapped out turkey sausage for scrambled eggs because residents did not like the smell of the scrambled eggs which were steamed liquid eggs in a steamer. 2. The facility's policy and procedure titled Production, Purchasing, Storage; Menu Substitutions dated 1/2017, indicated Executive chef .selects a substitute food .not served during the current, previous or subsequent day .obtain dietitian's approval for substitution(s) to the patient/resident menu. During a record review of the document titled, [Facility Name] Resident Dining Menu dated 5/14/19, indicated the following items to be served were cream of celery soup, beef chili beans, baked French fries, and canned fruit cocktail. During an observation on 5/14/19, at 11:50 a.m., of Resident 30's lunch tray meal ticket (an individualized tickets placed on resident's trays to let the staff know what foods to give and avoid for residents including preferences and allergies) was served a lunch tray without the cream of celery soup as indicated on the menu. There was no indication on the resident's lunch tray ticket that she did not want or could not have the soup. During a concurrent observation and interview with RD 1, on 5/14/19, at 12 p.m., Resident 30's lunch tray in resident 30's room, RD 1 confirmed there was no soup on the tray and there should have been. During a record review of the document titled, [Facility Name] Resident Dining Menu dated 5/14/19, indicated the following menu items for the pureed diet were puree cream of celery soup, pureed beef chili beans, mashed potatoes, and one pineapple mold. During an observation of the lunch meal service on 5/14/19, at 12:22 p.m., [NAME] 1 served residents on pureed diets a beef mold with a tomato based sauce and a pea mold. During an interview with [NAME] 1 on 5/14/19, at 12:58 p.m., he stated he was told by the Nutrition Supervisor (NS) to give the residents on pureed diets the beef mold with tomato sauce and pea molds because chili has beef and vegetables in it. He confirmed he did not puree the chili beans for the residents on pureed diets. During an interview with RD 1 on 5/16/19, at 10:34 a.m., she stated on 5/14/19 the residents on pureed diets should have received pureed chili beans and not beef mold with tomato sauce and pea mold. During a record review of the [Facility Name] Resident Dining Menu Week 4 Wednesday 5/15/19, indicated the following to be served: regular diet - cabbage soup, turkey cheese burger, one leaf of lettuce, two tomato slices, and pear halves; large portion diet - cabbage soup, two turkey cheese burgers, two leaves of lettuce, four tomato slices, and pear halves; and the puree diet - cabbage soup, two turkey molds, mashed potatoes, puree lettuce and tomatoes, and pear mold. During a concurrent observation of lunch meal service and record review of lunch tray ticket for Resident 92, on 5/15/19 at 11:58 am, [NAME] 1 and the Senior Director of Food and Nutrition (SDFN) were serving the residents' lunch plates. Resident 92 was on a mechanical soft (chopped food) diet and was served one #16 scoop of chopped bread, one #8 scoop of chopped meat, one slice of cheese, and chopped lettuce and tomato in place of the turkey cheese burger. Resident 92 was not given the cabbage soup. There was no indication on the lunch tray ticket that she did not want the soup. During an interview with RD 1 on 5/15/19 at 12:00 pm, she confirmed that Resident 92 did not receive soup on her tray and she should have. During an interview with [NAME] 1, RD 1, and SDFN on 5/15/19, at 12:36 p.m., [NAME] 1 confirmed he used the #16 scoop for the chopped bread. SDFN stated the #16 scoop is two ounces which is the same as one hamburger bun. During the observation of the lunch meal service on 5/15/19, starting at 11:58 a.m., [NAME] 1 and SDFN served residents on a large portion diet one bun, two turkey patties, one slice of cheese, two leafs of lettuce, and two slices of tomato. During a review of the diet list dated 5/2/19, indicated there were nine residents on a large portion diet. During an interview with [NAME] 1, RD 1 and SDFN on 5/15/19, at 12:39 p.m., RD 1 stated the residents on large portion diets stated they did not want so much bread and the kitchen staff started serving just one bun. SDFN agreed with the decision to serve one bun. RD 1 and SDFN stated they did not updated the menu to reflect this change. RD 1 stated residents on large portion diets should have received two slices of cheese and did not know why only one slice of cheese was served. During the observation of the lunch meal service on 5/15/19, starting at 11:58 a.m., [NAME] 1 and SDFN served residents on pureed diet cabbage soup, two turkey molds, two