**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when one of three sampled residents (Resident 1) was transferred to a general acute care hospital. This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge. Findings: A review of Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). Further review of the record indicated the resident was transferred to an acute care hospital on June 10, 2025. A review of Resident 1 ' s Progress Note date June 10, 2025, at 1:45 p.m., indicated .received new orders .Resident sent out to[name of hospital] .gangrene right foot .physician made aware .resident family made aware . A review of Resident 1 ' s SBAR (Situation, Background, Assessment, and Recommendation) dated June 10, 2025, indicated .resident returned from medical appointment .received new orders to transfer resident to Inland Valley Hospital .gangrene right foot . On June 25, 2505, at 1:41 p.m., an interview and concurrent record review was conducted with the Social Worker (SW). The SW stated Resident 1 was transferred to a general acute care hospital on June 10, 2025, for gangrene of the right foot. The SW verified there was no documented evidence the ombudsman was notified of Resident 1's transfer to the hospital. The SW further stated the ombudsman should be notified of transfers and she should have followed up on the transfer to assure the ombudsmen was notified. On June 25, 2505, at 1:46 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON) and the Administrator. The DON stated the facility process is for nursing to fax the ombudsman when a resident is being transferred or discharged and the SW is to follow up on all transfer and discharge for notification of the ombudsman. The DON stated the ombudsman should have been notified. The Administrator verified there was no documented evidence the ombudsman was notified of Resident 1 transfer June 10, 2025. The Administrator stated the facility should have notified the ombudsman of Resident 1 transfer. A review of the facility policy and procedure titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated .Notice of Transfer or Discharge .when residents are sent emergently to an acute care setting .the notice is given as soon as it is practicable but before the transfer or discharge .Notice of Transfer is provided to the resident .resident representative .as soon as practicable before the transfer .(LTC) ombudsman when practicable .monthly list of residents .includes all notice content requirements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure wound care treatments were provided to meet the needs of residents when four sampled residents ' (Residents 1, 2, 3, and 4) were not provided wound care treatment in accordance with the physician ' s orders. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 ' s wounds to worsen and could lead to serious complications. Findings: On June 25, 2025, at 9:37 a.m., Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). A review of Resident 1 ' s Order Summary Report from April 1, 2025, to June 25, 2025, indicated the following: a. Clean right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/16/2025. Start date: 05/09/2025. b. Cleanse right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/23/2025. c. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/30/2025. d. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day every other day for wound care for 14 days. Start date 05/31/2025 End date 06/14/2025. A review of Resident 1 ' s Treatment Administration Record (TAR) for the month of May 2025, indicated treatment for the right foot stump was not signed as provided on May 14, 16, and 17, 2025, at 9 a.m. On June 25, 2025, at 10:58 a.m., Resident 2 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included low back pain, congestive heart failure (heart can ' t pump blood well enough leading to fluid (congestion) build up in body), and hypertension (high blood pressure). A review of Resident 2 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/09/2025, Start date:05/03/2025. The TAR has no documentation indicating treatment for the left heel was provided on May 4,2025. b. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/23/2025, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided for the left heel on May 17, 2025. c. Cleanse left heel blister with normal saline and pat dry and apply betadine and leave open to air. One time a day for a wound care to left heel blister until June 6, 2025. The TAR has no documentation indicating treatment was provided to the left heel blister on May 31, 2025. On June 25, 2025, at 11:38 a.m., Resident 3 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), chronic obstructive pulmonary disease (lung disease that makes it hard to breath), and dysphagia (difficulty swallowing). A review of Resident 3 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left great toe with normal saline and pat dry and apply triple Antibiotic and leave open to air. One time a day for treatment to left great toe for 14 days, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided on May 16 and 17, 2025. On June 25, 2025, at 9:37 a.m., Resident 4 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included subdural hemorrhage (blood collects in brain), gangrene (death of body tissue), palliative care (specialized medical care). A review of Resident 4 ' s TAR for the month of May 2025 indicated the following: a. Left foot 4th gangrene toe. Cleanse with NS wound cleanser, pat dry, then apply betadine. Cover with clean dry dressing daily and prn for dislodgement and soiled dressing. Every 48 hours for wound care to left foot until 05/30/2025, Start date: 05/15/2025. The TAR has no documentation indicating treatment was provided to the left foot 4th great toe on May 17, 2025. On June 25, 2025, at 1:03 p.m., an interview and concurrent record review was conducted with the Treatment Nurse. The Treatment Nurse stated there was no documented evidence that the wound treatment was administered on Resident 1's right foot stump on May 14, 15, nd 17, 2025. The TN verified as well that no treatment was provided for Resident 2's left heel wound on May 4, 17, and 31, 2025. For Resident 3's left great toe, the treatment nurse verified no treatment was documented on May 16 and 17, 2025; and For Resident 4's left foot 4th gangrene toe, no treatment was provided on May 17, 2025. The Treatment Nurse stated that wound treatments should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. On June 25, 2025, at 2:04 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON verified there was no documented evidence that the wound treatment was administered on Resident 1, Resident 2, Resident 3, and Resident 4. The DON stated the facility process is for nursing to follow all physician orders and document that the order has been performed in the resident ' s chart. The DON stated that wound treatment should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. A review of the facility policy and procedure titled Charting and Documentation, revised July 2017, indicated .The following information is to be documented in the resident medical record .treatments or services performed . documentation of procedures and treatments will include care-specific details .date .time .procedure/treatment . assessment .unusual findings .resident tolerance of the treatment .refusal . signature .title of individual documenting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practice was followed for two of three residents reviewed (Residents 1 and 2) when: 1. For Resident 1, the oxygen (O2) cannula (a flexible tube with two prongs that fit into the nostrils and delivers supplemental O2) was not dated and an undated nebulizer mask (a medical device that fits over the nose and mouth and allows an individual to inhale a mist of medication directly into their lungs) was found on top of Resident 1 ' s nightstand. In addition, the undated nebulizer mask was not stored in a plastic bag and was exposed to the environment; and 2. For Resident 2, the nebulizer mask was not changed since admission. These failures had the potential for Residents 1 and 2 to be exposed to bacterial cross contamination and the development of infection. Findings: 1. On May 12, 2025, at 11:18 a.m., Resident 1 was observed sitting in bed, awake and alert. Resident 1 was receiving O2 at 2 (two) LPM (Liters Per Minute – a unit of measurement). The O2 tubing was not dated. In addition, a nebulizer mask was found on top of the nightstand, not stored in a plastic bag and was exposed to the environment. The nebulizer mask was not dated. Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection). The physician order dated January 20, 2025, indicated, .Change nasal cannula/mask every night shift every Sun (Sunday) .Change O2 tubing every night shift every Sun . On May 12, 2025, at 11:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed changing O2 plastic bag in resident ' s rooms. In a concurrent interview with LVN 1, he stated the O2 cannula, O2 plastic bag, and the nebulizer mask should be changed once a week. LVN 1 stated the night shift nurses were assigned to change them on Sunday night. He also stated the O2 cannula and the nebulizer mask should be stored in a clear plastic bag, labeled, and dated when not in use. LVN 1 stated the O2 cannula, and the nebulizer mask should not be left exposed for infection control. On May 12, 2025, at 11:48 a.m., the Respiratory Therapist (RT) was interviewed. He stated respiratory equipment such as nasal cannula and nebulizer mask should be changed once a week. He stated the respiratory equipment should be labeled, dated, and stored in a clean plastic bag when not in use for infection control purposes. On May 12, 2025, at 12:43 p.m., the Director of Staff Development (DSD) stated he was the acting Infection Preventionist (IP). He stated the RT would change the respiratory equipment every Monday for those residents assigned to them and the night shift Charge Nurse should change the respiratory equipment on Sunday night. He also stated, the nasal cannula, and the nebulizer mask should be stored in a clear plastic bag for infection control and should be changed once a week. A review of the facility policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, .Steps in the Procedure .store in a plastic bag with the resident ' s name and the date on it .Change equipment and tubing every seven days, or according to the facility protocol . 2. On May 12, 2025, at 11:08 a.m., a resident belongings bag was observed hanging, attached to the drawer knob of Resident 2 ' s nightstand. The belongings bag indicated, .(Name of Resident 2) .Neb (nebulizer) mask .4/9/25 . Resident 2 was not in his room. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included pneumonia. A review of Resident 2's physician order dated April 9, 2025, indicated, .Change nasal cannula/mask every nigh shift every Sun .Change O2 tubing every night shift every Sun for hygiene . On May 12, 2025, at 11:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed changing O2 plastic bag in resident ' s rooms. In a concurrent interview with LVN 1, he stated the O2 cannula, O2 plastic bag, and the nebulizer mask should be changed once a week. LVN 1 stated the night shift nurses were assigned to change them on Sunday night. He also stated the O2 cannula and the nebulizer mask should be stored in a clear plastic bag, labeled, and dated when not in use. LVN 1 stated the O2 cannula, and the nebulizer mask should not be left exposed for infection control. On May 12, 2025, at 11:48 a.m., the Respiratory Therapist (RT) was interviewed. He stated respiratory equipment such as nasal cannula and nebulizer mask should be changed once a week. He stated the respiratory equipment should be labeled, dated, and stored in a clean plastic bag when not in use for infection control purposes. On May 12, 2025, at 12:43 p.m., the Director of Staff Development (DSD) stated he was the acting Infection Preventionist (IP). He stated the RT would change the respiratory equipment every Monday for those residents assigned to them and the night shift Charge Nurse should change the respiratory equipment on Sunday night. He also stated, the nasal cannula, and the nebulizer mask should be stored in a clear plastic bag for infection control and should be changed once a week. On May 12, 2025, at 2:18 p.m., Resident 2 was observed in the Activities Room, sitting in the wheelchair. He stated his nebulizer mask had not been changed since he was admitted in the facility. On May 12, 2025, at 2:40 p.m., LVN 2 was interviewed. LVN 2 stated she gave Resident 2 ' s breathing treatment in the morning and did not change the nebulizer mask. LVN 2 stated the respiratory equipment should have been changed Sunday, by the night shift. She also stated respiratory equipment should be stored in a plastic bag when not in use. A review of the facility policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, .Steps in the Procedure .store in a plastic bag with the resident ' s name and the date on it .Change equipment and tubing every seven days, or according to the facility protocol .

