**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one of two residents (Resident 1) was free from physical restraint (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) when Certified Nursing Assistant 1 (CNA 1) tied the resident with a bed sheet to the waist and around the wheelchair on 4/11/24. According to CNA 1, she tied down the resident down in the wheelchair with a bed sheet to prevent the resident from getting up while she was attending to another resident (Resident 2) This deficient practice resulted in Resident 1's rights being violated, and held against her will. As a result of being tied down, Resident 1 expressed verbalization of feeling hopeless, humiliated, upset, cried, verbalized being treated like a kid, scared of CNA 1, and felt that day like a nightmare. Resident 1 verbalized that she felt helpless and overpowered . and that CNA 1 took her freedom away. On 4/16/2024 at 5:12 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the inappropriate use of physical restraint. The survey team notified the Director of Nursing (DON) and the Administrator (ADM) of an IJ situation due to the facility's failure to ensure Resident 1 was free from physical restraints imposed for discipline or staff convenience when CNA 1 tied Resident 1 to the wheelchair with a bedsheet, to restrict Resident 1's freedom of movement after finding Resident 1 playing with water in the toilet bowl and prevent the resident from falling, on 4/11/2024 during the 3 PM to 11 PM shift. On 4/17/2024 at 6:01 PM, the IJ was removed while onsite at the facility, in the presence of the ADM and the DON, after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated 4/16/2024, included the following: 1. CNA 1 was suspended from employment on 4/12/2024 and upon facility's investigation CNA 1 was terminated from the facility on 4/16/2024. 2. Resident 1 was assessed by the DON on 4/12/2024. There are no visible injuries noted on Resident 1. 3. Resident 1 was monitored by the DON initially and the Licensed Vocational Nurses (LVNs) every shift for 72 hours for negative psychosocial impact starting 4/12/2024. 4. Social Services Director (SSD 1) conducted an evaluation of Resident 1 for emotional distress on 4/12/2024, 4/15/2024 and 4/16/2024 and will continue daily visits for two weeks. Licensed nurses monitored Resident 1 every shift on 4/13/24 and 4 14/2024 to ensure the resident's psychosocial well-being. The facility's Interdisciplinary Team (IDT; team of professionals with a common goal) met with Resident 1 on 4/12/2024. 5. Resident 1 was seen by the primary care physician on 4/15/2024 and recommended Psychology (the scientific study of the human mind and its functions, especially those affecting behavior) and Psychiatry (the branch of medicine concerned with the study, diagnosis, and treatment of mental illness) consult. 6. Resident 1 was referred to and seen by the psychologist on 4/16/2024 via telehealth (facetime) in the resident's room and will be visited weekly. The Psychologist will follow up with a resident in-person visit on 4/18/2024, to continue to monitor and notify, will be seen via telehealth (facetime) as needed. 7. Resident 1 was referred to and seen by the psychiatrist on 4/16/2024 via telehealth (facetime) in the resident's room with recommendation to monitor for any changes and continue current medication regimen. 8. Residents who were assigned to CNA 1 were interviewed by the Assistant DON on 4/15/2024. There are no other residents identified to be affected by the same deficient practice. 9. Immediate in-service was provided to facility staff; CNA, Licensed Vocational Nurses, Registered Nurse (RN) Supervisor, Rehabilitation Department staff, housekeeping staff, Activity staff, Maintenance staff, Kitchen staff and laundry staff that started on 4/15/2024 and will continue until 100 % achieved (estimated completion: 4/17/2024) regarding the following: - Resident's rights to be free from physical restraint. - Policy and Procedure on the use of restraint - Policy and Procedure on Identifying Involuntary Seclusion and Unauthorized Restraint - Abuse Reporting (Timely reporting of abuse-2-hour reporting) - Any staff that has not undergone the above training will not be put in the facility's schedule. - The Director of Staff Development (DSD) rechecked professional licenses and certificate for current staff such as CNAs, Licensed staff and therapists on 4/17/2024 for any disciplinary action related to abuse. Any staff member with disciplinary action against their professional license will be subject for investigation by the ADM. 10. Department Managers will conduct room rounds in the morning for safety and observation of any physical restraints and will conduct interview with current residents who are alert and interviewable, for five days a week starting 4/17/2024. LVNs and RN supervisors will monitor residents every shift to ensure restraints are not being used. 11. During weekends, the Administrator/DON will assign room rounds to RN Supervisors and Manager of the day (MOD) regarding the inappropriate use of physical restraints. 12. For non-interviewable residents, LVNs and RN supervisors will monitor residents every shift to ensure physical restraints are not being used in the facility. 13. Any negative findings during room rounds and monitoring will be reported immediately to the ADM/DON and will conduct investigation appropriately and report to appropriate agencies (local police, ombudsman, CDPH licensing). 