**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and recorded review, the facility failed to ensure one of two sample residents (Resident 56) received a written notice, including the reason for the room change, prior to being moved to a different room with the facility, when Resident 56 was moved without receiving written communication explaining the change. This failure resulted in Resident 56 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of Resident 56's rights to make informed decision regarding her care and environment. Findings: During a concurrent observation and interview on 5/15/25 at 11:14 a.m. with Resident 56, in Resident 56's room. Resident 56 stated she was moved to a new room on 5/14/25 but did not receive a written notice of change and was not asked to sign anything. Resident 56 stated it was the second time she had to changed rooms. Resident 56 stated she understood the reason given, and she expressed frustrations being relocated multiple times. During a Review of Resident 56's admission Record (AR-a document containing resident profile information) dated 5/16/25, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and asthma (a chronic lung condition making it difficult to breathe). During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/10/25, the MDS assessment indicated Resident 56's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact [a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities], 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 56 was cognitively intact. During a concurrent interview and record review on 5/15/25 at 11:26 a.m. with the Social Services Director (SSD), the facility policy and procedures titled Room change/Roommate Assignment was reviewed. The SSD stated the facility did not provide Resident 56 with a written notice of the room change. The SSD stated the facility's policy required written notice to be provided to residents and/or their representatives which included the reason for the room change and information to assist with the adjustment to a new room or roommate. The SSD stated there was no written documentation or signed notice provided to Resident 56 prior to the move. The SSD stated this communication was important to help Resident 56 adjust and prevent emotional distress. During an interview on 5/15/25 at 3:12 p.m. with the Director of Nursing (DON), the DON stated there was no written notice or supporting documentation provided to Resident 56 prior to the room change. The DON stated the facility policy required a written notice to be provide in advance of a room move, and this communication should have been documented in Residents 56's medical record. The DON stated the expectation was that the communication should have been provided to Resident 56 before the room change. During a review of the facility's policy and procedure (P&P) titled Room Change/Roommate Assignment, dated 3/2021, the P&P indicated, .Prior to changing a room or roommate assignment, all parties involved in the change/assignment .are given .advanced written notice of such change. Advanced written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may be paid for Medicare and assume responsibility) for one three sampled residents (Resident 78) when the Medicare coverage was terminated for Resident 78. This deficient practice resulted in not protecting Resident 78's rights and Resident 78's Representative (RR) right to appeal the termination of Medicare Part A and possibly denying Resident 78's needed services. Findings: During observation on 5/13/25 at 10:13 a.m., in Resident 78's room during the initial tour of the facility, Resident 78 was lying in bed. Resident declined to answer questions. During a review of Resident 78's admission Record, (AR- a document containing resident profile information) dated 5/15/25, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (refers to the shrinking and weakening of muscle tissue due to various causes, including inactivity, aging or certain medical conditions), muscle weakness and retention of urine (unable to empty all urine from the bladder). During a concurrent interview and record review on 5/15/25 at 8:28 a.m. with the Business Office Assistant (BOA), the BOA stated her duties included but not limited to assisting residents to fill up applications for medi-cal (California's name for the federal Medicaid program [joint federal and state program that provides free or low-cost health coverage]). The BOA reviewed Resident 18's medical record titled, Skilled Nursing Facility Beneficiary Protection Notification Review. The BOA stated the SNF-ABN indicated Resident 78 start date was on 9/1/24 and the last covered day of Medicare Part A Services was on 11/29/24. The BOA stated Resident 78 remained in the facility after the last covered day. The BOA stated Resident 78 had Medicare Part A remaining days and a SNF ABN was not issued to Resident 78 because she did not know it was supposed to be issued. The BOA stated the SNF ABN letter should have been issued when the Notice of Medicare Provided Non-Coverage (NOMNC) was issued to Resident 78. The BOA stated the SNF ABN was very important because it provided Resident 78 steps to follow if Resident 78 wanted to continue receiving Medicare A benefits and steps to follow for an appeal. The BOA stated Resident 78 and RR were not able to appeal because they were not given the forms and information. During an interview on 5/20/25 at 4:55 p.m. with the Administrator (ADM), the ADM stated his expectation was to ensure Business Office issues SNF ABN and NOMNC letters to all residents needing the form. The ADM stated SNF ABN and NOMNC letters were supposed to be issued prior to the last covered Medicare part A Day to residents. During a review of facility's document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS 10055, dated 2024, the document indicated, . Medicare requires Skilled Nursing Facilities [SNFs] to issue the SNF ABN to Original Medicare, also called fee-for-service [FFS] , patients prior to providing care that Medicare usually covers, but may not pay for in this instance . The SNF ABN provides information to the patient so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNF ABN when applicable for SNF Prospective Payment System services (Medicare Part A) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report unusual occurrences for two of three sampled residents (Residents 28 and 244) when: 1. Resident 28 was attacked by Resident 29 (squeezed his toes and punched him 4 to 6 times in the lower left leg) and the facility did not contact local law enforcement or report the resident-to-resident abuse to the State Survey Agency. This failure put Resident 28's safety at risk, possibly other residents, as well as family and staff members in the facility. 2. Resident 244 was found on the floor by her bed, deceased and the facility did not report this unusual occurrence to the resident's responsible party (RP- a family member of designated person who is the point of contact for the nursing home staff. They can be kept informed about the resident's condition, receive updates, and ask questions) nor the State Survey Agency. This failure placed all residents' well-being and safety at risk residing in the facility due to lack of knowledge of reporting requirements. Findings: 1. During a concurrent observation and interview on [DATE] at 10:33 a.m., with Resident 28, in Resident 28's room, Resident 28 had dark purple bruising on his lower left leg. Resident 28 stated Resident 29 crawled over to his bed, grabbed his toes, started squeezing them and punched his left ankle and leg at least five times. Resident 28 stated Certified Nursing Assistant (CNA) 7 was already at his bedside, but other staff members came in and separated Resident 29 from him and he moved to another room in the facility. Resident 28 stated he had bruising to his leg and the facility had his left leg x-rayed, which were negative. Resident 28 stated he never spoke to the local police department. During a concurrent observation and interview on [DATE] at 8:05 a.m., with Resident 29, in Resident 29's room, a request was made to interview Resident 29 and he refused. During a review of Resident 28's admission Record (AR-a document containing resident profile information), dated [DATE], the AR indicated, Resident 28 was admitted to the facility on [DATE] with diagnosis of muscle weakness, difficulty in walking, morbid obesity (very severe, where someone is significantly overweight, often 100 pounds or more over their ideal weight) due to excess calories, chronic pain, repeated falls, embolism (a blood clot that blocks and stops blood flow) and thrombosis of unspecified artery (when a blood clot [a thrombus] forms inside a blood vessel, blocking the flow of blood). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE], the MDS assessment indicated Resident 28's Brief Interview for Mental Status (BIMS -assessment of cognitive (the mental processes involved in gaining knowledge and comprehension) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS assessment indicated Resident 28 was cognitively intact. During a review of Resident 28's Social Services Note (SSN), dated [DATE] at 9:38 a.m. the SSN indicated, .Writer spoke with patient in regard to another patient crawling out of bed and striking patients leg three times . He requested a X-ray be done to his leg as he has prior problems with that leg and he just wants his mind to be cleared with an x-ray. Writer informed nursing to request order from MD [Medical Doctor] . A grievance filed on behalf of patient. Nursing staff to continue to monitor report any changes. Writer sent referral to MD . During a review of Resident 28's Progress Notes (PN), dated [DATE] at 10:52 a.m. the PN indicated, . Resident was moved in the a.m. following his admit due to an alleged altercation with his roommate. X-ray was request and orders carried out Left Knee and Left Tibia 2 view . During a review of Resident 29's admission Record, dated [DATE], the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnosis of muscle weakness, difficulty in walking and major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy). During a review of Resident 29's MDS assessment, dated [DATE], the MDS assessment indicated Resident 29's BIMS assessment score was 15 out of 15. The BIMS assessment indicated Resident 29 was cognitively intact. During an interview on [DATE] at 2:05 p.m. with Licensed Vocational Nurse (LVN) 8 stated she was the nurse responsible for Resident 28 at the time of the confrontation. LVN 8 stated Resident 28 was the victim and Resident 29 had hit him. LVN 8 stated Resident 29 had also tried to hit CNA's as well. LVN 8 stated she did not tell the Administrator what occurred but did tell the Director of Nursing (DON). During an interview on [DATE] at 2:50 p.m. with the Abuse Coordinator/Administrator (ACA), the ACA stated he did not believe the punches were abuse but heard Resident 28 was punched. During an interview on [DATE] at 3:15 p.m. with the ACA, the ACA stated he was not sure when he was notified of the incident and he did not document when he was notified. The ACA stated he made the DON responsible for the incident investigation . The ACA stated punching someone would be abuse but had to speak to the DON on why the incident was not reported. The ACA stated after he spoke to the DON about the resident altercation, Yes, we should have reported this. During an interview on [DATE] at 11:46 a.m. with the DON, the DON stated staff called her over the phone and told her about the incident when it occurred. The DON stated she was out of town when this occurred and she did not do an investigation into this incident. The DON stated Resident 28 was attacked and the incident would qualify as resident abuse. The DON stated the expectation would be to report the incident to the State Survey Agency and to local police. The DON stated it did not appear that either of those reports were done. The DON stated the facility did not follow the facilities policy and procedures Unusual Occurrence Reporting, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and Identifying Types of Abuse. During an interview on [DATE] at 2:35 p.m. with the Unit Nurse Supervisor (UNS), the UNS stated a resident getting punched would be physical abuse. The UNS stated the abuse coordinator should have filled out form SOC 341 [Report of Suspected Dependent Adult/Elder Abuse], turn that into the State Survey Agency and notify the police. During an interview on [DATE] at 3:14 p.m. with the ACA, the ACA stated he did not think a call to local police was completed and could not provide proof of notification of the incident. The ACA stated he did not complete a SOC 341 nor report the incident to the State Survey Agency. The ACA stated, I should have done all that and I didn't. The ACA stated the policy and procedures Unusual Occurrence Reporting, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and Identifying Types of Abuse were not followed. The ACA stated a potential outcome of not reporting this incident would be I don't know, you tell me what the outcome could be. The ACA stated, I'm not sure, we report it because we are supposed to. During an interview on [DATE] at 3:45 p.m. with CNA 7, CNA 7 stated she was already in the room speaking to Resident 28 when Resident 29 crawled over, grabbed Resident 28's foot and started punching him. CNA 7 stated she could not recall everything because it all happened so fast. During an interview on [DATE] at 3:54 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the incident qualified as physical abuse toward Resident 28. The ADON stated the incident should have been reported to the State and police because of mandatory reporting laws. The ADON stated something else could have happened to the resident because the reports were not made. The ADON stated the non-reporting put Resident 28's safety at risk. During a review of the facility's policy and procedure (P&P) titled, Identifying Types of Abuse, dated 9/2022, the P&P indicated, . As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents . abuse toward a resident can occur as: a. resident-to-resident abuse . Physical Abuse: 1. Physical abuse includes, but is not limited to hitting . punching . During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated [DATE], the P&P indicated, . all reports of a resident abuse(including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Reporting Allegations to the Administrator and Authorities: 1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . law enforcement officials . 3. Immediately is defined as: a. Within two hours of an allegation involving abuse . or . b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated [DATE], 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, employees or visitors . g. Allegations of abuse . h. Other occurrences that interfere . the welfare, safety, or health of residents . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or otherwise required by federal and state regulations . 3. A written report detailing the incident and actions taken by the facility after the event shall be sent delivered to the state agency (and other appropriate agency as required by law) within 48 hours of reporting the event or as required by federal and state agencies . 2. During a review of Resident 244 Nurse's Note (NN), dated [DATE] at 4:15 p.m. the NN indicated, . At 2:03 p.m. charge nurse notified unit manager/writer that resident was unresponsive with no RR [respirations] or Pulse. Writer and ADON [Assistant Director of Nursing] responded immediately and verified patient pulseless and non-breathing. Resident noted on floor. Bed in lowest position and on LAL [low air loss] mattress. Writer notified at 2:08 p.m. and DON at bedside assessed resident and no pulses, no respirations, no breath sounds, and no BP [blood pressure] were noted. Skin clear with exception of mottled [caused by decreased blood flow and oxygen to the skin, often due to small blood vessels constricting] skin to RLE [right lower extremity]. No visible signs of injury noted related to rolling on to floor. Resident on Hospice care. Per LN [licensed nurse] earlier in the day pt was noted with COC. Routine morphine administered at 8:20 a.m. to support comfort focus treatment with pain assessment at 10:42 am by LN noting no signs of pain in resident. At 11:15 a.m. LN assessed patient for residuals per order and administered noon medication, all needs met at this time. CNA last checked on resident at 12:50 p.m. and resident was in bed and care was given with no s/sx [signs and symptoms] of distress. [Medical Director] notified and Time of death 2:08 p.m. Two RN's [Registered Nurse] at bedside at the time of confirmation. Family and [Hospice] notified. Postmortem care completed . During a review of Resident 244's admission Record, dated [DATE], the AR indicated, Resident 244 was admitted to the facility on [DATE] with diagnosis of hemiplegia (a medical condition that causes paralysis (a medical condition characterized by the loss or impairment of voluntary movement and muscle function) or weakness on one side of the body) and hemiparesis ( a condition where you have weakness on one side of your body, making it difficult to move or use that side as effectively as the other) following cerebral infarction (a medical emergency called a stroke, when a blood clot or blockage cuts off the blood supply to a part of the brain, leading to brain tissue death affecting non-dominant left side), dementia (a brain disease that causes a decline in thinking, memory, and other cognitive abilities), dysphagia (swallowing difficulty), left hand contracture ( a condition that causes one or more fingers to bend toward the palm of the hand) and muscle weakness. During a review of Resident 244's MDS - assessment, dated [DATE], the MDS assessment indicated Resident 244's BIMS assessment score was 00 out of 15. The BIMS assessment indicated Resident 244 was severely cognitively impaired. During a review of Resident 244's Section GG (GG)- Functional Abilities (assessment of functional abilities), dated [DATE], the GG indicated, . [box checked] Impairment on both sides. Upper extremities (shoulder, elbow, wrist, hand) Lower extremity (hip, knee, ankle, foot) . Code 1= Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity . Code 1 for A. Eating. Code 1 for Oral hygiene. Code 1 for Toileting hygiene. Code 1 for Shower/bathe self. Code 1 for Upper body dressing. Code 1 for Lower body dressing. Code 1 for Putting on/taking off footwear. Code 1 for Personal hygiene . Code 1 for Roll left and right. Code 1 for Sit to lying. Code 1 Lying to sitting on side of bed. Code 1 for Sit to stand. Code 1 for Chair/bed to chair transfer. Code 1 for Tub/shower transfer . During a review of Resident 244's Weights and Vitals Summary (VS), dated [DATE], the VS indicated, XXX[DATE] . Blood Pressure: 122/68 mmHg (millimeters of mercury- unit of measurement) . Pain Level Summary: 2 . Pulse Summary: 68 BPM (beats per minute) . Respiration Summary: 18 breaths per minute . Temperature Summary: 97.8 Forehead non-contact . During a review of Resident 244's Physician/Mid-level Provider Discharge Summary (DS), dated [DATE], the DS indicated, . Pertinent Physical and Laboratory Findings: N/A [Not attempted] . Course of Treatment: Hospice Care, Skilled Nursing . Condition on discharge: [Empty] . Follow-up and Discharge Medication Instructions: Resident Exp-at 2:08 p.m. All personal belongings were given to family . [signed Medical Director] . During a review of Resident 244's Death Certificate (DC), dated [DATE], the DC indicated, . Certificate of Death: [Resident 244] . Immediate Cause: A. Respiratory Failure [sequentially list conditions if any leading to cause on line A] . B. Aspiration Pneumonia C. Cerebral Infarction . Death reported to coroner: No . Biopsy Performed: No . Autopsy Performed: No . During an interview on [DATE] at 9:39 a.m. with Hospice [ a type of medical care that provides comfort and support to people who are nearing the end of their life] Nurse (HN), the HN stated he was Resident 244's hospice nurse. HN stated he was not notified until two and half hours after Resident 244 passed away. HN stated this was unusual and normally they are notified within minutes of one of their residents passing away. During a concurrent interview and record review on [DATE] at 10:33 a.m. with the DON, Resident 244's Electronic Medical Record (EMR) was reviewed. The EMR indicated Resident 244 was found on the floor deceased next to her bed. The DON stated when she walked into Resident 244's room she was on the floor lying on her right side, parallel to her bed. The DON stated she did an assessment and found she was pulseless and not breathing. The DON stated with the help of staff members, they put Resident 244 back in bed and she called the Medical Director. The DON stated over the phone she described her physical assessment and the physician called Resident 244's death a brain bleed that caused her to fall out of bed. The DON stated she spoke with the responsible party/family member (RP/FM) 4. The DON stated she was not sure if she had told the RP/FM 4 that Resident 244 was found on the ground, but she knew that it was not documented what was said. DON stated a person found on the ground would be considered to be a fall and a change of condition should be made. The DON stated again, she told the RP/FM 4 that her mom had died but was not sure if she mentioned the fall or was found on the floor. The DON stated her assessment showed no evidence of trauma so she did not find Resident 244's death to be unusual, even though she was confirmed to be found deceased on the floor. During an interview on [DATE] at 2:39 p.m. with the UNS, the UNS stated LVN 10 went to her office and told her Resident 244 was found on the floor and passed away. The UNS stated she went in the room and Resident 244 was on the floor and staff were scared. The UNS stated she went and got the DON and she came and did an assessment and called the MD. The UNS stated Resident 244 having been found on the floor would be a fall. The UNS stated she did not call the family, the DON did all of that. During an interview on [DATE] at 2:56 p.m. with LVN 10, LVN 10 stated she was the nurse for Resident 244 at the time of her death. LVN 10 stated CNA 9 reported Resident 244 was on the floor, LVN 10 went in Resident 244's room and saw her on the floor, checked Resident 244 for pulse and she had none. LVN 10 stated no one knew how she got on the floor. LVN 10 stated the RP/FM 4 should have been notified and told about the fall because it was unwitnessed. LVN 10 stated a fall was an accident. LVN 10 stated the DON had asked her what happened and when she was telling her she was very emotional and had to leave the facility. LVN 10 stated they didn't ask me any questions when I came back in. During an interview on [DATE] at 4:02 p.m. with the ADON, the ADON stated she went in the room with the UNS and saw Resident 244 on the floor, facing the window. The ADON stated it was an unwitnessed fall and the RP/FM 4 should have been notified of the fall. During an interview on [DATE] at 5:23 p.m. with CNA 9, CNA 9 stated CNA 8 was in Resident 244's room and he had stopped her as she walked by and told her Resident 244 was on the ground. CNA 9 stated she was shocked. CNA 9 stated this was a fall, she was down on the ground. During an interview on [DATE] at 5:33 p.m. with the MD, the MD stated he felt from her medical history that she died from pretty much natural causes, or a bleed. The MD stated he knew Resident 244 was found on the floor, deceased . The MD stated he felt like she died naturally and slid off the bed after. The MD stated it did not trigger a coroners report for him. The MD stated he didn't put it together that a fall was considered an accident. During an interview on [DATE] at 5:33 p.m. with CNA 8, CNA 8 stated he found Resident 244 on the floor. CNA 8 stated he was giving care to Resident 24's roommate, looked over and saw Resident 244's bed was empty. CNA 8 stated he saw Resident 244 and her bed sheets on the floor and was shocked at what happened. CNA 8 stated he was very emotional and he couldn't take seeing her like that. CNA 8 stated that Resident 244 having been found on the floor was an unwitnessed fall and an accident for sure. During an interview on [DATE] at 10:04 a.m. with the RP/FM 4, the RP/FM 4 stated her mom could not communicate, nor move at all in bed. The RP/FM 4 stated she was the responsible party for Resident 244. The RP/FM 4 [very upset and emotional] stated I had no idea she was found on the ground, oh my God, oh my God this is terrible. The RP/FM 4 stated no person from the facility told her or her family Resident 244 was found on the floor deceased it makes a huge difference that she was. The RP/FM 4 stated The DON just lied to us and it would be very unusual for her mother to be on floor. The RP/FM 4 stated the HN told her it was not normal that hospice was not notified timely. The RP/FM 4 stated if she had known she was found on the floor deceased she would have bought an autopsy but did not because she was told by the facility she died naturally. The RP/FM 4 stated she would have needed to know the way her mom was found and would have done things differently. The RP/FM 4 stated the facility withheld vital information that would have been very important to me and what to do next. During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated [DATE], 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, employees or visitors . d. Death of a resident . because of unnatural causes . e.g. [for example] . accidents .h. Other occurrences that interfere . the welfare, safety, or health of residents . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incidents or otherwise required by federal and state regulations . 3. A written report detailing the incident and actions taken by the facility after the event shall be sent delivered to the state agency (and other appropriate agency as required by law) within 48 hours of reporting the event or as required by federal and state agencies . During a review of the facilities P&P titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, .Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical . and/or status (e.g. [for example] changes in level of care . etc . Policy Interpretation and Implementation . The nurse will notify the resident's attending physician or physician on call when there has been a: a. accident or incident involving the resident .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . the resident is involved in any accident or incident that results in an injury including injuries of an unknown source . there is a significant change in the resident's physical . status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 one of five sampled residents (Resident 21) when Resident 21's deep tissue injury (DTI-localized area of discolored, intact skin, often purple or maroon, or a blood-filled blister due to damage to the underlying tissues) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 21's care needs not met and the potential for DTI to worsen. Findings: During a concurrent observation and interview on 5/13/25 at 9:40 a.m. during initial tour in Resident 21's room, Resident 21 was lying in bed. Resident 21 observed not able to move left upper extremity and lower extremities, and limited movement of right upper extremity. During a review of Resident 21's admission Record (AR- a document with personal identifiable and medical information) dated 5/15/25, the AR indicated Resident 21 was admitted tot he facility on 4/17/25 with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial or incomplete paralysis or weakness on one side of the body) and Pressure-Induced Deep Tissue Damage of Sacral Region (occurs when sustained pressure restricts blood flow to the tissues over the sacrum, leading to tissue damage During a concurrent observation and interview on 5/15/25 at 9:35 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was familiar with Resident 21's care. CNA 2 stated she took care of Resident 21 and assisted the treatment nurse when providing treatment to Resident 21. CNA 2 stated Resident 21 has a wound on her buttocks area but not sure how big. CNA 2 stated Resident 21 requires extensive assistance with turning and repositioning. CNA 2 stated, She [Resident 21] is not able to move her legs without assistance and her left arm too, she can use her right arm to grab the bar to assist with turning. During a concurrent interview and record review on 5/16/25 at 11:06 a.m. with the Treatment Nurse (TXN), the TXN reviewed Resident 21's progress note dated 4/18/25 and stated Resident 21 was admitted with deep tissue injury to sacrococcyx area (bones at the bottom[base] of the spine). TXN stated he sent a picture of Resident 21's wound to the wound doctor and the wound doctor said to put a diagnosis of DTI of the wound and gave treatment order to be started for Resident 21's DTI. The TXN stated Resident 21's DTI improved and size was smaller compared to the size when Resident 21 was admitted to the facility. During a concurrent interview and record review on 5/20/25 at 10:10 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 21's five day MDS assessment dated [DATE] section M (Skin Conditions), Resident 21's deep tissue injury was not coded in the MDS assessment. The MDSN reviewed Resident 21's treatment orders and stated Resident 21 had treatment order for DTI which was started on 4/18/25. The MDSN stated she did not code Resident 21 as having DTI and she should have. The MDSN stated it was her responsibility to ensure MDS assessments were accurate. During an interview on 5/20/25 at 4:09 p.m. with the Director of Nursing (DON), the DON stated the MDSN reports directly to the Administrator (ADM) and DON. The DON stated her expectation was for the MDSN to ensure accuracy of assessments. The DON stated the assistant director of nursing (ADON) completes the quarterly assessments in the point click care (PCC- software platform specializing in electronic health records [EHRs] and revenue cycle management for long-term care and senior living communities), the MDSN reviews and used the assessment to complete her MDS assessment. The DON stated there was a section of the MDS requiring a bedside assessment but not sure which section. During an interview on 5/20/25 at 4:52 p.m. with ADM, the ADM stated the MDSN reports directly to the administrator. The ADM stated his expectation was, MDSN to code MDS correctly and accurately. During a review of facility policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment dated 11/19, the P&P indicated, . 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation . period for that assessment . During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated. Definitions . a pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure injury can present as intact skin or an open ulcer and may be painful . Step 1: Determine Deepest Anatomical Stage . At Admission, code based on findings from the first skin assessment that is conducted on or after and as close to the admission as possible . Visualization of the wound bed is necessary for accurate staging .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of three sampled residents (Resident 52) when Resident 52's PASARR level I screening required PASARR Level II mental health evaluation on 9/24/24 and was not completed. This failure had the potential for Resident 52 to not receive the appropriate services related to her mental disorder. Findings: During a review of Resident 52's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 52 was admitted to the facility on [DATE] with diagnoses which included: unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (persistent sadness, loss of interest in activities and difficulty with relationships impacting a person's thinking and behavior), anxiety disorders (a group of conditions characterized by excessive fear, worry, and anxiety that significantly interfere with daily life). During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function), dated 3/25/25, the MDS section C indicated Resident 52 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score of 14 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 52 was cognitively intact. During a review of Resident 52's PASARR Level I Screening Report (PLISR) dated 9/24/24. The PLISR indicated .Resident Review (RR) (Status Change), .Diagnosed Serious Mental Illness (SMI) .- Yes, Specify the diagnosis .- Unspecified Psychosis . State Use Only comments: Level I - Positive for SMI/Negative for ID (intellectual disability) /DD (developmental disability) /RC (related conditions) . During a review of Resident 52's Notice of PASARR Level I Screening Result (NPSR) dated 9/24/24. The NPSR indicated . A Serious Mental illness (SMI) Level II mental health evaluation is required. Result: Positive for SMI/Negative for ID/DD/RC . During a review of Resident 52's Notice of Attempted Evaluation (NAE) dated 9/24/24. The NAE indicated, . In the event of a possible SMI level I screening, a SMI level II mental health evaluation is required to determine if the individual can benefit from specialized services. However, a SMI level II mental health evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening During an interview on 5/15/25 at 9:25 a.m. with the admission & Marketing Director (AMD), the AMD stated the facility receives the PASARR level I for residents via file exchange from the hospital. The AMD stated if the PASARR level I screening was positive, the Minimum Data Set Nurse (MDSN ) follows up with PASARR level II evaluation. During a concurrent interview and record review on 5/15/25 at 9:29 a.m. with the MDSN, Resident 52's PLISR dated 9/24/24, NPSR dated 9/24/24, NAE dated 9/24/24 and Progress Notes (PN) were reviewed. The MDSN stated Resident 52's PASARR level I screening was positive for SMI. The MDSN stated communication between MDSN and PASARR representative should be documented in Resident 52's PN. The MDSN validated there was no evidence of communication between MDSN and PASARR representative. The MDSN stated there was no follow up to ensure PASARR level II evaluation was completed for Resident 52. The MDSN stated the MDSN was responsible for the follow up process on the PASARR level II evaluation. The MDSN stated it was important that Resident 52 was assessed for PASARR level II evaluation if Resident 52 was taking antipsychotropic (medication used to treat psychosis, a condition characterized by symptoms like hallucinations, delusions, and disorganized thinking) medication. The MDSN stated it was important to complete the PASARR level II evaluation, so the state agency had accurate records. During a concurrent interview and record review on 5/15/25 at 11:56 a.m. with the Director of Nursing (DON), Resident 52's PLISR dated 9/24/24, NPSR dated 9/24/24, NAE dated 9/24/24 and PN were reviewed. The DON validated a PASARR Level II evaluation was triggered for Resident 52. The DON stated the importance of the PASARR evaluation was to make sure residents were placed appropriately based on their clinical needs and that services were provided based on their diagnosis. The DON validated there was no documentation of communication between MDSN and PASARR representatives. The DON stated the communication should have been documented in a PN in Resident 52's medical records. The DON stated it was important to document the communication between MDSN and PASARR representatives so there was appropriate information to complete the evaluation. The DON validated the NAE indicated .facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening . The DON stated the expectation was to follow up with contracted party/PASARR representative or DHS (Department of Health Services) to make sure the evaluation was completed. The DON stated it was important to follow up on the PASARR Level II evaluation to make sure Resident 52's mental health was supported. The DON stated the PASARR level II evaluation was not completed, therefore the PASARR policy was not followed. The DON stated there was a potential risk for the omission of necessary services for Resident 52. The DON stated Resident 52's mental disorder could have deteriorated if Resident 52 did not have the support needed. During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, admission Criteria PASARR, dated 03/2019, indicated, .Policy Statement- our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation .9.a. The facility conducts a level I PASARR screen for all potential admission . To determine if the individual meets the criteria for a MD (Mental Disorder), ID (Intellectual Disability/Developmental Disability) or RD (Related Conditions). b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD . is referred to the state PASARR representative for the level II (evaluation and determination) screening process . During a review of professional reference from the California Department of Health Care Services (DHCS) (a government agency that provides healthcare services to low-income and disabled Californians) titled, Preadmission Screening and Resident Review, undated, (found at https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx), the reference indicated .The (DHCS), PASRR Section is responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting, Specialized services. This is achieved by completing the PASRR process. The PASRR process consists of a Level I Screening, Level II Evaluation, and a final Determination. Level I Screening-The Screening is submitted online by the facility and is a tool that helps identify possible SMI and/or ID/DD/RC. Level II Evaluation- If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services. The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third-party contractor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan (a plan that provides direction for individualized care of the resident) within 48 hours of resident's admission for one of two sampled residents (Resident 79) when Resident 79's care plans was not created for the oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy per physician's order. This failure had the potential for Resident 79 to not receive oxygen therapy as prescribed by the physician which had the potential to result in hypoxia (a condition where tissues and organs don't receive enough oxygen) and respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide). Findings: During an observation on 5/13/25 at 1:23 p.m. with Resident 79 during the tour in Resident 79's room, Resident 79 was lying in bed with the head of the bed elevated wearing a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in his nostril. The O2 tubing hung from the resident down the left side of the bed connected to an oxygen concentrator (device that produces oxygen for breathing). The O2 setting was at 2 LPM (liters per minute-unit of measurement). Resident 79 opened his eyes but did not respond to any questions asked. During a review of Resident 79's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/16/25, the AR indicated, Resident 79, was admitted to the facility on [DATE] with diagnoses which included: encounter for palliative care (medical consultations focused on providing comfort and support to patients with serious, life-limiting illnesses), parkinsonism (condition which affects the body's movements), major depressive disorder (persistent sadness, loss of interest in activities and difficulty with relationships impacting a person's thinking and behavior), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hydrocephalus (buildup of fluid in the brain), . During a review of Resident 79's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 4/11/25, the MDS section C indicated, Resident 79 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 79 was severely impaired. During a review of Resident 79's MDS assessment dated [DATE], the MDS section O indicated Resident 79's Special Treatment, Procedures, and Programs included Resident 79 on Hospice care (a type of care that focuses on providing comfort and relief to terminally ill patients and their families, rather than focusing on curing the illness). During a review of Resident 79's Order Summary Report (OSR) dated 10/7/24 at 5:01 p.m. The OSR indicated .O2 at 2-5 LPM via NC PRN (as needed) per concentrator /tank as needed for Dyspnea (difficulty or discomfort in breathing) . During a review of Resident 79's Progress Notes (PN) dated 10/8/24 at 10:52 p.m. The PN indicated, .Resident is on monitoring for s/p (status post) new admit to facility under{name}hospice . During a concurrent interview and record review on 5/16/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 79's O2 order and care plans were reviewed. The LVN 6 stated, I do not see any care plan, there should be a care plan if the resident is on O2. LVN 6 stated it was important to have a care plan for O2 because it showed the interventions needed for Resident 79. LVN 6 stated the care plan guided the Licensed Nurses (LNs) and helps LNs know what problems Resident 79 had. LVN 6 stated the care plan should have been initiated when O2 was started on 10/7/24. During a concurrent interview and record review on 5/16/25 at 11:47 a.m. with the Minimum Data Set Nurse (MDSN), Resident 79's O2 order and care plans were reviewed. The MDSN stated there was no care plan for O2. The MDSN stated there should have been a care plan to ensure LNs were providing Resident 79 his O2 needs. The MDSN stated the care plan ensured staff with access to resident 79's care know what interventions the resident needs. The MDSN stated the care plan should have been completed as soon as the O2 was ordered on 10/7/24. During a concurrent interview and record review on 5/16/25 at 1:46 p.m. with the Director of Nursing (DON), the baseline care plan policy, the duties, job description for Registered Nurse (RN) & LVN, Resident 79's O2 order and care plans were reviewed. The DON stated care plans were initiated when residents were admitted to the facility. The DON stated baseline care plans should have been completed based on Resident 79's assessment on admission. The DON stated a baseline care plan should have been completed within 48 hours of admission. The DON stated there was no baseline care plan completed when resident 79 was admitted on [DATE]. The DON stated, It would be appropriate for Resident 79 to have a care plan so that anyone participating in his care would have information regarding the plan of Resident 79's care and other non -physician support can be incorporated in his care. The DON stated having a care plan could improve the care of Resident 79. The DON stated the care plan policy was not followed. The DON stated it was important for staff to follow the policy to ensure adherence to systems that will support residents' care. During a review of the facility's document titled, Job Description, LPN/LVN, dated 2/2024, the document indicated . Charting and Documentation- .Transcribe physician's order to resident . treatment/ care plans as required. Care Plan and Assessment Functions- Review care plans daily to ensure that appropriate care is being rendered . Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During a review of the facility's document titled, Job Description, Registered Nurse (RN), dated 2/2024, the document indicated, . Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care . Review resident care plans for appropriate resident goals, problems, approaches, revisions based on nursing needs. Ensure that all personnel involved in providing care to the resident are aware of the residents' care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed. Assist the Resident Assessment/ Care Plan Coordinator in planning, scheduling, and revising the MDS . Review resident's medical and nursing treatments to ensure that they are provided in accordance with the resident's care plan and wishes . Must be knowledge able of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, Care Plans-Baseline, dated 12/2016, indicated, .Policy Statement- 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. Policy Interpretation and Implementation 1. To assure that the resident's immediate care needs are met and maintained .2. The Interdisciplinary Team will review the healthcare practitioner's orders . 