Based on observation, interview, and record review, the facility failed to ensure safe storage practice was followed in accordance with the professional standards of practice when a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility. Findings: On May 12, 2025, at 12:12 p.m., during a brief kitchen tour with the Dietary Manager (DM), a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. In a concurrent interview with the DM, he stated the chocolate syrup should have been discarded one year after it was opened on October 19, 2023. He stated the chocolate syrup was only good for one year once opened. The DM stated the chocolate syrup should have been thrown away so the kitchen staff will not use it. He also stated expired food can cause stomach upset or stomach illnesses. On May 12, 2025, at 4:45 p.m., during a telephone interview with the Registered Dietician, she stated the facility should follow the guidelines for storing dry goods with regards to expiration dates and open dates. She stated there should be no expired food or food stored in the kitchen longer than the shelf like, whether it was opened or not. A review of the facility document titled, DRY GOODS STORAGE GUIDELINES, dated 2018, indicated, .FOOD ITEM .Chocolate Syrup .OPENED ON SHELF .6 (six) months .

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster was found overflowing with trash. In addition, the lid of the dumpster was not completely closed. This failure had the potential to attract pests. Findings: On May 12, 2025, at 12:33 p.m., during a garbage disposal inspection with the Dietary Manager (DM), a trash dumpster located outside the building by the parking lot area was observed overflowing with trash. In addition, the lid of the dumpster was not completely closed. In a concurrent interview with the DM, he stated the dumpster should not be overflowing with trash. He also stated, the dumpster lid should be completely closed to prevent attracting pests. On May 12, 2025, at 12:25 p,m, during an interview with the facility owner, he stated the dumpster should not be overflowing and the lid should be completely closed. A review of the facility policy and procedure, titled, Food-Related Garbage and Refuse Disposal, revised October 2017, indicated, .Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter .

Based on interview, medical record review, and facility Policy and Procedure (P&P) review, the facility failed to ensure: 1. A system was developed and implemented to accurately track the movement of controlled medications (medications with high potential for abuse or addiction) to prevent and identify loss or potential diversion (illegal distribution or use for purposes not intended by the prescriber) of controlled medications when the facility was unable to account for the missing controlled medications for ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had resulted in controlled medication abuse or diversion. 2. Accurate accountability of controlled medications. During a random controlled medication audit for four of six sampled residents (Residents 9, 11, 12, and 13), the controlled medications were signed out of the Count Sheet (a controlled medication record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. This failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion. Findings: On August 26, 2024, at 8:40 a.m., an unannounced visit was made to investigate a facility report of an unusual occurrence regarding missing controlled medications. 1. During an interview on August 26, 2024, at 9 a.m.,with the Director of Nursing (DON), the DON stated, on the morning of August 16, 2024, the DON received a phone call from Licensed Vocational Nurse (LVN) 1 about missing controlled medication count sheets and controlled medication cards for two residents (Residents 4 and 9). The DON, after being informed by LVN 1, the same day, started the investigation. The DON stated the investigation included inspection of all medication carts, nursing stations, medication disposal areas, medication disposal bins, trash cans, paper document shred bins, rechecked controlled medication count, reviewed recent MAR, and interviewed nursing staff. The DON stated the investigation identified a total 10 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) that were missing controlled medication count sheets and controlled medication cards. The DON stated all residents who were missing controlled medications received refills from the pharmacy and no residents missed doses of medications. The DON stated, based on the information gathered through the investigation, the facility suspected the new hire per diem nurse, LVN 2, to have diverted the missing controlled medications. The DON further added, a police report was filed the same day and LVN 2 was no longer employed at the facility. During the same interview, the DON described the facility ' s process of receiving pharmacy deliveries of controlled medications as follows: - When a pharmacy delivery arrived, nursing staff placed the pharmacy Packing Slip in a bin for Medical Records; - Nursing staff filed the count sheet in the narcotic (controlled substance) logbook; and - Then locked the controlled medication card in the designated controlled medication drawer in the medication cart. During the same interview, the DON further added, if the controlled medication count sheet and medication card were missing, the loss would not have been identified immediately. The DON acknowledged there was no process implemented to monitor the receipt of controlled medications. During a follow-up interview on August 26, 2024, at 2:40 p.m., with the DON, the DON stated, she had not monitored the controlled medication inventory, usage, or medication administration records. During a follow-up interview on August 26, 2024, at 4:30 p.m., with the DON, the DON stated, there was no controlled medication reconciliation process implemented to identify loss or potential diversion of controlled medications. The DON acknowledged there should have been a process. During a review of the facility ' s P&P titled, Controlled Substances, dated November 2022, the P&P indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up .The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records .The director of nursing services documents irreconcilable discrepancies in a report to the administrator . 2. a. Resident 11 had a physician's order, dated July 30, 2024, for Norco (hydrocodone-acetaminophen, a potent controlled medication for pain) 5/325 milligram (mg, unit of measurement) tablet, 1 tablet by mouth every 12 hours as needed for pain. During an interview on August 26, 2024, at 12:13 p.m., with LVN 3, LVN 3 stated, when administering pain medication to a resident, nurses needed to sign out from the count sheet and document on the MAR immediately. LVN 3 stated the count sheet should match the MAR. During a concurrent interview and record review on August 26, 2024, at 12:30 p.m. with LVN 3, a review of Resident 11's Count Sheet for Norco 5/325 mg and MAR dated August 2024 indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR: - August 18, 2024, at 12 p.m.; and - August 23, 2024, at 1 p.m. During this interview and record review, LVN 3 acknowledged two Norco 5/325 mg tablets for Resident 11 were unaccounted. LVN 3 stated, nurse should have documented on the MAR. During a concurrent interview and record review on August 26, 2024, at 4:50 p.m., with the DON, Resident 11's Count Sheet for Norco 5/325 mg and MAR dated August 2024 were reviewed. The DON confirmed the discrepancies on the dates and times as listed above and acknowledged two Norco 5/325 mg tablets were unaccounted for resident 11. The DON stated, the doses should have been documented on the MAR. b. Resident 12 had a physician's order, dated October 26, 2023, for Norco 5/325 mg tablet, 1 tablet by mouth every 6 hours as needed for moderate pain (5 -7). During a concurrent interview and record review on August 26, 2024, at 12:45 p.m., with LVN 3, a review of Resident 12's Count Sheet for Norco 5/325 mg and MAR dated August 2024 indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR: - August 12, 2024, at 2:30 a.m.; - August 13, 2024, at 9:04 p.m.; - August 14, 2024, at 2:30 a.m.; - August 14, 2024, at 7:30 a.m.; - August 14, 2024, at 3 p.m.; - August 14, 2024, at 11:30 p.m.; - August 15, 2024, at 6 a.m. (or 4 p.m.); and - August 25, 2024, at 5:30 p.m. During this interview and record review, the LVN 3 acknowledged eight Norco 5/325 mg tablets for Resident 12 were unaccounted and should have been documented on the MAR. During a concurrent interview and record review on August 26, 2024, at 4:56 p.m., with the DON, Resident 12's Count Sheet for Norco 5/325 mg and MAR dated August 2024 were reviewed. The DON confirmed the discrepancies on the dates and times as listed above and acknowledged eight Norco 5/325 mg tablets were unaccounted for Resident 12. The DON stated, the doses should have been documented on the MAR. c. Resident 9 had a physician's order, dated August 13, 2024, for Ativan (a controlled medication used to treat anxiety) 1 mg tablet, 1 tablet every 6 hours as needed for anxiety. During a concurrent interview and record review on August 26, 2024, at 3:43 p.m., with the DON, a review of Resident 9's Count Sheet for Ativan 1 mg and MAR dated August 2024 indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR: - August 15, 2024 (time illegible, looked like 6:30am); and - August 16, 2024, at 9 a.m. During this interview and record review, the DON acknowledged two Ativan 1 mg tablets for Resident 9 were unaccounted and should have been documented on the MAR. d. Resident 13 had the following physician's orders: - August 8, 2024, for Ativan 0.5 mg tablet, 1 tablet every 6 hours as needed for anxiety; and - August 23, 2024, for Ativan 0.5 mg tablet, 1 tablet every 6 hours as needed for anxiety. A record review of Resident 13's Count Sheet for Ativan 0.5 mg and MAR dated August 2024 indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR: - August 15, 2024, at 12 p.m.; - August 17, 2024, at 9 a.m.; - August 19, 2024, at 9 a.m.; and - August 25, 2024, at 7:42 p.m. During a concurrent interview and record review on August 27, 2024, at 4:30 p.m., with the DON, Resident 13's Count Sheet for Ativan 0.5 mg and MAR dated August 2024 were reviewed. The DON confirmed the discrepancies on the dates and times as listed above and acknowledged four Ativan 0.5 mg tablets were unaccounted for Resident 13. The DON stated, the nurse should have documented on the MAR. During a review of the facility ' s P&P titled, Medication Administration, dated April 2019, the P&P indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .the individual administering the medication records in the resident's medical record .the date and time the medication was administered .the dosage .the route of administration .the signature and title of the person administering the drug. Further review of the facility ' s P&P titled, Controlled Substances, dated November 2022, indicated, .an individual resident-controlled substance record is made for each resident who will be receiving a controlled substance .This record contains .name of the resident .name and strength of the medication .quantity received .number on hand .time of administration .method of administration .signature of nurse administering medication.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a privacy bag was used for 1 (Resident #26) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Resident Rights, revised in 12/2016, specified, Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to: a. a dignified existence. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #26 was always incontinent of bladder. Resident #26's care plan included a focus area initiated 06/18/2024 that indicated the resident had an indwelling urinary catheter related to a pressure ulcer on their coccyx. Resident #26's Order Summary Report with active orders as of 06/19/2024, revealed an order dated 06/18/2024 for a Foley catheter (indwelling urinary catheter), size 16 fr. (French) attached to bedside drainage bag due to urinary retention and wound management. An observation on 06/17/2024 at 1:22 PM, revealed Resident #26 being pushed in their wheelchair from the dining room to their room. Resident #26's urinary catheter bag was observed without a privacy bag, exposing the urine. An observation on 06/18/2024 at 1:04 PM revealed Resident #26 was in the designated smoking area. Resident #26's urinary catheter bag was without a privacy bag, exposing the urine. During an interview on 06/20/2024 at 9:24 AM, Certified Nursing Assistant (CNA) #3 stated Resident #26's urinary catheter bag should be covered. During an interview on 06/20/2024 at 9:52 AM, CNA #4 revealed Resident #26 should have had a privacy bag on their urinary catheter bag. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocational Nurse (LVN) #2 stated all urinary catheter bags should be covered with a privacy bag. During an interview on 06/20/2024 at 11:11 AM, the Director of Nursing (DON) stated privacy bags should always be used on urinary catheter bags. She added Resident #26 had a privacy bag and she was not sure why it was not being used. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated all urinary catheter bags should have a privacy bag.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed for 2 (Resident #26 and Resident #34) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 12/2016, specified, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The policy also indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #26 was always incontinent of bladder. The MDS revealed that under Appliances for bladder and bowel the Indwelling Catheter box was not check. Resident #26's Progress Notes dated 04/05/2024 indicated the resident was sent to the emergency room for an evaluation of their wound. Resident #26's hospital Plan of Care dated 04/10/2024, revealed under the Assessment/Plan section that an indwelling urinary catheter was placed for urinary retention. Resident #26's Progress Notes dated 04/16/2024 revealed the resident was readmitted to the facility from the hospital. Resident #26's Order Summary Report with active orders as of 06/17/2024, revealed an order dated 04/16/2024 to admit Resident #26 back to the facility under the direction of the Medical Director. Further review revealed no orders were present on the Order Summary Report related to the resident's urinary catheter or care related to its use. Resident #26's care plan revealed that prior to survey entrance on 06/17/2024, no care plan was present for the resident's urinary catheter. An observation on 06/17/2024 at 1:22 PM, revealed Resident #26 being pushed in their wheelchair from the dining room to their room. Resident #26 was observed with a urinary catheter. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator revealed she did not notice the catheter when she interviewed Resident #26 for a significant change MDS. She stated there were no orders for the urinary catheter that would have prompt her to look for the catheter. The MDS Coordinator stated the care plans were created by what was triggered in the MDS. She stated it was not triggered in the MDS, so there was no prompt to create a care plan. During an interview on 06/20/2024 at 11:11 AM, the Director of Nursing (DON) stated she and the MDS Coordinator created the bulk of the care plans, but nurses have the ability to create and revise a care plan. The DON stated a care plan for Resident #26's urinary catheter should have been created. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated all residents with urinary catheters should have a care plan for the urinary catheter. 2. An admission Record revealed the facility admitted Resident #34 on 07/31/2021. According to the admission Record, the resident had a medical history that included diagnoses of obstructive and reflux uropathy and hydronephrosis with renal and ureteral calculous obstruction. A Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of renal insufficiency, renal failure, or end stage renal disease and obstructive uropathy. The MDS revealed that under Appliances for bladder and bowel the Indwelling Catheter box was not check. A [Hospital Name] Emergency Department [ED] Record, dated 05/11/2024, revealed Resident #34 had experienced nausea and vomiting for four days. The record revealed the resident was admitted to the hospital and a urinary catheter was placed. The record revealed a urinalysis confirmed that the resident had a UTI. The record revealed Resident #34 had diagnoses of sepsis secondary to pyelonephritis and a right-sided staghorn ureteral calculus. The record revealed the ED consulted with urology for possible intervention. The record revealed the provider recommendation was for Resident #34 to have a cystoscopy with a right ureteral stent placed on 05/12/2024. The record revealed that the plan of care was to discharge the resident back to the skilled nursing facility, and to have a follow-up appointment with urology in four weeks for upsizing the resident's suprapubic catheter. Resident #34's Order Summary Report with active orders as of 06/17/2024, revealed an order dated 05/16/2024 to admit Resident #34 back to the facility under the direction of the Medical Director. The Order Summary Report revealed an order dated 05/16/2024 that indicated the resident may see a physician at a urology medical center. Further review revealed no orders were present on the Order Summary Report related to the resident's suprapubic catheter or care related to its use. Resident #34's care plan revealed that prior to survey entrance on 06/17/2024, no care plan was present for the resident's suprapubic catheter. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocation Nurse (LVN) #2 stated registered nurses (RNs) created the care plans, and she updated them as needed. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator stated she created the care plan from MDS triggers. She stated the nurses had access to edit care plans, especially those that would be short-term, such as medication changes, and they could add interventions on already existing care plans. The MDS Coordinator stated there was no care plan created for Resident #34's urinary catheter because there was not an order for it. During an interview on 06/20/2024 at 11:08 AM, the Director of Nursing (DON) stated that she could not believe that there were no orders or care plan (prior to survey entrance on 06/17/2024) for Resident #34 and that there was no excuse for it. The DON stated that the staff had missed Resident #34's suprapubic catheter during the resident's readmission. The DON stated that staff needed to have orders, care plans, and documentation about the insertion site and lack of infection. The DON stated she should have caught that Resident #34's urinary catheter was not covered in their orders and care plan and that she took full responsibility for Resident #34's urinary catheter orders and care plan not being available for the nurses. The DON stated that she created the care plans and that the nurses had the ability to create and revise a care plan if needed. She stated her expectation was for either she or the MDS Coordinator to create the care plan and for the floor nurses to help keep them up to date. She stated she expected the care plans to be done timely and accurately and completed for everything that needed covered in a care plan. During an interview on 06/20/2024 at 12:25 PM, the Administrator stated his expectation was for care plans to be done timely and accurately.

2. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #26 was always incontinent of bladder. The MDS revealed that under Appliances for bladder and bowel the Indwelling Catheter box was not check. Resident #26's Progress Notes dated 04/05/2024 indicated the resident was sent to the emergency room for an evaluation of their wound. Resident #26's hospital Plan of Care dated 04/10/2024, revealed under the Assessment/Plan section that an indwelling urinary catheter was placed for urinary retention. Resident #26's Progress Notes dated 04/16/2024 revealed the resident was readmitted to the facility from the hospital. Resident #26's Skin Observation Tool, dated 04/16/2024 did not indicate Resident #26 had a urinary catheter. Resident #26's Order Summary Report with active orders as of 06/17/2024, revealed an order dated 04/16/2024 to admit Resident #26 back to the facility under the direction of the Medical Director. Further review revealed no orders were present on the Order Summary Report related to the resident's urinary catheter or care related to its use. Resident #26's care plan included a focus area initiated 06/18/2024 (during the recertification survey), that indicated the resident had an indwelling urinary catheter related to a pressure ulcer on their coccyx. Further review revealed that prior to 06/18/2024, no care plan was present for the urinary catheter. A nursing Progress Note, dated 05/17/2024, revealed Resident #26's catheter bag was changed. The note also indicated there was no signs or symptoms of infection. An observation on 06/17/2024 at 1:22 PM, revealed Resident #26 being pushed in their wheelchair from the dining room to their room. Resident #26 was observed with a urinary catheter. On 06/18/2024 at 11:06 AM, Medical Records (MR) #5 stated there was no order for Resident #26's urinary catheter. She added she was unsure when the urinary catheter was placed but though it might have been placed during the residents last hospital stay. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator revealed she did not notice the catheter when she interviewed Resident #26 for the significant change MDS. She stated there were no orders for the urinary catheter that would have prompt her to look for the catheter. The MDS Coordinator stated the care plans were created by what was triggered in the MDS. She stated it was not triggered in the MDS, so there was no prompt to create a care plan. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocational Nurse (LVN) #2 stated Resident #26 came to the unit in April (2024) with a urinary catheter. LVN #2 stated it never triggered that Resident #26 had a urinary catheter and there was nothing in the resident's chart about it. LVN #2 stated the resident's urinary catheter should have orders and be care planned. She added that should have taken place when the resident was readmitted . LVN #2 said the treatment nurse was the one that changed the catheter, but it could be done by any nurse. During an interview on 06/20/2024 at 11:11 AM, the Director of Nursing (DON) stated that upon admission or readmission, an assessment was expected to be done. The DON stated Resident #26's Skin Observation Assessment dated 04/16/2024 was an admission/readmission assessment. The DON stated Resident #26's assessment should have noted a urinary catheter. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated the admitting nurse should have done a full body assessment. The Administrator stated that a urinary catheter should have been documented at that time. The Administrator stated, additionally, the doctor should have been contacted for an order, and that should have been completed by the admitting nurse or the DON. Based on observation, interview, record review, and facility policy review, the facility failed to ensure upon admission, that orders were obtained for the placement and ongoing care and maintenance of urinary catheters for 2 (Resident #34 and Resident #26) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care, Urinary, revised in 10/2010, revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy also revealed, The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. the name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain, and 9. The signature and title of the person recording the data. 1. An admission Record revealed the facility admitted Resident #34 on 07/31/2021. According to the admission Record, the resident had a medical history that included diagnoses of obstructive and reflux uropathy and hydronephrosis with renal and ureteral calculous obstruction. A Medicare 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of renal insufficiency, renal failure, or end stage renal disease and obstructive uropathy. The MDS revealed that under Appliances for bladder and bowel the Indwelling Catheter box was not check. Resident #34's care plan included a focus area initiated on 06/18/2024 (during the recertification survey), that indicated the resident had a suprapubic catheter related to obstructive and reflux uropathy. Interventions directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, check tubing for kinks once each shift, monitor for signs and symptoms of discomfort on urination and frequency, monitor and document for pain/discomfort due to the urinary catheter, and to monitor/record/report to the doctor any signs or symptoms of a urinary tract infection (UTI) such as burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and a change in eating patterns. Further review revealed that prior to 06/18/2024, no care plan was present for the suprapubic catheter. Resident #34 returned to the facility from the hospital with a suprapubic catheter in place on 05/16/2024. A [Hospital Name] Emergency Department [ED] Record, dated 05/11/2024, revealed Resident #34 had experienced nausea and vomiting for four days. The record revealed the resident was admitted to the hospital and a urinary catheter was placed. The record revealed a urinalysis confirmed that the resident had a UTI. The record revealed Resident #34 had diagnoses of sepsis secondary to pyelonephritis and a right-sided staghorn ureteral calculus. The record revealed the ED consulted with urology for possible intervention. The record revealed the provider recommendation was for Resident #34 to have a cystoscopy with a right ureteral stent placed on 05/12/2024. The record revealed that the plan of care was to discharge the resident back to the skilled nursing facility, and to have a follow-up appointment with urology in four weeks for upsizing the resident's suprapubic catheter. Resident #34's Order Summary Report with active orders as of 06/17/2024, revealed an order dated 05/16/2024 to admit Resident #34 back to the facility under the direction of the Medical Director. The Order Summary Report revealed an order dated 05/16/2024 that indicated the resident may see a physician at a urology medical center. Further review revealed no orders were present on the Order Summary Report related to the resident's suprapubic catheter or care related to its use. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocation Nurse (LVN) #2 stated if she saw a catheter and did not have orders for it, she would contact the doctor or hospital to get orders to flush and change the urinary catheter. She stated registered nurses (RNs) created the care plans, and she updated them as needed. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator stated she created the care plan from MDS triggers. She stated the nurses had access to edit care plans, especially those that would be short-term, such as medication changes, and they could add interventions on already existing care plans. The MDS Coordinator stated there was no care plan created for Resident #34's urinary catheter because there was not an order for it. During an interview on 06/20/2024 at 11:08 AM, the Director of Nursing (DON) stated that she could not believe that there were no orders or care plan (prior to 06/18/2024) for Resident #34 and that there was no excuse for it. The DON stated that for residents that readmit to the facility with a new urinary catheter, the nurses would complete a reassessment. The DON stated that the nurses should have become aware of Resident #34's suprapubic catheter during the admission assessment. The DON stated that the staff had missed Resident #34's suprapubic catheter during the resident's readmission. She further stated, any resident admitted with any lines such as a urinary catheter, were to be assessed and orders put in the medical record. The DON stated that staff needed to have orders, care plans, and documentation about the insertion site and lack of infection. The DON stated she should have caught that Resident #34's urinary catheter was not covered in their orders and care plan and that she took full responsibility for Resident #34's urinary catheter orders and care plan not being available for the nurses. The DON stated treatment nurses were responsible for doing urinary catheter care daily, and certified nursing assistants (CNAs) emptied the urinary catheter bags and reported the output and changes in urine to the nurse so the nurse could document on the input and output sheets. During an interview on 06/20/2024 at 12:25 PM, the Administrator stated the facility's admitting nurse should be completing a full body assessment and looking for urinary catheters. The Administrator stated once the nurses saw a urinary catheter, if it was not talked about in report, they should have called the doctor to get orders to care for the urinary catheter. The Administrator stated that the admitting nurse, an RN, or the DON should have put the orders in Resident #34's medical record.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure physician orders were followed for 1 (Resident #17) of 1 resident reviewed for supplemental oxygen use. Findings included: A facility policy titled, Medication and Treatment Orders, revised in 07/2016, specified, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. A facility policy titled, Oxygen Administration, revised in 10/2010, specified, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. An admission Record revealed the facility admitted Resident #17 on 02/22/2020. According to the admission Record, the resident had a medical history that included diagnoses of shortness of breath, acute upper respiratory infection, and dependence of supplemental oxygen. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #17 was on oxygen therapy. Resident #17's care plan included a focus area revised 03/15/2024 that indicated the resident was receiving continuous oxygen therapy due to shortness of breath related to an upper respiratory infection. Interventions directed staff to maintain supplemental oxygen settings at 2 liters per minute (lpm) as ordered. Resident #17's Order Summary Report with active orders as of 06/19/2024 revealed an order dated 03/31/2021 for supplemental oxygen at 2 lpm every shift for continuously low oxygen saturation. An observation on 06/17/2024 at 9:54 AM revealed Resident #17's supplemental oxygen was set at 4 lpm. An observation on 06/19/2024 at 8:43 AM revealed Resident #17's supplemental oxygen was set at 5 lpm. During an interview on 06/19/2024 at 8:47 AM, the Director of Nursing (DON) confirmed Resident #17's supplemental oxygen was set a 5 lpm. The DON then confirmed Resident #17's order indicated their supplemental oxygen should have been set at 2 lpm. She added it should be kept at 2 lpm; if Resident #17's oxygen levels were low with their current supplemental oxygen order then a new order should be received from the doctor prior to changing Resident #17's supplemental oxygen settings. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocational Nurse (LVN) #2 stated supplemental oxygen levels should not be changed unless there was a physician's order for the change. She added she had no idea why Resident #17's supplemental oxygen setting was set so high. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated all orders needed to be followed. The Administrator stated if a resident had low oxygen saturation levels with the current supplemental oxygen order, the doctor should be notified, and a new order obtained.

Based on interview, record review, and facility policy review, the facility failed to ensure staff assessed a resident's condition and monitored for complications before and after dialysis treatments and failed to ensure there was ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 1 (Resident #53) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Care of Resident on Renal Dialysis, revised in 06/2016, revealed, It is the policy of this facility to provide standards in the care of the residents on renal dialysis and the care of the vascular access site for hemodialysis. The policy revealed, under Documentation, 2. Facility Licensed Nurse will complete the baseline information, pre and post dialysis section of the Nurses Dialysis Communication Record. 3. Dialysis Center Licensed Nurse will complete the dialysis center section of the Nurses Dialysis Communication Record. An admission Record revealed the facility admitted Resident #53 on 04/26/2024. According to the admission Record, the resident had a medical history that included end stage renal disease (ESRD), hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, acute kidney failure, and dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2024, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had a diagnosis of renal insufficiency, renal failure, or ESRD and was dependent on dialysis. Resident #53's care plan included a focus area initiated 05/17/2024, that indicated the resident needed hemodialysis related to acute kidney failure, acute kidney injury, chronic kidney disease stage 3, hypertension, and abnormal lab values for BUN (blood urea nitrogen) and creatinine. The focus area revealed the resident had a tunneled CVC (central venous catheter) for hemodialysis in the right chest that was placed on 04/25/2024. Interventions directed staff to encourage Resident #53 to go to scheduled dialysis appointments; monitor labs and report to the doctor as needed; monitor, document, and report any signs or symptoms of infection to the access site, such as redness, swelling, warmth, or drainage; to monitor, document, and report signs or symptoms of renal insufficiency, such as changes in level of consciousness, skin turgor, oral mucosa, or heart and lung sounds; to monitor, document, and report any signs or symptoms of bleeding, hemorrhage, bacteremia (infection of the blood), or septic shock; and for the presence of unusual bleeding on catheter site, apply direct pressure over bleeding site till bleeding stops; if bleeding does not stop call 911 and notify the dialysis center. Resident #53's Order Summary Report with active orders as of 06/17/2024 revealed an order dated 04/27/2024 for dialysis on Mondays, Wednesdays, and Fridays. Resident #53's Dialysis Assessment Record for the timeframe from 05/01/2024 through 06/12/2024 revealed the following: - The Dialysis Assessment Record dated 05/01/2024, 05/03/2024, 05/17/2024, and 05/20/2024, revealed the Dialysis Nurse and Post-Dialysis Assessment (Facility Nurse) sections had not been completed. - The Dialysis Assessment Record dated 05/06/2024 and 05/08/2024 revealed that the pre-dialysis and post-dialysis assessment sections of the record were incomplete and were missing information regarding the vascular access site and the vascular access site assessment. The Dialysis Assessment Record dated 05/10/2024 revealed that the post-dialysis assessment section of the record was incomplete and was missing information regarding the vascular access site and the vascular access site assessment. - The Dialysis Assessment Record dated 05/03/2024, 05/08/2024 and 05/24/2024 revealed that the pre-dialysis assessment weight information was not completed. - The Dialysis Assessment Record dated 05/27/2024 and 06/12/2024, revealed the pre-dialysis assessment vital signs information was not completed. - The Dialysis Assessment Record dated 05/01/2024, 05/03/2024, 05/08/2024, 05/20/2024, 05/31/2024, 06/07/2024, and 06/12/2024, revealed that the pre-dialysis assessment last mealtime information was not completed. A nursing Progress Note dated 05/24/2024 at 6:52 PM revealed Resident #53 had returned from dialysis at 4:48 PM and after 30 minutes had vomited. The note revealed an order for Zofran (a medication for nausea) was ordered. A Dialysis Assessment Record dated 05/27/2024 revealed there was no documentation of the episode of vomiting 30 minutes after returning from dialysis on 05/24/2024. Resident #53's Progress Notes revealed a SBAR [Situation, Background, Assessment, and Recommendation] Summary, dated 