**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) had the specific competencies, and skill sets necessary to care for one of four residents (Resident 1), by failing to report Resident 1's alleged fall incident. This deficient practice resulted in a delay in Resident 1's treatment/evaluation. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included nondisplaced fracture of the left tibial spine (a break that has not shifted or separated at the top of the tibia bone in the lower leg near the knee), traumatic subdural hemorrhage without loss of consciousness (a serious condition where blood pools between the brain and its outer protective layer (the dura) after a head injury, potentially causing pressure on the brain), and end stage renal disease ([ESRD], is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/2/2025, the MDS indicated Resident 1 was assessed to have clear comprehension (the action or capability of understanding something). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and maximal assistance for personal hygiene, upper and lower dressing. During an interview on 3/26/2025 at 1:15 p.m. with Resident 1, Resident 1 stated on 3/15/2025, while Certified Nursing Assistant (CNA) 1 was cleaning her, she rolled off the bed and fell to the ground. Resident 1 stated, I think it was an accident. Resident 1 stated CNA 1 picked her up and put her back in the bed. Resident 1 stated she reported to CNA 1 that her head hurt, then CNA 1 left the room. During a review of the facility's CNA job description, dated 10/2021, the job description indicated CNAs were to promptly report any resident changes or concerns, such as injuries or falls, to appropriate licensed nursing personnel. The job description indicated CNAs were to safely lift, reposition, and transport residents, using proper body mechanics or lifting devices, as necessary. During an interview on 3/26/2025 at 2:33 p.m. with CNA 1, CNA 1 stated on 3/15/2025, while cleaning Resident 1 and changing the resident's bed, the resident rolled over and slid off the bed. CNA 1 stated he stopped Resident 1 from falling to the ground. CNA 1 stated after the incident Resident 1 complained of a headache. CNA 1 stated, I went and told the charge nurse that the resident had a headache. I did not tell her about the incident because in my perspective the resident didn't fall, I caught him while he was hanging off the bed and did not touch the ground. CNA 1 stated he should have told the charge nurse about the incident because the resident was hurt. During an interview on 3/26/2025 at 3:48 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was from a registry agency. The DSD stated this was the first time CNA 1 worked at the facility. The DSD stated CNA 1 was placed on a do not return list because of not reporting Resident 1's fall to the charge nurse. The DSD stated not reporting a fall would bring harm to the resident and delay timely medical attention. During an interview on 3/27/2025 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a CNA should always report a fall or near fall to the charge nurse. LVN 1 stated it was not within the CNAs scope of practice to assess the resident to see if they are injured. LVN 1 stated if a fall or accident was not reported immediately the resident would not get the care they would need in a timely manner. During an interview on 3/27/2025 at 12:35 p.m. with LVN 2, LVN 2 stated on 3/15/2025, when she went to pass the pain medication, she noticed a quarter size discolored, slightly raised bump, on the left side above Resident 1's eye. LVN 2 stated Resident 1 reported that he fell off the bed when CNA 1 was cleaning him. LVN 2 stated she was was never told by CNA 1 the resident fell or nearly fell, only that Resident 1 had a headache. During an interview on 3/27/2025 at 1:05 p.m. with CNA 2, CNA 2 stated if you witness a fall or a near fall you must report it to the charge nurse immediately, so they can assess the resident. CNA 2 stated this was for resident's safety. During an interview on 3/27/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated all staff must report a fall or near fall to the charge nurse or supervisor. The DON stated if it is not reported this would harm the resident, which was a safety issue. During a review of the facility's policy and procedure (P&P), titled Fall Management Program , revised 3/2025, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accidental hazards as possible. The P&P indicated a fall is unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. The P&P indicated the facility educates employees at the time of hire, annually and as indicated on the facility policy fall management, included intervention to reduce injury and fall related accidents. During a review of the facility's P&P, titled Patient Safety Plan , revised 3/2024, the P&P indicated any employee having knowledge or observation of accidents, including injuries, infections or other of an unknown source, must report to the department supervisor and the charge nurse, and complete an Incident Report Form must be completed on the shift that the incident occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) glucose (the process of measuring the amount of sugar in a patient ' s blood) was checked after returning to the facility after being out on pass. This deficient practice of not checking the blood sugar after returning to the facility had the potential for Resident 1 exacerbate (a worsening of a medical condition that increases symptoms and may require hospitalization) his diabetes (a chronic condition characterized by high blood sugar levels). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1's Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning) 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. During a review of Resident 1's Weights and Vital Summary, dated 1/21/2025 the blood sugar was 333 milligram per deciliter ([mg/dl]- is a unit of measurement used in medicine to express the concentration of a substance in a fluid such as blood or urine) at 6:57 a.m. During a concurrent interview and record review on 1/29/2025 at 12:55 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left out on pass at 1:57 p.m. on 1/20/2025 The Progress Notes indicated Resident 1 had returned to the facility at 1:48 a.m. on 1/21/2025. In addition, Resident 1 ' s Weights and Vital Summary, dated 1/21/2025 the blood sugar was 333 at mm/dl at 6:57 a.m. was reviewed. The DON stated the Resident 1 has diabetes. The DON stated when Resident 1 returned to the facility an assessment (a process where a nurse gathers, sorts, and analyzes of patient ' s health information) was done. The DON stated the blood sugar should have been checked when Resident 1 returned at 1:48 a.m. on 1/21/2025 as part of the assessment. The DON stated the blood sugar was not checked for four hours after the resident had returned. The DON stated Resident 1 was hyperglycemic (a condition in which there is too much glucose (sugar) in the blood) or hypoglycemic (a condition in which there is not enough glucose in the blood) which would have placed the resident at risk for falls, alter level of consciousness (a change in a patient ' s normal state of alertness and awareness), other signs and symptoms of diabetes. During a review of the facility ' s policy and procedure (P&P) titled, Diabetes Clinical Protocol, dated 3/2017, the P&P indicated to provide staff with clinical practice guidelines to care for residents with diabetes. The P&P indicated based on the comprehensive assessment, including causes and complications, the physician will order appropriate interventions, which may include treatment of underlying conditions causing impaired glucose tolerance. The P&P indicated monitor as indicated if the individual has returned to the facility after a significant absence. During a review of the facility ' s policy and procedure (P&P) titled, Resident Assessment, dated 3/2023, the P&P indicated the facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident ' s functional capacity. The P&P indicated assessments minimally includes the following special treatments and procedures. The P&P indicated the triggers identifying residents who have or are at risk for developing specific functional problems and require further assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) had a care plan for non-compliance (when a patient don't follow the rules, regulations, or advice that ' s been set in place) when out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not developing a care plan (a document that summarizes a person ' s health needs, current treatments, and desired outcomes) for Resident 1 ' s non-compliance had the potential to place the resident at risk for injury and not be continuously monitored for diabetes mellitus([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1's Fall Risk Evaluation, dated 1/19/2025, the Fall Risk Evaluation indicated Resident 1 had one to 2 falls in the past 3 months and was a high fall risk (a person has a significantly increased likelihood of experiencing a fall due to various factors such as poor balance, reduced muscle strength making the more susceptible to losing their footing and falling down). During a review of Resident 1's Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a review of Resident 1's Progress Notes, dated 1/22/2025. The Progress notes indicated Resident 1 left the facility out on pass on 1/22/2025 at 12:19 p.m. and returned to the facility on 1/23/2025 at 8:55 a.m. During a concurrent interview and record review on 1/29/2025 at 1:45 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/202/2025 and 1/22/205 were reviewed. The Progress Notes indicated Resident 1 had left the faciity on 1/20/2025 at 1:57 p.m. and did not return to the facility until 1:48 a.m. on 1/21/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/22/2025 at 12:19 p.m. and returned to the facility on 1/23/2025 at 8:55 a.m. The DON stated when a resident goes OOP the facility requests the resident goes out for four to six hours and return to the facility. The DON stated Resident 1 was OOP for 12 hours on dates 1/20/2025 to 1/21/2025 and was OOP for 21 hours on dates 1/22/2025 to 1/23/2025. The DON stated a care plan should have been done to address his non-compliance for not returning within the recommended time. The DON stated the Resident 1 was a high fall risk and had diabetes. During a review of the facility ' s policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 3/2023, the P&P indicated the facility develops a person-centered comprehensive care plans that address the resident ' s medical, physical, mental and psychosocial needs. The P&P indicated care plans shall include the discipline providing care or services, measurable objectives and timeframes in order to evaluate the resident ' s progress toward his/her goal(s). The P&P indicated when a resident ' s choice to decline care or treatment poses a risk to the resident ' s health or safety, the comprehensive care plan must 1. Identify the care or service being decline 2. The risk the declination poses to the resident 3. Attempts to find alternative means to address the identified risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident1) had a plan in place after being identified as a high risk for falls (a patient has a significantly increased likelihood of experiencing a fall due to various factors like poor balance, muscle weakness, which could potentially cause physical harm if they do fall) for continuous supervision and monitoring while out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not having a plan in place for continuous supervision and monitoring had the potential risk for Resident 1 to fall while out on pass. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1 ' s Fall Risk Evaluation, dated 1/16/2025, the Fall Risk Evaluation indicated Resident 1 had a history of falls in the past three months and was a high risk for falls. During a review of Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a concurrent interview and record review on 1/29/2025 at 12:24 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025 was reviewed. The Progress notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. The DON stated Resident 1 was OOP for 12 hours on 1/20/2025 and returned 1/21/2025 early morning the next day. The DON stated the recommendation for a resident to be OOP was four to six hours. The DON stated Resident 1 was a high risk for falls and had fallen on 1/18/2025 and prior to admission. The DON stated the staff should have documented the risk factors of safety, supervision, and monitored the resident once the resident didn ' t return within the recommended time. The DON stated once the resident left and was gone for long periods of time the staff is no longer able to monitor the resident which would put him at risk for injury. During a review of facility ' s policy and procedure (P&P) titled, Out on Pass Therapeutic Leave, dated 7/2024, the Out on Pass Therapeutic Leave indicated to provide staff with guidelines to ensure residents ' safety when residents choose to leave the facility for social or personal reasons. The P&P indicated the facility ensures that residents are aware of the risks associated with leaving the facility and are provided with necessary information and support to make informed decisions prior to leaving. During a review of facility ' s policy and procedure (P&P) titled, Fall Management Program, dated 3/2023, the P&P indicated to provide each resident with adequate supervision to minimize the risks associated with falls. The P&P indicated identify environmental hazards and individual resident risk of an accident, including the need for supervision. The P&P indicated monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure resident was involved in decision making and notified in change of physician for one of one sampled resident (Resident 52). This failure had violated Resident 52's resident rights to choose her own physician. Findings: During a review of Resident 52's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 52 was admitted to the facility on [DATE]. The admission Record indicated, Resident 52's diagnoses included left hip osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension ([HTN] - high blood pressure), and hyperlipidemia (a condition where there are high levels of fats, or lipids, in the blood). During a review of Resident 52's History and Physical (H&P), dated 12/21/2024, the H&P indicated, Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/27/2024, the MDS indicated, Resident 52 had the ability to express ideas and wants and ability to understood others. The MDS indicated Resident 52's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 52 required substantial assistance (helper does more than the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 52's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 52 had a change of physician order on 1/21/2025 due to insurance coverage. During an interview on 1/22/2025 at 1:34 p.m., with Resident 55, Resident 52 stated she was not aware regarding her change of physician. Resident 52 stated she had the right to be informed and choose her own physician since she would be responsible for the care and treatment of her medical condition while at the facility. During a concurrent interview and record review on 1/22/2025 at 2:44 p.m., with the Director of Nursing (DON), Resident 52's clinical records were reviewed. The DON stated there was no documentation by facility staff indicating Resident 52 was notified regarding her change of physician. The DON stated the facility did not validate with the resident regarding her new physician. The DON stated the change of physician was made due to change of Resident 52's level of care from skilled care (a type of medical care that requires the expertise of a licensed professional , such as a nurse or therapist) to custodial care (non-medical assistance with daily activities for people who need help with personal care). The DON stated no matter what the reason would be for a change of physician, Resident 52 should had given an opportunity to choose her own physician, and the facility violated Resident 52's rights to be informed of her new physician. During a review of the facility's policy and procedure (P&P), titled Choice of Attending Physician, dated 3/2023, the P&P indicated, The facility supports each resident's right to choose his or her attending physician. The P&P indicated the facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. During a review of the facility's P&P, titled Resident Rights, dated 3/2023, the P&P indicated, Residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Implement the facility's policy and procedures on reporting an unusual occurrence when Resident 58 left the facility and did not return. This deficient practice had the potential to result in serious harm, injuries and death. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of the facility's out on pass log, Resident 58 signed out on 11/19/2024 at 9:54 a.m. and did not return to the facility. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the faciity on [DATE] and did not return. The DON stated the facility did not inform law enforcement nor CDPH within 24 hours of Resident 58 not returning to the facility. The DON stated the risk of not following the facility's policy and procedures could result in serious harm or death for a resident. A review of the facility's policy and procedures, titled Reporting Unusual Occurrences, revised 03/2023, indicated, Our facility will report the following events to appropriate agencies: Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. and Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to: 1. Report to California Department of Public Health (CDPH) of resident leaving and not returning to the facility on [DATE] for one of two sampled residents (Resident 58). This deficient practice resulted in the delay of investigation by the CDPH. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of the facility's out on pass log, Resident 58 signed out on 11/19/2024 at 9:54 a.m. and did not return to the facility. During an interview, on 01/24/2025 at 2:35 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the faciity on [DATE] and did not return to the facility. The DON stated Resident 58 did not have a phone and was unable to be contacted. The DON stated Resident 58's housing case worker and nurse practitioner was notified of Resident 58 not returning to the facility by the Social Services Director. The DON stated the facility did not notify Resident 58's primary physician, local law enforcement nor CDPH of Resident 58 not returning the facility. The DON stated there was no documentation by licensed staff on Resident 58 not returning to the facility. The DON stated the risk of not reporting a resident not returning to the facility in a timely manner could result in not knowing whether the resident was safe or alive. We should have been concerned. During an interview, on 01/24/2025 at 3:28 p.m., with the Administrator (ADM), the ADM stated Resident 58 would leave the facility multiple times for hours and would always return. The ADM stated on 11/19/2024. Resident 58 took some of his belongings and did not return to the facility. The ADM stated Resident 58 left on his own will. The ADM stated he did not believe Resident 58 not returning to the facility affected the facility operations. The ADM stated law enforcement and CDPH were not notified as Residents have a right to go on pass and have a right to not come back to the facility. The ADM abruptly terminated the interview. A review of the facility's policy and procedures, titled Out on Pass Therapeutic Leave, dated 07/2024, indicated, When a resident has not returned from therapeutic leave as expected. the facility staff shall attempt to contact the resident and resident representative and document such efforts in the medical record. A review of the facility's policy and procedures, titled Abuse Prohibition and Prevention Program, revised March 2023, indicated The facility shall report all alleged violations and all substantiated incidents: (a) To the state agency and to all other agencies as required. And Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. A review of the facility's policy and procedures, titled Reporting Unusual Occurrences, revised 03/2023, indicated, Our facility will report the following events to appropriate agencies: (h) Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a smoking safety assessment was completed for one of 6 sampled residents (Resident 48). 2. Ensure an assessment was completed before going out on pass for one of 2 sampled residents (Resident 58). This deficient practice had the potential to result in a safety hazard for Resident 48 and serious harm for Resident 58. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's care plan, dated 12/31/24, indicated Resident 48 was noted to have a care plan for tobacco use. Resident 48's care plan indicated Resident 48 would adhere to the tobacco/smoking policies of the facility. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. During a concurrent interview and record review, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated Resident 48's smoking safety assessment was incomplete. The DON stated Resident 8's smoking safety assessment should've had a progress notes stating Resident 48 was an independent smoker. The DON stated the risk of not completing a smoking safety assessment could result in unsupervised smoke breaks and a safety issue. b. During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of Resident 58's assessments, there was no assessment found to determine if Resident 58 was able to leave the facility. During an interview, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated the facility did not conduct an assessment to determine nor obtain a physician's order on whether a resident was able to go out on a pass. The DON stated residents who were alert and oriented were able to leave the facility as they wished. The DON stated the risk of not obtaining an assessment for a resident who leaves the facility could result in serious harm or death if a resident wasn't assessed. A review of the facility's policy and procedures, titled Quality of Care, revised 03/2023, indicated, The interdisciplinary Team shall assess risk factors which place the resident at risk for specific conditions and/or problems. A review of the facility's policy and procedures, titled Resident Assessments, dated ?, indicated The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 36). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 36. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History and Physical (H&P), dated 12/12/2024, the H&P indicated, Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's MDS assessment, dated 12/19/2024, the MDS indicated, Resident 36's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 36 required moderate assistance (helper does less than half the effort) from staff with upper body dressing and personal hygiene. During a review of Resident 36's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 36's physician prescribed low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer) for wound management. During a concurrent interview and record review on 1/23/2025 at 8:28 a.m., with the Minimum Data Set Nurse (MDSN), Resident 36's MDS assessment, dated 12/19/2024 was reviewed. The MDSN stated Resident 36's MDS assessment was completed inaccurately. The MDSN stated Resident 36 MDS, under section M (Skin Condition) 1200B should have a checked mark on pressure reducing device on bed since Resident 36's had a physician's order for LALM. The MDSN acknowledge he did not encode the use of LALM on the MDS assessment. The MDSN stated by not completing the MDS assessment accurately, the facility is giving wrong information to the facility staff involved with resident and the care and services of resident would be affected. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessments, dated 10/2020, the P&P indicated, The facility ensures each resident receives an accurate assessment reflective of the resident's status at the time of the assessment by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. The P&P indicated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: 1. Submit a Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of three sampled residents (Resident 21) which included an existing psychiatric diagnosis. This deficient practice resulted in a delay of Resident 21 receiving a PASSR II evaluation for mental health needs. Findings: During a review of Resident 21's admission Record (Face sheet), the admission Record indicated Resident 21 was re-admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs) heart disease, hypertension (high blood pressure), and muscle weakness. During a review of Resident 21's Minimum Data Set (a comprehensive assessment and screening tool) dated 12/27/2024, the MDS indicated Resident 21 had severe impairment of cognitive skills for daily decision making. The MDS also indicated Resident 21, was receiving antidepressant medications. During a review of Resident 21's PASRR completed on 12/19/2019, the Level I PASRR indicated Resident 21 did not have a mental illness. During a review of Resident 21's physician's orders dated 12/28/2023, the physician orders stated to give Lexapro (used to treat anxiety and major depressive disorder) oral tablet 10 milligrams (mg, unit of weight) tablet once a day at night for major depressive disorder. During a review of Resident 21's Medical Administration Records (MAR- record that includes the date, time, medication name, dosage, administration method, and the name and signature of the administering healthcare professional), printed on 1/24/2025, the MAR indicated Resident 21 was receiving Lexapro related to major depressive disorder. During a review of the IDT (interdisciplinary team) assessment dated [DATE] indicated Resident 21 was taking Lexapro 10 mg once a day for depression. During an interview, on 1/22/2025 at 10:20 a.m., with the Director of Nursing (DON), the DON stated she was responsible for overseeing PASRR. The DON stated that she did not follow through with a PASRR regarding the need for Resident 21's Level II evaluation. The DON stated that Level II evaluation was to determine appropriate placement and/or the need for specialized services. A review of the facility's revised policy dated March 2023 and titled Preadmission Screening and Resident Review (PASRR) indicated that the facility will ensure individuals with a mental disorder or intellectual disability will continue to receive the care and services they need in the most appropriate setting when a significant change in their status occur and the facility Shall notify the appropriate state Mental health Authority when a resident with a mental disorder has a significant change in their mental condition. The facility will: 1. Complete a PASRR for all residents on admission and refer those with mental illness or intellectual disability to the state. 2. Facility personnel shall make a referral to Level II resident reviewed evaluation is required individuals previously identified by PASRR to have a mental disorder. 3. Facility will report a resident with behavioral, psychiatric, mood-related symptoms that have not responded to ongoing treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure a Level 2 Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) evaluation was obtained for one of six sampled residents (Resident 48). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 48. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Level 1 PASRR, dated 01/07/2025, the Level 1 PASRR indicated Resident 48's required a Level II PASRR evaluation. During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an interview, on 1/23/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated Resident 48's Level 1 PASRR was positive for a mental illness. The DON stated a Level 2 PASRR should had been resubmitted for Resident 48. The DON stated the risk of not resubmitting a PASRR for a resident could result in a delay in necessary mental health care and services. A review of the facility's revised policy, dated 03/2023, titled Preadmission Screening and Resident Review, dated 02/2023, indicated, Facility personnel shall make a referral for Level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure physician orders were carried out for one of 6 sampled residents (Resident 31). 2. Provide services which meet professional standards of quality regarding smoking safety for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in skin breakdown for Resident 31 and a smoking accident for Resident 48. Findings: a. During a review of Resident 31's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 31 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis (a narrowing of the spinal column that occurs over time, putting pressure on the spinal cord and nerves), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly), acute kidney failure (a sudden loss of kidney function that occurs when the kidneys are no longer able to filter waste from the blood) and embolism (a blockage in an artery caused by a blood clot or other substance) and thrombosis (blood clot) of the left lower extremity. During a review of Resident 31's history and physical (H&P), dated 7/30/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's physician orders, dated 12/12/2024, the physician orders indicated Resident 31 was to have a low air loss mattress (a mattress with tiny holes that slowly release air to keep the skin dry and cool, often used to treat and prevent bed sore) for skin management. During a review of Resident 31's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 01/3/2025, indicated Resident 31 cognitive skills were intact. The MDS indicated Resident 31 was dependent with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an observation, on 01/23/2025, at 9:12, in Resident 31's room, Resident 31 did not have an air loss mattress on the bed frame. Resident 31 stated he had been waiting for the facility to provide an air loss mattress since December of 2024 but did not receive one. Resident 31 stated he reported his mattress concerns to different staff members, but his concerns went unheard. During a concurrent interview and record review, on 01/23/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON stated all physician orders were to be carried out by licensed nurses. The DON stated Resident 31 had an order for 'Low Air Loss Mattress for skin management', with a start date 12/12/24. The DON stated Resident 31 did not have a Low Air Loss mattress as ordered. The DON stated the risk of not following the physician order for Resident 31 could had result in providing incomplete care and possible skin breakdown. b. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's care plan, dated 12/31/24, indicated Resident 48 was noted to have a care plan for tobacco use. Resident 48's care plan indicated Resident 48 would adhere to the tobacco/smoking policies of the facility. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. During a concurrent interview and record review, on 01/23/2025 at 3:30 p.m., with the DON, the DON stated Resident 48 did not have a physician's order for unsupervised smoking. The DON stated Resident 48's Smoking Safety Notes were incomplete. The DON stated the risk of not obtaining a physician's order for a smoking resident could result in a fire hazard. The facility's policy and procedures, titled Physician Medication Orders, dated 03/2023, did not disclose a policy regarding low air loss mattresses nor smoking safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Assess and monitor one of 6 sampled residents smoking safety (Resident 48). This deficient practice had the potential to result in serious harm due to smoking without supervision. 2. Ensure one out of six sampled residents (Resident 49) had their pain management referral processed timely. This deficient practice resulted in a delay in assessing, monitoring (Resident 48) and care to manage the pain of Resident 49. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. Resident 48's smoking assessment did not indicate whether supervision was required while smoking. During an observation, on 01/21/25 at 2:34 p.m., Resident 48 was observed smoking a cigarette on the facility's smoking patio, unsupervised. During a concurrent interview and record review, on 01/22/2025, at 3:40 p.m., with the Director of Nursing (DON), the DON stated the protocol for tobacco users was to complete a smoking safety assessment form indicating whether a resident required supervision or was able to smoke independently/unsupervised. The DON stated Resident 48's smoking assessment form was incomplete. The DON also stated there were no Interdisciplinary Team (IDT- a group of healthcare professionals with different areas of expertise who work together to achieve a common goal) meetings in place regarding Resident 48's smoking safety. The DON stated the risk of not having a completed smoking assessment form could result in not knowing whether a resident required supervision and not being able to contract for safety. A review of the facility's policy and procedures, titled Quality of Care, revised 03/2023, indicated, The interdisciplinary Team shall assess risk factors which place the resident at risk for specific conditions and/or problems. b. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), compression fracture of the spine, and surgical amputation of right lower leg. During a review of Resident 49's History and Physical (H&P), dated 12/27/2024, the H&P indicated Resident 49 has the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS] a resident assessment tool) dated 1/9/2025, the MDS indicated Resident 49's cognition (ability to think and understand) was intact. Resident 49 needed moderate assistance with dressing the lower body, bathing, and toileting. Resident 49 received a scheduled pain management regimen within the last five days. During a review of Resident 49's care plan, dated 12/27/2024, the care plan indicated Resident 49 was at risk for pain and discomfort related to a right below the knee amputation. (During an interview on 1/21/2025 at 11:27 a.m. with Resident 49, Resident 49 stated he is waiting for a pain management referral, and he hasn't seen anyone. Resident 49 stated he feels pissed his pain isn't controlled. During a concurrent interview and record review on 1/23/2025 at 12:19 p.m. with Registered Nurse (RN) 1, Resident 49's order summary was reviewed. The order summary indicated Resident 49 had a physician's order entered on 1/5/2025 to receive a pain management referral. RN 1 stated the referral should be given to the business office right away for processing. RN 1 stated she gave the business office the referral on 1/22/2025. RN1 stated Resident 49's pain is not being managed due to the delayed processing of the pain management referral. During a concurrent interview and record review on 1/23/2025 at 12:25 p.m. with the Admissions Coordinator (AC), Resident 49's pain management referral packet fax was reviewed. The fax indicated the referral was transmitted to the health plan for approval on 1/22/2025 at 1:20 p.m. The AC stated she is notified by nursing staff when a resident needs a physician referral. The AC stated 1/22/2025 is the first time the referral was sent out for processing. During an interview on 1/23/25 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 49's pain medications are not enough to alleviate his pain. LVN 2 stated Resident 49's pain management referral has not been completed. LVN 2 stated it's not acceptable for the resident to wait 18 days for a referral. The resident is in excruciating pain. It seems like he got ignored. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated March 2023, the P&P indicated residents will receive treatment and care in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting for one of two sampled residents (Resident 36). This deficient practice placed Resident 36 at risk for worsening of pressure ulcer/injury and further skin breakdown. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History and Physical (H&P), dated 12/12/2024, the H&P indicated, Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/19/2024, the MDS indicated, Resident 36's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 36 required moderate assistance (helper does less than half the effort) from staff with upper body dressing and personal hygiene. The MDS indicated, Resident 36 had one unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound is obscured (hidden) by slough (non-viable yellow, tan, ray, green or brown tissue) or eschar (dead tissue that is hard or soft tissue in texture, usually black, brown, or tan in color, and may appear scab-like) and one deep tissue injury ([DTI] - persistent non-blanchable deep red, [NAME] or purple discoloration). The MDS indicated, Resident 36 was at risk for developing pressure ulcers or injuries. During a review of Resident 36's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 36's physician prescribed LALM for wound management. During a review of Resident 36's Wound interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) Conference Record, dated 12/18/2024, the Wound IDT Conference Record indicated intervention for offloading measures with use of LALM. During a concurrent observation and interview on 1/21/2025 at 10:48 a.m., with Resident 36's in her room, Resident 36 was observed lying in bed. Resident 36 stated she was very extremely uncomfortable of her air mattress and the springs was so hard and it could touch her tail bone. During a concurrent observation and interview on 1/21/2025 at 10:55 a.m., with Treatment Nurse 1 (TN 1) in Resident 36's room. TN 1 stated Resident 36's was lying on a LALM with a setting of 350 pounds (lbs. - unit of measurement in weight). TN 1 stated Resident 36 did not weigh 350 pounds. TN 1 stated Resident 36 current weight was 132 pounds. TN 1 stated the setting of LALM should be based on Resident 36's current weight. The TN 1 stated incorrect setting of the LALM would cause extra air pressure on the bony prominence that would result in discomfort of the resident and would result in deterioration of the wound. During an interview on 1/21/2025 at 12:02 p.m., with the Director of Nursing (DON), the DON stated LALM setting should be based on the current weight of the resident and the severity of the pressure ulcer as determined by the physician. The DON stated if the LALM was not properly set based on the current resident weight would result in delayed wound healing and possible development of new pressure ulcer. During a review of the facility's policy and procedure (P&P), titled Low Air Loss Mattresses, dated 11/2024, the P&P indicated, The facility has guidelines to provide residents with a low air loss mattress to reduce skin irritation and breakdown and to allow maximal effectiveness of the low air loss mattress when a physician orders such therapy. The P&P indicated for maintenance, settings and care, the facility shall follow the manufacturer's guidelines. During a review of the facility's P&P titled, Treatment Services to Prevent/Heal Pressure Ulcers, dated 3/2023, indicated to provide care and services consistent with professional standards of practice to promote healing of existing pressure ulcers/injuries, including prevention of infection to the extent possible and prevent the development of additional pressure ulcer/injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one out of six sampled residents (Resident 37) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services timely and five days a week as ordered. This deficient practice had the potential to result in Resident 37 having a decline in function or development of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of Resident 37's care plan, dated 1/9/2025, the care plan indicated Resident 37 was at risk for decline in the bilateral (both) upper extremities. The care plan intervention indicated the RNA will provide bilateral upper extremity range of motion exercises five times a week. During a review of Resident 37's care plan, dated 1/17/2025, the care plan indicated Resident 37 required the RNA program to maintain and/or improve joint mobility. During a review of Resident 37's care plan, dated 1/17/2025, the care plan indicated Resident 37 was at risk for decline in sit to stand transfers. The care plan intervention indicated the RNA program will help Resident 37 sit to stand with a walker five times a week. During a review of Resident 37's Physical Therapy Discharge Summary for dates of service 12/12/2024 to 1/8/2025, the summary indicated Resident 37's discharge recommendation was to start the RNA program. During a review of Resident 37's Order Summary Report, dated 1/23/2025, the report indicated Resident 37 had an order entered on 1/8/2025 for the RNA program to provide sit to stand exercises with a walker five times a week. The report indicated on 1/9/2025 an order was entered for the RNA to provide bilateral upper extremity range of motion exercises five times a week. During a review of Resident 37's Document Survey Report, dated January 2025, the report indicated RNA services began on 1/16/2025. The report indicated RNA services were provided three days during the week of 1/12/2025 to 1/18/2025. During an interview on 1/23/2025 at 11:12 a.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated RNA services are provided to restore mobility and strength. RNA 1 stated he is informed by the director of rehab when a resident has a new order for RNA services. RNA 1 stated when a resident receives an order for RNA services it should be started the next day. If RNA services are not completed as ordered, the resident can have functional decline. RNA 1 cannot state why Resident 37 only received RNA services three days a week. During an interview on 1/23/2025 at 3:10 p.m. with the Director of Rehab (DOR), the DOR stated when residents are released from rehab and need to start RNA services, she directly gives the RNA the referral form. When RNA services are ordered it is started the next day. The DOR is unable to state why RNA services were ordered on 1/8/2025 and services were not started until 1/16/2025. The DOR stated if a resident does not receive RNA services as ordered they could have a decline in range of motion or mobility. The DOR cannot state why Resident 37 received RNA services only three days. During a review of the facility's policy and procedure (P&P) titled, Restorative Nurse Services, dated March 2023, the P&P indicated each resident shall receive restorative nursing care as needed to help promote optimal safety and independence. The facility will ensure each resident receives restorative nursing services as determined by their comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure whether supervision was required during smoke breaks and ensure the environment was free from a fire hazard for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in an accidental fire in the facility and lead to residents' injuries. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking safety assessment was found incomplete. During a concurrent observation and interview, on 01/21/2025 at 9:25 a.m., with Resident 48, a lighter and empty pack of cigarettes was observed on Resident 48's bedside table. Resident 48 stated the facility allowed him to keep his smoking materials with him. Resident 48 stated he was allowed to freely smoke unsupervised on the smoking patio. During a concurrent interview and record review, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated residents who were alert and oriented were allowed to have their smoking materials in their possession. The DON stated Resident 48 was an independent smoker. The DON stated Resident 48's smoking safety assessment form was incomplete. The DON stated the risk of residents possessing their own smoking materials could result in a fire and safety issue. A review of the facility's policy and procedures, titled Smoking Policy, dated 03/2023, indicated Residents who express a desire to smoke will be assessed for deficits and capabilities to smoke safely. Assessments will be completed on admission and quarterly and as the resident's needs or capabilities change. A review of the facility's policy and procedures, titled Free of Accidents Hazards/Supervision/Devices, dated 12/2024, indicated All staff is involved in observing and identifying potential hazards in the environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 110). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 110's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 110 was admitted on [DATE] with diagnoses which included dependence on oxygen, thrombocytopenia, anemia and benign prostatic hyperplasia. During a review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 110 cognitive skills were intact. The MDS indicated Resident 58 required substantial to maximal assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an observation, on 01/21/2025 at 8:40 a.m., Resident 110 was observed receiving oxygen via nasal cannula. Upon observation of Resident 110's oxygen concentrator, the oxygen concentrator showed 1.5 liters of oxygen being delivered via nasal cannula. During a concurrent observation and interview, on 01/23/2025 at 8:23 a.m., with Licensed Vocational Nurse (LVN 2), LNV 2 observed Resident 110's oxygen concentrator. LVN 2 stated Resident 110 was receiving 1.5 liters of oxygen. LVN 2 reviewed Resident 110's physician order and stated Resident 110's physician order indicated he was to receive 2 liters of oxygen continuously via nasal cannula. LVN 2 stated the risk of not administering oxygen per physician order could result in oxygen desaturation (a decrease in the amount of oxygen in your blood). A review of the facility's policy and procedures, titled Oxygen Therapy, revised 03/2023, indicated Residents receiving oxygen therapy will have a physician order outlining administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 166) by failing to: 2. Ensure Resident 166's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was readily available at the bedside, in case of excessive bleeding from the dialysis site. This deficient practice had the potential to result in staff inability to manage and control the bleeding from Resident 166's dialysis site in the event of an emergency. Findings: During a review of Resident 166's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 166 was admitted to the facility on [DATE]. The admission Record indicated, Resident 166's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure), hypertension ([HTN] - high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 166's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 166 was to receive HD treatment every Tuesday, Thursday, and Saturday. The Order Summary Report indicated, to monitor Resident 166's dialysis access site on right upper arm for redness, swelling, and pain. During a concurrent observation and interview on 1/21/2025 at 10:35 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 166's room, LVN 1 acknowledged and confirmed there was no dialysis E-KIT available at bedside. LVN 1 stated dialysis E-KIT consisted of dry gauze, tape, alcohol pads, bandage. LVN 1 stated Resident 166 had arteriovenous graft ([AV] - a surgical procedure that creates a connection between an artery and a vein using a synthetic tube) dialysis access site on right upper arm. LVN 1 stated dialysis E-KIT should be easily accessible and available at bedside at all times in case of an emergency bleeding. LVN 1 stated uncontrolled bleeding on the dialysis access site could cause resident to passed out that would likely require hospitalization and possible death. During an interview on 1/21/2025 at 12:04 p.m., with the Director of Nursing (DON), the DON stated it was the responsibility of the licensed nurses to check the dialysis E-KIT during the start of the shift and huddle meeting between the incoming and outgoing licensed nurses. The DON stated the dialysis E-KIT was a first aid kit that can be used in any emergency signs of bleeding. The DON stated it was a standard of practice to have dialysis E-KIT at bedside to all residents receiving HD treatment. During a review of the facility's policy and procedure (P&P), titled Dialysis Management, dated 3/2023, the P&P indicated, To provide residents who require dialysis care, services, consistent with professional standards of practice, a comprehensive person-centered care plan which meets the residents goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 28 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.14% for one of two sampled residents (Resident 167) observed during the medication administration facility task by failing to: 2. Administer Resident 167's Calcium Carbonate with Vitamin D (vitamin supplement, a mineral that builds and maintain strong bones and teeth, and for important physical functions such as muscle control and blood circulation) as prescribed by the physician and to monitor pulse rate (measurement of the heart rate, or the number of tines the heart beats per minute) prior to administration of Metoprolol Tartrate (medication used to treat high blood pressure) as ordered by the physician. These deficient practices had the potential to result in harm to Resident 167 by not administering medication and following physician orders to meet resident individual medication needs. Findings: During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 167 was admitted to the facility on [DATE]. The admission Record indicated, Resident 167's diagnoses included atrial fibrillation (irregular heartbeat), hypertension ([HTN] - high blood pressure), polyneuropathy (a damage or disease affecting peripheral nerves), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 167's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/14/2025, the MDS indicated, Resident 167's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 167 required moderate assistance (helper does less than the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 167's Physician's Order, dated 1/11/2025, the order indicated to give Calcium Carbonate 500 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) with Vitamin D 5 micrograms ([mcg] - unit of mass) once a day at 9 a.m. for supplement. During a review of Resident 167's Physician's Order, dated 1/9/2025, the order indicated to give Metoprolol Tartrate 25 mg to give 1 tablet orally once a day at 9 a.m. for HTN, hold for systolic blood pressure ([SBP] - the fist number in a blood pressure reading) less than 110 or pulse rate below 60. During a concurrent medication pass observation and interview on 1/22/2025 at 8:13 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed not giving the Calcium Carbonate 500 mg with Vitamin D 5 mcg to Resident 167. LVN 2 stated she did not have the house supply (over the counter medication) of the Calcium Carbonate 500 mg with Vitamin D 5 mcg on her medication cart 1 and that was the reason why she failed to administer the medication to the resident. During a concurrent medication pass observation and interview on 1/22/2025 at 8:27 a.m., with LVN 2, LVN 2 was observed checking the pulse rate of Resident 167 after Metoprolol Tartrate was administered to Resident 167. LVN 2 stated she checked Resident 167's blood pressure but forgot to check the PR prior to the administration of Metoprolol Tartrate. LVN 2 stated she did not follow the physician's order of Metoprolol Tartrate since it has a parameter (specific instructions that you can measure) to hold if SBP less than 110 or pulse rate below 60. LVN 2 stated it was a standard of practice to monitor resident vital signs that includes blood pressure and pulse rate prior to administration of any hypertensive medications. LVN 2 stated Metoprolol Tartrate could cause bradycardia (slows the heart rate) putting Resident 167 at risk for syncopal (loss of consciousness) and dizziness that would likely require hospitalization. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/2023, the P&P indicated, Medications must be administered in accordance with the orders and state and federal guidelines. The P&P indicated the allergies of medication and vital signs must be checked/verified for each resident prior to administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) 5 millimeter ([ml] - unit of measurement) of influenza vaccine (a vaccine that protects against the influenza virus) found from the facility's medication storage room [ROOM NUMBER] refrigerator. This deficient practice had the potential for harm to residents due to potential loss of strength of the influenza vaccine. 2. Remove two vials of unopened expired insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) from the facility's medication storage room [ROOM NUMBER] refrigerator for two of two sampled residents (Residents 14 and 15). This deficient practice had the potential to increase the risk of Resident 14 and 15 receiving expired insulin that could be ineffective in treating their blood sugar. Findings: 1. During a concurrent observation and interview on [DATE] at 11:35 a.m., of medication storage room [ROOM NUMBER] refrigerator with Registered Nurse 1 (RN 1), found one 1 vial of influenza vaccine with no opened date. RN 1 stated it was unknown at this time when the influenza vaccine was opened because it was not labeled with an opened date. RN 1 stated it was important to put the date it was opened in the box of the influenza vaccine so the staff would know the validity and when to discard the vaccine. RN 1 stated giving expired flu vaccine would not have the desired effect for the resident. During an interview on [DATE] at 11:44 a.m., with the Infection Preventionist Nurse (IPN), the IPN acknowledged she opened the one vial of influenza vaccine last week and did not put a label with an opened date. The IPN stated it was a standard of practice to label all medications with an opened date During a review of the facility's policy and procedure (P&P) titled, Labeling of Biologicals and Storage of Biologicals, dated 3/2023, the P&P indicated, If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within days unless the manufacturer specifies a different (shorter or loner) date for that opened vial. The P&P indicated the facility, in coordination with the licensed pharmacist provides accurate labeling to facilitate precautions and safe administration of medications, safe, and secure storage. 2. During a review of Resident 14's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 14's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease ([ESRD] - irreversible kidney failure). During a review of Resident 14's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set ([MDS] - a resident assessment tool) dated [DATE], the MDS indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 14 required substantial assistance (helper does more than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 14's Order Summary Report (a document containing active orders), dated [DATE], indicated Resident 14's physician prescribed insulin lispro (type of insulin medication) to inject subcutaneously ([SQ] - beneath or under the layer of the skin) there times a day before meals at 6:30 a.m., 11:30 a.m., 4:30 p.m., and at bedtime per sliding scale (increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if blood sugar 151-200 = 0, 201-250 = 2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, if blood sugar above 400 notify medical doctor. During a review of Resident 15's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 15's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 15's Minimum Data Set ([MDS] - a resident assessment tool) dated [DATE], the MDS indicated, Resident 15's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 15 was totally dependent (helper does all of the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 15's Order Listing Report indicated Resident 15's Levemir insulin (type on insulin medication) was discontinued on [DATE]. During a concurrent observation and interview on [DATE] at 11:55 a.m., of medication storage room [ROOM NUMBER] refrigerator with Registered Nurse 1 (RN 1), found one unopened vial of Lispro insulin expired on [DATE] for Resident 14 and one unopened vial of Levemir insulin expired on [DATE] for Resident 15. RN 1 stated it was the responsibility of the licensed nurses to check each insulin vial for the expiration date. RN 1 stated expired insulin vial should be discarded immediately and placed in the expired disposal bin. RN 1 stated giving expired insulin medication to resident can cause harm by resulting poor blood sugar control and could alter the desired effect of the medication. During a review of the facility's P&P titled, Labeling of Biologicals and Storage of Biologicals, dated 3/2023, the P&P indicated, If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 6). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 6 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an interview, on 01/23/2025 at 8:44 a.m., with Resident 6, Resident 6 stated he hadn't had his teeth cleaned by the facility's dentist as requested. Resident 6 stated he was last seen by the dentist in November 2024. Resident 6 stated he had informed the Social Services Director of wanting his teeth cleaned months ago but did not follow up. During an interview, on 01/23/2025 at 3:00 p.m., with the Social Services Director (SSD), the SSD stated she was responsible for setting dental appointments and follow up dental appointments for residents. The SSD stated she wrote Resident 6's name down on a list to have his teeth cleaned but could not find the list. The SSD stated Resident 6 did inform her that he wanted his teeth cleaned. The SSD stated she did not document nor followed up with the teeth cleaning that Resident 6 asked for. The SSD stated the risk of not following up on dental services could result in a resident not being taken care of. A review of the facility's policy and procedures, titled Dental Services, revised on 12/2020, indicated, The facility will ensure the dentist provides dental services in accordance with professional standards of quality and timeliness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Provide one out of six sampled residents (Resident 37) with a therapeutic diet at lunch time as ordered. This deficient practice put Resident 37 at risk for further weight loss. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of Resident 37's Order Summary Report, dated 1/23/2025, the report indicated Resident 37 had an order entered on 10/14/2023 for fortified (increased nutrient content) potatoes with lunch. During a review of Resident 37's care plan, dated 3/23/2023, the care plan indicated Resident 37 was at risk for/has altered nutrition. The care plan intervention indicated Resident 37 would receive fortified potatoes at lunch. During a review of Resident 37's care plan, dated 5/16/2024, the care plan indicated Resident 37 was at risk for malnutrition. During a review of Resident 37's Weight Variance Team Update, dated 8/8/2024, the update indicated Resident 37 had poor oral intake. Resident 37 consumed 62% of meals. Resident 37 will receive fortified potatoes with lunch. Resident 37 is underweight. The plan was for gradual weight gain. During a review of Resident 37's Nutrition Task, the task indicated on 1/22/2025 Resident 37 ate 75% of breakfast, 20% of lunch, and 30% of dinner. The task indicated on 1/23/2025 Resident 37 ate 65% of breakfast, 40% of lunch, and 30% of dinner. During a concurrent observation and interview on 1/23/2025 at 12:30 p.m. with the Registered Nurse (RN) 1 at the bedside of Resident 37, Resident 37's lunch tray was observed without fortified potatoes at lunch time. RN 1 stated fortified potatoes are ordered to add nutrition and increase the resident's calorie intake. RN 1 stated if Resident 37 does not receive fortified potatoes as ordered she could have more weight loss or not reach her desired weight. During an interview on 1/23/2025 at 3:19 p.m. with the Dietary Services Supervisor (DSS), the DSS stated fortified potatoes may be ordered to help a resident gain weight. The DSS cannot state why Resident 37 did not receive fortified potatoes today. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet, dated March 2023, the P&P indicated the facility will ensure residents receive and consume foods at the appropriate nutritive content to support the resident's treatment and plan of care. During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated December 2024, the P&P indicated the facility strives to maintain acceptable parameters of nutritional status and they will provide a therapeutic diet for residents with nutritional problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop an individualized person-centered care plan (a document that summarizes a person's health condition, care needs, and current treatments) with measurable objectives, timeframe, and interventions to meet the residents needs for two of two sampled residents (Residents 58 and 167) by failing to: 1. Ensure a care plan for out on pass was develop for Resident 58. 2. Ensure a care plan with interventions for Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) line was develop for Resident 167. These deficient practices had the potential to negatively affect the delivery of care and services for Residents 58 and 167. Findings: a. During a review of Resident 58's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 58 was admitted to the facility on [DATE]. The admission Record indicated, Resident 58's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 58 required moderate assistance (helper does less than the effort) from staff with toileting, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of Resident 58's care plan, there was no care plan in place for Resident 58 to go out on pass. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated care plans were to be initiated upon admission or during a change of condition for a resident. The DON stated Resident 58 did not have a care plan regarding going out on pass. The DON stated the risk of not having a care plan in place could result in inadequate and incompetent care. b. During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 167 was admitted to the facility on [DATE]. The admission Record indicated, Resident 167's diagnoses included atrial fibrillation (irregular heartbeat), hypertension ([HTN] - high blood pressure), and polyneuropathy (a damage or disease affecting peripheral nerves), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 167's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/14/2025, the MDS indicated, Resident 167's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 167 required moderate assistance (helper does less than the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 167 had an Intravenous ([IV] - into or within the vein) access. During a review of Resident 167's Order Summary Report (a document containing active orders), dated 1/23/2025, indicated Resident 167's physician prescribed Ceftriaxone (medication to treat infection) 2 grams ([gm] - metric unit of measurement, used for medication dosage and/or amount) IV daily for right foot osteomyelitis. During a concurrent interview and record review on 1/22/2025 at 3:30 p.m., with Registered Nurse 2 (RN 2), Resident 167's clinical records were reviewed. RN 2 stated Resident 167 had a PICC line on right upper arm and receiving IV medication once a day. RN 2 stated the facility did not formulate an individualized care plan to address Resident 167's PICC line. RN 2 stated Resident 167's PICC line was at risk for complications since facility staff did not develop a care plan that includes care maintenance and interventions. RN 2 stated the purpose of the care plan was to keep track of the progress of the resident and serve as a communication tool among the interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) for resident's continuity of care. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 10/2020, the P&P indicated, The facility develops a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1.Ensure four of six sampled residents' (Residents 15, 30, 37, and 38) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 15, 30, 37, and 38 at risk of not having medication irregularities identified. Findings: A. During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 12/20/2011 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). During a review of Resident 15's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 15's cognition (ability to think and understand) was intact. Resident 15 was dependent on staff with dressing, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). B. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). C. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 38's History and Physical (H&P), dated 12/27/2024, the H&P indicated Resident 38 does not have the capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set ([MDS] a resident assessment tool) dated 1/8/2025, the MDS indicated Resident 38 was dependent on staff with dressing the lower body, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, dated March 2023, the P&P indicated the facility's licensed pharmacist shall review at least monthly, each resident's drug regimen to prevent or minimize adverse consequences related to medication therapy. The P&P indicated the pharmacist must review monthly in order to identify irregularities, clinically significant risks; and/or potential adverse consequences which may result from or be associated with medications. D. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2020 with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs), heart disease (a general term that include many types of heart problems ), hypertension (high blood pressure), and muscle weakness (decreased strength in muscles). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 1/11/2025, indicated Resident 30's cognition and decision-making skills was severely impaired. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfer, dressing, bathing, eating, toilet use, and personal hygiene. During a review of the resident's medical record, indicated there was no documented evidence that the MRR was done for the month of October, November and December 2024. During an interview, on 1/23/2025, at 2:28 p.m., with the Director of Nursing (DON), the DON was unable to provide documented evidence of the MRR report for the months of October 2024, November 2024 and December 2024. The DON stated the practice of the facility was to have MRR done monthly. The DON stated when there was a recommendation from the consultant pharmacist, the DON gives the pharmacist's recommendation to the Registered Nurse (RN) supervisor who faxes the recommendation to the physician, signs and files the recommendation in the resident's chart as evidence this was communicated to the physician. A review of the facility`s policy and procedure, revised on March 2024, titled Drug Regimen Review indicated the facility must ensure that a pharmacist reviews each resident's medical chart every month and perform a drug regimen review, including the following expanded requirements:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess, and managed pain in a timely manner, for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the quality of life of the affected resident. Findings: A review of Resident 3's Face Sheet dated 4/4/2024, indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including cellulitis of left lower limb (wound infection), phantom limb syndrome with pain (sensation patients experience after removal of limb, and muscle weakness. A review of Resident 3's, History and Physical (H&P), dated 12/22/2023, indicated Resident 3 did not have the capacity to understand and make own decisions. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating, oral hygiene, and substantial assistance for toileting. Resident 3 was dependent for shower/bath, lower body dressing, putting on/taking off footwear and moderate assistance for upper body dressing and personal hygiene. A review of Resident's 3 care plan titled Pain Management therapy related to neuropathic pain, undated, indicated resident will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions were listed as Administer analgesic medications as ordered by physician. Monitor/document discomfort or adverse side effects and effectiveness every shift. Review for pain medication efficacy. Assess whether pain intensity acceptable to resident. A review of Resident 3's physician's order dated 12/20/2023, indicated to monitor level of pain using 0-10 scale every shift. A review of Resident 3's physician's order dated 2/29/2024, indicated order for Ultram (an opioid medicine for the short-term relief of moderate to severe pain) oral tablet 50 milligram (mg), give one table by mouth every 6 hours as needed for severe pain level 6-10. During an observation and interview on 4/9/2024 at 10:35 a.m., Resident 3 stated he had a pain level of 8 out of 10 and had been asking for pain medication since 9:00 a.m. Resident 3 stated he had debridement (the removal of dead (necrotic) or infected skin tissue to help a wound heal) on his right heel pressure ulcer. Resident 3 stated, he had pressed the call light and Certified Nurse Assistant (CNA 1) answere. Resident 3 stated CNA 1 told him she (CNA1)would get Licensed Vocational Nurse (LVN 2) to give him the pain medicine. Resident 3 stated, he pressed the call light at 11:15 a.m., again to ask for the pain medicine. Resident 3 stated, at 11:16 a.m., LVN 2 walked into the room asked Resident 3 what he needed and left. At 11:20 a.m., Resident 3 stated, LVN 2 walked back into the room and gave his pain medicine. During an interview with LVN 2 on 4/9/2024 at 11:20 a.m., LVN 2 stated she failed to assess Resident 3's pain level. LVN 2 stated she did not need to ask Resident 3 where the pain was because she just knew. During an interview with Resident 3 on 4/9/2024 at 12:01 p.m. Resident 3 stated he gets anxious when his pain is not managed. During an interview with Director of Nursing (DON) on 4/10/2023 at 4:33 p.m., the DON stated that proper pain assessment is required and if a resident is non-verbal the staf,f would have to look for non—verbal physical cues. DON stated pain should be treated immediately to maintain quality of life and for resident to be able to perform daily activities. A review of the facility's policy and procedure (P&P) titled Pain assessment and management, dated 1/2012, indicated the facility need to ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated that management consisted of assessing the potential for pain by identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, activities of daily living, for three of four residents (Residents 1, 3 and 4), were attended to, promptly. This deficient practice had the potential to result in residents developing skin breakdown and other needs not met. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included difficulty walking, muscle weakness, and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a review of Resident 1 ' s history and physical (H&P) dated 1/1/2024, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/30/2024, the MDS indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and could understand and be understood by others. The MDS indicated Resident 2 required substantial/ maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s care plan titled, Activity of Daily Living (ADL), dated 1/18/2024, the ADL care plan indicated, Resident 1 needs extensive assistance on ADLs total dependence on staff. One of Resident 1 ' s care plan interventions indicated to place call light within reach, prompt Resident 1 to use call light when assistance is needed and answer promptly. During an interview on 2/27/2024 at 9:08 a.m., Resident 1 stated, he needed assistance from two nurses when getting up from bed. Resident 1 stated, the 11:00 p.m. to 7:00 a.m. nursing staff took 30 minutes to one hour to answer call lights when he needed assistance to get up to use the bathroom or change brief. Resident 1 stated, it was never okay for the nurses to take long to come and assist with care. During a review of Resident 3 ' s admission record, the admission record indicated Resident 3 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included difficulty walking (problems with the joints, bones, circulation) muscle weakness (commonly due to lack of exercise, ageing, muscle injury), and acute osteomyelitis, right ankle, and foot (infection in a bone). During a review of Resident 3 ' s H&P dated 12/16/2023, the H&P indicated Resident 3 had the mental capacity to understand and make medical decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills (thought process) was independent. The MDS indicated Resident 3 required substantial/ maximal assistance with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 3 ' s activities of daily living (ADL) care plan dated 2/6/2024, the care plan indicated, Resident 3 had an alteration with ADL functions related to generalized weakness requiring assistance with ADLs. Resident 3's care plan interventions indicated, assist with ADLs as needed and maintain call light within easy reach and answer promptly. During an interview on 2/27/2024 at 10:00 a.m., Resident 3 stated he needed nurse's assistance to get up and use the bedside commode at night because he had incontinence episode and would need brief to be changed. Resident 3 stated, when he pressed the call light at night, it took the staff an hour to answer the call light to assist him to use the bedside commode, or changed brief when was wet. Resident 3 stated he does not want to develop a diaper rash because of my wet brief. During a review of Resident 4 ' s admission record, the admission record indicated Resident 4 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis that muscle weakness, alcoholic cirrhosis of liver with ascites (buildup of fluid in your abdomen) and encephalopathy (brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe). During a review of Resident 4 ' s H&P dated 1/11/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognitive skills was independent. The MDS indicated Resident 4 required substantial/ maximal assistance with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 4 ' s ADL care plan for dated 2/6/2024, one of the interventions indicated to assist Resident 4 with ADLs as needed, maintain call light within easy reach and answer promptly. During an interview on 2/27/2024 at 10:30 a.m., Resident 4 stated at nighttime, it took the nurses to answer the call light longer than 30 minutes to empty the urinal. Resident 4 stated, it made me feel bad to wait a long time for the nurses to come. During a record review on 2/27/2024 at 12:30 p.m., the Resident Council Meeting dated 11/2023 and 12/2023 was reviewed. The meeting indicated nursing problems and concerns against 3 p.m.-11 p.m. and 11 p.m. -7 a.m. shifts answering call lights longer. The Resident Council Meeting dated 1/2024 indicated nursing problems and concerns with 11 p.m.-7 a.m. shifts answering call lights longer. During an interview on 2/27/2024 at 1:00 p.m., the Director of Nursing (DON) stated, everybody is responsible in answering the call light. DON stated, it was important to answer the call lights in a timely manner because the resident could fall or have any medical issues. During an interview on 2/27/2024 at 2:52 p.m., CNA 3 stated, it was hard to answer the call lights promptly when you were assigned 16-17 residents. CNA 3 stated, most of the time, residents became so upset because it took us (CNAs) to answer call lights longer. CNA 3 stated, the call lights should be answered promptly, to respond to emergency situations, like falls. CNA 3 stated it is the facility ' s responsibility to provide the best quality care to residents. During an interview on 2/27/2024 at 3:00 p.m., the Registered Nurses (RN) stated, answering call lights is everybody ' s job at a facility. RN stated, if we do not answer the call light in a timely manner, residents could fall, aspirate, and can have skin issues. RN stated prevention of incidents and complications are important to provide to residents. During an interview on 2/27/2024 at 3:25 p.m., the DON stated, having the right number of nurses is very important so they can attend to residents ' needs promptly, prevent falls, bedsores, and provide good, quality care to the residents. During a review of the facility ' s undated policy and procedure (P/P) titled, Certified Nurse Assistant, the P/P indicated to timely answer call lights of assigned and unassigned residents. During a review of the facility ' s P&P, titled, Resident Call System dated 10/2022, the P&P indicated the facility is adequately equipped to allow residents to call staff assistance through a communication system which relays the call directly to a staff member to respond to the resident ' s request and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its Infection policy and procedure (P&P) by failing to report a Coronavirus disease ([Covid-19] a highly contagious illness caused by a virus that could easily spread from person to person) outbreak to the California Department of Public Health District Office (CDPH DO). This failure had the potential to result in the spread of Covid-19 cases in the facility and placed residents, staff and the community at risk for contracting the Covid 19 virus. Findings During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, and diabetes mellitus (high blood sugar). During a review of Resident 3's History and Physical (H&P) dated 8/24/2023, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 10/10/2023, the MDS indicated Resident 3 was dependent on staff for Activities of Daily Living (ADL's) such as toileting, showering and dressing. During a review of Resident 3's Change of Condition (COC) Evaluation, dated 1/18/2024, the COC indicated Resident 3 had symptoms of cough and runny nose. The COC also indicated Resident 3 tested positive for Covid-19 when a rapid test (testing method that provide result in 20 minutes or less) was conducted. During a review of Resident 3 COVID-19 PCR ([polymerase chain reaction] laboratory [lab] test) results dated 1/19/2024 at 6:35 a.m., the PCR indicated Covid-19 was detected for Resident 3. During an interview with the Infection Prevention Nurse (IP) on 1/25/2024 at 1:10 p.m., the IP stated the Covid-19 outbreak started on 1/19/2024 and was not aware she needed to report the Covid-19 outbreak to CDPH DO therefore was not done. During an interview with the Director of Nursing (DON) on 1/25/2024 at 2:00 p.m., the DON stated, Covid -19 outbreak needed to be reported to CDPH DO. DON also stated, reporting the cases of Covid-19 to CDPH DO, would help the facility to follow guidelines to control and stop the spread of the disease. During an interview with the Administrator (ADM), ADM stated, the facility's Covid -19 outbreak should have been reported to CDPH DO. ADM stated it was important to report to the CDPH DO so the facility could follow up with the guidelines and keep residents safe. During a review of the facility's P&P titled, infection Prevention and Control Program dated 10/2022, the P&P indicated to ensure the facility establishes and maintains and Infection Control Program to provide a safe environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The P&P also indicated to notify appropriate government agencies of reportable contagious or infectious diseases. During a review of the facility's P&P titled, Unusual Occurrence, dated 11/2017 and revised 10/2022, the P&P indicated As required by Federal or State regulations, our facility reports unusual occurrences or other reportable events which affect the health, safely, or welfare of our residents. The P&P indicated the facility would report an outbreak of any communicable disease to the appropriate agency within 24 hours of the incident or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to honor resident's right to visit family members outside of the facility for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss time with his family during the Christmas holiday and had the potential to negatively impact his psychosocial well-being. Findings: During a review of Resident 6's admission Record, dated 11/22/2023, the admission record indicated Resident 6 was admitted to the facility on [DATE] with the following diagnoses which included fracture (a break in the bone) of the occiput (back of the head), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) or stroke), benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow). During a review of Resident 6's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/27/2023, the MDS indicated Resident 6 was cognitively intact (has the ability to think, remember and reason) for daily decision making and required minimal assistance with eating, dressing upper body and oral hygiene and partial assistance toileting, bating and personal hygiene. The MDS also indicated that Resident 6 required moderate assistance with toilet, tub, chair and bed transfers (moving from one surface to another). During a review of Resident 6's History and Physical (H&P), dated 11/22/2023, the H&P indicated, Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Progress Note, titled Alert Note, dated 12/2/2023 at 3:36 p.m., the progress note indicated that Resident 6 presented with belligerent behavior due to a request to go out on a pass with his with a family member and to be allowed to bring his service dog inside of the facility. During a review of Resident 6's Progress Note, titled Alert Note, dated 12/18/2023 at 2:18 p.m., the progress note indicated that Resident 6 requested an Out on Pass for 12/25/2023. The progress note indicated that Resident 6 verbalized that his son would pick him up for Christmas dinner at approximately 5 p.m. and return him to the facility four hours later. During a review of Resident 6's Progress Note, titled Incident Note, dated 12/27/2023 at 3:49 p.m., the progress note indicated that the Director of Staff Development (DSD) spoke with Resident 6's case manager from an outside agency. The DSD noted in the progress note that the case manager informed him that a complaint would be filed on behalf of Resident 6. According to the DSD's progress note, the case manager stated that a text had been sent to nursing staff approving Resident 6's out on pass request for the Christmas holiday but the resident was not able to go. The DSD stated in the progress note that he apologized for the incident and would speak to the resident. During a review of Resident 6's Progress Note, titled, Communication with Resident, dated 12/27/2023 at 4:25 p.m., the progress note indicated that the DSD spoke with Resident 6 regarding the incident. The DSD noted in the progress note that Resident 6 was upset about not being able to go out on pass and stated, It's already past. During an interview on 1/9/2024 at 2:17 p.m., with Resident 6, Resident 6 stated that he was ready to be discharged because he missed his dog. Resident 6 stated that he was not happy with the facility because he requested an out on pass three weeks in advance to visit his family on Christmas Eve. Resident 6 stated that he informed the nursing staff that his son was coming to pick him up on Christmas Eve and provided the nursing staff with all of the information in advance. Resident 6 stated that he was assured that everything was taken care of. Resident 6 stated that he felt so bad on Christmas because he had been saving up to buy all of his grandchildren Christmas gifts and was looking forward to seeing them. Resident 6 stated that he was very disappointed that he did not get to see any of his grandchildren or give them gifts during the Christmas holiday. Resident 6 stated that when his family arrived on Christmas Eve, the facility would not let him go because the paperwork had not been completed. Resident 6 stated. It is too late now because Christmas is over, and it is very depressing. During an interview on 1/11/2024 at 3:24 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she worked the day that Resident 6 requested to go out with his family. LVN 1 stated that she was not Resident 6's nurse, but she remembered Resident 6 asking to go out on pass for Christmas with his family that day. LVN 1 stated that a text was sent to the MD, but Resident 6 asked for the out on pass the same day. LVN 1 stated that Resident 6's family arrived at the facility at 5 p.m. on Christmas Day. LVN 1 stated that Resident 6 did not want to come back the same day so the facility informed him that he would need to sign out against medical advice (AMA) if he stayed overnight. LVN 1 stated that Resident 6 was willing to sign out AMA, but his family advised him not to do it because he would not be able to come back to the facility. LVN 1 stated that Resident 6 was not happy that his family did not want him to go. During an interview on 1/11/2024 at 3:37 p.m., with the Social Services Director (SSD), the SSD stated she spoke with Resident 6 after the incident on 12/25/2023. The SSD stated that Resident 6 informed her that his family never came and they left him hanging. The SSD stated that she offered to call Resident 6's family to find out what happened but the resident declined. The SSD stated the family always does him (Resident 6) like that. The SSD stated that all Resident 6's family needed to do was sign him out and sign him back in when the resident returned. The SSD stated there was no paperwork needed, just an okay from the physcian. During an interview on 1/11/2024 at 4:50 p.m., with Registered Nurse (RN 1) Supervisor, RN 1 stated she was notified by the SSD on 12/18/2023 that Resident 6 requested an out on pass to visit with family for the Christmas holiday. RN 1 stated that she notified the physician via text on 12/18/2023 at 1:31 p.m. RN 1 reviewed the text on the facility's staff cell phone. RN 1 stated that she did not get a response from the physician before the end of her shift on 12/18/2023, so she endorsed it to the next shift. RN 1 stated that the original request for Resident 6's out on pass was forwarded again via text on 12/18/2023 at 7:02 p.m., but there was still no response from the physician. RN 1 stated that the physician was notified again via text on 12/22/2023 at 8:57 a.m., and again on 12/24/2023 at 4:37 p.m. RN 1 stated that according to the text, the physician finally replied on 12/24/2024 at 5:18 p.m. with K, which meant it was okay for Resident 6 to go out on pass. RN 1 stated that she did not work that day, so she was not sure why Resident 1 was not able to go. RN 1 stated that once the physician approved the out on pass for a resident, the nurse who received the approval should place an order in the resident's electronic medical records (EMR). RN 1 was asked if she would be able to locate the physician order for an out on pass for Resident 6's in the EMR. RN 1 searched Resident 6's EMR for any documentation related to the out on pass request. RN 1 stated she was unable to find the physician's order, or any documentation related to the out on pass request for Resident 6 on 12/24/2023 or 12/25/2023. RN 1 stated that a simple note in the communications section of the resident's EMR stating that the resident was okay to go out on pass with family along with the physician's order was all that would have been required for the resident to go out on pass with his family. RN 1 stated that whoever notified the physician via text on 12/24/2023, should have also documented that the out on pass was approved by the physician in Resident 6's EMR. During an interview on 2/12/2024 at 11:27 a.m., with the DSD, the DSD stated Resident 6 was supposed to go out on pass with his family during the Christmas holiday, but apparently it did not happen. The DSD stated that the orders were not put into the computer. The DSD stated that he only heard of the incident a couple of days later. The DSD stated that he went to Resident 6 to apologize for the incident and offered to get him an out on pass to see his family for the New Year holiday. The DSD stated that Resident 6 declined the pass and told him that Christmas had already passed. The DSD stated Resident 6 did not want to discuss the incident further. The DSD stated that it was unfortunate that he (DSD) was not there on Christmas to assist the resident. During a telephone interview on 1/12/2024 at 12:57 p.m. with Family Member (FM) 1, FM 1 stated they called the facility 2 weeks prior to make sure that Resident 6 would be ready to visit for Christmas. FM 1 stated that they spoke with someone at the facility that confirmed Resident 6 could go out on pass and that everything had already been approved by the case worker. FM 1 stated that when the family arrived to pick up Resident 6, at 5 p.m. on Christmas Eve, they were informed that the facility would not allow Resident 6 to leave. FM 1 stated that the charge nurse informed them that there was no approval for an out on pass order documented in the computer. FM 1 stated that while this charge nurse was attempting to help them figure out what to do, another charge nurse came out into the lobby and handed them a piece of paper to sign. FM 1 stated that this charge nurse was very rude to them and was attempted to get Resident 6 to sign out of the facility AMA. FM 1 stated that they (Resident 6's family) informed Resident 6 not to sign the AMA document because the resident would not be accepted back into the facility. FM 1 stated that the family left to return home without Resident 6 and that the incident ruined their entire family's Christmas holiday. FM 1 stated Resident 6 would not speak to them for 2 weeks. FM 1 stated that they wanted to file a complaint to the owner of the facility regarding the incident. During an interview on 1/12/2024 at 1:31 p.m. with the SSD, the SSD stated that she knew about the incident after it happened but did not document because she did not think it was a big issue. The SSD stated that she was not involved with getting the physician's orders or to verify if the physician called for out on pass requests. The SSD stated that if a resident requests an out on pass, she would direct them to the charge nurse. The SSD stated that there should be documentation in the communication note stating the resident could go out on pass per the physician's order. During a review of the facility's policy and procedure (P&P) titled, Exercise of Rights, effective October 2017 and revised March 2023, the P&P indicated, The facility ensures that the resident is supported by the facility in the exercise of his or her rights and can exercise his or her rights without interference, coercion, discrimination, or reprisal, The P&P also indicated that residents have autonomy and choice about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. During a review of the facility's P&P titled, Out on Pass, effective March 2023, the P&P indicated, The facility supports each resident's right to leave the facility for social or personal reasons and recognizes that leaving the facility on therapeutic outings may promote psychosocial well-being. During a review of the facility's P&P titled, Dignity and Respect, effective June 2016 and revised March 2023, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The P&P also that residents shall be assisted in attending the activities of their choice, including activities outside of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of two sampled residents (Resident 122 & 222). This deficient practice had the potential to cause inadequate oxygen therapy and respiratory distress for all residents. Findings: During a review of Resident 222's admission Record (Face Sheet), dated 1/2/2024, the Face Sheet indicated Resident 222 was admitted to the facility on [DATE] with a diagnoses including Heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), Hypertensive emergency (when the pressure in your blood vessels is too high), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Arteriosclerosis of Aorta (when fat and calcium has built up in the inside wall of a large blood vessel called the aorta), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in the body), Systemic inflammatory Response syndrome [SIRS] (an exaggerated defense response of the body to a noxious stressor to localize and then eliminated the endogenous or exogenous source of insult), Dementia (loss of memory, language, problem solving and other thinking abilities that are severe), Muscle Weakness (full effort doesn't produce a normal muscle contraction). During a review of Resident 222's Minimum Data Set ([MDS- a standardized assessment and care screen tool) dated 1/1/2024, the MDS indicates Resident 222 is severely impaired, and required extensive assistance from staff for his activities of daily living (ADL's). A review of Resident 222's History and Physical (H&P), dated 1/24/2024, indicated Resident 122 does not have the capacity to understand and make decisions. During a review of Resident 222's Care Plan titled, CHF exacerbation (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), dated 12/26/2023, the care plan indicated Resident 222 requires use of oxygen due to a diagnosis of congestive heart failure (CHF). Goal included to maintain targeted oxygen level through the provision of supplemental oxygen in a safe and effective way. Intervention included change tubing/cannula every weekly at 11-7 shift or as needed, keep HOB elevated to 30-45 degrees, Licensed nurse to monitor/check if cannulas/tubing/humidifiers are labeled, monitor oxygen saturation of the resident if indicated, Monitor placement of nasal cannula/face mask to the resident, notify medical doctor for any change of condition, place sign to entry room alerting that 02 is in use. During a review of Resident 222's Physician orders, dated 12/25/2023, the physician orders indicated 02 at 2 liters via nasal cannula (a tube that is placed approximately on-half inch into the resident's nose it is held in place by an elastic band paced around the resident head) for shortness of breath (SOB) to keep 02 sat greater than 92% every shift for SOB/Wheezing (breathing with a whistling or rattling sound in the chest). Record the following information in the medical record as applicable: During a review of Resident 222's Nurses Notes (NN), dated 1/11/2023, the NN indicated on 1/11/2023 at 9:55 a.m., Resident 222 Respiratory status utilizing oxygen indicating yes with oxygen at 1 liter per minute oxygen via nasal cannula. During an observation and interview on 1/9/2023 at 9:36 a.m. with LVN1. LVN1 observed the oxygen on 3 liters per minute. LVN1 stated he will check the physician orders, after doing so LVN1 stated the oxygen should be on 2 liters per the physician orders. LVN1 stated when the oxygen level is too high it could harm the lungs. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2027, the P&P indicated Residents receiving oxygen therapy will have a physician order outlining administration. Record the following information in the medical record as applicable: a. The date and time that the procedure was performed. b. The rate of oxygen flow, route, and rationale. c. The frequency and duration of the treatment. d. The reason for as needed (p.r.n.) administration. e. Resident adverse reaction to treatment as applicable and f. The signature and title of the person recording the data. B. During a review of Resident 122's admission Record (Face Sheet), dated 1/2/2024, the Face Sheet indicated Resident 122 was admitted to the facility on [DATE] with a diagnoses including Heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), Hypertensive emergency (when the pressure in your blood vessels is too high), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Atherosclerosis of Aorta (when fat and calcium has built up in the inside wall of a large blood vessel called the aorta), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in the body), Systemic inflammatory Response syndrome [SIRS] (an exaggerated defense response of the body to a noxious stressor to localize and then eliminated the endogenous or exogenous source of insult), Dementia (loss of memory, language, problem solving and other thinking abilities that are severe), Muscle Weakness (full effort doesn't produce a normal muscle contraction). During a review of Resident 122's Minimum Data Set ([MDS- a standardized assessment and care screen tool) dated 1/1/2024, the MDS indicates Resident 122 is severely impaired, and required extensive assistance from staff for his activities of daily living (ADL's). During a review of Resident 122's History and Physical (H&P), dated 1/24/2024, indicated Resident 122 does not have the capacity to understand and make decisions. During a review of Resident 122's Care Plan titled, CHF exacerbation (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), dated 12/26/2023, the care plan indicated Resident 122 requires use of oxygen due to a diagnosis of congestive heart failure (CHF). Goal included to maintain targeted oxygen level through the provision of supplemental oxygen in a safe and effective way. Intervention included change tubing/cannula every weekly at 11-7 shift or as needed, keep HOB elevated to 30-45 degrees, Licensed nurse to monitor/check if cannulas/tubing/humidifiers are labeled, monitor oxygen saturation of the resident if indicated, Monitor placement of nasal cannula/face mask to the resident, notify medical doctor for any change of condition, place sign to entry room alerting that 02 is in use. During a review of Resident 122's Physician orders, dated 12/25/2023, the physician orders indicated 02 at 2 liters via nasal cannula (a tube that is placed approximately on-half inch into the resident's nose it is held in place by an elastic band paced around the resident head) for shortness of breath (SOB) to keep 02 sat greater than 92% every shift for SOB/Wheezing (breathing with a whistling or rattling sound in the chest). Record the following information in the medical record as applicable: During a review of Resident 122's Nurses Notes (NN), dated1/11/2023, the NN indicated on 1/11/2023 at 9:55 a.m., Resident 122 Respiratory status utilizing oxygen indicating yes with oxygen at 1 liter per minute oxygen via nasal cannula. During an observation and interview on 1/9/2023 at 9:36 a.m. with LVN1. LVN1 observed the oxygen on 3 liters per minute. LVN1 stated he will check the physician orders, after doing so LVN1 stated the oxygen should be on 2 liters per the physician orders. LVN1 stated when the oxygen level is too high it could harm the lungs. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2027, the P&P indicated Residents receiving oxygen therapy will have a physician order outlining administration. Record the following information in the medical record as applicable: a. The date and time that the procedure was performed. b. The rate of oxygen flow, route, and rationale. c. The frequency and duration of the treatment. d. The reason for as needed (p.r.n.) administration. e. Resident adverse reaction to treatment as applicable and f. The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food served was palatable and attractive as voiced by one out of one sampled resident (Resident 46). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings: During a review of Resident 46's admission records indicated Resident 46's was originally admitted to the facility 4/27/2023 and re-admitted on [DATE] with a diagnosis of Transient ischemic attack [TIA] (a temporary blockage of blood flow to the brain), Vertebral Artery (arteries in the neck supply blood to the brain and spine), Hemiplegia and Hemiparesis ([Hemiplegia- refers to paralysis on one side of the body after a stroke] Hemiparesis [ weakness on one side of the body]), Hypertension ( when the pressure in your blood vessels is too high), Benign Prostatic Hyperplasia (a noncancerous enlargement of the Prostate gland), Hyperlipidemia (too many lipids [fats] in your body), Muscle weakness (full effort doesn't produce a normal muscle contraction), Dysphagia (swallowing difficulties). During a review of Resident 46's Minimum Data Set (MDS- comprehensive screening tool) dated 5/4/2023, Indicate Resident 46 is severely impaired. Resident 46's functional status includes two persons physical assist with ADLs with staff care. Duringa review of Resident 46's History and Physical (H&P), dated 4/28/2023, indicated Resident 46, has fluctuating capacity to understand and make decisions. During a review of Resident 46's Care Plan, dated 4/28/2023, indicated Resident 46 has a decline in self-feeding with pureed diet. Goal includes Improve ability for self-feeding with use of divided plant. Intervention included patient to use a divided plate with all meals. During a review of Resident 46's Care Plan, dated 5/5/2023, indicated Resident 46 is at risk for/has altered nutrition/hydration status due to diagnosis of CVA/TIA, HTN, Dysphagia. Goal included will consume at least 85% of meal served daily, will have no significant weight loss through review date, target date 2/4/2024, will have no signs and symptoms of dehydration through review date, will adhere to therapeutic diet. Interventions include Provide, serve diet as ordered. Monitor intake and offer substitute if refused meal served, Explain benefits of nutritional plan and risks for non-compliant with diet order, Monitor weights weekly times 4 week, then at least every month or as ordered and notify Medical Doctor and Registered Dietitian of significant weight loss/gain, Monitor for signs and symptoms (s/s) of dehydration, monitor/document/report any s/s of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals, honor food preferences. During an observation and interview on 1/9/2023 at 10:39 a.m. wit Resident 46. Resident 46 stated the food is not good, they give us the same food every day, I did not know I had choices. I will ask about my choices when my food comes. During a concurrent interview on 1/12/2023 at 12:30 p.m. with Resident 46, Resident 46 stated he ordered a turkey burger off the alternative menu when it was finally present to me. During a review of the facility's policy and procedure (P&P) titled, Selective Menus, dated (no date), the P&P indicated, Selective menus are provided to all individuals who choose to make their own menu selections. Assistance from family or staff is encouraged for those who cannot make their own men choices. The food service manager, or designee will review food choices for individuals on therapeutic diets and refer to the registered dietitian (RD) or designee if there are concerns. During a review of the facility's P&P titled, Menus, dated 3/2023, The P&P indicated, The facility assures menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document the resident's approved out on pass (OOP) order to visit family for the Christmas holiday for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss spending time with his family during the Christmas holiday and had the potential to negatively impact Resident 6's psychosocial well-being. Findings: During a review of Resident 6's admission Record, dated 11/22/2023, the admission record indicated Resident 6 was admitted to the facility on [DATE] with the following diagnoses which included fracture (a break in the bone) of the occiput (back of the head), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) or stroke), benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), type 2 diabetes mellitus (DM - condition that results in too much sugar circulating in the blood), hyperlipidemia (an abnormally high concentration of fat particles in the blood), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow). During a review of Resident 6's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/27/2023, the MDS indicated Resident 6 was cognitively intact (has the ability to think, remember and reason) for daily decision making. The MDS indicated Resident 6 required minimal assistance with eating, dressing upper body and oral hygiene and partial assistance toileting, bating and personal hygiene, and required moderate assistance with toilet, tub, chair, and bed transfers (moving from one surface to another). During a review of Resident 6's History and Physical (H&P), dated 11/22/2023, the H&P indicated, Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Order Summary Report, dated 12/9/2023, the order summary report did not include an order for Resident 6's to go out on pass to visit with family for the Christmas holiday on 12/24/2023 or 12/25/2023. During a review of Resident 6's Progress Note, titled Alert Note, dated 12/18/2023 at 2:18 p.m., the progress note indicated Resident 6 requested an Out on Pass order for 12/25/2023. The progress note indicated Resident 6 verbalized that his family member (FM 1) would pick him up for Christmas dinner at approximately 5 p.m. and return him to the facility four hours later the same day. The progress note indicated that the resident's physician (MD 1) was notified and the facility was waiting for a response. During a review of Resident 6's Progress Note, titled Incident Note, dated 12/27/2023 at 3:49 p.m., the progress note indicated that the Director of Staffing Development (DSD) spoke with Resident 6's case manager from an outside entity. The DSD noted in the progress note that the case manager would file a complaint on behalf of Resident 6 because there was a text from MD 1 that stated Resident 6 could go out on pass for the Christmas holiday but he was not able to go. During a review of Resident 6's Progress Note, titled, Communication with Resident, dated 12/27/2023 at 4:20 p.m., the progress note indicated that the DSD spoke with Resident 6 regarding the incident. The DSD noted in the progress note that Resident 6 verbalized that he did not go out on pass because it was not in the computer. The DSD noted that Resident 6 verbalized being upset stating it's already past. During an interview on 1/9/2024 at 2:17 p.m., with Resident 6, Resident 6 stated that he was not happy with the facility because he requested an out on pass three weeks in advance to visit his family on Christmas Eve. Resident 6 stated that he informed the nursing staff that FM 1 was coming to pick him up on Christmas Eve and provided the nursing staff with all of the information in advance. Resident 6 stated that when his family arrived on Christmas Eve, the facility would not let him go because the paperwork had not been completed. During an interview on 1/11/2024 at 3:24 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she worked the day that Resident 6 requested to go out with his family. LVN 1 stated that she was not Resident 6's nurse, but she remembered Resident 6 asking to go out on pass for Christmas with his family that day. LVN 1 was asked where this incident would be documented. LVN 1 stated that the incident should be documented in the communications section or under Resident 6's nursing progress notes. During an interview on 1/11/2024 at 3:37 p.m., with the Social Services Director (SSD), the SSD stated there was no paperwork needed to go out on pass, just an okay from MD 1. During an interview on 1/11/2024 at 4 p.m., with the Director of Nursing (DON), the DON stated when a resident requests an out on pass, the resident's physician would be notified in advance to make sure it was safe, and the risks and benefits were reviewed before the resident was approved to go out on pass. During a concurrent interview and record review on 1/11/2024 at 4:50 p.m., with Registered Nurse (RN) 1 Supervisor, RN 1 stated that she was notified by the SSD on 12/18/2023 that Resident 6 requested an out on pass order to visit with family for the Christmas holiday. RN 1 stated that she notified MD 1 via text using the facility's cell phone on 12/18/2023 at 1:31 p.m. RN 1 stated that she did not get a response from MD 1 before the end of her shift on 12/18/2023, so she endorsed it to the next shift. RN 1 stated that the original request for Resident 6's out on pass was forwarded again via text using the facility's cell phone on 12/18/2023 at 7:02 p.m., but there was still no response from MD 1. RN 1 stated that MD 1 was notified again via text using the facility's cell phone on 12/22/2023 at 8:57 a.m., but there was no response from MD 1. RN 1 stated that MD 1 was notified again on 12/24/2023 at 4:37 p.m. RN 1 stated that according to the text, MD 1 replied on 12/24/2024 at 5:18 p.m. with K, which meant it was okay for Resident 6 to go out on pass. RN 1 stated that once MD 1 approved the out on pass for Resident 6, the nurse who received the approval via text, should place an order in the resident's electronic medical records (EMR). Resident 6's EMR was reviewed. RN 1 stated that she was unable to locate any documentation, including nursing notes or MD 1's orders approving an out on pass order for Resident 6 on 12/24/2023 or 12/25/2023. RN 1 stated that a simple note in the communications section of the EMR stating that the resident was okay to go out on pass with family and the physician's order was all that would have been required for the resident to go out on pass with his family. RN 1 stated that whoever notified MD 1 via text on 12/24/2023 and received the approval should have also documented that the out on pass was approved by MD 1. During a concurrent interview and record review with the Medical Records Director (MRD), the MRD was asked if she could find any documentation for Resident 6 regarding the resident's approval for an out on pass order for 12/24/2023 or 12/25/2023. The MRD stated that there was nothing documented regarding an out on pass approval for Resident 6 on 12/24/2023 nor 12/25/2023. During an interview on 2/12/2024 at 11:27 a.m., with the DSD, the DSD stated that Resident 6 was supposed to go out on pass with his family during the Christmas holiday, but apparently it did not happen. The DSD stated that the orders were not put into the computer. The DSD stated that the request for an out on pass for Resident 6 was approved by phone, the nurse that received the approval by phone should have documented the approval in the EMR as a telephone order. During a telephone interview on 1/12/2024 at 12:57 p.m. with Family Member (FM) 1, FM 1 stated that they called the facility 2 weeks prior to make sure that Resident 6 would be ready to visit for Christmas. FM 1 stated that they spoke with someone at the facility that confirmed Resident 6 could go out on pass and that everything had already been approved by the case worker. FM 1 stated that when the family arrived to pick up Resident 6, at 5 p.m. on Christmas Eve, they were informed that the facility would not allow Resident 6 to leave because there was no approval for an out on pass documented FM 1 stated that because the out on pass was not documented, they were unable to take Resident 6 out home with them for the Christmas holiday. During an interview on 1/12/2024 at 1:31 p.m. with the SSD, the SSD stated that there should have been documentation in Resident 6's communication note stating that he could go out on pass per the physician's order. During a review of the facility's policy and procedure (P&P) titled, Documentation, effective July 2019 and revised March 2023, the P&P indicated, It is the policy of the facility to document relevant findings in the clinical record. The P&P also indicated that physician communications should be charted in nursing notes or other notes. Changes in resident's conditions and/or incidents involving residents will be charted and new orders must be documented, signed, and noted by the nurse receiving the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a dignity bag (a bag used for privacy to cover and hold the urine collection bag so that it is not visible) was used to cover the urine collection bag for one of two residents (Resident 9). This deficient practice had the potential to cause embarrassment and affect Resident 9's self-worth and dignity. Findings: During a review of Resident 9's admission Record, dated 7/18/2023, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included quadriplegia (paralysis from the neck down, affecting all four limbs), anxiety disorder (a group of mental disorders characterized by significant feelings of fear), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/4/2023, the MDS indicated Resident 9 was moderately impaired with cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Resident 9 had impairment on both sides of the body to the upper and lower extremities (arms and legs). The MDS indicated Resident 9 required total assistance of two or more staff for eating, toileting, showering, dressing, personal hygiene and bed mobility (ability to move around in bed). During a review of Resident 9's History and Physical (H&P), dated 3/1/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Order Summary Report, dated 11/30/2023, the order summary report indicated Resident 9 had an active order, dated 2/23/2022, for a Foley/condom catheter (medical device that helps drain urine from the bladder) as needed related to quadriplegia. During a review of Resident 9's care plan titled, At risk for dignity issue, injury and/or compromised health and safety issues due to resident's preference to be up in wheelchair without us of dignity bag for catheter initiated on 10/18/2019 and revised 10/10/2022 with a target date of 4/4/2024, the care plan indicated Resident 9's goal was to honor preferences as much as possible every day. Staff's interventions indicated Resident 9's rights, preferences and dignity would be respected. During an observation on 1/9/2024 at 10:37 a.m., in Resident 9's room, observed Resident 9's urine collection bag hanging on the bed. The urine collection bag was not placed inside of a dignity bag. During a concurrent observation and interview on 1/10/2024 at 1:28 p.m., with Certified Nursing Assistant (CNA) 1, in Resident 9's room, CNA 1, was asked if Resident 9's urine collection bag was located in the right place. CNA 1 observed Resident 9's urine collection bag hanging on the side of the bed outside of the dignity bag. CNA 1 placed the urine collection bag into the dignity bag, and stated, I apologize. There is no excuse for that. CNA 1 stated that the urine collection bag should be stored inside of the dignity bag for the resident's privacy and dignity and the exposed urine collection bag could make the resident feel uncomfortable. During an interview with the Director of Nursing (DON) on 1/11/2024 at 4:12 p.m., the DON stated that the dignity bag was placed over the urine collection bag for privacy and to maintain the dignity of the resident. The DON stated Resident 9 could have emotional disturbances because of lack of dignity. The DON also stated that the dignity bag would ensure that the resident's urine output was not exposed to everyone. During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect effective date June 2018 and revised March 2023, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure residents' call lighs devices were placed within the resident's reach for three out of four sampled residents (Residents 13, 51, 122). This deficient practice had the potential to result in a delay or an inability for the residents to obtain necessary care and services as needed. Findings: a. During a review of Resident 13's admission Record, dated 7/18/2023, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included failure to thrive (a state of decline and may be caused by chronic diseases and functional impairments; manifestations include weight loss, decreased appetite, poor nutrition, and inactivity), hepatic encephalopathy (loss of brain function occurs when the liver is unable to remove toxins from the blood), end stage renal disease (ESRD - a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), type 2 diabetes mellitus (DM - condition that results in too much sugar circulating in the blood), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow), hyperlipidemia (an abnormally high concentration of fat particles in the blood). During a review of Resident 13's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/4/2023, the MDS indicated Resident 13 was severely impaired with cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Resident 13 required total dependence for eating, toileting, showering and bed mobility (ability to move around in bed), and required substantial assistance with dressing, oral hygiene, and personal hygiene. During a review of Resident 13's History and Physical (H&P), dated 9/7/2023, the H&P indicated, Resident 13 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 13 was on fall, decubitus (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin), and aspiration (accidentally inhaling food or liquid through the vocal cords into airway) precautions. During a review of Resident 13's care plan titled, High Risk for Fall, initiated on 6/20/2023 and revised 1/5/2024 with a target date of 4/4/2024, the care plan indicated Resident 13's goal was to minimize the risk of injury and falls for three months. Staff's interventions indicated to assist during transfers as needed, keep head of bed at lowest position, and place call light within reach. During a review of Resident 13's care plan titled, At Risk for Falls related to dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), impaired mobility, impaired cognition (trouble remembering, learning new things, concentrating, or making decisions that affects everyday life), general muscles weakness and confusion, initiated on 7/4/2023, revised on 7/17/2023 with a target date of 4/4/2024, the care plan indicated Resident 13 would have no falls through the review date. Staff's interventions indicdated to maintain safe and hazard free environment, call light within reach, and prompt resident to use when needing staff assistance. During an observation on 1/9/2024 at 2:05 p.m., observed Resident 13's call light lying on the floor next to the resident's bed. During a concurrent observation and interview on 1/9/2024 at 2:41 p.m., in Resident 13's room with Licensed Vocational Nurse (LVN) 1, LVN 1 was asked if Resident 13's call light was in an acceptable position to the resident. LVN 1 observed the call light on the floor, picked it up and placed it on the bed next to Resident 13. LVN 1 stated that he had just left Resident 13's room and was not sure how the call light got on the floor. LVN 1 stated that the call light was very important. LVN 1 stated that Resident 13 may need the call light to call out for something simple or the resident may need the call light to call out for an emergency. During an interview with the Director of Nursing (DON) on 1/11/2024 at 4:47 p.m., the DON was shown a picture of Resident 13's call light on the floor next to his bed. The DON stated that the call lights should be within the resident's reach and not on the floor. The DON also stated, if the resident cannot reach the call light, then the resident's needs could not be met. The DON stated anything could happen to the resident if they could not get assistance. During a review of the facility's policy and procedure (P&P) titled, Resident Call System, revised March 2023, the P&P indicated that the purpose of the resident call system is to provide staff with a method to respond to the resident's requests and needs. The P&P also indicated that the resident call system should be accessible to residents while in their bed or other sleeping accommodations within the resident's room. During a review of the facility's P&P titled, Reasonable Accommodations of Needs - Preferences, revised March 2023, the P&P indicated that each resident shall have access to the resident call system within reach and to the ability the resident is able to use it if desired. b. During a review of the Resident 51's admission Record, dated 1/11/2024, indicated Resident 51 was admitted to the facility on [DATE], with a diagnoses including but not limited to, acute chronic systolic heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), Hypertension (when the pressure in your blood vessels is too high), Hemiplegia and Hemiparesis ([Hemiplegia- refers to paralysis on one side of the body after a stroke] Hemiparesis [ weakness on one side of the body]), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Hyperglycemia (a condition in which a person's blood glucose level is higher than normal), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve). During a review of Resident 51's Minimum Data Set (MDS- comprehensive screening tool) dated 12/11/2023, indicated Resident 51 is moderately impaired, the resident can understand conversations. During a review of Resident 51's History and Physical (H&P), dated 12/8/2023, indicates Resident 51 has the capacity to understand and make decisions. During a review of Resident 51's Care Plan dated 12/7/2023, indicates High Risk for falls Recent Fall (with injury) history of fall, gait and balance awareness needs assist with transfers and ADL's. Goal Minimize risks of injury and fall times 3 months. Interventions include assist during transfers as needed, keep bed at lowest position, place call light within reach, place personal items within reach, regular visual checks, remove clutter from patient environment. During a review of Resident 51's Care Plan dated 12/11/2023, indicated Resident 51 has ADL deficit requiring assistance in D-Dependent, M-Maximal/Substantial, P-Partial/Moderate, S-Supervision/Touching, set up/clean up, I-independent. Goals include will participate in care daily by making simple choices and cooperating with tasks through review. ADL status will improve after completion of rehabilitation therapy, Will be kept clean and odor free daily through review date, will be out of bed daily as tolerated, will have no further decline in ADL status through review date, will not develop any skin breakdown through review date, Target date 3/7/2024. Intervention included Explain all procedures before performing tasks; allow the resident to participate in making choices in care, Encourage the resident to fully participate possible with each interaction. Praise all efforts at self-care, Call light within reach and prompt resident to use when needing staff assistance, answer promptly. c. During a review of the admission record indicated Resident 122 was admitted to the facility on [DATE] with a diagnoses including Heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), Hypertensive emergency (when the pressure in your blood vessels is too high), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Atherosclerosis of Aorta (when fat and calcium has built up in the inside wall of a large blood vessel called the aorta), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in the body), Systemic inflammatory Response syndrome [SIRS] (an exaggerated defense response of the body to a noxious stressor to localize and then eliminated the endogenous or exogenous source of insult), Dementia (loss of memory, language, problem solving and other thinking abilities that are severe), Muscle Weakness (full effort doesn't produce a normal muscle contraction). During a review of Resident 122's Minimum Data Set (MDS- comprehensive screening tool) dated 1/1/2024, indicates Resident 122 is severely impaired. And required extensive assistance from staff for his activities of daily living (ADL's). During a review of Resident 122's History and Physical (H&P), dated 1/24/2024, indicated Resident 122 does not have the capacity to understand and make decisions. During a review of Resident 122's Care Plan, dated 1/1/2024, indicated Resident 122 has an Alteration with ADL functions related to (r/t) generalized weakness, Dementia requiring assistance with the ADL's. Goals include Resident will be neat, clean, odor free and well groomed daily. Interventions include assist during transfer with safety, assist with ADLs as needed, encourage participation with ADLs for patient as tolerated, encourage patient to make decisions on grooming and dressing, ensure patient is neatly and appropriately dressed. Maintain call light within easy reach and answer promptly, maintain patient dignity by providing privacy and respecting patient rights and choices when providing ADL care. Set up, extensive assistance on bathing, grooming, hygiene, dressing, transfer. Total dependence on staff on ambulation and is at risk for falls. Goal included will not develop any skin breakdown through review date, will have no fall through review dated target date 1/16/2024, Interventions include call light within reach and prompt resident to use when needing staff assistance, answer promptly, encourage resident to maintain good oral hygiene, assist with brushing teeth, oral care when needed. During a review of the facility's policy and procedure (P&P) titled, Resident Call System, revised March 2023, the P&P indicated that the purpose of the resident call system is to provide staff with a method to respond to the resident's requests and needs. The P&P also indicated that the resident call system should be accessible to residents while in their bed or other sleeping accommodations within the resident's room. During a review of the facility's P&P titled, Reasonable Accommodations of Needs - Preferences, revised March 2023, the P&P indicated that each resident shall have access to the resident call system within reach and to the ability the resident is able to use it if desired. During an observation and interview on 1/9/2023 at 9:38 a.m. with LVN1, LVN1 stated while standing in Resident 51 room both bed 5A and 5C call light was not within reach. LVN1 reached down on the floor and picked up the call light button and attached them to Resident 51 and 122 bed. LVN stated it is important for the residents to have a call light within reach to request needed help.