14. The Department Manager as part of room rounds will conduct safety and observation of any physical restraints and will conduct interview with current residents who are alert and interviewable five days a week in the morning. 15. Any findings of the use of physical restraints during daily rounds will be reported to CEO/Quality Assurance and Performance Improvement (QAPI) Committee for additional recommendations. 16. The QAPI Committee should evaluate weekly the implementation of the plan of correction (room rounds, daily safety observation of the residents), monitor for effectiveness and revise plan as necessary for continuous improvement until the resolution is achieved. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection of one or two lungs), anxiety (feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness) and bipolar disorder (mental illness that causes unusual shifts in mood from extreme happiness to extreme sadness and vice-versa) A review of Resident 1's History and Physical dated 3/22/2024, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of 3/28/2024, indicated the resident had severe cognitive (thought process) impairment. The MDS indicated Resident 1 was independent (able to complete task by themselves) in walking, with the use of a walker. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) on tasks such as lower body dressing, bathing, and toileting, moderate assistance (helper does less than half the effort) on tasks such as upper body dressing, and supervision on tasks such as sit to stand and bed mobility. The MDS indicated Resident 1 did not have physical restraints used during the MDS assessment reference date. A review of Resident 1's Fall Risk Evaluation, dated 3/22/2024, indicated Resident 1 was assessed at high risk for falls. The Fall Risk Evaluation indicated Resident 1 had no falls for the past 90 days. A review of Resident 1's care plan dated 3/23/2024, indicated the resident was high risk for falls related to confusion, balance problems, and cognitive impairment. The care plan interventions included anticipating/meeting the resident's needs, providing the resident with a safe environment, and reevaluating the use of adaptive equipment and devices to ensure the appropriateness on the use of least restrictive device or restraints. A review Resident 1's Progress Notes New, dated 4/12/24, timed at 9:30 AM, indicated a Nursing Progress Note authored by the DON, that the DON received a report from the Director of Rehabilitation (DOR) regarding an alleged incident of abuse; Resident [1] was tied with white single sheet around the waist in the wheelchair on 4/11/2024 during 3 to 11 shift . The progress notes indicated CNA 1 admitted tying Resident 1 in the wheelchair to prevent the resident from falling while CNA 1 was attending to other residents. The progress notes indicated the DON reached out to Speech Therapist (ST) 1 who saw Resident 1 in the resident's room on 4/11/2024. The progress notes indicated Resident 1 informed ST 1 that there was a sheet around Resident 1's waist and ST 1 immediately informed the charge nurse (LVN 1). The progress notes indicated Resident 1 was slightly upset/frustrated about the incident . and stated that someone tied her with a bed sheet around her waist in the wheelchair . A review of a facility record titled Care Plan Conference Summary dated 4/12/2024, authored by SSD 1, indicated that Resident 1 stated that the evening shift CNA tied her with a bedsheet around her waist while sitting in the wheelchair. The record indicated Resident 1 stated that she could not get up and became frustrated and informed ST 1 that she was tied to the wheelchair. A review of Resident 1's Psychosocial/Social Note, dated 4/16/2024, and timed at 6:36 PM, authored by SSD 1, indicated Resident 1 stated the incident made her feel helpless, and was asking for help when two people walked by. The Psychosocial/Social Note indicated Resident 1 felt overpowered by the CNA who seemed not seeing her even though she was there. During an interview on 4/12/2024 at 2:42 PM, Resident 1 stated she remembered being tied up yesterday (4/11/2024) with a staff that works at the facility. Resident 1 stated when the new nurse (CNA 1) came in the nurse tied Resident 1 using a bed sheet around the waist to the wheelchair for hours. Resident 1 stated she kept screaming while she was tied up. Resident 1 stated while she was screaming She heard two people walking by and nothing happened. Resident 1 stated being tied up upset her that she cried, felt humiliated, and being tied up made her feel like a person that got caught in a nightmare. Resident 1 further stated that being tied up made her feel like a kid who had no control and that her life was over because someone had the power to make her a bad person. Resident 1 stated she could not remove the bedsheet. Resident 1 stated she would feel scared if she ever sees CNA 1 again. Resident 1 stated CNA1 took her freedom away. During an interview on 4/12/2024 at 4:22 PM with CNA 1, CNA 1 stated she was assigned to Resident 1 and Resident 2 in the same room, on 4/11/2024 for the 3 PM to 11 PM shift. CNA 1 stated when she was doing her initial rounds for her assigned residents when Resident 2 asked for assistance go to the bathroom. CNA 