**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure compliance with its policies and procedures regarding resident appointment coordination and verification for one of three sampled residents (Resident 1), when Resident 1 was mistakenly prepared and transported to a medical appointment that was not scheduled for her. This failure resulted in unnecessary physical and emotional distress to Resident 1 and potentially exposed to inappropriate treatment or risk. Findings: During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), dated 4/22/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included, unspecified nondisplaced fracture of fifth cervical vertebrae, unspecified fracture of right acetabulum (concave surface of the of the pelvis), age related Osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment, undated, indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately impaired. During a phone interview on 4/21/25 at 12:03 p.m., with Resident 1's Family Member (FM), FM stated, she was the person responsible for Resident 1's care. FM stated Resident 1 had a fall at home on 2/21/25 and was admitted to the skilled nursing facility on [DATE]. FM stated she was not told that Resident 1 had an appointment at the cancer treatment center. FM stated the facility took Resident 1 to an appointment that was not meant for her. FM stated she spoke to Resident 1 who became upset and started to cry. FM stated Resident 1 did not have cancer and did not want cancer treatment because she did not want to die. During a concurrent interview and record review on 4/22/25 at 8:50 a.m , with the Director of Nursing (DON), the DON reviewed the facility document titled, Order List Report dated 4/22/25. The DON stated the Order list Report shows all scheduled and upcoming appointments for all residents. The DON stated according to the report, there were two residents scheduled for appointments on 2/27/25, but Resident 1 was not one of them. The DON stated Resident 3 and Resident 4 were the ones who had appointments scheduled on 2/27/25. The DON stated Resident 3 was on bed C and shared a room with Resident 1 who was bed A. The DON stated the WC was responsible for putting together the daily list of appointments. The DON stated the Orders List Report are kept at the nurse's station and added to the transport log. The DON stated nursing staff were supposed to check the list every day and make sure the right residents are dressed and ready for the appointments but did not. The DON stated on 2/27/25 the WC mistakenly told staff Resident 1 had an appointment, and staff got Resident 1 ready and sent her out for the appointment. During an interview on 4/22/25 at 9:15 a.m., with the [NAME] Clerk (WC), the WC stated she was responsible for tracking all follow up appointments for residents. The WC stated she reviewed documents for all new admissions and schedule follow up appointments. The WC stated it was her responsibility to inform the nursing staff daily for schedule appointments. The WC stated on 2/27/25 she did not tell the nurse Resident 1 had an appointment. The WC stated she did not schedule an appointment for Resident 1 on 2/27/25. During an interview and record review on 4/22/25 at 10:30 a.m., with licensed vocational nurse (LVN) 1, Resident 1's Medical Records, (MR- a collection of information about a person's health) was reviewed. LVN 1 stated Resident 1 was admitted to the facility on [DATE] and does not have a cancer diagnosis. LVN 1 stated Resident 1 had fractures on her neck and pelvis before coming to the facility and helping her out of bed and getting her dressed for an appointment could have caused more pain. LVN 1 stated there was a list at the nurse's station of residents who have appointments, and staff were supposed to review this list at the beginning of the shift. LVN 1 stated staff should also print a copy of the resident's face sheet and doctor's orders to take with them to the appointment. LVN 1 stated it was the nursing staff's responsibility to make sure the right resident goes to the right appointment, with the right documents, and the correct location. LVN 1 stated she was the nurse assigned to Resident 1 on 2/27/25. LVN 1 stated she did not take the necessary steps to ensure the right resident was sent for the appointment. During an interview on 4/22/25 at 12:20 p.m., the Director of Nursing (DON), The DON stated she spoke with nursing staff about the incident that happened on 2/27/25. The DON stated the nursing staff told her the WC informed them Resident 1 had an appointment on 2/27/25 and needed to be up and dressed. The DON stated the nursing staff helped Resident 1 get dressed. The DON stated Resident 1 was prepared for an appointment that was not scheduled for her. The DON stated the appointment was actually for Resident 3. The DON stated the cancer clinic identified the wrong resident had been sent to the appointment and the clinic notified us. The DON stated we arranged transport for Resident 3 to the clinic. The DON stated the LVN assigned to Resident 1 should have printed Resident 1's face sheet, current doctor's orders, and appointment location. The DON stated LVN's are responsible for making sure the right resident goes to the right appointment with the correct documents and the correct place. The DON stated the WC was responsible for making all transport arrangements. The DON stated the staff did not follow proper procedure for sending resident to appointments, as a result Resident 1 was mistakenly taken to an appointment. The DON stated the incident should not have happened. During an interview on 4/22/25 at 1:25 PM, the Administrator (ADM), the ADM stated the incident on 2/27/25, where Resident 1 was mistakenly sent to an appointment she wasn't scheduled for, should never have happened. The ADM stated this should not happen to any resident. The ADM stated the appointment was actually for Resident 1's roommate. The ADM stated the staff did not follow the facilities policies and procedure. During a review of the facility's Policy and Procedure (P & P), titled, Transportation dated December /2008, the P&P indicated . Our facility shall help arrange transportation for residents as needed . [NAME] Clerk will help the resident as needed to obtain transportation . During a review of the facility's P & P titled, Transfer or Discharge, Resident-Initiated, dated 2001, the P&P indicated . If the resident is being transferred, and return is expected, the following information is conveyed to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; d. All special instructions and/or precautions for ongoing care, as appropriate such as: (1) treatments and devices (oxygen, implants [medical device or object inserted into the body], IVs [intravenous-delivering fluids or medications directly into the veins], tubes/catheters [a medical device use to access or drain areas of the body]); (2) transmission-based precautions such as contact, droplet, or airborne [infection control measures use in healthcare to prevent the spread of infections]; and special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precaution .

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 6) when Resident 6 ' s low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer ' s recommendation. This failure had the potential to result in Resident 6 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 6 at an increased risk for falls and discomfort. Findings: During a review of Resident 6's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/2/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/12/25 to the facility, with diagnoses that included Squamous Cell Carcinoma of Skin (a type of skin cancer most commonly caused by long-term exposure from the sun), Open Wound to Left Cheek, Muscle Weakness, Protein-Calorie Malnutrition (a severe type of malnutrition due to disease progression or lack of food intake), Chronic Pain Syndrome (pain longer than six months and impacting daily life), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 6's Physician Order Summary Report (POS), dated 4/2/25, the POS indicated, . May have Low air loss mattress R/T [related to] Redness to Coccyx area [tail bone] . Order Date 3/18/25 . During a review of Resident 6's Nursing Care Plan (CP), dated 2/12/25, the CP indicated, . Skin: Resident is at risk for skin breakdown related to open wound to left cheek (face) blanchable redness to Coccyx . Interventions . Air Mattress . Date Initiated: 3/18/25 . During a concurrent observation and interview on 4/1/25 at 2:08 p.m., with Registered Nurse (RN) 1, inside Resident 6 ' s room. RN 1 looked at Resident 6 ' s air mattress setting and stated it was set to 450 lbs (pounds, unit of measurement). RN 1 stated Resident ' s weight on 4/1/25 was 78 lbs. RN 1 stated the LAL mattress control clearly states the setting should be according to Resident ' s weight and it was not. RN 1 stated Resident 6 redness to the coccyx area could worsen and potentially develop to a pressure ulcer (bedsore) because of incorrect setting. RN 1 stated Resident 6 could potentially be uncomfortable lying in a firm LAL mattress and placed at increased risk for falls. During a concurrent interview and record review on 4/1/25 at 3:27 p.m., with the Director of Staff Development (DSD), Resident 6 ' s photo of Low Air Loss (LAL) Mattress, dated 4/1/25, and Resident 6 ' s Monthly Weights, undated were reviewed. The DSD stated the photo showed Resident LAL mattress was set at 450 lbs. The DSD stated Resident ' s weight on 4/1/25 was 78 lbs. DSD stated the LAL mattress control clearly states the setting should be according to Resident ' s weight and it was not. DSD stated Resident 6 could potentially develop pressure ulcer because of incorrect setting. DSD stated Resident 6 could potentially be experiencing pain from lying in a firm LAL mattress. During an interview on 4/2/25 at 12:00 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to follow the manufacturer ' s recommendation for use of LAL mattress. The DON stated Resident 6 ' s incorrect LAL mattress setting was not effective in reducing pressure ulcer and could be uncomfortable. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, dated 9/13, the P&P indicated, . The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . 14. Follow any air support surface mattress manufacture guidelines . During a review of the facility ' s document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . During a review of the facility ' s document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Nursing Care Functions . Review the resident ' s chart for specific treatments, medications . Implement and maintain established nursing objectives and standards . During a review of the manufacturer's instructions for use (IFUs) titled, USER MANUAL [brand name] ' , dated 2012, the document indicated, . 4.1 General operation . 5. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level . Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 12 sampled residents (Resident 6) when Resident 6's low air loss (LAL - a special mattress used to prevent skin injuries, often occurring in individuals who are bedbound) mattress setting was not used according to the manufacturer's recommendation. This failure had the potential to result in Resident 6 to develop pressure ulcer (injury to the skin and underlying tissues by prolonged pressure on the skin) and placed Resident 6 at an increased risk for falls and discomfort. Findings: During a review of Resident 6's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) , dated 4/2/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/12/25 to the facility, with diagnoses that included Squamous Cell Carcinoma of Skin (a type of skin cancer most commonly caused by long-term exposure from the sun), Open Wound to Left Cheek, Muscle Weakness, Protein-Calorie Malnutrition (a severe type of malnutrition due to disease progression or lack of food intake), Chronic Pain Syndrome (pain longer than six months and impacting daily life), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 6's Physician Order Summary Report (POS) , dated 4/2/25, the POS indicated, . May have Low air loss mattress R/T [related to] Redness to Coccyx area [tail bone] . Order Date 3/18/25 . During a review of Resident 6's Nursing Care Plan (CP) , dated 2/12/25, the CP indicated, . Skin: Resident is at risk for skin breakdown related to open wound to left cheek (face) blanchable redness to Coccyx . Interventions . Air Mattress . Date Initiated: 3/18/25 . During a concurrent observation and interview on 4/1/25 at 2:08 p.m., with Registered Nurse (RN) 1, inside Resident 6's room. RN 1 looked at Resident 6's air mattress setting and stated it was set to 450 lbs (pounds, unit of measurement). RN 1 stated Resident's weight on 4/1/25 was 78 lbs. RN 1 stated the LAL mattress control clearly states the setting should be according to Resident's weight and it was not. RN 1 stated Resident 6 redness to the coccyx area could worsen and potentially develop to a pressure ulcer (bedsore) because of incorrect setting. RN 1 stated Resident 6 could potentially be uncomfortable lying in a firm LAL mattress and placed at increased risk for falls. During a concurrent interview and record review on 4/1/25 at 3:27 p.m., with the Director of Staff Development (DSD), Resident 6's photo of Low Air Loss (LAL) Mattress , dated 4/1/25, and Resident 6's Monthly Weights , undated were reviewed. The DSD stated the photo showed Resident LAL mattress was set at 450 lbs. The DSD stated Resident's weight on 4/1/25 was 78 lbs. DSD stated the LAL mattress control clearly states the setting should be according to Resident's weight and it was not. DSD stated Resident 6 could potentially develop pressure ulcer because of incorrect setting. DSD stated Resident 6 could potentially be experiencing pain from lying in a firm LAL mattress. During an interview on 4/2/25 at 12:00 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to follow the manufacturer's recommendation for use of LAL mattress. The DON stated Resident 6's incorrect LAL mattress setting was not effective in reducing pressure ulcer and could be uncomfortable. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines , dated 9/13, the P&P indicated, . The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . 14. Follow any air support surface mattress manufacture guidelines . During a review of the facility's document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Nursing Care Functions . Review the resident's chart for specific treatments, medications . Implement and maintain established nursing objectives and standards . During a review of the manufacturer's instructions for use (IFUs) titled, USER MANUAL [brand name]', dated 2012, the document indicated, . 4.1 General operation . 5. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of six sampled residents' (Resident 5) oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. This failure placed Resident 5 at an increased risk to develop respiratory and healthcare-associated infections. Findings: During a review of Resident 5's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/7/25, the AR indicated, Resident 5 was admitted from an acute care hospital on 2/19/25 to the facility, with diagnoses that included Interstitial Pulmonary Disease (a condition that causes inflammation and scarring in the lungs), Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Generalized Muscle Weakness. During a review of Resident 5's Order Summary Report (OSR), dated 7/7/25, the OSR indicated, . Order Summary . Oxygen at 2 liters per minute [L- unit of measurement] via nasal cannula (a device used to deliver supplemental oxygen) . Order Date 2/19/25 . During a review of Resident 5's Nursing Care Plan (CP), dated 4/7/25, the CP indicated, . Resident requires oxygen therapy r/t [related to] INTERSTITIAL PULMONARY DISEASE . Interventions . Administer oxygen as per order . Date Initiated: 11/7/24 . During an observation on 4/1/25, at 2:05 p.m., in Resident 5's room. Resident 5 was lying in bed, asleep and had an oxygen cannula connected to an oxygen concentrator. The oxygen was being given at 2L/min continuously. The oxygen concentrator filter was operating without the filter installed. During a concurrent observation and interview, on 4/1/25, at 2:20 p.m., in Resident 5's room with Registered Nurse (RN) 1, RN 1 looked at Resident 5's oxygen concentrator and stated the oxygen concentrator was operating without a dust filter and it should. RN 1 stated Resident 5's respiratory condition could worsen. RN 1 stated maintaining the cleanliness of oxygen concentrator was the responsibility of the licensed nurses. During an interview on 4/2/25, at 11:54 a.m., with the Director of Nursing (DON), the DON stated using an oxygen concentrator without a filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated she expects the oxygen concentrator to be cleaned weekly and as needed for the safety and well-being of all residents receiving oxygen. The DON stated residents using dirty oxygen concentrators could have respiratory infection such as Pneumonia (lung infection caused by bacteria) and Bronchitis (inflammation of the airways). During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, dated 2/24, the document indicated, . Essential Duties . Ensure that your unit's resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's document titled, Job Description: Registered Nurse (RN), dated 2/24, the document indicated, . Nursing Care Functions . Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner . Safety and Sanitation . Ensure that all nursing service personnel comply with established departmental policies and procedures . Ensuring that all resident care rooms and treatment areas are clean, safe and sanitary manner . Ensure that nursing service personnel follow established infection control policies . During a review of the facility's P&P titled, Oxygen Administration, dated 10/10, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 12/23, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 3. Surveillance and reporting . monitoring adherence to infection and control practices . During a review of the facility's P&P titled, Maintenance Service, dated 12/09, the P&P stated, . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 was found on the floor in his room, and Resident 2 was found on the bathroom floor in his room. Resident 1 and Resident 2 required transportation to the emergency Department (ED) for higher level of care. This failure resulted in Resident 1 and Resident 2 falls not investigated timely within the required time frame and had the potential to result in Resident 1's and Resident 2's safety needs not being met. Findings: During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), dated 03/17/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Alzheimer's (a disease characterized by a progressive decline in mental abilities) . and Chronic Respiratory Failure . During a review of Resident 1's Acute Care Hospital (ACH) document titled, ED Provider Notes, dated,03/01/25 the note indicated, . patient is a 86 y.o. [year old] male . presents to the ED [emergency department] after ground level fall at a Skilled Nursing Facility (SNF) .Patient is unable to bear weight secondary to right hip pain .Emergency Medical Staff (EMS) noted the leg is shortened and extremely rotated (turned) .patient reports nine out of ten pain with any movement to right hip . During a review of Resident 1's Progress Notes (PN) dated 3/17/25 was reviewed. The PN indicated, .Resident 1 admitted to the facility on [DATE] PN indicated, Resident 1 had an unwitnessed fall on 3/1/25 at 1:39 a.m. in his room. PN indicated, staff heard Resident 1 yell and went into his room and found Resident 1 lying on the floor next to bed. PN indicated, Resident 1 complained of pain to his right leg and right hip. PN indicated Resident 1 was noted with abrasions (superficial skin injury caused by scrapping against a rough surface) to his right knee, right shoulder, back of right hand, and right-hand middle finger . During a review of Resident 2's AR dated 03/17/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Muscle wasting and Atrophy (wasting away or decrease in size of a body part) . During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated, Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 3 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2's cognition was severely impaired. During a review of Resident 2's Acute Care Hospital (ACH) document titled, Acute Care Surgery Center Discharge Summary, dated, 2/22/25 the note indicated, . patient is a 77 y.o. [year old] male . presented after being found by SNF staff on ground in bathroom .injuries sustained, Laceration (cut in the skin caused by injury) to scalp . superior/inferior rami (arm or branch of bone) Fracture (Fx) of Pubis (forms the lower and anterior(front) part of each side of the hip) . During an interview on 3/17/25 at 9:30 a.m., with Administrator (ADM), the ADM stated, we do not report all falls. The ADM stated, when a resident was sent to the hospital after a fall, the facility does not know the extent of the injuries, so they did not report the fall incident. During an interview on 3/17/25 at 9:45 a.m., with Assistant Director of Nursing (ADON), the ADON stated, Resident 1 and Resident 2 sustained injuries after the fall. The ADON stated the falls of Resident 1 and Resident 2 should have been reported to the state agency. During a concurrent interview and record review on 3/17/25 at 11 a.m., with the ADON, Resident 2's Medical Records, (MR) dated 2/18/25 were reviewed. The MR indicated, . Resident 2, had an unwitnessed fall on 2/18/25 in his room. The ADON stated, Resident 2 was found on the floor on 2/18/25 at 10:08 p.m. and was sent to the hospital. The ADON stated, MR indicated Resident 2 sustained a Fx to his sacrum (large triangular bone at base of spine). The ADON stated, the fall should have been reported to CDPH. During an interview on 3/17/25 at 11:15 a.m., with ADM, the ADM stated, the Director of Nursing (DON) and I decides if a fall was a reportable event. The ADM stated, Resident 1 and Resident 2 falls were not reported to CDPH within the time frame. The ADM stated, the falls should have been reported to CDPH. During a review of the facility's document titled, Job Description: Administrator, undated, the document indicated . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . During a review of the facility policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001 .The P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations .A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within a forty-eight hour of reporting the event or as required by federal and state regulation . Based on interview and record review, the facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH- State survey agency) within the required time frame for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 was found on the floor in his room, and Resident 2 was found on the bathroom floor in his room. Resident 1 and Resident 2 required transportation to the emergency Department (ED) for higher level of care. This failure resulted in Resident 1 and Resident 2 falls not investigated timely within the required time frame and had the potential to result in Resident 1's and Resident 2's safety needs not being met. Findings: During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), dated 03/17/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Alzheimer's (a disease characterized by a progressive decline in mental abilities) . and Chronic Respiratory Failure . During a review of Resident 1's Acute Care Hospital (ACH) document titled, ED Provider Notes, dated,03/01/25 the note indicated, . patient is a 86 y.o. [year old] male . presents to the ED [emergency department] after ground level fall at a Skilled Nursing Facility (SNF) .Patient is unable to bear weight secondary to right hip pain .Emergency Medical Staff (EMS) noted the leg is shortened and extremely rotated (turned) .patient reports nine out of ten pain with any movement to right hip . During a review of Resident 1's Progress Notes (PN) dated 3/17/25 was reviewed. The PN indicated, .Resident 1 admitted to the facility on [DATE] PN indicated, Resident 1 had an unwitnessed fall on 3/1/25 at 1:39 a.m. in his room. PN indicated, staff heard Resident 1 yell and went into his room and found Resident 1 lying on the floor next to bed. PN indicated, Resident 1 complained of pain to his right leg and right hip. PN indicated Resident 1 was noted with abrasions (superficial skin injury caused by scrapping against a rough surface) to his right knee, right shoulder, back of right hand, and right-hand middle finger . During a review of Resident 2's AR dated 03/17/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) . Muscle wasting and Atrophy (wasting away or decrease in size of a body part) . During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated, Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 3 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2's cognition was severely impaired. During a review of Resident 2's Acute Care Hospital (ACH) document titled, Acute Care Surgery Center Discharge Summary, dated, 2/22/25 the note indicated, . patient is a 77 y.o. [year old] male . presented after being found by SNF staff on ground in bathroom .injuries sustained, Laceration (cut in the skin caused by injury) to scalp . superior/inferior rami (arm or branch of bone) Fracture (Fx) of Pubis (forms the lower and anterior(front) part of each side of the hip) . During an interview on 3/17/25 at 9:30 a.m., with Administrator (ADM), the ADM stated, we do not report all falls. The ADM stated, when a resident was sent to the hospital after a fall, the facility does not know the extent of the injuries, so they did not report the fall incident. During an interview on 3/17/25 at 9:45 a.m., with Assistant Director of Nursing (ADON), the ADON stated, Resident 1 and Resident 2 sustained injuries after the fall. The ADON stated the falls of Resident 1 and Resident 2 should have been reported to the state agency. During a concurrent interview and record review on 3/17/25 at 11 a.m., with the ADON, Resident 2's Medical Records, (MR) dated 2/18/25 were reviewed. The MR indicated, . Resident 2, had an unwitnessed fall on 2/18/25 in his room. The ADON stated, Resident 2 was found on the floor on 2/18/25 at 10:08 p.m. and was sent to the hospital. The ADON stated, MR indicated Resident 2 sustained a Fx to his sacrum (large triangular bone at base of spine). The ADON stated, the fall should have been reported to CDPH. During an interview on 3/17/25 at 11:15 a.m., with ADM, the ADM stated, the Director of Nursing (DON) and I decides if a fall was a reportable event. The ADM stated, Resident 1 and Resident 2 falls were not reported to CDPH within the time frame. The ADM stated, the falls should have been reported to CDPH. During a review of the facility's document titled, Job Description: Administrator, undated, the document indicated . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . During a review of the facility policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001 .The P&P indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations .A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within a forty-eight hour of reporting the event or as required by federal and state regulation .

Based on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate of less than 5%. There were 2 medication errors out of 26 medication opportunities which resulted in a medication error rate of 7.69% affecting 1 (Resident #26) of 6 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An admission Record indicated the facility admitted Resident #26 on 06/26/2024. According to the admission Record, the resident had a medical history that included a diagnosis of protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #26's Care Plan revealed a focus area initiated on 07/02/2024, that indicated the resident had a nutritional problem or potential nutritional problem. Interventions directed staff to administer medications as ordered and to provide and serve supplements as ordered. The Care Plan revealed a focus area initiated 01/06/2025, that indicated the resident was at risk for dehydration and/or electrolyte imbalance. Interventions instructed staff to administer nutrition related medications per physician order. The Care Plan revealed a focus area initiated on 06/26/2024, that indicated the resident was at risk for complications with bowel regimen due to constipation. Interventions directed staff to administer medications pr physician order. Resident #26's Order Summary Report for active orders as of 01/29/2025 revealed an order dated 06/26/2024 for multivitamin with minerals with instructions to give one tablet by mouth one time a day. The Order Summary Report revealed an order dated 08/01/2024 for senna 8.6 milligram (mg) with instructions to give two tablets by mouth two times a day. Observations on 01/29/2025 at 8:28 AM revealed Licensed Vocational Nurse (LVN) #1 preparing and administering medications for Resident #26. Medications included one multivitamin tablet that did not include minerals and two tablets of senna plus (senna with docusate sodium) 8.6-50 mg instead of the senna 8.6 mg ordered without the docusate sodium. During an interview on 01/29/2025 at 11:38 AM, LVN #1 confirmed that she gave a multivitamin tablet without minerals and a senna plus tablet instead of plain senna. She stated she should have checked the label against the order to verify it was the correct medication and then check it again. During an interview on 01/30/2025 at 8:13 AM, the Assistant Director of Nursing (ADON) stated the nurse should follow the seven rights of medication administration, including the right resident, right medication, right route, right time, right dose, right reason, and right documentation. During an interview on 01/30/2025 at 8:17 AM, the Director of Nursing (DON) stated that when the nurses were passing medications, they should be following the seven checks and a triple check against the medication administration record, orders, and medication label. The DON stated the seven checks included the right resident, right medication, right route, right dosage, right reason, right documentation, and right time. She stated the nurses should be following physician orders. During an interview on 01/30/2025 at 8:29 AM, the Administrator stated the nurses should follow the physician orders to ensure they were giving medications accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their admissions policy and procedure for one of three sampled residents (Resident 1) when the facility admitted Resident 1 from the general acute care hospital (GACH) for intravenous (IV-within a vein) antibiotics (medication that fight bacterial [small organism which can cause disease] infections) therapy and the facility did not have registered nurse (RN) on duty to administer the IV antibiotic medication. This failure resulted in Resident 1 not receiving his prescribed IV antibiotic medication and Resident 1 had to be transported back to the GACH just 3 hours after being admitted to the facility. Findings: During a telephone interview on 7/3/24 at 5:02 p.m. with Family Member (FM) 1, FM 1 stated Resident 1 was transferred from the GACH and admitted to the skilled nursing facility for IV antibiotics therapy. FM 1 stated shortly after Resident 1's admission, she received a phone call from the charge nurse informing her the facility did not have an RN on duty to administer the IV antibiotic. FM 1 stated the facility did not provide the services they had said they were capable of, and Resident 1 had to be sent back to the GACH within hours of admission. During a review of Resident 1's Order Summary Report (OSR), dated 6/7/24, the OSR indicated, . Vancomycin HCl [hydrochloride-a salt used to help medication dissolve in liquid] Intravenous Solution [an antibiotic used to treat resistant strains of bacteria] . 750 MG [milligrams-unit of measurement] . Use 167 ml [milliliters-unit of liquid measurement] intravenously every 12 hours for Bacteremia [presence of bacteria in blood] MRSA [methicillin-resistant Staphylococcus aureus-a type of bacteria resistant to certain antibiotics] for 3 Days . During a review of Resident 1's admission Record, (AR-document containing resident demographic information and medical diagnosis), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included disease of anus (opening of the rectum) and rectum (end part of the large intestine), bacteremia (presence of bacteria in blood), dementia (impaired ability to remember, think, or make decisions), major depressive disorder (low or depressed and a loss of interest in activities), and anxiety (feeling or fear, dread, and uneasiness that may occur as a reaction to stress). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1's cognition was moderately impaired. During a concurrent interview and record review on 7/8/24 at 11:22 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's Nurse's Note, dated 6/7/24 at 9:23 p.m. was reviewed. The Nurse's Note indicated, . sent resident to [name of GACH] because she had an IV medication, Vancomycin HCL . due at 2000 [8:00 p.m.] that was not available and also no RN would have been available to administer it . EMT's from [name of ambulance company] left with resident at 1950 [7:50 p.m.] . Writer notified D.O.N. [Director of Nursing] at 1918 [7:18 p.m.] about the order and she called back and said to send resident to hospital . The MDSC stated she did not know why an RN was not available to administer the antibiotic medication. During a telephone interview on 7/8/24 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was the charge nurse on 6/7/24 when Resident 1 was admitted . LVN 1 stated Resident 1 arrived at the facility around 5:30 p.m. and was due for her IV medication at 8:00 p.m. LVN 1 stated there were no RNs on duty to administer the medication. LVN 1 stated he called the Director of Nursing (DON) and was instructed to send the resident back to the hospital because there were no RNs available. LVN 1 stated he notified Resident 1's responsible party and the nurse practitioner (NP) the facility was unable to administer the IV medication and Resident 1 was being transferred back to the GACH. During an interview on 7/15/24 at 2:07 p.m. with the DON, the DON stated Resident 1 was admitted on [DATE] for IV antibiotics and the facility did not have an RN available to administer the 8:00 p.m. dose. The DON stated she was not aware Resident 1's IV antibiotic was ordered every 12 hours prior to her admission. The DON stated she attempted to find an RN to administer the medication but was unsuccessful and Resident 1 was sent back to the GACH. During a telephone interview on 7/15/24 at 3:59 p.m. with LVN 2, LVN 2 stated she was Resident 1's admission nurse on 6/7/24. LVN 2 stated she had received Resident 1's orders and report from the hospital after Resident 1 was transferred to the facility. LVN 2 stated Resident 1 had an order for IV vancomycin every 12 hours and the next dose was due in a couple of hours after her admission. During a telephone interview on 7/15/24 at 4:11 p.m. with the NP, the NP stated the charge nurse contacted her on 6/7/24 and notified her Resident 1 had an order for IV vancomycin but there were no RNs to administer the medication. The NP stated she was concerned Resident 1 not receiving the IV antibiotics and decided it would be safe to send Resident 1 back to the GACH instead of missing an antibiotic dose. During a telephone interview on 7/16/24 at 5:06 p.m. with the Marketing Director/Admissions (MDA), the MDA stated she had received Resident 1's referral from the GACH which indicated Resident 1 was on IV antibiotics every 12 hours. The MDA stated when Resident 1 arrived at the facility from GACH and there was no RN on duty to administer the IV antibiotic medication. The MDA stated Resident 1 should not have been transferred to the facility since there were no RNs available to administer the IV antibiotic medication. During a telephone interview on 7/31/24 at 11:22 a.m. with the Administrator (ADM), the ADM stated Resident 1 was admitted to the facility for IV antibiotics. The ADM stated the facility did not have an RN available to administer Resident 1's IV antibiotic and Resident 1 was transferred back to the GACH. During a review of the facility's job description titled Admissions Director, dated 1/2019, indicated, . Reports to . Administrator and Director of Nursing . Primary purpose of your job is to plan and coordinate admission to the facility . Completes resident intake process. Coordinates with Director of Nursing and/or Case Manager to assure appropriateness of facility admissions . During a review of Resident 1's GACH document titled Discharge Summary (DS), dated 6/7/24, the DS indicated, . admit date . 5/26/24 . Hospital Diagnosis . MRSA bacteremia [presence of bacteria in your blood] . DISCHARGE MEDICATION LIST . vancomycin 750 mg/250 mL solution IVPB [IV piggy back-small bag of solution given IV] . every 12 (twelve) hours for 3 days . Discharging to: Skilled Nursing Facility . Destination [name of SNF] . During a review of the facility's policy and procedure (P&P) titled Admissions Policies, dated 12/2006, the P&P indicated, . primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility . Our admission policies apply to all residents admitted to the facility . The objectives of our admission policies are to . Admit residents who can be adequately cared for by the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of eight sampled residents (Resident 83) was provided a shower three times a week in accordance with the facility practice and the scheduled number of showers for Resident 83. This failure had the potential to result in a negative impact to the resident's quality of life and self-esteem. Findings: During a review of Resident 83's admission Record, (document providing admission date, name, date of birth , emergency contact, insurance information, and diagnoses), dated 2/16/23, the face sheet indicated Resident 83 was admitted on [DATE] for a short term stay with Resident 83's daughter as the first emergency contact. Resident 83 had the following diagnosis on admit: intracranial injury (a condition where a sudden, external, physical blow damages the brain), traumatic subdural Hemorrhage (a condition of bleeding inside the skull, and pressure in the brain), Type 2 Diabetes (an impairment in the way the body regulates and uses sugar), chronic kidney disease (kidneys are damaged and cannot filter blood normally), congestive heart failure (a condition where the heart muscle doesn't pump blood normally), abnormal gait and mobility, hyperlipidemia (condition where fat molecules build up in the blood), syncope (fainting) and collapse (fall), history of falling, chronic pain. During a review of Resident 83's document titled MDS 3.0 (Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents.), dated 12/21/22, indicated in Section C Cognitive Patterns a Brief Interview for Mental Status (BIMS- test is used to get a quick snapshot of how well a resident is functioning cognitively at the moment. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment.) was completed and indicated Resident 83 had a BIMS of 3 suggesting his cognitive status was severely impaired. MDS 3.0 section G Functional Status for Bathing How resident takes full-body bath/shower, sponge bath, and transfers in /out of tub/shower .4. Total dependence . During an interview on 2/15/23, at 11:02 a.m., with Resident 83's Daughter who is his Responsible Party/Emergency contact (RP), the RP stated her father was upset that he did not have a shower for two weeks. During a concurrent interview and record review on 2/15/23, at 1:36 p.m. with the Licensed Vocational Nurse (LVN) 1, Resident 83's ADL (Activities of Daily Living- shower/bath, teeth brushed and more) Bathing/Shower documentation for January 2023, dated 2/16/23 and the Facility's Station 1 AM Shower Schedule were reviewed. LVN 1 stated Resident 83 was scheduled to have showers on Tuesday's, Thursday's and Saturdays. LVN 1 stated while reviewing the ADL Bathing/Shower document the documentation on 1/13/23-1/17/23, 1/19/23 and 1/23/23 indicated NA (not applicable). LVN 1 reviewed the nursing notes and other areas of Resident 83's electronic health record and stated she was not able to locate any notes indicating the resident had refused or why there were no showers given. During an interview on 2/15/23, at 1:47 p.m., with the Director of Nursing (DON), the DON stated we try and encourage residents to take showers or baths three to four times a week and staff will adjust the schedules for the resident preferences. The DON stated she did not know what was meant by the NA on the ADL Bathing/Shower documentation and stated she would get back with an answer. During an interview on 2/16/23, at 2:38 p.m., with two Certified Nursing Assistants (CNA), CNA 1 and CNA 2 both stated showers/baths are offered to residents three times a week. During an interview on 2/17/23, at 10:35 a.m., with CNA 3, CNA 3 stated, NA for showers means it's not their shower day, not applicable. If shower is refused, hit (meaning to document/click) the refuse box. Every time the resident takes a shower, fill out a shower sheet with the body picture on it. During an interview on 2/17/23, at 11:24 a.m., with The Director of Staff Development (DSD), the DSD stated she conducts the education for staff for bathing/showering and where it should be documented. The DSD stated this task comes up in the staff's PCC (Point click Care- electronic charting required for their shift) for their assigned showers. DSD stated staff are supposed to document if the activity was a bed bath or shower, chart and fill out a shower sheet even if the resident refused, and notify the nurse or charge nurse if the resident refused and obtain that nurses signature on the shower sheet. The DSD stated if the charge nurse is not available, the staff can bring it to her. The DSD stated she noticed the PCC is generating a shower for every shift, every day when the resident is admitted . The DSD stated since showers are showing up every day for some residents' staff have been clicking the NA if it is not their shower day. During a concurrent interview and record review on 2/17/23, at 3 p.m., with the Director of Nursing (DON), Resident 83's shower sheets were reviewed. The DON stated residents are offered showers three times a week and the staff use a shower schedule based on what room the resident is in. The DON stated after reviewing the shower sheets for Resident 83's admission starting 12/15/22 and discharged [DATE], there were shower sheets missing for the following days 1/17/23, 1/21/23, 1/28/23 and 1/3/23. The DON stated it is the facility's practice if the resident refuses, the staff should still be filling out a shower sheet and indicate that the resident has refused along with telling the charge nurse that the resident refused and getting a signature on the shower sheet from the charge nurse. The DON stated she is not sure why this did not happen for Resident 83. The DON stated it is important that residents get their ADL (activities of daily living to include showers, oral care and more) care for proper hygiene. Review of facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 3/2018, indicated, Policy Statement Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . During a review of the facility's P&P titled, Resident Rights, dated 12/2016, indicated, Policy Statement Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c.be free from abuse, neglect, misappropriation of property, and exploitation; . e. self-determination; . g. exercise his or her rights as a resident of the facility . h. be supported by the facility in exercising his or her rights .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for one of 76 sampled residents as evidenced when: 1. The facility failed to ensure Resident 74 with severe unplanned weight loss was identify in a timely manner and recommend nutritional interventions. This failure resulted in Resident 74 experienced severe unplanned weight loss 21 pound (lb.) 16.2 percent (%) within five months from 7/1/2022, until 12/3/2022. 2. The Registered Dietician failed to reevaluate Resident 74's comprehensive nutrition assessment per facility policy. This failure had the potential risk to place Resident 74 for impaired nutrition status or compromised nutritional status. (Cross reference F801). Findings: During a review of Resident 74's admission Record (document containing resident demographic information and medical diagnosis), dated 2/15/23, the admission record indicated Resident 74 was admitted to the facility on [DATE]. Resident's diagnoses included .Unspecified Dementia (the loss of ability to think, remember, learn and make decisions) .Muscle weakness (Lack of muscle strength) .Pure Hyperglycemia (high levels of cholesterol in the blood) . A record review of Resident 74 was conducted. During a weight record reviewed, Resident 74 had a 21 pound (lb.) 16.2 percent (%) weight loss in five months from July 1, 2022, until [DATE]. The five month weight loss percent was calculated using the 130 lbs. on 2/1/2022, and the 109 lbs. on 12/3/2022. 7/1/22- 130 lbs. 8/1/22- 120 lbs. 8/7/22-117 lbs. 8/15/22-118 lbs. 9/2/22-117.2 lbs. 10/2/22-114 lbs. 11/2/22-112 lbs. 12/3/22-109 lbs. 12/11/22-108 lbs. 12/18/22-108.2 lbs. 12/25/22-105.2 lbs. 12/28/22-105 lbs. 1/1/23-106 lbs. 1/8/23 107.6 lbs. 1/15/23-107 lbs. 1/22/23-107 lbs. 1/29/23-109.6 lbs. 2/2/23-110 lbs. 2/5/23-110.4 lbs. During a review of Resident 74's Minimum Data Set (MDS) (a clinical assessment tool), Section K, dated 12/4/22, indicated, weigh loss of 5% or more in the last month-not on physician-prescribed weight-loss regimen. During a review of Resident 74's Physician's orders dated, 2/15/23, the Physician's Orders indicated as the following .Date ordered 12/6/22: Fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement in residents' nutrition status) Regular texture, Thin Liquids consistency, for weight loss . Dated ordered 1/5/23: House Nourishment (Nutrition drinks that has high calories and protein which use to promote improvement in residents' nutrition status) three times a day for weight loss with meals-give 4 oz . Dated ordered 1/5/23: Magic Cup (a special kind of ice cream has high calories which use for promoting improvement in residents' nutrition status) three times a day with meals-supplements . Dated ordered 5/31/22: Weekly weights x 4 weeks . Dated ordered 12/13/22: Megestrol Acetate Suspension 40 MG/ML Give 10 ml by mouth one time a day for Appetite Stimulant for 60 Days until end date 2/12/23 . During a record review of Resident 74's Nutritional Risk Assessment (Admission), dated 6/10/22, the Nutritional Risk Assessment indicated, .F. Cueing at meals, .J.Significant weight changes: > or = 5 % within 30 days, . Comments: Severe 12 % weight loss from 150 pounds at the acute hospital. K. Food Intake: 26-74% of Meals .M. Resident information: . Most Recent Weight: 132.0 pound, Date: 6/02/2022 . Diet: Regular . S. Nutrition Goals/Monitoring and Evaluation: 1. Nutrition Goals/Monitoring and Evaluation: No significant nutrition issues . During a review of Resident 74's Progress - Weight Change Note, dated 8/3/22, the Progress Note indicated, IDT (Interdisciplinary team): Certified Dietary Manager (CDM), Social Service Director (SSD), Registered Dietician (RD). Weight: 120 pounds 8/1/22. Comparison weight 7/1/22, 130 pounds, -7.7 %, -10 pounds per month. She consumed < 50 % on Regular diet and is refusing some meals. Son brings in food from outside sources that she enjoys. Eats with supervision.Encourage her to eat. Recommend dining room at lunch and dinner. Progress note signed by Registered Dietician (RD 2) . During a review of Resident 74's IDT Weight Variance Assessment (WVA), dated 12/19/22, the WVA indicated, .Problem: 1. Weight -21.8 lbs. 2. Weight loss (%) -16.8, . 4. In (x) number of months: 5 months, .Current interventions: Megace, Fortified diet, Magic cup 2 times per day (BID), House Nourishment three times per day (TID), Diet: Fortified diet, Regular texture, This Liquids consistency, Average % intake: 32%, Nourishment: None, Appetite Stimulant: Megestrol Acetate Suspension 40 MG/ML, Previous Weight: 108lb. on 12/11/2022, current weight 108.2 lbs. on 12/18/2022, Review of Potential Casual Factors: Meal observation (Nursing/Dietary) Slow eater Root cause Analysis: Significant weight decrease may be related to 1. Decrease oral intake. 2. History of dementia, 3. Recent lumbar fracture. 4. Possible pain related to lumbar fracture.Intervention/Implementations: 1. Continue current diet. 2. Honor food preferences, 3. Encourage oral intake. 4. History of dementia. 5. Continue supplements. Add to task list. 6. Weekly weights. 7. Continue appetite stimulant. 8. CDM to re-obtain food preferences . During a review of Resident 74's IDT Weight Variance Assessment (WVA), dated 12/27/22, the WVA indicated, .Problem: 1. Weight -24.8 lbs. 2. Weight loss (%) -19.1 . 4. In (x) number of months: 5 months, .Current interventions: Megace, Fortified diet, Magic cup BID, House Nourishment TID, Diet: Fortified diet, Regular texture, This Liquids consistency, Average % intake: 32%, Nourishment: Magic cup BID, House Nourishment TID, Appetite Stimulant: Megestrol Acetate Suspension 40 MG/ML, Previous Weight: 108.2 on 12/18/2022, current weight 105.2 lbs. on 12/25/2022, .Usual body weight: 132 lb. Review of Potential Casual Factors: Meal observation (Nursing/Dietary) Slow eater . Root cause Analysis: Significant weight decrease may be related to 1. Decrease oral intake. 2. History of dementia, 3. Recent lumbar fracture. 4. Possible pain related to lumbar fracture. Intervention/Implementations: 1. Continue current diet. 2. Honor food preferences, 3. Encourage oral intake. 4. Continue supplements. Add to task list. 5. Weekly weights. 6. Care conference for potential hospice . During a review of Resident 74's IDT Weight Variance Assessment (WVA), dated 1/10/23, the WVA indicated, .Problem: 1. Weight -14 lbs. 2. Weight loss (%) -11.7 . 4. In (x) number of months: 6 months, .Current interventions: Megace, Fortified diet, Magic cup BID, House Nourishment TID, Diet: Fortified diet, Regular texture, This Liquids consistency, Average % intake: 39%, Nourishment: Magic cup BID, House Nourishment TID, Appetite Stimulant: Megestrol Acetate Suspension 40 MG/ML, Previous Weight: 106 on 1/1/2023, current weight 107.6 lbs. on 1/8/2023, .Usual body weight: 132 lb. B. Review of Potential Casual Factors: Meal observation (Nursing/Dietary) Slow eater .Root cause Analysis: Significant weight decrease may be related to 1. Decrease oral intake. 2. History of dementia, 3. Recent lumbar fracture. 4. Possible pain related to lumbar fracture. Intervention/Implementations: 1. Continue current diet. 2. Honor food preferences, 3. Encourage oral intake. 4. Continue supplements. Add to task list. 5. Weekly weights. 6. Refer to RNA dining when open . During a review of Resident 74's IDT Weight Variance Assessment (WVA), dated 1/16/23, the WVA indicated, .Problem: 1. Weight -23 lbs. 2. Weight loss (%) -17.69 . 4. In (x) number of months: 6 months, .Current interventions: Megace, Fortified diet, Magic cup BID, House Nourishment TID, Diet: Fortified diet, Regular texture, This Liquids consistency, Average % intake: 37%, Nourishment: Magic cup BID, House Nourishment TID, Appetite Stimulant: Megestrol Acetate Suspension 40 MG/ML, Previous Weight: 107.6 on 1/8/2023, current weight 107 lbs. on 1/15/2023, .Usual body weight: 132 lb. B. Review of Potential Casual Factors: Meal observation (Nursing/Dietary) Slow eater Root cause Analysis: Significant weight decrease may be related to 1. Decrease oral intake. 2. History of dementia, 3. Recent lumbar fracture. 4. Possible pain related to lumbar fracture. Intervention/Implementations: 1. Continue current diet. 2. Honor food preferences, 3. Encourage oral intake. 4. Continue supplements. Add to task list. 5. Weekly weights. 6. Refer to RNA dining when open . During a review of Resident 74's Interdisciplinary Team note, dated 1/19/23. The IDT note indicated, .IDT met 1/18/23 regarding weight loss -23 lbs. or -17.69 % in 6 months. Resident is on a fortified regular texture diet with thin liquid, 38% meal intake, history of dementia, possible pain due to Hx (history) of lumbar fracture, current/new interventions 1. Continue current diet. 2. Honor food preferences. 3. Encourage oral intake. 4. Continue supplements. Add to task list. 5. Weekly weights. 6. Refer to RNA dining when open and will notify MD for any changes . During a review of Resident 74's IDT Weight Variance Assessment (WVA), dated 1/23/23, the WVA indicated, .Problem: 1. Weight -23 lbs. 2. Weight loss (%) -17.69 . 4. In (x) number of months: 6 months, .Current interventions: Megace, Fortified diet, Magic cup BID, House Nourishment TID, Diet: Fortified diet, Regular texture, This Liquids consistency, Average % intake: 38%, Nourishment: Magic cup BID, House Nourishment TID, Appetite Stimulant: Megestrol Acetate Suspension 40 MG/ML, Previous Weight: 107.6 on 1/15/2023, current weight 107 lbs. on 1/22/2023, .Usual body weight: 132 lb.Review of Potential Casual Factors: Meal observation (Nursing/Dietary) Slow eater Root cause Analysis: Significant weight decrease may be related to 1. Decrease oral intake. 2. History of dementia. Intervention/Implementations: 1. Continue current diet. 2. Honor food preferences, 3. Encourage oral intake. 4. Continue supplements. Add to task list. 5. Weekly weights. 6. Continue RNA dining. 7. Continue plan of care . 1. During a concurrent interview and record review, on 2/15/23, at 11:46 AM, with the Director of Nursing (DON) and the Registered Dietician (RD), Resident 74' Weight Change progress note, dated 8/3/22, Resident 74's IDT Weight Variance Assessment, dated 12/19/22, 12/27/22, 1/10/23, 1/16/23, 1/19/23 and 1/23/23 were reviewed. The RD stated criteria put Resident on weekly IDT weight variance was significant weight loss/gain 3 lbs. for 1 week, 5% in 1 month, 7.5% in 3 months, 10% in 6 months. The DON and the RD reviewed all IDT weight variance progress note and stated Resident 74 only have one IDT weight variance progress note on 8/3/22 from previous Registered Dietician. The DON and the RD acknowledged based the facility' Policy Nutritionally At Risk, the Nutritional at Risk Committee supposed monitor Resident 74 weekly for weight loss since 8/3/22. As evidence showed that the Nutritional at Risk Committee did not monitor and intervene in the care of Resident 74, Resident 74 experienced severe unplanned weight loss 21 pound (lb.) 16.2 percent (%) within five months from 12/1/2022, until 12/3/2022. According to the American Academy of Family Physician journal, indicated Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4). According to the American Academy of Family Physician journal, indicated Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician). During a review of the facility's policy and procedure (P&P) titled, Nutritionally At Risk (NAR) Committee, dated 12/30/14, the P&P indicated,The facility has a Nutritionally at Risk (NAR) Committee for the purpose of monitoring and intervening in the care of patients as it relates to weight loss and weight gains . Procedure: The committee will identify, prevent, and reduce the risk factors associated with nutritional disorders. Criteria for NAR monitoring: Significant weight loss/gain -3% in 1 week, 5% in 1 month, 7.5% in 3 months, 10% in 6 months .Consuming less than 50 % of meals and weight loss has been identified. Key Components and Procedures for NAR Monitoring 1.It is the responsibility of the entire team (dietician, Director of Nursing, QA (Quality Assurance) Nurse, Unit managers, ADON (Assistant Director of Nursing), Social Service (S.S), Nurse Assessment Coordinator (MDS), Dietary Manager and Administrator) to assure that all residents meeting the criteria for NAR monitoring are placed on the weekly weight list . 2. During a concurrent interview and record review, on 2/15/23, at 11:46 AM, with the Registered Dietician (RD). Resident 74 had history of several unplanned weight loss since July 1, 2022, there was no reevaluate comprehensive nutrition assessment done by the RD. The RD stated, it should be a more recent comprehensive nutritional assessment for Resident 74. I do plan to see her. She is on my list of comprehensive nutritional assessment . During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 2017, the P&P indicated, Policy Statement: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Policy Interpretation and Implementation: 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident . as indicated by a change of condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: . d.) Dietitian: (1) An estimate of calorie, protein, nutrient and fluid needs; (2) Whether the resident's current intake is adequate to meet his or her nutritional needs. (3) Special food formulations . During a review of the facility's Job Description position titled, Registered Dietician, dated on 9/2017, the Job Description indicated, General Purpose: Complete nutritional .and significant change reviews on residents according to federal and state guidelines.Complete nutritional reviews monthly on high risk residents (significant weight loss, .). Essential Duties: .Assess nutritional needs .