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. During a review of the Order Listing Report, dated 1/12/2024, the order listing report indicated that nine residents were receiving a regular diet. During observation of the lunch tray line on 1/9/2024 at 11:40 a.m., observed [NAME] 1 drop a red ladle on the kitchen floor that was used to serve regular size portions of gravy. Observed [NAME] 1 replace the red ladle with a white handled scoop which serves a smaller portion. During an interview on 1/9/2024 at 1 p.m., [NAME] 1, [NAME] 1 stated that she used the white smaller scoop to serve the gravy because she dropped the red ladle which is larger. [NAME] 1 stated that the ladles and scoops are numbered to indicate the portion size. [NAME] 1 admitted that the portion size of the white handled scoop was not the same size as the red ladle. During an interview on 1/9/2024 at 3:03 p.m. with DM 1, DM1 stated that when the wrong size ladle is used, the residents can receive portions sizes that are incorrect which can give them too much or too little nutrients. During a review of the facility's Policy and Procedure (P&P), titled, Menu Planning, dated 2013, the P&P indicated, Regular and therapeutic menus are written by the facility's food and nutrition professional in accordance with the facility's approved diet manual. All menus should be approved by the registered dietitian or designee. During a review of the facility's P&P, titled, Menu Substitution, not dated, the P&P indicated, To provide a substitute when an uncontrollable situation has temporarily made the item unavailable and decisions on menu substitutions will be made after discussion with the food service manager whenever possible. The P&P also indicated that the kitchen staff will consult with the food service manager or designee on any needed menu substitutions and the date, menu item, substitution and reason for the substitution will be recorded on the Menu Substitution Sheet. During a review of the facility's P&P, titled, Therapeutic Diet, dated March 2023, the P&P indicated, The facility ensures residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team. Based on observation, interview and record review, the facility failed to: 1. Follow menu as written for nine residents on renal and regular diets. 2. Follow menu one of nine residents (Resident 54) by putting crunchy fish instead of baked fish plate. This deficiency had the potential for resident to receive the wrong carb and caloric intake when not following the menu, resulting meal dissatisfaction, decreased nutritional intake and weight loss and potentially alter the nutritional value of meals for residents. Findings: A. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was initially admitted to the facility on [DATE]. Resident 54's diagnoses included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), gout (a type of inflammatory arthritis that causes pain and swelling in your joints). During a review of Resident 54's History and Physical (H&P), dated 9/7/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 54's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/12/2023, the MDS indicated Resident 54 had clear cognition (ability to learn, reason, remember, understand, and make decisions). During an observation of Resident 54's lunch tray on 1/12/2023 at 12:49 p.m., Resident 54 who was on a renal diet was served crunchy fish, mashed potatoes, mixed vegetables, chocolate yogurt mousse, beverage and 8-ounce milk. During a concurrent interview and record review on 1/12/2024 at 1:34 p.m. with [NAME] (CK) 1, a Picture of Resident's 54 meal ticket and meal tray for lunch on 1/12/2024 were reviewed. The CK1 stated that resident was on a renal diet. CK1 stated there should not be potatoes, milk and the fish should be baked fish. CK1 stated if they eat those curtain foods it could possibly hurt the resident by eating foods they are not supposed to eat. During a review of facility's Therapeutic Spreadsheet, dated 1/12/2024, the therapeutic spreadsheet indicated liberal renal and cc/renal diet menu was: Baked Fish, #8 scoop noodles, #16 scoop spinach/sauteed onions, 1 each roll/margarine, #8 scoop chocolate yogurt mousse, and 4-ounce beverage. During an interview on 1/12/2024 at 1:34 p.m. with [NAME] (CK) 1, CK1 stated I did make noodles for the residents on renal diet. CK1 stated that I forgot to put the noodles on the renal diet plates I put potatoes. CK1 stated it is important to follow the diets for vitamins, renal residents can't have citrus, no potatoes, no pork. CK1 stated if they eat those curtain foods it could possibly hurt the resident by eating foods they are not supposed to eat. During a review of the facility's Policy and Procedure (P&P) titled, Therapeutic Diet, dated March 2023, the P&P indicated, The facility ensures residents receive and consume foods in the appropriate form and/or the appropriate nutritive content on prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with this/her goals and preferences. Therapeutic diet, a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet. During a review of the facility's Policy and Procedure (P&P) titled, Menu Substitutions, undated, the P&P indicated, decisions on menu substitutions will be made after discussion with the food service manager whenever possible. Kitchen staff will consult with the food service manager or designee on any needed menu substitutions.

Based on observations, interviews, and facility policy review the facility failed to ensure food preparation operations were conducted under sanitary conditions in the facility's kitchen for 54 of 62 residents by. 1. Failing to ensure proper hand hygiene was performed during the preparation of meals. 2. Failing to ensure hairnets, gloves, and masks were worn while in the kitchen and during the preparation of meals. 3. Failing to ensure the kitchen was free of standing water on the kitchen equipment and the floor. 4. Failing to ensure there were no unopened foods or foods stored on the floor in the dry storage area. 5. Failing to ensure clean utensils were used to serve and prepare food. These deficient practices had the potential to put residents at risk by spreading illness, contaminating food, and causing the growth of microorganisms that could lead to food-borne illnesses (food poisoning). Findings: During the initial kitchen tour observation on 1/9/2024 at 8:56 a.m., observed the following: 1. Standing water on top of the juice machine and on the floor next to the juice machine. 2. Juice containers hanging out of the cartons and an empty juice container sitting on the shelf with red juice spilled on the juice cartons. 3. An open packet of sugar in the dry storage area. 4. 2 boxes of bananas and a crate with loaves of bread sitting on the floor in the dry storage area. During a concurrent observation and interview on 1/9/2024 at 10 a.m., with Dietary Manager (DM0 1, in the kitchen, the juice machine and dry storage area was observed. DM 1 stated that the juice machine had condensation that caused a puddle of water to accumulate on the machine. DM 1 stated that it was not sanitary to keep standing water in the kitchen because the standing water could attract bugs and fruit flies and could also be an electrical issue. DM 1 stated that anytime there was water or any other type of residue, it should be wiped up. DM 1 also stated that open food should not be in the dry storage area because the food could attract rodents and other pests. DM 1 stated that when food was delivered it should not be placed directly on the floor because the floor was dirty. DM 1 stated the vendors should have left the food on the cart or off the floor. During observation of the lunch tray line on 1/9/2024 at 11:57 a.m., DM 1 was observed wearing a baseball cap with hair exposed and not wearing a hairnet. DM 1 was also observed picking up a menu from the kitchen floor without wearing gloves. DM 1 then proceeded to handle the lunch trays and plates with her bare, unwashed hands. During observation of the lunch tray line on 1/9/2024 at 12:08 p.m., [NAME] 2 was observed dropping a piece of chicken onto the dirty countertop and used the prongs to pick up the piece of chicken from the countertop. [NAME] 2 continued to use the same prongs to place the chicken onto the residents' plates. During the lunch tray line observation on 1/9/2024 at 12:50 p.m., [NAME] 1 was observed preparing trays with her mask located under her chin and not covering her mouth and nose. During an interview on 1/9/2024 at 1 p.m., in the kitchen with [NAME] 1 and [NAME] 2, [NAME] 1 and [NAME] 2 agreed that hairnets and masks should be worn while preparing food. [NAME] 2 stated that if food falls on the countertop, it must be thrown away because the countertop was considered dirty. [NAME] 2 stated that she should have gotten a clean pair of prongs and not have continued to use the dirty prongs. During an interview on 1/9/2024 at 3:03 p.m., in the kitchen with DM 1, DM 1 stated that everyone that participated in the tray lines should wear gloves, hair nets and masks. DM 1 stated that the Infection Preventionist Nurse (IPN) gave DM 1 the regulations of whether to wear masks while on the tray line. DM 1 stated that it was mandatory to wear a mask because a couple of employees tested positive to COVID-19 (highly infectious respiratory infection) a few weeks prior. DM 1 stated that hairnets were to make sure hair did not get in the food or that particles from the hair did not contaminate the food. DM 1 stated that she did not have on a hair net because she thought that her cap would be sufficient. DM 1 stated that upon further investigation, she felt she should have put on a hairnet since the back of her hair was uncovered. DM 1 also stated that she should have had gloves while working on the tray line and she should have washed her hands before continuing to work on the tray line. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised March 2023, the P&P indicated, When food, food products or beverages are delivered to the nursing home, facility staff must inspect items for safe transport and quality upon receipt and ensure proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. The P&P also indicated that food and food products should always be kept off the floor and clear of the ceiling sprinklers, sewer/waste disposal pipes, and vents to maintain food quality and prevent contamination. Dry foods and goods should be handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. During a review of the P&P titled, Safe Food Preparation, revised March 2023, the P&P indicated, The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses. The P&P also indicated that food items can be re-contaminated by unsanitary handling practices or cross contaminated from other food products, utensils, and equipment. During a review of the facility's P&P titled, Food Contaminants, Revised March 2023, the P&P indicated, The most common chemicals that can be found in a food system are cleaning agents and insecticides. Chemicals used by the facility staff, in the course of their duties, may contaminate food (e.g., if a spray cleaner is used on a worktable surface while food is being prepared it becomes exposed to a chemical. The P&P also indicated that physical contaminants are foreign objects that may inadvertently enter the food. Examples include, but are not limited to, staples, fingernails, jewelry, hair, glass, metal shaving from can openers, and pieces or fragments of bones from fish or chicken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 41's admission Record, dated 12/22/2023, the admission record indicated Resident 41 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), congestive heart failure (CHF - when the heart is unable to pump enough blood to provide the body with the blood and oxygen it needs), pressure ulcer (bed sores or injuries to skin and underlying tissue resulting from prolonged pressure on the skin) Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) of the sacral region (tailbone) and pressure ulcers of the right and left heel. During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognition was severely impaired for daily decision making. The MDS also indicated that Resident 41 was totally dependent on two or more staff for eating, toileting, bathing, dressing and personal hygiene and required maximal assistance to roll left to right while lying on the back in bed. During a review of Resident 41's H&P, dated 12/11/2023, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to cleanse the left buttocks pressure injury with normal saline (medical solution used to cleanse wounds), pat dry, apply zinc oxide (promotes wound healing) and cover with dry dressing every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to cleanse/irrigate (flushing a wound with a gentle stream of liquid in order to remove dead tissue) the sacro-coccyx (lower back) pressure injury with normal saline, pat dry, apply Black Granufoam (used along with a negative pressure wound therapy system to aid and promote wound healing by removing excess exudates [fluid that leaks out of blood vessels into nearby tissues]), infectious material and tissue debris and cover with Tegaderm (a transparent dressing used to cover and protect wounds and maintain moisture) then apply negative pressure wound vacuum therapy (a method of drawing out fluid and infection from a wound to help it heal) at -125 millimeters of mercury (mmhg, unit of measurement) continuously every dayshift every 3 days for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to cleanse the left heel pressure injury with normal saline, pat dry and apply moist collagen matrix (a dressing that provides moisture to the wound) and cover with dry dressing as needed for 30 days if wet or dirty. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the left fifth toe blister every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the left fourth toe blister every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the left mid foot pressure injury every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the left great toe pressure injury every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the right second toe wound every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to cleanse the right heel pressure injury with normal saline, pat dry apply Santyl (an ointment used to remove dead tissue from wounds so they can start to heal) cover with dry dressing every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply the betadine to the side of the 5th toe on right foot pressure injury, cover with ABD (a gauze dressing that absorbs fluid from large or heavily draining wound) and wrap with dressing every dayshift for 30 days. Order date: 12/26/2023. During a review of Resident 41's Order Summary Report, dated 1/2/2024, the order summary report indicated Resident 41 had an active order to apply skin lotion to the middle section of the 1st toe on the right foot, pressure injury every dayshift for 30 days. Order date: 12/26/2023. During an observation on 1/11/2024 at 9:12 a.m., in Resident 41's room, observed Treatment Nurse (TN) performing wound care to Resident 41's various pressure injuries. After the TN completed wound care on the sacro-coccxy area, and applied the wound vacuum, the TN removed gloves, washed hands, and left Resident 41's room to get a clean Chux (a bed pads that protect beds and other surfaces from bodily fluids and can be tossed after use) from a cart located in the hallway. The TN returned to Resident 41 without performing hand hygiene. The TN then applied clean gloves, removed the soiled Chux and removed the soiled gloves and performed hand hygiene. During an observation on 1/11/2024 at 10:09 a.m., in Resident 41's room, observed the TN remove a soiled dressing from Resident 41's right foot, removed soiled gloves, performed hand hygiene, and proceeded outside of Resident 41's room to retrieve plastic cups from the treatment cart located in the hallway. The TN returned to Resident 41, sat the cups down on the table with clean wound care supplies and applied clean gloves but did perform hand hygiene. The TN then poured normal saline into the cups, soaked sterile gauze in the cups of normal saline and proceeded to clean the wound on Resident 41's right foot. The TN wrapped the right foot with a clean dry dressing, removed soiled gloves and performed hand hygiene. The TN then proceeded back to the treatment cart located in the hallway to retrieve more gloves. The TN returned, applied clean gloves but did not perform hand hygiene. The TN continued to clean the fifth left toe with normal saline. The TN then removed soiled gloves and performed hand hygiene. During an interview on 1/11/2024 at 10:41 a.m., with the TN, the TN was asked if it was acceptable to leave the room to retrieve supplies and proceed with wound care without performing hand hygiene. The TN stated that the treatment cart was cleaned before wound care was started on Resident 41 which meant the cart was clean and hand hygiene did not need to be performed. Asked the TN if she also cleaned the cart that supplies the Chux. The TN stated that she did not. The TN was also asked how she could ensure that the treatment cart remained clean when it was in the hallway while she was performing wound care on the resident. The TN stated that she could not ensure the cart was clean. The TN agreed that hand hygiene should have been performed before continuing with wound care when leaving the room to retrieve more supplies. The TN stated that hand washing prevented infections for the resident and for herself. The TN also stated that by not performing hand hygiene the resident could have been introduced to an infection casing the wound to get worse. During an interview on 1/11/2024 at 4:41 p.m., with the Director of Nursing (DON), the DON stated that handwashing was to prevent contamination and cross infection or infecting a wound. The DON stated, Hand washing is a priority. The nurses should have wash their hands each time they return from the treatment cart. During a review of the facility's policy and procedure (P&P) titled, Negative Pressure Wound Therapy effective date November 2017 and revised March 2023, the P&P indicated guidelines that included using aseptic technique for the procedure. During a review of the facility's P&P titled, Hand Washing-Hand Hygiene, effected date August 2018 and revised March 2023, the P&P indicted that the facility considers hand hygiene the primary means to prevent the spread of infections. Personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. And shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections of other personnel, residents, and visitors. Based on observation, interview, and record review, the facility failed to observe infection control measures for two of two sampled residents (Resident 41, Resident 51) by failing to: 1. Ensure Resident 51's indwelling catheter (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor. 2. Ensure hand hygiene was performed after touching soiled items while performing wound care on Resident 41. These deficient practices resulted in contamination of the resident's care equipment and placed the residents at risk for infection and had the potential to spread infection that could delay the healing process and cause further complications for Resident 41. Findings: a. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses including but not limited to, acute chronic systolic heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), hypertension (high blood pressure), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body), Type 2 diabetes mellitus (high levels of sugar in the blood), hyperglycemia (a condition in which a person's blood glucose level is higher than normal), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve). During a review of Resident 51's Minimum Data Set (MDS- comprehensive screening tool) dated 12/11/2023, the MDS indicated Resident 51 had moderately impaired cognition (ability to think and reason) and was able to understand conversations. During a review of Resident 51's History and Physical (H&P), dated 12/8/2023, the H&P indicated Resident 51 had the capacity to understand and make decisions. During a review of Resident 51's Care Plan titled, Risk for infection due to use of foley catheter related to Neurogenic Bladder (when a person lacks bladder control due to brain, spinal cord or nerves of the urinary system), dated 12/7/2023, the care plan indicated Resident 51 would show no signs and/or symptoms of infection related to use of the catheter until the next review date (target date 3/7/3034). The staff's interventions included to provide catheter care and monitoring daily, educate resident / representative on techniques to prevent infection, such as handwashing, adequate rest, nutrition and avoidance of crowds, encourage fluids, monitor for signs/symptoms of infection, monitor laboratory results, staff to flow standard precautions, including proper hand washing techniques, to minimize microorganism transmission, and maintain catheter bag below the level of the resident's bladder. During a concurrent observation and interview on 1/9/2023 at 9:35 a.m. with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the catheter bag should not be touching the floor. LVN 1 began to increase the height of the bag until the catheter was off floor. During a review of the facility's Policy and Procedure (P&P) titled, Bowel Bladder Incontinence Catheter UTI, dated 3/2023, the P&P indicated . To ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. Residents admitted with incontinence of bladder, receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement abuse prohibition and prevention program policy and procedure by not reporting an allegation of physical abuse for one of three sampled resident (Resident 1) to the California Department of Public Health (CDPH), after Resident 2 slapped Resident 1 on the face on 12/10/2023. This deficient practice had the potential for the underreporting of abuse incidents, and delay in investigation a physical abuse allegation, placing Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), cardiomyopathy (enlargement of heart), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/7/2023, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated, Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, and upper body dressing (the ability to dress and undress above the waist). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), atrial fibrillation (irregular and abnormal heartbeat), and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/14/2023, the MDS indicated Resident 2's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated, Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating and oral hygiene. During a review of Resident 2's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 12/10/2023, electronically signed by Registered Nurse (RN 1), the SBAR indicated Resident 2 slapped another resident (Resident 1) in the face. During an interview on 12/26/2023 at 12:15 p.m. with the Director of Staff Development (DSD), the DSD stated he was fully aware of the incident that happened between Resident 1 and Resident 2 as it was mentioned in the huddle and stand-up meeting. The DSD stated he did not report the allegation to the licensing agency since he assumed that the Administrator (ADM), Director of Nursing (DON), and the Social Service Director already did the reporting since they did initiate and conducted the investigation. The DSD stated any allegation of abuse should be reported to California Department of Public Health (CDPH) immediately so they can conduct their own investigation. The DSD stated the facility did not follow the process of abuse reporting to the regulatory agency and the risk of not reporting abuse in a timely manner can result in jail and monetary fine. During an interview on 12/26/2023 at 12:45 p.m. with the Social Services Director (SSD), the SSD stated the physical altercation between Resident 1 and Resident 2 occurred on the weekend. The SSD stated any allegation of abuse should be reported to the CDPH and the timeframe was 2 hours if there is an injury and 24 hours if no bodily injury. The SSD stated it was very important to report to the licensing agency for the safety and well-being of all the residents in the facility. During a concurrent interview and record review on 12/26/2023 at 1:23 p.m. with the Administrator (ADM), the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) provided by the facility, was reviewed. The ADM stated, the SOC 341 was completed on 12/10/2023 by RN 1 and RN 1 made a telephone report to Adult Protective Services (APS), Law Enforcement Agency and Ombudsman. The ADM could not provide any evidence that RN 1 called the CDPH or faxed the SOC 341 to CDPH or Local District Office. The ADM stated the process for abuse reporting was to call in, fax the SOC 341, and submit the initial report to CDPH. The ADM stated it was an oversight on his part, the abuse was reported to a different government agency, not to CDPH. The ADM stated for any allegations of abuse such as physical, verbal, misappropriation of property, seclusion, neglect, resident to resident altercation, being the abuse coordinator, he needs to report to CDPH immediately within 2 hours. The ADM stated he will inform the and submit his written report to CDPH today or tomorrow. During a review of the facility's policy and procedure (P&P), titled Abuse Prohibition and Prevention Program, revised October 2022, the P&P indicated, The facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriations of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prohibition and prevention program policy by failing to submit the results of the investigation of an allegation of physical abuse to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of three sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), cardiomyopathy (enlargement of heart), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/7/2023, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated, Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, and upper body dressing (the ability to dress and undress above the waist). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), atrial fibrillation (irregular and abnormal heartbeat), and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/14/2023, the MDS indicated Resident 2's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated, Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating and oral hygiene. During a review of Resident 2's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 12/10/2023, electronically signed by Registered Nurse (RN 1), the SBAR indicated Resident 2 slapped another resident (Resident 1) in the face. During an interview on 12/26/2023 at 12:45 p.m. with the Social Services Director (SSD), the SSD stated the physical altercation between Resident 1 and Resident 2 occurred on the weekend. The SSD stated any allegation of abuse should be reported to the CDPH and the timeframe was 2 hours if there is an injury and 24 hours if no bodily injury. The SSD stated it was very important to report to the licensing agency for the safety and well-being of all the residents in the facility. The SSD stated the Administrator (ADM) and Director of Nursing (DON) conducted the investigation but she was not given any update regarding the outcome of the investigation. The SSD stated the facility should submit the final written result of investigation to CDPH in 7 days after the incident. During an interview on 12/26/2023 at 1:23 p.m. with the Administrator (ADM), the ADM stated for any allegations of abuse such as physical, verbal, misappropriation of property, seclusion, neglect, resident to resident altercation, being the abuse coordinator, he needs to report to CDPH immediately within 2 hours and the final investigation report within 5 days. The ADM stated he did not submit the final report to CDPH because he does not have the full conclusive result of the investigation since Resident 1 was discharged on 12/11/2023. ADM stated moving forward he will call CDPH for the initial report and submit the final investigation summary result within the timeframe. During a review of the facility's policy and procedure (P&P), titled Reporting of Alleged Violations, revised October 2022, the P&P indicated, A completed copy of all investigation findings, documentation forms and written statements from witnesses, for all allegations of abuse, must be provided to the Administrator/designee; and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken.