06/03/2024 at 7:30 PM, that indicated Resident #53 had a change of condition. The summary revealed following dialysis, the resident's blood pressure had dropped to 82/52 mmhg (millimeters of mercury). The summary revealed the primary care physician was notified and recommended Midodrine 10 mg (milligrams) three times a day. A nursing Progress Note dated 06/04/2024 at 10:43 PM revealed Resident #53 had a blood pressure at 4:00 PM of 88/50 mmhg, Midodrine was given, and the resident's blood pressure was rechecked and was 103/65 mmhg. Resident #53's Dialysis Assessment Record dated 06/05/2024 revealed there was no documentation of the low blood pressure incidents from 06/03/2024 and 06/04/2024, nor the addition of Midodrine 10 mg three times a day for low blood pressure. A nursing Progress Note dated 06/06/2024 at 10:39 PM, revealed Resident #53's blood pressure was 94/56 mmhg at 4:00 PM. A Dialysis Assessment Record dated 06/07/2024 revealed there was no documentation of the incident of low blood pressure on 06/06/2024. A nursing Progress Note dated 06/10/2024 at 10:56 PM, revealed Resident #53 came back from dialysis, and their blood pressure was 78/53 mmhg. The note revealed Midodrine was given, and that resident's blood pressure was rechecked and was 97/55 mmhg. Resident #53's Dialysis Assessment Record dated 06/12/2024 revealed there was no documentation of the low blood pressure incident on 06/10/2024 right after dialysis. During a phone interview on 06/19/2024 at 8:45 AM, Dialysis Technician (DT) #1 stated the facility was not good at communication regarding Resident #53. She stated that on 06/17/2024, during the afternoon following the surveyors' entrance, the facility faxed over several Dialysis Assessment Records that were not completed and asked for them to be filled out and faxed back. DT #1 stated they were not able to fill out information all the way back to 05/01/2024 and would not be sending the sheets back to the facility completed. She stated the dialysis center was not made aware of Resident #53's low blood pressure readings, the new order for Midodrine 10 mg three times a day to treat low blood pressures, the episode of nausea and vomiting following dialysis, or the order for Zofran. DT #1 further stated that dialysis staff would have wanted to know that information, especially regarding the low blood pressure, as it would indicate the dialysis center would need to be more gentle in pulling the amount of fluid they were pulling from Resident #53. During an interview on 06/20/2024 at 10:04 AM, Licensed Vocational Nurse (LVN) #2 stated she had worked at the facility for nine years and the protocol for a dialysis resident was to know where they were going to receive treatment, contact transportation, get the fluid restrictions in place, and to tally intakes and outputs. She stated the nurse on duty was to fill out the sheet (Dialysis Communication Assessment) to include the last time the resident ate, if they had any edema (swelling), and bruit and thrill. LVN #2 stated that dialysis staff would want to know if the resident was nauseous or if their blood pressure was running low, so they could take precautions while they were there. During an interview on 06/20/2024 at 11:08 AM, the Director of Nursing (DON) stated that the communication provided between the dialysis center and the facility should be a baseline weight and vitals. The DON stated the middle portion of the Dialysis Communication Record was where the dialysis center would write what went on during the treatment and make suggestions based on the resident's needs. The DON stated the nurses were supposed to check the vascular access site for bleeding and take an additional set of vitals to ensure the resident was stable. She stated the dialysis center should know about a resident being nauseous or vomiting after treatments and if their blood pressure kept going low. During an interview on 06/20/2024 at 12:25 PM, the Administrator stated his expectation for residents who required dialysis was when the resident came back to the facility, the nurses should be assessing them for bleeding.

3. An admission Record revealed the facility admitted Resident #39 on 09/15/2023. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, anxiety disorder, mood disorder, and personality change due to known physiological condition. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #39 did not have a PASRR Level II. Resident #39's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report and letter from the State of California - Health and Human Services Agency Department of Health Care Services, both dated 09/19/2023, revealed a PASRR Level II was completed for Resident #39. Resident #39's care plan included a focus area initiated 01/31/2024 that indicated the resident had behavior management. The focus area also indicated that Resident #39 had a PASRR Level II evaluation. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator stated a PASRR Level II should have been triggered on the MDS. During an interview on 06/20/2024 at 11:11 AM, the Director of Nursing (DON) stated the PASRR information should have been accurate on the MDS. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated PASRR Level IIs should be triggered on the MDS. 4. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). Resident #26's hospital Plan of Care dated 04/10/2024, revealed under the Assessment/Plan section that an indwelling urinary catheter was placed for urinary retention. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #26 was always incontinent of bladder. The MDS revealed that under Appliances for bladder and bowel the Indwelling Catheter box was not check. Resident #26's Order Summary Report with active orders as of 06/17/2024, revealed an order dated 04/16/2024 to admit Resident #26 back to the facility under the direction of the Medical Director. Further review revealed no orders were present on the Order Summary Report related to the resident's urinary catheter or care related to its use. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator revealed she did not notice the catheter when she interviewed Resident #26 for the significant change MDS. She stated there were no orders for the urinary catheter that would have prompt her to look for the catheter. The MDS Coordinator stated the care plans were created by what was triggered in the MDS. During an interview on 06/20/2024 at 12:00 PM, the Administrator stated that for residents with urinary catheters, the catheter should be triggered on the MDS. Based on record review, interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 3 (Residents #11, #18, and #39) of 15 sampled residents and failed to code a resident with an indwelling catheter for 1 (Resident #26) of 15 sampled residents reviewed for MDS accuracy. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised in 12/2009 revealed, All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. The policy revealed, 1. The Assessment Coordinator must sign and certify that an MDS assessment has been completed for each resident. 2. All personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment. 1. An admission Record revealed the facility admitted Resident #11 on 01/25/2022. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, schizophrenia, bipolar disorder, mood disorder due to known physiological condition, and anxiety disorder due to known physiological condition. An annual Minimal Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed that Resident #11 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of psychiatric/mood disorders to include anxiety disorder, depression, bipolar disorder, and schizophrenia, and had taken an antipsychotic medication during the seven-day look-back period. Resident #11's care plan included a focus area revised 05/05/2023, that indicated the resident used psychotropic medication aripiprazole for schizophrenia with mood and behavior of verbal aggression. Resident #11's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 07/28/2022, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The report indicated the determination was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 07/28/2022. During an interview on 06/20/2024 at 8:27 AM, the MDS Coordinator stated she was aware that Resident #11 had a PASRR Level II but forgot to code it. The MDS Coordinator indicated that the PASRR was uploaded in Resident #11's electronic health record on 03/05/2024. The MDS Coordinator stated that going forward she would make sure the PASRR was uploaded in the electronic health record and will communicate with medical records staff. During an interview on 06/20/2024 at 10:37 AM, Medical Record (MR) #5 stated that she uploaded the PASRR information in the resident's electronic health record. She further indicated that she had a list of residents that had a PASRR Level II but was not aware if the MDS Coordinator had that list. During an interview on 06/20/2024 at 11:49 AM, the Director of Nursing (DON) stated that she used a checklist for MDS and usually focused on new admissions and readmissions. The DON stated that moving forward she will include residents with a PASRR Level II on the checklist and will provide the MDS Coordinator with the checklist. The DON further stated that it was her expectation that the MDS was coded accurately. During an interview on 06/20/2024 at 12:14 PM, the Administrator stated that it was his expectation that the MDS was coded accurately. 2. An admission Record revealed the facility admitted Resident #18 on 10/22/2015. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, schizophrenia, and personality change due to known physiological condition. An annual Minimal Data Set (MDS), with an Assessment Reference Date (ARD) of 04/19/2024 revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #18 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of psychiatric/mood disorders that included depression and schizophrenia and had taken an antipsychotic medication during the seven-day look-back period. Resident #18's care plan included a focus area revised 05/19/2024, that indicated the resident used psychotropic medications Zyprexa related to schizophrenia with mood and behavior of striking out. Resident #18's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 03/23/2024, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The report indicated the determination was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 03/23/2024. During an interview on 06/20/2024 at 10:37 AM, Medical Record (MR) #5 stated that she uploaded the PASRR information in the resident's electronic health record. She further indicated that she had a list of residents that had a PASRR Level II but was not aware if the MDS Coordinator had that list. During an interview on 06/20/2024 at 11:49 AM, the Director of Nursing (DON) stated that she used a checklist for MDS and usually focused on new admissions and readmissions. The DON stated that moving forward she will include residents with a PASRR Level II on the checklist and will provide the MDS Coordinator with the checklist. The DON further stated that it was her expectation that the MDS was coded accurately. During an interview on 06/20/2024 at 12:14 PM, the Administrator stated that it was his expectation that the MDS was coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of imposed charges for services required for residents to achieve their goals and needs safely, when the facility developed and implemented a policy to charge residents, and/or their families when facility staff accompanied the resident to an appointment outside of the facility. This failure had the potential for residents to be charged for covered services and for residents of the facility to avoid necessary appointments. Findings: On March 7, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to residents' rights. On March 7, 2024, at 10:09 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was in her room, in her bed, and was alert and oriented. Resident 1 stated the facility informed her they will start charging her $25 if she requests a facility staff member to accompany her at outside appointments. Resident 1 stated sometimes she needs help at outside appointments, and she felt like avoiding outside appointments because of the $25 charge. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis of hip (breakdown of cartilage, leading to pain and inflammation), spondylosis (osteoarthritis of the spine), mood disorder, and anxiety. The Physician's orders, dated September 6, 2023, indicated Resident 1 .May Have Ophthalmology Consult per resident request . , and the order dated November 9, 2023, indicated Resident 1 May have Podiatry consult and follow up treatment as needed . Resident 1's care plan, initiated on July 22, 2022, indicated, .The resident is at risk for falls r/t (related to) decreased mobility, chronic hip pain, DM (Diabetes Mellitus), Depression. Patient is pending for Bilateral (both sides) Hip Surgery .Staff will assist with transfers to minimize risk of falls .2 person transfer assist .Anticipate and meet The resident's needs . Resident 1's MDS (Minimum Data Set - an assessment tool), dated January 24, 2024, indicated Resident 1 needed wheelchair for mobility and needed substantial/maximal assistance with transfers. On March 7, 2024, at 10:52 a.m., the Director of Nursing was interviewed. The DON stated the facility gave notice to all residents that starting February 1, 2024, a $25 charge will be implemented if the residents require facility staff to accompany residents to appointments outside of the facility. On March 7, 2024, at 1:58 p.m., the Administrator was interviewed. The Administrator stated the facility gave notice to all residents that starting February 1, 2024, a $25 charge will apply if the residents require facility staff assistance to appointments outside of the facility. The facility's notice letter titled, .Changes to Accompanying Residents to Appointments ., dated January 22, 2024, was reviewed. The letter indicated, .Effective February 1, 2024 a $25 charge will be implemented if staff assistance is required to accompany residents to appointments beyond our premises. Required is defined as resident is deemed unsafe to attend appointment alone, resident or family requests an escort or location of appointment requests that resident be accompanied . The facility's policy titled, Escort Service for Resident Appointments, dated February 1, 2024, was reviewed. The policy indicated, .A $25 escort service fee will be applied when staff assistance is required to accompany a resident to appointments outside the facility .The escort service fee will be billed to the resident's account .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications was administered for two of the four sample residents (Residents 3 and 4) in accordance with the physician order. This failure has the potential to negatively affect the health status of Residents 3 and 4. Findings: On March 20, 2024, at 10:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. 1. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included Type 2 diabetes ((condition in which body has trouble controlling blood sugar), end stage renal disease (a person's kidneys cease functioning on a permanent basis leading to long-term dialysis), hypertensive heart disease (changes in the heart as a result of chronic blood pressure elevation), and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 3's Physician orders, indicated the following: a. June 1, 2023, Protonix 40 mg (milligram) give one tablet by mouth one time a day for GERD (gastro esophageal reflux disorder-a chronic disease that occurs when stomach acid flows into the food pipe and irritates the lining). b. November 4, 2023, Bisacodyl EC (enteric coated) by mouth 5 mg, two tablets two times a day for constipation (when a person passes less than three bowel movements a week) hold if loose stools. c. February 17, 2024, Velphoro (helps prevent low calcium in the blood) chewable tablets 500 mg give by mouth two tablets, four times a day before meals. A review of Resident 3's medical record titled, Electronic Medication Administration Record (EMAR), for March 2024, indicated the following: a. No entries for March 1st, 10th, 17th, and 18th, 2024, at 6:30 a.m., for Protonix. b. No entries for March 1st, 10th, 17th, and 18th at 6:00 a.m., for Bisacodyl. c. No entries for March 1st, 10th, 17th, 18th at 6:30 a.m., for Velphoro. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis which included injury of cauda equina (when nerve roots in the spine are compressed cutting off sensation and movement), hyperlipidemia (imbalance of cholesterol) and Type 2 diabetes (condition in which body has trouble controlling blood sugar). A review of Resident 4's Physician orders dated August 19, 2023, indicated Tamsulosin HCL (hydrochloride) 0.4 mg by mouth, one time a day for bladder relaxation. A review of Resident 4's medical record titled, Medication Administration Record (MAR) for October 2023, noted a blank on the MAR on October 15, 2023. On March 20, 2024, at 11:07 a.m., during an interview with Licensed Vocational Nurse (LVN 1) stated the process for medication administration was to do all seven rights of medication administration, check each medication against the orders, administer to the resident and document in the EMAR. LVN 1 stated this was important for the safety of the resident. On March 20, 2024, at 1:10 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated per facility policy it was the nurse's responsibility to document in EMAR after a medication was administered to a resident. The DON stated not documenting in EMAR would place a resident at risk for complications either from not getting the medication or from an overdose of the medication. A review of the EMAR of Resident 3, the DON confirmed there was a blank on the dates indicated and not sure if the medication was administered. On March 20, 2024, at 3:00 p.m., during a concurrent interview and record review with the Medical Records Director of Resident 4's MAR, The Medical Records Director confirmed it was blank on the date indicated. The Medical Records Director stated there was no other documentation indicating the medication was administered to the resident. A review of the facility policy and procedure titled, Administering Medications revised December 2012, indicated, .medications shall be administered in a safe and timely manner, and as prescribed .medications must be administered in accordance with the orders, including any required time frame .if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed, for two of three residents reviewed (Residents 1 and 3), to ensure an inventory of the residents ' belongings were completed upon admission. This failure has the potential for the facility to not be able to protect the resident ' s property or personal belongings from loss or theft. Findings: On January 4, 2024, at 9:44 a.m., an unannounced visit was conducted at the facility to investigate a report on missing personal belongings. a. On January 4, 2024, at 11:06 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on December 25, 2023. The DON stated Resident 1 claimed she had personal bank cards and 15 dollars cash in her belongings that she did not receive after her discharge on [DATE]. On January 4, 2024, Resident 1 ' s record was reviewed, Resident 1 was admitted to the facility on [DATE]. There was no documented evidence the facility conducted an inventory list of Resident 1 ' s personal belongings upon admission and upon her discharge on [DATE]. On January 4, 2024, at 1:15 p.m., an interview with a concurrent record review was conducted with the DON. The DON stated no one knew, or was aware of Resident 1 ' s personal bank cards and cash during her stay at the facility and it was not listed on her personal belongings list.The DON stated there was no documented belonging list for Resident 1 upon admission. The DON stated Resident 1 ' s belonging list should have been completed upon admission, discharge ,and updated when personal items were brought in and/or during Resident 1's stay in the facility. b. On January 4, 2024, at 11:00 a.m, an observation with a concurrent interview was conducted with Resident 3. Resident 3 was in bed, alert, and conversant. Resident 3 stated she was not aware of the facility ' s personal belongings policy. On January 4, 2024, Resident 3 ' s record was reviewed. Resident 3 was admitted to the facility on [DATE]. There was no documented evidence the facility conducted an inventory list of Resident 3 ' s personal belongings upon admission. On January 4, 2024, at 10:30 a.m., an interview with a concurrent record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 3 ' s inventory of personal belongings was not done upon her admission to the facility. LVN 1 stated this should have been done by the Certified Nursing Assistant (CNA) upon admission to the facility. The facility's policy and procedure titled, Personal Property, dated September 2012, was reviewed. The policy indicated, .The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished .The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician of a resident's medication that was being taken at home prior to admission, after being notified by a family member (FM), for one of three residents reviewed (Resident 1). This failure resulted in Resident 1 not receiving her Seroquel (an antipsychotic medication used to treat mental disorders) from January 3, 2024 to January 5, 2024, which she had been taking at home. In addition, Resident 1 had shown behavior of being non compliant when redirected during episodes of wandering and had episodes of being aggressive to staff. Findings: On January 24, 2024, at 8:58 a.m., a telephone interview was conducted with Resident 1's family member (FM). The FM stated Resident 1 had been taking Seroquel at home. She stated the medication kept Resident 1 calm and without the Seroquel Resident 1 could get aggressive. She stated she brought the medications to the facility on January 3, 2024, and gave the medications to the licensed nurse. She stated Resident 1 should have received her Seroquel while in the facility. During a review of Resident 1's record on January 24, 2024, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and deep vein thrombosis (blood clot in the deep vein usually in the legs) on the right lower extremity. The physician's orders from January 3, 2024 through January 5, 2024, was reviewed. There was no documented evidence the Seroquel medication was included in Resident 1's active medications. The nurse's notes from January 3, 2024 through January 5, 2024, was reviewed. There was no documented evidence the licensed staff received the Seroquel medication from Resident 1's FM. There was no documented evidence Resident 1's physician was notified regarding the Seroquel medication Resident 1 had been taking at home. The nurse's notes dated January 4, 2024, entered at 1:57 p.m., indicated, .Resident requires frequent redirection, non compliant with following direction .Wanders throughout facility. Does not want to participate in group activities . The nurse's note dated January 5, 2024, entered at 4:47 p.m., indicated, .non compliant with elevating legs . The nurse's note dated January 6, 2024, entered at 12:47 a.m., indicated, .Pt (patient) has new order for Seroquel 25 milligram (mg- a unit of measurement). It is ordered due to aggresiveness towards .CNA . During an interview with Certified Nursing Assistant (CNA) 1, on January 24, 2024, at 3:02 p.m., CNA 1 stated she took care of Resident 1 on January 4, 2024, from 3 p.m., to 11p.m. CNA 1 stated Resident 1 was confused and combative. CNA 1 stated Resident 1 had hit her on the chest when she attempted to transfer her from the wheelchair to the bed. CNA 1 stated Resident 1's FM told her that when Resident 1 missed her Seroquel medication Resident 1 would be aggressive. CNA 1 stated she did not report Resident 1's behavior and the FM's statement about the medication to the licensed staff. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on January 24, 2024, at 3:22 p.m., LVN 1 stated Resident 1's FM brought two medication containers from home. She did not document what medications she received from the FM. LVN 1 stated the medications brought from home by the FM were not listed in the list of medications Resident 1 had received at the acute hospital. LVN 1 stated she did not contact the attending physician regarding the Seroquel medication. LVN 1 stated she gave the medications to the Director of Nursing (DON) on January 3, 2024. During an interview with the DON on January 24, 2024, at 3:58 p.m., the DON stated she received two containers of medications from LVN 1 on January 3, 2024, when Resident 1 was admitted to the facility. She stated she was told by LVN 1 that the medication Seroquel was not listed in the list of medications from the hospital. The DON stated she did not know the Seroquel's dose, frequency and the indications for use. She stated she did not contact Resident 1's FM to ask about the medications that were brought to the facility. The DON stated she did not contact Resident 1's physician. She stated she should have contacted Resident 1's primary physician regarding the Seroquel medication. The DON acknowledged Resident 1's Seroquel medication should have been clarified with the physician on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's right leg swelling and active medical diagnoses of deep vein thrombosis (DVT - blood clot) on the right leg were assessed and monitored for one of three residents reviewed (Resident 1). This failure resulted in Resident 1's development of increased edema (swelling) on the right leg with blisters after three days of admission without staff knowledge, leading to Resident 1's transfer to the acute hospital. Findings: On January 24, 2024, at 12:40 p.m., an unannounced visit was conducted at the facility to investigate one complaint related to the quality of care. During a review of Resident 1's record on January 24, 2024, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included right leg DVT and dementia (memory loss). Resident 1's assessment from the acute hospital on January 2, 2024, indicated 3+ pitting edema (a condition when excess fluid builds up in the body and when pressure is applied to the swolen area an indentation will remain) up to the knee of the right leg, and 1+ piting edema up to the knee of the left leg. The nurse's notes from January 3, 2024 to January 6, 2024, were reviewed. There was no documented evidence Resident 1's right leg DVT and edema were assessed and monitored by licensed staff on all shifts from January 3, 2024 to January 5, 2024. The nurses's note dated January 6, 2024, at 12:44 p.m., indicated a change in Resident 1's condition. The note indicated .Increased in swelling to right leg with weeping blisters (a condition when swelling become severe that fluid will leak out directly to the skin). Family request transfer to (name of the hospital) for evaluation in ED (energency department). On January 24, 2024, at 3:35 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 acknowledged she was the charge nurse on duty when Resident 1 was admitted on [DATE]. LVN 1 stated she did not conduct an assessment of Resident 1's right and left legs on both days when she was on duty on January 3, 2024 and January 4, 2024. On January 24, 2024, at 4:50 p.m., a concurrent interview and record review was conducted with the Director Of Nursing (DON). The DON acknowledged there was no assessment of Resident 1's both lower legs on admission and on all nursing shifts, until there was a change in Resident 1's condition on January 6, 2024. The DON stated all licensed staff should have performed physical assessment on Resident 1 upon admission and monitored Resident 1's right leg swelling on all shifts. On January 25, 2024, at 4:23 p.m., an interview was conducted with LVN 2. LVN 2 stated she was designated as treatment nurse in the facility. LVN 2 stated she would conduct skin assessment on new admissions. LVN 2 stated she did not perform skin assessment for Resident 1 on admission and during resident's stay at the facility. During a review of the facility's policy and procedure titled, admission Assessment and Follow Up: Role of the Nurse, dated December 2012, indicated, .The purpose of this procedure is to gather the resident's physical, emotional, cognitive and psychological condition upon admission .Conduct an admission assessment (history and physical), including .a summary of the individual's recent medical history, including hospitalizations, acute illness .especially related to reasons for admission to the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1) had a physician order to go out on pass (OOP–temporarily leave the facility for a specific time period) when Resident 1 went OOP for more than 24 hours on December 21, 2023. This failure had the potential for Resident 1 to be at risk for harm, accidents, and/or injury. Findings: On January 4, 2024, at 11:00 a.m., a concurrent interview and record review was conducted with the Administrator. The Administrator stated Resident 1 left the facility OOP on December 21, 2023, early morning with a family member, and returned to the facility on December 23, 2023, at 6:46 p.m. The Administrator stated Resident 1 went OOP for more than 24 hrs. On January 4, 2023, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnoses of Diabetes Mellitus (disease that causes high blood sugar), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), anxiety, and kidney failure. The History and Physical, dated May 13, 2023, indicated Resident 1 had fluctuating capacity to understand and make decisions. The Nursing Progress Notes, dated December 23, 2023, 6:46 p.m., indicated Resident 1 returned to the facility with a family member. There was no documented evidence of Resident 1 going OOP with a family member on December 21, 2023, in the Nursing Progress Notes. There was no documented evidence a physician ' s order was obtained prior to Resident 1 going OOP with a family member for more than 24 hours on December 21, 2023. In addition, there was no documented evidence Resident 1 and/or family signed out for OOP on December 21, 2023, and signed back in upon return to the facility on December 23, 2023. On January 4, 2024, at 1:15 p.m., an interview with a concurrent record review was conducted with the Administrator. The Administrator stated the Licensed Nurse (LN) assigned to Resident 1 on December 21, 2023, should have notified the physician and obtained a physician ' s order for OOP prior to Resident 1 leaving the facility. The Administrator stated the LN should have notified the physician when Resident 1 did not return to the facility after six hours from the time she left with the family member. The Administrator stated there was no documented evidence this process was done. On January 4, 2024, at 3:00 p.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated Resident 1 did not have a physician ' s order for the OOP with a family member on December 21, 2023. The DON stated Resident 1 or her family member did not sign out when they left for OOP on December 21, 2023, and did not sign in when they returned to the facility on December 23, 2024. The DON stated the facility ' s procedure for a resident going OOP was to obtain a physican order for the OOP. The DON verified residents should be signed out for OOP. The DON stated these processes were not followed with Resident 1. On January 22, 2024, at 3:48 p.m., an interview was conducted with the DON. The DON stated residents in the facility should have a physician ' s order for OOP indicating the date and length of time for the OOP, prior to leaving the facility. The facility's policy and procedure titled, Signing Resident Out, dated August 2006, was reviewed. The policy indicated, .All residents leaving the premises must be signed out .Each resident leaving the premises (excluding transfers/discharges) must be signed out .A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return . The facility ' s policy and procedure did not include obtaining a physician ' s order for the resident prior to going OOP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure services for skin management and prevention of breakdown was implemented for Resident 1 when the facility did not conduct skin check to identify progression and deterioration of pressure ulcer development to Resident 1 ' s heels and sacro-coccyx (area between the oval surface at the apex of the sacrum, and the base of the coccyx) area. The facility failure had resulted to delayed identification and treatment implementation of pressure ulcer development on Resident 1 ' s bilateral heels on August 15, 2023, and breakdown to sacro-coccyx area the day Resident 1 was discharge on [DATE]. Findings: On September 25, 2023, at 9:35 a.m., an unannounced visit was conducted to investigate complaint for quality of care/treatment issues for allegation the facility had not implemented pressure sore precaution for the prevention of skin breakdown of Resident 1. On September 25, 2023, Resident 1 ' s record was reviewed. The Skin Observation Tool completed by Licensed Vocational Nurse 1 (LVN) on January 23, 2023, admission indicated, A. OBSERVATIONS .2. Intact skin . Further record review indicated deteriorated skin condition prior to discharge day on August 16, 2023, were as follows: * Change of Condition (COC), dated August 15, 2023, indicated skin wound or ulcer, change in skin color or condition, as appears to have a Right Heel 6 x 6 cm (centimeter) closed blister on his Right Foot. The Left Heel has 11 x 7 cm Redness with a 7 x 6 cm Open Blister with scattered discoloration on the Left Foot. and * COC change in skin condition, dated August 16, 2023, by Treatment Nurse (TXN) indicated, Sacro-coccyx Moisture Associated Skin Damage (MASD) 4 x 4 cm (name of medication ointment), Dry Dressing. Resident has 4 x 4cm MASD Deep Redness, Flakey Skin. On September 25, 2023, at 11:55 a.m., the TXN was interviewed. TXN stated Resident 1 ' s heel blister was brought to his attention by Certified Nursing Assistant (CNA) and so does Resident 1 ' s breakdown on his sacro-coccyx area. TXN stated, Resident 1 had no heel protectors on and does not remember if Resident 1 had a low air loss mattress in place for support. TXN stated Resident 1 had a high risk for skin breakdown. TXN indicated he does skin sweep but was unable to provide for documented evidence he had an official program of Skin Management and Prevention of Breakdown, that included a skin check on a fairly regular basis to identify and address skin irregularities. TXN stated, he would in future skin check for early detection of skin issues to prevent delay in treatment, and prevent deterioration of wound or skin breakdown. TXN stated the skin breakdown of Resident 1 could have been prevented. TXN stated he was new and learning new ways to improve the PU (pressure Ulcer) prevention in the facility. On September 25, 2023, at 3:43 p.m., the Director of Nursing (DON) was interviewed. DON stated early identification of skin issues during care provision, and identification of residents at risk for breakdown during initial admission to the facility will help them address residents who are at most need of intervention. DON stated early identification and reporting of skin irregularities and breakdown to physician and family member is the best thing to do to prevent delay of providing treatment and intervention. DON stated early intervention is the best prevention. DON stated that Resident 1 ' s skin breakdown was not identified as early and this delayed the treatment. A review of the website article from the Joint Commission, titled Quick Safety 25: Preventing pressure injuries, dated March 2022, indicated, .The prevention of pressure injuries is a great concern in health care today. Many clinicians believe that pressure injury development is not solely the responsibility of nursing, but the entire health care system .Optimizing overall care and increasing attention to prevention can save patients from unnecessary harm and death . Skin Care. Protecting and monitoring the condition of the patient ' s skin is important for preventing pressure sores and identifying .sores early so they can be treated before they worsen .