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 .3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person- centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. the initial goals of the resident . During a review of the facility's policy and procedure titled, Oxygen Administration, dated 10/2010, indicated, .the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation-1. Verify that there is a physician's order for this procedure .2. Review the resident's care plan to assess for any special needs of the resident . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive resident-centered care plans for 11 of 24 sampled residents (Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79) when the Activities Director (AD) did not develop resident-centered activity care plans for Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 since their admission to the facility. These failures resulted in Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 not having activities they could engage in, which could lead to boredom, loss of interest, inactivity, depression, feelings of isolation and decreased socialization with others while residing in the facility. Findings: During a review of Resident 7's admission Record (AR- a document containing resident profile information) dated 5/16/25, the AR indicated, Resident 7 was admitted to the facility with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dysphagia (difficulty swallowing), and contractures (stiffening/shortening at any point, that reduces the joint's range of motion) of right and left hand. During a review of Resident 12's AR dated 5/16/25, the AR indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia and contracture of left hand. During a review of Resident 18's AR dated 5/16/25, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included emphysema (long-term lung condition that causes shortness of breath), chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing) and Alzheimer's Disease. During a review of Resident 21's AR dated 5/15/25, the AR indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses which included dysphagia, hemiplegia and hemiparesis, and difficulty in walking. During a review of Resident 32's AR dated 5/16/25, the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, epilepsy (recurrent seizures[episodes of abnormal brain activity]) and absence of right and left upper limb, absence of right leg below knee and absence of left leg above knee. During a review of Resident 39's AR dated 5/16/25, the AR indicated, Resident 39 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, difficulty in walking, hemiplegia and hemiparesis. During a review of Resident 45's AR dated 5/16/25, the AR indicated Resident 45 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (decrease muscle size and strength) diabetes mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing). During review of Resident 53's AR dated 5/15/25, the AR indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses which included fracture of right femur (break in the longest bone in the body), muscle weakness and respiratory disorder. During a review of Resident 76's AR dated 5/16/25, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, muscle weakness and osteoporosis (weak and brittle bone). During a review of Resident 78's AR dated 5/16/25, the AR indicated, Resident 78 was admitted to the facility on [DATE] with diagnoses which included DM, muscle weakness and muscle wasting and atrophy. During a review of Resident 79's AR dated 5/16/25, the AR indicated Resident 79 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), depression (persistent low mood or loss of interest in activities for extended periods) and Alzheimer's Disease. During an interview on 5/16/25 at 8:18 a.m. with Activities Director (AD), the AD stated activities were important because the activities helped resident be active, stimulated their minds and was important for their social well-being. The AD stated other residents who are not able to participate in activities were provided one on one activities by the activity assistant. The AD stated she did not know how often residents were provided one on one activity per week. The AD reviewed Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79's activity care plans and stated Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79's care plans had the same focus, goals, and interventions. The AD stated the care plans were not individualized or person-centered to meet the needs of each resident. The AD stated care plans needed to be personalized and addressed the needs of each resident. The AD stated the activity care plans for Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 were not individualized to their activity needs. The AD stated she was not sure if they were meeting the activity needs of each resident. During a concurrent interview and record review on 5/16/25 at 9:17 a.m. with Activities Assistant (AA), the AA reviewed activities electronic charting and stated she did not have a list of residents who were needing one on one activities. The AA stated every morning, she went down the hallways to resident rooms and distributed coffee or any beverages and snacks to all residents. The AA stated she provided one on one to residents by spending few minutes with each resident talking with them while distributing snacks/coffee. The AA stated, I think in a week, I visit residents at least once and spent at least five minutes talking with them. The AA stated she thinks activities provided was enough to meet each resident's activity needs. The AA stated she did not know the care plans for each residents, she went around and talked to each resident. During an interview on 5/20/25 at 4:15 p.m. with the Director of Nursing (DON) the DON stated activities care plans were the responsibilities of the AD. The DON stated she talked with the AD regarding care plans and that the care plans had to be individualized and addressed the needs of each residents. The DON stated care plans should be personalized because not all residents are the same. During a review of facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team [IDT-group of individuals from different backgrounds who collaborate to achieve a common goal], with input from the resident, and his/her family or legal representative . The care plan intervention should be derived from information obtained from the resident and his/her family/responsible party . Includes measurable objectives and times frames . During a review of facility's policy and procedure titled, Activity Programs, dated 8/2006, the P&P indicated, .Our activity programs are designed to encourage maximum participation and are geared to the resident's needs . consist of individual and small and large group activities that are designed to meet the needs and interests of each resident . Activities include but are not limited to, daily coffee social, birthday and holiday parties .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for seven out of 12 sampled Residents (Residents 24, 27, 29, 48, 56, 58, and 143) when: 1. Resident 24 and Resident 29's oxygen (a colorless, odorless, tasteless gas essential to living organism) flow rate (the amount of oxygen being delivered to the body) were not administered according to their physician order. These failures resulted in Resident 24 and Resident 29 to not received the prescribed amount of oxygen via oxygen concentrator (a machine that pulls in oxygen from the surrounding air) and placed Resident 24 at risk for breathing problems which could include difficulty breathing, headache, and confusion. 2. No Oxygen in Use signage outside of Resident 143's room. This failure had the potential to result in Resident 143's accidental burn. 3. Resident 58 had a physician's order for oxygen at 3 liters per minute (LPM- unit of measurement) and she was receiving 2.5 LPM. This failure had the potential to place Resident 58's safety at risk by developing hypoxia (a condition where the body's tissues do not receive enough oxygen) and her specific needs not being met . 4. The facility failed to follow their policy and procedure (P&P) Change in Resident's Condition or Status for Resident 48 when he had an unwitnessed fall and the physician was not notified, nor a change in condition completed. This failure put Resident 48's safety at risk by not addressing his fall, increasing the risk of additional fallsand his specific needs not met . 5. Resident 27 was high fall risk for falls, had a physician order for a Dycem (a flexible, non-slip material used to stabilize surfaces and objects) device to be placed on the wheelchair which was not in place during observation and was falsely documented as presented by the nursing staff. This failure resulted in wheelchair instability and increased the risk of falls and injury. 6. Resident 27 had a physician order for a Magnetic resonance imaging (MRI - medical imaging used to create detailed, non-invasive images of the body's internal structures, to help doctors diagnose a wide range of conditions and monitor treatment effectiveness.) -due to gait instability and full history which was not scheduled or completed. This failure had the potential to result in delayed diagnosis and treatment for Resident 27. 7. Resident 56 was administered 4 L/min (liters-unit of measurement)/min (minute) of oxygen via Nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 2L/min of oxygen per physician's order. This failure had the potential to put Resident 56 at risk for oxygen toxicity (lung damage that can occur from breathing in too much extra oxygen which can cause coughing and troubled breathing. 8. Resident 56 had a physician order for a left knee X-ray (a type of electromagnetic radiation that can pass through certain objects, including the human body) due to pain which was not completed and marked completed in the electronic charting system without follow up. This failure had the potential to delay treatment for Resident 56. Findings: 1. During a concurrent observation and interview on 5/13/25 at 9:10 a.m. during initial tour in Resident 24's room, Resident 24 was lying in bed, eyes closed and TV on. Resident 24 stated he needed the oxygen to help him breath. Resident 24's oxygen flow rate on the oxygen concentrator indicated 3 l/minute via (through) nasal cannula (NC-a tube used to deliver supplemental oxygen through the nose), During a review of Resident 24's admission Record, (AR-a document with personal identifiable and medical information), dated 5/15/25, the AR indicated Resident 24 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 24's Medication Review Report (MRR) dated 5/15/25, the MRR indicated, .O2 [oxygen] 2 [two] LPM [liters per minute] VIA NASAL CANNULA PRN PER CONCENTRATOR /TANK as needed . During an observation on 5/13/25 at 8:59 a.m. during initial tour in Resident 29's room. Resident 29 observed lying in bed eyes closed and did not answer questions asked. Resident 29's bed was in lowest position and cup of water placed on top of overbed table positioned across the bed. Resident 29 observed with oxygen via NC connected to oxygen concentrator. Resident 29's oxygen flow rate was between 2.5 L and 3L. During a review of Resident 29's oxygen order dated 5/20/25, the order indicated, .O2 2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK . During an interview on 5/13/25 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated oxygen flow rate should be according to physician order. LVN 1 stated, We could not give more than the ordered rate of oxygen. LVN 1 stated giving more oxygen to residents could cause hyperventilation (condition where a person breathes rapidly and deeply, leading to a decrease in the amount of carbon dioxide in the blood) which could result in more serious condition. LVN 1 stated she was the nurse for Resident 24 and Resident 29 and she did not check the flow rate of their oxygen when she administered their medications. During a concurrent interview and record review on 5/13/25 at 9:15 a.m. with Treatment Nurse (TXN), the TXN checked Resident 24's oxygen flow rate and stated, Oxygen is set at 3L/min. TXN reviewed Resident 24's oxygen order and stated Resident 24's oxygen order was 2L/min. TXN checked Resident 29's oxygen flow rate and stated, Oxygen is set between 2.5L/min and 3L/min. TXN reviewed Resident 29's oxygen order and stated, His [Resident 29] oxygen order is 2L/min. TXN stated Resident 24 and Resident 29 were receiving more than the ordered amount of oxygen prescribed by their physician and could lead to more serious respiratory problem. During a concurrent interview and record review on 5/15/25 at 2:15 p.m. with LVN 2, Resident 24's clinical record was reviewed. LVN 2 stated Resident 24's oxygen order was 2L/min via NC. LVN 2 stated licensed nurses were responsible in making sure physician order for oxygen were followed. LVN 2 stated residents receiving more than the ordered oxygen flow rate could, increases the amount of carbon dioxide [CO2-naturally occurring gas in the atmosphere] in the blood and decrease the amount of oxygen into the blood which could lead to delirium [a serious disturbance in a person's mental abilities], lethargy[feeling unusually tired, sluggish, or lacking in energy], cyanotic [bluish or purplish discoloration of the skin, lips, or nail beds caused by a lack of oxygen in the blood] and leads to cardiovascular issues. During an interview on 5/20/25 at 3:58 p.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to follow physician's orders for oxygen flow rate. The DON stated residents not receiving the correct physician order for oxygen could lead to respiratory problems. During a review of facility policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing, Carrying Out and Implementing (Noting), undated, the P&P indicated, .Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented . Appropriate dose administration times are established for each medication per facility guidelines . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 2. During a review of Resident 143's admission Record, undated, the AR indicated, Resident 143 was admitted to facility on 5/3/25 with diagnoses which included muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), and syncope (fainting or passing out) and colllapse (to fall or cave in). During a review of Resident 143's Order Summary Report, undated, the Order Summary Report, indicated, . O2 2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK . During observation on 5/13/25 at 8:30 a.m. during initial tour in Resident 143's room, Resident 143 was lying in bed and observed with oxygen via NC. Resident 143 refused to answer question asked. No signage outside of Resident 143's doorway to indicated use of oxygen in the room. During an interview on 5/13/25 at 8:35 a.m. with TXN, the TXN stated there should have been a signage outside of Resident 143's room to let people (visitors and families) know oxygen was being used in the room. TXN stated it was important to put signage outside the door for safety issues. During an interview on 5/20/25 at 4:05 p.m. with the DON, the DON stated it was important to ensure Oxygen in Use signage was placed outside the doors of residents using oxygen. The DON stated it was for safety issue. The DON stated it was the responsibility of all staff to ensure there was signage outside of each resident using oxygen. The DON stated, It was a team effort, if no signage or if sign fell on the ground to pick up the sign and placed outside residents' door. During a review of facility policy and procedure (P&P) titled Oxygen Administration dated 10/2010, the P&P indicated, . The following equipment and supplies will be necessary when performing this procedure . No Smoking/Oxygen in Use signs . Place an Oxygen in Use sign on the outside of the room entrance door . Place an Oxygen in Use sign in a designated place . 3. During an observation on 5/13/25 at 8:32 a.m., in Resident 58's room, Resident 58 was receiving oxygen from an oxygen concentrator that was set at 2.5 LPM. During a concurrent observation and interview on 5/14/25 at 10:50 a.m., in Resident 58's room with Licensed Vocational Nurse (LVN) 4, Resident 58 was receiving oxygen from an oxygen concentrator that was set at 2.5 LPM. LVN 4 stated Resident 58 had a physician order for her oxygen to be running at 3 LPM, but it was running at 2.5 LPM. LVN 4 stated she was the nurse responsible for Resident 58 and the physician orders should have been followed and they were not. During a review of Resident 58's AR, dated 5/20/25, the AR indicated, Resident 58 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a lung disease that causes chronic inflammation and narrowing of the airways, making it difficult to breathe) with (acute) exacerbation (a flare-up where symptoms become significantly more severe than usual and require immediate attention) and dependence on supplemental oxygen (provides extra oxygen to people who have trouble breathing and are not getting enough oxygen from their lungs alone). During a review of Resident 58's MDS assessment, dated 3/31/25, the MDS assessment indicated Resident 58's BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15. The BIMS assessment indicated Resident 58 was cognitively intact. During a review of Resident 58's Medication Review Report (MRR), dated 5/20/25, the MRR indicated, .Order Summary: . Continuous O2 3L [Liters- unit of measurement] via NC [Nasal Cannula- a simple, flexible tube with two prongs that fit inside your nostrils that is used to deliver extra oxygen] per concentrator/tank related too Diagnosis of Acute Respiratory Failure [a life-threatening emergency your lungs aren't working properly to get enough oxygen into your blood and/or remove carbon dioxide] with Hypoxia [a condition where the body's tissues do not receive enough oxygen] . Active . Order date: 5/13/25 . Start date: 5/13/25 . During an interview on 5/16/25 at 1:55 p.m., with LVN 8, LVN 8 stated that she was Resident 58's nurse on 5/13/25. LVN 8 stated the oxygen was not set at what the physician had ordered (was 3 LPM at that time). LVN 8 stated it was important to follow the physician's order and they did not. LVN 8 stated Resident 58 did not receive the appropriate amount of oxygen and that could have caused respiratory distress, which could have resulted in hospitalization. During an interview on 5/20/25 at 1:38 p.m., with the Director of Nursing (DON), the DON stated it was important to follow the physician's order so their plan of care is supported. The DON stated Resident 58 would have been receiving clinically subtherapeutic oxygen delivery. The DON stated there was potential for Resident 58 to become hypoxic (a condition where the body's tissues do not receive enough oxygen). The DON stated the facility did not follow the policy and procedure Oxygen Administration. During an interview on 5/20/25 at 2:27 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated the expectation for nursing staff was to set the oxygen rate exactly per the physician order. The UNS stated if the oxygen was not set per the physician order than the resident could go into respiratory distress and have complications. The UNS the policy and procedure for Oxygen Administration was not followed. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated October 2010, the P&P indicated, .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . During a review of RegisteredNursing.org professional reference titled, Does a Nurse Always Have to Follow a Doctor's Orders?, dated 1/18/25, (found at https://www.registerednursing.org/articles/does-nurse-always-follow-doctors-orders/#:~:text=Unless%20there%20is%20a%20safety,not%20follow%20a%20doctor's%20order.) the reference indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect. During a review of the National Library of Medicine professional reference titled, Nursing Rights of Medication Administration, dated 9/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . Right Dose . Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient's personal safety . 4. During a review of Resident 48's Progress Notes (PN), dated 5/2/25 at 1:31 p.m., the PN indicated, . Created by: LVN 4 . Resident [48] found on floor next to his bed at 1 p.m., no injury noted, staff assist resident back to bed, resident stated that he was going to the bathroom, educated resident the use of call light for assistant. Resident thinks that he can walk, writer asked Spanish speaking staff to explain that we can help resident with all needs, resident verbalize understanding. Bed to lowest position, placed floor mats too both sides, Will continue to monitor . During a review of Resident 48's AR, dated 5/20/25, the admission Record indicated, Resident 48 was admitted to the facility on [DATE] with a diagnosis of difficulty in walking, muscle weakness. During a review of Resident 48's MDS assessment, dated 5/2/25, the MDS assessment indicated Resident 48's BIMS assessment score was 7 out of 15. The BIMS assessment indicated Resident 48 was severely cognitively impaired. During an interview on 5/16/25 at 2:05 p.m., with LVN 8, LVN 8 stated if a resident was found on the ground it would be an unwitnessed fall. LVN 8 stated if the resident was found on the ground and has issues communicating, they were to contact the responsible party (RP), notify the DON and the physician. During an interview and record review on 5/20/25 at 1:43 p.m., with the DON, Resident 48's Electronic Medical Record (EMR) was reviewed. The EMR indicated Resident 48 had an unwitnessed fall which occurred on 5/2/25 at 1:31 p.m., but there was no physician notification, nor change of condition completed. The DON stated she was not aware of this fall that was documented in PN. The DON stated the physician was to be made aware of the fall as well and nothing was documented that he was. The DON stated Resident 48 had a fall that same day at 2 a.m. that everyone knew about, but not the 1:31 p.m. fall. The DON stated a change of condition should have been completed for the second fall and it was not per the EMR. The DON stated the P&P Change in Resident's Condition or Status was not followed. The DON stated because it was not followed Resident 48 could have had another fall due to lack of staff support strategies for future fall prevention. During an interview on 5/20/25 at 2:32 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated for an unwitnessed fall a nurse should have notified a physician and completed a change of condition to adjust the plan of care. The UNS stated if this was not done the resident could have an injury from another fall. The UNS stated that a person had a second fall in the same day they would need additional fall interventions put in place. There was an attempt to interview LVN 4 on 5/20/25 at 5 p.m., but she refused to comment on the incident. During a review of the facilities P&P titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, .Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical . and/or status (e.g. [for example] changes in level of care . etc . Policy Interpretation and Implementation . The nurse will notify the resident's attending physician or physician on call when there has been a: a. accident or incident involving the resident .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . there is a significant change in the resident's physical . status . 5. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a concurrent observation and interview on 5/16/25 at 9:26 a.m. with Resident 27 in Resident 27's room, Resident 27 sat at the edge of the bed, dressed in shorts and a tee shirt with compression socks on, and Resident 27's wheelchair was next to the bed. Resident 27's wheelchair was noted to have a seat cover with a picture of black and white feathers with red color accents on the feathers, No Dycem slip prevention mat was seen. Resident 27 stated she fell out of her wheelchair, outside the facility on 5/14/25 at night coming back from the market next door. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 27 told her she fell on Wednesday night (5/14/25). CNA 4 acknowledged Resident 27 should have prevention interventions in place, to keep Resident 27 safe from falls. Durning an observation on 5/20/25 at 10:07 a.m. Resident 27 was observed sitting on the wheelchair. Resident 27 stated the Dycem was not on her chair. Durning a concurrent interview and record review on 5/20/25 at 4:16 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 27's Medication Administration Record (MAR), dated 5/20/25 was reviewed. The MAR indicated LVN 3 had document on multiple dates of monitoring for Dycem to prevent resident from sliding off. Monitor placement every shift for fall prevention, start date 10/22/2024. LVN 3 stated she had knowledge of Resident 27's fall on 5/14/25. LVN 3 stated she did document the placement of the Dycem was on the wheelchair, LVN 3 stated she did not see the Dycem and should not have documented falsely. Durning a concurrent interview and record review on 5/20/25 at 4:59 p.m. with the Unit Nurse Supervisor (UNS), Resident 27's MAR dated 5/20/25 was reviewed. The MAR indicated on 5/16/25 for the dayshift time, the UNS confirmed her initials, documented confirmed placement and monitoring of the Dycem. The UNS stated she did not personally see the placement and should not have documented falsely. The UNS stated she was not performing to facility expectation of documentation. Durning an interview on 5/20/25 at 4:34 p.m. with the DON, the DON stated it is the expectation for the facility staff to document accurately and for the physician orders to be fulfilled. During a review of the facility's policy and procedures (P&P) tilted Charting and Documentation, dated April 2008, indicated .All observations, medications administered, services preformed .must be documented in the resident's medical record .Documentation .include at a minimum .assessment data and/or any unusual findings . 6. During a concurrent interview and record review on 5/16/25 at 2:30 p.m. with the DON, Resident 27's Progress notes, dated 5/8/25 were reviewed. The progress notes indicated, .follow up appointment orders .Outpatient referral for MRI due to gait inability . The DON acknowledged this note made on 5/8/25 as orders to follow, author indicated LVN 5. DON indicated the order was not carried out timely, the DON stated the expectation of the nursing staff was to complete the order as soon as possible for the accurate assessment of Resident 27. Durning an interview on 5/20/25 at 4:16 p.m. with LVN 5, LVN 5 was unable to provide a clinical rationale why the physician's orders of an MRI for Resident 27 had not been completed. During a review of the facility's P&P titled Lab and Diagnostic Test results-Clinical Protocol, dated November 2018, the P&P indicated, .physician identify and order diagnostic and lab testing based on the residents' .monitoring needs. The staff will process test requisitions and arrange for test .A nurse will determine whether the test was done . During a review of National Center for Biotechnology Informatiom.gov Professional Reference titled, Legal Implications- Nursing Management and Professional Concepts, dated 2024, (found at https://www.ncbi.nlm.nih.gov/books/NBK610473/#:~:text=A%20nurse%20may%20be%20charged,revocation%20of%20a%20nurse%27s%20license.) the reference indicated, .A nurse may be charged with fraud for documenting interventions not preformed or altering documentation cover up an error. Fraud can result in civil and criminal charges and also suspension or revocation of a nurse's license . During a review of My American Nurse. Com Professional Reference titled, Understand the risk of erroneous and incomplete documentation, dated 8/7/23, (found at https://www.myamericannurse.com/proper-documentation-protects-patients-and-your-license/#:~:text=Takeaways:,or%20licensing%20board%20disciplinary%20action) the reference indicated, .Nursing documentation plays a critical role in healthcare. Errors or incomplete information can affect data accuracy and ultimately best practices. Improper documentation also can contribute to adverse, sometimes fatal, patient outcomes. When you document completely and accurately, you reduce your liability risk and have the strongest legal defense in the event of a malpractice lawsuit or licensing board disciplinary action . 7. During a Review of Resident 56's AR dated 5/20/25, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and Asthma (a chronic lung condition making it difficult to breathe). During a concurrent observation and interview on 5/13/25 at 8:43 a.m. in Resident 56's room, Resident 56 was sitting in her wheelchair with oxygen via nasal cannula receiving 4L/min. Resident 56 stated she was always feeling short of breath, normally had oxygen on. During a concurrent interview and record review on 5/13/25 at 4:27 p.m. with LVN 3, Resident 56's order summary was reviewed, the order summary indicated Resident 56 should be receiving 2L/min of oxygen via NC ordered by the physician. LVN 3 checked Resident 56's oxygen setting and confirmed the resident was receiving 4 l/min of oxygen via NC. LVN 3 stated Resident 56 should not receive 4 l/min of oxygen that is not the physician order. LVN 3 stated she will monitor Resident 56, and inform the doctor, as well as update the care plan. LVN 3 stated it is important for Resident 56 who has diagnosis of COPD to not over inflate the lungs placing a lot of pressure on her lungs and it can lead to other issues like confusion. During an interview on 5/15/25 at 3:12 p.m. with the DON in the DONs office. The DON stated it was the expectation of the nurses to follow the physician orders as stated. During a review of the facility's policy and procedures (P&P) tilted Oxygen Administration, dated October 2010, indicated .Verify that there is a physician's order .review the physician's orders or facility protocol for oxygen administration .after completing the oxygen setup or adjustment, the following information should be recorded .the rate of oxygen flow . 8. During a record review on 5/15/25 at 9:20 a.m. of Resident 56's Progress notes dated 5/5/25, the progress note indicated the medical doctor gave a telephone order for a 3 view x-ray to the knee of Resident 56, and a copy of the order and face sheet was sent to via fax. During an interview on 5/15/25 at 11:14 a.m. with Resident 56, Resident 56 stated she was unable to bare weight on her left leg. Resident 56 stated she did not fall but did slip and head her left knee pop. Resident 56 stated the facility informed her she would get an x ray and it was not done. Resident 56 expressed frustration on being told something and not being done. During an interview on 5/15/25 at 2:17 p.m. with LVN 1, LVN 1 was unable to provide confirmation the x-ray was completed. LVN 1 stated the order was marked as complete, and results were not found. LVN 1 stated she cannot confirm the order was completed. LVN 1 stated the nurses had to carry out the physican orders as soon as possible and the nurses needed to communicate orders to each other via hand off report (verbal communication between shifts). During an interview on 5/15/25 at 3:12 p.m. with the DON, the DON acknowledged the order was not completed, and the x-ray person did not receive a fax about Resident 56. DON stated it is the expectation of orders to be carried out, this order was missed. During a review of the facility's P&P titled Lab and Diagnostic Test results-Clinical Protocol, dated November 2018, the P&P indicated, .physician identify and order diagnostic and lab testing based on the residents' .monitoring needs. The staff will process test requisitions and arrange for test .A nurse will determine whether the test was done . During a review of the facility's P&P titled Physician orders, accepting, transcribing, carrying out and implementing (Noting) undated, the P&P indicated, Licensed nursing During a review of the facility's P&P titled Physician orders, accepting, transcribing, carrying out and implementing (Noting) undated, the P&P indicated, Licensed nursing personnel will ensure .all physician orders are to be completed and clearly defined to ensure accurate implementation . During a review of Job Description: LPN/LVN dated February 2024, the Charting and Documentation indicated Receive .orders from physicians and record on the Physicians' Order Form. Transcribe physician's order to resident charts, cardex, medication cards, treatment/ care plans, as required .Nursing Care Functions Requisition and arrange for diagnostic and therapeutic services, as order by the physician, and in accordance with our established procedures. Review the resident's chart for specific treatments, medication orders, diets, ect., as necessary. Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotion status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a hazard free environment and adequate supervision to prevent accidents was provided for two of three sampled residents (Resident 23 and Resident 27) when: 1. Resident 23 was using two phone books covered with duct tape as a step-stool to assist in getting up into bed that were made by therapy staff. This failure put Resident 23's safety at risk by creating a hazardous environment that could have caused an accident or fall. 2. The facility failed to ensure Resident 27 received adequate supervision to prevent accidents despite being identified as a high fall risk. This failure resulted in repeated falls and unsafe situations, with an increased risk of potential bodily harm. Findings: 1. During a current observation and interview on 5/14/25 at 10:08 a.m., with Resident 23, in Resident 23's room, Resident 23 stepped on two blocks made of duct tape (a very strong adhesive tape with a waterproof backing, used to seal home ducts, hoses) to get into her bed. Resident 23 stated rehab made them for her and she needed to step on them to get in and out of bed. Resident 23 stated she was unsure of what they were made of. During a review of Resident 23's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 23 was admitted to the facility on [DATE] with diagnosis of muscle weakness, morbid (severe) obesity (a chronic condition characterized by an excessive accumulation of body fat that can negatively impact health), muscle wasting (when muscles shrink and become weaker) and atrophy (gradual wasting away or shrinking), unsteadiness on feet, ataxic gait (a wobbly, unsteady, and uncoordinated way of walking), chronic pain and other abnormalities of gait and mobility (movement). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/29/25, the MDS assessment indicated Resident 23's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 13 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 23 was cognitively intact. During an interview on 5/15/25 at 3:17 p.m., with the Director of Rehabilitation (DOR), the DOR stated the two blocks were actually phone books covered with duct tape. The DOR stated a facility staff member, Occupational Therapist (OT) 1, made the blocks. The DOR stated the phone books (a physical book that is like a directory or list of names, addresses, and phone numbers of people and businesses in a particular area) were designed to be a therapeutic intervention , but they were not appropriate. The DOR stated the stepping stool made of phone books was a potential safety hazard and could have increased Resident 23's risk for a falls because, she could slip. The DOR stated the facilities policy and procedure Staff Physical Therapist and Clinical Standards of Practice were not followed. During an interview on 5/16/25 at 1:55 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated she had seen the phone books since January 2025 in Resident 23's room. LVN 8 stated she used them to help her get into bed. LVN 8 stated that Resident 23 could trip on them and they were a safety concern. LVN 8 stated she never said anything to anyone because she used them all the time. During an interview on 5/16/25 at 3:43 p.m., with OT 1, OT 1 stated Resident 23 used them for positioning. OT 1 stated that he did make the blocks and they were phone books wrapped in duct-tape. OT 1 stated the phone books were never intended to be used as an everyday thing and were not made for her to step on the bed. OT 1 stated she needed to be ordered something specifically for stepping on the bed, but that got overlooked. OT 1 stated the way Resident 23 used the blocks would have increased her fall risk During an interview on 5/20/25 at 1:29 p.m., with the Director of Nursing (DON), the DON stated the blocks were not the facilities preferred use for getting up into bed. The DON stated the blocks could have been safer and they were not appropriate. The DON stated the facilities policy and procedures Staff Physical Therapist and Clinical Standards of Practice were not followed. During an interview on 5/20/25 at 2:23 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated the blocks should not have been used by Resident 23. The UNS stated they were a safety issue for the resident and the blocks were not professional. The UNS stated the facilities policy and procedures Staff Physical Therapist and Clinical Standards of Practice were not followed. During a review of the facility's policy and procedure (P&P) titled, Staff Physical Therapist undated, the P&P indicated, .General Purpose: The staff Physical Therapist evaluates and treats patients . Essential Duties: . Recommend and facilitate the ordering of necessary durable medical equipment for patients . Report any problems with department equipment so that it is maintained in good working order . During a review of the facility's P&P titled, Clinical Standards of Practice, undated, the P&P indicated, .All rehab services are delivered in a professional and quality manner . 2. During an interview on 5/15/25 at 3:22 p.m. with the DON, in the DON's office, Resident 27 was observed through a large window, propelling her wheelchair unsupervised out of the facility's parking lot toward the adjacent street. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a review of Resident 27 ' s Minimum Data Set assessment, dated 4/7/25, the MDS assessment indicated Resident 27 ' s BIMS assessment score was 14 out of 15. The BIMS assessment indicated Resident 128 was cognitively intact. During an interview on 5/16/25 at 9:26 a.m. with Resident 27, in Resident 27's room. Resident 27 stated she was coming back from the Asian market around the corner. Resident 27 stated it was dark at this time, and she could not get her wheelchair over the bump in the pavement, I flipped over. Resident 27 stated she hit the ground hard and could not get herself back up and into her chair. Resident 27 stated she laid there on the ground, yelling for help. Resident 27 shared her call history on her personal cellphone with multiple calls to the facility and nobody answered, nobody came. Resident 27 stated eventually, she somehow got herself back in the chair and into the facility. Resident 27 stated she reported her fall. Resident expressed frustration with inconsistent support and the feel of needing help. Resident 27 stated, I don't feel I have anyone to advocate for me. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 27 does a lot on her own, but when she falls it's bad. She told me she hit her head last time. CNA 4 stated when a resident falls, the resident is checked every 15 minutes, but when Resident 27 outside, I don't know. During an interview on 5/20/25 at 9:57 a.m. with the Receptionist, the receptionist stated, Resident 27 would go three times a day to get her cigarettes. The Receptionist stated he's seen Resident 27 go out front alone. The Receptionist stated each residence has a Leave of Absences (LOA) sheet and they are to sign themselves out. The receptionist reported his shift is over at 5 p.m., when the phone rings anyone can answer the phone, because it will ring throughout the facility. During an interview on 5/20/25 at 10:33 AM with LVN 4, LVN 4 stated, she observed Resident 27 leave the facility. LVN 4 stated Resident 27 signs herself out. LVN 4 could not provide documentation of Resident 27 signing herself out. LVN 4 acknowledged Resident 27 as a high fall risk and not knowing when she was off the property. LVN 4 stated when a resident was a high fall risk they were watched closely. LVN 4 was unable to provide clinical evidence of what watching closely was. LVN 4 acknowledged she was responsible for the residents' well-being and needed to provide adequate supervision for Resident 27 who was at high risk for falls. During a review of Resident 27's Progress Note (PN) dated 5/14/25 and Resident 27's call history, the PN and call history, indicated Resident 27 made calls to the facility on 5/14/25 at 8:34 p.m., 8:37 p.m., 8:39 p.m., and 8:40 p.m., with durations ranging from seventeen seconds to two minutes. No documentation was found indicating that staff were aware of the calls or responded to the resident's request for assistance. During a concurrent interview and record review on 5/20/25 at 3:33 p.m. with the DON, the facility's policy and procedure (P&P) titled Fall Prevention Program and Falling Star Program, undated, was reviewed. The P&P indicated, .residents at high risk .a visual identifier placed on the name plaque outside the door .a yellow armband for further identification . The DON acknowledged the resident had not signed the LOA form, and the team did not always know when she left the building. The DON confirmed consistent individualized interventions should have been in place. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated December 2007, the P&P indicated, .staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling .If the resident continues to fall, staff will re-evaluate the situation .staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist . 2. During an interview on 5/15/25 at 3:22 p.m. with the DON, in the DON's office, Resident 27 was observed through a large window, propelling her wheelchair unsupervised out of the facility's parking lot toward the adjacent street. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a review of Resident 27 ' s Minimum Data Set assessment, dated 4/7/25, the MDS assessment indicated Resident 27 ' s BIMS assessment score was 14 out of 15. The BIMS assessment indicated Resident 128 was cognitively intact. During an interview on 5/16/25 at 9:26 a.m. with Resident 27, in Resident 27's room. Resident 27 stated she was coming back from the Asian market around the corner. Resident 27 stated it was dark at this time, and she could not get her wheelchair over the bump in the pavement, I flipped over. Resident 27 stated she hit the ground hard and could not get herself back up and into her chair. Resident 27 stated she laid there on the ground, yelling for help. Resident 27 shared her call history on her personal cellphone with multiple calls to the facility and nobody answered, nobody came. Resident 27 stated eventually, she somehow got herself back in the chair and into the facility. Resident 27 stated she reported her fall. Resident expressed frustration with inconsistent support and the feel of needing help. Resident 27 stated, I don't feel I have anyone to advocate for me. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 27 does a lot on her own, but when she falls it's bad. She told me she hit her head last time. CNA 4 stated when a resident falls, the resident was checked every 15 minutes, but when Resident 27 outside, I don't know. During an interview on 5/20/25 at 9:57 a.m. with the Receptionist, the receptionist stated, Resident 27 would go three times a day to get her cigarettes. The Receptionist stated had seen Resident 27 go out front alone. The Receptionist stated each residence has a Leave of Absences (LOA) sheet and they are to sign themselves out. The receptionist stated his shift was over at 5 p.m., when the phone rings anyone could answer the phone, because it will ring throughout the facility. During an interview on 5/20/25 at 10:33 AM with LVN 4, LVN 4 stated, she observed Resident 27 leave the facility. LVN 4 stated Resident 27 signs herself out. LVN 4 could not provide documentation of Resident 27 signing herself out. LVN 4 acknowledged Resident 27 as a high fall risk and not knowing when she was off the property. LVN 4 stated when a resident was a high fall risk they were watched closely. LVN 4 was unable to provide clinical evidence of what watching closely was. LVN 4 acknowledged she was responsible for the residents' well-being and needed to provide adequate supervision for Resident 27 who was at high risk for falls. During a concurrent interview and record review on 5/20/25 at 3:33 p.m. with the DON, the facility's policy and procedure (P&P) titled Fall Prevention Program and Falling Star Program, undated, was reviewed. The P&P indicated, .Residents at high risk .a visual identifier placed on the name plaque outside the door .a yellow armband for further identification . The DON acknowledged the Resident 27 had not signed the LOA form, and the team did not always know when Resident 27 left the building. The DON confirmed consistent individualized interventions should have been in place. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated 12/2007, the P&P indicated, .staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling .If the resident continues to fall, staff will re-evaluate the situation .staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Answering the Call Light, for six of 12 sampled residents (Residents 7, 14, 46, 59, 78, and 293) when the staff did not response to Residents 7, 14, 46, 59, 78, and 293's call lights within 5 minutes. These failures had the potential to result in Residents 7, 14, 46, 59, 78, and 293 not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: During a concurrent observation and interview on 5/16/25 at 2:58 p.m. with Resident 7 in her room, Resident 7 was lying in bed, and did not respond to any questions. During a review of Resident 7's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive brain disorder that gradually damages memory, thinking, and other cognitive functions), dysphagia (difficulty swallowing), essential hypertension (a condition where the force of blood against your artery walls is consistently too high), presence of cardiac pacemaker (a small, battery-operated device that helps regulate the heart's rhythm by providing electrical impulses when the heart's natural sinus node isn't functioning properly), all those symptoms and signs involving cognitive (the mental processes involved in knowing, learning, understanding, and thinking) functions and awareness, muscle weakness generalized, hypotension (a condition where blood pressure drops below normal levels), irritable bowel syndrome (a digestive system disorder characterized by abdominal pain and changes in bowel habits, such as diarrhea or constipation), pain, contracture(a condition where muscles, tendons, ligaments, or skin become tight and shortened, limiting the range of motion in a joint) right hand, contracture of muscle left hand, aphasia (loss of ability to understand or express speech caused by brain damage), anemia (a condition where the body has a lower than normal number of red blood cells, or the red blood cells don't function properly, leading to a reduced ability to carry oxygen). During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function), dated 5/15/25, the MDS section C indicated, Resident 7 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score was not complete, (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). During a review of Resident 7's MDS assessment dated [DATE], the MDS section GG indicated, Resident 7's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 7 uses wheelchair, Resident 7 is dependent (helper does all the effort, resident does none of the effort to complete self-care) on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 7 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. Sit to stand, toilet transfer and tub/shower transfer was not attempted, and Resident 7 did not perform these activity prior to the current illness . During a review of Resident 7's MDS assessment dated [DATE], the MDS section H indicated, Resident 7's Bladder and Bowel function included Resident 7 is always incontinent (no episodes of continent voiding) for urinary continence. Resident 7 is always incontinent (no episodes of continence bowel movement) for bowel continence. During a review of Resident 7's MDS assessment dated [DATE], the MDS section M indicated, Resident 7's Skin Conditions included Resident 7 uses pressure reducing device for chair, and pressure reducing device for bed. During a concurrent observation and interview on 5/16/25 at 2:50 p.m. with Resident 14 in her room, Resident 14 was sitting in bed, with the head of the bed elevated . Resident 14 stated at night, the staff said it should take them 5-10 minutes to answer the call light, but it took them 30-40 minutes. Resident 14 stated it took the CNAs 4.5 hours to respond to the call light on a particular day last month. Resident 14 stated I was in my own dried stool. Why should it take that long? Resident 14 stated Resident 7 had been in her room for 2-3 years, had contracture and could no longer talk. Resident 14 stated she tried to advocate for Resident 7 and was told Resident 7 was none of her concern. Resident 14 stated I don't feel like I am treated with dignity and respect. During a review of Resident 14's AR dated 5/20/25, the AR indicated, Resident 14, was admitted to the facility on [DATE] with diagnoses which included: partial traumatic amputation (surgical procedure involving the removal of all or part of a limb) of left shoulder and upper arm, type 2 diabetes mellitus (a chronic disease characterized by high blood sugar levels) with diabetic neuropathy (nerve damage caused by high blood sugar levels), acquired absence of right upper limb below elbow, acquired absence of right leg below knee, acquired absence of left leg below knee, pain. During a review of Resident 14's MDS assessment dated [DATE], the MDS section C indicated, Resident 14's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 14 was cognitively intact. During a review of Resident 14's MDS assessment dated [DATE], the MDS section GG indicated, Resident 14's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 14 uses wheelchair, Resident 14 is dependent on oral hygiene, toileting hygiene, shower/bath self, lower body dressing and personal hygiene. Resident 14 is partial/moderate assistance (helper does less than half the effort in care) on upper body dressing. Resident 14 is dependent on chair/bed to chair transfer and tub/shower transfer. Resident 14 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed. During a review of Resident 14's MDS assessment dated [DATE], the MDS section H indicated, Resident 14's Bladder and Bowel function included Resident 14 is frequently incontinent for urinary continence. Resident 14 is frequently incontinent for bowel continence. During a review of Resident 14's MDS assessment dated [DATE], the MDS section M indicated, Resident 14's Skin Conditions included Resident 14 uses pressure reducing device for chair, and pressure reducing device for bed. During a review of Resident 14's MDS assessment dated [DATE], the MDS section N indicated, Resident 14's Medications included Antiplatelets (medications that work by preventing platelets from sticking together and forming clots ). During a concurrent observation and interview on 5/13/25 at 9:37 a.m. with Resident 46 during the initial tour in Resident 46's room, Resident 46 was sitting in her wheelchair looking through some documents. Resident 46 stated I cannot walk. Resident 46 stated, the facility is short-staffed. Resident 46 stated she wheeled herself to the staff before they attend to her. Resident 46 stated it usually took about 20-30 minutes before staff responded to her call light. During a review of Resident 46's AR dated 5/20/25, the AR indicated, Resident 46, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: heart failure, adult failure to thrive, essential hypertension, specified osteoarthritis (a degenerative joint disease where cartilage breaks down, leading to pain, stiffness, and decreased range of motion), unequal limp length acquired, pain,, history of falling, unspecified protein calorie malnutrition, muscle weakness generalized. During a review of Resident 46's MDS assessment dated [DATE], the MDS section C indicated, Resident 46's BIMS assessment score was 14 out of 15. BIMS scores indicated Resident 46 was cognitively intact. During a review of Resident 46's MDS assessment dated [DATE], the MDS section GG indicated, Resident 46's Functional Abilities included Resident 46 uses walker and wheelchair. During a review of Resident 46's MDS assessment dated [DATE], the MDS section M indicated, Resident 46's Skin Conditions included Resident 46 uses pressure reducing device for chair, and pressure reducing device for bed. During a review of Resident 46's MDS assessment dated [DATE], the MDS section N indicated, Resident 46's Medications included Diuretics (medications that help the body get rid of excess fluid and salt by increasing urine production). During a concurrent observation and interview on 5/13/25 at 10:10 a.m. with Resident 59 during the initial tour in Resident 59's room, Resident 59 was sitting up in bed with the head of the bed elevated, with contracture of the neck to the right watching television. Resident 59 stated staff took too long to respond to the call light. During a review of Resident 59's AR dated 5/20/25, the AR indicated, Resident 59, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: other intervertebral disc degeneration (condition where cushions between the bones of the spine break down, wear down, or dry out over time), muscle weakness generalized, chronic obstructive pulmonary disease (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction),, primary generalized osteoarthritis , , pain, adult failure to thrive . During a review of Resident 59's MDS assessment dated [DATE], the MDS section C indicated, Resident 59's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 59 was cognitively intact. During a review of Resident 59's MDS assessment dated [DATE], the MDS section GG indicated, Resident 59's Functional Abilities included impairment on one side to the upper extremity, Resident 59 uses wheelchair. Resident 59 is dependent on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 59 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer . During a review of Resident 59's MDS assessment dated [DATE], the MDS section H indicated, Resident 59's Bladder and Bowel function included Resident 59 is frequently incontinent for urinary continence. Resident 59 is frequently incontinent for bowel continence. During a review of Resident 59's MDS assessment dated [DATE], the MDS section M indicated, Resident 59's Skin Conditions included Resident 59 has Moisture Associated Skin Damage (MASD). Resident 59 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 59 gets application of ointments/ medications. During a review of Resident 59's MDS assessment dated [DATE], the MDS section N indicated, Resident 59's Medications included Diuretics and Antiplatelets. During a concurrent observation and interview on 5/13/25 at 12:46 p.m. with Family Member (FM) 1 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated. FM 1 was sitting in room with Resident 78. FM 1 stated, sometimes the CNAs are standing out there doing nothing. FM 1 stated it takes about 20-30 minutes after the call light was initiated before staff respond. FM 1 stated the facility was short staffed. During a concurrent observation and interview on 5/14/25 at 12:10 p.m. with FM 3 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated, eating a burger. FM 3 stated resident did not get adequate supervision when eating. FM 3 stated there was no respect and dignity. FM 3 stated, while visiting Resident 78, FM 3 could hear Resident 78 yelling while coming through the facility doors. FM 3 stated Resident 78 was hungry but was ignored. FM 3 stated on another day, FM 3 saw another resident screaming she had to go to the bathroom; the resident was left alone in the hallway and nobody paid attention to the resident. FM 3 stated some of the CNAs don't like being bugged. FM 3 stated when the family members needed anything for Resident 78, FMs go out to where the staff were and let the staff know what Resident 78 needed, and it took staff about 15- 20 minutes to get resident 78 what was needed. FM 3 stated Resident 59 is Resident 78's roommate. FM 3 stated when Resident 59 uses the call light, and it takes more than 15mins for staff to respond then Resident 59 starts yelling out. FM 3 stated I sometimes go out there and tell them Resident 59 needs help. During a review of Resident 78's AR dated 5/20/25, the AR indicated, Resident 78, was admitted to the facility on [DATE] with diagnoses which included: muscle wasting and atrophy (loss of muscle tissue and is often characterized by decreased muscle size and strength), muscle weakness generalized, unspecified abnormality of gait and mobility, type 2 diabetes mellitus, encounter for palliative care (medical consultations focused on providing comfort and support to patients with serious, life-limiting illnesses),retention of urine. During a review of Resident 78's MDS assessment dated [DATE], the MDS section C indicated, Resident 78's BIMS assessment score was 00 out of 15. BIMS scores indicated Resident 78 had severe cognitive deficit. During a review of Resident 78's MDS assessment dated [DATE], the MDS section GG indicated, Resident 78's Functional Abilities included Resident 78 uses wheelchair. Resident 78 is dependent on lower body dressing and putting on/taking off footwear. Resident 78 needs substantial/ maximal assistance (helper does more than half the effort) on toileting hygiene. Resident 78 needs partial/moderate assistance on oral hygiene, shower/bath self, upper body dressing, and personal hygiene. Resident 78 is dependent on sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 78 needs partial/moderate assistance on roll left and right, sit to lying, and lying to sitting on side of bed. During a review of Resident 78's MDS assessment dated [DATE], the MDS section H indicated, Resident 78's Bladder and Bowel function included Resident 78 has an indwelling urinary catheter for urinary continence. Resident 78 is always incontinent for bowel continence. During a review of Resident 78's MDS assessment dated [DATE], the MDS section M indicated, Resident 78's Skin Conditions included Resident 78 uses pressure reducing device for chair, and pressure reducing device for bed. During a concurrent observation and interview on 5/13/25 at 3:15 p.m. with Resident 293 during the initial tour in Resident 293's room, Resident 293 was lying in bed. Resident 293 stated it takes staff too long to answer the call light. Resident 293 stated it took about 20 -30 minutes for staff to respond. Resident 293 stated this can be frustrating because when I need help, I don't get it on time. During a review of Resident 293's AR dated 5/20/25, the AR indicated, Resident 293 was admitted to the facility on [DATE] with diagnoses which included: disorder of the autonomic nervous system (a condition where the nerves that regulate involuntary bodily functions (like heart rate, blood pressure, digestion) are not functioning correctly), difficulty in walking, muscle weakness generalized, pain due to vascular prosthetic devices implants and grafts (man-made materials used to replace or repair damaged blood vessels), immunodeficiency (a condition where the immune system is unable to effectively fight off infections and diseases), type 2 diabetes mellitus, anemia, unspecified mood affective disorder (mental health conditions characterized by persistent or severe disturbances in mood and emotions), unspecified hearing loss bilateral (hearing loss affecting both ears), essential hypertension, hypertensive heart disease, chronic ischemic heart disease (a condition where the heart muscle receives less oxygen-rich blood due to narrowed or blocked coronary arteries), foot drop right foot, injury of sciatic nerve at hip and thigh level right leg (results in range of symptoms, including pain, numbness, weakness, and difficulty with movement and sensation in the leg and foot) . During a review of Resident 293's MDS assessment dated [DATE], the MDS section C indicated, Resident 293's BIMS assessment score was 12 out of 15. BIMS scores indicated Resident 293 has moderate cognitive deficit. During a review of Resident 293's MDS assessment dated [DATE], the MDS section GG indicated, Resident 293's Functional Abilities included impairment on one side to the lower extremity, Resident 293 uses wheelchair. Resident 293 needs substantial/ maximal assistance on toileting hygiene, shower/bath self, lower body dressing, and putting on/taking off footwear. Resident 293 is partial/moderate assistance on personal hygiene. Resident 293 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 293 is partial/moderate assistance on picking up objects. During a review of Resident 293's MDS assessment dated [DATE], the MDS section H indicated, Resident 293's Bladder and Bowel function included Resident 293 is occasionally incontinent for urinary continence. During a review of Resident 293's MDS assessment dated [DATE], the MDS section M indicated, Resident 293's Skin Conditions included Resident 293 has Moisture Associated Skin Damage (MASD). Resident 293 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 293 gets application of ointments/ medications. During a review of Resident 293's MDS assessment dated [DATE], the MDS section N indicated, Resident 293's Medications included Anticoagulant (medications that prevent or reduce blood clot formation), Antiplatelets and Hypoglycemic (drugs used to lower blood sugar levels). During a review of the facility's Resident Council Minutes, dated 1/30/25, the document indicated .Review of past month's issues: .Call lights still take too long to respond .floor staff having attitude when responding to call lights. Concerns: Call lights have not improved on all shifts, still having to wait 30 minutes to be assisted with and CNA are still not assisting residents that are not assigned to that CNA. Call light takes too long to respond Call light is being ignored, and CNA will walk past light and yell back that they will be right back . During a review of the facility's Resident Council Minutes, dated 2/26/25, the document indicated .Concerns: Call lights still take too long to respond CNA limit time assisting with residents so they can get to the next resident. {Unnamed} resident states he/she doesn't get clean .Call lights still waiting 30 to 35 minutes to get assisted. Would like floor staff to acknowledge call lights . During a review of the facility's Resident Council Minutes, dated 3/27/25, the document indicated .Concerns: NOC (Night Shift) CNA are responding to call light with attitude when responding to a 30-to-40-minute wait on call light. CNA tells resident to quit messing with the call light . Residents wants more help and staff on floor at PM and NOC shifts to help with call lights . During a review of the facility's Resident Council Minutes, dated 4/25/25, the document indicated .Concerns: CNA at NOC/PM shift takes too long to respond. One night [resident] had to wait 4 hours for a CNA to respond to call light. CNA stated she was busy. CNAs still has attitude when responding to call light. There is no improvement on call lights Residents would like floor staff to be retrained (for the new hires). Residents feel that new floor staff don't know what they are doing. New CNA on the floor needs more training on how to assist a patient and to know how to change patients Wait 30 minutes on call light on PM shift from 3p.m. to 11p.m Call light takes too long to respond to . During the assigned facility task Resident Council dated 5/15/25 at 10:03 a.m. in the facility's dining room, there were concerns of staff not responding to the call light in a timely manner. Resident 14 stated there was no dignity and respect all the time. Resident 14 stated CNAs, especially the new CNAs, have attitude. Resident 14 stated she was given attitude when she told the CNAs regarding Resident 7's care because Resident 7 is unable to talk. Resident 14 stated the facility tells her complaints will be addressed, but complaints are not addressed. Resident 14 stated They always tell me; everything will be alright. It makes me feel like I am nothing. Resident 14 stated it shouldn't take 30-40 minutes to answer the call light. Resident 14 stated this happens on a regular basis, on the PM and NOC shift. Resident 14 stated she had used the bathroom and had dried stool all up her back and it took a CNA 4.5 hours to respond to her call light. Resident 14 stated she addressed it with the LNs, DSD and DON. Resident 14 stated DSD and DON took a report and there was no feedback. Resident 14 stated I am concerned about the call lights. During an interview on 5/20/25 at 1:39 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated the call light policy states call lights should be answered within 15 mins . During an interview on 5/20/25 at 1:43 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated sometimes there were not enough CNAs on PM shifts. CNA 5 stated, sometimes CNAs were unable to get to all the residents. During a concurrent interview and record review on 5/20/25 at 1 :37p.m. with the Director of Staff Development (DSD), the call light policy was reviewed. The DSD stated the expectation was for CNAs to check residents who were unable to call for assistance every 2 hours or as needed. The DSD stated the expectation from staff was that the call lights should be answered within 7 minutes. The DSD stated the expectations were not met. The DSD stated the P&P indicated .Answer immediately, .within 5 minutes. The DSD stated the policy was not followed. During a concurrent interview and record review on 5/20/25 at 3:11 p.m. with the Director of Staff Development (DSD), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DSD validated there were lots of complaints about call lights from the resident council minutes. The DSD stated the minutes indicated call lights were not answered timely. The DSD confirmed been aware of the complaints. The DSD stated the complaints were not properly addressed by the facility; therefore, residents continue to complain. During a concurrent interview and record review on 5/20/25 at 3 :02 p.m. with the Director of Nursing (DON), the call light policy was reviewed. The DON stated the expectation were when residents turn on their call light, staff should respond and assess the needs of the residents and if unable to meet the needs, staff should refer to another department or discipline if needed. The DON stated staff should answer call light in a timely manner as soon as practically possible. The DON stated the policy was not followed. The DON stated it was important to follow the policy, so the patient gets timely responses to their needs. During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Director of Nursing (DON), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DON stated a 4.5-hour response to the call light was not appropriate. The DON stated potential outcome of not responding to the call light would be that the residents' needs would not be acknowledged. The DON stated she was not aware of the incident of resident in own stool unattended to after initiating call light for 4.5 hours. The DON stated that a resident left unattended in own stool for 4.5 hours was not fair and was not right. During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Administrator (ADM), the call light policy and the resident council minutes for the months of January 2025 - April 2025 were reviewed. The ADM stated the resident council minutes were reviewed with the activity's director after the resident council meetings. The ADM stated if there were issues in any department, something should be done about it. The ADM stated he was aware of the call light complaints. The ADM stated staff needed to be educated more on proper call light response time with more of a focus on the afternoon shift night shift. The ADM stated the call light policy was not followed. During a review of the facility's document titled, Job Description, Certified nursing assistant (CNA), dated 2/2024, the document indicated, . General purpose . to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Essential Duties . create and maintain an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment throughout the unit and shift, . ensure that residents who are unable to call for help are checked frequently, answer resident calls promptly, check residents routinely to ensure that their personal care needs are met, . cooperate with . other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents, . assist residents with daily functions (dental and mouth care, bath functions, combing of hair, dressing and undressing as necessary), keep residents dry (change gown, clothing and linens, when it becomes wet or soiled), check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes . During a review of the facility's document titled, Job Description, LPN/LVN, dated 2/2024, the document indicated, . Directs the day-to-day functions of the nursing assistants in accordance with current rules regulations and guidelines ., ensure all nursing personnel assigned to you comply with written policies and procedures ., make daily rounds of your unit/ shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . ensure that personnel providing direct care to residents are providing such care in accordance with the resident care plans and wishes, ensure that residents who are unable to call for help are checked frequently . ensure that your assigned certified nursing assistants (CNAs) are aware of the residents care plan . During a review of the facility's document titled, Job Description, Registered Nurse (RN), dated 2/2024, the document indicated, . Ensure that all nursing service personnels are in compliance with their respective job descriptions ., ensure that a sufficient number of licensed practical and/ or registered nurses are available for your tour of duty to ensure that quality care is maintained, ensure that a sufficient number of certified nursing assistants are available for your tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident, . make daily rounds of nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards, . visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status, . ensure that residents who are unable to call for help are checked frequently . During a review of Job Description: Director of Staff Development (DSD), dated 2/2024, the document indicated, .General Purpose . is responsible to plan and implement facility orientation, job skill training . for the nursing assistants as required by regulation. Work with the Director of Nursing and Administrator to ensure that the highest degree of quality care is maintained at all times . Essential Duties . plan and conduct meaningful in-service education programs according to requirements for nursing personnel and all facility staff to assure competency in and new skills and as directed by administrator. Make rounds and observe delivery of patient care . During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, Answering the Call Light, dated 09/2022, indicated, .Policy Statement- The purpose of this procedure is to ensure timely responses to the resident's requests and needs . Steps in the procedure 1. Answer the resident call system immediately .a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. if the resident's request requires another staff member, notify the individual. c. if the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.2. if assistance is needed when you enter the room, summon help by using the call signal . During a review of the facility's policy and procedure titled, Resident Rights, dated 2/2021, indicated, .Policy Statement- Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence. b. be treated with respect, kindness and dignity. c. be free from abuse neglect misappropriation of property and exploitation . u. Voice grievances to the facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. v. Have the facility[TRUNCATED]

Based on observation, interview, and record review, the facility failed to follow the facility's Policy and Procedure (P&P) Medication Storage when two of four sampled medication carts ((Cart 1 and Cart 2) were left unlocked and unattended by Licensed Nurses (LNs). These failures had the potential for residents, staff, and visitors to have unauthorized access to resident medications resulting in theft, overdose, and/or residents not having access to their medications. Findings: During a concurrent observation and interview, on 5/13/25 at 9:47 a.m. with Licensed Vocational Nurse (LVN) 8, in the hall near the nurse station, medication Cart 1 was observed unlocked and unattended. LVN 8 stated the unlocked medication cart was her cart and she should not have left the cart unlocked when she walked away to get supplies. LVN 8 stated a resident, staff member or visitor could have gotten into the medication cart and harmed themselves by taking unprescribed medication. During an interview on 5/13/25 at 10:30 a.m. with the Director of Nursing (DON), the DON stated, the medication carts should always be locked. DON stated it was the responsibility of the nurse that was assigned to the cart to make sure it was always locked. During an observation on 5/20/25 at 4:16 p.m., medication Cart 2 was observed left unattended and unlocked, with the medication keys attached to the medication cart. The nurse assigned to the cart was observed on the opposite side of the nurses' station counter, gathering juices, not keeping the medication cart in her line of vision. Assisstant Director of Nursing (ADON) was observed to approach the cart, remove the keys, lock the medication cart, and discreetly attempt to place the keys into heLVN 5's pocket. During an interview on 5/20/25 at 4:28 p.m. with LVN 5, LVN 5 stated the cart was not left unlocked, it was a pulse oximeter (a small, portable medical device that measures the oxygen saturation in the blood). LVN 5 acknowledged the ADON placed the medication keys in her pocket. LVN 5 stated she should not have lied, and it was important to keep medication cart locked for safety. During an interview on 5/20/25 at 4:31 p.m. with the ADON, at the nurses' station next to medication Cart 2. The ADON acknowledged the observation of her removing the keys from the unlocked medication cart (Caret 2), lock Cart 2 and placed the keys in LVN 5's pocket. The ADON stated LVN 5 should not have walked away from the medication cart with keys left in the lock of Cart 2 and out of her line of sight. The ADON stated the expectation of the nurses was to have the medication carts locked when unattended, to prevent unauthorized access. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication dated 2019, indicated, .The facility stores all drugs and biological in a safely, securely and properly .only licensed nurses .are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by people with authorized access .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 193's admission record (AR), dated 5/20/25, indicated the resident was admitted to the facility on [DATE] with the following diagnosis: Myelodysplastic Syndrome (a group of blood disorders where the bone marrow, responsible for making blood cells, doesn't function properly), leukemia (a type of blood cancer). During a concurrent observation and interview on 5/13/25 at 12:15 p.m. with the REC in the hall outside of Resident 193's room. The REC put on a yellow paper gown and purple gloves and took the lunch tray into Resident 193's room. Resident 193 had a sign outside of her door instructing staff and visitors to put on gloves, mask and gown prior to going into the resident's room. The REC stated that he would have put on a face mask but there were not any face masks in the personal protection equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), bin outside of the resident's room. The REC stated he should have looked for a mask before he entered Resident 193's room. The REC stated, he could have exposed Resident 193 to infections. During an interview on 5/16/25 at 3:42 p.m. with the IP, the IP stated it was her responsibility to check the PPE bins and make sure they are stocked but all staff have access to masks, gloves, and gowns. IP stated her expectation for the REC would have been to go to the supply closet and get more masks or inform her so that she could get another box of masks for the PPE bin. The IP stated the REC should not have gone into Resident 193's room without a mask. IP stated the REC could transmit germs to Resident 193 and cause her to become ill. During an interview on 5/20/25 at 10:20 a.m. with the DON, the DON stated her expectation was for the REC to obtain and wear a face mask prior to going into Resident 193's room. The DON stated Resident 193 was vulnerable and staff not following the rules could put her life at risk. 4. During a concurrent observation and interview on 5/13/25 at 12:15 p.m. with CNA 1, in the hallway outside of the large dining room, a standing lift (is used to transfer residents) was placed against the wall. The standing lift had a white filmy residue, and powdery substance left on the black cushioned pads and on the bottom standing tray of the lift. CNA 1 stated that the lift was not clean, and it should have been cleaned prior to being placed in the hallway. CNA 1 stated the lift could have been contaminated with infectious matter and could spread infection to other residents in the facility. During an interview on 5/16/25 at 3:30 p.m. with the IP, the IP stated it was her expectation for the staff to clean the lift after each use. IP stated the lift has a lot of contact areas and infection could be easily transmitted from resident to resident. During a review of the facility's policy and procedure (P&P), titled Cleaning and Disinfecting Non-Critical Resident Care Items dated 6/2021, indicated, . noncritical care items are those that come into contact with skin but not mucous membranes . reusable items are cleaned and disinfected or sterilized between residents . Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for four of 25 sampled residents ( Resident 27, 41, 76, and 193 ) when: 1. Resident 41's urinary catheter bag (a bag attached to a urinary catheter, which is a thin tube inserted into the bladder to drain urine when someone can't urinate normally) and urinary catheter tubing (a thin, flexible tube inserted into the bladder to drain urine) was observed to be on the floor. This failure placed Resident 41 at risk for cross-contamination ( the unintentional transfer of harmful substances from one person, object, or place to another) which could result in infections and illness. 2. LVN 5 did not perform hand hygiene before she went into Resident 27 and 76's room and completed a fingerstick (a finger prick, a way to get a small blood sample from your fingertip) to check their glucose (sugar) levels. This failure placed Residents 27 and 76 at risk of cross-contamination, which could result in infections and illness. 3. The facility failed to follow neutropenic precautions (wearing a face mask, gown, and gloves, when in the room with resident to protect the resident from getting sick because their body's defense against germs is weaker than usual), when Resident 193 was on neutropenic precautions and the Receptionist (REC), went in to Resident 193's room and served a lunch tray without wearing a face mask. This failure had the potential to expose Resident 193 to bacterial and or viral pathogens (a tiny germ that can make you sick), which could lead to illness or death. 4. The facility failed to follow their policy and procedure (P&P), for Cleaning and Disinfecting Non- Critical Resident-Care Items when a standing lift (a device that helps people who can't stand up on their own get from a seated position to a standing position), was left with powder and other visible residue on the lift. This failure had the potential to spread skin infection or other contact infections to other residents in the facility Findings: 1. During an observation on 5/13/25 at 8:29 a.m., in Resident 41's room, Resident 41 was asleep in bed and his urinary catheter bag was on the ground. During a concurrent observation and interview on 5/13/25 at 1 p.m., with Certified Nursing Assistant (CNA) 6, in Resident 41's room, Resident 41 was in his wheelchair and had his urinary catheter tubing touching the floor. CNA 6 stated the catheter tubing should not have been on the ground. During a review of Resident 41's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/20/25, the admission Record indicated, Resident 41 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness, overactive bladder (a condition characterized by a sudden, strong urge to urinate, often accompanied by frequent urination and, in some cases, urinary incontinence [loss of bladder control]), obstructive and reflux uropathy (a blockage in the urinary system, preventing urine from flowing properly) and urinary tract infection (an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/29/25, the MDS assessment indicated Resident 41's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 00 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 41 was severely impaired. During a review of Resident 41's Physician Order Summary (POS), dated 4/25/25, the POS indicated, . Order date: 4/25/25 . Communication Method: Phone Order Summary: Indwelling urinary (foley) catheter is in privacy bag and catheter leg strap on at all times During an interview on 5/16/25 at 10:34 a.m., with the Infection Preventionist ( IP- specialists who work to make sure healthcare facilities are safe and free from infections), the IP stated a catheter bag and tubing should never touch the ground because the ground was dirty and carries bacteria. The IP stated the urinary catheter bag and tubing issues put Resident 41 at risk for an infection due to cross-contamination of that bacteria. The IP stated an infection could lead to sepsis (a person's extreme and potentially life-threatening response to an infection) and a hospitalization for Resident 41. The IP stated the facility did not follow the policy and procedure Catheter Care, Urinary. During an interview on 5/16/25 at 11:25 a.m., with CNA 6, CNA 6 stated the catheter tubing was contaminated and it should not have been on the ground. CNA 6 stated this issue would have made the Resident 41 more prone to infection. CNA 6 stated the catheter bag should have been on the side of the bed, off the ground and not on the floor. During an interview on 5/16/25 at 2:05 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 41's catheter bag and tubing should not have been on the ground and it was a safety issue. LVN 8 stated bacteria could get on the catheter and could have caused an infection for the Resident 41. LVN 8 stated an infection with Resident 41 could lead to hospitalization. During an interview on 5/20/25 at 1:19 p.m., with the Director of Nursing (DON), the DON stated the expectation would be for the urinary catheter bag and tubing to not have been on the floor. The DON stated this put Resident 41 at risk for infection control issues and cross-contamination of bacteria could have occurred. The DON stated the facility did not follow the policy and procedure Catheter Care, Urinary. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, dated 9/2014, the P&P indicated, .Purpose: the purpose of this procedure is to prevent catheter associated urinary tract infections . Infection Control: be sure the catheter tubing and drainage bag are kept off the floor . 2. During an observation on 5/15/25 at 11:27 a.m., in Resident 76's room, LVN 5 did not perform hand hygiene before she completed a fingerstick to check Resident 76's glucose level. During an observation on 5/15/25 at 11:40 a.m., in Resident 27's room, LVN 5 did not perform hand hygiene before she completed a fingerstick to check Resident 27's glucose level. During a review of Resident 76's AR, dated 5/20/25, the AR indicated, Resident 76 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (a condition where a body doesn't make enough insulin [a natural hormone that turns food into energy and manages your blood sugar level] or doesn't use insulin well). During a review of Resident 76's MDS assessment, dated 4/14/25, the MDS assessment indicated Resident 76's BIMS assessment score was 12 out of 15. The BIMS assessment indicated Resident 76 was moderately impaired. During a review of Resident 27's admission Record dated 5/20/25, the admission Record indicated, Resident 27 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus. During a review of Resident 27's MDS assessment, dated 4/7/25, the MDS assessment indicated Resident 27's BIMS assessment score was 14 out of 15 The BIMS assessment indicated Resident 27 was cognitively intact. During an interview on 5/15/25 at 11:55 a.m., with LVN 5, LVN 5 stated she did not realize she had not completed hand hygiene before having touched both residents. LVN 5 stated she should have completed hand hygiene before she touched them but did not. LVN 5 stated she put the residents at an increased risk of infection by not doing appropriate hand hygiene. During an interview on 5/16/25 at 10:34 a.m., with the IP, the IP stated by not performing hand hygiene before touching a resident, cross-contamination of bacteria could occur. The IP stated the expectation would be to have performed hand hygiene before having touched a resident. The IP stated as a result of not performing hand hygiene, the residents could have acquired an infection. The IP stated the facility P&P Handwashing/Hand Hygiene was not followed. During an interview on 5/16/25 at 2:05 p.m., with LVN 8, LVN 8 stated appropriate hand hygiene was important to control risk of infections. LVN 8 stated if hand hygiene was not performed before touching a resident, it could have resulted in an infection and ultimately a hospitalization. During an interview on 5/20/25 at 1:54 p.m., with the DON, the DON stated hand hygiene should have been completed before touching a resident. The DON stated the lack of hand hygiene would cause infection control concerns. The DON stated there was potential for an infection that could manifest into an illness. The DON stated the facility P&P Handwashing/Hand Hygiene was not followed. During an interview on 5/20/25 at 4:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated hand hygiene should have been completed before the resident's received care. The ADON stated by not completing hand hygiene the residents could have been exposed to contamination that could have caused an infection. During a review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene dated 10/2023, the P&P indicated, .Policy Statement: this facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections . Administrative Practices to Promote Hand Hygiene . all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident . Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves .

Based on observation, interview, and record review, the facility failed to ensure food storage was stored under sanitary conditions in accordance with professional standards for food service safety when: 1. A large plastic container of rice was in the dry storage pantry without a label and did not have an opened date or an expiration date. 2. Freezer 1 of 2 was observed without an internal thermometer. Refrigerator 1 of 3 was observed without an internal thermometer (a tool used to measure how hot or cold something is). These failures had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, that could cause disease. Pathogens included things like bacteria, viruses and fungi) and posed a risk of foodborne illness (any illness resulting from eating contaminated/spoiled foods) symptoms which could range from nausea, vomiting, diarrhea, abdominal pain, fever, headache, and confusion to residents who received meals and nourishment from the facility's kitchen. Findings: 1. During a concurrent interview and observation on 5/13/25 at 8:22 a.m. with the Certified Dietary Manager (CDM), in the dry storage pantry, a large clear plastic container of rice had no label, open date or expiration date. The CDM stated, her expectation is that all food in the dry storage should be labeled with what the food item was, the open date and expiration date to prevent residents from receiving old or expired food. During an interview on 5/16/25 at 3:15 p.m. with the Registered Dietitian (RD), the RD stated, all foods in pantry need to label with name of food, open date and expiration date. The RD stated, if the food is not labeled correctly, it increases the risk of residents being served expired food or food, they may have an allergy to resulting in food born illness and possibly death. 2. During a concurrent interview and observation on 5/13/25 at 8:39 a.m. with the CDM in the kitchen , one of two freezers did not have an internal thermometer. The CDM stated, a thermometer was required inside of every freezer. The CDM stated the temperatures were to be taken every morning and documented in a temperature log book to prevent food from going into the Danger Zone (temperatures above 41 degrees Fahrenheit (F - unit of measure) and below 32 degrees F for cold storage. Food that goes into the Danger Zone could spoil, and bacterial growth could begin and expose residents to food borne illness). During a concurrent observation and interview on 5/13/25 at 8:41 a.m. with the CDM in the kitchen, one of three refrigerators did not have an internal thermometer . The CDM stated the refrigerator should have had an internal thermometer to monitor the temperature inside the refrigerator to ensure food is being kept at a temperature to prevent bacterial growth and resident food born illness. During an interview on 5/16/25 at 3:18 p.m. with the RD, the RD stated, every refrigerator and freezer need to have a working internal thermometer that was to be monitored to prevent food from being out of safe food storage temperatures . The RD statd the refrigerator needed to be maintained between 34- to 39-degrees F, and the freezer needs to be maintained below these temperatures, if not the food will lose freshness and will not be safe, resulting in possible food born illness for the residents. During a review of the facility's policy and procedure (P&P), titled Food Preparation and Service, dated 11/2022, indicated, . Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices . thermometers need to be kept clean and calibrated to ensure food safety and to prevent food born illness . During a review of California Code of Regulations, Title 22 - Social Security Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative Article 3 - Services Section 76888 - Food and Nutrition Services-Food Storage, Universal Citation: 22 CA Code of Regs 76888 dated December 27, 2024, indicated, . All readily perishable foods or beverages shall be maintained at temperatures of 7°C (45°F) or below, or at 60°C (140°F) or above, always, except during necessary periods of preparation and service. Frozen foods shall be always stored at minus 18°C (0°F) or below. There shall be an accurate thermometer in each refrigerator and freezer and in any other storage space used for perishable food .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus (condition when the body doesn ' t use insulin properly, resulting in high blood sugar). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/30/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a record review of Resident 1 ' s, Progress Note (PN), dated 12/16/24, the PN indicated, . Staff reported resident to be sweating and clothes were changed twice within the last 30 minutes of this shift. When writer entered the room resident was found awake but not verbally responsive . fasting blood sugar noted 51 . During a concurrent interview and record review on 1/8/25 at 11:40 a.m. with Registered Nurse (RN) 1, Resident 1 ' s electronic medical record (EMR) was reviewed. The EMR indicated there was no change of condition assessment completed for Resident 1 on 12/16/24. RN 1 stated there should have been a change of condition assessment completed for Resident 1 on 12/16/24 when Resident 1 was sent to the acute care hospital. RN 1 stated it was the facility ' s process to complete a change of condition assessment when there was a change in Residents health status. RN 1 stated it was important to complete a change of condition assessment because it was a form of communication used to document change of residents ' condition for other staff members and physicians. During an interview on 1/8/25 at 12:21 p.m. with the director of nursing (DON), the DON stated it was the facility 's expectation that a change of condition assessment be completed when there was a change in resident health status. The DON stated completing the change of condition assessment was an important form of communication between staff and initiated an appropriate response for Resident 1. During a telephone interview on 1/8/25 at 4:16 p.m. with Licensed vocational nurse (LVN) 1, LVN 1 stated on 12/16/24, Resident 1 experienced a change in condition when his blood sugar was documented at 51. LVN 1 stated the expectation was to complete a change of condition assessment when there was a change in residents ' health status. LVN 1 stated the purpose for completing a change of condition assessment was to effectively communicate the change of condition and interventions completed to other staff. During a review of the facility 's policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/2021, the P&P indicated, . A significant change of condition is a major decline or improvement in the residents status that will normally not solve itself without intervention by staff . the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted . During a review of the facility ' s P&P titled, Charting and Documentation, dated 2001 , the P&P indicated, . All services provide to the resident, progress towards 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 . the following information is to be documented in the resident medical record . treatments or services performed, changes in resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete and accurate . documentation of procedures and treatments will include care specific details, including . the assessment data and or/any unusual findings obtained . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly . Based on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus (condition when the body doesn ' t use insulin properly, resulting in high blood sugar). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/30/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a record review of Resident 1 ' s, Progress Note (PN), dated 12/16/24, the PN indicated, . Staff reported resident to be sweating and clothes were changed twice within the last 30 minutes of this shift. When writer entered the room resident was found awake but not verbally responsive . fasting blood sugar noted 51 . During a concurrent interview and record review on 1/8/25 at 11:40 a.m. with Registered Nurse (RN) 1, Resident 1 ' s electronic medical record (EMR) was reviewed. The EMR indicated there was no change of condition assessment completed for Resident 1 on 12/16/24. RN 1 stated there should have been a change of condition assessment completed for Resident 1 on 12/16/24 when Resident 1 was sent to the acute care hospital. RN 1 stated it was the facility ' s process to complete a change of condition assessment when there was a change in Residents health status. RN 1 stated it was important to complete a change of condition assessment because it was a form of communication used to document change of residents ' condition for other staff members and physicians. During an interview on 1/8/25 at 12:21 p.m. with the director of nursing (DON), the DON stated it was the facility 's expectation that a change of condition assessment be completed when there was a change in resident health status. The DON stated completing the change of condition assessment was an important form of communication between staff and initiated an appropriate response for Resident 1. During a telephone interview on 1/8/25 at 4:16 p.m. with Licensed vocational nurse (LVN) 1, LVN 1 stated on 12/16/24, Resident 1 experienced a change in condition when his blood sugar was documented at 51. LVN 1 stated the expectation was to complete a change of condition assessment when there was a change in residents ' health status. LVN 1 stated the purpose for completing a change of condition assessment was to effectively communicate the change of condition and interventions completed to other staff. During a review of the facility 's policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/2021, the P&P indicated, . A significant change of condition is a major decline or improvement in the residents status that will normally not solve itself without intervention by staff . the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted . During a review of the facility ' s P&P titled, Charting and Documentation, dated 2001 , the P&P indicated, . All services provide to the resident, progress towards 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 . the following information is to be documented in the resident medical record . treatments or services performed, changes in resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete and accurate . documentation of procedures and treatments will include care specific details, including . the assessment data and or/any unusual findings obtained . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 and LVN 2 did not administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician's order. This failure had the potential to cause Resident 1 to experience episodes of unstable blood sugar levels such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could have a serious outcome affecting resident ' s health and wellness. Finding: During a review of Resident 1's admission Record (a document containing demographic information), dated, 11/20/2024 the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 had the following diagnosis . Partial Traumatic Amputation (loss of a body part) of Left Shoulder and upper Arm .Absence of Right Upper Limb below elbow .Absence of Right Leg Below Knee .Absence of Left Leg Below Knee .Type 2 Diabetes Mellitus (DM) (Chronic Condition that happens when you have persistently high blood sugar). 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 15 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 cognitively intact. During an interview on 12/12/2024 at 08:45 a.m. with Resident 1, Resident 1 stated, she has two separate orders for Humalog (fast acting insulin) insulin. Resident 1 stated, she received her 10 units of insulin and a sliding scale (the amount of insulin administered based on current blood sugar level) insulin when needed. Resident 1 stated, staff checked her blood sugar prior to her meals and if her blood sugar was high and she needed insulin from her sliding scale order staff combine both orders for insulin and administer in one shot after her meals. Resident 1 stated, she had received more than 10 units of insulin after her meals. During a concurrent interview and record review on 11/26/24, at 10:10 a.m., with LVN 1, Resident 1's Medication Administration Record (MAR) dated 11/01/2024 and 12/01/2024 were reviewed. LVN 1 stated Resident 1 had two separate insulin orders. The MAR indicated, .physician orders . HumalOG Kwik pen SolutionPen-injector100 UNIT/ML Milliliters (Unit of measure) (Insulin) Lispro Unit Dial) Inject 10 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . LVN 1 stated, the following was physician ' s order for sliding scale: HumalOG 100 Unit/ML (Insulin Lispro (Human) Inject as per sliding scale: If 0-150=0 units 151-200=2 units 201-250=4 units 251-300=6 units 301-350=8 units 351-400=10 units Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400. During an interview on 11/26/24, at 10:10 am with LVN 1. LVN 1 stated, Resident 1 had an order for 10 units of Humalog after every meal and a sliding scale order before meals. LVN 1 stated, we checked her blood sugar about fifteen minutes before her meal arrived. LVN1 stated, physician order for the sliding scale insulin was indicated to be administered before her meals. LVN 1 stated, when Resident 1 needed insulin from her sliding scale order, LVN 1 was combining the required sliding scale insulin with the scheduled order of 10 unit. LVN 1 stated, for example on 11/02/2024, Resident 1 needed four units from her sliding scale and ten units from her scheduled order. LVN 1 stated, she administered fourteen units of Humalog using one insulin pen after Resident 1 was finished eating. LVN 1 stated, she administered the combined units of insulin after meals to Resident 1 on following days: 11/2/24,11/5/24,11/6/24.11/7/24,11/8/24,11/14/24,11/18/24,11/19/24,11/20/24,11/29/24, 11/30/24, and 12/2/24. LVN 1 stated, her signature on the MAR indicated, she administered the insulin. LVN 1 stated, she did not follow physician orders and Resident 1 could have experienced adverse reactions affecting her health and wellness. LVN 1 stated, We were to follow physician orders at all times, and I did not. During a concurrent interview and record review on 11/26/24, at 10:50 a.m., with LVN 2, Resident 1's Medication Administration Record (MAR) dated 11/2024 and 12/11/2024 was reviewed. LVN 2 stated, her signature on the MAR indicated she administered insulin to Resident 1. LVN 2 stated she administered the combined units of insulin using one insulin pen after the meal to Resident 1 on the following dates: 11/3/24,11/4/24,11/9/24, 11/10/24,11/15/24, 11/16/24,11/21/24,11/22/24,11/27/24, 11/28/24, 12/3/24,12/4/24,12/9/24, and 12/10/24. LVN 2 stated, We were not following physician orders for the sliding scale insulin to be administered prior to Resident 1 ' s meals. LVN 2 stated, she was combining the scheduled dose of ten units with the sliding scale units using one insulin pen and administering after Resident 1 ' s meals. During a review of Resident 1's Physician Orders (PO), dated 12/01/2024, the PO indicated, .HumalOG Kwik pen SolutionPen-injector100 UNIT/ML Milliliters (Unit of measure) (Insulin) Lispro Unit Dial) Inject 10 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . During a review of Resident 1's PO, dated 12/01/2024, the PO indicated, .HumalOG Solution 100 Units/ML (Insulin Lispro(Human) Inject as per sliding scale If 0-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400 . During a concurrent interview on 11/26/24, at 11:25 a.m., with Assistant Director on Nursing (ADON), ADON stated, Resident 1 had two separate orders for Humalog insulin. ADON stated, Resident 1 had a scheduled order for ten units of insulin after meals. ADON stated, Resident 1 had a sliding scale order for insulin before meals. ADON stated, the physician order indicated sliding scale Humalog be administered before meals. ADON stated I am aware the LVN ' s are using one insulin pen to administer both insulin orders. ADON stated, LVN ' s were not following physician order to administer sliding scale insulin to Resident 1 prior to meals. ADON stated, Resident 1 could have episodes of hypoglycemia or hyperglycemia if physician orders were not followed. During a concurrent interview on 11/26/24, at 11:45 a.m., with Director of Nursing (DON), [NAME] stated, Resident 1 had two separate orders for insulin. DON stated, LVNs should be administering two separate insulin shots if sliding scale insulin were needed, DON stated, she was not aware LVNs were administering insulin using one insulin pen after meals. DON stated, LVNs were not following physician orders for sliding scale insulin. DON stated, it was out of the scope of the LVNs to deviate from a physician order without consulting the physician. DON stated, Resident 1 ' s blood sugar could become unstable causing harm and affecting her health and wellness. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration dated 2001, the P&P indicated. Purpose .to provide guidelines for the safe administration of insulin to residents with diabetes .Types of insulin, dosage requirements, strength and method of administration must be verified before administration, to assure that it corresponds with the order on the medication order on the medication sheet and physician ' s order During a review of the facility's document titled Job Description LPN/LVN, dated 02/2024 the job description indicated, .The primary purpose of your job position is to provide direct care to the residents .Prepare and administer medications as ordered by the physician During a review of the facility's (P&P) titled, Administering Medication dated 2001, the P&P indicated, .Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified example before and after meals .The individual administering the medications 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 . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] and 10/28/24 and no inventory of personal belongings was completed, and the facility did not follow their policy and procedure (P&P) titled Personal Property. These failures resulted in Resident 1's personal belongings not being inventoried and the risk for Residents 1's wallet, checkbook and bankcard getting lost. Findings: During a concurrent observation and interview on 11/5/24 at 12:47 p.m. in Resident 1's room, Resident 1 was lying down in bed awake. Resident 1 stated, he was admitted to the facility about three months ago. Resident 1 stated, when he was admitted , he came to the facility with his checkbook, wallet and bank card. Resident 1 stated, he believed his checkbook, wallet and bankcard was in his bedside cabinet. During a review of Resident 1's Face Sheet (FS-include the patient's name, address, date of birth , insurance information, and emergency contact information.) dated 11/6/24, the FS indicated, Resident 1 was initially admitted to the facility on [DATE] with primary diagnosis of Polyneuropathy (several nerves that malfunction at the same time) and Muscle Weakness. Resident 1's FS indicated he was his own Responsible Party (RP- the person in charge of and responsible for making decisions). During a review of Resident 1's Minimum Data Set [MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment], dated 11/1/24, the MDS section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 11/5/24 at 12:51 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, the process at the facility was when residents were admitted to the facility, the CNA took inventory of the belongings on paper and gave the belongings and the paper to the Licensed Vocational Nurse (LVN). During a concurrent interview and record review on 11/5/24 at 1:10 p.m. with Medical Records (MR), Resident 1 Electronic Medical Record (EMR) was reviewed. The EMR indicated, Resident 1 was admitted to the facility on [DATE], and was re-admitted to the facility on [DATE] and on 10/28/24. MR stated, Resident 1 was admitted to the facility on [DATE]. MR stated, there was no inventory list completed for Resident 1 when he was admitted on [DATE]. MR stated, there was no inventory list in the EMR for the re-admissions on 10/4/24 and 10/28/24. MR stated, Resident 1 should have had an inventory list completed for each admission. MR stated, the CNA was responsible for filling out the inventory paper form, and the LVN was responsible to input the items from the inventory form into the computer and get a signature of the resident or the Residents RP. During a concurrent observation and interview on 11/5/24 at 1:21 p.m. with CNA 1 in Resident 1's room, CNA 1 went through Resident 1's bedside cabinet and was unable to find his wallet, checkbook or bank card. CNA 1 went through Resident 1's pants and jackets that were hung up in the closet and went through Resident 1's closet drawers and was unable to find his check book, wallet or bank card. CNA 1 looked through two pink bags, one white bag and one [retail store] bag that were stored in the closet and was unable to find Resident 1's check book, wallet or bank card. CNA 1 stated, she was not able to find Resident 1's wallet, check book or bank card in his belongings. During an interview on 11/5/24 at 1:48 p.m. with the Social Services Director (SSD), the SSD stated, an outside agency social worker filed a grievance that Resident 1's wallet and check book were missing. The SSD stated, she checked Resident 1's inventory list and did not find the wallet and check book on the inventory list. The SSD stated, Resident 1's wallet, checkbook and bankcard were found in the back of the dining room. The SSD stated, she did not know how Resident 1's items ended up in the dining room. The SSD stated, the CNA and the LVN admitting the resident were responsible for inventorying the resident's belongings. The SSD stated, the LVN was responsible for entering the resident's inventory into the residents EMR. The SSD stated, it was important for resident's belongings to be inventoried to ensure personal items and reimbursement to a resident if something went missing. During an interview on 11/5/24 at 2:54 p.m. with the LVN, the LVN stated, when a resident was admitted to the facility, the CNA or the LVN would make a list of the resident's inventory on paper. LVN stated, it was the LVN's responsibility to enter the inventory into the EMR and make a copy for medical records. LVN stated, if the CNA made the list of items, the LVN had to verify everything on the list was physically present. The LVN stated, the resident or their RP needed to sign the inventory form. The LVN stated when a resident was admitted they had to have an inventory list completed. The LVN stated, if a resident came in with no belongings, they would still had to do an inventory list and document there was no belongings. The LVN stated, it was important to complete an inventory list in case something went missing. During an interview on 11/7/24 at 2:03 p.m. with the Director of Nursing (DON), the DON stated, it was her expectation that an inventory list be completed when a resident was admitted and re-admitted to the facility. The DON stated the process of completing the inventory was that the LVN or CNA would fill out the inventory form and the nurse would enter it into the EMR. The DON stated, Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/28/24. The DON stated, she was unable to find documentation that an inventory list had been completed on 7/12/24, 10/4/24 or 10/28/24 in the EMR or in Resident 1's hard chart (physical medical record). The DON stated, it was important for resident's belongings to be inventoried when they were admitted to ensure their personal belongings were tracked. The DON stated, when inventories were not completed on admission there was a potential for resident's personal belongings to get lost. The DON stated, the facility's P&P for Personal Property required for an inventory to be completed upon admission. The DON stated, the P&P for Personal Property was not followed. During a review of RESIDENT GRIEVANCE FORM, dated 10/14/2024, the RESIDENT GRIEANCE FORM indicated, . [Resident 1] . DESCRIBE THE NATURE OF THE GRIEVANCE: Patient lost items wallet / checkbook Last seen in 8/02/24 per email on 10/14/24 . INVESTIGATION: FINDINGS: . looked for items [at] bedside no findings writer added to communications to be on the look out for items . 10/18/2024 writer put on communications again . 10/21/2024 staff member [initials] looked through all Patient belongings no tracings of items . 10/22/24 Items Found [and] Placed in Social [services] Safe . During a review of the facility's (P&P) titled, Personal Property dated 2001, the P&P indicated, . Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . During a review of Job Description LVN dated 2/2024, the Job Description LVN indicated, . Essential Duties . Charting and Documentation . Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge . During a review of Resident 1's Clinical Census (CC) dated, 11/5/24, the CC indicated, Resident 1 was admitted [DATE], discharged on 10/3/24, readmitted on [DATE], discharged on 10/21/24 and re-admitted on [DATE]. During a review of professional reference from https://canhr.org/nursing-home-admission-agreements/#:~:text=Personal%20Possessions,current%20and%20save%20a%20copy.,titled, NURSING HOME admission AGREEMENTS dated, 9/4/2024, indicated, . When you are admitted to a nursing home, you will be asked to sign an admission agreement that explains your rights and responsibilities and those of the nursing home . Signing Other Documents at admission . Personal Possessions . At admission, the nursing home must establish a personal property inventory and give you or your representative a copy. (California Health & Safety Code §1289.4) . During a review of professional reference from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483 titled REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES dated 11/4/24, indicated, . Resident Rights . Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide . A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings . The facility shall exercise reasonable care for the protection of the resident's property from loss or theft . Admission, transfer, and discharge rights . Admissions policy . The facility must establish and implement an admissions policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician obtained informed consents (a process in which residents are given important information of the possible risk and benefits of the use of medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) and antipsychotic medication (a medication used to treat certain types of mental health problems) were completed for one of six sampled residents (Resident 31) when Resident 31 received Citalopram hydrobromide (an antidepressant medication used to treat a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and Resident 31 received Quetiapine (an antipsychotic medication that can treat several mental health conditions such as bipolar disorder [a disorder associated with episodes of mood swings ranging from depressive lows to manic highs]) without a signed informed consent. These failures resulted in Resident 31 to receive psychotropic and antipsychotic medications without being fully informed of the risk and benefits of the medications being administered; preventing them from making an informed choice which placed the resident at risk of negative side effects. Findings: During an observation on 7/22/24 at 8:02 a.m. in Resident 31's room, Resident 31 was observed sleeping in her bed. During a review of Resident 31's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/25/24, the AR indicated Resident 31 was admitted on [DATE] with diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/28/24, the MDS section C indicated Resident 31 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 31 was cognitively intact. During a concurrent interview and record review on 7/25/24 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 31's Medication Administration Record (MAR), dated 7/26/24 was reviewed. The MAR indicated Resident 31 was taking Citalopram and Quetiapine. LVN 1 stated Resident 31 started taking Citalopram on 6/15/24. LVN 1 stated Resident 31 started taking Quetiapine on 6/15/24. During a concurrent interview and record review on 7/25/24 at 10:51 a.m. with LVN 1, Resident 31's Informed Consent - Psychoactive Medication (IC), dated 6/14/24 was reviewed. The IC indicated Resident 31 was taking antidepressant and antipsychotic medications. LVN 1 stated Resident 31 did not sign the IC. LVN 1 stated the physician signed Resident 31's IC, without dating his signature. LVN 1 stated two nurses initialed Resident 31's IC without dating their initials. LVN 1 stated Resident 31's IC was electronically signed by the Director of Nursing (DON) on 7/19/24. LVN 1 stated Resident 31 was admitted on [DATE]. LVN 1 stated Resident 31 should have signed the IC on admission when she started taking the antidepressant and antipsychotic medications. During a concurrent interview and record review on 7/26/24 at 2:34 p.m. with the Pharmacy Consultant (PC), Resident 31's IC, dated 6/14/24 was reviewed. The IC indicated Resident 31 was taking antidepressant and antipsychotic medications without signing her IC. The PC stated she first saw Resident 31 and reviewed Resident 31's records on 7/10/24. The PC stated she gave a recommendation on 7/10/24 to get dated signatures on Resident 31's consents. The PC stated Resident 31 needed to sign the consents before taking the antidepressant and antipsychotic medications. During an interview on 7/26/24 at 3:09 p.m. with the DON, the DON stated residents on antidepressant or antipsychotic medications should have a signed IC for the medications. The DON stated the IC was not valid if the physician did not sign and date the IC. The DON stated antidepressant and antipsychotic medications should not be started without valid ICs. During a review of the facility policy and procedure (P&P) titled, Informed Consent Policy (IC), dated 4/2017, indicated . the physician will provide education to the resident or responsible party to include the risks, benefits, and alternatives of a given procedure or intervention . During a review of the facility P&P titled, Behavior Management, dated 12/31/15, indicated, . whenever an order is obtained for psychotropic medication(s), the licensed nurse verifies that informed consent has been obtained . During a review of the facility P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, . residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of five sampled residents (Resident 59) when Certified Nursing Assistant (CNA) 8 stood over Resident 59 while spoon feeding her breakfast while lying in bed. This failure resulted in Resident 59 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. Findings: During an observation on 7/22/24 at 8:25 a.m. in Resident 59's room, Resident 59 was lying in bed with head of the bed elevated and bed was in the highest position. Bedside table on the side of the bed and CNA 8 was standing on the side of Resident 59's bed while spoon feeding her breakfast. During a review of Resident 59's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information) dated 7/25/24, the AR indicated, Resident 59 was admitted to the facility with diagnoses which included intervertebral (between) disc degeneration (breakdown) lumbar region (lower back) and muscle weakness. During an interview on 7/24/24 at 10:10 a.m. with CNA 8, she stated Resident 59 was dependent on staff to meet all her activities of daily living (ADL-related to personal care like bathing, dressing, transfers, eating and toileting). CNA 8 stated she was assisting Resident 59 with breakfast on 7/22/24. CNA 8 stated she was standing on the side of the bed while spoon-feeding Resident 59 and it was wrong. CNA 8 stated, . I should have been sitting next to her [Resident 59] while I was assisting her [Resident 59] during breakfast because it was a dignity issue . During an interview on 7/25/24 at 10:40 a.m. with CNA 9, CNA 9 stated the practice when assiting residents with meals in bed was to lower resident's bed, elevate the head of the bed and sit next to resident bed and at eye level with resident. CNA 9 stated it was a dignity issue standing over resident while assiting during meals. During an interview on 7/26/24 at 11:15 a.m. with the Director of Nursing (DON), the DON stated staff should be sitting on a chair next to the resident when assisting during meals. The DON stated staff should not be standing next to resident when assisting during meals because it was a dignity issue. The DON stated CNA 8 should have lowered Resident 59's bed and sat on a chair to spoon-feed Resident 59. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self worth and self-esteem . During a review of the facility's P&P titled, Resident Rights, dated 2/2021, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility . be treated with respect, kindness and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a homelike environment for three of eight sampled residents (Residents 19, 44 and 137) when meals were served on plastic trays. This failure did not enhance or promote the rights of the residents to live and experience dining in a manner or environment that was homelike. Findings: During a concurrent observation and interview on 7/22/24 at 12:01 p.m. in the dining room, staff served Residents 19, 44 and 137 their meals on a plastic trays. Staff placed the entire tray in front of each resident, but did not remove the food plates, beverage glass, utensils, and napkins from the plastic tray. Residents 19, 44 and 137 did not answer any questions asked. During a review of Resident 19's admission Record dated 7/25/24, the AR indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). During a review of Resident 44's AR dated 7/25/24, the AR indicated, Resident 44 was admitted to the facility on [DATE], with diagnoses which included hemiplegia, unspecified affecting right dominant hand. During a review of Resident 137's AR dated 7/25/24, the AR indicated, Resident 137 was admitted to the facility on [DATE], with diagnoses which included displaced fracture (bone snaps into two or more parts and moves so that the two ends are not lined up straight) of left femur (thigh bone). During an interview on 7/22/24 at 12:25 p.m. in the dining room with Center Scheduler (CS), the CS stated she was also a Certified Nurse Assistant. The CS stated, the food plates, drinks and utensils should have been removed from the plastic tray and placed in front of residents. The CS stated the practice had always been to remove the plates, drinks and utensils from the plastic tray and placed on the table in front of resident because of homelike environment. During an interview on 7/22/24 at 12:35 p.m. in the dining room with Rehabilitative Nursing Assistant (RNA)2, RNA 2 stated, . The practice was to make sure food plates are removed from the plastic tray, placed in front of residents and remove lids . RNA 2 stated it was not acceptable to leave food plates, drinks and utensils in the plastic tray because it was not a homelike environment. RNA 2 stated the facility was the residents's home and therefore they should eat like they were eating in their own homes. During an interview on 7/25/24 at 8:19 a.m. with the Certified Dietary Manager (CDM), the CDM stated her area of concern was only the kitchen and nursing staff were responsible in the dining room. The CDM stated food plates, utensils, water and juice glasses were removed from the plastic tray and placed in front of residents for a homelike environment. During an interview on 7/25/24 at 2:45 p.m. with Licensed Vocational (LVN) 4, LVN 4 stated she did not really know what was going on in the dining room. LVN 4 stated staff needed to make sure food was checked by licensed nurse before serving to residents making sure they were served the correct food consistency. LVN 4 stated food needed to be removed from the plastic tray and served in front of residents to make it more like homelike environment. During an interview on 7/26/24 at 10:25 a.m. with the Director of Nursing (DON), the DON stated food should not be left in the plastic tray when serving to residents because it was not homelike environment. The DON stated the facility was the residents home so they [residents] should eat like they were in their own home. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 2/21, the P&P indicated, . 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences . 3. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutionalized, institutional setting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for one of five sampled residents (Resident 55) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge and readmit MDS tracking assessment for Resident 55. This deficient practice resulted in the potential harm of residents' needs upon discharge going unmet. Findings: During a concurrent observation and intervention on 7/22/24 at 8:45 a.m. in Resident 55's room, Resident 55 was sitting up in bed eating breakfast. Resident 55 refused to answer question stated, .Why are you picking on me . During a review of Resident 55's admission Record (AR), dated 7/25/24, the AR indicated, Resident 55 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar) and psychosis (mental disorder characterized by a disconnection from reality). During a concurrent interview and record review, on 7/25/24 at 11:07 a.m. with the MDSN, the MDSN reviewed the MDS assessment dated [DATE] and submission for Resident 55. The MDSN stated the last MDS assessment for Resident 55 was dated 7/9/24. The MDSN stated Resident 55 was sent out to acute hospital on [DATE] and readmitted to the facility on [DATE]. MDSN stated she did not find a completed and transmitted MDS discharge assessment tracking for Resident 55 when Resident 55 was sent out to acute on 12/15/23. MDSN stated she did not find a completed and transmitted MDS admitted assessment tracking for Resident 55 when Resident 55 was admitted back in the facility on 12/18/24. The MDSN stated it was a mistake on her part, she should have made sure she opened an assessment for the transfer and readmission of Resident 55. The MDSN stated the RAI (core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) manual recommendation was to open assessment on discharges and re-admissions, I did not follow the RAI guideline when I did not open assessments for the discharge and readmission. The MDSN stated it was important to open MDS assessment to identify any improvement or decline of Resident 55. During an interview on 7/26/24 at 10:25 a.m. with the Director of Nursing (DON), the DON stated, . I do not know what was going on in MDS . The DON stated she was not trained on MDS and did not have anything to do with MDS when she was working as a charge nurse on the floor. During an interview on 7/26/24 at 4:55 p.m. with the Administrator (ADM), the ADM stated his expectations when it came to MDS was for MDS to be complete and accurate. The ADM stated the MDSN was new but she could have asked question if she was not sure. During a review of facility's policy and procedure titled, MDS Assessment Coordinator, dated 11/2019, the P&P indicated, . Each individual who completes a portion of the assessent (MDS) must certify the accuracy of that portion of the assessment . Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action . During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.18.11 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/23, indicated, .Any of the following situations warrant a Discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds: . Resident is admitted to a hospital or other care setting (regardless of whether the nursing home discharges or formally closes the record). Resident has a hosptal observation stay greater than 24 hours, regardless of whether the hospital admits the resident Entry of a term used for both admission and reentry and requires completion of an Entry tracking record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to revise and implement a person centered comprehensive care plan for one of four sampled residents (Resident 34) when Resident 34 had a decrease in meal intake and care plan interventions were not revised. This failure had the potential for Resident 34's nutritional needs to go unmet. Findings: During a review of Resident 34's admission Record (AR-document containing resident demographic information and medical diagnosis) undated, the AR indicated Resident 34 was admitted to the facility on [DATE]. Resident 34's diagnosis included unspecified cerebrovascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus (condition in the way body regulates and uses sugar as a fuel) hypertension (high blood pressure), heart failure (when the heart is failing and cannot supply enough blood to the body) gastroesophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During an observation on 7/22/24 at 12:41 p.m., in Res 34's room, Resident 34 was lying in bed. Resident 34 stated, he was not hungry and did not like his lunch. Resident 34 ate less than 25% of his lunch. During a review of Resident 34's Minimum Date Set (MDS-an evaluation of a resident's cognitive and functional status), dated 7/17/24, the MDS indicated the Brief Interview for Mental status (BIMS assessment of a resident's cognitive status for memory recall) score of three out of 15 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) which indicated Resident 34 had severe cognitive impairment During an interview on 7/23/24 at 1:22 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 34 refused breakfast and lunch. CNA 8 stated Resident 34 was on regular diet and regular fluids. During an interview at 7/26/24 at 11:52 a.m., with CNA 9, CNA 9 stated, Resident 34 refused breakfast and sometimes lunch. CNA 9 stated Resident 34 was able to feed himself and at times needed help with meals. CNA 9 stated she notified the charge nurse when Resident 34's refused meals. CNA 9 stated Resident 34 did not eat as much as he used to. During an interview on 7/26/24 at 2:00 p.m. with License Vocational Nurse (LVN) 3, LVN 3 stated Resident 34 lost his appetite and had a decreased in meal intake within the last two weeks. LVN 3 stated he offered Jello, pudding, and fluids when Resident 34 refused his meals. LVN 3 stated a decreased in meal intake was considered a changed in condition. LVN 3 stated Resident 38's nutritional care plan was not revised for the decreased in meal intake and should have been. LVN 3 stated the nutritional care plan had not been revised since 6/28/24. During an interview on 7/26/24 at 3:33 p.m., with the Director of Nursing (DON), the DON stated, Resident 34's decreased in food intake should have been updated in the care plan. The DON stated, the care plan should have interventions to address Resident's decrease in meal intake. During a review of the facility's policy and procedure (P&P) titled, Care plans, Comprehensive Person-Centered, dated revised 3/2022, the P&P indicated, .A comprehensive, person-centered care plan should include measurable objective and timetable to meet the resident's physical, psychosocial and functional needs . Describes the services that are to be furnished in an attempt to assist the resident attained or maintain that level of physical, mental, and psychosocial wellbeing .the interdisciplinary team should review and update the care plan .there has been a significant change in the resident's condition .