1 stated she was helping Resident 2 in the bathroom when Resident 1 started getting up from the bed. CNA 1 stated she did not call other staff for help because when she looked outside of Resident 1's room, there was no other staff available in the hallway. CNA 1 stated she put Resident 1 in the wheelchair and tied her to the wheelchair using a bed sheet. CNA 1 stated she tied Resident 1 to prevent the resident from falling because Resident 1 kept trying to get up. CNA 1 stated she started her initial rounds within 30 minutes of her arrival into the facility during the 3 PM to 11 PM shift. CNA 1 stated she finished the evening shift and had Resident 1 in her assignment throughout the shift, on 4/11/2024. CNA 1 stated that she informed LVN 2 on 4/11/2024, that she tied Resident 1 to the wheelchair. During an interview on 4/12/2024 at 4:36 PM with ST 1, ST 1 stated he went to Resident 1's room at around 5:45 PM to 6 PM and when he opened the door, he heard a resident yelling for help. ST 1 stated when Resident 1 saw ST 1, Resident 1 called ST 1 by his first name, asking for help to get her out. ST 1 stated he walked closer to Resident 1's bedside and he saw that Resident 1 was sitting on a wheelchair with a bed sheet wrapped around the waist and the wheelchair. ST 1 stated Resident 1 had a bedside table in front of her. ST 1 stated that during that same time, CNA 1 was inside the room, feeding another resident (Resident 3). ST 1 stated he reported what he saw to LVN 1 and the DOR. During an interview on 4/12/2024 at 4:13 PM with the DOR, the DOR stated she received a text message from ST 1 on 4/11/2024 at around 6 PM, stating that a resident was tied to the wheelchair. The DOR stated the text message also indicated that ST 1 informed a nurse about the incident. During an interview on 4/12/2024 at 5:33 PM with LVN 1, LVN 1 stated ST 1 reported to her that there was something blocking Resident 1. LVN 1 stated she started to walk towards Resident 1's room, but as she got closer to the room, she saw the resident walking outside of the room with LVN 2 and CNA 1. LVN 1 further stated she did not approach the resident or staff. During an interview on 4/12/2024 at 6 PM with LVN 2, LVN 2 stated CNA 1 did not inform him on 4/11/2024 that she tied Resident 1 to the wheelchair. LVN 2 stated he was not aware that CNA 1 tied Resident 1 with a bedsheet to the wheelchair on 4/11/2024. During an interview on 4/16/2024 at 3:19 PM, with Resident 2 (Resident 1's roommate) and Resident 2's family member (Family 1), Family 1 stated she talked to Resident 2 on 4/11/2024, on the phone but there was a lot of noise during that time, and she could not make sense of what Resident 2 was telling her. Family 1 stated so she told Resident 2 to stop talking about it. Family 1 stated that when she was at the facility, she had seen Resident 1 attempts to get up from bed frequently. During the interview, Resident 2 stated she was in the room with Resident 1, on the evening of 4/11/2024 but did not see Resident 1 being tied up in the wheelchair. However, Resident 2 stated that she heard Resident 1 screaming for help and swearing at the nurse (CNA 1) that evening. Resident 2 stated Resident 1 was screaming for a long time. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included weakness, hypertension (consistent high blood pressure), and lack of coordination. A review of Resident 2's MDS dated [DATE], indicated Resident 2 has intact cognition. The MDS indicated Resident 2 has adequate (no difficulty) hearing without the use of a hearing aid. On 4/16/2024 at 6:14 PM, during another interview with Resident 1, in the presence of SSD 1, five days after Resident 1 was tied up in the wheelchair on 4/11/2024, Resident 1 stated she remembered being tied to the wheelchair with a bedsheet by a staff. Resident 1 stated her trauma does not go away. Resident 1 stated that she cried and was upset. Resident 1 stated she remembered calling for help because she heard two people passing by and they did not stop. During an interview on 4/12/2024 at 8:24 PM, with the DON, the DON stated CNA 1 tied Resident 1 to the wheelchair with the bed sheet and it was a form of physical restraint. The DON stated other non-restrictive alternatives must be unsuccessful before physical restraints may be used and there must be a physician's order, proper monitoring, consent, and evaluation prior to the use of restraints. The DON stated Resident 1 could suffer from emotional trauma and physical injuries affecting the resident's quality of life with the improper use of restraints. During an interview on 4/15/24 at 3:10 PM, with the ADM, the ADM stated the improper use of restraints on Resident 1 with or without consent, could be classified as a form of physical, emotional, and psychological abuse. The ADM stated there was no reason for CNA 1 to tie down Resident 1. A review of the facility's policy and procedure titled, Identifying Involuntary Seclusion and Unauthorized Restraint, revised in September 2022, indicated Risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. The policy and procedure indicated Restraints that are used as a last resort to protect the safety of the resident and others must be accompanied by an order from the practitioner and documentation reflecting the circumstances that led up to the decision to restrain the resident. A review of the facility's