Based on observation, interview, and record review, the facility failed to ensure residents were free of unnecessary drugs for two of five sampled residents (Resident 5 and Resident 41) when: 1. Facility failed to remove lidocaine patch (used for relief of neuropathic nerve pain [occurs when a health condition damages the nerves that carry sensation to the brain]) to left knee within 12 hours as specified by manufacturer guidelines for Resident 5. 2. Facility failed to monitor, and order Thyroid Stimulating Hormone (TSH- a hormone produced by the pituitary gland [a gland in the brain]. It prompts the thyroid gland to make and release thyroid hormones into the blood) labs (a blood test which measures TSH) annually as clinically indicated for levothyroxine (used to treat thyroid hormone deficiency) for Resident 41. Theses failures had the potential for Residents prescribed medications to be inadequately monitored and assessed for the need and effectiveness of the medications being received. Findings: 1. During an observation of medication administration on 2/14/23, at 9:12 a.m., at Station 3 with Registered Nurse (RN) 1, RN 1 placed a lidocaine 4% patch to Resident 5's left knee. No prior patch in place that required removal was noted or observed. During a concurrent interview and record review, on 2/14/23, at 2:15 p.m., with License Vocational Nurse (LVN) 4, LVN 4 reviewed Point Click Care (PCC- Health care software that stores residents' health record electronically) and indicated Resident 5's PCC Electronic Medical Record (E-MAR) lidocaine patch 4% with start date of 5/3/22 stated, Apply to left knee topically one time a day for left knee pain and remove per schedule. Scheduled for application daily at 9 a.m. and removal at 8:59 a.m. LVN 4 stated according to the schedule, the patch would be left on the left knee for 24 hours prior to removal, followed by immediate application of a new lidocaine patch. Upon reviewing the manufacturer instruction provided by facility, LVN 4 stated the manufacturer guidelines indicated lidocaine patch should be on for 12 hours within a 24-hour period. LVN 4 acknowledged the facility was not following directions according to manufacturer guidelines. LVN 4 stated if the lidocaine patch was left on more than what the manufacturer indicated, the possibility of skin irritation and interactions with other medications could possibly occur for Resident 5. During a concurrent interview and record review, on 2/14/23, at 2:50 p.m., with the Director of Nursing (DON) and RN 1, the DON reviewed PCC and stated Resident 5's current order indicated lidocaine patch to be applied at 9 a.m. and removed right before administration at 8:59 a.m. RN 1 stated Resident 5's mother was very involved in care and when she stated her son was in pain so primary physician ordered lidocaine Patch to left knee. During a review of Resident 5's E-MAR record dated 2/15/23, the E-MAR indicated .lidocaine order start date of 5/2/22 18:55, Lidocaine path 4% Apply to left knee topically one time a day for left knee pain and remove per schedule . During a concurrent interview and record review, on 2/15/23, at 3:05 p.m. with the DON, the DON stated order for lidocaine patch has been clarified and changed to lidocaine patch to be applied at 9 a.m. and removed and 9 p.m. The DON acknowledged the nursing staff was not removing and applying Resident 5's lidocaine patch according to manufacturer specifications. The DON stated medication has been proven to work best when following manufacturer guidelines. The DON stated irritation would occur if patch was not used per manufacturer guidelines. During an interview on 2/15/23, at 3:56 p.m. with the Contracted Registered Pharmacist (RPH), the RPH stated, lidocaine patch should be removed within 12 hours and that is the standard to which he would hold the facility. RPH stated usually lidocaine patches are ordered in two separate orders, one order for application time and another for removal time. RPH stated it is important to follow manufacture guidelines in order to prevent accumulation when patch remains on past the designated allotted time; removing patch as per guidelines prevents irritation. During a review of the facility's P&P titled, Administering Medications revised 4/2019, the P&P indicated, .Medication are administered in accordance with prescriber orders . 2. During a concurrent interview and record review, on 2/14/23, at 2:45 p.m., with RN 1, RN 1 reviewed PCC indicated Resident 41 received 75 mcg [microgram] (a unit of measurement) every day at 6 a.m. with a start date of 12/23/22. RN 1 was unable to provide documentation of lab monitoring of levothyroxine for the year 2022. RN 1 stated the importance of TSH labs obtain proper medication dosage to ensure levothyroxine was helping Resident 41's condition. During a review of Resident 41's clinical record, the DON was unable to provide documentation of TSH lab order or results for 2022. The DON acknowledged TSH labs should have been obtained for Resident 41. During a concurrent interview and record review, on 2/15/23, at 3:05 p.m., with the DON, the DON stated Resident 41's TSH labs are important as they ensure medications are doing what they are supposed to in the proper dosage required. By not ensuring proper dosage is being provided, resident is at risk for weight fluctuations and behaviors. During a review of Resident 41's admission Records, dated 2/15/23, the admission Records indicated Resident 41 diagnosis information history included .hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream) . During a review of Resident 41's E-MAR record dated 2/15/23, the E-MAR indicated an order start date of 12/23/22 Levothyroxine Sodium Tablet 75 mcg, Give 1 tablet by mouth in the morning for Hypothyroidism. Administration of medication was noted on E-MAR with dates and initials of nurses providing the medication for the month of February. During an interview on 2/15/23, at 3:55 p.m. with The RPH, the RPH stated TSH labs were generally conducted one a year unless a change of dosage then it is conducted within 6 weeks from that change. The RPH stated that the importance of TSH labs were to ensure normal ranges and desired effects of levothyroxine medication are being distributed. During a review of DailyMed (https://dailymed.nlm.nih.gov/dailymed/getFile.cfm?setid=5be7ee95-a27e-409d-881f-927f42074033&type=pdf) a National library of Medicine that publishes up to date accurate drug labels to health care providers and general public . In adult patients with primary (thyroidal) hypothyroidism, serum TSH levels (using a sensitive assay) alone may be used to monitor therapy. The frequency of TSH monitoring during levothyroxine dose titration depends on the clinical situation but it is generally recommended at 6-8 week intervals until normalization.It is recommended that a physical examination and a serum TSH measurement be performed at least annually in patients .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** BASED ON IDR REVIEW F756 WAS MOVED TO F836 Based on interview and record review, the facility's Pharmacy Consultant (PC) failed to follow standards of practice to identify irregularities and make recommendations for two of five sampled residents (Resident 5 and Resident 41) when: 1. Facility failed to remove lidocaine patch (used for relief of neuropathic nerve pain [occurs when the nerves that carries sensation to the brain is damage]) to left knee of Resident 5 within 12 hours as specified by manufacturer guidelines. 2. Facility failed to order Thyroid Stimulating Hormone (TSH- a hormone produced by the pituitary gland [a gland in the brain] which tells the thryroid how much hormone it [NAME] to make) labs - a blood test which measures the thyroid hormone level in the blood) annually as clinically indicated for Levothyroxine (used to treat thyroid hormone deficiency, including a severe form known as myxedema coma) for Resident 41. These failures had the potential to result in the residents increased risk for adverse effects as follows but not limited to, skin irritation, burning, discomfort, redness or swelling for Resident 5 and not providing the proper dosage of medication for hypothyroidism (a condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream) for Resident 41. Findings: 1. During an observation on 2/14/23, at 9:12 a.m., medication cart 3 on station 3 with Registered Nurse (RN 1), RN 1 was observed placing Lidocaine 4% patch to Resident 5's left knee. No prior patch in place that required removal was noted or observed. During a concurrent interview and record review, on 2/14/23, at 2:50 p.m., with the Director of Nursing (DON), the DON reviewed Point Click Care (PCC- Health care software) and indicated Resident 5's order currently indicate Lidocaine patch to be applied at 9:00 a.m. and removed right before administration at 8:59 a.m. During a concurrent interview and record review, on 2/14/23, at 2:15 p.m., with License Vocational Nurse (LVN4), LVN 4 reviewed Point Click Care and stated Resident 5's PCC Electronic Medical Record (E-MAR) Lidocaine patch 4% with start date of 5/03/22 states, apply to left knee topically one time a day for left knee pain and remove per schedule. Scheduled for application daily at 9:00 a.m. and removal at 8:59 a.m. LVN 4 stated according to that schedule the patch would be left on the left knee for 24 hours prior to removal and application of new Lidocaine Patch. Upon reviewing the manufacturer instruction provided by facility and reviewed by LVN 4, LVN 4 stated that manufacturer guidelines state patch should be on for 12 hours within a 24-hour period. LVN 4 stated, facility was not following directions according to manufacturer guidelines. LVN 4 stated if the Lidocaine patch is left on more than what the manufacturer states, the possibility of skin irritation and interactions with other medications can possibly occur for Resident 5. During a concurrent interview and record review, on 2/15/23, at 3:05 p.m., the DON stated order for Lidocaine patch has been rectified and order now indicated for Lidocaine patch to be applied at 9 a.m. and removed at 9 p.m. Previous orders were not according to manufacturer specifications per DON. The DON stated medication has been proven to work best when following manufacturer guidelines. The DON stated irritation would occur if patch was not used per manufacturer guidelines. The DON stated she will follow up with Resident 5's primary physician to obtain as needed orders in case patch were to fall off during care. During a review of Resident 5's admission Records(AR- document with resident demographic information), dated 2/15/23, the AR indicated Resident 5's diagnosis information history included; .Polyneuropathy in diseases classified elsewhere (disease process that includes symptoms that range from weakness and a pins-and-needles sensation or loss of sensation) and .Quadriplegia (refers to paralysis from the neck down, including the trunk, legs and arms) . During a review of Resident 5's Electronic Medication Administration(E-MAR), record dated 2/15/23, the E-MAR indicated Lidocaine order start date of 5/02/22 6:55 p.m., Lidocaine path 4% Apply to left knee topically one time a day for left knee pain and remove per schedule . During an interview on 2/15/23, at 3:56 p.m. with the Contracted Registered Pharmacist (RPH), the RPH stated lidocaine patch should be removed within 12 hours and that is the standard he would hold the facility to do so. The RPH stated usually Lidocaine patches are ordered in two separate orders, one order for application time and another for removal time. The RPH states it is important to follow manufacture guidelines in order to prevent accumulation when patch remains on past the designated allotted time. Removing patch as per guidelines prevents irritation. During a review of the facility's P&P titled, Pharmacy Services-Role of the Consultant Pharmacist revised April 2019, the P&P indicated, . The consultant pharmacist will provide specific activities related to medication regimen review including: . Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated . 2.) During a concurrent interview and record review, on 2/14/23, at 2:45 p.m., with RN 1, RN 1 reviewed Point Click Care (PCC- Health care software) indicating Resident 41 receives 75 mcg [micrograms] (a unit of measurement) every day at 6:00 a.m. with a start date of 12/23/22 prescribed by Physician. No recent TSH labs were noted or observed in electronic medication administration records by RN 1. RN 1 stated the importance of TSH labs being ordered are to ensure adjustments are made for the medication in order to obtain proper dosage if not, the dosage is not helping her condition. During a review of Resident 41's General Acute Hospital labs dated 10/01/21, TSH results indicated a range of 3.6 uIU[micro-international units per milliter]/ML [milliliter] (a unit of measurement) within the normal range of 0.4-5.5 iIU/ML. This lab was the most recent indication that the resident's TSH levels were checked while being on Levothyroxine. No TSH labs were collected for year 2022. Confirmed with DON. During a concurrent interview and record review, on 2/15/23, at 3:05 p.m., with the DON, the DON stated Resident 41's TSH labs are important as they ensure medications are doing what they are supposed to in the proper dosage required. By not ensuring proper dosage is being provided, resident is at risk for weight fluctuations and behaviors. During a review of Resident 41's AR dated 2/15/23, the AR indicated Resident 41 diagnosis information history included .Hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream) . During a review of Resident 41's E-MAR record dated 2/15/23, the E-MAR indicated an order start date of 12/23/22 Levothyroxine Sodium Tablet 75 mcg, Give 1 tablet by mouth in the morning for Hypothyroidism. Administration of medication was noted on E-MAR with dates and initials of nurses providing the medication for the month of February. During an interview on 2/15/23, at 3:55 p.m. with the RPH, the RPH stated, TSH labs are generally conducted one a year unless a change of dosage then it is conducted within 6 weeks from that change. The RPH stated the importance of TSH labs are ordered to ensure normal ranges and desired effects of Levothyroxine medication are being distributed. During a review of the facility's P&P titled, Pharmacy Services-Role of the Consultant Pharmacist revised April 2019, the P&P indicated, . The consultant pharmacist will provide specific activities related to medication regimen review including: . Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated . During a review of Medline Plus (https://medlineplus.gov/lab-tests/tsh-thyroid-stimulating-hormone-test/), a National Library of Medicine used as a reliable public resource guideline for consumers, indicates . A TSH test is used to find out how well your thyroid is working . which allows physicians to treat appropriately with proper medication for those suffering from Hyper and Hypothyroidism.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during the survey period of 2/13/23 through 2/17/23, the facility failed to ensure each bedroom accommodated no more than four residents in eight of 37 rooms (Rooms' 9, 11, 27, 29, 34, 36, and 38 and 39). This failure had the potential to adversely effect care provided to residents. Findings: Throughout the survey period from 2/13/23 through 2/17/23, observations and interviews were conducted for the following rooms: Rooms' 9, 11, 27, 29, 34, 36, 38 and 39. There was an open partition between room [ROOM NUMBER] and room [ROOM NUMBER] which would allow visitors, staff and residents to enter both rooms freely without accessing a door. There were four residents occupying room [ROOM NUMBER] and four residents in room [ROOM NUMBER], totaling eight residents with the shared open partition in the center wall of both rooms. The same configuration was observed for room [ROOM NUMBER] and room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. During survey observations and residents and staff interviews, there was reasonable amount of privacy provided, storage closet was adequate and storage space was available. Wheelchairs and toilet facilities were accessible to residents. There was sufficient space for residents and staff to provide resident care. Nursing care of the residents was not impacted. Recommend waiver continue in effect. --------------------------------------------------------------- Date Health Facilities Evaluator Supervisor II Signature ____________________________________ Facility Administrator Signature Date

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 69's AR, dated 3/2021, the AR indicated, Resident 69 was admitted to the facility on [DATE]. Resident 69's diagnoses included .MAJOR DEPRESSIVE DISORDER (mental condition characterized by persistent sadness, loss of pleasure or interest in life) . ANXIETY DISORDER (persistent and excessive worry that interferes with daily activities) . The AR indicated a Responsible Party (an individual that holds responsibility and oversees decision making for a resident) for the resident. During a review of Resident 69's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/12/22, the MDS indicated, Resident 69's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall. 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), scored 5 of 15 which indicated Resident 69 had severe cognitive impairment. During a concurrent interview and record review, on 2/17/23, at 11:50 a.m., with DON, Resident 69's Informed Consent-Psychoactive Medication (ICPM), dated 12/19/22 was reviewed. The ICPM indicated Resident 69's Responsible Party agreed the use of mirtazapine (a medication used to treat depression [mood disorder characterized by feelings of sadness and loss of interest]) on 12/19/22. Resident 69's MAR was reviewed. The DON stated Resident 69 was administered mirtazapine once a day from 12/6/22 through 12/31/22. The DON stated the Informed Consent to administer mirtazapine to Resident 69 was not obtained and the doctor did not explain the risk and benefits to Resident 69's Responsible Party prior to medication administration and should have. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/16, the P&P indicated, . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: . be informed about his or her rights and responsibilities . be notified of his or her medical condition and of any changes in his or her condition. be informed of, and participate in, his or her care planning and treatment . During a review of the facility's P&P titled, Informed Consent Policy, dated 4/17, the P&P indicated, the resident or responsible party will be provided informed consent when applicable . the physician will provide education to the resident or responsible party to include the risks, benefits, and alternatives of a given procedure or intervention . Based on observation, interview and record review, the facility failed to ensure a physician Informed Consent (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) for two of five sampled residents (Resident 34, and Resident 69) was obtain when: 1. Resident 34 was administered lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) without an Informed Consent. 2. Resident 69 was administered mirtazapine (a medication used to treat depression [mood disorder characterized by feelings of sadness and loss of interest]) on 12/6/22 to 12/31/22 and Informed Consent was not obtained prior to medication administration. These failures resulted for Resident 34 and Resident 69 to be administered with psychotropic medications and not fully informed of the risk and benefits and did not have the knowledge to make an informed decision which could place Resident 34 and Resident 69 at risk for negative side effects. Findings: 1. During a concurrent observation and interview on 2/13/23, at 11:40 a.m., in room [ROOM NUMBER], Resident 34 was lying in bed watching TV. Resident 34 stated he was admitted in the facility on 12/2022 due to a fall and injured his back. During a review of Resident 34's clinical record titled, admission Record (AR), (document with resident demographic information), dated 2/15/23, the AR indicated, Resident 34 was admitted on [DATE], with a diagnoses which included wedge compression fracture (break in the front of the vertebrae) of first and third lumbar ( lower back bones), anxiety and depression. During a review of Resident 34's, Order Details dated, 12/31/22, the Order Details indicated, .[brand name] 1 MG [one milligram- unit of measurement] one tablet PRN [as needed] every 8 for Anxiety . During a review of Resident 34's, Medication Administration Record (MAR- a document that shows the medications ordered and taken by an individual), dated 1/1/23-1/31/23, the MAR indicated, lorazepam medication was administered every day starting from 1/1/23 thru 1/11/23. During a concurrent interview and record review on 2/15/23, at 1:49 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 34's electronic clinical record order for lorazepam. LVN 2 stated the lorazepam was first ordered on 12/31/22, and the Informed Consent for the lorazepam was signed on 1/4/23. LVN 2 stated the lorazepam was administered to Resident 34 on 1/1/23, 1/2/23, 1/3/23 and 1/4/23 before the informed consent was signed. LVN 2 stated psychotropic medications should have an Informed Consent prior to administration. LVN 2 stated the licensed nurse who received the order for lorazepam should have obtained an Informed Consent and explained the risk and benefits to Resident 34 prior administration. During a concurrent interview and record review on 2/17/23, at 9:50 a.m., with the Director of Nursing (DON), the DON reviewed Resident 34's electronic clinical record for the psychotropic medication Informed Consent form. DON stated Resident 34's Informed Consent for the lorazepam was signed on 1/4/23. DON stated Resident 34 was administered lorazepam medication on 1/1/23, 1/2/23, 1/3/23 and 1/4/23 without an Informed Consent signed. DON stated the lorazepam should have not been administered to Resident 34 without an Informed Consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 2/13/23, at 10:55 a.m., Resident 17 was seen in her bed, head of bed elevated 30 degrees, slightly turned to her left side, when we attempted to converse with Resident 17, she was talking to herself in Spanish and never indicated that she was being spoken to. During a review of Resident 17's AR, dated 2/17/23, the AR indicated Resident 17 was an [AGE] year old female admitted on [DATE] with diagnoses that included Alzheimer's disease (generalized degeneration of the brain causing memory loss), major depressive disorder (mental condition characterized by persistent depressed mood and long-term loss of pleasure or interest in life), Anxiety disorder (intense excessive and persistent worry and fear about everyday situations), tremor (involuntary quivering movement), Osteoporosis (bones become brittle and fragile from loss of tissue). During a review of Resident 17's MDS Section C Cognitive Patterns, dated 1/27/23, the MDS indicated in C0100 entered code '0', 0. No (resident is rarely/never understood) 'Skip to and complete C0700-C1000. Staff Assessment for Mental Status . C0700. Short-term Memory OK (coded) 1. Memory problem C0900. Long-term Memory OK (coded) 1. Memory problem . C1000. Cognitive Skills for Daily Decision Making (coded) 3. Severely impaired - never/rarely made decisions . Section M Skin Condition M0300. Current Number of Unhealed Pressure Ulcers/Injuries at End Stage (not coded) ., Sections M letters A-G are all uncoded indicating these areas were not filled in, Section N Medications . N0410. Medications Received Indicate the number of DAYS the resident received the following medications . during the last 7 days . Enter Days (coded) '0' F. Antibiotic . During a review of Resident 17's, Change in Condition Evaluation (CCE), dated 1/10/23, the CCE indicated, 1. Signs & Symptoms Identified 1. The change in condition, symptoms or signs I am calling about is/are: (check marked) 25. Skin wound or ulcer 2. This starred on: 01/10/2023 3. What time of day did this start? (marked) 1. Morning . 