Based on observation, interview and record review, the facility failed to accommodate resident meal preferences and provide an appropriate alternative for one of 18 sampled residents (Resident 35) when Resident 35 received a sandwich on white bread instead of wheat bread. This failure resulted in Resident 35 refusing to eat lunch and missing out on the nutritional value of the meal and had the potential to cause Resident 35 to experience weight loss as a result of not eating. Findings: During an observation on 7/22/2024 at 12:28 P.M. in Resident 35's room, Resident 35 received a sandwich on white bread instead of wheat bread. Resident 35's meal tray ticket indicated wheat bread under preferences. Resident 35's meal ticket indicated his sandwich should have been on wheat bread. During an interview on 7/22/2024 at 12:28 P.M. with Resident 35, Resident 35 stated he did not like white bread, and he would not eat his lunch. Resident 35 stated he had told staff about his preference, and wheat bread was listed on his meal ticket under preferences. During a concurrent observation and interview on 7/22/2024 at 12:34 P.M. with the Dietary Manager (DM), Resident 35 was served white bread instead of wheat bread. The DM stated Resident 35 should have been served wheat bread. The DM stated the kitchen ran out of wheat bread the previous night and was aware there was none left for the following day. The DM stated resident preferences print out on the meal ticket and should have been followed. During an interview on 7/25/24 at 3:12 P.M. with Dietary Aid (DA)1, DA 1 stated meal tickets list residents likes and dislikes under preferences. If a preference was for wheat bread, kitchen staff would have given the resident their preference. DA 1 stated if the preference was not available the DM would discuss an alternative with the resident. DA 1 stated it was the dietary aids, certified nursing assistants (CNA) and licensed vocational nurses (LVN) duty to check meal tickets match resident meal orders, as well as to notify the DM. DA 1 stated it was important to follow meal preferences so residents will eat their meals; if residents did not like their meals they will not eat. During an interview on 7/25/24 at 3:24 P.M. with the DM, the DM stated a kitchen staff member should have identified wheat bread was out of stock the night before and notified the DM so alternatives could be discussed with Resident 35. The DM stated it was important to follow meal tickets as residents may not eat if their preferences were not followed. DM stated they should have discussed alternatives with residents if preferences were not available. During an interview on 7/25/2024 at 4:18 P.M. with CNA 1, CNA 1 stated LVN's checked every meal tray for accuracy. CNA 1 stated the CNA's role was to help set up meal trays and report to the LVN if a resident did not receive food that was their preference. CNA 1 stated meal ticket preferences should have been followed. CNA 1 stated if a resident did not receive their preference, they would not have eaten their meal. During an interview on 7/26/24 at 11:04 A.M. with LVN 1, LVN 1 stated at mealtime the tray contents should have been compared to the meal ticket and reviewed with the resident, this should have been done for every meal delivery. LVN 1 stated this was done to ensure the correct diet and preferences were given to each resident. LVN 1 stated if food items were inaccurate, staff should have sent the food back to the kitchen and ensure the resident got the correct order. LVN 1 stated it was important to follow preferences so the resident would eat their meals. During an interview on 7/26/23 at 3:33 p.m. with the Director of Nursing (DON), the DON stated Resident 35's meal ticket should have been followed. The DON stated nurses were responsible for checking the meal trays for accuracy and they should have checked Resident 34's meal tray more carefully. The DON stated if Resident34's meal preferences were not followed, he would not eat and it could have led to Resident 35 experiencing weight loss. During a review of the facility's policy and procedure (P&P) titled, Menus, dated 10/21, the P&P indicated, . menu items and available snacks reflect .preferences of the residents . During a review of the facility's P&P titled, Resident Food Preferences, dated 7/2017, the P&P indicated, . Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain complete and accurately documented records for one of 18 sampled residents (Resident 47) when, Resident 47's hearing aids were not documented on her inventory sheet. This failure resulted in Resident 47 not wearing her hearing aids and staff being unaware of where they were located causing Resident 47 to think they went missing. Findings: During a review of Resident 47's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 12/20/23, the AR indicated, Resident 4's admitting diagnoses included: encephalopathy (term for any brain disease that alters brain function), muscle weakness, chronic obstructive pulmonary disease(a common lung disease causing restricted airflow and breathing problems), and epilepsy (condition which causes recurrent involuntary movements of the muscles). During a review of Resident 47's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive (Mental) abilities), dated 6/21/24, the MDS indicated a BIMS (brief interview for mental status- assessment used to determine the cognitive ability of a resident) score of 10 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 47 had moderate cognitive impairment. During a concurrent observation and interview on 7/2/24 at 8:25 a.m. with Resident 47, in Resident 47's room, Resident 47 was using a walker and had no hearing aids in place. Resident 47 stated she was hard of hearing. Resident 47 stated her hearing aids went missing and she had difficulty hearing without them. During a concurrent observation and interview on 7/24/24 at 8:42 a.m. with Certified Nursing Assistant (CNA) 6 outside of Resident 47's room, Resident 47 was seen in her room without her hearing aids . CNA 6 stated Resident 47 was hard of hearing, and she needed hearing aids to properly hear. CNA 6 stated staff members had to raise their voices when speaking with Resident 47 if she did not have hearing aids on. CNA 6 stated she had seen Resident 47's hearing aids in the past and they should have been inventoried so staff were aware she had them. CNA 6 stated CNAs were responsible for documenting inventory upon admission. CNA 6 stated staff should inventory anytime they see new resident' belongings. CNA 6 stated Resident 47's hearing aids should have been documented upon admission. During a concurrent observation and interview on 7/24/24 at 8:50 a.m. with CNA 6 in Resident 47's room. Resident 47's hearing aids were found in the drawer next to her bed. CNA 6 stated CNAs should have documented Resident 47's hearing aids upon admission and they should have accurately been reflected in her inventory sheet. During a concurrent interview and record review on 7/24/24 at 2:00 p.m. with the social services director (SSD), Resident 47's inventory sheet, dated 12/20/23 was reviewed. The inventory sheet indicated Resident 47's hearing aids were not inventoried. The SSD stated hearing aids were considered high value items and staff should have documented them on the inventory sheet. The SSD stated all resident belongings needed to be documented on the inventory sheet. The SSD stated it was important to include hearing aids on the inventory sheet, so staff were aware of all the belongings Resident 47 had. During an interview on 7/25/24 at 4:35 p.m. with CNA 1, CNA 1 stated CNAs were responsible for filling out inventory sheets upon admission. CNA 1 stated all residents' belongings needed to be included on the inventory sheet. CNA 1 stated if residents received new items during any time of their stay, those new items should also be documented on the inventory sheet. CNA 1 stated it was important to inventory all resident belongings, so residents had all their items with them during their stay and when they get discharged . During an interview on 7/25/24 at 4:35 p.m. with Licensed vocational Nurse (LVN) 1, LVN 1 stated CNAs were supposed to ensure the inventory sheet for Resident 47 was completed upon admission. LVN 1 stated all inventory items residents came in with or acquired during their stay needed to be inventoried. LVN 1 stated it was important to inventory resident belongings, so residents have all their possessions during stay and upon discharge. During a concurrent interview and record review on 7/26/24 at 2:49 p.m. with the minimum data set coordinator (MDSC), Resident 47's MDS, dated [DATE] was reviewed. The MDS indicated no hearing aids were documented for Resident 47. The MDSC stated the MDS is documented at bedside and through a review of resident records. The MDSC stated if she did not see Resident 47's hearing aids at bedside or if they were not documented in her record the hearing aids would be missed during her documentation. The MDSC stated Resident 47's hearing aids should have been included in her MDS in order to accurately reflect the care provided. During an interview on 7/26/24 at 3:33 p.m. with director of nursing (DON), the DON stated Resident 47's hearing aids should have been inventoried. The DON stated it was important to have a completed inventory sheet that included the hearing aids so Resident 47's items did not go missing. During a review of the facility's job descriptions titled Certified Nursing Assistant, dated 2/19, indicated, . Inventory and mark the resident's personal possessions as instructed . During a review of the facility's policy and procedure (P&P) titled, Hearing Impaired Resident, Care of, dated 2001, the P&P indicated, .staff will assist residents with care and maintaining hearing devices .5. When interacting with the hearing impaired or deaf resident, staff will implement the following: a. Evaluate the resident's preferred method of communication . During a review of the facility's policy and procedure (P&P) titled, Personal Property, dated 8/22, the P&P indicated, . 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 7/22/24 at 7:33 a.m. with Resident 67 in Resident 67's room, Resident 67 was observed in bed with his urinary catheter bag uncovered, hanging on the side of his bed. Resident 67 stated staff did not put his urinary catheter bag in a cover. Resident 67 stated when he was transferred to the hospital, people could see Resident 67's urine. Resident 67 stated his urine was red with blood. During an interview on 7/22/24 at 7:51 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 67's urine bag should have been covered for Resident 67's privacy. During a concurrent interview and record review on 7/25/24 at 10:33 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 67's Progress Notes, dated 7/20/24 were reviewed. The progress notes indicated Resident 67 was sent to the hospital after reinsertion of Resident 67's foley Catheter, red tinged urine was observed inside Resident 67's catheter bag. LVN 1 stated Resident 67 should have had a privacy bag over his urine catheter bag when he was transferred to the hospital. LVN 1 stated the catheter privacy bag was used to preserve Resident 67's dignity. During an interview on 7/26/24 at 3:09 p.m. with the Director of Nursing (DON), the DON stated Resident 67's urine catheter bag should have been covered in a dignity bag to preserve Resident 67's dignity. The DON stated her expectation was all staff should watch for residents with urine catheters to have covers on the catheter bags to preserve resident's dignity. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2016, indicated, . employees shall treat all residents with kindness, respect, and dignity . these rights include the resident's right to: . a dignified existence . be treated with respect, kindness, and dignity . During a review of professional reference retrieved from https://www.researchgate.net/publication/229538320_The_impact_of_urological_conditions_on_patients'_dignity titled, The Impact of Urological Conditions on Patient's Dignity, dated March 2007, indicated, . patients with urological conditions are particularly vulnerable to a loss of dignity . staff promoted dignity by providing privacy . Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for two of three sampled residents (Resident 14 and Resident 67) when: 1. Licensed Vocational Nurse (LVN) 2 did not address Resident 14 by her name. This failure had the potential for Resident 14 to feel disrespected. 2. Resident 67' foley catheter (an indwelling urinary catheter (a thin tube placed in the bladder to drain urine into a bag) drainage bag was without a dignity cover (a cover used to cover and hold the catheter drainage bag so it is not visible). This failure violated Resident 67's right to dignity and privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 67. Findings: 1. During an observation on 7/24/24 at 8:57 a.m. in Resident 14's room, LVN 2 addressed Resident 14 by calling her mama and honey while obtaining Resident 14's blood pressure (the pressure of blood on the walls of your arteries as your heart pumps blood around your body). During a concurrent observation and interview on 7/24/24 at 9:03 a.m., near Resident 14's room entrance, Resident 14 was seated in her wheelchair. Resident 14 stated she wanted to be addressed by her name and not being called 'mama or honey because it did not sound right. During a review of the clinical record for Resident 14, the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment dated [DATE], Section C indicated Resident 14's Brief Interview for Mental Status (BIMS) score was of 8 of 15 possible points (0-7: severe impairment, 8-12: moderately impaired, 13-15: cognitively intact). Resident 14 was moderately impaired. During an interview on 7/24/24 at 9:32 a.m. with LVN 2, LVN 2 validated addressing Resident 14 by calling her mama and honey. LVN 2 stated residents should be addressed by their name. During a concurrent interview and record review on 7/26/24, at 4:03 p.m., with the Director of Nursing (DON), the facility policy titled, Dignity dated 2/2021 was reviewed. The policy indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs Staff are expected to treat cognitively impaired residents with dignity and sensitivity . The DON stated residents should be addressed by their name unless specified otherwise in their care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 one of three sampled residents (Resident 59) when Resident 59's functional limitation in range of motion was inaccurately coded on the quarterly MDS assessment dated [DATE] and 5/23/24. This failure had the potential to result in Resident 59's care needs not met. Findings: During observation on 7/22/24 at 8:25 a.m. in Resident 59's room, Resident 59 was lying in bed and was assisted by Certified Nursing Assistant (CNA) 8 with breakfast. CNA 8 was spoon-feeding Resident 59. During a concurrent observation and interview on 7/24/24 at 12:35 p.m. in the dining room, Resident 59 was seated on her wheelchair, left hand holding a rolled towel and right hand was observed with weakness. CNA 8 was sitting next to Resident 59 and spoon-feeding her lunch. CNA 8 stated Resident 59 was dependent on staff to meet all her activities of daily living (ADL-activities related to personal care which includes bathing/shower, dressing, transfers, walking, toileting and eating) needs. CNA 8 stated Resident 59 was not able to move her upper extremities and needing assistance during meals. During a review of Resident 59's admission Record (AR), dated 7/25/24, the AR indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses which included hereditary (passed from parent to child) and idiopathic (unknown cause) neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). During a concurrent interview and record review on 7/24/24 at 2:45 p.m. with Minimum Data Set Nurse (MDSN), Resident 59's quarterly assessments dated 2/22/24 and 5/23/24, section GG were reviewed. The MDSN stated Resident 59 was coded as no impairment of upper extremity (shoulder, elbow, wrist, hand) on the MDS assessment. MDSN stated she completed the assessment on Resident 59 but did not perform bedside assessment. MDSN stated she pulled the information in collaboration with the CNA charting, therapy and Director of Nursing (DON). MDSN stated the quarterly assessments dated 2/22/24 and 5/23/24 were inaccurate. MDSN stated Resident 59 should have been coded with impairment on her upper extremities because she has contractures. MDSN stated she will review the RAI manual on how to assess the functional limitations to avoid inaccurate assessments. MDSN stated the facility follows the Long Term Care Facility Resident Assessment Instruction (RAI-core set of screening, clinical, and functional status elements, including common definition and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing home certified to participate in Medicare or Medicaid) guideline. During an interview on 7/26/24 at 10:45 a.m. with the DON, the DON stated she assumed the position as DON in June 2024. The DON stated she did not know what was going on in MDS. DON stated she did not get oriented on MDS yet and she did not do any MDS assessment when she was working as a charge nurse on the floor. During an interview on 7/26/24 at 4:55 p.m. with the Administrator (ADM), the ADM stated MDSN is new in her position. The ADM stated his expectation was for the MDS assessment to be complete and accurate. The ADM stated MDSN should have asked question if she was not sure. During a review of facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 11/19, the P&P indicated, . Any healthcare professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident . The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment . During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.18.11 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/23, indicated, .With resident seated on a chair, instruct them to reach with both hands and touch palms to back of head . touch each shoulder with the opposite hand . Code 1, impairment on one side: if resident has an upper- and/or lower-extremity impairment on one side that interferes with daily functioning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan (CP -a detailed approach to care customized to an individual resident's needs) for five of six residents (Residents 25, 31, 58, 67, and 74) when Residents 25, 31, 58, 67 and 74 did not have a baseline care plan for the monitoring of anti-platelet medication (medication that prevents blood clots from forming). These failures placed Residents 25, 31, 58, 67, and 74 at risk for complications resulting from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. These failures placed Residents 25, 31, 58, 67, and 74 at risk for bleeding and signs of bleeding to go unidentified. Findings: a. During a concurrent observation and interview on 7/22/24 at 11:14 a.m. with Resident 25 in Resident 25's room, Resident 25 was observed dressed sitting in a chair in her room. Resident 25 stated she had been in the facility for four months. No bleeding or bruising observed on Resident 25. During a review of Resident 25's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/25/24, the AR indicated Resident 25 was admitted on [DATE] with diagnoses of venous insufficiency (a condition where the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins of the legs), lymphedema (a buildup of fluid in the tissues that causes swelling), and hyperlipidemia (a condition where fats build up in the arteries, increasing the risk of a stroke [a condition when a blood vessel that carries oxygen and nutrients to the brain is either blocked or ruptures] or heart attack [a condition with the blood flow that brings oxygen to the heart is severely reduced or blocked]). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/9/24, the MDS section C indicated Resident 25 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 25 was cognitively intact. During a concurrent interview and record review on 7/25/24 at 10:42 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 25's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated Resident 25 was ordered Aspirin 81 mg daily on 1/6/24. LVN 1 stated Resident 25 was on Aspirin for prophylaxis (an attempt to prevent disease). LVN 1 stated there were no orders for anticoagulation monitoring in place for Resident 25. LVN 1 stated Resident 25 should have had orders for monitoring Resident 25 for signs and symptoms of bleeding or bruising. During a concurrent interview and record review on 7/25/24 at 10:44 a.m. with LVN 1, Resident 25's Care Plan (CP), dated 7/25/24 was reviewed. The CP indicated Resident 25 was . at risk for DVT (deep vein thrombosis [clot] . medication as ordered . LVN 1 stated there was no CP in place for anticoagulation monitoring for Resident 25. LVN 1 stated Resident 25 should have had a CP for monitoring Resident 25 for signs and symptoms of bleeding or bruising. LVN 1 stated Resident 25 did not have an individualized CP. LVN 1 stated nurses were responsible for CPs being initiated. LVN 1 stated she was responsible for follow up to verify CPs were accurate. b. During an observation on 7/22/24 at 8:02 a.m. Resident 31 was observed in bed sleeping. No bleeding or bruising was observed on Resident 31. During a review of Resident 31's AR, dated 7/25/24, the AR indicated Resident 31 was admitted on [DATE] with diagnoses of joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), cirrhosis of the liver (permanent scarring that damages the liver and interferes with its functioning), hyperlipidemia, and personal history of transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) . During a concurrent interview and record review on 7/25/24 at 10:50 a.m. with LVN 1, Resident 31's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated Resident 31 was ordered Aspirin 81 mg daily for DVT prophylaxis on 6/14/24. LVN 1 stated Resident 31 did not have orders for monitoring Resident 31 for signs and symptoms of bleeding. LVN 1 stated Resident 31 should have orders for anti-coagulant monitoring for signs and symptoms of bleeding. During a concurrent interview and record review on 7/25/24 at 10:52 a.m. with LVN 1, Resident 31's CPs, dated 7/24/24 were reviewed. There was no CP in place for monitoring Resident 31 for bleeding or bruising. LVN 1 stated Resident 31 did not have a CP for Aspirin monitoring for bleeding or bruising. LVN 1 stated Resident 31 did not have an individualized CP. c. During a concurrent observation and interview on 7/22/24 at 11:29 a.m. with Resident 58, in Resident 58's room, Resident 58 was observed in bed. No bleeding or bruising was observed on Resident 58. Resident 58 stated she had an abdominal wound from a removed feeding tube (a flexible plastic tube placed into the stomach to provide nutrition when a person cannot eat or drink safely by mouth) that was not healing. During a review of Resident 58's AR, dated 7/25/24, the AR indicated Resident 58 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body)and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction, cerebral aneurysm (a bulging, weakened area in the wall of an artery in the brain), non-ruptured (not broken), and hyperlipidemia. During a review of Resident 58's MDS, dated 4/10/24, the MDS section C indicated Resident 58 had a BIMs score of 12, which indicated Resident 58 was moderately impaired. During a concurrent interview and record review on 7/25/24 at 10:16 a.m. with LVN 1, Resident 58's Summary Order Report (Report), dated 7/25/24, the Report indicated Resident 58 was ordered Aspirin 81 mg, one tablet daily on 9/1/23. The Report indicated Resident 58 had orders to . observe for signs or symptoms of bleeding (2nd to anticoagulant use) every shift . order date 9/1/23 . LVN 1 stated Resident 58 was taking Aspirin for prophylaxis as ordered by the physician. During a concurrent interview and record review on 7/25/24 at 10:17 a.m. with LVN 1, Resident 58's CP, dated 7/25/24 was reviewed. The CP indicated, no CP was in place to monitor Resident 58 for signs or symptoms of bleeding. LVN 1 stated Resident 58 did not have a CP for anti-coagulation monitoring. LVN 1 stated Resident 58 should have had a CP for anti-coagulation monitoring. LVN 1 stated Resident 58 did not have an individualized CP. d.During a concurrent observation and interview on 7/22/24 at 7:33 a.m. with Resident 67 in Resident 67's room, Resident 67 was observed in dressed in bed. No bleeding or bruising was observed on Resident 67. Resident 67 stated he came back from the hospital yesterday. Resident 67 stated he was in the hospital for bleeding after staff changed his urinary catheter (a thin tube placed in the bladder to drain urine into a bag). During a review of Resident 67's AR, dated 7/25/24, the AR indicated Resident 67 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis and hyperlipidemia. During a review of Resident 67's MDS, dated 5/31/24, the MDS section C indicated Resident 67 had a BIMs score of 15, which indicated Resident 67 was cognitively intact. During a concurrent interview and record review on 7/25/24 at 10:27 a.m. with LVN 1, Resident 67's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated resident 67 was ordered Aspirin 81 mg, one tablet daily on 5/29/24. LVN 1 stated Resident 67 was taking Aspirin for CVA (Cerebral Vascular Accident [stroke]) prophylaxis. LVN 1 stated Resident 67 did not have orders for anticoagulation monitoring. LVN 1 stated Resident 67 should have had orders for anticoagulation monitoring. During a concurrent interview and record review on 7/25/24 at 10:30 a.m. with LVN 1, Resident 67's CP, dated 7/25/24 was reviewed. The CP indicated no CP was in place for monitoring for bleeding or bruising. LVN 1 stated Resident 67 did not have a CP for anticoagulation monitoring for signs or symptoms of bleeding or bruising. LVN 1 stated Resident 67 should have had a CP for anticoagulation monitoring. LVN 1 stated Resident 67 did not have an individualized CP. e.During an observation on 7/22/24 at 8:00 a.m. in Resident 74's room, Resident 74 was observed in bed. No bruising observed. During a review of Resident 74's AR, dated 7/25/24, the AR indicated Resident 74 was admitted on [DATE] with diagnoses of cerebral infarction, TIA, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and hyperlipidemia. During a review of Resident 74's MDS, dated 5/15/24, the MDS section C indicated Resident 74 had a BIMs score of 10, which indicated Resident 74 was moderately impaired. During a concurrent interview and record review on 7/25/24 at 11:11 a.m. with LVN 1, Resident 74's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated Resident 74 was ordered Aspirin 81 mg, one tablet daily on 5/11/24. LVN 1 stated Resident 74 was taking Aspirin for prophylaxis. LVN 1 stated there were no orders for monitoring for side effects of Aspirin. LVN 1 stated Resident 74 should have orders for anticoagulation monitoring for bleeding and bruising. During a concurrent interview and record review on 7/25/24 at 11:14 a.m. with LVN 1, Resident 74's CP, dated 7/25/24 was reviewed. The CP indicated no CP was in place for anticoagulation monitoring. LVN 1 stated Resident 74 did not have a CP for anticoagulation monitoring for bleeding and bruising. LVN 1 stated Resident 74 should have had a CP for anticoagulation monitoring for bleeding and bruising. LVN 1 stated Resident 74 did not have an individualized CP. During an interview on 7/25/24 at 11:15 a.m. with LVN 1, LVN 1 stated all residents on Aspirin should have had orders and CPs for anticoagulation monitoring for bleeding and bruising. LVN 1 stated it was important to monitor residents for bleeding and bruising. LVN 1 stated licensed nurses will put monitoring into resident's CP. LVN 1 stated anticoagulant monitoring was entered into resident's CP as a standard of practice. LVN 1 stated nurses, the Unit Manager, the MDS coordinator, Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were responsible for verifying CPs were accurate for each resident. LVN 1 stated CPs should have been individualized for each resident. LVN 1 stated each resident was different. LVN 1 stated the CPs were important to help make sure the residents' needs were met and helped improve the residents' goals of care. During an interview on 7/26/24 at 2:34 p.m. with the Pharmacist Consultant (PC), the PC stated Aspirin was considered an anti-platelet medication. The PC stated resident CPs should have had monitoring for bleeding and bruising for residents who were taking Aspirin daily. During an interview on 7/26/24 at 3:09 p.m. with the DON, the DON stated CPs should have been individualized for each resident. The DON stated each resident was different and each resident had different diagnoses. The DON stated the CP planned the resident's care according to the goals and interventions for each resident. The DON stated her expectation was for residents on anticoagulation or antiplatelet medications be monitored for bleeding and bruising. During a review of the facility policy and procedure (P&P) titled, Care Plans - Baseline, dated 3/2022, 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 . the baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission) . that includes, but is not limited to . the stated goals and objectives of the resident . any services and treatments to be administered by the facility . During a review of the facility P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . the care plan interventions should be derived from . the comprehensive assessment . describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 387's admission Record (document containing resident demographic information and medical diagnosis) dated 7/24/24, the admission record indicated Resident 387 was admitted to the facility on [DATE]. The admission record indicated, Resident 387 diagnoses included muscle weakness, dysphagia (difficulty swallowing), hypertension (high blood pressure), atrial fibrillation (abnormal heartbeat). The admission record indicated primary language [NAME]. During a concurrent observation and interview on 7/22/24 at 9:32 a.m., Resident 387 was lying in his bed. Resident 387 had no picture board (a board to communicate needs). Family Member (FM) FM 1 stated, she had to provide translation for staff member. During an interview on 7/24/24 at 10:19 a.m., with Certified Nursing Assistant (CNA) 6, CNA 6 stated she worked for the facility for three years. CNA 6 stated she did not know what language Resident 387 spoke. CNA 6 stated she was not sure if the facility provided a language line. CNA 6 stated, a picture board and language line was important for residents to communicate their needs. During a concurrent interview and record review on 7/24/24 at 3:30 p.m., with License Vocational Nurse (LVN) 7, Resident 387's care plans were reviewed. LN 7 stated, Resident 387 was admitted on [DATE] and there was no care plan for communication. LVN 7 stated, Resident 387 was identified as speaking a different language. LVN 7 stated, Resident 387 was admitted on [DATE] and there was no care plan for communication. LVN 7 stated, a care plan for communication should have been developed when Resident 387 was admitted to the facility. During an interview on 7/26/24 at 3:49 p.m., with the Director of Nursing (DON), the DON stated a communication care plan was not done. The DON stated the admission nurse was responsible for creating care plans upon admission. The DON stated a communication board was important for residents to communicate their needs. The DON stated, a comprehensive person-centered care plan should include communication. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, dated 2001 indicated, A comprehensive person center care plan should include .resident's physical, psychosocial and functional needs .2. A comprehensive person-center care plan should be developed within the seven (7) days of the completion of the required MDS assessment . 2. During a review of Resident 47's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 12/20/23, the AR indicated, Resident 4's admitting diagnoses included: encephalopathy (term for any brain disease that alters brain function), muscle weakness, chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), and epilepsy (condition which causes recurrent involuntary movements of the muscles). During a review of Resident 47's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive (mental) abilities), dated 6/21/24, the MDS indicated a BIMS (brief interview for mental status- assessment used to determine the cognitive ability of a resident) score of 10 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 47 had moderate cognitive impairment. During a concurrent observation and interview on 7/2/24 at 8:25 a.m. with Resident 47, in Resident 47's room, Resident 47 was walking using a front wheel walker with no hearing aids in place. Resident 47 stated she was hard of hearing. Resident 47 stated her hearing aids went missing and she had difficulty hearing without them. During a concurrent observation and interview on 7/24/24 at 8:42 a.m. with Certified Nursing Assistant (CNA) 6 outside of Resident 47's room, Resident 47 was seen in her room without her hearing aids . CNA 6 stated Resident 47 was hard of hearing, and she needed hearing aids to properly hear. CNA 6 stated staff members had to raise their voices when speaking with Resident 47 if she did not have hearing aids on. CNA 6 stated she had seen Resident 47's hearing aids in the past and staff were aware she used them. During an interview on 7/25/23 at 4:38 p.m. with CNA 1, CNA 1 stated nurses were responsible for creating resident care plans and CNAs could view the care plan after it was created. CNA 1 stated it was important to have updated and accurate care plans to communicate resident conditions to care staff. CNA 1 stated Resident 47's hearing aids should have been care planned. CNA 1 stated if Resident 47's hearing aid use was not care planned, staff members would be unaware on Resident 47's need to use hearing aides. During a concurrent interview and record review on 7/26/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 47's care plan, dated 12/20/23 was reviewed. No preexisting care planning for Resident 47's use of hearing aid was found prior to 7/24/24. LVN 1 stated Resident 47 use of hearing aids should have been care planned upon admission. LVN 1 stated care plans were important because the care plans contain details for the individual care needs, goals, and interventions for the resident. During a concurrent interview and record review on 7/26/24 at 2:57 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 47's care plan, dated 12/20/23 was reviewed. The care plan indicated hearing aid use was added to the care plan on 7/24/24. The MDSC stated Resident 47 should have had her hearing aids care planned prior to 7/24/24. The MDSC stated Resident 47's hearing aides should have been care planned because it helped to accurately reflect and communicate Resident 47's care needs to staff. During an interview on 7/26/24 at 3:33 p.m. with the Director of Nursing (DON), the DON stated Resident 47's hearing aid use should have been care planned. The DON stated it was important to have the hearing aids care planned because it helped set goals and interventions staff members needed to implement when caring for Resident 47. During a review of the facility's LPN [Licensed practical nurse]/LVN job description, dated 11/2018, the job description indicated, . Review care plans daily to ensure that appropriate care is being rendered Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that your assigned certified nursing assistants are aware of the resident care plans. Ensure that the CNA's refer to the resident's care plan prior to administering daily care to the resident . 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, . A comprehensive, person centered care plan should include measurable objectives and timetables to meet the residents physical psychosocial and functional needs . 3. The care plan interventions should be derived from the information obtained from the resident and his/ her family/ responsible party, with possible discretionary modifications resulting from the comprehensive assessment . 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level physical, mental, and psychosocial well-being that the resident desires or that is possible . 8. The interdisciplinary team should review and updates the care plan: a period when there has been a significant change in the residence condition; b. When the resident has been readmitted to the facility from a hospital stay; and c. At least quarterly, in conjunction with the required quarterly MSD assessment . Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for three of 22 sampled residents (Resident 55, 47, and 387 ) when: 1. Resident 55 did not have a care plan for diagnosis of psychosis (mental disorder characterized by a disconnection from reality). This failure placed Resident 55 at a potential risk for not monitoring behavior which could lead to psychotic breakdown. 2. Resident 47's use of hearing aids was not care planned. This failure had the potential to cause staff to be unaware of Resident 47's need for the usage of hearing aids and resulted in Resident 47 not wearing her hearing aids. 3. Resident 387 did not have a care plan for communication for a foreign language. This failure had the potential for Resident 387's needs to go unmet. Findings: 1. During a review of Resident 55's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 7/25/24, the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses which included psychosis . onset date: 1/5/22. During a review of Resident 55's Psychologist Consultation/follow-up, (PC) dated 1/3/24 and 3/20/24, the PC indicated, . Diagnostic Impression: Depressive Episode . Anxiety Disorder . Psychosis . During observation on 7/22/24 at 8:35 a.m. in Resident 55's room, Resident 55 was sitting up in bed eating breakfast and appropriately dressed. Resident 55 answered simple questions then stated, . Why are you picking on me . Resident did not answer any more questions. During a review of Resident 55's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 6/9/24, indicated the Brief Interview for Mental Status (BIMS) score was 13 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 55 was cognitively intact. During an interview on 7/24/24 at 9:10 a.m. with Certified Nursing Assistant (CNA) 12, CNA 12 stated she was familiar with Resident 55. CNA 12 stated Resident 55 has a behavior of yelling out at staff and non compliant with activities of daily living (ADL-activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a concurrent interview and record review on 7/25/24 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 1, she reviewed Resident 55's clinical record and stated Resident 55 was admitted on [DATE] with diagnosis of psychosis. LVN 1 stated she was not able to find a care plan for Resident 55's diagnosis of psychosis and there should have been a care plan. LVN 1 stated licensed nurses were responsible in initiating a care plan. LVN 1 stated she was not sure when a comprehensive care plan should have been initiated. During a concurrent interview and record review on 7/25/24 at 2:15 p.m. with LVN 4, she reviewed Resident 55's clinical record and stated Resident 55 was admitted to the facility with diagnosis of unspecified psychosis. LVN 4 stated she was not able to find a care plan for psychosis and there should have been a care plan. LVN 4 stated Resident 55 had a behavior of striking out and spitting at staff. During an interview on 7/26/24 at 10:35 a.m. with the Director of Nursing (DON), the DON stated she was not sure why Resident 55 did not have a care plan for her diagnosis of psychosis. DON stated there should have been a care plan for Resident 55's psychosis diagnosis to monitor behavior and adjust intervention as needed. DON stated she was not sure what the expectation was with comprehensive care plans. DON stated she thinks comprehensive care plans should be done within 72 hours of admission. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Cemtered, dated 3/22, the P&P indicated, . The comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment . The comprehensive person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing . The interdisciplinary team should review and updates the care plan: When there has been a significant change . readmitted to the facility from a hospital stay .