policy and procedure titled Resident Rights, (undated), indicated it is the resident's right to be free from corporal punishment or involuntary seclusion, and physical restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two (2) of two (2) sampled residents (Residents 285 and 131), who had food intolerances (food sensitivity and inability to digest a certain food) and food allergies (a serious and potentially life-threatening medical condition to substances that are usually not harmful) were assessed for food restrictions, including food allergies and served with food substitutions (replaced food with allergens with food without allergens) as indicated in the facility ' s policies and procedures titled, Food Allergies and Intolerances, and Nutrition Assessment, by failing to: 1. Ensure [NAME] 1 did not serve fish and fish containing products to Resident 285 and Resident 131, who were allergic to fish on 2/18/2024. [NAME] 1 served seashell tuna bake [tuna casserole, made with pasta and canned tuna (a type of fish)] on 2/18/2024 for dinner to Resident 285 and Resident 131. 2. Ensure Resident 285 and 131 ' s Primary Care Provider (PCP) 1 was aware that Residents 285 and 131 were allergic to fish, and Resident 285 was intolerant to milk. 3. Ensure Resident 285 ' s food allergies/intolerance were indicated in Resident 285 ' s physician ' s orders and Resident 131 ' s food allergies were indicated in Resident 131 ' s physician ' s orders. 4. Ensure the Dietary Services Supervisor (DSS) did not serve a High Protein Nutrient (HPN) [contains 2% milk and sugar] milk supplement from the facility ' s kitchen, on 2/20/2024, 2/21/2024, and 2/22/2024 to Resident 285, who was intolerant (unable to fully digest) to milk. 5. Ensure the Registered Dietitian (RD) conducted a resident interview with Resident 285 and did not rely on the information entered by the Admitting Licensed Nurse (ALN) to complete Resident 285 ' s Nutrition Assessment and documented NKFA (No Known Food Allergies) in Resident 285 ' s nutrition assessment. 6. Ensure the DSS conducted a thorough verification during Resident 285 ' s interview for Resident 285 ' s food allergies and preferences when Resident 285 informed the DSS not to give Resident 285 fish or milk. 7. Ensure the DSS maintained a record of Resident 285 ' s allergy to fish in Resident 285 ' s tray card (a card on each meal tray that indicated food allergies/preferences) after Resident 285 reported fish allergy to [NAME] 1 on 2/17/2024. These deficient practices had the potential for Resident 285 and Resident 131 to experience severe allergic reaction to fish, which could cause a life-threatening condition such as severe tachycardia (increased heart rate), anaphylaxis (severe allergic reaction including closure of airways), cardiac arrest (sudden loss of heart function, breathing and consciousness), and or death. On 2/22/2024 at 3:45 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding food and nutrition services. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Registered Dietitian (RD) of the IJ situation due to Resident 285 and Resident 131, who reported food allergies to fish were served with seashell tuna bake on 2/18/2024; and Resident 285 who was lactose intolerant (unable to fully digest the sugar [lactose] in milk) was served with HPN on 2/20/2024, 2/21/2024, and 2/22/2024. On 2/23/2024 at 6:13 PM, the IJ was removed in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility ' s implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated 2/23/2024, included the following: 1. On 2/22/2024, Residents 285 and 131 were immediately assessed for food allergies and food preferences by the Assistant Director of Nurses (ADON). PCP 1 was informed by the ADON. The food preferences and food allergies were communicated to the DSS and updated the [NAME] (a reference that is separate from the resident ' s chart). 2. On 2/22/2024, Resident 285 was interviewed by the Interdisciplinary Team (IDT - a group of professionals all working collaboratively toward a common goal) for food allergies. 3. On 2/22/2024, findings of Residents 285 and 131 ' s food preferences and food allergies were documented on Resident 285 and 131 ' s electronic medical record and meal cards so it could be reflected when diet types are printed and used during meal tray verification prior to serving the resident ' s meal trays. 4. On 2/22/2024, the DON, ADON, RD and DSS conducted a review of all current residents for verification of food allergies through resident/responsible party interviews and record reviews to ensure food allergens (a substance that causes an allergic reaction) and dislikes are not served to residents with known food allergies and dislikes. 5. On 2/22/2024, nine residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) were identified with food allergies. The food allergies and food preferences identified were documented on each of the residents ' medical records and meal cards. Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285 ' s food preferences and allergies would reflect in the residents ' diet orders were printed and used during meal tray verification prior to serving the resident ' s meal trays. 6. On 2/22/2024, The DSS and Licensed Nurses (all Licensed Nurses) conducted food preference assessment to all active residents and updated diet care plans. 