bread molds, and a pear mold. During an interview with [NAME] 1, RD 1, and SDFN on 5/15/19, at 12:36 p.m., [NAME] 1 stated he gave the residents on pureed diet the pureed bread instead of the mashed potatoes because he wanted them to have what everyone else was having. [NAME] 1 confirmed mashed potatoes were on the menu and not pureed bread and he should have followed the menu. During a review of the diet list dated 5/2/19, indicted there were five residents on the puree diet. During a record review of [Facility Name] Resident Dining Menu Week 4 Thursday 5/16/19 indicated the pureed diets were to be served two chicken molds, half cup (four ounces) puree rice, half cup puree beans, one bread mold, one ounce sour cream, one ounce puree salsa, and half cup puree Mexican rice pudding. During an observation of the lunch meal service on 5/16/19 at 12:14 pm, a test tray (tray ordered to test for temperature and palatability) was ordered for pureed and regular diets. [NAME] 3 served the trays and the pureed diet tray did not have the bread mold on it. During a concurrent observation and interview with NS and [NAME] 3 in the kitchen on 5/16/19 at 12:59 pm, [NAME] 3 stated she had served the residents on pureed diets the bread mold but had run out of the bread molds by the time she served the test tray. [NAME] 3 stated she had the wrappers for the bread molds. [NAME] 3 pulled an unopened bread mold out of the trash and stated it had been an extra. [NAME] 3 pulled another unopened bread mold out of the trash. [NAME] 3 was unable to produce any opened wrappers for bread mold. The lunch tray for Resident 30 (a resident on a pureed diet) was brought into the kitchen after lunch service and inspected. NS confirmed Resident 30's tray showed left over pureed beans, pork mold, and pureed rice. NS confirmed there was no evidence of bread mold on the tray. NS confirmed the unopened packages of bread mold in the trash and concluded residents on pureed diets did not received bread mold on lunch service and should have. During a concurrent interview with RD 1 and NS and record review on 5/16/19, at 11:27 a.m., of Resident Dining Menu Week 4 for Tuesday and Wednesday, RD 1 stated she expected staff to follow the menus and spreadsheets. RD 1 stated on 5/14/19 residents on pureed diet were served beef molds and pea molds and should have been served pureed chili beans. RD 1 stated on 5/15/19 residents on pureed diets were served bread mold and should have been served mashed potatoes. NS stated RD 1 was to approve all substitutions and staff should have asked RD 1 before making the substitutions. RD 1 and NS confirmed that the Wednesday menu did not indicate how much bread or chopped meat to give residents on mechanical diets and had not been altered for the residents on large portion diets to indicate only receive one bun instead of two. RD 1 confirmed the recipe for the turkey burger did not state or include anything for the mechanical diet and there was no recipe for the mechanical soft burger.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Egg salad, cubed ham, cubed turkey and sliced turkey were stored in a refrigerator at a temperature exceeding the safety temperature limit of 41 degrees Fahrenheit (F) in accordance with facility policy and procedure and FDA Food Code. The refrigerator temperature was not set to maintain the internal temperature of refrigerated food stored at 41 degrees or below per facility policy. These failures had the potential to result in foodborne illnesses from inappropriate food storage for the 52 residents eating food prepared in the facility. (Cross reference 801) Findings: 1. During a concurrent observation and interview with [NAME] 1, on 5/14/19, at 8:36 a.m., in the kitchen, the temperature gauge on the outside of the cook's reach in refrigerator (R1) was an internal temperature of 38 degrees F and the thermometer on the inside indicated 38 degrees F. Inside R1 there was a plastic container of egg salad dated 5/14/19, which was 44.2 degrees F when temperature was checked. [NAME] 1 stated egg salad was classified as a time/temperature control for safety (TCS) food. During a concurrent observation and interview with the Nutrition Supervisor (NS) and [NAME] 1, on 5/14/19, at 10:37 a.m., in the kitchen, the thermometer inside R1 was a temperature of 40 degrees F. The egg salad temperature in R1 was 43.3 degrees F. The temperatures of three other plastic containers of TCS foods in R1 were checked. The temperature of the cubed ham was 43.2 degrees F, cubed turkey was 44.2 degrees F, and the sliced turkey was 47 degrees F. NS stated the temperatures were not acceptable and [NAME] 1 transferred the contents of R1 to