4. During an observation on 7/24/25 at 11:48 a.m. in Unit 4 with (LVN) 5, LVN 5 checked Resident 57's fingerstick. LVN 5 returned to the medication cart (movable piece of equipment used in healthcare facilities to store, transport, and dispense mediation) with her gloves on LVN 5 opened the medication cart with her gloves and obtained Resident 57 's insulin medication (used to lower blood sugar). LVN 5 did not take off her gloves and did not perform hand hygiene. During an observation on 7/24/25 at 11:50 a.m., in Unit 4 with LVN 5, LVN 5 administered insulin to Resident 57 and returned to the medication cart. LVN 5 removed her gloves and no hand hygiene was performed. During an interview on 7/24/25 at 11:55 a.m. in Unit 4 with LVN 5, LVN 5 stated, It was important to take gloves off and perform hand hygiene to prevent infection and cross contamination. During an interview on 7/26/24 at 3:49 p.m., with the DON, the DON stated, all staff should perform hand hygiene before and after resident care. The DON stated all staff should perform hand hygiene after removing gloves. The DON stated, LVN 5 should have removed her gloves and performed hand hygiene before touching the medication cart. The DON stated hand hygiene was important to prevent the spread of infections and cross contamination. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2001, the P&P indicated, .The facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections .Indications for hand hygiene .C. after contact with blood, body fluids or contaminated surfaces .G. immediately after glove removal . 3. During an observation on 7/23/24 at 10:39 a.m. CNA 2 did not perform hand hygiene after transporting a bag of feces down the hall and disposing of it. During an interview on 7/23/24 at 12:38 p.m. with the Infection Preventionist (IP), the IP stated hand hygiene should have been done anytime staff members interacted with a resident or handled bodily fluids. The IP stated hand hygiene was important in order to not spread infections or contaminate surfaces. During an interview on 7/25/24 at 4:22 p.m. with CNA 1, CNA 1 stated hand hygiene was supposed to be done before and after handling feces. CNA 1 stated it was important to perform hand hygiene to prevent cross contamination. During an interview on 7/26/24 at 3:33 p.m. with the DON, the DON stated hand hygiene should have been performed by staff before handling resident waste and after they disposed of it. The DON stated it was important to perform hand hygiene in order to prevent infections from spreading. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 10/23, indicated, .This facility considers hand hygiene the primary means to prevent the spread if healthcare-associated infections . Administrative Practices to Promote Hand Hygiene . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and infections . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility . Indications for Hand Hygiene 1. Hand Hygiene is indicated: . c. after contact with blood, body fluids, or contaminated surfaces . Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Licensed nurses did not maintain one of one medication rooms in a sanitary manner in accordance with the standards referenced by the Centers for Disease Control and Prevention (CDC) and facility policy. This failure resulted in the potential harm of cross contamination. 2. Powder was observed on the surface areas around four of four pill crushers and Licensed Vocational Nurses (LVN's) did not use appropriate cleaning disinfectant as per manufacturer guidelines. This failure resulted in the potential harm of cross contamination. 3. A certified nursing assistant (CNA) did not perform hand hygiene after handling a bag with feces. This failure had the potential to cross contaminate (the process in which harmful germs transfer from one surface to another) other surfaces and get residents sick. 4. LVN 5 did not remove her gloves or perform hand hygiene (a general term referring to any action of hand cleansing) after obtaining a fingerstick (a method that involves the use of a lancet (needle) to draw a few drops of blood from a fingertip) and giving insulin (medication to control blood sugar) to Resident 57. This failure had the potential for cross contamination. Findings: 1. During a concurrent observation and interview on 7/24/24 at 11:15 a.m. with LVN 1, in the medication room, two spoons, dust, hair and two cockroaches were observed on the ground. Surveyor washed hands at the sink in the medication room and no trash bin was located to discard the paper towel. LVN 1 validated the dirty medication room and stated the medication room should be clean. LVN 1 stated there was no trash bin to discard the paper towel. During a concurrent interview and records review on 7/26/24 at 3:48 p.m. with the Director of Nursing (DON), the facility policy titled Storage of Medications dated 11/2020 was reviewed. The policy indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . The DON stated the medication room should be clean and that it was housekeeping and nurses responsibility to keep the medication room clean. During a review of the Centers for Disease Control and Prevention, titled Environmental Cleaning Procedures, dated 3/2024, retrieved from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, the Environmental Cleaning Procedures indicated .Departments or areas where medication is prepared (e.g., pharmacy or in clinical areas) often service vulnerable patients in high-risk and critical care areas, in addition to other patient populations. The staff who work in the medication preparation area might be responsible for cleaning and disinfecting it, instead of the environmental cleaning staff. Table 13. Recommended Frequency and Process for Medication Preparation Areas. Frequency: Before and after every use. Countertops and portable carts used to prepare or transport medications. At least once every 24-hours: All high -touch surfaces (e.g., light switches, countertops, handwashing skinks, cupboard doors) and floors. Scheduled basis (e.g., weekly, monthly): low-touch surfaces, such as the tops of shelves, walls, vents . 2. During a concurrent observation and interview on 7/25/24 at 10:41 a.m. with LVN 3, in the facility hallway, the pill crusher on medication cart number three was coated in white and orange colored powder-like debris. LVN 3 stated the pill crusher should be clean and free of debris to prevent potential medication mixture. LVN 3 stated he would use bleach disinfectant wipes to clean the pill crusher. During a concurrent observation and interview on 7/25/24 at 10:45 a.m. with LVN 5, in the facility hallway, the pill crusher on medication cart number four and number one was coated in white and orange colored powder-like debris. LVN 5 stated the pill crusher should be clean and free of debris to prevent potential medication mixture. LVN 5 stated she would use bleach disinfectant wipes to clean the pill crusher. During a concurrent observation and interview on 7/25/24 at 11:09 a.m. with LVN 4, in the facility hallway, the pill crusher on medication cart number two was coated in white and orange colored powder-like debris. LVN 4 stated the pill crusher should be clean and free of debris to prevent potential medication mixture. LVN 4 stated she would use bleach disinfectant wipes to clean the pill crusher and did not clean the ledge of pill crusher. During a concurrent interview and records review on 7/26/24 at 3:48 p.m. with the DON, the Instruction for Using (IFU) [Brand Name] pill crusher titled Cleaning and Maintenance Instructions undated was reviewed. The IFU indicated, .Made entirely of non-rusting materials. When dirty it may be cleaned with soap and water and a damp cloth. Do not use bleach . The DON stated the pill crusher should be clean and bleach should not be used to clean the pill crusher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 7/22/24 at 12:28 p.m., in his room, Resident 38 was lying in bed. Resident 38 stated he was taking an antibiotic and did not know the reason he was taking it. Resident 38 stated he had a wound. During a review of Resident 38 's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 38 was admitted to the facility on [DATE]. Resident 38's diagnosis included muscle weakness, muscle wasting, pressure ulcer (an injury that breaks down the skin and underlying tissue), dysphagia (difficulty swallowing), atrial fibrillation (irregular heartbeat) and hypertension (high blood pressure). During a review of Resident 38's Minimum Date Set (MDS-an evaluation of a resident's cognitive [mental function] and functional status), dated 6/14/24, the MDS indicated the Brief Interview for Mental status (BIMS assessment of a resident's cognitive status for memory recall) score of 11out of 15 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) indicating Resident 38 was cognitively intact. During a concurrent interview and record review on 7/25/24 at 2:27 p.m., with License Vocational Nurse (LVN) 1, Resident 38's [Facility name] Order Summary Report (OSR), dated 7/25/24 was reviewed. The OSR indicated, .Wound culture today 7/25/24 r/t [related to] DTI [a type of tissue damage beneath the skin that results from an external pressure] right 1st toe . LVN 1 stated the wound culture was ordered on 7/25/24. LVN 1 stated Resident 38 started on doxycycline (antibiotic) for deep tissue injury) to the right toe on 7/19/24. During a review of [Facility name] Progress Note (PN) dated 7/19/24, the PN indicated .wound bed has 100% eschar (dead tissue that sheds or falls off from the skin) with no drainage noted, moderate odor present. Peri-wound (tissue surrounding a wound) does not exhibit [display] s/s [signs and symptoms] of infection or complication. Received new order on 7/19/24 doxycycline hyclate [a medication used in the management and treatment of a variety of infections.] tablet 100 mg [milligram-unit of measure] give 1 table via G-tube [a tube inserted through the belly that brings nutrition directly to the stomach]. twice a day for PPX [prophylactically] for 10 days of 1st (first) toe right foot . The PN indicated, no wound culture was ordered on 7/19/24. During an interview on 7/25/24 at 3:13 p.m., with the Infection Preventionist (IP- professionals who make sure staff, residents and visitors are doing all the things they should to prevent infections), the IP stated, she worked as an IP for six months. The IP stated, It is not standard of practice to start antibiotic for DTI. The IP stated she was notified that Resident 38 started on antibiotic on 7/19/24. The IP stated the wound culture was obtained on 7/25/24. During an interview on 7/26/24 at 3:49 p.m., with the Director of Nursing (DON), the DON stated, a wound culture should have been done the same day the antibiotic was started. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome, Dated revised 12/2016, the P&P indicated, .The IP [infection preventionist] or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consist with the appropriate use of antibiotics .4.Thearpy [a form of treatment] was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics . During a review [NAME] the University of Florida Drug and Therapy title Article, Collect before you treat: obtaining cultures before antibiotic treatment dated 12/2006, retrieved from: chrome extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ufhealth.org/assets/media/Professionals-Bulletins/1006-drugs-therapy-bulletin.pdfthe, the article indicated, .Obtaining appropriate cultures before initiating antimicrobial therapy plays an important role in patient [residents] care .Obtaining culture after antimicrobial therapy has been started can cause inconclusive results because organisms that would otherwise be detected may not necessarily grow after exposure to an antibiotic agent Appropriate antibiotic therapy plays an import role in of antibiotic resistance . The Centers for Disease Control and Prevention (CDC) outlines that in order to help control antibiotic resistance and effectively diagnose and treat infection, it is very important to obtain cultures in order to target antimicrobe therapy to susceptibility results . 3. During an observation on 7/22/24 at 9:56 a.m. in Resident 337's room, Resident 337 was observed dressed, in bed with a nasal cannula in his nostrils. Resident 337 stated he had been in the facility for two weeks. Resident 337's oxygen concentrator (a device that produces high levels of oxygen from the air in the room to supply an oxygen-enriched product gas stream) was observed to be infusing oxygen through Resident 337's nasal cannula at five liters per minute. During a review of Resident 337's admission Record (AR), dated 7/2/24, the AR indicated Resident 337 was admitted on [DATE] with diagnoses of pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), acute respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), and acute pulmonary edema (a buildup of fluid in the lungs). During a concurrent interview and record review on 7/25/24 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, a photograph dated 7/22/24 at 9:56 a.m. of Resident 337's oxygen concentrator was reviewed. LVN 1 verified the photograph indicated Resident 337's oxygen was delivering oxygen at 5 liters per minute. Resident 337's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated Resident 337 had admission orders dated 7/2/24 for oxygen to be administered at 2 liters per minute, via nasal cannula, as needed. LVN 1 stated Resident 337 was admitted on [DATE]. LVN 1 stated there were no physician orders for oxygen to be administered at five liters per minute to Resident 337 prior to 7/22/24 at 11:10 a.m. LVN 1 stated Resident 337's oxygen orders were changed on 7/22/24 at 11:10 a.m. to administer oxygen at five liters per minute. LVN 1 stated on 7/22/24 before 11:10 a.m., Resident 337 should have been receiving oxygen at 2 liters per minute. LVN 1 stated if a resident was given too much oxygen, it could blow out the resident's lungs. LVN 1 stated it was very important for staff to follow physician's orders. During an interview on 7/26/24 at 3:09 p.m. with the Director of Nursing (DON) the DON stated, it was very important for staff to follow physician's orders. The DON stated if staff did not follow physician's orders, it could cause harm to the residents. The DON stated if staff did not follow physician orders for oxygen, it could cause shortness of breath or harm to the resident. The DON stated her expectation was for staff to follow physician's orders. During a review of professional reference retrieved from https://my.clevelandclinic.org/health/treatments/25187-nasal-cannula, dated 8/4/23, indicated, . oxygen therapy has some risks. These risks include: . lung damage or pulmonary oxygen toxicity. This is damage to your lungs and airways from too much oxygen . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, indicated, . verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . adjust the oxygen delivery device so . the proper flow of oxygen is being administered . 4. During an observation on 7/22/24 at 9:56 a.m. in Resident 337's room, Resident 337 was observed dressed, in bed with an undated nasal cannula in both his nostrils, infusing oxygen at five liters per minute. Resident 337's oxygen humidifier tank was observed to be undated, with water inside the tank. Resident 337 stated he had been in the facility for two weeks. Resident 337 stated he had pneumonia. During a concurrent observation and interview on 7/22/24 at 10:04 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 337's room, Resident 337's oxygen tubing and oxygen humidifier tank were observed. CNA 3 stated the oxygen tubing and oxygen humidifier tank were not dated. CNA 3 stated the oxygen tubing and oxygen humidifier tank should be dated with the date they were last changed. During an interview on 7/25/24 at 2:26 p.m. with LVN 1, LVN 1 stated Resident 337's oxygen tubing should have been dated with the date the tubing was changed. LVN 1 stated Resident 337's oxygen humidifier tank should have been dated with the date the tank was changed. LVN 1 stated dated oxygen tubing and dated humidifier tanks were important for resident infection prevention. LVN 1 stated if the oxygen tubing or the oxygen humidifier tank was not changed, they could have dust or mold growth inside the tank or tubing which could cause infection to Resident 337. During an interview on 7/26/24 at 3:09 p.m. with the DON, the DON stated nurses were responsible for making sure the residents' oxygen tubing and humidifier tanks were changed weekly and dated. The DON stated it was important to change the oxygen tubing and oxygen humidifier tank weekly. The DON stated residents were at an increased risk of infection if the oxygen tubing or oxygen humidifier tank were not changed weekly. During a review of Resident 337's Order Summary Report (Report), dated 7/25/24, the Report indicated, . change humidifier bottle/tubing every day shift every Sun Date & Initial . order date 7/2/24 . During a review of professional reference retrieved from https://www.ucsfhealth.org/education/your-oxygen-equipment, titled, Patient Education Your Oxygen Equipment, dated 2022-2024 indicated, . the nasal cannula should be changed every week . if you are using a humidifier, empty it at least once a day . 5. During a review of Residents 24's admission Record (AR), dated 1/12/24, the AR indicated, Resident 24 was not his own RP. Resident 24's admitting diagnoses included the following: muscle wasting and atrophy (condition which causes the muscles to diminish and weaken), and muscle weakness. During a review of Resident 24's Minimum Data Set (MDS), dated [DATE], the MDS indicated BIMS score of ten (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 24 had moderate cognitive impairment. During an observation on 7/22/24 at 8:14 a.m. in Resident 24's room. Resident 24 was observed lying on a low air loss mattress. During an interview on 7/25/24 at 4:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated a change to Resident 24's low air loss mattress should have been communicated to the RP. CNA 1 stated low air loss mattresses were doctor's orders and doctor's orders needed to be communicated to the RP. CNA 1 stated it was important to communicate to the RP in order to have a cognitively intact person consent to treatments needed. During concurrent interview and record review on 7/26/24 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 24's progress notes, dated 07/22/24 were reviewed. The progress note indicated, .Received new LAL [low air loss mattress] but noted low pressure . ADON [assistant director of nursing] notified. Resident is self RP and made aware. Will [continue] to monitor . LVN 1 stated Resident 24 was not supposed to act as his own RP. LVN 1 stated staff should have contacted his actual RP regarding his mattress. LVN 1 stated it was important to contact Resident 24's RP so appropriate decisions could have been made by a cognitively intact person. During a concurrent interview and record review on 7/26/24 at 2:38 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 24's MDS, dated [DATE] was reviewed. The MDS indicated Resident 24 had a BIMS score of 10. The MDSC stated residents with a BIMS score less than 13 could not serve as their own RP. The MDSC stated Resident 24's BIMS was 10 which indicated he had moderate cognitive impairment. The MDSC stated Resident 24's RP should have been contacted. The MDSC stated if a residents RP was not contacted, the resident would receive inaccurate care. During an interview on 7/26/24 at 3:33 p.m. with the director of nursing (DON), the DON stated Resident 24's RP should have been contacted regarding his mattress. The DON stated the RP would have been unaware of any changes occurring with Resident 24 if he was not contacted. During a review of the facility's policy and procedure (P&P) titled, Informed Consent Policy, dated 4/17, the P&P indicated, . Resident or responsible party will be provided an informed consent whenever applicable . 6. During a review of Resident 19's admission Record (AR), dated 6/28/24, the AR indicated Resident 19 was her own RP. Resident 19's admitting diagnoses included: Major Depressive Disorder (a mental health disorder characterized by persistently sad mood or loss of interest in activities), Alzheimer's disease (condition which causes memory loss), psychotic disorder with hallucination (condition which causes false beliefs such as hearing or seeing things that are not there). During a review of Resident 19's Minimum Data Set (MDS), dated [DATE], the MDS indicated a BIMS score of 11 indicating Resident 19 had moderate cognitive impairment. During an interview on 7/25/24 at 4:31 p.m. with CNA 1, CNA 1 stated residents with impaired cognitive abilities and confusion could not sign their own consents or serve as their own RP. CNA 1 stated if Resident 19 had a low BIMS score it meant she could not act as her own RP. CNA 1 stated residents with lower BIMS scores should not serve as their own RP because they could have signed consents they would not have understood. During an interview on 7/26/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents with a BIMS score between 8-12 were cognitively impaired. LVN 1 stated MDSC was the person who calculated the BIMS scores and determined if residents were able to act as their own RP. During a concurrent interview and record review on 7/26/24 at 2:42 p.m. with the MDSC, Resident 19's MDS Section C, dated 6/1/24, was reviewed. The MDS Section C indicated Resident 19 had a BIMS score of 11. The MDSC stated it was the facility's practice that residents with a BIMS score under 13 could not serve as their own RP. Resident 19 should not have been her own RP with a BIMS score of 11. The MDSC stated a different RP should have been selected at the time of her admission on [DATE]. The MDSC stated having an appropriate RP was important in order to adequately provide care for residents . During a review of the facility's policy and procedure (P&P) titled, Informed Consent Policy, dated 4/17, the P&P indicated, . Resident or responsible party will be provided an informed consent whenever applicable . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for five of 15 sampled residents (Resident 19, Resident 24, Resident 38, Resident 40 and Resident 337) when: 1. Resident 40 was administered 2.5L/min (two point five liter- unit of measurement)/min (minute) oxygen via nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 3L/min of oxygen per physician's order. This failure resulted in Resident 40's oxygen needs going unmet and caused Resident 40 received oxygen at different rate. 2. Resident 38 was started on antibiotic (medicines that fight bacterial infections in people) without obtaining a wound (an injury to the skin) culture (a test to find germs such as bacteria, a virus, or a fungus). This failure had the potential to result in Resident 38 receiving unnecessary antibiotic and had the potential for placing Resident 38 at risk for adverse effects (an undesired harmful effect resulting from a medication or other intervention) and increased antimicrobial (substance that kills bacterial, mold or stops them from growing) resistance. 3. Resident 337 was administered 5L/min oxygen via NC instead of 2L/min per physician's order. This failure had the potential to put Resident 337 at risk for oxygen toxicity (lung damage that can occur from breathing in too much extra [supplemental] oxygen. Symptoms include coughing, trouble breathing, dizziness and death). 4. Oxygen tubing for Resident 337 was not labeled with the date it was changed and the oxygen humidifier (a device designed to increase the moisture level by emitting water droplets or steam into the air) water tank was not labeled with the date the tank was changed. These failures had the potential to put Resident 337 at risk for infection from contaminated oxygen tubing and oxygen humidifier water tank. 5. Resident 24's responsible party (RP-person who can make medical decisions for a resident) was not contacted for updates regarding his low air loss mattress (mattresses designed to distribute the patient's body weight over a broad surface area to help prevent skin breakdown). This failure caused Resident 24's RP to not be informed of changes regarding Resident's 24's care. 6. Resident 19 was listed as her own responsible party (RP-person designated to make decisions and be informed regarding the care of a resident) when she had a Brief Interview of Mental Status (BIMS- assessment which determines the cognitive [the ability to think, learn, and memorize] impairment of a person) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment.). This failure resulted in the facility not following their own practices of having an RP in place for Residents with a BIMS score under 13. Findings: 1. During a review of Resident 40's admission Record (AR-a document containing resident profile information) dated 7/26/24, the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic(long term) respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily functions). During a concurrent observation and interview on 7/22/24 at 9:55 a.m. in Resident 40's room, Resident 40 laid in bed with oxygen via nasal cannula receiving 2.5L/min. Resident 40 stated she was getting 3L/min of oxygen and had been using oxygen for a long time to help her breath. During observation on 7/23/24 at 12:10 p.m. in Resident 40's room, Resident 40 laid in bed watching TV. Resident 40's oxygen was set at 2.5L/min via NC. Resident 40 stated she was supposed to be receiving 3L/min of oxygen to help with her breathing problem. During a concurrent observation and interview on 7/23/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 8 in the hallway, LVN 8 checked Resident 40's oxygen and stated Resident 40's oxygen was set at 2.5L/min. LVN 8 stated the oxygen should be set at 3L/min if it was the order. LVN 8 stated Resident 40's oxygen order was not being followed per physician's order. LVN 8 stated Resident 40 was not receiving the amount of oxygen ordered which could lead to respiratory distress. During a concurrent interview and record review on 7/23/24 at 12:25 p.m. with LVN 4, LVN 4 reviewed Resident 40's oxygen order and stated Resident 40 should be recceiving 3L/min of oxygen via NC as ordered by the prhysician. LVN 4 stated she did not checked the oxygen setting in the morning at the start of her shift and she should have. LVN 4 stated all the licensed nurses should have been checking the oxygen setting of residents' receiving oxygen. LVN 4 stated Resident 40 not receiving the correct amount of oxygen could lead to respiratory issues which could result to more serious problem. During an interview on 7/26/24 at 11:03 a.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses checking the oxygen settings and comparing with the order to ensure residents are receiving the correct amount of oxygen. DON stated licensed nurses should be checking residents's oxygen at the start of their shift and throughout their shift making sure residents' were receiving the correct amount of oxygen to prevent respiratory distress. Durimg a review of facility's policy and procedure titled, Oxygen Administration dated 10/10, the P&P indicated, . Verify that there is a physician's order . Review the physician's orders or facility protocol for oxygen administration . After completing the oxygen setup or adjustment, the following informatio should be recorded . The rate of oxygen flow .

2. During a concurrent observation and interview on 7/24/24 at 11:09 a.m., with LVN 1 in the medication storage room, an emergency kit was found in the refrigerator with a missing zip tie. LVN 1 stated, there should be two zip ties on the emergency kit. During an interview on 7/26/24 at 9:14 a.m., with the Pharmacist Consultant (PC), the PC stated the E-kit needed to have two zip ties on it. The PC stated, if an emergency kit was missing a zip tie, the staff need to notify the pharmacy right away. The PC stated, the E-kit needed to be replaced as soon as possible. The PC stated it was important for the E-kit to have two zip ties to prevent tampering. The PC stated someone can access the E-kit with a missing zip tie. During an interview on 7/26/24 at 3:49 p.m., with the DON, the DON stated, E-kit needed two zip ties to ensure it was sealed. During a review of the facility's policy and procedure titled, Storage of Medication dated revised 11/2022, the P&P indicated, .The facility stores all drugs and biological in a safe, secure and orderly manner .Drugs containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing . 3. During a concurrent observation and interview on 7/25/24 at 10: 47 a.m., with LVN 5, the medication cart three had hearing aid batteries stored with the medications. LVN 5 stated, Hearing aid batteries should not be stored with medications. During an interview on 7/26/24 at 9:14 a.m. with the PC, the PC stated, hearing aid batteries should not be stored in the same compartment as medications. The PC stated it was important to stored hearing aid in a different compartment to prevent giving hearing aid batteries as medications. During an interview on 7/26/24 at 3: 49 p.m., with the DON, the DON stated hearing aid batteries should not be stored in the medication compartment. The DON stated hearing aid batteries needed to be stored and separated away from the medications. During a review of the facility's policy and procedure titled, Medication Storage dated 2019, the P&P indicated, . Potentially harmful substance (such as urine test reagent tablets, household poison, cleaning supplies, disinfectant are clearly identified and stored in a lock area separately from medications . 4. During a concurrent observation and interview on 7/25/24 at 10:02 a.m., with LVN 3 in the hall, medication cart three had one multivitamin pill in a cup. LVN 3 stated, the multivitamin was for Resident 77. LVN 3 stated he should have discarded the medication and should not have left it in the medication cart. During a concurrent observation and interview on 7/25/24 at 10:03 p.m., with LVN 3 in the hall, medication cart three had two sodium (supplemental medication to treat low salt level) pills in a clear plastic bag. LVN 3 stated, it was a sodium pill. LVN 3 stated the sodium pills should not be stored with the other medications. LVN 3 stated the sodium pills should be destroyed as soon as possible. During a concurrent observation and interview on 7/25/24 at 10:57 a.m., with LVN 5 in the nurses' station, medication cart four had a cup with medications and applesauce. LVN 5 stated she did not know who it belonged to or what medication the cup contained. During an interview on 7/26/24 at 9:14 a.m., with the PC, the PC stated, over the counter medications that was not given should be destroyed and placed in the medication destruction container. During an interview on 7/26/24 at 3:49 p.m., with the DON, the DON stated medications that were not given needed to be discard after medication pass. During a review of the facility's policy and procedure titled, IE5: Medication Destruction dated 2019, the P&P indicated, .C. Non-controlled medication destruction occurs only in the presences of (two) individuals .Medications dropped on the floor or spit out by resident shall be placed in medication waste containers . 5. During a concurrent observation and interview on 7/25/24 at 10:51 a.m., with LVN 5 in the nurses' station, one insulin pen did not contain the resident name or open date. LVN 5 stated, there should have been a name on the pen. LVN 5 stated, it was important to label the insulin pen with the resident's name. LVN 5 stated, labeling the pen with the resident's name ensured it was given to the correct resident. During an interview on 7/26/24 at 9:14 a.m., with the PC, the PC stated, insulin pen should always have the name of the resident and the date it was opened. The PC stated insulin pens were sent in a bag. The PC stated, insulin pen could fall out of the bags and mixed with other insulin pens. The PC stated insulin pens without names can be given to the wrong residents. During an interview on 7/26/24 at 3:49 p.m., with the DON, the DON stated insulin pens should be labeled with the resident's name. The DON stated it was important to have a label with the resident's name on the insulin pen to ensure it was administered to the correct resident. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated revised 12/2012, the P&P indicated, .14. Insulin pens will be clearly labeled with the resident's name or other identifying information . 6. During an observation on 7/22/24 at 12:35 p.m. between bathroom one and two, a treatment cart (a cart use to store medical or treatment supplies) was observed unattended with the key in the lock and other keys on a keychain dangling from the lock. During a concurrent observation and interview on 7/22/24 at 12:37 p.m. with Licensed Vocational Nurse (LVN) 6, in front of the treatment cart, LVN 6 removed the keys from the lock of the unattended treatment cart. LVN 6 stated, the keys should not be left in the lock when the treatment cart was unattended. LVN 6 stated, residents could get into the treatment cart and harm themselves. During an interview on 7/25/24 at 10:29 a.m. with Wound Nurse (WN), the WN stated, keys should never be left in the lock of the wound cart when unattended. During an interview on 7/25/24 at 10:30 a.m. with LVN 1, LVN 1 stated, keys should never be left in the lock of the medication carts or treatment carts, a resident could get into the medication cart and take another resident's medication or get something sharp from inside the treatment cart and cause harm to themselves or other residents. During an interview on 7/26/24 at 3:00 p.m. with Director of Nurses (DON), the DON stated the wound cart should be locked when unattended to keep residents and visitors from getting into medications and wound supplies. During a review of the facility's policy and procedure (P&P) titled, ID1: Storage of Medications dated 2019, indicated .Medications and biologicals are stored safely, securely .medication supply is assessable only to license nursing personnel . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Based on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. One medication cart (out of four) was left unlocked and unattended by Licensed Vocational Nurse (LVN) 3. This failure resulted in a potential for residents and staff to have unauthorized access to medications. 2. One emergency kit (E-kit- emergency medication stored in container) was found without second zip tie in the medication storage room. This failure had the potential for unauthorized access to medication and missing medication. 3. A package containing hearing aid batteries were stored with medication in the medication cart number 4. This failure had the potential for medications and hearing aid batteries to be mixed together. 4. Medications were found in one unlabeled bag, one cup containing multivitamin pill in medication cart number 3. A cup containing medications with applesauce was found in the medication cart number 4. This failure had the potential for residents receiving wrong medication because they were unlabeled. 5. Insulin pen (medication used to control high blood sugar) was not labeled with resident name and open date. This failure had the potential for insulin given to wrong residents. 6. One treatment wound cart was unattended with the keys left in the lock. This failure had the potential to harm residents to access to treatment supplies. Findings: 1. During an observation on 7/26/24 at 1:51 p.m., medication cart three was located next to the nurses' station against the wall, the medication cart drawers were facing the hall. The medication cart was unlocked and unattended. During an observation on 7/26/24 at 1:54 p.m., LVN 3 Walked out of the nurses' station and placed a bag of spoons on the side of the medication cart three. LVN 3 walked back into the nurses' station without locking the medication cart three. During an observation on 7/26/24 at 1:55 p.m., LVN 3 walked out of the nurses' station and proceeded down the hall towards the main entrance. The medication cart three was unlocked and unattended. During an observation on 7/26/24 at 1:57 p.m., medication cart three remained unlocked and unattended. During a concurrent observation and interview on 7/26/24 at 1:59 p.m. medication cart three was located next to the nurses' station against the wall. Central Supply (CS) walked by the medication cart and pushed the locking mechanism in place, locking the cart. CS stated she spotted the unlocked medication cart and locked it. During a concurrent observation and interview on 7/26/24at 2:00 p.m. in the facility hallway, LVN 3 walked back to the medication cart. LVN 3 stated the medication cart should be locked for safety so no unauthorized person can access it. During a concurrent interview and records review on 7/26/24 at 4:00 p.m. with the Director of Nurses (DON), the facility policy and procedure titled Storage of Medications dated 2019 was reviewed. The policy indicated . Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated the medication cart should be locked when unattended to prevent unauthorized access.