7. On 2/22/2024, the RD started reassessments of all residents ' Nutritional Status to ensure nutritional plan, dietary restrictions and food preferences are up to date. 8. On 2/22/2024, the Director of Staff Development (DSD) provided in-service to all Licensed Nurses to check the dietary slip for food allergies or food references prior to serving meal trays to the residents. 9. On 2/22/2024, the DON and DSD provided in-service and training to the RD and the DSS regarding the facility ' s system in place for all newly admitted residents having thorough verification for food allergies conducting through resident/responsible party interviews and record reviews to ensure food allergens were not served to residents with known food allergies. 10. On 2/23/2024, the ADM, and the RD interviewed Resident 285 for lactose intolerance. Resident 285 ' s care plan and [NAME] (allergic to fish, lactose intolerance, no milk) was immediately updated, and offered Resident 285 with soy milk. 11. On 2/23/2024, the facility signed a contract and implemented a new menu system, called Menus 2U which integrated in the facility ' s Electronic Health Records (EHR-electronic version of a patient ' s medical history) to ensure that all new dietary orders, food allergies and food references that were entered in EHR would be automatically generated. The software would include printing of the updated diet slip for each meal by the DSS or designee and the dietary would reference the meal preparation during tray line avoiding inaccuracies and identifying food dislikes and allergies list. Included in the diet slip are Diet Order, Diet Consistency, Diet Texture, Likes and Dislike, Food Allergy, Beverage Preference, Tray Instruction, and Feed Instructions. 12. On 2/23/2024, a list of residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) with food allergies and dislikes was posted in the kitchen meal preparation area. Thus, allowing all dietary staff to easily identify all residents with allergies, and help with accuracy. 13. On 2/23/2024, Licensed Nurses assessed all residents on PO (per orem -by mouth) meals to ensure accuracy on the meal served for breakfast. 14. As of 2/23/2024, the Registered Nurse Supervisor would oversee the allergy report upon admission. 15. As of 2/23/2024, upon admission, Registered Nurse Supervisor/Licensed Nurses would input the allergy information obtained from the residents to the facility ' s EHR and provide a printout to Dietary Department, Activity Department. Nursing Department, and Dietary Department should ensure a Dietary list in each Meal Cart. 16. Starting on 2/23/2024, Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285 ' s diet orders to match in the individual meal tray cards with identified food allergies written in bold red font with orange sticker attached and in addition those residents identified will wear orange bands. 17. As of 2/23/2024, identified residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) with food allergies and food dislike upon admission would be given/served alternate/substitute meals. 18. As of 2/23/2024, upon admission, the DSS would conduct a food preference interview with the resident including food allergies, food preferences and ensure to communicate with nursing to input in the EHR. In addition, the RD would include food allergies/food preferences when conducting assessment during quarterly, annually and/or significant change assessment and would include in RD recommendation report to nursing if any identified food allergies and food preferences that was not captured prior to nutritional assessment. Findings: 1.A review of Resident 285 ' s admission Record indicated the facility admitted the resident on 2/5/2024, with diagnoses that included severe protein-calorie malnutrition [occurs when an elderly does not eat enough protein and energy (measured by calories) to meet nutritional needs], muscle weakness, age-related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding due to aging), and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). A review of a facility document titled Resident Meet and Greet, dated 2/6/2024, completed by the DSS for Resident 285, indicated No fish listed under food dislikes, and No milk listed under beverage of choice. A review of Resident 285 ' s Minimum Data Set (MDS, a standard assessment tool that measures health status), dated 2/11/2024, indicated Resident 285 was cognitively intact (able to understand and process information). The MDS indicated Resident 285 needed set up or clean up assistance for eating and needed supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral/personal hygiene. A review of Resident 285 ' s Order Summary Report, dated 2/22/2024, indicated Resident 285 had a diet order of regular diet with regular texture, and regular/thin consistency since 2/6/2024. During a concurrent observation and interview on 2/20/2024 at 9:45 AM, with Resident 285 in Resident 285 ' s room, a glass of milk covered with a plastic food wrap with written HPN was on Resident 285 ' s meal tray. Resident 285 stated Resident 285 was severely allergic to fish and mildly with milk but the facility served Resident 285 with fish on 2/18/2024, during dinner time and milk with almost every meal. During an observation on 2/20/2024 at 12:57 PM, in Resident 285 ' s room, a meal card was observed on Resident 285 ' s meal tray indicating No fish, No