Based on interview and record review, the facility failed to ensure controlled narcotic drugs (strong pain medicine) for one of three sampled residents (Resident 1) was accurately accounted for. This deficient practice resulted in 30 tablets of Norco 10-325 mg for Resident 1 and the narcotic count sheet missing. This deficient practice had the potential of preventing Resident 1 from getting the prescribed medications and exposing the staff and others to drug misuse or diversion. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 5/10/2023 with diagnoses including fracture (cbroken bone) of the left arm, Fall, bipolar disorder (a disorder associated with episodes of mood swings), hypertension (high blood pressure), and major depressive disorder (Persistent feeling of sadness and loss of interest). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/17/2023, indicated Resident 1 had the ability to understand and to be understood by others. The MDS indicated Resident 1 required limited to extensive assistance with transfer, dressing, and eating. A review of Resident 1 ' s history and physical examination (H & P) dated 5/11/2023 indicated had the capacity to understand and make decisions. A review of Resident 1 ' s physician ' s Active Order dated 5/29/2023 indicated Norco 5-325millugrams ([mg] unit of measurement), one tablet by mouth every 4 hours for moderate pain. A review of Resident 1 ' s physician ' s order dated 5/31/2023 indicated Norco 10-325 mg by mouth every 4 hours for severe pain. A review of Resident 1 ' s Medication Administration Record (MAR) indicated Resident 1 was receiving Norco 10-325 mg since 5/10/23 as a needed for pain. During an interview, on 6/9/2023 at 11:50 a.m., with the Director of Nursing (DON), the DON stated on 5/30/2023 she was notified Resident 1 ' s Norco 10-325 mg was missing along with the narcotic count sheet. The DON stated she interviewed the staff, and none of them could give an account of the missing narcotics. During an interview, on 6/9/2023 at 12:25 p.m., with Licensed vocational Nurse (LVN) 1, LVN 1 stated on 5/27/2023 around 10 p. m., the pharmacy delivered Norco 10-325 mg for Resident 1. LVN 1 stated she signed the ticket brought in by the pharmacy personnel indicating that she received Resident 1 ' s narcotic. LVN 1 stated she put the new Norco in the narcotic drawer and placed the narcotic sheet in the narcotic count binder. LVN 1 stated at the end of her shift she counted the narcotics in the drawer with the incoming nurse LVN 2, and the count was correct. LVN 1 stated all the narcotics drugs were accounted for. LVN 1 stated she was off for two days and when she returned to work on 5/30/2023 for the 3 to 11 pm shift, LVN 3 asked if LVN 1 received Resident 1 ' s Norco from the pharmacy, and she stated yes that it should be in the narcotic drawer. LVN 1 stated she was then informed that the Norco was missing and was not in the narcotics drawer. During an interview on 6/9/2023 1:05 p.m., with LVN 2, LVN 2 stated she counted the narcotics at the start of her shift (night shift) with the evening shift nurse and the count was correct. LVN 2 stated that she did not recall seeing a new bubble pack Norco for resident 1 and, did not recall seeing the narcotic count sheet. During an interview on 6/9/2023 at 2:10 p.m., with LVN 3, LVN 3 stated that on 5/27/2023 she put in a request for Resident 1 ' s Norco 10-325 mg to be refilled because it was running low. LVN 3 stated on 5/30/2023, Resident 1 requested for Norco 10-325 mg for severe pain rated at 8 (on a scale of 0-10, with 10 being the worse pain). LVN 3 stated when she checked the Narcotics drawer to administer the medication to Resident 1, she noticed there was no Norco in the narcotic drawer. LVN 3 stated she called the pharmacy and was told Resident 1 ' s Norco was delivered on 5/27/23 at approximately 10 p.m. LVN 3 stated she looked for the Norco in the medication room and in the other medication cart, but could not find it. LVN 3 stated she reported the incident to the DON and since Resident 1 was in severe pain, she called the pharmacy and with their permission she removed Norco 10-325 mg from the E-kit (Emergency medication Kit) and medicate Resident 1. During an interview on 6/9/2023 at 3:38 p.m., with the Administrator (ADM), the ADM stated the facility was still investigating the incident. The ADM Stated Resident 1 did not suffer much pain due to the loss of her medication because the staff was able to manage Resident 1 ' s pain with the medication from the E-kit. A review of the facility ' s policy and procedures (P/P), dated 3/2023, titled, Safeguarding Controlled Substances indicated, the facility will establish guidelines for safe handing receiving, storing, administering, reconciling, and safeguarding controlled substances. The P/P indicated the following: 1. Only authorized License nurse and pharmacy personnel will have access to controlled substances. 2. Only those nurses assuming responsibility over a particular supply of controlled substances will be authorized to possess the keys to access that supply until such responsibility is assumed by another nurse. 3. The director of nursing will maintain back-up keys to all medication storage areas including those for controlled medications. 4. Controlled substances are to be appropriately stored under two (2) separate locks as required. 5. Controlled substances will be counted at the onset and completion of each shift by two nurses and verified accurately through each nurses ' signature on the reconciling log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse Reporting & Investigations by not reporting an alleged abuse incident to the California Department of Public Health (CDPH) within 2 hours for one of three sampled residents (Resident 1). Resident 1 alleged a Certified Nursing Assistant (CNA) 1 pushed his fingers backward. As a result of not reporting to the CDPH there was a delay in the investigation by the State agency. Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including repeated falls, muscle weakness and multiple fractures of the ribs. During a review of Resident 1 ' s History and Physical (H/P), dated 4/7/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/26/22, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required a one-person assist for bed mobility, locomotion (moving from one place to another), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required a two-person assist for transfers. During a review of Resident 1 ' s radiology ([X-RAY] process of taking pictures of body tissues and structures inside the body) results dated 10/23/20233 indicated acute right fifth proximal phalanx fracture. During a review of the facility ' s Final Summary report dated 10/28/2022, the report indicated on 10/22/22, at 10:35pm., during care, a Certified Nursing Assistant (CNA) 2, observed a slight swelling at the base of Resident 1 ' s right fifth digit. The report indicated CNA 2 notified Licensed Vocational Nurse (LVN) 2 of the incident. During an interview with the Director of Nursing (DON) on 10/27/2022 at 3:30 p.m. the DON stated Licensed Vocational Nurse (LVN) 1 was aware of the abuse allegation on 10/22/2023 at 10:28 p.m., but LVN 1 did not notify the DON and did not report the incident to the Department within 2 hours per the facilities policy. The DON stated on 10/23/2022 at 3:00 p.m., LVN 4 notified the DON of the incident and report was submitted to the CDPH on 10/23/2023 around 8:50 p.m. The DON stated not reporting the alleged abuse incident timely could have led to more abuse. During a review of the facility ' s P/P titled Abuse - Reporting & Investigations and dated March 2018, the P/P indicated its purpose was to protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. The P/P indicated the Administrator or designated representative will notify law enforcement immediately by telephone and in writing (SOC-341) within two (2) hours of an initial report of alleged physical abuse resulting in serious bodily injury. (Serious bodily injury means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ or of mental faculty, or requiring medical intervention, including but not Limited to, hospitalization, surgery, or physical re habilitation.) B. Administrator or designed representative will also notify the LTC Ombudsman, and CDPH by telephone and in writing (SOC 341) within two (2) hours of initial report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to implement its abuse policies and procedures (P/P) titled Reporting of Alleged Violations by failing to remove Certified Nursing Assistant (CNA) 1 from the facility after one of three sampled residents (Resident 1) alleged CNA 1 grabbed Resident 1 ' s right hand and bent the fourth (4th) and fifth (5th) fingers backwards, 10/22/2023 at 10:35 p.m. This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including repeated falls, muscle weakness and multiple fractures of the ribs. During a review of Resident 1 ' s History and Physical (H/P), dated 4/7/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/26/22, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required a one-person assist for bed mobility, locomotion (moving from one place to another), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required a two-person assist for transfers. During a concurrent observation and interview on 10/27/2022 at 11:40 a.m., in Resident 1 ' s room, Resident 1 was noted with a purple and green discoloration at the base of the first knuckle of pinky (small) and ring fingers. Resident 1 was noted with discoloration on the palm of the right hand. Resident 1 stated on 10/22/2022, CNA 1 took her to the shower and did not talk to her at all. Resident 1 stated CNA 1 opened the shower head, sprayed very hot water on her (Resident 1) and CNA 1 started to wash the resident. Resident 1 stated she told CNA 1 the water was too hot, and that she (CNA 1) was burning her. Resident 1 stated CNA 1 kept pouring the very hot water from her feet moving towards her upper body and as the water was reaching Resident 1 ' s face, Resident 1 raised her hands to protect her face from the hot water. Resident 1 stated CNA 1 threw the shower head on the floor and CNA 1 grabbed Resident 1 ' s fingers with her hand placing her weight onto the resident ' s right hand. Resident 1 stated she told CNA 1 that she was breaking her hand, but CNA 1 kept pushing on her fingers with all her weight. Resident 1 stated she kept yelling at CNA 1 to stop but CNA 1 would not stop, until Resident 1 tried to reach out with her left hand and attempted to pull CNA 1 ' s hair then CNA 1 stopped. Resident 1 stated her right hand hurt so bad and she reported the entire incident to CNA 2 and Licensed Vocational Nurse (LVN) 1 during night shift. During an interview with Licensed Vocational Nurse (LVN 1) on 10/27/2023 at 12:45 p.m. LVN 1 stated she (LVN 1) worked on the 3:00 p.m. to 11:00 p.m., shift. LVN 1 stated on 10/22/2023 at 10:45 p.m., Resident 1 reported she had swelling, pain and discoloration to her right hand. LVN 1 stated she observed right lower hand swollen, bluish, purple and when she touched the area Resident 1 complaint of pain. Resident 1 informed her that CNA 1 hurt her in the shower. LVN 1 stated she did a change of condition report and endorsed it to the next shift. LVN 1 stated she did not send CNA 1 home that night because CNA 1 had to complete her assignment. During an interview with Certified Nurse Assistant (CNA 3) on 10/27/2023 at 1:30 p.m. CNA 3 stated that night CNA 1 was doing a double shift with her, and that CNA 1 was not sent home. During an interview with the Director of Nursing (DON) on 5/31/2023 at 1:31 p.m., the DON stated the facility was supposed to remove the alleged perpetrator (CNA 1) immediately after Resident 1 alleged to have been abused. The DON stated the alleged abuser if a staff member, must be suspended until the allegation was investigated. The [NAME] stated not removing an alleged perpetrator could cause harm including stress, anxiety ad fear to Resident 1 and other residents in the facility. During a review of the facility ' s P/P tiled Abuse-Reporting & investigations dated March 2018, the P/P indicated the facility would report all allegations of abuse as required by law. The P/P indicated the if the suspected perpetrator was an employee, the facility would remove the employee immediately from the care of the resident(s)and immediately suspend the employee pending the outcome of the investigation in accordance with the facility ' s policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment for one (Resident 2) out of three residents by failing to ensure: 1. Exercise of resident ' s right to deny visitors by not being aware of, or monitoring visitors who enter residents ' (Resident 2) room without their permission or knowledge beforehand. 2. Monitoring who enters and exits the facility from an unlocked and unmonitored back entrance. This failure had the potential to result in psychosocial harm for Resident 2 per his statement that he does not feel safe since people have entered his room without his permission or knowledge beforehand. During a record review of Resident 2 ' s Face Sheet, dated 5/16/2023, indicated Resident 2 was admitted on [DATE]. Resident 2 had admission diagnosis that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), amputation of left lower extremity, and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to limbs). During a record review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), indicated Resident 2 ' s cognitive decision was mildly impaired, and Resident 2 required extensive assistance for personal hygiene. During a concurrent observation and interview, on 5/16/2023, at 11:59 a.m., with Resident 2, in his room, Resident 2 was wheelchair bound, alert and oriented, and stated he does not feel safe since the back entrance facility doors are unlocked. Resident 2 stated a few months ago a random person came in his room, and a month ago his prosthetist and pastor just walked in his room unannounced. Resident 2 stated his pastor did not check in with the front, and he would appreciate it if staff would let him know before someone enters his room so he can be presentable and prepared. Resident 2 stated he told a charge nurse about his concern for safety with people being able to walk in unnoticed, but she just apologized and stated they did not notice. Resident 2 does not remember the nurse ' s name. Resident 2 stated they have no security, and nobody monitors the back entrance like they used to. Resident 2 stated he brought up his safety concern in resident council meetings, but nothing came of it. During an observation on 5/16/2023, at 12:15 p.m., outside the back entrance, the door was fully closed, with a buzzer noted on the side of the wall, but author was able to open it and come in without being noticed or having to use the buzzer. Staff were busy in rooms and hallways and did not acknowledge entrance. There was a sign at the door that stated STOP, visitors and vendors, please check in and wait for a visitor badge to print, then go to the nursing station for assigned visitation area, which was next to a kiosk machine. During an observation on 5/16/2023, at 1:00 p.m., outside the back entrance, the door was fully closed, and author was able to open it and come in without being noticed due to no staff being around. During an interview on 5/16/2023, at 1:05 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated staff used to sit at the back entrance, and staff must know who is in the facility. CNA 1 stated visitors must call ahead of time to coordinate visits and must go through the front entrance. CNA 1 stated there are no security measures in. CNA 1 stated that it could potentially be bad for residents if the wrong person gets in unnoticed. During an interview on 5/16/2023, at 1:23 p.m., with Registered Nurse (RN) 1, RNA 1 stated visitors are allowed to check themselves in, but they advise visitors to call and schedule before showing up. RN 1 stated she has been working here for 6 years, and prior to COVID, visitors are allowed to walk in through the back without being monitored until 5p.m RN 1 stated now that the COVID guidelines have changed they do not need to monitor the doors. RN 1 stated something could potentially happen to residents if the wrong person gets in the building. During an interview on 5/16/2023, at 1:30 p.m., with the Director of Nursing (DON), DON stated visitors are to check in at the front and call ahead of time to coordinate visits. DON stated visitors that are not allowed to visit residents (Resident 2) could potentially come in through the back entrance since it is unlocked and unmonitored. DON stated they do not have a policy on keeping the doors locked/unlocked. DON states administrator is out of the country until Monday, 5/22/23. During a review of the facility ' s policy and procedure (P&P) titled Resident Rights, dated 8/2020, indicated residents have a right to visit and be visited by others outside from the facility. However, Resident Rights policy does not mention residents ' right to refuse visitation or deny a visitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices according to the facility's policy and procedure (P/P) by failing to: 1. Ensure Certified Nurse Assistant (CNA 1) performed hand hygiene (cleaning hands by handwashing or using alcohol-based hand sanitizer) after handling dirty linen and prior to touching the clean linen and supplies cart. 2. Ensure CNA 3 wore a face shield or eye protection (protective covering for the eyes and face worn to reduce the spread of a transmissible disease) while assisting residents in the red cohort (area in the facility to house residents who have covid-19 [a highly contagious respiratory infection caused by a virus that can easily spread from person to person). These deficient practices had the potential for cross contamination and spread of covid-19 which could lead to hospitalization or death to facility residents and staff. 1. During an observation on 3/16/2023 at 10:46 a.m., CNA 1 was observed, coming out of Resident's 1 room, holding a plastic bag with a dirty blanket without wearing gloves. CNA 1 proceeded to open the lid to the dirty linen recepticle lid to place the soiled blanket inside then walked to the clean linen and supplies cart to obtain a deodorant without performing hand hygiene. During an interview on 3/16/2023 at 10:50 a.m. with CNA 1, CNA 1 stated, she had forgotten to sanitize her hands before touching the clean supplies cart and also stated, it was very important to sanitize or wash hands when working between dirty and clean areas for safety reasons and to prevent the spread of covid 19 to residents and staff. 2. During an observation on 3/16/2023 at 12:10 p.m., CNA 3 was observed not wearing a face shield while passing lunch trays and assisting residents inside of resident's rooms [ROOM NUMBER] in the red cohort. During an interview on 3/16/2023 at 12:20 p.m. with CNA 3, CNA 3 stated she had forgotten to put her face shield on after removing it to eat lunch. CNA 3 also stated it was very important to use full Personal Protective Equipment ([PPE], equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) which included a gown, mask, gloves, and face shield in the red cohort to prevent the spread of covid 19. During an interview on 3/16/2023 at 2:30 p.m. with Infection preventionist (IP), IP stated, staff were required to wear a face shield when entering resident's rooms and providing any care or assistance to residents in the red cohort. IP stated it was important to ensure staff wore proper PPE to prevent the spread of covid 19. IP also stated, staff needed to perform hand hygiene after touching dirty surfaces and before touching clean linen and supplies to prevent the spread of infection. During a review of the facility's P/P titled, Hand Hygiene dated 8/2020, the P/P indicated personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Personnel should follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. During a review of the facility's P/ P titled, Covid-19 Mitigation Plan, dated 3/3/2023 the P/P indicated, PPE for covid 19 included use of eye protection in all resident care areas in the Red Cohort. The P/P also indicated covid 19 designed areas should have signage at the entrance or start of rooms instructing health care provider to wear eye protection: or when splashes, spills, or respiratory secretions spray were anticipated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors for four of four sampled residents (Residents 1, 2, 3, 4) by failing to ensure Residents 1, 2, 3, and 4 received their medications in a timely manner as ordered. This deficient practice had the potential to cause complications of hypertension ([HTN] high blood pressure); inadequate blood sugar management, which can cause hyperglycemia (high blood sugar) and if left untreated could lead to complications, such as eye, kidney, or heart disease, nerve damage; risk of blood clots, an increase in eye pressure that can lead to damage to the optic nerve; possible worsening symptoms of asthma; relapse in symptoms of depression; increased incidence of heart attack and stroke; and an increase in seizure frequency. Findings: 1. During a review of Resident 1's Face sheet (admission record), the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including paroxysmal atrial fibrillation ([AFIB] occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days), myocardial infarction (heart attack), and HTN. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 3/3/2023, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think). The MDS indicated Resident 1 had clear speech, and the ability to understand and be understood by others. The MDS indicated Resident 1 required limited assistance for activities of daily living (ADL'S) including bed mobility. The MDS also indicated Resident 1 required extensive assistance with transfer (how resident moves between surfaces to or from; bed, chair; wheelchair, standing positions), walking, locomotion (how resident moves between locations), dressing, toilet use, and personal hygiene. During a review of Resident 1's Care Plan titled, Potential for elevated blood pressure dated 1/26/2023, the care plan intervention indicated to provide medication as ordered by the doctor. During a review of Resident 1's Care Plan titled, At risk for impaired output related to atrial fibrillation dated 1/26/2023, the care plan intervention indicated to provide medication as ordered by the doctor. During a review of Resident 1's Physician's Order Summary Report dated 1/13/2023, the report indicated to administer the following medications: 1. Apixaban (medication used to treat AFIB) 5 milligrams ([mg] unit of measurement) 0.5 tablet (tab) by mouth every 12 hours for AFIB. 2. Lisinopril (medication used to lower blood pressure) 2.5 mg, 1 tab by mouth in the morning for HTN. 3. Metoprolol Tartrate (medication used to lower blood pressure) 50 mg, 1 tab by mouth in the morning for HTN. 4. Dorzolamide HCL solution 2% 1 drop to right eye two times a day, 9:00 a.m. and 5:00 p.m., for right eye blindness. During a concurrent interview and record review on 3/13/2023 at 2:44 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 1's Medication Administration Record (MAR) dated 3/2023, was reviewed. The MAR indicated Resident 1 was given her 9:00 a.m. Apixaban, Lisinopril, Metoprolol and Dorzolamide scheduled medications at 11:50 a.m. LVN 2 stated she was late to pass Resident 1's medication because she was not familiar with the facility's system. LVN 2 stated on average it takes about five to 15 minutes to pass each resident's medications. LVN 2 also stated she had 27 residents to pass medications to that day. LVN 2 stated medications should be administered one hour before or one hour after the scheduled time. LVN 2 further stated the importance of administering medications on time was for residents to always have a consistent amount of any given medication for health improvement. During a concurrent interview and record review on 3/16/2023 at 12:16 p.m., with LVN 3, Resident 1's MAR dated 3/2023 was reviewed. The MAR indicated Resident 1's morning medications Apixaban, Lisinopril, Metoprolol was due at 9 a.m., and was administered late on the following dates and times: 3/2/2023 at 10:18 a.m. 3/3/2023 at 10:43 a.m. 3/5/2023 at 10:43 a.m. 3/7/2023 at 10:55 a.m. 3/8/2023 at 11:14 a.m. 3/11/2023 at 10:16 a.m. 3/13/2023 at 11:50 a.m. The MAR indicated Dorzolamide scheduled to be administered at 9 a.m., and 5 p.m., was given late as follows: 3/2/2023 at 10:18 a.m. 3/3/2023 at 10:43 a.m. and 8:23 p.m. 3/4/2023 at 7:01 p.m. 3/5/2023 at 10:43 a.m. 3/7/2023 at 10:55 a.m. 3/8/2023 at 11:14 a.m. 3/9/2023 at 7:14 p.m. 3/10/2023 at 7:58 p.m. 3/11/2023 at 10:16 a.m. 3/13/2023 at 11:50 a.m. 2. During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction ([CVA] when a clot blocks a blood vessel that feeds the brain and causes cell death), diabetes mellitus ([DM] abnormal blood sugar), and HTN. During a review Resident 2's Physician's Progress Notes, dated 2/1/2023, the progress notes indicated Resident 2 was depressed and to continue taking Lexapro (medication used to treat depression). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment (ability to think). The MDS also indicated Resident 2 had clear speech, and the ability to understand and be understood. The MDS indicated Resident 2 received antidepressants and opioids. The MDS indicated Resident 2 required extensive assistance for activities of daily living (ADL'S) including bed mobility, transfer (how resident moves between surfaces to or from; bed, chair; wheelchair, standing positions), walking in room, locomotion (how resident moves between locations), dressing, toilet use, and personal hygiene. During a review of Resident 2's undated History and Physical (H&P), the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Care Plan titled, Potential for elevated blood pressure (BP) initiated on 8/1/2022, the care plan intervention indicated to provide medication per doctor order. During a review of Resident 2's Care Plan titled, Alteration in comfort related to CVA, DM, HTN initiated on 8/1/2022, the care plan intervention indicated to provide medication as ordered. During a review of Resident 2's Care Plan titled, At risk for bleeding and unusual bruising related to anticoagulant initiated on 8/1/22, the care plan intervention indicated to give medication per doctor. During a review of Resident 2's Care Plan titled Resident on anti- depressant therapy (Lexapro) for major depressive disorder initiated on 2/3/2023, the care plans intervention indicated to administer antidepressant medications as ordered by physician. During a review of Resident 2's Physician Order Summary, dated 8/1/2022- 1/11/2023, the physician orders indicated to administer the following medications: 1. Advair Diskus Aerosol Powder Breath Activated 250- 5 micrograms ([mcg] unit of measurement) two puffs inhale orally two times a day for COPD. 2. Carvedilol 3.125 mg, 1 tab by mouth two times a day for HTN. 3. Lexapro tablet 10 mg, 1 tab by mouth in the morning for depression. 4. Lisinopril tab 10 mg, 1 tab by mouth one time a day for HTN. 5. Metformin HCL tab 500 mg, 1 tab by mouth two times a day for DM, take with food or snack. 6. Norvasc tab 10 mg, 1 tab by mouth one time a day for HTN. 7. Plavix tab 75 mg, 1 tab by mouth one time a day for DVT. 8. Singular tab 10mg, 1 tab by mouth one time a day for COPD. During a concurrent medication pass observation and interview with LVN 1 and Resident 2, on 3/13/2023, at 12:01 p.m., in front of Resident 2's room, LVN 1 was preparing to administer Resident 2's 9 a.m. scheduled medications. Resident 2 stated she was very upset because she has not received her morning medications until now. Resident 2 stated it was important for her to get her blood pressure medications. Resident 2 stated it made her feel angry when she received her medications late. LVN 1 stated she had a 2-hour window to administer Resident 2's medications, but was distracted with other residents. During a concurrent interview and record review on 3/13/2023 at 2:06 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR dated 3/2023, was reviewed. Resident 2's MAR indicated Resident 2 received her morning medications on 3/13/202 at 12:10 p.m. LVN 1 stated medications should be given one hour before or one hour after their scheduled times. LVN 1 stated if a resident refused medications, she (LVN 1) returned within 30 minutes to attempt giving the resident the medication again. LVN 1 stated if one license nurse assigned to administer medications to 26 residents in the morning with no additional gastrostomy tube ([G- tube] a tube inserted through the wall of the abdomen directly into the stomach for food, drinks, and medication administration), eye drops, or required vital signs to be taken before medication administration, and no interruptions such as being pulled to another resident for any reason, it could take two hours or more to administer medications to one resident. LVN 1 stated she had 26 residents to pass medications to that day. LVN 1 stated it was important to administer residents' medications on time to help with residents' current disease process. LVN 1 also stated it was important to administer medications that were supposed to be given with food, so the medication won't upset the resident's stomach. · During a concurrent interview and record review on 3/16/2023 at 12:29 p.m., with LVN 3, Resident 2's MAR dated 3/2023 was reviewed. Resident 2's MAR indicated Resident 2's morning medications, Carvedilol and Metformin, which were to be given with food, was due at 7 a.m. and 5 p.m. but were given late on the following dates: Carvedilol: 3/2/2023 at 12:32 p.m. and 6:02 p.m. 3/3/2023 at 8:50 a.m. and 6:34 p.m. 3/4/2023 at 6:44 p.m. 3/5/2023 at 6:25 p.m. 3/6/2023 at 8:32 a.m. 3/7/2023 at 10:44 a.m. 3/8/2023 at 10:27 a.m. 3/9/2023 at 9:52 a.m. and 6:49 p.m. 3/10/2023 at 9:41 a.m. and 6:11 p.m. 3/11/2023 at 09:10 a.m. and 7:14 p.m. 3/12/2023 at 12:02 p.m. and 6:24 p.m. 3/13/2023 at 12:10 p.m. 3/14/2023 at 10:43 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. Metformin: 3/1/2023 at 10:57 a.m. 3/2/2023 at 9:47 a.m. and 6:02 p.m. 3/3/2023 at 8:50 a.m. and 6:33 p.m. 3/4/2023 at 6:45 p.m. 3/5/2023 at 9:45 a.m. and 6:24 p.m. 3/6/2023 at 8:32 a.m. 3/7/2023 at 10:44 a.m. 3/8/2023 at 10:27 a.m. 3/9/2023 at 9:11 a.m. and 6:49 p.m. 3/10/2023 at 9:41 a.m. and 6:10 p.m. 3/11/2023 at 09:10 a.m. and 7:14 p.m. 3/12/2023 at 12:02 p.m. and 6:25 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. The MAR Details indicated Resident 2's morning medication, Advair, due at 9 a.m. and 5:00 p.m. was given late on: 3/3/2023 at 6:33 p.m. 3/4/2023 at 10:30 a.m. and 6:44 p.m. 3/8/2023 at 10:27 a.m. 3/10/2023 at 6:12 p.m. 3/12/2023 at 12:02 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. The MAR Details indicated Resident 2's morning medications, Lexapro, which were due at 9 a.m. was given late on the following dated: 3/8/2023 at 10:27 a.m. 3/12/2023 at 12:02 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. The MAR Details indicated Resident 2's morning medications, Lisinopril, and Norvasc, due at 9 a.m. was given late on the following dates: 3/1/2023 at 10:58 a.m. 3/2/2023 at 12:32 p.m. 3/3/2023 at 10:51 a.m. 3/6/2023 at 10:25 a.m. 3/7/2023 at 10:45 a.m. 3/8/2023 at 10:28 a.m. 3/12/2023 at 12:02 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. The MAR Details indicated Resident 2's morning medications, Plavix which was due at 9 a.m. was given late on the following dated: 3/8/2023 at 10:29 a.m. 3/12/2023 at 12:02 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. The MAR Details indicated Resident 2's morning medications, Singulair, was due at 9 a.m., but was given late on the following dates: 3/6/2023 at 10:25 a.m. 3/8/2023 at 10:28 a.m. 3/12/2023 at 12:02 p.m. 3/13/2023 at 12:11 p.m. 3/14/2023 at 10:39 a.m. 3/15/2023 at 11:14 a.m. 3/16/2023 at 10:11 a.m. During an interview with LVN 3 on 3/16/23 at 10:38 a.m., LVN 3 stated the medications were to be administered one hour before or one hour after the scheduled time, unless otherwise indicated. LVN 3 stated a change in condition or emergencies may cause a nurse to experience a delay in passing medications in a timely manner. LVN 3 stated realistically it can take two to three hours to finish passing all routine morning medications, due to interruptions such as mentioned above, including if a resident is calling for as needed medications, dialysis residents, checking BP, or when administering more than one eye drop medication. LVN 3 also stated medications ordered to be given with food should be given with breakfast or dinner as ordered. LVN 3 further stated breakfast is served at 7:15 a.m. and dinner at 5:00 p.m. LVN 3 stated the importance of administering medications on time is for resident disease maintenance, and to prevent stomach irritation for medications ordered to be administered with food. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included epilepsy (a brain disorder that causes recurring, unprovoked seizures), congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need), hypertension and cerebral infarction. During a review of Resident 3's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 2/28/2023, the MDS indicated Resident 3 had severe cognitive impairment (ability to think). The MDS also indicated Resident 3 had clear speech, and the ability to understand and be understood. The MDS further indicated Resident 3 had heart failure, HTN, CVA, seizure disorder. The MDS indicated Resident 3 required extensive assistance for activities of daily living (ADL'S) including for bed mobility, transfer (how resident moves between surfaces to or from; bed, chair; wheelchair, standing positions), locomotion (how resident moves between locations), toilet use, and personal hygiene. During a review of Resident 3's Care Plan titled Has a seizure disorder initiated on 1/10/2023, the care plan intervention indicated to provide medication as ordered by the doctor. During a review of Resident 3's Order Summary Report (Physician Orders), dated 2/26/2023, the physician orders indicated to administer the following medications: 1. Carvedilol tablet 6.25 mg, 1 tab by mouth two times a day for HTN. 2. Enoxaparin sodium injection prefilled syringe 40 mg subcutaneously ([SQ] injection into the fatty tissue) one time a day for DVT. 3. Furosemide oral tab 40 mg, 1 tab by mouth one time a day for CHF. 4. Levetiracetam oral tab 1000 mg, give 2000 mg by mouth two times a day for seizure disorder. 5. Lisinopril tab 10 mg, 1 tab by mouth one time a day for HTN. During a concurrent interview and record review on 3/13/2023 at 2:08 p.m., with Licensed Vocational Nurse (LVN) 1, of Resident 3's Medication Administration Record Details (MAR Details) dated 3/2023, the MAR Details indicated Resident 4's 9 a.m. scheduled medication was administered at 12:40 p.m. LVN 1 stated she was late passing medications for Resident 3 because initially Resident 3 refused, but then she got busy with other residents and her other work duties to return before 10:00 a.m. During a concurrent interview and record review on 3/16/2023 at 12:50 p.m., with LVN 3, of Resident 3's MAR Details dated 3/2023, the MAR Details indicated Resident 3's medication Carvedilol was to be given with food, and was due at 7 a.m. and 5 p.m. but was given late on the following dated: 3/2/2023 at 12:22 p.m. 3/3/2023 at 12:39 p.m. and 7:00 p.m. 3/4/2023 at 10:50 a.m. and 6:43 p.m. 3/5/2023 at 9:47 a.m. and 6:10 p.m. 3/6/2023 at 12:15 p.m. 3/7/2023 at 7:34 p.m. 3/8/2023 at 11:03 a.m. 3/9/2023 at 6:34 p.m. 3/10/2023 at 9:43 a.m. 3/11/2023 at 09:08 a.m. and 6:11 p.m. 3/12/2023 at 9:38 a.m. 3/13/2023 at 12:39 p.m. 3/14/2023 at 10:37 a.m. 3/15/2023 at 10:36 a.m. Resident 3's MAR Details indicated Resident 3's morning medication Levetiracetam which was scheduled to be administered at 9 a.m. and 6 p.m. was given late on the following dates: 3/2/2023 at 12:23 p.m. and 7:57 p.m. 3/3/2023 at 12:39 p.m. 3/4/2023 at 10:50 a.m. 3/6/2023 at 12:15 p.m. 3/7/2023 at 7:34 p.m. 3/8/2023 at 11:04 a.m. and 7:32 p.m. 3/9/2023 at 11:05 a.m. 3/13/2023 at 12:40 p.m. 3/14/2023 at 10:37 a.m. 3/15/2023 at 10:36 a.m. 3/16/2023 at 10:20 a.m. Resident 3's MAR Details indicated Resident 3's morning medications such as Clopidogrel, Enoxaparin, Furosemide, and Lisinopril scheduled to be administered at 9 a.m. were given late on the following dated: 3/2/2023 at 12:23 p.m. 3/3/2023 at 12:39 p.m. 3/4/2023 at 10:50 a.m. 3/6/2023 at 12:15 p.m. 3/8/2023 at 11:03 a.m. 3/9/2023 at 11:05 a.m. 3/13/2023 at 12:40 p.m. 3/14/2023 at 10:37 a.m. 3/15/2023 at 10:36 a.m. 3/16/2023 at 10:20 a.m. 4. During a review of Resident 4's admission record, the admission record indicated Resident 4 was initially admitted to the facility on [DATE] and 10/28/2020. Resident 3's diagnoses included epilepsy (a brain disorder that causes recurring, unprovoked seizures), dysphasia (language disorder affecting how one speaks and understands others), and cerebral infarction. During a review of Resident 4's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 3/3/2023, the MDS indicated Resident 4 rarely makes self-understood and rarely had the ability to understand others. The MDS further indicated Resident 4 had CVA, and a seizure disorder. The MDS indicated the Resident 4 required total dependence for activities of daily living (ADL'S) including bed mobility, transfer (how the resident moves between surfaces to or from; bed, chair; wheelchair, standing positions), locomotion (how resident moves between locations), toilet use, and personal hygiene. During a review of Resident 4's Care Plan titled Has a seizure disorder revised on 9/12/2019, the care plan intervention indicated to administer seizure medication as ordered by the doctor. During a review of Resident 4's Order Summary Report (Physician Orders), dated 10/28/2020, the physician orders indicated to administer the following medications: 1. Keppra solution 100 mg, 5 milliliters via G- tube two times a day for seizures. During a concurrent interview and record review on 3/13/2023 at 2:08 p.m., with Licensed Vocational Nurse (LVN) 1, of Resident 4's Medication Administration Record Details (MAR Details) dated 3/2023, the MAR Details indicated Resident 4 was given his 9:00 a.m. scheduled medication at 10:12 a.m. The LVN 1 stated she was late passing medication for Resident 4 because she was busy with other residents and her other work duties. During a concurrent interview and record review on 3/16/2023 at 12:43 p.m., with LVN 3, of Resident 4's MAR Details dated 3/2023, the MAR Details indicated Resident 4's medication Keppra, due at 9 a.m. and 5 p.m. was given late on the following dated: 3/1/2023 at 6:14 p.m. 3/4/2023 at 10:46 a.m. and 6:13 p.m. 3/6/2023 at 10:02 a.m. 3/8/2023 at 7:30 p.m. 3/9/2023 at 10:45 a.m. and 6:08 p.m. 3/10/2023 at 6:06 p.m. 3/11/2023 at 6:12 p.m. 3/12/2023 at 6:17 p.m. 3/13/2023 at 10:12 a.m. and 6:30 p.m. 3/14/2023 at 6:26 p.m. 3/15/2023 at 10:36 a.m. 3/16/2023 at 6:53 p.m. During aninterview on 3/13/2023 at 5:42 p.m., with the facility's Administrator (ADM), the ADM stated it was standard practice to give medications one hour before or one hour after the scheduled time. The ADM stated the facility had no policy and procedure (P&P) on medication refusal that addressed what to do if a resident refused medications or on medication administration time frames. During an interview on 3/16/2023 at 1:46 p.m., with the Director of Nursing (DON), the DON stated, it was important to receive medications on time especially BP meds so the BP can be controlled, and other significant medications to prevent further worsening of the disease. The DON stated if residents received medications on time, it could help prevent a change in condition. The DON stated the time frame for the medication pass was one hour before or one hour after unless otherwise ordered. The DON also stated medications ordered to be given with food should be given between half an hour time frames such as 6:30 a.m.- 7:30 a.m., with breakfast since breakfast was served at 7 am, and medications to be given between 4:30 p.m.- 5:30 p.m. with dinner since dinner was served at 5 p.m. The DON further stated the importance of receiving medications with meals as ordered was to prevent side effects such as irritation to the stomach and other adverse reactions. During a review of the facility's P&P titled Administering Medications revised on 3/2020, the P&P indicated medications must be administered in accordance with the orders. The P&P indicated medications must be administered in accordance with state and federal guidelines. The P&P however did not indicate the time frame for medications to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for two out of two sampled residents (Resident 25 and 261) by: 1. Failing to explain the menu and pureed ( a texture modified diet, where all the foods have a soft pudding like consistency) food items to Resident 25 and 261 while feeding assistance was provided during mealtime. 2. Failing to accommodate Resident 261's request to provide Resident 261's denture. This failure had the potential to affect Resident 25 and 261's self-worth and dignity. Findings: 1. During a review of Resident 25's admission record, the admission record indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included pneumonia (an infection that inflames one or both lungs), difficulty in walking, dysphagia (difficulty swallowing), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), lung cancer, and lack of coordination. During a review of Resident 25's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 12/21/2023, the MDS indicated Resident 25's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 25 required extensive assistance from one staff with bed mobility, transfer, toilet use, personal hygiene, total dependence from one staff with dressing and supervision from one staff for eating. During a concurrent observation and interview on 2/21/2023, at 12:25 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 was assisting Resident 25 with eating lunch. The meal ticket (a card with information about the residents' prescribed diet, likes, and allergies) on the tray indicated pureed diet with no added salt and thin liquid (liquids that take little or no effort to drink) in divided plate. CNA 2 stated, she did not know Resident 25 had vision impairment (a loss of vision that cannot be corrected to normal vision) and required assistant for feeding. Resident 25 stated, I need help because I could not see and control my hands. CNA 2 did not explain what kinds of pureed food items were on the tray and started feeding Resident 25. CNA 2 did not offer any liquid or condiments such as packets of butter and pepper which was on the tray during feeding. CNA 2 stated, it was important to explain and describe to Resident 25 who had impaired vision, what pureed food items were on the plate, and what condiments were available. During a concurrent observation and interview on 2/22/2023, at 12:18 p.m., with Licensed Vocational Nurse (LVN) 2, in the dining room, LVN 2 was assisting Resident 25 eat lunch. LVN 2 instructed Resident 25 to hold the spoon. Resident 25 stated, she could not hold the spoon because of vision impairment and lack of hand coordination. LVN 2 proceeded to feed Resident 25, without explaining what food items were on the plate. Resident 25 stated, What are you giving me? What kind of food is this? LVN 2 stated, she did not know what food items were on the tray and stated, I am not sure, the white one looks like mashed potatoes. When eating desert Resident 25 stated, she did not like vanilla ice cream, but LVN 2 did not offer a substitute. LVN 2 acknowledged, it was important to respect Resident 25's preference and let Resident 25 know what the different food items on the tray were before feeding Resident 25. During a review of Resident 25's Care Plan (CP), Revised 1/20/2022, the CP Problem indicated, Resident 25 was at risk for self-care deficit and needed assistance for bathing, dressing, feeding, bed mobility, transfer, toileting, ambulation, locomotion, and hygiene. The CP Intervention indicated, provide meal support per the resident's need. During a review of Resident 25's Care Plan (CP), Revised 10/13/2022, the CP Problem indicated, Resident 25 was at risk for altered nutrition status. The CP Intervention indicated, monitor intake, and offer substitute if refused meal served. Honor food preferences. During a review of Resident 25's Care Plan (CP), Revised 1/17/2023, the CP Problem indicated, compromised memory recall ability, and impaired decision making ability as manifested by self-care deficit. The CP Intervention indicated, explain to resident procedures prior to start of care. The CP Problem indicated, altered visual function as evident by at risk for dependency. The CP Intervention indicated tell the resident the consistent placement of their items. The CP Problem indicated, alteration with ADL (Activities of Daily Living) functions requiring assistance. The CP Intervention indicated maintain the resident's dignity by providing privacy and respecting resident's rights and choices when providing ADL. During a review of Resident 261's admission record, the admission record indicated Resident 261 was admitted to the facility on [DATE]. Resident 261's diagnoses included traumatic subdural hemorrhage (a serious condition where blood collects between the skull and the surface of the brain), difficulty in walking, dysphagia, and epilepsy (a disorder of the brain characterized by repeated seizures). During a review of Resident 261's MDS, dated [DATE], the MDS indicated Resident 261's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 261 required extensive assistance from one staff with bed mobility, transfer, toilet use, personal hygiene, dressing, and limited assistance from one staff for eating. During a concurrent observation and interview on 2/21/2023, at 12:37 p.m., with CNA 3, CNA 3 was preparing to feed lunch to Resident 261. The meal ticket indicated pureed diet, no added salt, and thin liquid. CNA 3 did not explain what the pureed food items were before starting to feed Resident 261. CNA 3 did not offer packets of butter and pepper which were on the tray during the feeding. CNA 3 stated, she should have explained what food items were given to Resident 261 before starting the feeding since it was hard to tell what kind of food items were there because they were pureed. CNA 3 stated, Resident 261 had a right to know what was being he was being fed for lunch. During a concurrent observation and interview on 2/22/2023, at 12:16 p.m., with Resident 261, in the dining room, Resident 261 was observed to be sitting on wheelchair at the table. There was no tray in front of Resident 261 and Resident 261 looked upset. Resident 261 stated, CNA who Resident 261 did not recognized, took the tray away before Resident 261 finished the meal and did not explain what was on the plate. Resident 261 stated, I don't know what I ate. CNA fed me green stuff. Resident was left alone at the table while other residents were eating lunch in the dining room. During an interview on 2/24/2023, at 08: 14 a.m., with Director of Staff Development (DSD), at DSD's office, DSD stated, CNA should sit at eye-level with the resident, explain the food items before starting to feed the resident, only scoope proper amount of food per spoon, and let the resident know what substitute are available when CNA was assisting with feeding. During an interview on 2/23/2023, at 04: 08 p.m., with Director of Nursing (DON), DON stated, CNAs are trained to take care of resident with vision and physical limitation. DON stated, when feeding the resident with impaired vision, CNA should let the resident know what they are about to feed the resident and should know what is on the menu. DON stated, the CNA should respect the resident's preference and add any condiments if resident asked and offer anything to enhance the appetite and the CNA should explain where certain food items are located, if the resident is only visually impaired but can eat without assistance DON stated, CNA should allow the resident to finish chewing and swallowing before giving the next bite. DON stated Resident should be treated with respect all time. DON stated removing the meal tray before the resident finishing the meal was very disrespectful and it could affect the resident's dignity and self-worth. During a review of Resident 261's Care Plan (CP), Revised 2/21/2023, the CP Problem indicated, compromised memory recall ability, and impaired decision making ability as manifested by self-care deficit. The CP Intervention indicated explain to resident procedures prior to start of care. 2. During a concurrent observation and interview on 2/21/2023, at 12:37 p.m., with CNA 3 was feeding Resident 261 for lunch. Resident 261 was asking for his upper and lower dentures. CNA 3 stated, she could not find the dentures at the bedside and Resident 261 was on pureed diet because of missing denture. CNA 3 found the dentures were kept in the social services office. During an interview on 2/23/2023, at 12: 11 p.m., with Resident 261's Family Member (FM) 1 via phone, FM1 stated, Resident 261 wore the dentures to eat and to meet other people. FM 1 stated, Resident 261 was self-conscious about his appearance and did not want to see others without wearing dentures. During an interview on 2/24/2023, at 8: 14 a.m., with DSD, DSD stated, the resident should have access to their own belongings regardless of their mental status. DSD stated keeping a resident's belongings away from them, might affect the resident negatively by lowering self-esteem and self-worth. During an interview on 2/23/2023, at 4: 08 p.m., with DON, DON stated, all resident belongings should be accessible because it was the resident's right. Resident's belongings could be stored with staff or Social Services Director, but they should be accessible to the resident upon request. DON stated it would be disrespectful if the resident was not allowed to have their belongings. During a review of Resident 261's Care Plan (CP), Revised 2/21/2023, the CP Problem indicated, Resident 261 is at risk for inadequate nutrition and alteration in comfort related to dental problems: wears dentures upper and lower. The CP Intervention indicated, monitor viability of current dental appliance, if present. Dental consult as needed. During a review of the facility's policy and procedure (P&P) titled, 'Dignity, revised 3/2020, the P&P indicated, Policy statement: Each resident shall be cared for in a manner that promotes an enhanced quality of life, dignity, respect, and individuality. Procedure: 1. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth 10. Procedures shall be explained before they are performed. During a review of the facility 's P&P titled, 'Resident Rights, Revised 8/2020, the P&P indicated, Policy: Residents in long-term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, communication with, and access to persons and services inside and outside the facility. During a review of the facility 's P&P titled, 'Respect and Dignity Right to Have Personal Property, Revised 10/2020, the P&P indicated, All resident's possessions, regardless of their apparent value to others, must be treated with respect. Guidelines: 14. The facility and its staff shall not refuse to allow a resident to retain any personal belongings not based on space limitations or on a determination that the rights, health, or safety of other residents would be infringed. During a review of the facility's P&P titled, 'Resident Rights, Revised 8/2020, the P&P indicated, Procedure: 1. The facility promotes the rights of each resident, including but not limited to .k. Retain and use personal possessions to the maximum extent that space and safety permit. During a review of the facility's P&P titled, 'Dignity, Revised 3/2020, the P&P indicated, Procedure .5. Residents' private space and property shall be respected at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of eight sampled residents (Resident 16). This deficient practice had the potential to prevent Resident 16 from receiving necessary care and services. Findings: A review of Resident 16's admission Record (AR) indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including right hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood to the brain, causing or resulting in brain tissue death), muscle weakness, and epilepsy (disorder that causes episodes of seizures or altered consciousness). A review of Resident 16's Minimum Data Set (MDS), an assessment and care-screening tool, dated 12/27/2022, indicated Resident 16 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making, had unclear speech, and was rarely/never understood when expressing ideas or wants. The MDS indicated Resident 16 required extensive assistance for bed mobility, supervision for eating, and total dependence for transfers, dressing, toilet use, personal hygiene, and bathing. The MDS further indicated the resident had functional limitations in range of motion (full movement potential of a joint) on one upper extremity (shoulder, elbow, wrist, hand) and two lower extremities (hip, knee, ankle, foot). A review of Resident 16's Fall Risk Evaluation dated 9/28/2022 indicated Resident 16 received a total score of 11, indicating Resident 16 was at risk for falls. A review of Resident 16's care plan, dated 1/2/2020 indicated Resident 16 was at risk for falls and required assistance with activities of daily living (ADL, basic activities such as eating, dressing, and toileting). The care plan interventions included ensuring the call light was accessible and within Resident 16's reach. During an observation on 2/22/2023 at 9:19 a.m., in the resident's room, Resident 16 was laying in bed. Resident 16's call light cord was hanging off the top of the right side of the bed (Resident 16's weakest side). Resident 16 tried to find the call light by feeling around the bed using the left arm but was unable to locate and reach the call light when asked. During an observation and interview on 2/22/2023 at 9:32 a.m., in the resident's room, Licensed Vocational Nurse 2 (LVN 2) stated Resident 16's call light was out of reach and the resident would be unable to call for nursing assistance if needed. LVN 2 stated the call light should be always within Resident 16's reach but was not. LVN 2 picked up the call light, clipped the call light cord onto the blanket, and placed the call light on Resident 16's abdomen. During an interview on 2/24/2023 at 1:44 p.m., the Director of Nursing (DON) stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met. A review of the facility's policy and procedure revised 10/2022 titled, Resident Call System indicated call lights were to be accessible and placed within the resident's reach at all times to enable staff to meet the needs of the resident.

Based on interview and record review, the facility failed to ensure the resident received an assessment on the Minimum Data Set (MDS - a standardized assessment and care screening tool) for one of one sample resident (Resident 14) that was completed timely and accurately. This deficient practice could potentially affect the care services of Resident 14. Findings: A review of Resident's 14 admission Record indicated the facility admitted the resident, on 4/1/2021, with diagnoses that included encephalopathy (brain disease), congestive heart failure (a serious condition in which the heart does not pump blood efficiently), cardiomegaly (enlargement of the heart), diabetes mellitus (abnormal blood sugar), and benign prostatic (empties urine into bladder) hypertrophy (enlargement). A review of the History and Physical (H&P), dated 4/12/2022, indicated Resident 14 was alert and oriented with a primary medical history of congestive heart failure, benign prostatic hypertrophy and diabetes mellitus. The H&P indicated Resident 14 had the capacity to understand and make decisions. During an interview, on 2/23/2023 at 10:13 a.m. with MDS 1 (a nurse that collects and assess information for the health and well-being of residents in Medicare or Medicaid certified nursing homes) stated the MDS should be completed within 14 days after admission, quarterly, and yearly. MDS 1 stated if there was a significant change of resident's status, the facility should transmit the assessment right away. When asked if the quarterly MDS assessment, dated 1/3/2023, was completed accurately and accepted by CMS (Centers for Medicare and Medicaid Services), he stated it was completed but was not accepted by the CMS because of the error coding on AO410 (unit certification or licensure designation) which was the criteria for the facility billing status. MDS 1 stated it should be coded 3 instead of 1. MDS 1 stated he did the assessment and failed to double check the right entry. MDS 1 stated the assessment was not accurate. MDS 1 stated if the facility did not put the correct assessment in the MDS, there would be a problem with the care of the resident. During an interview, on 2/23/2023 at 11:09 a.m. the Director of Nursing (DON) acknowledged the resident's MDS quarterly assessment, dated 1/3/2023, under section A0410 was not coded and assessed accurately. A review of facility's policy and procedure, titled Automated Data Processing revised 10/2020, indicated within 14 days after a facility completes a resident's assessment, the facility shall electronically transmit encoded, accurate and complete the MDS data to the CMS system, Accurate means that the encoded MDS date matches the MDS form in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement an individualized, person-centered, comprehensive care plan with measurable objectives, timeframe, and interventions for four of four sampled residents (Resident 10, 14, 27 and 37) by failing to: 1. Develop a care plan for the use of an anticoagulant (medication that helps prevent blood clots) for Residents 14 and 37. 2. Develop a care plan for Restorative Nursing Aide (RNA, nursing aide program that help residents maintain their function and joint mobility) for Resident 10. 3. Develop a care plan for the use of an antidepressant (class of medications used to treat major depressive disorder [persistent feeling of sadness and loss of interest that can interfere with everyday life]) medication for Resident 27 This deficient practice had the potential to negatively affect the delivery of necessary care, delay of interventions and services for Residents 10, 14, 27 and 37. Findings: 1a. A review of Resident 14's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (occurs when the heart muscle does not pump blood as well as it should.), atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel. It often results in too much sugar circulating in the bloodstream). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/3/2023, indicated Resident 14's cognitive (mental capacity to make decisions, ability to remember, learn, and understand) skills for daily decision making were intact. The MDS indicated the resident required an extensive assistance with bed mobility, transfer, and personal hygiene. A review of Resident 14's Physician Order Summary Report dated 1/16/2023, indicated an order to give Xarelto (an anticoagulant) 10 milligrams (MG- unit of measurement) 1 tablet by mouth one time a day for arterial fibrillation. During a review of Resident 14's care plans, there was no documentation that a care plan for the care of Resident 14's anticoagulant was developed. During an interview on 2/24/2023 at 1:29 p.m., with Director of Nursing (DON), DON stated, it was important to develop a care plan and update it as needed for residents under anticoagulant treatments to prevent any possible complications with the drug. The complications include bruises, bleeding, and discoloration of skin. . 1b. A review of Resident 37's admission record indicated Resident 37 was admitted to the facility 6/22/2022 and readmitted [DATE] with diagnoses of muscle weakness and essential hypertension (high blood pressure). A review of Resident 37's History and Physical (H/P) report dated 1/15/2023, indicated Resident 37 had the capacity to understand and make decisions. A review of Resident 37's MDS, a standardized assessment dated [DATE], indicated Resident 37 was receiving anticoagulant medication. During a review of Resident 37's Order Summary Report (OSR) on 2/23/2023 at 5:17 a.m., the OSR indicated that Resident 27 had a current order for Enoxaparin (Lovenox- an anticoagulant medication) 40 mg/ 0.4 milliliters (mL- a unit of measurement) subcutaneously (injected under the skin) one time a day for deep vein thrombosis (DVT- blood clot) prophylaxis. During an interview and concurrent record review on 2/23/2023 at 11:46 a.m., with Minimum Data Set Nurse (MDS1), MDS1 confirmed that Resident 37 had a physician order for Lovenox but did not have a care plan for anticoagulant (Lovenox) use. MDS1 stated that care plans are important to address the interventions needed for the residents and to monitor for change of condition. MDS1 indicated it was important to have a care plan for anticoagulant use so the facility can provide the intervention of monitoring for bleeding and bruising. MDS1 indicated care plans are important to provide continuity of care for residents between staff. 2. A review of Resident 10's admission Record, indicated Resident 10 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including acute respiratory failure (sudden condition that affects breathing function and results in lungs not functioning properly) and congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and other parts of the body). A review of Resident 10's MDS), dated [DATE], indicated Resident 10 was cognitively intact. The MDS indicated Resident 10 required supervision for eating and total assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS further indicated Resident 10 had functional limitations in range of motion (full movement potential of a joint) on one upper extremity (shoulder, elbow, wrist, hand) and two lower extremities (hip, knee, ankle, foot). A review of Resident 10's physician's orders, dated 7/11/2022, indicated for the Restorative Nursing Aide (nursing aide program that helps residents maintain their function and joint mobility) to provide passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to both legs and left arm five times a week and to place a left hand roll splint (apparatus used to support and/or immobilize a broken bone or impaired joint) five times a week for 2 hours or as tolerated. During an interview and record review on 2/24/2023 at 11:07 a.m., MDS 1 stated the purpose of a comprehensive care plan was to identify a resident's problem areas and create a plan to address each problem area appropriately. MDS 1 reviewed Resident 10's care plan and confirmed Resident 10 did not have a care plan for RNA. MDS 1 stated RNA should be a part of Resident 10's comprehensive care plan because the resident was receiving RNA services. During an interview on 2/24/2024 at 1:44 p.m., the DON stated comprehensive and accurate care plans were important because they identified the needs of the residents and the type of care to provide to properly address those needs. The DON stated if a problem area or service was not care planned, it could potentially have a negative effect on the resident's care. 3. A review of Resident 27's admission record indicated Resident 27 was admitted to the facility 7/16/2020 with diagnoses of schizoaffective disorder, depressive type (a mental health condition with symptoms of schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly]and a mood disorder) and muscle weakness. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 had severely impaired cognition. The MDS indicated Resident 27 was receiving antidepressant medications. During a review of Resident 27's OSR, dated as of 2/2/2023, the OSR indicated that Resident 27 had an order for: Escitalopram Oxalate (antidepressant medication) Tablet 10 mg. give one (1) tablet by mouth 1 time a day for depression manifested by sadness and crying spells. During a concurrent interview and record review on 2/23/2023 at 12:12 p.m., with MDS1, the MDS1 confirmed during a review of Resident 27's care plans, Resident 27 did not have a care plan specific to her antidepressant medication, Escitalopram. MDS1 stated that care plans specific to the medication the resident was taking is important because each medication could be different and have different side effects, especially when there is a need to monitor for the side effects of a medication. MDS1 stated care plans are important for nurses to provide continuity of care for residents. During a review of the facility's policy and procedure (P/P) titled Develop-Implement Comprehensive Care Plans dated 11/2022, indicated comprehensive care plans were to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two out of two sampled residents (Resident 25 and 257) by: 1.Failing to appropriately discard in the pharmaceutical waste bin, the used Nitro-Bid patch (a medication ointment patch used to prevent chest pain in people with a certain heart conditions) for Resident 257. This failure had the potential to increase the risk of accidental exposure and adverse effects of Nitro-Bid by touching the improperly disposed medication. 2. Failing to obtain an order to crush medications for Resident 25. This failure has the potential to delay or decrease the effectiveness of Resident 25's medications due to Resident 25's difficulty swallowing. Findings: 1.During a review of Resident 257's admission record, the admission record indicated Resident 257 was admitted to the facility on [DATE]. Resident 257's diagnoses included congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), encephalopathy (any disease of the brain that alters brain function or structure), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 257's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/22/2023, the MDS indicated Resident 257's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 257 required extensive assistance from one staff with bed mobility, dressing, toilet use, personal hygiene, extensive assistance from two staff with transfer and supervision from one staff for eating. During a review of Resident 257's Order Summary Report (OSP), dated 2/17/23, the OSP indicated, apply 1 inch Nitro-Bid Ointment 2% on patch via transdermal (a route of administration wherein active ingredients is delivered across the skin for systemic distribution) two times a day for congestive heart failure. During a concurrent observation and interview on 2/22/2023, at 9:29 a.m., LVN 3 was administering Resident 257's medications. LVN 3 took off the used Nitro-Bid patch from Resident 257's chest and discarded it into bedside trash bin. LVN 3 stated he was not sure of how to properly dispose of the used Nitro-Bid patch. LVN 3 stated he did not realize the used Nitro-Bid patch could cause dizziness, headache, and hypotension (low blood pressure) if touched without wearing gloves. LVN 3 stated he should have disposed of it in the pharmaceutical waste bin in the medication room near nursing station. During an interview on 2/22/2023, at 10:22 a.m., with Director of Staff Development (DSD), DSD stated, all medications including over the counter medications except narcotics (a controlled substance used to treat moderate to severe pain) should be disposed of in the pharmaceutical waste bin. Improperly disposed of Nitro-Bid could cause hypotension and other adverse reaction to residents or staff that may come in contact with it accidently. During an interview on 2/22/2023, at 11:30 a.m., with Pharmacy Consultant (PC) , PC stated, all non-narcotic medications should be discarded in pharmaceutical waste bin due to possible exposure to the residents and staff. During a review of the facility's policy and procedure (P&P) titled, 'Medication Destruction, revised 12/2020, the P&P indicated, Policy Statement: Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 2. During a review of Resident 25's admission record, the admission record indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), difficulty in walking, dysphagia (difficulty swallowing), lung cancer, and lack of coordination. During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25's cognition was severely impaired. The MDS indicated Resident 25 required extensive assistance from one staff with bed mobility, transfer, toilet use, personal hygiene, total dependence from one staff with dressing, and supervision from one staff for eating. A review of Resident 25's OSP, dated 2/7/2023, indicated, a pureed texture diet with no added salt diet ordered for dysphagia. OSP also indicated, give 1 tablet of amlodipine besylate 5 milligrams (mg. a unit of measure) by mouth two times a day for hypertension (high blood pressure). During a concurrent observation and interview on 2/22/23, at 9:29 a.m., LVN 3 was preparing medications for Resident 25. LVN 3 placed the Amlodipine 5 mg. 1 tablet into the medication cup. LVN 3 stated, he realized Resident 25 was on pureed (food prepared to a pudding consistency, so there is no chewing required) diet by looking at the breakfast tray on Resident 25's bedside table. LVN 3 stated, he would crush the tablet (Amlodipine) because Resident 25 was on pureed diet. LVN 3 stated there was no order (from the physician)to crush medication on Resident 25's chart after reviewing Resident 25's chart. LVN 3 acknowledged he should have verified the route of medication with Resident 25's physician and obtained an order to crush the medication. During an interview on 2/22/2023, at 9:59 a.m., with Director of Nursing (DON), DON stated, LVN 3 should have clarified with the primary physician if LVN 3 was not sure how to administer whole tablets for Resident 25 who has difficulty swallowing and obtained an order to crush the medication. During an interview on 2/22/2023, at 10:22 a.m., with DSD stated, DSD stated all licensed nursing staff should verify with the primary physician and obtain an order when in doubt medication administration. During a review of the facility's P&P titled, Administering Medications, Revised 3/2020, the P&P indicated, Guidelines .3. Medications must be administered in accordance with the orders .8. The licensed nurse must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. During a review of Resident 25's Position Description for Licensed Vocational Nurse (PD), revised 1/27/17, the PD indicated, Accountability .Corporate Compliance .Major Tasks, Duties, and Responsibilities .Administers medication and charts according to the treating physician's orders .Communicates with the physician as indicated by resident status. Assures follow through.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure two out of two sampled residents, (Resident 12 and Resident 16) who were aphasic, (a disorder that affects how you communicate, it can impact speech as well as the way you write and understand both spoken and written language) were provided access if needed, to a communication aide (such as a communication board- filled with pictures of every day items and tasks) to help facilitate communication between the residents and staff. This deficient practice had the potential to cause increased frustration due to communication barriers and decreased ability to understand and meet residents' needs for Resident 12 and Resident 16. Findings: A. A review of Resident 12's Face Sheet (admission record) indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (unable to move the right side of the body due to a stroke [blockage of blood flow in the brain]) and aphasia. A review of Resident 12's history and physical report (H&P), dated 10/16/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/16/2022, indicated Resident 12 had unclear speech and was usually understood. During an observation on 2/21/2023 at 10:06 a.m., certified nursing assistant (CNA1) was helping Resident 12 in his room. Resident 12 was pointing at his feet and CNA1 was trying to guess what he wanted, CNA1 then exited the room and asked another staff member (unknown) if she knew what Resident 12 wanted. The second staff member informed CNA1 that if Resident 1 was pointing at his feet, he wanted his shoes. CNA1 reentered Resident 12's room and asked him if he wanted help putting on his shoes in which he replied, yes. During an observation on 2/21/2023 at 12:14 p.m. and 2/22/2023 at 9:17 a.m., there was no communication board present in Resident 12's room. During an interview on 2/21/2023 at 12:14 p.m., Resident 12 answered yes when asked if he had difficulty communicating his needs to staff. Resident 12 answered I don't know and a shoulder shrug when asked where his communication board was. Resident 12 answered yes when asked if he knew what a communication board was and if he believed it would be helpful to communicate. Resident 12 replied frustrated when asked how it makes him feel when he can not communicate with staff and shook his head. During an observation and concurrent interview on 2/23/2023 at 7:47 a.m., the director of staff development (DSD) was inside Resident 12's room helping him with his breakfast. Resident 12 was trying to communicate with the DSD but was unable to relay what he was trying to say and was flapping his right arm in frustration, the DSD was patient and giving Resident 12 time to explain but the DSD was unable to figure out what Resident 12 needed. The DSD was inside the room when surveyor asked Resident 12 where his communication board was in which he replied, I don't know. When asked if he wanted a communication board, Resident 12 shook his head yes, smiled and gave a thumbs up. The DSD helped look in room for communication board, but one was not located. During an observation on 2/23/2023 at 8:05 a.m., the activities director (AD) entered Resident 12's room and provided Resident 12 with a communication binder filled with pictures of everyday items needed for activities of daily living (ADLs- activities related to personal care), tasks, and food. During an interview on 2/23/2023 at 10:07 a.m., the speech therapist (ST) stated that he can usually understand what Resident 12 wants but if Resident 12 gets angry or upset, he becomes very hard to understand. The ST stated that Resident 12 could benefit from a picture book (communication board), especially one that includes food items because that is usually the biggest concern for Resident 12. The ST indicated that the activities department are the ones who issue the picture books to residents. During a concurrent record review and interview on 2/24/2023 at 1:44 p.m., the director of nursing (DON) reviewed Resident 12's care plan and confirmed that the care plan indicated Resident 12 had impaired communication related to aphasia and interventions included a communication board if applicable. The DON stated that a communication board is appropriate for Resident 12 and Resident 12 becomes frustrated when he can't communicate. The DON stated that it was important for residents to be able to communicate because they need to know the resident's needs. B. A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including right hemiplegia and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood to the brain, causing or resulting in brain tissue death), muscle weakness, and epilepsy (disorder that causes episodes of seizures or altered consciousness). A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 16 had unclear speech and was rarely/never understood when expressing ideas or wants. A review of Resident 16's care plan, dated 9/4/2020 indicated Resident 16 had impaired communication with interventions that included assessment of other alternate means of communication to establish means of anticipating needs and the use of communication board if applicable. During an observation on 2/21/2023 at 9:29 a.m., in the resident's room, two staff members transferred Resident 16 into a wheelchair with a mechanical lift ( a device that allows a person to be transferred from one surface to another). While seated in the wheelchair, Resident 16 tried yelling simple words, but the words were unclear. Resident 16 tried pointing to objects in the room to communicate but staff did not understand what she wanted. Staff tried to guess what Resident 16 wanted but were unsuccessful. Resident 16 became increasingly frustrated when both staff members had difficulty understanding what she was trying to communicate. No communication board was observed at the bedside or in the room. During a concurrent observation and interview on 2/22/2023 at 9:19 a.m., in the resident's room, Resident 16 was lying in bed and had difficulty speaking. Resident 16 was observed to understand the spoken language, consistently nodded (yes) and shook head no when asked questions and was able to speak some simple words. No communication board was at the bedside or in the room. Resident 16 nodded (yes) when asked if she had difficulty communicating with staff. Resident 16 nodded (yes) when asked if it would be helpful to have a communication board with pictures and/or words that she was able to point at to communicate her needs. During an interview on 2/23/2023 at 9:49 a.m., Restorative Nursing Aid 1 (RNA 1) stated she had difficulty communicating with Resident 16 during Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) sessions. RNA 1 stated Resident 16 had a communication board in the past but had not seen it recently. During a concurrent observation and interview on 2/23/2023 at 11:44 a.m., in the hallway outside the resident's room, CNA 4 stated it was difficult to communicate with Resident 16. CNA 4 stated she always had to guess what Resident 16 wanted. CNA 4 stated Resident 16 became very angry and started cursing when she was unable to communicate with staff. CNA 4 confirmed Resident 16 did not have a communication board at the bedside or in the room. CNA 4 stated a communication board would have been very helpful for Resident 16 to improve communication with staff. During an interview and observation on 2/23/2023 at 12:00 p.m., in the resident's room, Activities Director (AD) stated Resident 16 had a communication board in the past but did not know where it was. AD confirmed Resident 16 did not have a communication board at the bedside and stated she re-issued Resident 16 a new communication board that morning. During a concurrent record review and interview on 2/24/2023 at 1:44 p.m., the DON) reviewed Resident 16's care plan and confirmed the care plan indicated Resident 16 had impaired communication with interventions which included a communication board if applicable. The DON stated a communication board was appropriate for Resident 16 to improve communication with staff. The DON stated Resident 16 became easily frustrated when she was unable to communicate with staff and a communication board should have been issued to help her communicate. The DON stated it was important for residents to be able to communicate so staff would be able to know and anticipate the resident's wants and needs. During a review of the facility's policy and procedure (P/P) titled communication barrier and dated 11/2020, indicated the facility was to protect and facilitate each resident's right to communicate with individuals and entities within and external to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility staff failed to label Resident 36's Levalbuterol (a medication that is inhaled, prescribed for conditions that cause difficulty breathing) with an opened date. This deficient practice had the potential to result in the prolonged use and loss of strength of the inhaler and can lead to ineffective treatment of respiratory symptoms. Findings: A review of Resident 36's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA- loss of blood flow to part of the brain causing tissue damage or death), hypertension (condition when blood pressure is higher than normal), and hyperlipidemia (a condition where blood has a concentration of unhealthy fats). A review of Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/20/2022, indicated Resident 36's cognitive (capacity to make decisions, ability to remember, learn, and understand) skills for daily decision making were intact. The MDS indicated the resident required an extensive assistance with bed mobility, transfer, toileting, and personal hygiene. A review of Resident 36's Physician Order Summary Report dated 06/21/2022, indicated an order to give Levalbuterol HCI nebulization solution 0.63mg/3ml 1 puff inhale orally via nebulizer (device for producing a fine spray of liquid, used for inhaling a medicinal drug) every 6 hours as needed for wheezing (breathing with a whistling or rattling sound in the chest). A review of Resident 36's care plan (CP) revised 6/24/2022, indicated Resident 36 was at risk for shortness of breath. One of the CP listed goals for Resident 36 was to minimize signs and symptoms of shortness of breath for 90 days. One of interventions was to provide medication as ordered. During an interview on 2/22/2023 at 3:25 p.m., Licensed Vocational Nurse (LVN 1) confirmed, she does not see any written label with an opened date of the Levalbuterol medication. When asked what the process was, LVN 1 stated, after nurses opened the foil pouch for the nebulizer, they need to write an opened date on the medication box, so nurses would know it was time to discard the medication. During an interview on 2/24/2023 at 1:38 p.m., Director of Nursing (DON) stated, an oral inhaler medication is good to use for 14 days after opening the foil container per manufacture guideline. DON stated, nurses should discard and not use the medication if there is no documented opened date because it might no longer be effective. A review of the facility's policy and procedure (P/P), titled, Administering Medications, revised 03/2020, the P/P indicated the expiration/beyond use date on the medication label must be checked prior to administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1.Cut watermelon stored in the facility walk in refrigerator, dated 2/6/2023, exceeded storage period for fresh fruits. There were several bags of bread and tortilla stored in the refrigerator that were past best by dates. 2.Nutritional supplements labeled store frozen with manufacturer's instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this timeframe. One box of sugar free strawberry banana flavor health shakes was stored in facility walk in refrigerator with no thaw date. There was received date of 12/6/22 on the box. Since there was no thaw date on the supplement, there was no way to determine how long the supplement had been thawed. This deficient practice had the protentional to result in food borne illness in four residents who were on nutrition supplements at the facility. 3.Several previously cooked foods were stored on top of raw ground beef, and other raw meat products in the reach in freezer. Left over frozen pancakes in a plastic storage bag, leftover cooked breakfast sausage in a small plastic bag, previously cooked creamed spinach, and gourmet breaded onion rings, were found on the bottom shelf of the reach in freezer mixed with meat products. 4.Personal staff belongings were stored on the shelf inside the dry storage area. 5.The nozzle of juice dispenser was slimy and dirty. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 54 out of 56 residents who were served food from the kitchen and 4 residents on nutritional supplement. Findings: 1.During a concurrent observation and interview with Dietary Service Supervisor (DSS), on 2/21/2023 at 8:30 a.m., there were three opened bags of hamburger buns with best buy date 2/12/2023, a box of corn tortillas, dated 12/2/2022, stored in the walk-in refrigerator. There was one cut watermelon and three small cups of cut watermelon for individual serving, dated 2/6/2023, stored in the walk in refrigerator. Dietary service supervisor, stated We usually follow the used by date for the breads and tortillas and will discard it when it is past date. During the same observation and interview, DSS stated that we used to have a menu that used a lot of these hamburger buns, but we do not cook that meal and the bread was not discarded. DSS also stated that most fresh fruits and vegetables was stored for five days. She added that the watermelon was labeled incorrectly. DSS then discarded the watermelon. A review of facility's policy, dated 2010, titled Suggested storage of Perishable and Non-Perishable Food indicated, refrigerator storage of fresh fruits and vegetables for 5-7 days. A review of facility's policy, titled Food receiving and storage - refrigerated storage guidelines revised 11/2020, indicated separating raw foods (e.g., beef, fish, [NAME], pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices, do not drip onto these foods, and labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen(where applicable) or discarded. A review of the 2022 U.S. Food and Drug Administration Food Code, code:3-501.17, titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, indicated refrigerated, ready-to-eat, time/ Temperature Control for Safety Food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 2. During a concurrent observation and interview with DSS, on 2/21/2023 at 8:40 am, one box of sugar free strawberry-banana flavored health shake were stored in the facility walk in refrigerator with received date 12/6/2022, with no thaw date or use by date. DSS stated this is bad, I'm going to throw it, it is a dairy product, it is good only for 14 days once thawed. DSS stated there should be a date to indicate when it was stored in refrigerator to thaw. She added these products are frozen. A review of nutritional supplements labeled Store Frozen with manufacturer's instruction to use within 14 days of thawing. A review of facility's policy titled Food receiving and storage, revised 11/2020,indicated, when food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated 3. During a concurrent observation and interview with DSS, on 2/21/2023 at 9:20 a.m., gourmet breaded onion ring, leftover pancakes, breakfast sausage in plastic bag and previously cooked frozen creamed spinach were stored on top of raw meats in the reach in freezer. The cooked products were on the bottom shelf in the same container as the raw frozen meats. Dietary supervisor stated, It should not be mixed because it can cause cross contamination. Dietary supervisor then discarded all the ready to eat or previously cooked items from the freezer. A review of facility's policy with revision date 11/2020, titled Food receiving and storage under refrigerated storage guidelines, indicated separating raw foods (e.g., beef, fish, [NAME], pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices, do not drip onto these foods, and labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen(where applicable) or discarded. 4. During a concurrent observation and interview with DSS, on 2/21/2023 at 9:50 am, personal belongings of staff placed in a plastic bin was stored inside the dry food storage area. The plastic bin was labeled For staff personal belongings only and was at the bottom shelf on one of the rack/shelves inside the dry storage room. The bin contained car keys, purse, phone, and clothing item. DSS stated the staff personal belongings were in a bin and not touching food items. DSS then said she would remove and place in the office outside if the kitchen. DSS stated items brought into the kitchen from outside could cause cross contamination of food items. A review of facility policy titled Food receiving and storage- Dry food storage, revised 11/2020, indicated, Dry storage may be in a room or area designated for storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not potentially hazardous foods. The focus of protection for dry storage is to keep non-refrigerated foods, disposable dishware, and napkins in a clean, dry area, which is free from contaminants. A review of U.S Food and Drug Administration Food code 2022, code 6-305.11 titled Designation Indicated, Street clothing and personal belongings can contaminate food, food equipment, and food-contact surfaces. Proper storage facilities are required for articles such as purses, coats, shoes, and personal medications. In addition, U.S. Food and Drug food code 6-403.11 titled Designated areas indicated, Because employees could introduce pathogens to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single-use articles must not be in jeopardy of contamination from these areas. 5. During a concurrent observation and interview with DSS, on 2/21/2023 at 10:20 a.m., the nozzle of Juice dispenser was slimy and dirty. Dietary supervisor looked at the nozzle where juice was dispensed and acknowledged that it was dirty and should be washed daily in between meals with soap and hot water DSS asked the dietary aide (DA1) to clean the equipment right away. On 2/24/2023 at 8:21 a.m., DSS presented a copy of undated policy titled Beverage equipment cleaning instructions indicated daily care and cleaning of beverage equipment. A review of U.S Food and Drug Administration Food Code 2022 code 4-602.11 titled Equipment Food-Contact Surfaces and Utensils indicated Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview and record review, the facility failed to properly prevent and or contain COVID-19 by failing to ensure: 1.staff wore face shields and gowns while perform care to residents in the yellow zone (designated area for potentially COVID-19 positive residents) area in the facility to house residents who are awaiting corona virus ([COVID-19] a deadly virus that easily spreads from person to person) test results and may have symptoms of the virus. 2. staff was screened for signs and symptoms of the COVID-19 These deficient practices had the potential to spread Covid-19 to non-infected residents, staff and the community. a. During an observation on 11/30/2022 at 11:02 a.m. in the yellow zone a Certified Nursing Assistance (CNA) 4 did had goggles on top of her head and did not have an isolation gown. CNA 4 was observed making Resident's 8 bed and arranging the resident's water pitcher on the bedside table. Resident 8 was in the room sitting in a wheelchair, and CNA pulled Resident 8's wheelchair close to his bed. During an interview on 11/30/2022 at 11:10 a.m., CNA 4 stated, before entering a resident's room in the yellow zone staff must wear personal protective equipment ([PPE] equipment worn to minimize exposure and spread of infectious diseases such as gowns, gloves, face shields). CNA 4 stated PPE helped prevent the spread of COVID- 19. CNA 4 stated she forgot to wear a gown or eye googles while in Resident 8's room. CNA 4 stated she should have worn a gown and googles to stop the spread of diseases and not put the resident at risk of getting sick. During an interview on 12/1/2022 at 11:43 a.m., the Infection preventionist ([IP] licensed nurse in charge of infection prevention) stated it was very important to use PPE to prevent the spread of disease. The IP stated PPE consist of an N95 mask, goggles, gowns, and gloves. The IP stated staff was required to use PPE before entering residents' rooms, when providing care or when touching residents' belongings. During an interview on 12/1/2022 at 11:55 a.m., the Director of Nursing (DON) stated PPE was used to protect residents and staff from infection. The DON stated staff must wear PPEs before entering residents' rooms, when arranging residents' belongings to prevent the spread of COVI-19. During a review of the facility's Covid-19 Mitigation Plan, dated 9/30/2022, the plan indicated gowns should be used in the yellow and red zones for Covid-19 precautions during resident's care. During a review of the facility's policy and procedure (P&P) titled Personal Protective Equipment-Gowns dated 6/2018, the P&P indicated, when use of a gown was indicated, all staff must wear a gown before entering the resident's room. During a review of the facility's P&P titled Personal Protective Equipment-Protective Eyewear dated 6/2018, the P&P indicated, staff was to wear a face shield to protect the employee's eyes, nose and mouth from potentially infectious materials. b. During an interview on 11/30/2022 at 12:48 p.m., the IP stated last time CNA 2 worked in the facility was on 11/14/2022. The IP stated CNA 2 became symptomatic on 11/17/22. The IP stated CNA 2 got swabbed for COVID- 19 from her other job on 11/17/22. During a concurrent interview and record review of the Employee/Staff Only COVID- 19 Screening log with the IP on 12/1/2022 at 11:47 a.m., the IP stated CNA 2 did not screen for COVID- 19 prior to working on 11/14/2022. The IP stated CNA 2 developed signs and symptoms of COVID- 19 on 11/17/2022. The IP stated CNA 5 did not also screen for COVID- 19 screen prior to working on 11/21/2022. The IP stated CNA 5 developed signs and symptoms of COVID- 19 on 11/22/22. The IP stated the importance for staff to COVID- 19 screen at entrance prior to the start of each shift was to ensure staff did not have any signs and symptoms of COVID- 19. During an interview on 12/1/2022 at 12:53 p.m., the DON stated staff, visitors and anyone entering the facility must be screened for COVID- 19 before entering residents care areas. The DON stated everyone must sign in and out of the building to ensure everyone was screened. The DON stated the importance to COVID- 19 screening was to help prevent the spread of the virus an protect residents, staff and the community. During a review of the facility's Covid-19 Mitigation Plan, dated 9/30/2022, the plan indicated at the beginning of each shift, all health care providers will be screened for symptoms of COVID-19 and the results documented indicating the absence of COVID-19 symptoms.