Based on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety for 91 of 96 residents when: 1. A plastic container of dry bran cereal was uncovered in the dry food storage. 2. An uncovered Styrofoam cup with brown liquid was left on top of an ice chest in the dry food storage. 3. No air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the sink where food was being prepared. 4. The food thermometer (a tool to measure temperature), was not calibrated (verifying the capability and performance of an item of measuring and test equipment by comparison to traceable measurement standards), prior to use during lunch service. 5. The thermometer was not sanitized prior to being placed in a metal container of freshly cooked broccoli during lunch service. 6. The temperature of the soup was not measured prior to serving to residents. 7. The cook touched multiple surfaces with gloves on and then continued to serve food during lunch service without changing gloves. 8. The cook did not follow the recipe during tray line and used the same size scoop for small, regular, and large portions. 9. A Dietary Aid (DA) 2, walked through the kitchen without a hair net while food was being served. These failures placed all residents that receives meals are at risk for food borne illness. Findings: 1. During a concurrent observation and interview on 07/22/24 at 7:41 a.m. in the dry storage area with the Certified Dietary Manager (CDM), a plastic container of dry bran cereal was uncovered in the dry food storage. The CDM stated, the lid should have been replaced on the bin to prevent insects and other contaminants from getting into the food. During an interview on 7/22/24 at 7:42 a.m. with the Registered Dietitian (RD), the RD stated there should be no uncovered food in the dry food storage area, uncovered food could get flies, debris, or other contaminants. During a review of the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage dated 11/2022, indicated, .Food services maintain clean .food storage area at all times .all foods are covered . 2. During a concurrent observation and interview on 7/22/24 at 7:46 a.m. in the dry food storage area, with the CDM and the RD, a white Styrofoam cup half full of brown liquid was sitting uncovered on top of an ice chest sitting on the floor next to the shelves in the dry storage area. The CDM stated, staff personal drinks were not to be in the food pantry area. The RD stated personal drinks were not to be stored in pantry area, the drinks could spill onto the food being stored and contaminate it. During a review of the facility's P&P titled, Food Receiving and Storage dated 11/2022, indicated, .Food services maintain clean .food storage area at all times .all foods are covered . 3. During a concurrent observation and interview on 7/22/24 at 8:24 a.m. in the facility's kitchen, with the CDM and the RD, the food preparation sink was observed to not have an air gap. The CDM stated, she was not familiar with the food preparation sink needing an airgap, the CDM stated Maintenance would be the department responsible for the airgap. The RD stated, she needed to review the air gap regulations. During an interview on 7/25/24 at 5:10 p.m. with the Administrator (ADM), the Administrator stated the facility does not have an air gap under the food preparation sink. The facility does not have an air gap policy. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue . 4. During an observation on 7/23/24 at 11:54 a.m. of the facility's lunch tray line service, the [NAME] (CK), did not calibrate the new food thermometer prior to taking the temperature of the food. During an interview on 7/23/24 at 1:15 p.m. with the CK, the CK stated she did not follow the facilities expectations during the lunch meal service. CK stated she should have calibrated the food thermometer to verify the temperatures were accurate. During an interview on 7/23/24 at 2:27 p.m. with CDM, the CDM stated, the cook should have calibrated the thermometer prior to taking the temperature of the food during the tray line service to prevent food born illness from food being served at incorrect temperatures. During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with the RD, the facility's P&P, titled, Food Preparation and Service dated 11/2022, was reviewed. The P&P indicated, .Adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of food borne illness .food preparation staff are to adhere to proper hygiene and sanitary practices .food thermometers . are clean, sanitized, and calibrated .foods held in steam tables are monitored throughout the meal service . the RD stated, the CK should have should have calibrated the food thermometer . During a review of facility P&P titled, Thermometer and Calibration dated 2018, indicated, .Food thermometer are to be used properly and calibrated to ensure accurate temperature reading .food thermometer are to be calibrated each week .when a thermometer is new .it is recommended to put thermometer calibration on a cook's duties/sanitation list that must be initialed upon completion . During a review of Job description: Cook (JD), [undated], the JD indicated, .Maintain kitchen and cooking area in a safe, orderly, clean, and sanitary manner .follow .portion control guidelines .record food temperatures for the meals . During a review of JD Dietary Supervisor. [undated], the JD indicated, .Supervises all dietary functions and personnel .inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian. [undated], the JD indicated, .Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations . 5. During an observation on 7/23/24 at 11:55 a.m. of the facility's lunch tray line service, the CK did not sanitize the thermometer prior to placing it into a container of broccoli. During an interview on 7/23/24 at 1:15 p.m. with the CK, the CK stated she should have sanitized the food thermometer before she placed it into the broccoli to prevent contamination of the broccoli. During an interview on 7/23/24 at 2:27 p.m. with the CDM, the CDM stated, the CK should have sanitized the food thermometer prior to placing it into the container of broccoli to prevent cross contamination. During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with the RD, the facility's policy and procedure (P&P), titled, Food Preparation and Service dated 11/2022, was reviewed. The P&P indicated, .Adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of food borne illness .food preparation staff are to adhere to proper hygiene and sanitary practices .food thermometers . are clean, sanitized, and calibrated .foods held in steam tables are monitored throughout the meal service . the RD stated, the cook should have sanitized the thermometer During a review of facility P&P titled, Thermometer and Calibration dated 2018, indicated, .Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .thermometers are to be cleaned and sanitized after use . During a review of Job description: Cook (JD), [undated], the JD indicated, .Maintain kitchen and cooking area in a safe, orderly, clean, and sanitary manner .follow .portion control guidelines .Record food temperatures for the meals . During a review of JD Dietary Supervisor [undated], the JD indicated, .supervises all dietary functions and personnel .Inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian. [undated], the JD indicated, .Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations . 6. During an observation on 7/23/24 at 11:56 a.m. of the facility's lunch tray line service, The CK did not take the temperature of the soup prior to serving to residents. During an interview on 7/23/24 at 1:16 p.m. with the CK, the CK stated she should have taken the temperature of the soup prior to serving to the residents. Serving food not cooked to the proper temperature could lead to food born illness. During an interview on 7/23/24 at 2:26 p.m. with the CDM, the CDM stated, the cook should have taken the temperature of the soup prior to serving to Residents. prevent food born illness from food being served at incorrect temperatures. During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with the RD, the facility's P&P, titled, Food Preparation and Service dated 11/2022, was reviewed. The P&P indicated .Adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of food borne illness .food preparation staff are to adhere to proper hygiene and sanitary practices .food thermometers . are clean, sanitized, and calibrated .foods held in steam tables are monitored throughout the meal service . the RD stated, the CK should have taken the temperature of the soup . During a review of Job description: Cook (JD), [undated], the JD indicated, .Maintain kitchen and cooking area in a safe, orderly, clean, and sanitary manner .follow .portion control guidelines .Record food temperatures for the meals . During a review of JD Dietary Supervisor. [undated], the JD indicated, .Supervises all dietary functions and personnel .inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian [undated], the JD indicated, .Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations . 7. During an observation on 7/23/24 at 11:55 a.m. of the facility's lunch tray line service, the cook stopped serving food to open a drawer, retrieved a ladle and continued serving food while without changing gloves. During an interview on 7/23/24 at 1:17 p.m. with the CK, the CK stated, she should have changed her gloves prior to serving food during the lunch tray line, not changing gloves could have resulted in cross contamination. During an interview on 7/23/24 at 2:27 p.m. with the CDM, the CDM stated, the CK should have changed her gloves prior to serving food during tray line to prevent cross contamination which could lead to food borne illness. During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with the RD, the facility's policy and procedure (P&P), title Food Preparation and Service dated 11/2022, was reviewed. The P&P indicated, .Adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of food borne illness .food preparation staff are to adhere to proper hygiene and sanitary practices .food thermometers . are clean, sanitized, and calibrated .foods held in steam tables are monitored throughout the meal service . the RD stated, the CK should have changed her gloves before returning to the tray line to serve food . During a review of JD Cook [undated], the JD indicated, .Maintain kitchen and cooking area in a safe, orderly, clean, and sanitary manner .follow .portion control guidelines .Record food temperatures for the meals . During a review of JD Dietary Supervisor [undated], the JD indicated, .supervises all dietary functions and personnel .inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian. [undated], the JD indicated, .Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations . 8. During an observation on 7/23/24 at 11:56 a.m. of the facility's lunch tray line service, the CK used the medium scoop for small, medium, and large portions. During an interview on 7/23/24 at 1:17 p.m. with the CK, the CK stated, she did not follow the menu when she used the same size scoop for small, medium, and large portions. During an interview on 7/23/24 at 2:27 p.m. with the CDM, the CDM stated, the CK should have followed the menu and used the correct scoop for the small, medium, and large portions. CDM stated not following the menu could cause weight loss, weight gain, and or improper nutrition to the residents. During an interview on 7/23/24 at 2:50 p.m. with the RD, the RD stated, the CK should have used the scoop size listed on the menu . During a review of the Food Code U.S Food and Drug Administration § 483.60 42 CFR Ch., dated 1-1-19, indicated, .Menus must .be prepared in advance . be followed . be reviewed by the facility's dietitian . During a review of Job description: Cook (JD), [undated], the JD indicated, .Maintain kitchen and cooking area in a safe, orderly, clean, and sanitary manner .follow .portion control guidelines .Record food temperatures for the meals . During a review of JD Dietary Supervisor. [undated], the JD indicated, .Supervises all dietary functions and personnel .inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian. [undated], the JD indicated, .monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations . 9. During a concurrent observation and interview on 7/23/24 at 12:30 p.m. of the facility's lunch tray line service, with DA 2, DA 2 walked through the kitchen without having a hair net, DA 2 stated, she knew she was not to be in the kitchen without a hair net. DA 2 stated her hair could have gotten in the food and contaminated it. During a concurrent interview and record review on 7/23/24 at 2:50 p.m. with the RD, the facility's P&P, titled, Food Preparation and Service dated 11/2022, was reviewed. The P&P indicated, .Adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of food borne illness .food preparation staff are to adhere to proper hygiene and sanitary practices .food thermometers . are clean, sanitized, and calibrated .foods held in steam tables are monitored throughout the meal service .Gloves are worn when handling food directly .changed between tasks .hair restraints (hair net, hat, beard restraint, etc.) so, hair does not contact the food . The RD stated, the DA 2 should have had a hair net so that hair did not contaminate the food. During a review of DA 2's Verification of Job Competency Demonstration-Diet Aides (JC) dated 3/18/24, the JC indicated DA 2 was competent on the use of hair coverings. During a review of JD Dietary Supervisor. [undated], the JD indicated, .supervises all dietary functions and personnel .inspects Dietary Department .ensures continued compliances with all federal, state, and local regulations . During a review of JD Registered Dietitian. [undated], the JD indicated, .Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulat

Based on observation, interview and record review, the facility failed to follow their policy and procedure Food-Related Garbage and Refuse Disposal for one of three outside trash bins, when one of the trash bins was uncovered, and a large amount of plastic and debris was noted on the ground behind the trash bin. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions, and the spread of disease. Findings: During an observation on 7/22/24 at 2:24 p.m. behind the facility in the trash bin storage area, a trash bin was observed with the lid open and large amounts of thin clear plastic and other debris was noted behind the trash bins along the fence. During an interview on 7/23/24 at 2:30 p.m. with the Certified Dietary Manager (CDM), the CDM stated, the trash bins should be closed at all times and there should not be trash on the ground or around the trash bins. The CDM stated, the open trash bin and trash on the ground around the trash bins could attract rats and bugs. During an interview on 7/23/24 at 2:45 p.m. with the Registered Dietitian (RD), the RD stated, the trash bins should always be closed, and there should never be trash on the ground to prevent an infestation of pests. During an interview on 7/24/24 at 2:22 p.m. with the Environmental Director (ED), the ED stated, the lid of the trash should not have been open and there should never be trash on the ground around the trash bins. The ED stated trash around the trash bin can attract animals and insects which could cause infestation. During an interview on 7/26/24 at 3:40 p.m. with the Administrator (ADM), the ADM stated there should be no garbage or debris on the ground around the trash bins and the trash bins should be always covered to discourage insects and animals from getting into the trash and bringing infection. During a review of the facilities policy and procedure titled, Food Related Garbage and Refuse Disposal dated 10/2017, indicated, .Food Related Garbage and Refuse Disposal indicated . 1. All food waste shall be kept in containers .garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . outside dumpsters will be kept closed ad free of surrounding litter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of ten sampled residents (Resident 1) when Registered Nurse (RN) 1 left Resident 1's three medications (2 tablets and 1 capsule) in a plastic cup on top of the medication cart unattended. This failure had the potential for other residents to take and administer Resident 1's medications which could result in undesired effects and harm. Findings: During a concurrent observation and interview on 8/17/23, at 8:06 a.m. with RN 1 outside of Resident 1's room, RN 1 was preparing Resident 1's medications for administration. RN 1 placed Resident 1's buspirone (a medication that treat anxiety [a mental health condition characterized by feeling unease or fear]) 5 MG tab, Donepezil (a medication used to treat Dementia [progressive or persistent loss of brain functioning]) 5 MG and Ramipril (a medication use to treat high blood pressure [the force of blood pushing against the walls of the heart)]) 2.5 MG into a plastic medication cup on top of the medication cart. RN 1 stated, she was going to check Resident 1's blood pressure. RN 1 turned around and walked away from the medication cart into Resident 1's room left Resident 1's medication unattended and out of her line of sight. RN 1 stated, she left the medication on top of the cart because she needed to check Resident 1's blood pressure. RN 1 stated, it was the process at the facility to not leave meds on top of the medication cart unattended. RN 1 stated, medications had to be locked in the medication cart or in her possession until administered to the resident. RN 1 stated, it was important to not leave medications unattended because another resident could grab the medication and administer it in error. RN 1 stated, there was a potential for a medication error if a resident administered medications that were not ordered. During a review of Resident 1's admission Record (AR), dated 8/17/23, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Anxiety Disorder, Essential Hypertension (abnormally high blood pressure that is not the result of a medical condition) and Vascular Dementia (a form of dementia caused by an impaired supply of blood to the brain). During a review of Resident 1's Order Summary Report (OSR), dated 8/17/23, the OSR indicated Resident 1 had a doctors order for buspirone [hydrochloride] Tablet 5 MG (milligram [unit of measurement]) Give 1 tablet by mouth two times a day for anxiety [manifested by] excessive worrying over health . Start Date 07/06/2022 . Donepezil [hydrochloride] Tablet 5 MG Give 1 tablet by mouth one time a day for dementia . Start Date 07/06/2022 . Ramipril Capsule 2.5 MG Give 1 capsule by mouth one time a day for [hypertension] . Start Date 07/06/2022 . During an interview on 8/17/23, at 10:00 a.m. with the Assistant Director of Nursing (ADON), the ADON stated, it was not following facility practice to leave medications unattended. The ADON stated, if medications are on top of the medication cart a nurse had to be present with the medications. The ADON stated, there was a potential for another resident to take the medication. The ADON stated, there was a potential for a resident's blood pressure to drop if they administered another resident's medication for hypertension. During a review of the facility's policy and procedure titled, Storage of Medications dated 11/2020, indicated, . The facility stores all drugs and biologicals in a safe place, secure and orderly manner . Drugs and biologicals used in the facility are stored locked compartments . Only persons authorized to prepare and administer medications have access to locked medications . The nursing staff is responsible for maintaining medication storage and preparation . During a review of the facility's policy and procedure titled, Medication Administration dated 2019, indicated, . Medications are administered at the time they are prepared . Medications are administered without unnecessary interruptions . Medications supplied for one resident are never administered to another resident . During administration of medications . No medications are kept on top of the cart .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide a complete and accurate discharge notice to ensure a safe discharge for one of three sampled residents (Resident 1) when a written 30-day notice of proposed discharge did not indicate the location to which Resident 1 would be discharged to. This failure resulted in Resident 1 not knowing where she would be residing after the 30 days, causing Resident 1 distress and anxiety. Findings: During a review of Resident 1 ' s admission Record (AR) the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Parkinson ' s Disease . (a progressive disease of the nervous system) .Bipolar disorder .(characterized by both manic and depressive episodes) .Epilepsy .(A disorder in which nerve cell activity in the brain is disturbed) . During a review of Resident 1 ' s Minimum Data Set [MDS- a resident assessment tool used to identify cognitive (mental processes)] and physical functional level assessment dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 [0-7 indicated severe cognitive impairment - (memory loss, poor decision making-skills) 8-12 moderate cognitive impairment 13-15 cognitively intact] indicating Resident 1 was cognitively intact. During an interview on 4/25/23, at 9:40 a.m., with Resident 1, Resident 1 stated, she received a letter from the Administrator (ADM) on 3/31/23 during a care conference meeting. Resident 1 stated, it was a Thirty Day Notice of Proposed Discharge. During an telephone interview on 7/28/23, at 10:25 a.m., with Family Member (FM), FM stated, she was at the care conference meeting on 3/31/23 when the 30 day notice of proposed discharge was given to Resident 1 and FM. FM stated, How can the facility give us a 30 day notice of discharge without a place to go FM stated, this situation had caused Resident 1 to be anxious and distressed. During a telephone interview on 7/28/23 at 2:00 p.m., with Social Services Director (SSD), SSD stated, the discharge notice was provided to the Resident 1 and FM during a care conference meeting held on 3/31/23. SSD stated, this was a facility-initiated discharge. SSD stated, during the care conference meeting, I was not able to definitively tell the FM and Resident [Resident 1] where they would be going after the 30 days. SSD stated, I don't feel there should be a destination documented on the 30-day notice because we did not have an exact location for Resident 1. During a telephone interview on 7/28/23, at 3:35 p.m., with the ADM, ADM stated he was present at the care conference meeting held on 3/31/23 for Resident 1. ADM stated, he typed up the 30-day notice for discharge and presented it to Resident 1 and FM during the meeting. ADM stated this was a facility-initiated discharge. ADM stated the document did not have a destination location for Resident 1 after the 30 days. ADM refused to answer yes or no regarding, if the destination location should be on the 30-day notice of discharge. During a review of the facility ' s policy and procedure (P&P) titled, Transfer of Discharge Notice dated March 2021, the P&P indicated, Residents and/or representative are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge The facility's P&P did not indicate a destination or location of discharge on the 30-day notice of proposed discharge. During a review of California Advocates of Nursing Homes Reform titled, Transfer and Discharge Rights was reviewed at https ://canhr.org/transfer-and-discharge-rights/, updated on 7/15/2022, indicated, .Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident ' s representative in a language and manner they understand. 42 CFR §483.15(c)(3)(i) .the notice must be given at least 30 days before the resident is transferred or discharged .the location to which the resident will be transferred or discharged (42 CFR §483.15(c)(5)(iii)) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were fully informed, in advance of the care to be furnished for one of three sampled residents (Resident 1), when Resident 1 was referred and was seen for a psychological consultation without discussing and notifying Resident 1 of the referral. This failure resulted in denying the right of Resident 1 by receiving psychological consultation and not being fully informed of the treatment and to choose the alternative or option preferred. Findings: During a review of Resident 1's clinical record titled, admission Record, (AR-document containing resident personal information) dated 11/30/22, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included, . Fracture of Right Femur [break of the thigh bone], Morbid Obesity, anxiety [excessive and persistent worry and fear about everyday situation] . During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level) assessment, dated 11/17/22, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit])indicating Resident 1 had no cognitive deficit. During a concurrent interview and record review on 11/30/22, at 10: 09 a.m., with the Social Service Director (SSD), the SSD reviewed Resident 1's clinical record titled, Progress Note, Type: Social Service Note dated 10/19/22, at 15:03, SSD stated Resident 1 had angry outburst in the lobby on 10/19/2022. SSD stated, After the outburst on 10/19/22, the IDT (interdisciplinary team- consist of health professionals working as a team) held a meeting and had decided to refer Resident 1 to be seen by a psychologist. SSD stated she was not able to find a note of the IDT meeting. SSD stated she faxed the referral to the psychologist office on 10/19/22 after Resident 1 had the outburst. SSD stated she did not remember going back in Resident 1's room to let her know of the referral. SSD stated, . I assumed she did not want to see me after her outburst . SSD stated she should have tried and informed Resident 1 of the referral because it was her right . During an interview on 11/30/22, at 12:15 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the IDT made the decision to refer Resident 1 to a psychologist for an evaluation after Resident 1 had the outburst. ADON stated she did not remember talking to Resident 1 to let her know she was referred to a psychologist for an evaluation. ADON stated Resident 1 should have been made aware of the referral because it was her right. During a phone interview on 1/13/23, at 12:05 p.m., with the Administrator (ADM), the ADM stated he remembered Resident 1 talking to him and was upset after the psychologist talked to her . ADM stated, . I do not remember if she (Resident 1) was more upset the psychologist talked to her or because she was referred and was not made aware . The ADM stated the SSD took care of scheduling the referrals and was not sure if Resident 1 was made aware of the referral. During a phone interview on 1/13/23, at 12:10 p.m., with the Director of Nursing (DON), the DON stated Resident 1 talked to her after the psychologist talked to Resident 1. DON stated Resident 1 was upset that she was not made aware of the referral to see a psychologist. DON stated she thought the SSD told Resident 1 of the referral. DON stated Resident 1 was alert and oriented and should have made aware of the referral. During a review of facility's clinical document titled, Job Description: Social Services Director, dated 3/2017, the Job Description, indicated, .Assist residents with health care decisions . Assist in obtaining resources from community and social services agencies as well as health and welfare agencies to meet the needs of the resident . Develop and maintain a strong working relationship with other departments in the facility, and outside community agencies, so that social services can be provided to meet the needs of the residents . During a review of the facility's policy and procedure titled, Resident Rights dated 2001, revised date 2016, the policy and procedure indicated, .o. be notified of his or her medical condition and of any changes in his or her conditions. P. be informed of, and participate in, his or her care planning and treatment . s. choose an attending physician and participate in decision-making regarding his or her care .

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for one of eight sampled residents (Resident 89) when Humalog Lispro Insulin (is a fast-acting insulin that controls blood sugar around mealtimes for both type 1 and type 2 diabetes) was given without food per professional standard of practice. This failure placed Resident 89 at risk for a low sugar event with the potential to develop symptoms of hypoglycemia (low blood sugar) including dizziness, headache, feeling weak, shaking, fast heartbeat, confusion, hunger, sweating or change of consciousness. Findings: During a medication administration observation on 1/19/22, at 11:34 a.m. in resident hallway 1, Registered Nurse (RN) 1 checked Resident 89's blood sugar by fingerstick (a procedure to check blood sugar), and the result was 127. During a medication administration observation on 1/19/22, at 11:43 a.m. in Resident 89's room, RN 1 gave 18 units of Humalog Lispro Insulin subcutaneous injection (injection given in the fatty tissue) in Resident 89's abdomen and the lunch tray was not at the bedside. During an observation on 1/19/22, at 12:23 p.m., in Resident 89's room, staff passed out Resident 89's lunch tray. During a review of Resident 89's Face Sheet (a document containing resident profile information, dated 1/20/22, the Face Sheet indicated, Resident 89 was admitted to the facility with a diagnosis of type 2 diabetes mellitus (a disease that results in high blood sugar). During a review of Resident 89's Order Summary Report, dated 1/20/2022, the Order Summary Report indicated, .Insulin Lispro Solution 100 UNITS/ML (milliliter is unit of measurement). Inject 18 unit subcutaneously (in the fat) before meals related to TYPE 2 DIABETES WITHOUT COMPLICATIONS . During a concurrent interview and record review, on 1/19/2022, with RN 1, Resident 89's Medication Administration Record (MAR), dated 1/20/2022 was reviewed. The MAR indicated, in 1/20/2022, Resident 89's fingerstick blood sugar before lunch ranged from 109 to 244. RN 2 stated lunch should be given within fifteen minutes of getting the insulin injection. RN 1 stated Resident 89's blood sugar could drop if he did not received a meal tray was later than thirty minutes. RN 1 stated she did not have a professional reference to look up medications. During an interview on 1/21/2022, at 11:12 a.m., with RN 2, RN 2 stated Humalog Insulin should be given within fifteen minutes of the resident receiving the food tray. RN 2 stated if the food is delayed, the resident could potentially develop low blood sugar symptoms (dizziness, headache, feeling sleepy, feeling weak, shaking, a fast heartbeat, confusion, hunger, or sweating). During an interview on 1/21/2022, at 11:15 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated insulin should be given when the tray was at the resident's bedside. LVN 1 stated the resident could potentially have low blood sugar symptoms if food was not there. During an interview on 1/21/2022, at 2:05 p.m., with Consultant Pharmacist (CP) 1, CP 1 stated Humalog Insulin should be given within fifteen minutes after the injection is given to the resident. CP 1 stated there is a potential for the resident to have a low blood sugar symptom if the food tray is not available. During a concurrent interview and record review, on 1/21/22, at 2:21 p.m., with the Director of Nursing (DON), the Package Insert for Humalog Insulin (Package Insert), [undated] was reviewed. The Package Insert indicated, .administer the Humalog Insulin fifteen minutes before a meal or immediately after a meal . The DON stated the Package Insert was provided by Model pharmacy. The DON stated her expectation for a resident taking insulin should have a meal tray on their bedside table within fifteen minutes of administration of the insulin but no later than thirty minutes. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2019, the P&P indicated, .10) Medications are administered within (60 minutes) before or after the scheduled time, except before or after meal orders, which are administered (based on mealtimes) . During a review of the professional reference titled, Lexicomp, the clinical practice guidelines, dated 1/2020, the Lexicomp indicated, .Humalog: Administer within 15 minutes before or immediately after a meal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of accidents for one of three sampled residents (Resident 83) when Resident 83, who was assessed to require two-person assist for transfers, was transferred by one Certified Nursing Assistant (CNA) on 12/18/21 and did not follow the facility policy and procedure. This failure resulted in Resident 83's fall on 12/18/21 and the potential injury from the fall. Findings: Review of Resident 83's clinical record titled, admission record (document containing resident personal information) dated 12/28/21, indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included: .Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), other lack of coordination, Age-related osteoporosis without current pathological fracture (is a broken bone that's caused by a disease, rather than an injury), abnormal posture and muscle weakness. During a review of Resident 83's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level) assessment dated [DATE], indicated Resident 83's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 99, which indicated resident was unable to complete the interview. MDS Assessment Section G, dated, 10/27/21, indicated, .B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . 1. Self Performance . code 4. Total dependence (full staff performance every time during entire 7-day period . 2. Support: code: 3. Two+ persons physical assist . E. Locomotion on unit . 4. Total dependence . F. Locomotion off unit . 4. Total dependence . G. Dressing . 4. Total dependence . H. Eating .4. Total dependence . G 0400. Functional Limitation in Range of Motion . A. Upper extremity (shoulder, elbow, wrist, hand) .2. Impairment on both sides. B. Lower extremity (hip, knee, ankle, foot) .2. Impairment on both sides . During a review of Resident 83's clinical record titled, Radiology Results Report, dated 12/18/21, indicated, . Procedure: Lumbar Spine 2-3 views. Interpretation: Significant Findings Lumbar Spine 2-3 views: See Note: LUMBOSACRAL SPINE History: Closed fracture of lumbar vertebra. Comparison to prior chest exam dated 08/09/2021 which includes portions of the upper aspect of the lumbar spine lateral projection. Findings: AP and lateral projections are presented and demonstrate generalized osteoporosis. There is a subtle anterior compression with bowing of the upper vertebral endplate of the L1 vertebral body. Minimal compression anteriorly and bowing of the upper endplate of L2 and L3 is noted as well. There is minimal osteoporotic compression of L4. L5 vertebral body appears intact. Intervertebral disc spaces appear adequately maintained. There is no spondylolysis or spondylolisthesis. Right sacroiliac joint appears normal. Left SI joint is not included . During an observation on 12/28/21, at 9:15 a.m., in Resident 83's room , Resident 83 was observed sitting up in her wheelchair next to the foot of her bed and pushed back against the wall. Resident 83's eyes were closed and was covered with a small blanket. Resident 83 did not respond to any questions. During an interview on 12/28/21, at 9:30 a.m., with Resident 10 (Resident 83's roommate), Resident 10 stated she had been roommate with Resident 83 for a long time and she [Resident 83] did not talk and was also blind. Resident 10 stated Resident 83 had fallen when a CNA transferred Resident 83. Resident 10 stated she was coming back from an outing when she entered her room, Resident 83 was sitting on the floor with her back against the bed and the CNA was sitting next to Resident 83. Resident 10 stated she asked the CNA what happened and was told by CNA Resident 83 slipped out of her hand during transfer. Resident 10 stated, .How could she slipped out of the CNA's arm when Resident 83 did not even move . During an interview on 12/28/21, at 10:09 a.m., with CNA 2, CNA 2 stated she cared for Resident 83 and was familiar with the care. CNA 2 stated Resident 83 was totally dependent on staff with all activities of daily living (ADL) including transfers. CNA 2 stated a mechanical lift was used to transfer Resident 83. CNA 2 stated, .I will not transfer her [Resident 83] by myself, she is dead weight . CNA 2 stated she did not remember witnessing other CNAs' tried to transfer Resident 83 without using the mechanical lift. During an interview on 12/28/21, at 11:15 a.m., with CNA 1, CNA 1 stated she started working for the facility less than a month. CNA 1 stated she was the CNA assigned to Resident 83 on 12/18/2021 when Resident 83 was assisted to the floor. CNA 1 stated it was her first time to take care of Resident 83. CNA 1 stated she asked one of the CNAs how to transfer Resident 83 and was told to do a manual transfer. CNA 1 stated, .I transferred Resident 83 manually and realized she was bottom heavy, so I lowered her to the floor next to her bed . CNA 1 stated she did not remember Resident 83 hitting her back against the bed when she lowered Resident 83 on the floor. CNA 1 stated she sat next to Resident 83 on the floor to prevent Resident 83 from leaning on the side and sat down with their back against the bed. CNA 1 stated the charge nurse (RN 3) entered the room with Resident 10 and saw her and Resident 83 sitting on the floor. CNA 1 stated she observed RN 3 assessed Resident 83 while on the floor and after Resident 83 was transferred back to bed. CNA 1 stated the nurse found a pink spot on the middle of Resident 83's back. CNA 1 stated the pink spot was where Resident 83's back was pressed against the bed. CNA 1 stated she should have asked the nurse how to transfer Resident 83. CNA 1 stated she did not know Resident 83 was transferred using a mechanical lift because she did not remember getting report about Resident 83. CNA 1 stated she should have known because Resident 83 was totally dependent on staff to meet all her ADL needs. During a phone interview on 12/28/21, at 2:30 p.m., with Registered Nurse (RN)3, RN 3 stated she was the nurse assigned to Resident 83 on 12/18/21, when Resident 83 was lowered to the floor. RN 3 stated she found Resident 83, and CNA 1 sitting on the floor next to Resident 83's bed when she assisted and pushed Resident 10's wheelchair into the room. RN 3 stated she asked CNA 1 what happened, and CNA 1 stated she lowered Resident 83 on the floor because she was not able to complete the transfer. RN 3 stated she did not see a mechanical lift in the room, CNA 1 manually transferred Resident 83 and did not complete the transfer because Resident 83 was not able to assist with the transfer. RN 3 stated CNA 1 should have used a mechanical lift to transfer Resident 83. RN 3 stated she did not know if CNA 1 knew Resident 83 was a total assist with transfers and uses a mechanical lift for all transfers. RN 3 stated she did not remember CNA 1 asking her about Resident 83's transfers whether a mechanical lift was needed. RN stated the fall could have been prevented if only CNA 1 did not transfer Resident 83 by herself and have used a mechanical lift. RN 3 stated she performed a head-to-toe assessment on Resident 83 and there was a red spot on the back where Resident 83's back was resting against the bed. During a phone interview on 12/28/21, at 2:46 p.m., with CNA 3, CNA 3 stated he was familiar with Resident 83's care because he was assisting other staff in taking care of her. CNA 3 stated Resident 83's transfers were always with the use of a mechanical lift because Resident 83 was totally dependent on staff with all her care. CNA 3 stated the charge nurse should have told the CNA taking care of Resident 83 that she needed to use a mechanical lift to transfer Resident 83 especially if the nurse knew it was the first time the CNA was taking care of Resident 83. During a phone interview on 12/28/21, at 3:14 p.m., with CNA 4, she stated she had never taken care of Resident 83 but she was familiar with her care because she had assisted other staff in taking care of Resident 83. CNA 4 stated she remembered offering assistance to CNA 1 with Resident 83's transfer because a mechanical lift was needed to transfer Resident 83 but CNA 1 declined her offer. CNA 4 stated the fall could have been prevented if CNA 1 used a mechanical lift and accepted the assistance offered to help transfer Resident 83. During a concurrent phone interview and record review on 12/28/21, at 4:30 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he was assigned to Resident 83 on 12/18/21, afternoon shift the day Resident 83 was assisted to the floor by CNA 1. LVN 2 reviewed his notes dated 12/19/21, 00:04 a.m., LVN 2 stated the fall happened around the time of the shift changed (morning shift to afternoon shift). LVN 2 stated the out-going nurse gave him report to follow-up with Resident 83's family because she was not able to talk to the daughter, but she left a message. LVN 2 stated Resident 83's daughter was in the facility and accompanied her to check on Resident 83's redness on her midback. LVN 2 stated the redness on Resident 83's back was flat, skin intact and size smaller than a tennis ball. LVN 2 stated he called the physician assistant (PA) who was on-call for the primary physician and obtained an order for an X-ray on the back. LVN 2 stated she notified the Director of Nursing (DON) as soon as the X-ray result was received. LVN 2 stated Resident 83 used a mechanical lift for transfers and two person assistance. During a concurrent interview and record review on 1/20/22, at 10:41 a.m., with Minimum Data Set Coordinator (MDSC), the MDSC stated, .Falls is when a part of the body hit the ground or touches the floor. MDSC stated assisted to the floor is a fall, the reason was because the body hit the floor . The MDSC stated she reviewed and edit care plans. MDSC reviewed Resident 83's care plan dated 10/2019, revised 12/28/21, indicated, .Focus: Resident at risk for falls: age-related osteoporosis . Interventions: .place call light within reach while in bed .Remind resident to use call light when attempting to ambulate or transfer .When resident is in bed, place all necessary personal items within reach . Care plan dated 10/20/29, revised 10/27/20, . Focus: .is at risk for impaired ADL/mobility function: . Interventions: .bed mobility: I am dependent with level of support varying .dressing: I am dependent with level of support varying .Transfers: I am dependent with level of support varying . The MDSC stated the care plan is not individualized to Resident 83's need and support, care plans should be individualized to the need of residents. The MDSC verified the word varying in the interventions as depending on the time of day. The MDSC stated for Resident 83 the level of support for transfer should be the same all the time because she is dependent on staff to meet all her ADL needs and the MDS indicated she needed two person assist with transfers. During a concurrent interview and record review on 1/21/22, at 11:50 a.m., with the director of nursing (DON), the DON reviewed Resident 83's clinical record titled, Fall Risk Observation/Assessment, dated 10/29/21, the DON stated the Fall risk assessment indicated Resident 83 had a score of 22, category: High Risk. Fall risk Observation/Assessment, dated 12/18/21, indicated, score of 24, category: High Risk. The DON stated Resident 83's risks for falls were impaired vision, non-ambulatory, dependent on staff with all ADL needs, incontinent, confined to chair and multiple diagnosis. The DON stated interventions prior to fall were call lights within reach, personals within reach, bed in lowest position. The DON stated the intervention post fall was lift me up program (use of mechanical lift) for transfers. The DON stated the CNA should have used the lift to transfer Resident 83 and used two CNAs instead of one CNA. During a review of the facility's record titled, Job Description: LPN/LVN, dated 11/2018, indicated, .Ensure that all nursing service personnel are in compliance with their respective job descriptions . Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the residents . During a review of the facility's record titled, Job Description: Certified Nursing Assistant, dated 2/2019, indicated, .Perform only those nursing care procedures that you have been trained to do . Cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents . Assist with lifting, turning, moving, positioning and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc . During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, dated 3/2018, the P&P indicated, .a. Staff will ask the resident and the caregiver or family about a history of falling .While many fall are isolated individual incidents, a few individuals fall repeatedly . For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hrs of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 295's Face sheet, dated 1/20/22, the face sheet indicated, Resident 295 had an initial admission to the facility on 9/25/21. The face sheet indicated Resident 295 was discharged home on [DATE]. The face sheet indicated Resident 295 was readmitted to the facility on [DATE] from the acute care hospital after a fall. The face sheet indicated, Resident 295 was readmitted with a diagnosis of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety, epilepsy (seizures-a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), lack of expected normal physiological development in childhood, diabetes mellitus (a disease in which blood sugar's level is too high), history of falls, laceration of scalp, and hyperlipidemia (high fats in blood) During a review of Resident 295's Medication Administration Record (MAR), dated 1/20/22, was reviewed. The MAR indicated, .OLANZapine Tablet 15 milligrams (MG-unit of measurement). Give 1 tablet by mouth at bedtime for psychosis (characterized by a disconnection from reality and a symptoms of a mental illness) related to schizophrenia (a chronic mental disorder) manifested by striking out during care causing self-harm. Start date 1/14/22. The MAR indicated the medication was started on 1/15/22 at 8:00 a.m. During an interview on 1/21/22, at 8:40 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 295 needed assistance with her Activities of Daily Living (ADL) and was pleasant. CNA 1 had not observed bad behaviors like striking out to self or others since Resident 295 was readmitted to the facility. During a concurrent interview and record review, on 1/21/22, at 8:46 a.m., with Registered Nurse (RN) 3, Resident 295's Medication Administration Record for Behaviors (MARB), dated 1/20/22 was reviewed. The MARB indicated, no behaviors were documented since admission. RN 3 stated Resident 295 was aggressive, yelling and hitting at staff on 1/14/22, the day of admission. RN 3 was unable to find the documentation of those behaviors in Resident 295's clinical record. RN 3 stated non-pharmacological interventions would be important before starting an anti-psychotic medication. During a concurrent interview and record review, on 1/21/22, at 10:00 a.m., with Social Services Director (SSD) 1, Resident 295's Diagnosis Information (DI), dated 1/20/22 was reviewed. The DI indicated, Resident 295 had the schizophrenia diagnosis onset date on 9/25/21. SSD 1 did not know when Resident 295 was first diagnosed with schizophrenia or when the OLANZapine was first started. During a review of Resident 295's Social Service Note, dated 1/18/22, the Social Service Note indicated, .This writer spoke with resident [acute care hospital] case manager yesterday 1/17/22 to discuss resident .explained that resident was first prescribed olanzapine 5 milligrams (mg-unit of measure) on 7/8/21 by her primary care physician and was increased to 15 mg on 8/9/21 related to increased agitation . During a concurrent interview and record review, on 1/21/22, at 10:06 a.m., with the Director of Nursing (DON), Resident 295's Clinical Record was reviewed. The DON was unable to find documented evidence that non-pharmacological interventions were tried/attempted before starting the OLANZapine on 1/15/22. The DON stated it was important to document person centered non-pharmacological interventions in order to have Resident 295's needs met and to minimize the need for antipsychotic medications. During a phone interview and record review, on 1/21/22, at 1:47 p.m., with the Consultant Pharmacist (CP) 1, CP 1 stated Resident 295 was admitted with a diagnosis of schizophrenia. CP 1 did not know how long Resident 295 had a schizophrenia diagnosis. CP 1 stated she would review Resident 295's behaviors of hitting self or others before attempting a Gradual Dose Reduction (GDR-is a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.) of the OLANZapine. CP 1 stated she would like to attempt a GDR in the first six months. CP 1 stated it would be important to attempt nonpharmacological interventions before a anti-psychotic medication was started because of the extrapyramidal (involuntary or uncontrollable movements like lip smacking) symptoms that could occur. CP 1 stated Resident 295 should see a psychiatrist because of the schizophrenia diagnosis. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/16, the P&P indicated, .Indications for use and therapeutic goals are consistent with current medical literature and clinical practice guidelines .5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . During a review of the professional reference titled, Daily Med-Zyprexa-Olanzapine (Boxed Warning), retrieved from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=d5051fbc-846b-4946-82df-341fb1216341&type=display, dated 2/21, indicated, .Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.Appropriate educational placement is essential and psychosocial intervention is often helpful. The decision to prescribe atypical antipsychotic medication will depend upon the healthcare provider's assessment of the chronicity and severity of the patient's symptoms . During a review of the professional reference titled, Use of Antipsychotic Medications in Nursing Facility Residents, retrieved from https://cdn.ymaws.com/www.ascp.com/resource/collection/28D69F2D-18D9-4EF8-A086-675AB7E4ECD8/final_Dec13__ASCP--antipsychotics-statement_[2].pdf, dated 12/13/17, .The use of antipsychotics is supported in this guideline when non-pharmacologic strategies are inadequate . Based on interview and record review, the facility failed to implement non-pharmacological interventions (individualized approaches to care other than by administering medications, including supportive physical and psychosocial methods) for two of seven sampled residents (Resident 69 and 295) when Resident 69 and 295 had no documented evidence non-pharmacological interventions were tried or attempted first before starting antipsychotic medications (class of medications to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality). These failures put the residents 69 and 295 at risk for experiencing adverse medication side effects and receiving unnecessary psychotropic medications without the appropriate indication. Findings: a. During a review of Resident 69's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/21/22, the AR indicated, .Original admission Date 12/21/21 .Diagnosis Information .Unspecified Psychosis Not Due to a Substance or Known Physiological Condition (inadequate information to make a diagnosis of a specific psychotic disorder) . During a review Resident 69's Order Summary Report, dated 1/21/22, indicated, .Aripiprazole (medication used to treat psychotic disorders that are characterized by a disconnection with reality) Tablet 5 MG (milligram- unit of measurement) Give 1 tablet via PEG-tube (feeding tube inserted into the abdominal wall and into the stomach for nutrition and medications) one time a day for psychosis m/b (manifested by) striking out during care causing self harm . During a concurrent interview and record review, on 1/21/22, at 10:50 a.m., with the Director of Nursing (DON), Resident 69's Care Plan, dated 1/18/22, indicated, .uses antipsychotic medication aripiprazole r/t (related to) psychosis m/b striking out during care causing self harm .will be/remain free of drug related complications .Administer medications as ordered. Monitor/document for side effects and effectiveness .Monitor for episodes/behavior of: aripiprazole r/t psychosis m/b striking out during care causing self harm .Monitor/record occurrence for target behavior symptoms, striking out during care causing self harm, and document per facility protocol .Monitor/record/report to MD (medical doctor) prn (as needed) side effects and adverse reactions of psychoactive medications . The DON stated there should have been non-pharmacological interventions in place for Resident 69 to provide the best care and meet the specific needs for the resident. During a phone interview on 1/21/22, at 1:47 p.m., with the Consultant Pharmacist (CP) 1, CP 1 stated it would be important to attempt nonpharmacological interventions before anti-psychotic medication was started because of the extrapyramidal (involuntary or uncontrollable movements like lip smacking) symptoms that could occur. During a review of the facility policy and procedure (P&P) titled, Antipsychotic Medication Use, dated December 2016, indicated, .8. Diagnoses alone do not warrant the use of antipsychotic medication .antipsychotic medications will generally only be considered if the following conditions are also met .Behavioral interventions have been attempted and included in the plan of care .10. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are .c. Not sufficiently relieved by non-pharmacological interventions . During a review of the professional reference titled, Use of Antipsychotic Medications in Nursing Facility Residents, retrieved from https://cdn.ymaws.com/www.ascp.com/resource/collection/28D69F2D-18D9-4EF8-A086-675AB7E4ECD8/final_Dec13__ASCP--antipsychotics-statement_[2].pdf, dated 12/13/17, .The use of antipsychotics is supported in this guideline when non-pharmacologic strategies are inadequate .