milk. A glass of milk covered with a plastic food wrap with written HPN was on Resident 285 ' s meal tray. During a concurrent observation and interview on 2/21/2024 at 12:30 PM with Resident 285 in Resident 285 ' s room, a glass of milk covered with a plastic food wrap with written 4 oz HPN, was on Resident 285 ' s meal tray. Resident 285 stated, Resident 285 ' s meal card indicated No milk but the facility kitchen staff gave Resident 285 milk again. During an observation on 2/22/2024 at 6:45 AM, in the kitchen, the DSS was observed making HPN. The HPN was made out of 2% milk (reduced fat milk) with a cup of sugar. During an observation on 2/22/2024 at 7:15 AM, by the facility hallway in front of the kitchen, two food carts were observed coming out of the kitchen. Treatment Nurse (TN) 1 and TN 2 were reading from a printout titled Diet Type Report dated 2/22/2024, during meal verification of each resident ' s meal trays. During a concurrent interview and record review of the Dietary Type Report dated 2/22/2024 and a random resident ' s (Resident 102 ' s) tray card, on 2/22/2024 at 7:17 AM, with TN 1 and TN 2, TN 1 stated that licensed treatment nurses (all treatment nurses) were responsible for using the Diet Type Report, to compare with each residents ' tray card during meal tray verification to check for the right diet, texture, and any additional directions. TN 1 stated, when a resident had preferences or any other instruction for eating, the information would be included in the tray card, and Diet Type Report written under Additional Directions. TN 1 stated, when a resident ' s food allergies and preferences were not listed in the Additional Directions or the resident ' s tray card, the licensed nurses would not know. TN 2 stated, resident ' s tray card only listed likes and dislikes. TN 2 stated a resident ' s tray card had no section that listed food allergies and preferences. During a concurrent interview and record review of the Dietary Type Report, dated 2/22/2024 and Resident 285 ' s tray card, on 2/22/2024 at 7:20 AM with TN 2, TN 2 stated there was no information listed under Additional Direction indicating Resident 285 was allergic to fish. TN 2 stated Resident 285 ' s tray card listed No fish, No milk under the Dislikes section of the tray card. TN 2 stated that the dislike meant that Resident 285 did not like eating fish or drinking milk. TN 2 stated, there should be no fish and no milk in Resident 285 ' s meal tray. During a concurrent interview and record review of Resident 285 ' s Nutritional Assessment Form, dated 2/13/2024, on 2/22/2024 at 7:37 AM, the Form indicated NKFA under the Food Allergies section of the Form. The RD stated Resident 285 had no known food allergy, according to the information in Resident 285 ' s EHR. The RD stated, she would know if a resident had any food allergy by looking at the EHR because it would show under the resident ' s dashboard. The RD stated the information was entered by the admitting licensed vocational nurse (LVN 8) who admitted the resident to the facility. The RD stated she used the admitting licensed nurse ' notes and progress notes to complete Resident 285 ' s Nutritional Assessment and RD recommendations. The RD stated she did not interview Resident 285 personally. The RD stated, the RD would not know Resident 285 ' s food preferences because the DSS took care of it (Resident 285 ' s food references). The RD stated it was important to make sure the facility ' s staff (in general) knew Resident 285 ' s food allergies because consuming food allergens could lead to allergic reaction and death. During an interview on 2/22/2024 at 8:14 AM, the DSS stated, Resident 285 disliked fish and milk because Resident 285 told him I don ' t eat fish, and no milk. The DSS stated, he did not ask Resident 285 why Resident 285 did not eat fish and stated, no milk. The DSS stated Resident 285 ' s fish allergy and milk intolerance were not documented in Resident 285 ' s medical records. The DSS stated, it was important to document Resident 285 ' s or any resident ' s food allergies int the medical record because it could cost their life. During a concurrent record review and interview of Resident 285 ' s Nursing-Dietary Communication Form (resident ' s meal order form) dated 2/17/2024 (Saturday), on 2/22/2024 at 8:32 AM, with the DSS in the DSS ' s office, the DSS stated that the communication form was handwritten by Resident 285. The DSS stated the communication form indicated Allergic to Fish. The DSS stated the DSS did not know (did not review the communication form) and did not update the information (fish allergy) indicated in Resident 285 ' s Nursing-Dietary Communication Form because the DSS received all communication forms submitted over the weekend on the following week/Monday (2/19/2024) to keep for records purposes only. During a concurrent interview and record review of a facility document titled, Winter Menu, undated, on 2/22/2024 at 8:38 AM, the DSS stated, the main dinner menu served to the residents (including Resident 285 and 131) on 2/18/2024 was seashell tuna bake, made from canned tuna, a type of fish. During a concurrent interview and record review on 2/22/2024 at 8:45 AM, the DSS stated, when a resident (in general) was allergic to any food from the facility ' s main menu, the resident would be served with the alternative menu or whatever