3. Review Findings and Provider Notifications . 4. Summarize your observations, evaluation and recommendations: Hospice nurse here today to see resident, noted st. 2 pressure ulcer to palm of left hand. N.O. start on Metrodinazole (antibiotic) 250 mg [milligrams] tab topically as follows: cleanse area with n/s, pat dry, crush Metrodinazole tab apply to affected area, apply dry dressing and wrap with Kerlix (bandage rolls) x 7 days and monitor Q [every] shift for s/s [signs and symptoms] of infection . During a review of Resident 17's MAR for 1/2023, the MAR indicated Resident 17 was on Metrodinazole . Apply to left palm topically in the evening for left palm wound infection until 01/24/2023 23:59 . Start Date- 01/18/2023 1900 . During a concurrent interview and record review on 2/17/23, at 12:01 p.m., with the DON, Resident 17's Change of Condition Evaluation dated 1/10/23, MDS dated [DATE], and MAR for 1/2023 was reviewed. The DON stated the MDSC is in training and new to his position. The DON stated after reviewing the documents for Resident 17 the stage 2 pressure ulcer and the antibiotic Metrodinazole were not placed on the MDS dated [DATE] and the expectation was that if the stage 2 were still present and if the resident was still on the antibiotic within the 7 day look back period they should have been placed on the next MDS and this was not done. During a review of facility's P&P titled, Resident Assessment, dated 3/22, the P&P indicated, .the interdisciplinary team uses the MDS form currently mandated by federal and State regulations to conduct the resident assessment . Review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, indicated in Chapter 2 Assessments, An SCSA is appropriate when: there is a determination that a significant change (either improvement of decline in a resident's condition . resident's condition is not expected to return to baseline within two weeks . any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as activity did not occur since last assessment . emergence of a new pressure ulcer at stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status Must be completed . within 14 days after the determination that the criteria are met for a Significant Change in Status assessment. 1. During a review of Resident 9's face sheet titled admission Record, undated, the face sheet indicated, resident 9 was admitted to the facility on [DATE], with diagnoses which included fracture (break in bone) of shaft of right tibia (shin bone), rheumatoid arthritis (autoimmune disease causes inflammation in the body including joints), cerebral infarction (stroke- result of disrupted blood flow to the brain), wedge fracture of unspecified lumbar vertebrae (fractured spine), and personal history of malignant neoplasm of bronchus and lung (cancer in the tissues of the lung). During a review of Resident 9's MDS assessment, dated 2/10/23, the MDS assessment indicated Resident 9's Brief Interview for Mental Status (BIMS-screening tool used in nursing facility to assess cognition) assessment score was 10 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 9 has moderate cognitive deficit. During a concurrent observation and interview on 2/15/23, at 11:42 a.m., Resident 9 was observed laying in bed with her eyes closed. Resident 9 had wound closure strips (strips of tape put across an incision or minor cut) on the back of the right hand. Resident 9 opened her eyes and stated she hit her hand on an object which caused a skin tear. During a concurrent interview and record review on 2/15/23, at 4:25 p.m., with Licensed Vocational Nurse (LVN) 2 and LVN 3, Resident 9's physician orders dated 2/2023 was reviewed. Resident 9's physician orders indicated, .Enoxaparin Sodium Injection Solution Prefilled Syringe 40mg [milligrams]/0.4 ml [millilitters] (units of measurement) (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for DVT PPX (deep vein thrombosis [a blood clot in the legs, pelvis] prophylaxis- [measured to diminish the risk of DVT]) for 2 weeks. LVN 2 stated Resident 9 received an anticoagulant injection daily. LVN 3 stated the anticoagulant increased Resident 9's risk for excessive bleeding in the body which could be dangerous, and the resident should be monitored for anticoagulant side effects. During a concurrent interview and record review on 2/16/23, at 2:51 p.m., with the MDS, the MDS reviewed Resident 9's MDS admission assessment Section N dated 2/3/23, Section N indicated, .Injections . Record the number of days that injections of any type were received . last 7 days or since admission . [coded as 2] . Indicate the number of DAYS the resident received the following medications by pharmacological classification . during the last 7 days or since admission/entry or reentry if less than 7 days . Enter 0 if medication was not received by the resident during the last 7 days . Enter [number or] Days . Anticoagulant [coded as 0] . The MDS reviewed Section N and stated he had entered a 2 for injections since admission and 0 for anticoagulant. The MDS reviewed Resident 9's physician orders and medication administration record and stated Resident 9 had [brand name] anticoagulant injection twice since admission to the facility. The MDS stated the anticoagulant in Section N was inaccurate and should have been coded as 2. During an interview on 2/17/23, at 9:50 a.m., with the DON, the DON stated her expectation was for the MDS assessment to be performed accurately and the MDS should match the assessment of the resident when it was reported to Centers for Medicare and Medcaid Services (a goverment agency which provides health coverage). BASED ON THE IDR REVIEW, RESIDENTS' 43, 52, AND 7'S FINDINGS WERE DELETED, THEREFORE, LOWERING THE SCOPE/SEVERITY TO E. Based on observation, 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 two of nine sampled residents ( Resident 9 & Resident 17) when: 1. Resident 9's anticoagulant medication (medication used to prevent blood clots in the legs) was inaccurately coded on the MDS section N (medications). 2. Resident 17's new pressure ulcer and current antibiotic were not coded in the MDS. These failures had the potential for Resident 9, and Resident 17's necessary care and services not met. Findings:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 3 of 4 sampled residents (Resident 9, Resident 79 and Resident 40) when: 1. Resident 9 did not have a care plan addressing the use of anticoagulant medication. This failure had the potential for Resident 9 to experience severe bruising and bleeding which could lead to serious medical condition and hospitalization. 2. The facility did not implement interventions and a plan of care to treat Resident 79's significant edema (when excess fluid collects in the body) to his bilateral (both right and left) upper extremities (arms). This failure had the potential for Resident 79 to experience medical complications including fluid overload (too much fluid in the body), worsening heart failure (heart does not pump blood effectively) and shortness of breath which could lead to hospitalization. 3. Resident 40 was administered anticoagulant (blood thinner), and receiving oxygen via nasal cannula and did not have care plans for the use of anticoagulant medication and use of oxygen. This failure had the potential for Resident 40 to experience severe bruising and bleeding which could lead to serious medical condition and respiratory needs not met. Findings: 1. During a review of Resident 9's AdmissionRecord (AR), (a document that gives a patient's information at a quick glance, which includes brief medical history, preference, and contact information) undated, the face sheet indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses which included fracture (break in bone) of shaft of right tibia (shin bone), rheumatoid arthritis (autoimmune disease causes inflammation in the body including joints), cerebral infarction (stroke- result of disrupted blood flow to the brain), wedge fracture of unspecified lumbar vertebrae (fractured spine), and personal history of malignant neoplasm of bronchus and lung (cancer in the tissues of the lung). During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment, dated 2/10/23, the MDS assessment indicated Resident 9's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) assessment score was 10 out of 15 which indicated Resident 9 had moderate cognitive deficit. During a concurrent observation and interview on 2/15/23, at 11:42 a.m., Resident 9 was observed lying in bed with her eyes closed. Resident 9 had a wound closure strips (a strip of tape put across an incision and minor cut) on the back of the right hand. Resident 9 opened her eyes and stated she hit her hand on an object which caused a skin tear. During a concurrent interview and record review on 2/15/23, at 4:25 p.m., with Licensed Vocational Nurses (LVN) 2 , Resident 9's Physician Orders, dated 2/2023 was reviewed. Resident 9's physician orders indicated, .Enoxaparin Sodium Injection Solution [medication used to prevent blood clots in the legs] Prefilled Syringe 40mg[milligrams]/0.4 ml[milliliter] (unit of measurements) (Enoxaparin Sodium) Inject 40 mg subcutaneously one time a day for DVT PPX (deep vein thrombosis [a blood clot in the legs, pelvis] prophylaxis- [measured to diminish the risk of DVT]) for 2 weeks. LVN 2 stated Resident 9 was administered anticoagulant medication by way of injection daily. During a concurrent interview and record review on 2/15/23, at 4:30 p.m., with LVN 3, Resident 9's electronic medical record (EMR-an electronic collection of medical information about a patient stored on a computer) undated was reviewed. LVN 3 stated she was unable to locate the care plan for the use of anticoagulation medication. LVN 3 stated the anticoagulant medication administered to Resident 9 was not care planned and placed Resident 9 at risk to go unmonitored for major bleeding complications from the use of anticoagulation medication. During a concurrent interview and record review on 2/16/23, at 3:54 p.m., with the Director of Nurses (DON), the DON stated Resident 9's physician orders included an order for [brand name of anticoagulant] 40 mg one time daily from 2/4/23 to 2/18/23. The DON stated the [brand name of anticoagulant] should have been care planned on admission to the facility, and the care plan nursing interventions should have included to monitor Resident 9 for bruising, bleeding, discoloration, black tarry (dark sticky stools can indicate sign of internal bleeding) stools, severe headache, nausea and vomiting, diarrhea and report symptoms to the physician. The DON stated the anticoagulant was a high risk medication and the side effects should have been monitored closely to prevent serious medical complications from anticoagulant medication used. During a review of the facility's Policy and Procedure (P&P) titled Anticoagulation-Clinical Protocol, dated November 2018, The P&P indicated, .Assessment and Recognition . 1. As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example those with the recent history of deep vein thrombosis DVT (blood clots in the deep veins which could loosen and travel to lungs), or heart valve replacement, atrial fibrillation (irregular rapid heart beat) or those who have had recent joint replacement surgery . a. Assess for any signs or symptoms related to adverse drug reactions due to medication alone or in combination with other medications . b. Assess for evidence of effects related to the subtherapeutic (lower than therapeutic) or greater than therapeutic drug level related to that particular drug . 2. In addition, the nurse shall assess and document/report the following . a. Current anticoagulation therapy, including drug and current dosage . b. Recent labs, including therapeutic drug monitoring . 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems . a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant . 2. During a review of Resident 79's AR, undated, the admission record indicated, Resident 79 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (loss of muscle mass and decreased strength), type 2 diabetes mellitus (impairment in the way your body uses sugar for fuel), acute kidney failure (kidneys are not able to remove waste and extra water from blood), hypertensive heart disease with heart failure (chronic high blood pressure which causes heart to not pump blood effectively), and cirrhosis of the liver (scarring in the liver). During a review of Resident 79's MDS assessment, dated 2/7/23, the MDS assessment indicated Resident 79's BIMS assessment score was 10 out of 15 indicating Resident 9 has moderate cognitive deficit. During a concurrent observation and interview on 2/13/23, at 11:04 a.m., Resident 79 was observed sitting in a wheelchair next to his bed. Resident 79 was Spanish speaking only and hard of hearing. Resident 79's right hand had significant edema. Resident 79 held up his hands and made fists, his right hand remained significantly swollen and the knuckles were not visible. Resident 79's left hand had moderate edema with his knuckles slightly visible. Resident 79 wore brown, elastic geri-sleeves (used to provide slight compression to aid in relieving the discomfort associated with swelling) on bilateral arms, Certified Nursing Assistant (CNA) 4 entered the room and adjusted the sleeves down over Resident 79's hands. CNA 4 stated the edema to Resident 79's hands had been present for a few days. During a concurrent interview and record review on 2/15/23, at 4:16 p.m., with LVN 2, Resident 79's care plans were reviewed. LVN 2 stated she was unable to locate a care plan addressing Resident 79's upper extremity edema. LVN 2 stated the purpose of care plans were direct the nursing interventions for the resident's care. During a concurrent interview and record review on 2/15/23, at 4:20 p.m., Resident 79's care plans were reviewed. LVN 3 stated she was the treatment nurse and Resident 79 had significant edema to his upper extremities. LVN 3 stated she located a care plan for heart failure but it did not address the upper extremity swelling and edema. LVN 3 stated she was unable to locate a care plan addressing the upper extremity edema. LVN 3 stated the licensed nursing staff should have assessed Resident 79's upper extremities and entered a care plan to direct the medical care of the resident. During a concurrent interview and record review on 2/16/23, at 11:22 a.m., with LVN 2, Resident 79's physician orders (PO) dated February 2023 were reviewed. LVN 2 stated she was unable to locate an order to monitor Resident 79's upper extremities. LVN 2 stated edema could affect Resident 79's blood pressure and cause fluid overload. LVN 2 stated she was unable to locate a care plan regarding Resident 79's upper extremity edema and if it was not documented it was not done. LVN 2 stated care plans were important because another nurse should be able to review a care plan and have a full picture of what the resident needs were and how to meet them. During an interview and record review on 2/16/23, at 3:16 p.m., with the DON, Resident 79's PO, care plans and nurse's notes were reviewed. The DON stated Resident 79 had chronic edema to his legs. The DON stated Resident 79 had a recent weight gain due to his edema and starts and stops [brand name of diuretic]. The DON looked surprised when asked if she had looked at Resident 79's arms and would not answer if she was aware of the upper extremity edema. The DON reviewed the PO dated February 2023 and stated Resident 79 had geri-sleeves ordered for his arms on 2/12/23. The DON reviewed the indication for the geri-sleeves and stated they were ordered due to his picking at the skin. The DON reviewed Resident 79's admission assessment and stated the admission assessment indicated left hand swelling, abrasions and bruises to arms. The DON reviewed Resident 79's care plans and stated she was unable to locate a care plan for the bilateral upper extremity edema. The DON stated the licensed nurses should have entered a care plan to address the upper extremity edema. The DON stated Resident 79's care plan needed to be updated to provide Resident 79 the best care. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated March 2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident . Policy interpretation and implementation . 3. The care plan interventions derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person centered care plan . a. includes measurable objectives and time frames . b. describes the services that are furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being, including . (1) Services that would otherwise be provided for the above .(3) Which professional services are responsible for each element of care . c. Includes the resident stated goals upon admission and desired outcomes .e. Reflex currently recognize standards of practice for problem areas and conditions . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the residents problem areas and their causes, and relevant clinical decision making . 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change . 3. During a concurrent observation and interview on 2/13/23, at 11:30 a.m., in Resident 40's room, Resident 40 was observed with oxygen via nasal cannula (plastic tubing device to deliver supplemental oxygen), family member (FM) 2 at bedside. Resident 40 was Spanish Speaking and FM 2 was interpreting. FM 2 stated Resident 40 had been in the facility for more than two months. During a review od Resident 40's clinical record titled, admission Record, dated 2/15/23, indicated Resident 40 was admitted to the facility with diagnosis of atrial fibrillation ([AFIB]irregular, often rapid heart rate that commonly causes poor blood flow). During a concurrent interview and record review on 2/15/23, at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 40's Order Summary Report dated 2/15/23, was reviewed. Order Summary Report undated, indicated, . Oxygen- at 2 Liters/Min via nasal cannula PRN (as needed) for SOB (shortness of breath). Goal to maintain 02 (oxygen) sats (saturation) greater than 90% (percent) as needed for SOB . Order Status Active . Order Date 02/11/2023 . [[NAME] name] Tablet 2.5 MG [milligram-unit of measure-used to prevent blood clots]. Give 1 tablet by mouth two times a day for AFIB . Order Status Active . Order Date 11/29/22 . LVN 1 reviewed Resident 40's care plans. LVN 1 stated, there was no care plan developed for the use of oxygen and [brand name]. LVN 1 stated care plans was developed to direct the care of the resident. LVN 1 stated the care plan should have been started as soon as the orders were received and the nurse who received the orders should have made the care plan. During a concurrent interview and record review on 2/15/23, at 3:03 p.m., with LVN 5, LVN 5 stated Resident 40 used oxygen via nasal cannula and was started due to her difficulty of breathing. LVN 5 reviewed Resident 40's care plans and stated there was no care plan developed for the use of oxygen. During an interview on 2/17/23, at 10 a.m., with the DON, the DON stated her expectation was for the licensed nurse to start the care plan right away as soon as the order was received. The DON stated she needed time to teach the licensed nurses to do care plans. The DON stated, . I need more time to clean up and help MDSC with the care planning . During a review of the facility's policy and procedure (P&P) titled, Care Plans- Baseline, dated 2022, the P&P indicated, . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within forty-eight (48) hours of the resident's admission and meets the requirements of a comprehensive care plan . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment . The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident; highest practicable physical, mental, and psychosocial well-being . During a review of the facility's Policy and Procedure (P&P) titled Anticoagulation-Clinical Protocol, dated November 2018, The P&P indicated, .Assessment and Recognition . 1. As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example those with the recent history of deep vein thrombosis DVT (blood clots in the deep veins which could loosen and travel to lungs), or heart valve replacement, atrial fibrillation (irregular rapid heart beat) or those who have had recent joint replacement surgery . a. Assess for any signs or symptoms related to adverse drug reactions due to medication alone or in combination with other medications . b. Assess for evidence of effects related to the subtherapeutic (lower than therapeutic) or greater than therapeutic drug level related to that particular drug . 2. In addition, the nurse shall assess and document/report the following . a. Current anticoagulation therapy, including drug and current dosage . b. Recent labs, including therapeutic drug monitoring . 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems . a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant .

Based on observation, interview and record review, the facility failed to ensure residents were free of medication errors in excess of five percent when the facility's medication error rate was 9.52 percent. There were 42 opportunities for errors and 4 medication errors occurred with four of eight sampled residents (Resident 5, Resident 13, Resident 38 and Resident 41). This failure resulted in medication errors for Resident 5, Resident 13, Resident 38 and Resident 41 which placed residents at risk of experiencing adverse side effects without adequate monitoring. Findings: 1. During a medication pass observation on 2/14/23, at 7:58 a.m., with Registered Nurse (RN 1), RN 1 was observed preparing the following medications for Resident 13: Insulin Aspart (a man-made insulin used to control high blood sugar in adults and children with diabetes mellitus [a disease that result in too much sugar I he blood] 14 units (a unit of measurement) and Insulin glargine (is a long acting insulin used in adults with type 2 diabetes and adults and children (6 years of age and older) with type 1 diabetes) 42 units (a unit of measurement). RN 1 administered insulin injections insulin Aspart 14 units to Lower right Abdomen and Insulin glargine 42 units to Upper Right Abdomen to Resident 13 who was in resting in bed. During a concurrent interview and record review, on 2/14/23, at 1:54 p.m., with Registered Nurse (RN 1), RN indicated during the insulin injections for Resident 13, nursing staff have four options in the abdomen on where to inject, Left upper abdomen, Left lower abdomen, Right upper abdomen and Right lower abdomen. RN 1 stated nursing staff try to rotate sites but its whatever the resident prefers. RN 1 confirmed insulin injection to Left upper abdomen was utilized and documented for injection received on 2/14/23 at 7:58 a.m. as well as previous history on Point Click Care (PCC-Health Care software) indicated previous injection given and documented by RN 1 the day before on 2/13/23 at 7:47 a.m., was also given to Resident on Left upper abdomen. RN 1 stated it is important to rotate sites as resident may not be getting full absorption of insulin and blood sugars may not go down as indicated with use of insulin. During a concurrent interview and record review, on 2/15/23, at 3:14 p.m., with Director of Nursing (DON), The DON stated the expectation for insulin administration is for nursing staff to rotate injection sites in order to make sure medication is absorbing correction, if not, resident may not be getting correct dosage. The DON will educate staff concerning rotation of sites and will provide body chart with designated locations to assist with rotation of sites. During a review of Resident 13's admission Records, dated 2/15/23, the admission Records indicated Resident diagnosis information history included Type 2 Diabetes Mellitus (DM II) with other specified complications (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems) . During a review of Resident 13's E-MAR (Electronic Medication Administration) record dated 2/15/23, the E-MAR stated Insulin glargine (, a drug used to control the amount of sugar in the blood of patients with diabetes) insulin pen-injector (a pre-filled pen that contains multiple doses of insulin) inject 42 units subcutaneously in the morning for DM II. Hold if FSBS (Fingerstick Blood sugar-one method of glucose (sugar) monitoring) is less than 70 or great than 400 . During a review of Resident 13's E-MAR dated 2/15/23, the documentation for 2/13/23, at 7:47 a.m., indicated RN 1 documented subcutaneous injection of Lantus to Abdomen Left upper quadrant and on 2/14/23, at 7:58 a.m., documentation indicates RN injected Lantus subcutaneous to Resident 13's Left upper quadrant again, utilizing the same quadrant location as the day before. Blood sugar documented indicating a reading of 143 on 2/14/23. During a review of clinical drug information from [name of facility's pharmacy] for Insulin glargine , manufacture guideline state . move site where you give the shot each time . During a review of the facility's policy and procedure (P&P) titled, Administering Medications revised April 2019, the P&P indicated, .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: . d. injection site (if applicable) . During a review of Healthline (https://www.healthline.com/health/diabetes/lipohypertrophy#symptoms)a committed health guidance resource guideline, indicated .Lipohypertrophy (a lump of fatty tissue under your skin caused by repeated injections in the same place) can occur with repeated insulin injections in the same location which can cause fat and scar tissue to accumulate Areas with Lipohypertrophy can cause delays in absorption of medication administered to the affected area, like insulin, which can result in difficulties controlling blood sugar . 2. During a medication pass observation on 2/14/23, at 8:31 a.m., with RN 1, RN 1 was observed preparing the following medications for Resident 38: Insulin glargine 30 units and Insulin Aspart 18 units. RN 1 administered insulin injections to Resident 38's right lower abdomen. Resident 38 had a partially eaten breakfast tray which consisted of but not limited to a sesame seed sandwich and banana on the tray. During a concurrent interview and record review, on 2/14/23, at 2:08 p.m., with RN 1, RN 1 indicated she administered Insulin Aspart 18 units of insulin injection to resident while Resident 38 had already started on his breakfast. Upon review of PCC, RN 1 stated orders indicate to provide insulin before meals. RN 1 states the importance to do so is to ensure accurate blood sugars are obtained prior to food consumption in order to provide correct dosage. During a concurrent interview and record review, on 2/15/23, at 3:16 p.m., with the DON, the DON stated the expectation for insulin administration is for nursing staff normally provides insulin 15 minutes before meals. DON states since Resident 38 had already started eating, she would question if the blood sugar take was accurate prior to insulin administration. The DON states staff normally check blood sugar before the Residents meal. During a review of Resident 38's admission Records, dated 2/15/23, the admission Records indicated Resident diagnosis information history included . Type 2 Diabetes Mellitus without complications (DM II) . During a review of Resident 38's E-MAR dated 2/15/23, the E-MAR indicated Insulin Aspart 18 units insulin pen (device pre-filled with insulin) inject 18 units subcutaneously before meals and at bedtime for DM. Hold if FSBS is less than 80. Notify MD if FSBS is less than 70 or greater than 400. Blood sugar documented indicating a reading of 129 on 2/14/23 with injection of Insulin Aspart documented and administered on 2/14/23, at 7:03 a.m., to Left upper quadrant in abdomen by RN 1. During a review of clinical drug information from [name of facility's pharmacy] for Insulin Aspart, manufacture guideline state . inject the dose within 5 to 10 minutes before a meal . During a review of the facility's policy and procedure (P&P) titled, Administering Medications revised 4/2019, the P&P indicated, .Medications are administered in accordance with the prescriber orders, including any required time frame . 3. During a medication pass observation on 2/14/23, at 8:50 a.m., with RN 1, RN 1 was observed preparing the following medication for Resident 41 Fluticasone Nasal Spray (is used to relieve symptoms of nonallergic rhinitis such as sneezing and runny or stuffy nose). Bottle was new and unwrapped, RN 1 unwrapped bottle and while preparing medication, did not prime or shake spray prior to administration to resident. Resident self-administered medication while sitting up in wheelchair next to her bed. RN 1 did not provide instruction to Resident prior to self-administration. During a concurrent interview and record review, on 2/14/23, at 2:15 p.m., with RN 1, RN confirmed, during medication observation pass, new bottle of Fluticasone was unwrapped but not primmed prior to administration of medication. RN 1 stated resident she did not provide instruction to resident as resident takes it everyday, so Resident knows. RN 1 stated it is important to prime bottle in order to get the adequate dosage. During a concurrent interview and record review, on 2/15/23, at 3:14 p.m., with the DON , the DON stated the expectation for fluticasone is to prime bottle to ensure patient gets the accurate dosage and to follow manufacture specifications. During a review of Resident 41's admission Records, dated 2/15/23, the admission Records indicated Resident 41's diagnosis information history included .Type 2 Diabetes mellitus with diabetic polyneuropathy(affects multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs and feet) . Type 2 Diabetes mellitus with Diabetic chronic kidney disease(affects the kidneys' ability to do their usual work of removing waste products and extra fluid from your body) .hypertensive heart disease without heart failure(a long-term condition that develops over many years in people who have high blood pressure) . During a review of Resident 41's E-MAR record dated 2/15/23, the E-MAR indicated Fluticasone Propionate 1 spray in each nostril one time a day for Seasonal allergies one spray to each nostril once a day. RN 1 documented initials indicated administration on 2/14/23. During a review of clinical drug information from Model Drug Inc for Fluticasone Nasal Spray, manufacture guideline state .some products may have different ways to prime the pump. Some pumps may also need to be primed if not used for different periods of time. Follow how and when to prime as you have been told . shake well before use . During a review of the facility's policy and procedure (P&P) titled, Administering Medications revised 4/2019, the P&P indicated .Medications are administered in accordance with the prescriber orders . 4. During a medication pass observation on 2/14/23, at 9:12 a.m., with RN 1, RN 1 was observed preparing the following medication Phenytoin (used to control certain type of seizures, and to treat and prevent seizures that may begin during or after surgery to the brain or nervous system) 125 mg [milligrams]/5 ml [milliliters] (a unit of measurement) and poured out 5ml's in a plastic medicine cup (cups that are used for dispensing medications). RN 1 did not shake bottle of solution prior to pouring in medicine cup and administered medication via gastrostomy tube (also called a G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 5. During a concurrent interview and record review, on 2/14/23, at 2:50 p.m., with RN 1, RN confirmed, during medication observation pass, Phenytoin solution bottle was not shaken before pouring medication onto medicine cup prior to administration. RN 1 states the importance of shaking solution is to ensure Resident 5 is obtaining the correct prescribed dosage. During a concurrent interview and record review, on 2/15/23, at 3:27 p.m., with the DON , the DON stated the expectation for Phenytoin solution, nursing staff are to follow manufacture guidelines and should be rocked prior to administration. If solution is not mixed properly, medication is not being given in the appropriate dosage. During a review of Resident 5's admission Records, dated 2/15/23, the admission Records indicated Resident 5's diagnosis information history included; Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus (A disorder in which nerve cell activity in the brain is disturbed, causing seizures) .Unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy) . During a review of Resident 5's E-MAR, record dated 2/15/23, the E-MAR indicated Phenytoin Suspension 125 mg/5 ml, Give 5 ml's via G-Tube three times a day for seizures. Documented administration noted on E-MAR by RN 1 on 2/14/23. During a review of the facility's policy and procedure (P&P) titled, Administering Medications revised 4/2019, the P&P indicated .Medications are administered in accordance with the prescriber orders . During a review of DailyMed, (https://medlineplus.gov/druginfo/meds/a682022.html) a National library of Medicine that publishes up to date accurate drug labels to health care providers and general public .Follow the directions on your prescription label . Shake the liquid well before each use to mix the medication evenly .

Based on interviews, and record review, the facility failed to ensure the Registered Dietician effectively monitored the food and nutrition services in accordance with the Registered Dietician job description when the Registered Dietician failed to monitor food services operations to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Ice machine curtain had calcium build up. 2. The walk-in refrigerator food storage shelving contained a black fuzzy, brown, and white substance, the floor had decomposed food, the wall had black substance, and the door had brown and black grime. 3. The fan located above the dishwashing station was covered with brown debris and was blowing directly on the cleaned dish area 4. The can opener based in the kitchen was not kept in a sanitary condition and had black and brown grim build up. 5. The baseboard located under the ice machine had a hole, debris and trash. 6. The floor under the dish machine and dry storage room contained trash, debris, and food crumbs. 7. The reach in meat freezer, reach in refrigerator and reach in vegetable freezer gaskets were torn and contained black and brown grime. 8. The stainless-steel food preparation table had brown debris hanging and underneath stored 3 large white plastic containers. 9. The drying Dome (a piece of kitchen equipment used as a cover to keep food hot) rack was covered with brown debris. 10. The food shelving racks in the reach in refrigerator, dry storage room and walk-in refrigerator had chipped paint. 11. Expired and unlabeled food items were found in the Resident refrigerator. These failures had the potential to place 73 out of 76 sampled residents at potential risk of exposure to foodborne illness (stomach illness acquired from ingesting contaminated food), compromised their nutrition status and further compromising resident's medical status. And also The Registered Dietician failed to reevaluate comprehensive nutrition assessment for Resident 74 had the potential risk to place Resident 74 for impaired nutrition status or compromised nutritional status. (Cross reference F692 and F812). Findings: During an interview on 02/13/23, at 10:16 AM, with the Registered Dietician (RD), the RD stated he had been working in this facility since December 2022, total 20 - 32 hours per week. And the RD also stated he did dietary sanitation audit quarterly. During the initial kitchen tour on 02/13/23, at 10:30 AM, a concurrent observations and interviews were conducted of the overall kitchen sanitation and cleanliness with the RD and Food and Nutrition Service Director. The RD failed to monitor food services operations to ensure safe and sanitary food preparation and storage practices in the kitchen. (Cross reference F812) During a concurrent interview and record review, on 02/15/23, at 11:46 AM, with the RD. Resident 74 had history of several unplanned weight loss since July 1, 2022, there was no reevaluate comprehensive nutrition assessment done by the RD. (Cross reference F692) During an interview on 02/15/23, at 03:52 PM, with Administrator (ADM). With several deficient practices were identified during the survey in the areas of poor overall kitchen cleanliness, equipment maintenance, food safety and sanitation practices, ADM agreed the RD did not perform the job duties. ADM stated, I expect the RD perform kitchen inspection monthly instead quarterly, follow job description duties and identify any concerns regarding food and Nutrition services. During a review of the facility's Job Description position titled, Registered Dietician, dated on 09/2017, the Job Description indicated, General Purpose: Complete nutritional initial .and significant change reviews on residents according to federal and state guidelines .Complete nutritional reviews monthly on high-risk residents (significant weight loss .) Essential Duties: .Assess nutritional needs, diet restrictions and current health plans to develop and implement dietary care plans . Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations .

**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 used in the facility were stored and labeled in accordance with current accepted professional standards of practice when: 1. Resident 34's Lorazepam (a medication used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting) was discontinued on 2/11/13 and the medication was not separated from active medications and was stored in medication cart. 2. Resident 5's Lorazepam with directions that did not match current physician Lorazepam orders and the medication cards of Lorazepam did not have change of direction stickers. These failures had the potential for Lorazepam to be administered past the discontinued date which could result in medication being distributed without physician orders and for Lorazepam to be administered incorrectly without updated directions as prescribed by physician. 3. A treatment cart in A wing station 1 hallway was left unlocked and unattended by Licensed Vocational Nurse (LVN) 3. This failure resulted in the availability of medications to unauthorized residents, staff and visitors. Findings: 1. During a concurrent observation and interview on 2/13/23, at 11:04 a.m., with LVN 4 at med cart 1, station 1, Resident 34's medication card was observed and indicated the following: Lorazepam 1 mg [milligram] (a unit of measurement) with directions indicating to provide 1 tablet by mouth T.I.D. (three times a day) PRN (as needed) with 63 total doses. The Lorazepam was observed inside the Narcotics locked storage bin inside the medication cart utilized for scheduled II (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) medications. LVN 4 stated when medications are discontinued from the locked storage bin, the DON is given the medication for destruction. LVN 4 indicated medication should not be stored in the medication cart after being discontinued. During an interview on 2/13/23, at 11:19 a.m., LVN 4 stated the importance in removing medications after discontinuing was to assure medications are not accidentally given, administered, or popped from bubble packaging. During an interview on 02/15/23, at 3:28 p.m., with the Director of Nursing (DON), the DON stated Resident 34's medications should have been removed right away and given to DON after discontinuing orders. The DON stated the potential harm if the medications are not given to the DON after discontinuing, there was a potential for it to be given if left with the other medications on the cart. During a review of Resident 34's admission Records (AR- document with resident demographic information), dated 2/15/23, the AR indicated Resident 34 diagnosis information history included; Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) . During a review of Resident 34'sElectronic Medication Administration Record(E-MAR), dated 1/28/2023, the e-MAR indicated Lorazepam orders to be provided 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days manifested by panicky feelings as evidence by feelings of head exploding, unable to become calm. Medication had a discontinued date of 02/11/23. During a review of the facility's policy and procedure (IP&P) titled, Discontinued Medications revised 4/2007, the P&P indicated, .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy . The Nurse receiving the order to discontinue a medication is responsible for recording the information and notifying the dispensing pharmacy of the discontinuation Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with the established policies . 2. During a concurrent observation and interview on 2/13/23, at 11:22 a.m., with Registered Nurse (RN) 1 at med cart #3, station 3, Resident 5's medication card was observed without a change of direction sticker on the medication card with #94 tablets with current orders indicating Lorazepam 0.5 mg take 1 tablet of 0.5 mg via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) everyday as needed. Can have every 5 minutes 2 tabs, no more than 4 tabs per day. RN 1 stated current medication orders indicated in E-MAR Lorazepam 0.5 mg provide 1 tab 0.5 mg via G-tube one time and day and every 8 hours as needed for seizures. RN 1 stated the current medication card should have a direction change sticker as orders have changed. RN 1 stated utilizing change of direction stickers are meant to provide staff the indication of a change of in orders to prevent medications errors which could affect the resident. During an interview on 2/15/23, at 3:28 p.m., with the DON, the DON stated Resident 5's medications should have a change of direction sticker on the medication card as well as the narcotic sign off log. During a review of Resident 5's AR dated 2/15/23, the AR indicated Resident 5's diagnosis information history included; Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus (A disorder in which nerve cell activity in the brain is disturbed, causing seizures) .Unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy). During a review of Resident 5's E-MAR record dated 5/3/2022, the E-MAR indicated .Lorazepam 0.5 mg orders to be provided 1 tablet via G-Tube one time a day for seizures and Give 1 tablet via G-Tube every 8 hours as needed for Seizures. Start date indicated on 05/03/22 with end date being indefinite . During a review of Resident 5's Physician Prescription, dated 7/12/22, the Physician Prescription indicated .Lorazepam 0.5 mg take 1 Tablet via G-tube every day as needed- can have every 5 minutes for 2 tabs not more than 4 tabs per day . During a review of the facility's policy and procedure (P&P) titled, Appendix 23: CQI Process Example: Medication Labeling dated 2019, the P&P indicated, .was filled, a direction change sticker is affixed to container . 3. During an observation on 2/16/23, at 11:15 a.m., LVN 3 was observed preparing treatment for a resident in room [ROOM NUMBER]. LVN 3 left the treatment cart unlocked and unattended in the hallway and went inside room [ROOM NUMBER] and behind the privacy curtain. The unlocked treatment cart in the hallway was easily accessible to residents, staff and visitors. During an interview on 2/16/23, at 11:30 a.m., with the DON, in the hallway next to the unlocked treatment cart, DON stated she locked the treatment cart because it was unlocked. DON stated treatment cart should always be locked whenever the licensed nurses turned their back so only the licensed nurses have access to the cart. DON stated other staff and residents could access the medications. During an interview on 2/16/23, at 11:45 with LVN 3, LVN 3 stated she should have made sure the treatment cart was locked when she turned her back and went inside room [ROOM NUMBER]. LVN 3 stated there are medications in the treatment cart. LVN 3 stated staff and residents could have accessed the medications inside the treatment cart which could lead to self medication and or overuse of medication. LVN 3 stated the treatment cart should not have been left open and unattended. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 11/2020, the P&P indicated, . Drugs and biologicals used in the facility are stored in the locked compartments . Only persons authorized to prepare and administer medications have access to locked medications . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with the professional standards for food safety service and safety for 73 residents when: 1. The ice machine curtain had calcium build up. 2. The walk-in refrigerator food storage shelving contained a black fuzzy, brown, and white substance, the floor had decomposed food, the wall had black substance, and the door had brown and black grime. 3. The fan located above the dishwashing station was covered with brown debris, and was blowing directly on the cleaned dish area. 4. The can opener based in the kitchen was not kept in a sanitary condition and had black and brown grime build up. 5. The baseboard located under the ice machine had a hole, debris and trash. 6. The floor under the dish machine and dry storage room contained trash, debris, and food crumbs. 7. The reach in meat freezer, reach in refrigerator and reach in vegetable freezer gaskets were torn and contained black and brown grime. 8. The stainless-steel food preparation table had brown debris hanging and underneath stored 3 large white plastics containers. 9. The drying Dome (a piece of kitchen equipment used as a cover to keep food hot) rack was covered with brown debris. 10. The food shelving racks in the reach in refrigerator, dry storage room and walk-in refrigerator had chipped paint. 11. Expired and unlabeled food items were found in the Resident refrigerator. These failures to ensure safety in food service, and sanitary condition resulted in the potential for residents to develop food-borne illnesses from cross contamination and growth of microorganism (living things that are too small to be seen with the naked eye, bacteria, viruses, and some molds) for 73 residents eating food prepared in the facility. (Cross reference 801) Findings: 1. During a concurrent observation and interview, on 2/13/22, at 4:05 p.m., with the Registered Dietician (RD), the Food and Nutrition Service Director (FND) and the Maintenance Supervisor (MS), in the Kitchen. The ice machine curtain (a piece of plastic covered in front of ice maker where ice touched before traveling to the ice storage bin) had calcium build up. The FND stated the ice machine was the only ice machine in the building. The FND stated the dietary department used the ice made from the ice machine for food prep and served the ice to residents. The RD, the MS and the FND validated the calcium build on the ice machine curtain, and stated the ice machine curtain should not have a calcium build up. The RD stated the calcium build up on the ice machine had the potential for cross contamination and he expected the maintenance be held accountable to keep the ice machine clean and sanitary. During a review of the facility's policy and procedures (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: .3. All equipment, food contact surface .are cleaned . 2. During an observation on 2/13/23, at 11:32 a.m. there were 5 food storage shelving units in the walk-in refrigerator. The storage shelving units was brown and green colored. One of the green color shelving unit which had 3 food storage shelves had white substances spread all over underneath of the 2nd and 3rd food storage shelves. The two brown color shelving units which also had 3 food storage shelves had black fuzzy substances and brown substances spread all over underneath of the 2nd and 3rd shelves. Foods were stored on the top and under the food storage shelves which had black fuzzy, brown and white substances. Two tomatoes covered with gray fuzzy substances and white fuzzy substances found on the walk in refrigerator floor. There was black substances on the walk-in refrigerator wall and black and brown grime found on the walk-in refrigerator door. During a concurrent observation and interview, on 2/13/23, at 3:01 p.m., with the RD, the FND, the Administrator (ADM), and the Infection Preventionist (IP), in the walk in refrigerator, the black fuzzy, brown and white substances on the food storage shelves were validated by the RD, the FND, the ADM, and the IP. The RD, the FND, the ADM, and the IP was not able to identify the black fuzzy, brown and white substances on the food storage shelves. The FND stated the walk-in refrigerator food storage shelves were cleaned once a week by the Prep [NAME] or the Dietary Aide. The FND stated when Prep [NAME] or the Dietary Aide cleaned the shelves, he/ she probably cleaned the top of the shelves not underneath. The FND stated the walk-in refrigerator food storage shelves should not have a black fuzzy, brown and white substances. The IP stated the black fuzzy, brown and white substances were probably dirt and 2 tomatoes on the floor were decomposed food. During a concurrent observation and interview on 2/14/23, at 12:37 p.m., with Refrigerator Mechanical (Mech) vendor, in the walk-in refrigerator, the Mech stated the black substances on the walk-in refrigerator door and walls was dirt. The Mech stated the black grime on the door was dirt caused by hands from dietary staff opening and closing the door. During an interview on 2/15/23, at 2:20 p.m., with the RD and in the presence of the FND, the RD stated the findings in the the walk-in refrigerator, which includes the black fuzzy, brown, and white substance found on food storage shelves, decomposed food on the floor, black and brown grime on the walls and door had the potential to attract pest, caused cross contamination, and was a food safety issue. The RD stated the dietary staff should keep the walk-in refrigerator clean free from food debris, dust, and build ups. During a review of the facility's policy and procedures (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All . kitchen areas .are kept clean, free from garbage and debris 2. All .shelves and equipment are kept clean .3. All equipment, food contact surfaces . are cleaned . 3. During a concurrent observation and interview, on 2/13/23, at 10:50 a.m., with the RD and the FND, at the dish washing station, the fan located above the dishwashing station covered with brown debris was blowing air directly towards the clean dishes. The RD stated the fan covered with brown debris blowing air directly to the clean dishes was not acceptable and had the potential to contaminate the clean dishes. The RD stated the expectation was to have the fan clean and maintain all the time. During a review of the facility's policy and procedure (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen areas .are kept clean, free from .debris .3. All equipment, .are cleaned . 4. During a concurrent observation and interview, on 2/13/23, at 4:12 p.m., with the RD and the FND, in the kitchen, the base of the can opener was covered with black and brown grime and buildup. The RD stated the dietary staff should have clean the base of the can opener to prevent the potential risk of cross contamination. During a review of the facility's policy and procedures (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation .3. All equipment, food contact surfaces are cleaned . 5. During a concurrent observation and interview, on 2/13/23, at 11:08 a.m., with the RD, in the kitchen, underneath the ice machine had debris, trash and the baseboard of the wall had a quarter size hole. The RD validated the debris underneath the ice machine and the hole on the baseboard of the wall. The RD stated the hole to the baseboard had the potential to attract pests. During an interview on 2/15/23, at 2:18 p.m., with the RD, the RD stated the hole to the baseboard underneath the ice machine was from a missing pipe. The RD stated the hole should have been filled, and cleanliness should have been maintain underneath the ice machine. During a review of the facility's policy and procedures (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas .are kept clean, free from garbage and debris, and protected from rodents and insects. During a review of the Federal Food and Drug Administration (FDA) 2022 Food Code indicated, Food Establishment shall be protected against the entry of insects and rodents by: Filling or closing holes and other gaps along floors, walls, and ceilings. 6. During a concurrent observation and interview, on 2/13/23, at 10:26 a.m., with the RD and the FND, at the dish washing station, the floor under the dish machine had trash, black grime, and a damage wooden shelf on the floor. The RD and the FND validated the floor under the dish washing machine had trash, black grime and damage wooden shelf on the floor. The RD stated the potential risk for not keeping the floor clean was the risk to attract pests. During a concurrent observation and interview, on 2/13/23, at 3:32 p.m., with the FND, in the dry storage room, the floor underneath the storage shelves had food crumbs, black and brown debris, and trash. The FND validated the food crumbs, black and brown debris, and trash found on the floor underneath the storage shelves. During an interview on 2/15/23, at 2:20 p.m., with the RD and the FND, the FND stated the floor underneath the appliances was not sanitary because dietary staff were unable to reach and clean underneath the appliances. The FND stated the dietary staff needed to do better in certain areas for sanitation. The RD stated he expected the dietary staff to keep the kitchen floor clean. During a review of the facility's policy and procedure (P&P) titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas .are kept clean, free from garbage and debris, and protected from rodents and insects . 7. During a concurrent observation and interview, on 2/13/23, at 10:52 a.m., with the RD and the FND, in the kitchen, the reach in meat freezer gaskets (rubber that is put between the door and the freezer to prevent cool air escaping) was torn, and the gaskets had black and brown grime. During a concurrent observation and interview, on 2/13/23, at 11:19 a.m., with the RD and the FND, in the kitchen, the reach in refrigerator gaskets was torn and had brown and black grime on the gaskets. During a concurrent observation and interview, on 2/13/23, at 11:25 a.m., with the RD and the FND, the reach in vegetable freezer had a torn gasket with brown and black grime. The RD and the FND confirmed the reach in meat freezer, reach in refrigerator and reach in vegetable freezer had torn gaskets with brown and black grime. The RD and FND stated the gaskets needed to be replaced. The RD stated the potential risk of a torn and dirty gaskets was food contamination for foods stored in the reach in meat freezer, reach in refrigerator and reach in vegetable freezer and it was a food safety issue. During an interview on 2/15/23, at 2:25 p.m., with the RD, the RD stated he expected the gaskets of the reach in meat freezer, reach in refrigerator and reach in vegetable freezer needed to keep clean and damage free. During a review of the facility's policy and procedure titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: .2. All .equipment are kept clean, maintained in good repair and are free from breaks, . open seams, .that may affect their use or proper cleaning . 8. During a concurrent observation and interview, on 2/13/23, at 4:13 p.m., with the RD and the FND, in the kitchen, Underneath the stainless-steel preparation table had an accumulation of brown debris hanging and there was 3 large white plastic storage containers keep under the stainless-steel preparation table. The RD and the FND validated the brown debris hanging underneath the stainless-steel preparation table. The RD stated the brown debris could potentially fall into the three large food storage containers. During a review of the facility's policy and procedure titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen areas .are kept clean, free from .debris .3. All equipment, .are cleaned . 9. During a concurrent observation and interview, on 2/13/23, at 11:14 a.m., with the RD and the FND, in the kitchen, the Dome rack that stored clean domes was covered with brown debris. The FND stated, the brown debris is dust. The RD stated the potential risk for not keeping dome rack clean was cross contamination and he expected the dietary staff to keep the dome rack free from buildup and dust. 10. During a concurrent observation and interview, on 2/13/23, at 11:19 a.m., with the RD and the FND, in the kitchen, the reach in refrigerator had three gray shelves was worn with chipped paint and was validated by the RD and the FND. During an observation on 2/13/23, at 11:32 AM, in the walk-in refrigerator, the green storage shelving units were worn, with chipped paint, a brown substance located on the posts of the shelves. During a concurrent observation and interview, on 2/13/23, at 3:01 p.m., with the RD and the FND, the RD and the FND validated the green storage shelving units were worn, with chipped paint, had brown substance located on the posts of the shelves. During a concurrent observation and interview, on 2/13/23, at 3:32 p.m., with the FND, in the dry storage room, three white storage shelving units had chipped paint and discoloration. The FND validated shelving unit had chipped paint and discoloration. During an interview on 2/15/23, at 2:18 PM, with the RD and the FND, the RD and the FND stated the potential risk for chipped paint and discoloration on shelving units was potential for cross contamination. The RD expected all shelves keep in good condition, clean and sanitary on regular basis and free of dust, debris, and build up. During a review of the facility's policy and procedure titled, Sanitization, Revised 11/2021, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: .2. All .shelves . are kept clean, maintained in good repair and are free from .chipped areas that may affect their use or proper cleaning . 11. During a concurrent observation and interview, on 2/15/23, at 11:28 a.m., with the RD and the Director of Nursing (DON) in front of the resident refrigerator located at station 4, unlabeled and expired items were found in the resident refrigerator. Items found included, 3 unlabeled 10 ounces (oz- a unit of measurement) protein shake bottles with an expiration date of 1/25/23, 1 unlabeled 20 oz bottle of soda, one unlabeled 8 oz bottle of Chocolate drink with an expiration date of 1/16/23 and a box of 12-24-32 oz Squeeze Fruit and Veggiez packets with an expiration date of 11/03/22. The DON stated the resident refrigerator was only use to store residents' foods. The DON stated all food items stored in the resident refrigerator were supposed to be labeled with residents' name and expired foods should have been disposed to prevent the risk for resident to consumed expired food items. During an interview on 2/15/23, at 2:20 p.m., with the RD, the RD stated it was the license nurse's responsibility to check for expired and unlabeled food items stored in the resident refrigerator. The RD stated stored expired and unlabeled food items in the resident refrigerator had the potential risk for a resident to consumed expired food products. During a review of the facility's policy and procedure titled, Foods Brought in by Family/Visitors , Revised 3/9/2020, the P&P indicated, .7. The nursing staff is responsible for discarding perishable foods on or before the use by date . During a review of the facility's policy and procedure titled, Bringing in Food for a Resident, Revised 11/12/2020, the P&P indicated, .Foods or beverages should be labeled with the resident's name and the date they were brought to the facility to monitor food safety .