the walk in refrigerator (R2). NS stated the temperature for R1 was not set low enough and placed a maintenance work order to have the temperature settings lowered. [NAME] 1 stated he did not check the temperatures of the TCS foods because the ingredients were all stored in a refrigerator and not at room temperature. The facility policy and procedure titled Food and Supply Storage dated 1/2017, indicated Refrigerated Storage .temperature must be maintained at 41 degrees F or below .units must be capable of maintaining an internal product temperature of 41 degrees F during service periods, which may require a lower ambient air temperature. The facility policy and procedure titled Food Handling Guidelines (HACCP) dated 1/2017, indicated Cold food preparation .Products are chilled again after preparation to 41 degrees F before being served and Cold holding temperatures .Foods should be held cold for service at a temperature of 41 degrees F or less. Professionall reference reivew from the Food and Drug Administration (FDA) Food Code 2017, indicated Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding (A) .(TCS) food shall be maintained .41ºF or less .Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of .41 degrees F to 135 degrees F too long.

Based on interview and record review, the facility failed to have a policy that allowed the storage of food brought into the facility. The facility policy discouraged food from outside the facility being brought into the facility for residents by friends and family. This failure resulted in residents not being able to exercise their right to self-determination in food choices, residents not being able to save left over foods for later consumption, and residents being forced to throw away all perishable foods after two hours. This failure also had the potential to result in decreased amount of foods provided to the residents from family and friends. (Cross reference 806) Findings: During an interview with Registered Dietitian (RD) 1, on 5/14/19, at 10:56 a.m., RD 1 stated the facility did not encourage outside food and the facility would not store the food. She stated the residents had to eat the outside food when it was brought into the facility and then discard any leftovers. During an interview with Resident 88, and Resident 74 on 5/15/19 at 4:05 pm, the residents were expressing concern about the quality of the food in the facility. Both residents stated there was a lack of fresh fruit. Resident 88 stated her family brought her fresh fruit but the facility would not store it for her. Resident 88 stated she was sad she was not able to enjoy the fresh fruit her family brought her beyond the day they brought it in. During an interview with the Activity Coordinator (AC), on 5/15/19, at 4:33 p.m., he stated the residents were allowed to keep food for two hours only and then they had to throw it out. AC stated the facility did not have a refrigerator to store the residents' food and the residents' were not allowed to have personal refrigerators because they would not fit in the residents' rooms. During an interview with the Chief Nursing Officer, the [NAME] President of Ambulatory and Post-Acute, the Director of Nursing (DON), and the Chief Operations Officer (COO), on 5/17/19, at 5:32 pm, COO stated it was a corporate hospital policy to not allow the storage of outside food in the facility and to discourage friends and family from bringing in outside food. The COO stated the facility could not ensure the safety of the food for the residents. DON stated the corporate hospital policy was to discourage outside food but the residents were allowed to have it. DON also stated that no leftovers were stored in the facility and leftover food was thrown away two hours after it was brought in. During an interview with Registered Dietitian (RD) 2, on 5/20/19, at 8:08 a.m., RD 2 stated the residents often ordered in food from outside restaurants if they did not like what was offered on the menu. She stated the facility could not store leftover food per facility policy. RD 2 stated the residents had two hours to eat the food and the residents often shared it but she was unsure what happened to any leftover food after the two hours. The facility policy and procedure titled Food Provision for Patients by Family dated 8/12/13, indicated .food brought into the hospital by family/friends is to be discouraged .food brought in from outside the organization must be eaten by the patient at the time it is brought in and any leftover perishable items will be sent home with the family or discarded within two hours. The facility document titled Food from Home dated March 2011, indicated .we encourage patients and their families to refrain from bringing in prepared foods from home. The document also indicated we [facility] are not allowed to store/refrigerate any prepared food brought in from home.