the resident would order using the Nursing-Dietary Communication Form. The DSS stated, the DSS could not find any Nursing-Dietary Communication Form that Resident 285 submitted on 2/18/2024 for dinner, to indicate that Resident 285 ordered an alternative menu, aside from Seashell tuna bake that was served on 2/18/2024. During an interview on 2/22/2024 at 9 AM with [NAME] 1 in the DSS ' s office in the absence of the DSS, [NAME] 1 stated she was in charge of receiving the Nursing-Dietary Communication Forms and cooked during the weekend. [NAME] 1 stated, she received the Nursing-Dietary Communication Forms, kept the forms for record purposes and handed them to the DSS, on Monday of the following week. [NAME] 1 stated, she was aware that Resident 285 was allergic to fish because she remembered one of Resident 285's Nursing-Dietary Communication Forms indicated allergic to fish was handwritten by Resident 285 on 2/17/2024. [NAME] 1 stated she did not inform anyone from the facility, including the DSS about Resident 285 ' s Nursing-Dietary Communication form of allergic to fish. [NAME] 1 stated she just left all communication forms on the DSS ' s desk. During an interview on 2/22/2024 at 9:45 AM, with the DSS, the DSS stated he did not have a printout list of all residents in the facility with food allergies, intolerances, or preferences. The DSS stated he had a binder with all the residents ' nutrition assessments, titled Resident Meet and Greet. The DSS stated he would just go through the binder as needed. During the time of the interview, the DSS stated the facility had a total of four (4) residents with identified food allergies (not nine residents). During a concurrent interview and record review of Resident 285 ' s physician orders, admission assessments, care plans, and medication records since admission on [DATE], on 2/22/2024 at 10:28 AM, Registered Nurse (RN) 1 stated she could not find documented evidence of Resident 285 ' s food allergy to fish or milk. RN 1 stated when a resident was admitted to the facility, the licensed nurses (in general) must complete an admission Data Collection form for a thorough assessment that included the resident ' s allergies. RN 1 stated the information the licensed nurses entered in the admission Data Collection Form were all based on the information that the acute hospital provided to the facility through a discharge paper packet and phone call for report, which did not include Resident 285 ' s food allergies. During the same interview, on 2/22/2024 at 10:28 AM, RN 1 stated that when Resident 285 informed the facility staff (Cook 1) of an allergy, [NAME] 1 had to report to the DSS, and the DSS had to document Resident 285 ' s food allergy in the EHR, so Resident 285 ' s allergy information could be updated. RN 1 stated, it was important to make sure Resident 285 had the most updated allergy list because the resident could die from an allergic reaction. During an interview on 2/22/2024 at 12:15 PM, with Dietary Assistant (DA) 2, [NAME] 1 and the DSS in the kitchen, DA 2 stated he worked with [NAME] 1 on 2/18/2024. DA 2 stated a nurse (DA 2 could not recall who) came to the kitchen during dinner time on 2/18/2024, to return Resident 285 ' s dinner plate, stating that Resident 285 complained about having fish in her pasta plate, and requested a replacement. [NAME] 1 stated, when serving the main dinner menu for all residents on 2/18/2024, she served pasta with tuna fish (Seashell tuna bake). During an interview on 2/22/2024 at 1:30 PM with Resident 285, Resident 285 stated, she had severe allergic reaction to fish. Resident 285 stated, her face and throat were swollen, and she could not breathe when she ate fish in the past during her teenager year (could not recall the exact year) that led to her transfer to an acute hospital. Resident 285 stated, she never ate fish again after that incident. Resident 285 stated, she could have died from eating fish. Resident 285 stated, when ingesting milk or milk products on an empty stomach, she would have abdominal bloating, nausea and stomach upset. Resident 285 stated, she did not want to be served with milk due to uncomfortable experience with milk. During a concurrent interview and observation on 2/23/2024 at 1:10 PM, with Resident 285 in Resident 285 ' s room, Resident 285 stated the facility kitchen staff served her milk again during breakfast, and stated she was upset because facility staff did not respect her food preferences. During an interview on 2/23/2024 at 1:20 PM, the RD stated she did not ask Resident 285 if Resident 285 was lactose intolerant. The RD stated she assumed Resident 285 was not intolerant to milk because Resident 285 could take ice-cream and a little bit of milk with cereal for breakfast. During another interview with Resident 285, on 2/23/2024 at 1:30 PM, in the presence of the ADM and the RD, Resident 285 stated she was lactose intolerant, and she did not want milk. Resident 285 stated that in the morning when breakfast did not taste good, she had no choice but to take a little bit of milk for the cereal. Resident 285 stated she could not take a lot of milk or take milk on an empty stomach because milk always gave her discomfort. 