During an observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when Dietary [NAME] (DC) did not wear a hairnet while inside the kitchen preparation area per facility's policy and procedure (P&P). This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object or place to another) and foodborne illness (caused by consuming contaminated foods or beverages) to 74 of 77 sampled residents who consumed food from the kitchen. Findings: During initial tour on 1/18/2022, at 9:20 a.m., in the kitchen with the Registered Dietitian (RD) and Dietary Manager (DM), the DC was observed standing in the food preparation area next to the stove and was not wearing a hairnet. During an interview on 1/18/2022, at 9:30 a.m., with the DM, the DM stated the DC should have been wearing a hairnet. The DM stated, Everyone entering the kitchen to the food preparation area were expected to wear a hairnet. During an interview on 1/19/2022, at 8:30 a.m., with the DC, the DC stated she was inside the kitchen in the food preparation area and was not wearing a hairnet. The DC stated the practice was to put on a hairnet as soon as she enters the kitchen and crossed the yellow line to the food preparation area. DC stated she should have been wearing her hairnet in the food preparation area. The DC stated it was an infection control issue. During an interview on 1/20/2022, at 8:23 a.m., with the RD, the RD stated the expectation for the staff working in the kitchen was to wear a hairnet. The RD stated dietary staff needed to put on a hairnet and wash their hands. The RD stated the purpose of the hairnet was to prevent hair from falling on the food. The RD stated it was an infection control issue. During a review of the facility's P&P titled, Dress Code for Women and Men, dated 2018, the policy and procedure indicated, .Personal hygiene and appropriate dress are very important part of the total appearance of the Food and Nutrition Services Department . 6. Hairnet or hat which completely covers the hair .8. Beards and mustaches (any facial hair) must wear beard restraint . During a review of Health and Safety Code (HSC)113969 (b) found on website, https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=113969, dated 10/11/2009, indicated, . all food employees preparing, serving, or handling food or utensils shall wear hair restraints, such as hats, hair coverings, or nets, which are designed and worn to effectively keep their hair from contacting non prepackaged food, clean equipment, utensils, linens, and unwrapped single-use articles .

Based on observation, interview, and record review the facility failed to ensure a home like environment for four of 43 sampled residents (Residents 49, 76, 77, and 93) when, the laundry department did not have towels and linens readily available for resident care, and personal clothes were misplaced in the laundry and delayed in getting back to residents. This failure resulted in not meeting residents' basic needs and prefrence by not providing clean linen, towel and personal clothes. Findings: During an interview, on 1/18/22, at 1:47 p.m., with Resident 76, Resident 76 stated the laundry department was a problem. Resident 76 stated there were occasions when she would request linen for her bed, and there would not be any upon request. Resident 76 stated she had clothes and quilts misplaced in the laundry room. Resident 76 stated items were found weeks later after finding them in the donation bin (items donated by either residents or family no longer in the facility) in the laundry storage room. Resident 76 stated the laundry department manager told her they would fix the laundry concerns but nothing ever got done. During a Resident Council Meeting (meeting with residents designed to give the opportunity to voice any concerns or grievances about the facility) interview on 1/19/22, at 10 a.m., with Residents 10, 14, 19, 49, 77, 81, and 93, Resident 49 stated on several occasions clothes had taken one to two weeks to get back from the laundry. Resident 49 stated there were occasions when Certified Nursing Assistants (CNA) could not provide towels during showers because there were no towels in the clean linen room. Resident 77 stated it would take a while for his clothes to come back from the laundry room. Resident 77 stated it could take up to two hours to get clean linen when requested. Resident 77 stated sometimes there was not enough linen in the clean linen room to give to residents. Resident 93 stated it could take one to two weeks to get clothes back from the laundry. Resident 93 stated he would like to have his clothes in his room when he wanted to wear them. During an interview on 1/20/22, at 8:53 a.m., with the Housekeeping Manager (HM), the HM stated residents' clothes were labeled with residents' names by using labels that stick to clothes. The HM stated there had been times when labels would come off the clothes after being washed so many times. The HM stated when using a marker to write residents' names on the clothes could also wear off when washed numerous times. The HM stated there were times when residents' clothes would get misplaced because the laundry personnel did not know who clothes belong to. The HM stated due to residents' clothes losing labels, clothes could be misplaced and take a while for them to get back to residents. The HM stated there should have been a better process to keep track of residents' clothes to ensure they were brought back to residents in so they could use them when they wanted to wear them. The HM stated towels and linen could be used frequently by staff due to many residents requesting linen or towels. The HM stated the laundry staff would leave the facility at 8 p.m. and were back at 5 a.m. the next morning and could allow for linen to be empty by the time the laundry staff got to work. The HM stated his expectation was for staff to fully stock the clean linen rooms before they would leave at night to ensure there was enough clean linen overnight. The HM stated he knew of CNAs throwing linen and towels in the trash due to being soiled. The HM stated he expected CNAs to put in dirty linen cart so that they could be washed and reused instead of being thrown away. The HM stated if linen was being used frequently or thrown away it could cause a shortage of linen at night. The HM stated he needed to encourage staff not to throw away soiled towels or linen. The HM stated it was important to provide linen and towels to residents in order to accommodate their needs. The HM stated it was their right to be provided a homelike environment and have their clothes available as needed. During a concurrent observation and interview on 1/20/22, at 9:25 a.m., with the HM, outside the clean linen room near the nurse's station, the HM saw the linen and towels in the clean linen room. The HM stated the clean linen room was low on linen and towels. The HM stated the clean linen room needed to be fully stocked by the laundry staff. The HM stated the clean linen rooms should have been fully stocked by 8:30 a.m. During a review of the contract service job title AM Laundry, undated, indicated, .6:50 a.m. Deliver Linen to Closets . During a review of the contract service job title PM Laundry, undated, indicated, .7:25 p.m. Deliver Linen to Closets . During a concurrent observation and interview on 1/20/21, at 10:50 a.m., with the HM, inside the laundry storage room, there was a plastic bin full of clothes with no labels. The HM stated it was the donation bin used for residents containing donated clothes or clothes with no labels on them. The HM stated there were clothes in the bin from residents that had no labels. During an interview on 1/21/22, at 8:54 a.m., with the Director of Nursing (DON), the DON stated there needed to be a different process of labeling residents' clothes to ensure items were not misplaced and given back to residents. The DON stated it was her expectation to have towels and linens readily available for residents to meet their needs and uphold their preferences. During an interview on 1/21/22, at 2:47 p.m., with the Administrator (ADM), the ADM stated it was important to have linens and towels available upon request by residents. The ADM stated it was important for residents' clothes not be misplaced and given back to residents as they had a right to their belongings and to a homelike environment. During a review of the facility policy and procedure titled, Resident Rights, dated December 2016, indicated, Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: .ee. Retain and use personal possessions to the maximum extent that space and safety permit . During a review of the facility contracted service's policy and procedure titled, Patients'/Residents' Rights, dated June 2016, indicated, .The resident has the right to choose activities, schedules, and make choices about aspects of his/her life in the facility that are significant to the resident. This means the resident is within his/her rights to make requests or deny services .The facility must listen to the views and act upon the grievances and recommendations of the resident/patient and their families. This means the resident or their family may question decisions made that affect resident care and life in the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 1/18/21, at 10:57 a.m., in Resident 59's room, Resident 59 was lying in bed asleep with oxygen at 2 Liters Per Minute (LPM- unit of volume flow measurement) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). During a review of Resident 59's Order Summary Report, dated 11/29/21, the Order Summary Report indicated, .Oxygen (O2) at 2 Liters Per Minute (LPM) via Nasal Cannula prn (as needed) per concentrator (a medical device that concentrates oxygen from ambient air) every shift . During a review of Resident 59's Minimum Data Set (MDS-assessment of healthcare and functional needs) assessment dated [DATE], indicated, .Section C . Cognitive Patterns. Section C0500 . Brief Interview for Mental Status (BIMS-assessment of cognitive status) Summary Score 11 of 15 points which indicated Resident 59 had moderate cognitive impairment . During a concurrent interview and record review, on 1/19/22, at 8:55 a.m., with Registered Nurse (RN) 1, Resident 59's Care Plan, dated 12/16/21, indicated, .Give medications as ordered by physician. Monitor/document side effects and effectiveness . RN 1 stated Resident 59's care plan indicated generic (not specific) interventions and an unmeasurable (not able to be measured) goal for Resident 59's oxygen therapy needs. RN 1 stated Resident 59's interventions were not person centered because the care plan indicated to give medications as ordered by physician and was not specific around what Resident 59's medications were being used. During a concurrent interview, on 1/21/22, at 10:27 a.m., with the Director of Nursing (DON), the DON stated it was very important to provide person centered care plans with specific resident goals to meet Resident 59's individual oxygen needs. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .e. Include the residents' stated goals upon admission and desired outcomes . During a review of the professional reference titled, Lippincott procedures-Care plan preparation, long-term care, the, dated 5/20/2021, the Lippincott procedures indicated, .A care plan is driven by both resident's conditions and issues as well as a resident's unique characteristics. Each resident's care plan should be based on assessment of the resident, effective clinical decision making, and must be compatible with current standards of clinical practice. Per Center for Medicare and Medicaid Services (CMS- a federal agency that runs the Medicare program.), each care plan should: evaluate each patient as an individual and include unique (unlike anything else) characteristics and strengths, use the MDS to evaluate distinct functional areas to elucidate (clear) knowledge regarding functional status, provide a strong understanding of the patient to the interdisciplinary team, .includes timeline for re-evaluation of resident's status in a prescribed interval and modification of the care plan as appropriate . 3. During a review of Resident 83's clinical record titled, admission record (document containing resident personal information) dated 12/28/21, indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included: .Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), other lack of coordination, Age-related osteoporosis without current pathological fracture (is a broken bone that's caused by a disease, rather than an injury), abnormal posture and muscle weakness. During a review of Resident 83's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level) assessment dated [DATE], indicated Resident 83's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 99, which indicated resident was unable to complete the interview. MDS Assessment Section G, dated, 10/27/21, indicated, .B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . 1. Self-Performance . code 4. Total dependence (full staff performance every time during entire 7-day period . 2. Support: code: 3. Two+ persons' physical assist . E. Locomotion on unit . 4. Total dependence . F. Locomotion off unit . 4. Total dependence . G. Dressing . 4. Total dependence . H. Eating .4. Total dependence . G 0400. Functional Limitation in Range of Motion . A. Upper extremity (shoulder, elbow, wrist, hand) .2. Impairment on both sides. B. Lower extremity (hip, knee, ankle, foot) .2. Impairment on both sides . During a concurrent interview and record review on 1/20/22, at 10:05 a.m., with licensed vocational nurse (LVN) 4, LVN 4 stated Resident 83 was dependent on staff to meet all her needs. LVN 4 reviewed the care plan of Resident 83 and stated, . resident did not use a call light and not able to remember to use a call light . LVN 4 stated Resident 83 was a total assist and needed a mechanical lift for all transfers. During a concurrent interview and record review on 1/20/22, at 10:41 a.m., with Minimum Data Set Coordinator (MDSC), the MDSC stated, .Falls is when a part of the body hit the ground or touches the floor .assisted to the floor is a fall, the reason was because the body hit the floor . The MDSC stated she reviewed and edited care plans. MDSC reviewed Resident 83's care plan dated 10/2019, revised 12/28/21, titled, .Focus: Resident at risk for falls: age-related osteoporosis . Interventions: .place call light within reach while in bed .Remind resident to use call light when attempting to ambulate or transfer .When resident is in bed, place all necessary personal items within reach . Care plan dated 10/2019, revised 10/27/20, Focus: .is at risk for impaired ADL/mobility function: . Interventions: .bed mobility: I am dependent with level of support varying .dressing: I am dependent with level of support varying .Transfers: I am dependent with level of support varying . The MDSC stated the care plan was not individualized to Resident 83's needs. MDSC stated, care plans should be individualized to the need of residents. The MDSC verified the word varying in the interventions as depending on the time of day. The MDSC stated for Resident 83, the level of support for transfer should be the same all the time because she is dependent on staff to meet all her ADL needs. During a concurrent interview and record review on 12/21/2022, at 11:50 a.m., with the director of Nursing (DON), the DON reviewed Resident 83's clinical record titled, Care Plan dated 10/27/21, the care plan indicated, .Focus: [Resident 83] is at risk for impaired ADL/mobility function r/t (related to) . Goal: My cares will be anticipated and met daily . Interventions: .Bathing: I am dependent with my baths with level of support varying .locomotion: I am dependent with level of support varying .Transfers: I am dependent with level of support varying. Care plan date initiated: 10/20/19 and revised date: 12/28/21, Focus: Resident is at risk for falls: age-related to osteoporosis without current pathological fracture .Goal: Resident will have no falls with injury next 30 days . Interventions: .Place call light within reach while in bed .Remind resident to use call light when attempting to ambulate or transfer . place all necessary personal items within reach . DON stated Resident 83 is dependent on staff to meet all her needs. DON verified the word varying in the intervention and she stated the amount of people or level of assistance depends on the time of day. The DON stated, . Well, we have to put it there, I know we should have put more interventions . During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated, 12/2016, the P&P indicated, .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between resident's problem areas and their causes, and the relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . Based on interview and record review, the facility failed to have a person-centered care plan for three of 18 sampled residents (Residents 36, 59 and 83) when: 1. Resident 36 did not have a person-centered care plan to address goals and interventions for antidepressant (medications used to treat major depressive disorder-mental health disorder characterized by persistent feeling of sadness and loss of interest) use. This failure had the potential to place Resident 36 at risk for not meeting the goals and interventions for antidepressant use that could lead to further depression of Resident 36. 2. Resident 59's care plan did not include person centered interventions or resident specific goals to address the diagnosis of chronic obstructive pulmonary disease. This failure had the potential to result in Resident 59's individualized care needs not being met according to his diagnosis including oxygen therapy. 3. Resident 83's care plan for activities of daily living (ADL's- like bathing, bed mobility, transfers, locomotion) was not person-centered to address her individual needs. This failure resulted in Resident 83's fall and potential for injury as evidenced by sustaining redness to middle of back. Findings: 1. During a review of Resident 36's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/21/22, the AR indicated, .Original admission Date 4/15/21 .Diagnosis Information .Major Depressive Disorder . During a review Resident 36's Order Summary Report, dated 1/21/22, indicated, .Sertraline HCL (used to treat major depressive disorder) Give 1 tablet by mouth one time a day related to Major Depressive Disorder . During a concurrent interview and record review, on 1/21/22, at 11:16 a.m., with the Director of Nursing (DON), Resident 36's Care Plan, dated 1/3/22, indicated, .The Resident uses antidepressant medication Sertraline HCL tab for depression M/B (manifested by) sadness and feelings of despair, causing self-distress .The resident will be free from discomfort or adverse reactions related to antidepressant therapy (medications for major depression) through the review date .Administer ANTIDEPRESSANT medications as ordered by the physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) .Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given .Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy . The DON stated Resident 36's Care Plan was not person centered for antidepressant medication use. The DON stated Resident 36's Care Plan should have been person centered to give Resident 36 the best care possible to meet the residents' specific needs. During a review of the facility policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plan, dated December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled Residents (Resident 11 and 79) received the necessary care and respiratory services, consistent with professional standards of practice when: 1. Resident 11's nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and humidifier (to humidify the air you breathe) did not have dates to indicate when it was changed. 2. Resident 79's suction catheter (oral suctioning tool made with firm plastic tip used to suction oral secretions to prevent aspiration) connected to the suction machine at bedside did not have date when it was changed and the suction catheter tip was unprotected. These failures had the potential to put Residents 11 and 79 at risk for developing respiratory infection. Findings: 1. During a review of Resident 11's clinical record titled, admission Record (document containing resident personal information) dated 1/18/22, indicated Resident 11 was admitted to the facility on [DATE] with diagnosis which included: .Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), muscle weakness and anemia (condition in which the blood doesn't have enough healthy red blood cells) . During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level) assessment dated [DATE], indicated Resident 11's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit] indicating Resident 11 had no cognitive deficit. During a review of Resident 11's clinical record titled, Physician Order, order date range: 1/1/2022-1/31/2022, indicated, .Oxygen 2.5 L (liter-unit of measurement) NC (nasal cannula) PRN (as needed) for SOB (shortness of breath) . During a concurrent observation and interview on 1/18/22, at 11:23 a.m., with Resident 11 in her room, Resident 11 was sitting up in her wheelchair at bedside. Resident 11 was observed with a nasal cannula and a humidifier connected to oxygen concentrator (is a medical device that gives you extra oxygen). Resident 11 stated she had been using oxygen for a long time. During a concurrent observation and interview on 1/18/22, at 11:30 a.m., with occupational therapist (OT- a health care professional who assist patients using scientific bases and a holistic perspective to promote a person's ability to fulfill their daily routines), the OT verified the oxygen tubing and the humidifier of Resident 11 and stated the nasal cannula and the humidifier did not have dates labeled. OT stated, the tubing should have been labeled. During a concurrent observation and interview on 1/18/22, at 11:35 a.m., with licensed vocational nurse (LVN) 5, LVN 5 verified Resident 11 did not have date labeled on the nasal cannula and humidifier. LVN 5 stated the practice was to change the tubing every week and label with the date it was changed. 2. During a review of Resident 79's clinical record titled, admission Record, dated, 1/20/22, indicated, Resident 79 was admitted in the facility on 8/31/16 with diagnosis which included hemiplegia (severe or complete loss of strength or paralysis [loss of the ability to move and sometimes to feel anything on one side of the body that can affect the arms, legs, and facial muscles]) on one side of the body, hemiparesis (mild or partial weakness or loss of strength on one side of the body), dysphagia (difficulty or discomfort in swallowing ), aphasia (loss of ability to understand or express speech, caused by brain damage ) and salivary secretions (fluid produced and secreted in the mouth). During a review of Resident 79's MDS dated [DATE], indicated Resident 79's BIMS assessment score was 2 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit] indicating Resident 79 had severe cognitive deficit. During a concurrent observation and interview on 1/18/2022, at 10:55 a.m., with Resident 79 in her room with LVN 5, Resident 79 was lying in bed with eyes closed. Resident 79 did not answer any questions asked. The suction machine was located at bedside with a suction tubing lying on top of the bedside table and connected to the suction machine. The suction tubing and tip was exposed and unprotected lying on top of the bedside table. The suction tubing did not have a label indicating the date when it was last changed. LVN 5 verified the suction tubing did not have a label with the date and the tip was unprotected. LVN 5 stated suction tubing should have been labeled with the date it was changed and covered with a plastic bag. LVN 5 stated the practice was to change every seven days, labeled with the date and covered with a plastic bag. LVN 5 stated it was an infection control issue. During an interview on 1/20/2022, at 9:51 a.m., with LVN 4, LVN 4 stated the practice was to change the oxygen tubings, humidifiers and suction tubings every seven days and label with the date it was changed. LVN 4 stated labeling the tubings was to ensure the facility policy was being followed and preventing infection. LVN 4 stated the suction catheter needed to be placed in a clean plastic bag. During an interview on 1/21/2022, at 11:50 a.m., with the director of nursing (DON), the DON stated the facility policy was to change suction tubing every seven days and placed it in a plastic bag. The DON stated the bags are also changed every seven days and labeled with the date. DON stated the expectation was for staff to check daily and making sure tubings were changed as per facility policy. DON stated, . the staff are to follow doctors orders, patient care, best practice and infection control . During a review of the facility's policy and procedure (P&P), titled, Prevention of Infection Respiratory Equipment, dated 11/2011, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff . Change the oxygen cannula and tubing every seven (7) days .Keep the oxygen cannula and tubing used PRN ('pro re nata,'-as needed) .Documentation: The date and time .

Based on observation, interview and record review, the facility failed to ensure food served met the daily nutritional needs for seven of 77 residents (Residents 4, 14, 45, 65, 77, 78 and 83) when: 1. Residents on large portion diets (Residents 4, 14, 45, 65, 77 and 78) were served more than the required portion size of the mashed potatoes based on the facility's menu. This failure had the potential to result in Residents 4, 14, 45, 65, 77 and 78 to receive more than the recommended daily calorie intake based on the Medical Doctor's order and Registered Dietitian's (RD) assessment of residents' nutritional dietary needs and the potential for unintended weight gain. 2. Resident 83 did not receive a fortified (foods with nutrients added to help boost nutritional value and benefit health) diet as ordered by the physician. This failure had the potential to result in Resident 83 to not receive the additional calories recommended based on resident nutritional dietary needs. Findings: 1. During a review of facility document titled, Order Listing Report, dated 1/19/22, the order listing report indicated, .Status: Current, Order Description: Diet, Order Status: Active. Resident Name: [Resident 78], Order Summary: Double Portions diet Regular texture .[Resident 77], ., Large Portion diet Regular with chopped meat texture .[Resident 65], Large Portion diet Regular with ground meat texture . [Resident 14], Regular diet Regular texture .[Resident 4], Large Portion diet Regular with ground meat texture . [Resident 45], .diet mechanical soft with chopped meat texture . During a tray-line observation on 1/19/22, at 12 p.m., the dietary cook (DC) served two #8 (4 ounces-unit of measurement) scoops of the mashed potatoes instead of a 3/4 scoop (6 ounces) to residents with order for large portion diets. The DC stated Residents 4, 14, 45, 65, 77 and 78 had orders for large portions diet and was served two ounces more than the required serving of six ounces of mashed potatoes. During a concurrent interview, and record review on 1/19/22, at 12:55 p.m., after tray line with the DC, the DC stated she gave two #8 scoops of mashed potatoes to residents that had orders for large portion diets. The DC reviewed the facility document titled, Winter Menus, undated, the winter menu indicated, .mashed potatoes . small: #16, Regular: #8, Large: 3/4c (cup-unit of measurement) .#8=1/2 cup, #12=1/3 cup . The DC stated #8 scoop was 4 ounces and 3/4 cup was 6 ounces. The DC stated she gave residents with the large portions diet two scoops of the #8 scoop which was more than it was indicated on the menu and these residents received more than the calories ordered by their doctors and could lead to weight gain and may make the residents sick. The DC stated she did not review the menu and the scoops required. The DC stated she should have checked the menu. During a concurrent interview and record review on 1/20/22, at 8:23 a.m., with the Dietary Manager (DM) and the Registered Dietitian (RD), the DM and RD stated the expectation was to follow the [portion sizes] menu. The RD reviewed the diet orders for Residents 4, 14, 45, 65, 77 and 78. The RD stated Residents 4, 14, 45, 65, 77 and 78's diet orders were large portion diet. The RD stated Residents 4, 14, 45, 65, 77 and 78 were served mashed potatoes more than it was required in the menu. The RD stated the outcome was possible weight gain. 2. During a review of facility document titled, Order Listing Report, dated 1/19/22, the order listing report indicated, .Status: Current, Order Description: Diet, Order Status: Active. Resident Name: [Resident 83], Order Summary: Fortified diet Pureed texture, thin liquids consistency . During a concurrent observation, interview and record review on 1/19/22, at 12:55 p.m., after tray line in the kitchen, the DC was observed preparing food for Resident 83 who had a fortified diet and added melted butter to Resident 83's meal. The facility document titled, Resident Summary Report dated 1/18/22 was reviewed and indicated, .[Resident 83] thin liquids fortified diet .[Resident 83] thin liquids fortified diet . The DC stated she only knew one resident who was on fortified diet. The DC stated residents on fortified diet received an ounce of melted butter in their food. The DC stated she was not aware Resident 83 was on fortified diet and the dietary assistant did not state Resident 83 was on a fortified diet. During a concurrent interview and record review on 1/20/22, at 8:25 a.m., with the DM and RD, the RD stated Resident 83 was started on fortified diet 12/21 due to Resident 83 losing weight. The RD stated the cook did not serve Resident 83 the fortified diet ordered by her doctor. The RD stated the dietary aide did not mention the fortified diet when she called Resident 83's tray. The RD stated the expectations from the staff was to follow [fortified] diet order for the Resident 83. The RD stated Resident 83 may continue to lose weight if the diet order was not followed. During a review of facility's policy and procedure (P&P), titled, Menu Planning, dated, 2020, the P&P indicated, .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible .Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle . The facilities diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. Menus are written for regular and modified diets in compliance with the diet manual .