Based on observation, interview and record review, the facility failed to ensure resident call lights were easily accessible and within reach for one of 38 sampled residents (Resident 62). This deficient pra resulted in Resident 62's embarrassment when he did not have a call light to call for help which caused him to urinate on himself and prevented Resident 62's needs from being met. Findings: During a concurrent observation and interview, on 3/2/20, at 12:05 p.m., through 12:13 p.m., in Resident 62's room. Resident 62's call light was wrapped around the bed frame and out of Resident 62's reach. Resident 62 was lying on the bed in his room and stated, Move my leg. Take me to the hospital. Need the bathroom. Resident 62's words were garbled and difficult to understand. Resident 62 had a full-leg splint (a devise made of a rigid material used for supporting and immobilizing a bone) on his left leg. Resident 62 turned onto his left side and urinated on the mattress. Resident 62 continued to call out for help. Resident 62 was unable to activate the call light (pushed the button to activate a light and audible ring). The call light remained wrapped around the bed frame and out of Resident 62's reach. Resident 62 did not answer questions when asked about his call light. During a concurrent observation and interview on 3/2/20, at 12:13 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 and CNA 2 walked into Resident 62's room and stated the call light was wrapped around the bed frame and was not within Resident 62's reach and it should have been. During an interview on 3/2/20, at 12:23 p.m., with CNA 2, CNA 2 stated Resident 62 was unable to use his call light because it had been attached to the bed frame and not within his reach. CNA 2 stated Resident 62's call light should have been placed in an area of the bed where he would have easy access and that did not occur. CNA 2 stated Resident 62's inability to access his call light and call for help resulted in Resident 62 having to urinate on his bed. During a concurrent interview and record review on 3/5/20, at 11:16 a.m., with the Director of Nursing (DON), the DON reviewed the Interdisciplinary Team (IDT - team made up of the Administrator, the DON, the Social Services Director, the Activities Coordinator) progress note, dated 3/2/20, at 5:09 p.m., which indicated, .IDT went to the patient's room to assess the call light. It was clipped to his sweater. He was able to press it [call light] several times . The DON stated the call light had a clip on it and should have been placed within Resident 62's reach on 3/2/20. The DON reviewed the fall care plan dated on 3/2/20 which included the intervention, .During rounds monitor placement of call light . call light to be clipped to [Resident 62's] clothing or blanket. During a review of the facility policy titled, Accommodation of Needs dated 1/2011, indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being . In order to accommodate individual needs . adaptations may be made to the physical environment, including the resident's bedroom . Examples of such adaptations may include . a. Providing access to assistance devices [call light] . During a review of the facility policy titled, Answering the Call Light dated 2001, indicated, .The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines . 4. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to develop a baseline care plan for one of 16 sampled residents (Resident 186) when Resident 186 was taking anticoagulation (AC - medications that slow down clot formation and have the potential to increase bleeding) medication and a baseline care plan was not developed for the use of the anticoagulation medication. This deficient practice placed Resident 186 at risk for episodes of bleeding not being detected and monitored timely. Findings: During a concurrent interview and record review on 3/4/20, at 11:04 a.m., with the Director of Nursing (DON), the DON reviewed Resident 186's admission physician order dated 2/23/20, which indicated rivaroxaban to (an anticoagulant medication) 20 milligram (mg - a metric measurement) tablet, one tablet by mouth daily. The DON stated Resident 186 was administered rivaroxaban since admission to the facility. The DON reviewed Resident 186's care plans and stated Resident 186 did not have a care plan to monitor rivaroxaban's high risk side effects such as bleeding and there should have been a care plan developed. The DON provided and reviewed the newly developed care plan titled, ANTICOAGULANT CARE PLAN dated 3/4/20, which indicated, [Resident 186] Is at risk for bleeding/bruising secondary to: Anticoagulant Therapy (rivaroxaban) . intervention . Observe for blood in urine, bruises, changes in LOC [level of consciousness], blood in stool, epistaxis [nose bleeds]. During a concurrent interview and record review on 3/4/20, at 2:44 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 186's clinical record and stated Resident 186's rivaroxaban was a drug with high-risk for side effects and should have been care planned within 48 hours of receiving the order and it was not. The DSD stated the Anticoagulant Use - [rivaroxaban] 20 mg was identified on the Observation Detail List Report [an alert for the license nurses] dated 2/24/20, which indicated .admission -- (2) Baseline Care Plan: Person-Centered Care Planning . What Nursing Services Will be Provided to Meet Resident Individualized Goals for Care? The DSD stated the medication rivaroxaban was clearly identified on the Observation Detail report on admission as requiring baseline care plan and it should have had a baseline care plan developed within 48 hours but that did not occur. During a review of the facility policy and procedure titled, Care Plans - Baseline dated 12/16, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders 9 . medications . and implement a baseline care plan to meet the resident's immediate care needs including but not limited to . a. Initial goals based on admission orders; b. Physician orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dialysis (the process of artificial filtering and removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) services consistent with professional standards of practice for one of two sampled dialysis residents (Resident 188) when the SNF [Skilled Nursing Facility]/Dialysis Assessment Communication Form (SNF/DACF - form used to communicate pertinent dialysis resident assessment information between the facility nursing staff and dialysis center staff to ensure residents are in stable condition prior to and after dialysis treatment) was incomplete on three of three sampled forms. This deficient practice resulted in inaccurate pre (before) and post (after) dialysis assessment and communication of Resident 188's status and placed resident at increased risk of experiencing undetected adverse reactions from dialysis treatment. Findings: During a concurrent observation and interview on 3/2/20, at 10:53 a.m., Resident 188 stated she was new to the facility and had peritoneal dialysis (PD- a type of dialysis in which the lining of the abdominal cavity is used as a filtration membrane for removal of waste products) for the past three years before coming to the facility. Resident 188 stated she still had the PD line (tubing or catheter to form a connection to allow filtration of blood) on her right groin and planned to return to PD after discharge from the facility. Resident 188 stated she was required to switch from PD to hemodialysis (HD - the most common form of dialysis, where blood is drawn from your body into a machine that filters out all the toxins in your blood, then pumps the blood back into your body) during her stay at the facility. Resident 188 stated switching from PD to HD required the insertion of a new dialysis line. Resident 188 displayed the new HD line site on her upper right chest. The HD line had two tails (a soft plastic tube (twice the length and half the width of a pen) placed through the skin into one of the large veins in the neck) one red, and one blue. The HD site was covered with a clean, dry white bandage. Resident 188 stated she received dialysis treatments three days a week on Monday, Wednesday and Fridays. During a review of the clinical record for Resident 188, the Face Sheet (a document containing resident demographic information) undated, indicated Resident 188 was admitted on [DATE] with diagnosis which included End Stage Renal (kidney) Disease. The clinical record contained three SNF/DACFs with both pre and post dialysis assessment findings dated 2/21/20, 2/24/20, and 2/26/20 on each form. The three SNF/DACFs inaccurately indicated assessment findings for Thrill (a pulsing sensation) and Bruit (the swishing sound heard with a stethoscope) present during assessment as YES which Resident 188's HD access site would not have. During a concurrent interview and record review on 3/3/20, at 2:26 p.m., with the Director of Nursing (DON), the DON reviewed the SNF/DACF dialysis assessment forms and stated the purpose of the SNF/DACF was to establish and accurately communicate details of Resident 188's baseline assessment to quickly identify any change of condition in Resident 188's dialysis site or health status. The DON stated the SNF/DACF was the main interfacility communication form between the SNF and the dialysis center. The DON stated the three SNF/DACFs assessment forms, both before and after dialysis, inaccurately documented a bruit and a thrill which Resident 188's HD site assessment would not have. The DON stated the license nurses were expected to accurately document the assessment findings on the SNF/DACF and they were not. During a concurrent interview and record review on 3/3/20, at 2:30 p.m., Licensed Vocational Nurse (LVN) 1 stated, I completed the pre-dialysis SNF/DACF dated 2/26/20, and it is inaccurate. I documented YES to the presence of the Bruit and Thrill . LVN 1 stated Resident 188's HD site would not have a bruit or a thrill. LVN 1 indicated the only way to detect bruit and thrill was to touch the dialysis site and listen using a stethoscope. During a concurrent interview and record review on 3/3/20, at 2:52 p.m., with Registered Nurse (RN) 1, RN 1 stated she had marked that she assessed for bruit and thrill on the three SNF/DACFs in error. RN 1 stated Resident 188's HD would not have a bruit or thrill. RN 1 stated Resident 188's assessments were incorrect. During a review of the facility policy and procedure titled, Dialysis Services, dated 11/17, indicated, It is the policy of the facility that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice including the: Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . During a review of the facility policy and procedure titled, End-Stage Renal Disease, Care of a Resident with dated 9/10, indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: .b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . During a review of the facility policy and procedure titled, Charting and Documentation dated 7/17, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were functioning properly for one of 36 sampled rooms (Rm 39) and four of four sample residents (Resident 11, 13, 50, and 76) when the call light monitor in RM [ROOM NUMBER] was not blinking nor sounding at the nurse's station, and the Maintenance Director (MD) did not document call light equipment checks. This failed practice had the potential to result in resident call lights not being answered timely and for emergent situations to be undetected by staff which could lead to resident injuries and/or harm. Findings: During a concurrent observation and interview on 3/2/20, at 11:02 a.m., in room [ROOM NUMBER], Resident 50 stated his call light was not working. Resident 50 stated he needed assistance on 2/28/19 to put on his socks and noticed the call light was not functioning. Resident 50 pushed his call light, and call light monitor above room [ROOM NUMBER] did not light. Resident 50 did not recall who he informed about the call light functioning as he did not use the call light frequently for assistance. Resident 50 stated he had changed rooms but could not recall when or how long the call light was not functioning. During a review of the clinical record for Resident 50, the Minimum Data Set (MDS - resident assessment for cognitive function) assessment dated 1/14/20, indicated Resident 50 had no cognitive impairment. During a concurrent observation and interview on 3/2/20, at 11:35 a.m., in room [ROOM NUMBER] with Certified Nursing Assistant (CNA) 3, CNA 3 entered room [ROOM NUMBER] and pushed the call light button to activate the call light for Resident 11, 13, and 76. The call light monitor did not light. CNA 3 left the room to check if the call light was functional at the nurses' station and stated room [ROOM NUMBER]'s call button was not flashing at the nurse's station. CNA 3 stated when call lights were non-functional in resident rooms, bells were given to residents as a temporary call system. CNA 3 stated when staff knew about call lights not functioning, they needed to place an repair order for maintenance department to repair the call light. CNA 3 gave resident 11, 13, 50, and 76 bells at bedside and called the maintenance department to repair call lights. During an interview with the MD, on 3/2/20, at 11:51 a.m., the MD stated call light checks were performed two times a week, on Mondays and Fridays to ensure call lights were functioning. The MD stated he did not document room call light checked on those days. The MD stated he documented repairs of the call light system when nursing staff informed him of call lights not functioning. The DM stated he did not know how long the call lights were not working for room [ROOM NUMBER] and was unable to find documentation indicating he was performing maintenance checks for functional call lights. During an interview with Resident 11, on 3/2/20, at 3 p.m., Resident 11 stated he would yell out for help when he needed someone. Resident 11 stated did not know how long the call light was not functioning. During an interview with Resident 13, on 3/2/20, at 3:10 p.m., Resident 13 stated he could use the call light and would use it if he needed assistance. Resident 13 stated he did not recall the last time he used the call light. Resident 13 stated he did know the call light was not functioning. During a review of the clinical record for Resident 13, the MDS assessment dated 12/6/19, indicated Resident 13 was moderately cognitively impaired. During a concurrent interview and record review on 3/3/20, at 10:49 a.m., with the MD, the MD reviewed the facility Logbook Documentation dated 2/25/20, which indicated station 3 rooms (Rm 39) had bulbs replaced and call light system was functioning on 2/7/20. The MD stated station 3's call lights were functioning on 2/7/20, but he did not know when room [ROOM NUMBER]'s call light quit functioning because the call light system tests performed twice a week were not documented. During an interview with the Administrator (ADM), on 3/4/20, at 4 p.m., the ADM stated the MD was documenting only when call light repairs were done and did not document call light testing checks completed twice a week. The ADM stated the last documented call light repair on room [ROOM NUMBER] was 2/7/20. The ADM stated the MD should have been documenting all call light testing checks. The ADM stated the facility did not have a policy on how often call light testing was performed or when to document the call light testing. During a review of the facility policy and procedure titled, Answering the Call Light dated 2001, indicated, .The purpose of this procedure is to respond to the resident's requests and needs . check . Report all defective call lights to the nurse supervisor promptly .ensure call light in working order .

Based on observation, interview and record review, the facility failed to ensure food items and dishware were stored in a sanitary manner when: 1. One container of coffee creamer was torn and leaking onto other food items in the walk-in refrigerator. 2. Two steam table food pans were not air dried and stored away wet. These deficient practices placed residents at risk of consuming contaminated food and having food prepared in unsanitary food pans could lead to foodborne illness. Findings: 1. During a concurrent observation and interview on 3/2/20, at 8:13 a.m., in the walk-in refrigerator, a container of coffee creamer was on a tray with liquid leaking from the bottom of the coffee creamer carton. The Dietary Manager (DM) stated the coffee creamer needed to be discarded from the refrigerator because it was torn and leaking, and air could enter inside the carton and cause it to spoil. The DM stated if the coffee creamer were to become spoiled, staff would not be aware and could possibly serve spoiled coffee creamer to residents. The DM stated spoiled food items should not be given to the residents because it could cause residents to become sick. During an interview with the Registered Dietician (RD), on 3/4/20, at 3:45 p.m., the RD stated the coffee creamer was compromised when it was found leaking. The RD stated if the creamer would have been left in the walk-in refrigerator for days it could have spoiled and if given to the residents it could have made the residents ill. During a review of the facility policy and procedure titled, Food Storage-Dented Cans dated 2018, indicated, Food in .leaking .containers .shall not be retained or used by the facility .All leaking cans are to be disposed of immediately. 2. During a concurrent observation and interview on 3/2/20, at 9 a.m., in the kitchen near the dishware storage area, there were two steam table pans with flesh water drops on them. The DM stated the steam table pans needed to be air dried before being stored. The DM stated it was important to have the steam table pans air dried because water could attract bacteria that could potentially grow on the pans. The DM stated if residents were to eat food that was on bacteria contaminated pans, residents could get sick. During an interview with the RD, on 3/4/20, at 3:45 p.m., the RD stated the steam table food pans needed to be air dried before being stored. The RD stated dietary staff needed to make sure there was no condensation (water drops) on the pans to prevent any cross contamination (process by which bacteria are unintentionally transferred from one substance or object to another with harmful effect) and lead to illness for the residents. During a review of the facility policy and procedure titled, Dish Washing dated 2018, indicated, .5. Dishes are to be air died in racks before stacking and storing .

Based on observation, interview and record review, the facility failed to provide for the storage of foods brought to residents from outside sources, when the facility policy did not allow residents to store food brought in by family or visitors. This failed practice prevented residents from exercising their rights to store food in the facility that was brought in from outside sources. Findings: During a concurrent observation and interview on 3/3/20, at 10:13 a.m., near the nursing unit, food items from the kitchen were stored in the unit refrigerator. The Dietary Manager (DM) stated food items stored in the unit refrigerator were from the kitchen. The DM stated food items were for nurses or activities personnel to distribute to residents if residents wanted a snack in the evening or throughout the day. The DM stated the facility did not allow food brought in by visitors from outside the facility to be stored in the unit refrigerator. The DM stated the facility policy did not allow storage of food brought in from outside sources. The DM stated residents had to eat food brought in by visitors at the time of the visit. The DM stated residents' food brought in by visitors needed to be discarded after two hours. During an interview with the Registered Dietician (RD), on 3/4/20, at 3:30 p.m., the RD stated residents were not allowed to store food brought in by visitors in the unit refrigerator. The RD stated residents needed to eat perishable food (type of food that will go bad quickly if left out of the refrigerator) at the time food was brought to the resident and then discarded after two hours. The RD stated the facility policy did not allow storage of perishable food brought in by visitors. During an interview with the Administrator (ADM), on 3/4/20, at 3:54 p.m., the ADM stated the facility did not have a policy to allow food brought in by visitors for residents. The ADM stated the facility did not have a policy and procedure that would allow the storage of food brought in from outside sources into the facility. The ADM stated residents' perishable food from outside sources needed to be discarded if not eaten within two hours. During a review of the facility policy and procedure titled, Foods Brought in by Family/Visitors from Outside Sources undated, indicated, .5. Perishable foods must be consumed at time of visit and cannot by stored for the resident by the facility. 6. The nursing staff is responsible for discarding perishable foods kept at bedside for greater than 2 hours .