2. A review of Resident 131 ' s admission Record indicated the facility admitted the resident on 1/24/2024, with diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone) and type 2 diabetes mellitus (a disease that occurs when blood sugar level is too high). A review of Resident 131 ' s MDS dated [DATE], indicated Resident 131 was cognitively intact, independent (resident competes the activity by themselves with no assistance from a helper) in eating, oral hygiene, and personal hygiene. A review of Resident 131 ' s Allergy Report indicated in the EHR with created date 1/25/2024, indicated Resident 131 had a food allergy and the allergen was Fish. The Allergy Report severity indicated Moderate. The Allergy Report did not indicate an information under Reaction Manifestation and was left blank under Reaction Note. A review of a facility document titled, Resident Meet and Greet dated 1/24/2024, indicated Resident 131 was allergic to fish. The document did not have Resident 131 ' s allergy manifestation or reactions. A review of Resident 131 ' s Nutrition assessment dated [DATE], indicated Resident 131 was allergic to fish. A review of Resident 131 ' s physician diet order dated 2/22/2024, indicated Resident 131 ' s diet order of consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal) with regular texture, and regular/thin consistency. During a concurrent interview and record review of the Dietary Type Report dated 2/22/2024, on 2/22/2024 at 7:20 AM with TN 2, TN 2 stated there was no listed allergy information for Resident 131 in the Dietary Type Report. During a concurrent interview and record review of Resident 131 ' s physician orders, admission assessments, care plans, and medication records since admission to the facility from 1/24/2024, on 2/22/2024 at 12:33 PM, the MDS nurse stated Resident 131 was known to be allergic to fish since admission to the facility on 1/24/2024. The MDS nurse stated the facility did not develop a care plan to address Resident 131 ' s fish allergy since admission. The MDS nurse stated the RD needed to create the care plan to address Resident 131 ' s food allergies. The MDS nurse stated she did not know how to pull up a list of residents with allergies in the EHR. The MDS stated the facility did not have a list of residents with food allergies. A review of Resident 131 ' s Care Plan Conference Summary, dated 2/22/2024 at 4 PM, indicated Resident 131 was allergic to fish, and during the facility ' s IDT conference meeting with Resident 131, the Care Plan Conference Summary indicated, Resident 131 informed the IDT that he was also served with seashell tuna bake on 2/18/2024. During an interview on 2/23/2024 at 8:39 AM with the Social Service Assistant (SSA) in the SSA ' s office, the SSA stated she came and talked to Resident 131 on 2/22/2024. The SSA stated that Resident 131 told her that he was served with fish by the facility but could not remember the exact date. The SSA stated Resident 131 told her that when Resident 131 was served with fish in the facility, he pushed the tray away and called a Certified Nurse Assistant (CNA [unable to recall who]) in to replace the food. A review of the facility ' s policy and procedure (P&P) titled, Food Allergies and Intolerances, revised August 2017, indicated the following: -Residents are assessed for history of food allergies and intolerances upon admission and as part of the comprehensive assessment. -All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident ' s care plan. -Severe food allergies are noted on the face of the chart (in the form of a sticker or permanent marking indicating Severe Food Allergy: (number of food) and communicated in writing directly to the dietitian and the director of food and nutrition services. -Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. A review of the facility ' s P&P titled, Nutritional Assessment, revised October 2017, indicated the following: -As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. -The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .Food preferences and dislikes (including flavors, textures, and forms); Food restrictions, including food allergies and cultural or religious practices affecting food choices. A review of the facility ' s P&P titled, Diet Orders and Profile Card ([NAME] Card), revised 1/1/2018, indicated a current profile card shall be maintained for each patient (resident), indicating diet order, likes, dislikes, allergies to foods, diagnosis and instructions or guidelines to be followed in the preparation and serving of food for the patient (resident). A review of the facility ' s P&P titled, Dietary Services Manager-Job Description, dated September 2020, indicated responsibilities included the following: -Visit resident/family on admission to complete diet history/nutritional assessment and to review dietary requirements and preferences of each resident admitted . -Maintains a record of diet orders and food preferences. Ensures an accurate menu or tray card is available for each meal for each resident. A review of the facility ' s P&P titled, Registered Dietician-Job Description, dated September 2020, indicated responsibilities included the following: -Ensures that a current, legible diet card with resident ' s name, room number, diet order, food preferences and any other pertinent information is available for all residents who receive meals and is updated as needed. -Ensures documentation is accurate, informative, and descriptive of resident ' s condition, care provided and resident ' s response.