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when three of three outside dumpster's were full of trash and left open. This failure had the potential to encourage the presence and provide safety for rodents and pests. Findings: During a concurrent observation and interview with Dietary Aide (DA) 3 and the Senior Director of Food and Nutrition (SDFN), on 5/15/19, at 9:31 a.m., DA 3 was taking out the kitchen trash. DA 3 stacked a rolling cart with cardboard boxes and three large garbage bags of food service trash. DA 3 took the rolling cart of trash to the outside dumpster area. There were two trash dumpster's in one gated area and one recycling dumpster was in an adjacent gated area. The trash dumpster's were open and trash bags were stacked higher than the top edge of the dumpster's. The trash dumpster's were positioned one in front of the other which left no extra room in the gated area to be closed. The recycling dumpster was open and overflowing with cardboard boxes. DA 3 stated she did not know when the trash was scheduled to be picked up. SDFN stated the trash was picked up daily. DA 3 stated the trash dumpster's were always placed one in front of the other and all three dumpster's were always positioned and left with the lids open. During a concurrent observation and interview with the Environmental Supervisor (ES), on 5/15/19, at 10:41 a.m., ES stated the lids on the dumpster's should always be closed and should not be left open. The facility policy and procedure titled Waste Control and Disposal dated 6/5/18 made no indication that the lids of outside dumpster's were to be closed or for staff to remove the dumpster's from the gated area to open or close the lids. Professional reference review from the Food and Drug Administration (FDA) Food Code 2017, indicated, Section 5-501.15 Outside Receptacle, (A) Receptacles and waste handling units for refuse .shall be designed and constructed to have tight-fitting lids.

During a concurrent observation and interview with the Registered Nurse (RN) 1, on 5/14/19, at 10:13 a.m., in Resident 447's room RN 1 stated there was no label on the tubing attached to the IV (intravenous) antibiotic that hung from a pole beside Resident 447's bed. RN 1 stated there should have been a label on the tubing. During a concurrent observation and interview with RN 3, on 5/15/19, at 4:53 p.m., RN 3 stated Resident 447 had a peripherally inserted central catheter (PICC) for intravenous access site had a dressing dated 5/8/19 over the tubing and was intact and clean. RN 3 stated it was her responsibility to change the dressing since it was scheduled to be changed weekly. During an interview with the DSD, on 5/15/19, 9:43 a.m., he stated all tubing's should have a label with a name and date. The DSD stated the tubing for intravenous antibiotic for Resident 447 should have been changed every 24 hours. During a review of the clinical record for Resident 447, the Client Diagnosis Report dated 1/29/19 indicated .IV medications .Interventions .Medications as ordered .Change dressing and IV as ordered . The facility policy and procedure titled, Intravenous Tubing Changes, Intermittent Infusion Devices & IV Sites dated 9/28/16, indicated, Tubing changes of the main IV set, IV sites, IV Piggybacks and intermittent infusions are to be done every 96 hours .Pharmacy or nurse compounded IV fluids/products are to be infused or discarded within 24 hours or the expiration date on the label, whichever comes first . Based on observation, interview and record review, the facility failed to maintain an effective infection control program to prevent the development and transmission of organisms (germs) for seven of 52 sampled residents (Residents 45, 46, 67, 14, 81, 79, 31 and 447) when medical equipment and supplies used by the residents were not handled or stored in a manner that maintained a sanitary environment. These failures placed Residents 45, 46, 67, 14, 81, 79, 31 and 447 at risk to healthcare-associated infection (infections that Residents that could develop in a healthcare facility while receiving care for other conditions) and compromised their health. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN 4), on 5/14/19, at 10:55 a.m., Resident 45's catheter bag was lying on the ground. LVN 4 stated the urinary bag should not be on the ground. LVN 4 stated Resident 45 could develop a urinary tract infection from laying on the ground. LVN 4 stated, It's an infection control issue. During a concurrent observation and interview with LVN 4, on 5/14/19, at 10:58 a.m., Resident 46's catheter bag was on the ground. LVN 4 stated the urinary bag for Resident 46 should not be on the ground. LVN 4 stated Resident 46 could develop a urinary tract infection from laying on the ground. LVN 4 stated, It's an infection control issue. During an interview with the Director of Staff Development (DSD), on 5/17/19, at 8:03 a.m., the DSD stated all catheter bags were required to hang on the side of the bed and not be on the floor. The DSD stated most catheter associated infections were associated with catheters left on the floor. The facility policy and procedure titled Urinary Catheters, Indwelling and Intermittent - Adult & Adolescent dated 12/13/18, indicated, Purpose A. To reduce the incidence of urinary Catheterization and catheter-associated urinary tract infection [CAUTI] . Catheter collection bag is not touching floor . Review of professional reference from the Centers for Disease Control (CDC) titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS dated 2/15/2017 (https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf) indicated, . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . During a concurrent observation and interview with the Registered Nurse (RN) 1 in Resident 31's room on 5/14/19 at 10:13 a.m., there was a new and unopened carton labeled Jevity 1.5 cal [calorie] (a supplemental liquid nutrition) which hung from a pole. Resident 31's water enteral bag hung from a pole. A label appeared on the water bag dated 5/13/19. An enteral feeding tube was attached to the water bag and contained drops of liquid nutrition. The end of the tubing was dangling and left without being covered. RN 1 stated the tubing needed to be covered and not left dangling on the tube. During a concurrent observation and interview with LVN 5, on 5/14/19, at 10:14 a.m., in Resident 67's room, the enteral (nutrition hydration by way of the gastrointestinal tract) bag dated 5/12/19 hung from a feeding pole. RN 5 stated the bag was dated 5/12/19 which indicated the last time the bag was changed. RN 5 stated all enteral water bags needed to be changed every 24 hours. During a concurrent observation and interview with LVN 5, on 5/14/19, at 11:19 a.m., Resident 14's enteral feeding syringe dated 5/14/19, laid on top of the bedside table. The enteral feeding syringe was without a name or room number. LVN 5 stated all feeding syringes were required to be dated and have the name and room number on the package. During an interview with the DSD, on 5/16/19, at 2:42 p.m., he stated the nurses and the CNA's changed the feeding syringes every day. The DSD stated syringes were labeled with the room number and/or the Resident's name. The DSD stated, We don't have a policy; it's our practice. During an interview with the DSD, on 5/15/19 at 9:43 a.m., he stated the practice for changing the tubing used for administering enteral nutrition is limited to a 24-hour period. The DSD stated licensed nurses needed to throw away the tubing when the feeding was complete for the 24-hour period. The facility policy and procedure titled Continuous Enteral Feeding dated 3/1/18, indicated, Ensure tubing and water bags are changed, dated, and timed prior to hanging a new formula .syringes are dated when changed. Syringes are discarded every 24 hours. Ensure bags that are filled by staff is discarded after 24 hours . During a concurrent observation and interview with LVN 5 on 5/14/19 at 11:46 a.m., Resident 81's small oxygen tank was in the corner of the room on a stand. An uncovered and undated nasal cannula was wrapped around the tank. Resident 81 stated, That's my oxygen and I use it when I need it and when I am short of breath. LVN 5 stated she believed the tubing was changed every 24 hours and all oxygen tubing needed to be labeled with date and time they were changed. LVN 5 stated the oxygen tubing should have been stored inside a bag to protect from contamination. LVN 5 stated Resident 81 could develop a respiratory infection from using the undated oxygen tubing that was not stored inside a bag. During a concurrent observation and interview with LVN 5, on 5/15/19, at 9:16 a.m., Resident 79's small oxygen tank sat on a stand with oxygen tubing rolled around tank. An oxygen cannula was uncovered and unlabeled. LVN 5 stated the oxygen tubing need to be inside a storage a bag when not in used and needed to be labeled with a current date. The facility policy and procedure titled, Respiratory Care Equipment Changes dated 3/1/18, indicated, 2 . nasal cannula's and oxygen administration masks are changed weekly or as needed .All equipment is labeled with the date, and time.