Based on observation, interview, and record review, the facility failed to report an allegation of sexual abuse to the California of Department of Public Health (CDPH - a state department responsible for enforcing some of the laws in the California Health and Safety Codes) for two of three residents reviewed (Residents 1 and 2). This failure had the potential to result in a delay of investigation and reporting of further allegation of abuse. Findings: During an interview on June 7, 2023, at 10:50 a.m., the administrator (ADM) stated, he received a call from Licensed Vocational Nurse (LVN) on June 4, 2023, at about 7 p.m. The ADM stated the LVN said there were signs of inappropriate behavior by Resident 1 towards Resident 2, his roommate. The ADM stated Resident 1 had a tube of A&D ointment (Vitamin A and D ointment - moisturizer to treat rough, scaly, and itchy skin) in his hand and was next to Resident 2. Resident 2's brief was unfastened. The ADM stated there was no room available to transfer Resident 1 and remained on the same room with Resident 2 on June 4, 2023. The ADM stated Resident 1 was monitored closely for his alleged behavior on June 4, 2023. The ADM stated, on June 5, 2023, Resident 1 was moved to another room. The ADM stated, on June 6, 2023, the Director of Nursing (DON) and himself spoke with the Certified Nurse Assistant (CNA). The ADM stated the CNA saw Resident 1 had a tube of the A&D ointment in his hand and was next to Resident 2. The ADM stated, Resident 2 had A&D ointment in his brief on the night of June 4, 2023. During an interview on June 7, 2023, at 2:10 p.m., with the DON, the DON stated she found out about the incident between Resident 1 and Resident 2 on June 6, 2023, two days after the alleged incident. The DON stated she told the ADM to file a report. The DON stated the ADM had not completed the report. The DON stated she started to interview staff and the residents for information. The DON stated the CNA said there was A&D ointment on Resident 2's genitals on June 4, 2023. The DON stated, she told the CNA and the LVN they were both mandated reporters and could have filed the paper work and reported to CDPH. During an interview on June 13, 2023, at 1:50 p.m., with the ADM, the ADM stated, he was called Sunday (June 4, 2023) evening about the incident. The ADM stated there was no concrete evidence abuse happened on June 4, 2023, and did not report immediately. During a review of the facility's policy and procedure (P&P) titled, ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE AND REPORTING REASONABLE SUSPICION OF A CRIME IN THE FACILITY POLICY AND PROCEDURE, revised August 12, 2022, the P&P indicated, .The Facility will report allegations of abuse .When .Immediately - no later than 2 hours - all abuse (actual, alleged or potential) OR results in serious bodily injury .No later than 24 hours - all other conduct (actual, alleged, or potential neglect mistreatment, misappropriation of property, and injuries of unknown source) And did not result in serious bodily injury .The Facility must have documentation of the report, including what was reported and the date and time when the report was made to the State Agency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for one of three residents (Resident 1) was implemented when Resident 1 was not placed in a private room after an allegation of inappropriate sexual behavior. This failure placed Resident 1's new roommate at risk of potential inappropriate sexual behavior conducted by Resident 1. Findings: During an interview on June 7, 2023, at 10:50 a.m., the administrator (ADM) stated, he received a call from Licensed Vocational Nurse (LVN) 1 on June 4, 2023, at about 7 p.m. The ADM stated LVN 1 said there were signs of inappropriate behavior by Resident 1 towards Resident 2, his roommate. The ADM stated Resident 1 had a tube of A&D ointment (Vitamin A and D ointment - moisturizer to treat rough, scaly, and itchy skin) in his hand and was next to Resident 2. Resident 2's brief was unfastened. The ADM stated there was no room available to transfer Resident 1 and remained on the same room with Resident 2 on June 4, 2023. The ADM stated Resident 1 was monitored closely for his alleged behavior on June 4, 2023. The ADM stated, on June 5, 2023, Resident 1 was moved to another room. The ADM stated Resident 1 had a roommate in his new room. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and schizophrenia (a mental disorder). During a review of Resident 1's Care Plan (CP), dated June 5, 2023, the CP indicated, .Focus .Inappropriate sexual advancement towards roommate's roommate (sic) .Goal (dated June 7, 2023) .Resident will be relocated to private room .Interventions (dated June 7, 2023) .Resident to be placed in private room . During a concurrent observation and interview on June 13, 2023, at 10:40 a.m., Resident 3 (the new roommate of Resident 1) was in his room, sitting in a wheelchair. Resident 3 was awake and alert. Resident 3 stated he had a new roommate and they got along. During a concurrent observation and interview on June 13, 2023, at 10:50 a.m., Resident 1 was in his room sitting in a wheelchair. Resident 1's new roommate was also in the room. Resident 1 was awake and alert. Resident 1 denied he inappropriately touched his previous roommate, Resident 2. During an interview on June 13, 2023, at 2:25 p.m., the ADM, the DON, and the MDS (Minimum Data Set) coordinator stated Resident 1 should have been placed in a private room as per the care plan. The ADM, the DON, and the MDS coordinator stated the care plan was not followed.

Based on interview, and record review, the facility failed to ensure facility's policies and procedures were implemented to track accurately the movement of medications in the controlled substances (CS) emergency supply container (Narcotic E-Kit) and to account for use of all CS in order to minimize the time and loss of diversion. This had the potential for drug diversion by staff caring for the residents. Findings: Review of the facility's notification letter to the department dated, October 25, 2022, indicated: .The report is with regards to the missing narcotic reported by [the pharmacy provider prior to September 1, 2022] (RX 1) .The facility switched pharmacy on 9/1/2022 to [the present pharmacy provider] (RX 2) . On 10/18/2022 the facility was notified by RX 2 that 4 tabs (tablets) of Dilaudid (narcotic pain medication) 2 mg (milligram; unit of measurement) was not accounted for . On October 26, 2022, at 9:45 a.m., in an interview, the Director of Nursing (DON) stated the facility transitioned to the new pharmacy provider (RX 2) on September 1, 2022. On October 14, 2022, the previous pharmacy provider (RX 1) informed the facility the following Federally Scheduled II controlled substances were missing from the Narcotic E-Kit that was picked up on October 12, 2022, from the facility: Two tablets of hydromorphone (narcotic pain medication) 2 mg (milligram; unit of measurement); Two tablets of Percocet (narcotic pain medication) 10/325 mg; and One tablet of Norco (narcotic pain medication) 5/325 mg. The DON stated she was not able to resolve the above missing tablets. On October 26, 2022, at 11:10 a.m., in an interview, the Administrator stated RX 1 contacted the facility late September 2022 to inform the E-Kits would be picked up from the facility and the E-Kits were separately locked away until RX 1 picked them up on October 12, 2022. On October 26, 2022, at 11:45 a.m., in an interview, Licensed Vocational Nurse (LVN) 1 stated there were two narcotic E-Kits in the narcotic drawer of the medication cart located in the East Nursing Station, the one by RX 2 on top and the one by RX 1 was underneath it. Before RX 1 picked up the E-Kit, LVN 1 noticed the lock to the narcotic E-Kit was broken. LVN 1 stated she did not look into the E-Kit content or the reason for it being opened. LVN 1 stated the process now was the nurse who opened and used the E-Kit would need to notify the pharmacy immediately upon opening of the E-Kits and assumed someone else had already done so. LVN 1 stated before the recent process change, there was no shift count regarding E-Kits. There was no documentation to indicate the E-Kit was open. The status of E-Kit was verbally communicated and not documented. LVN 1 stated there was also a logbook for RX 1 Narcotic E-Kit. LVN 1 stated the facility staff would need to obtain the combination from RX 1 to unlock the combination lock to get narcotic medications from the E-Kit, which was unique to the RX 1 Narcotic E-Kit. LVN 1 stated the staff would document in the resident's medication administration record (MAR), took from E-Kit and in the residents' progress notes. LVN 1 stated this process was supposed to be ongoing but was not consistently done. Review of the E-Kit log indicated there was no usage of the narcotic E-Kit supplied by RX 1 since it was last replaced on August 26, 2022. On October 27, 2022, at 8:40 a.m., in an interview, the previous Director of Nursing (pDON) for the facility, from September 6, 2022 to September 30, 2022, stated she removed the Narcotic E-Kit from the medication cart to return to RX 1. The pDON stated, when she called the pharmacy to have the all E-Kits picked up, RX 1 told her they were still the pharmacy that provided the service to the facility. The pDON then placed the Narcotic E-Kit back in the medication cart for the nursing staff to use when needed. The pDON stated, when RX 1 told the facility all their E-Kits were going to be picked up late September, she sequestered all the E-Kits in the metal drawer in the DON's office. The pDON stated all E-Kits were sealed with zip ties but she could not recall if they all had the same color or not. On October 27, 2022, at 11:25 a.m., in an interview, LVN 1 stated she noticed the Narcotic E-Kit was not locked when the delivery staff from RX 1 was at the facility to pick up all their E-Kits. LVN 1 stated she did not recall telling the delivery staff about the open Narcotic E-Kit or other facility staff because all E-Kits were being returned to RX 1 and the facility no longer used them. On October 27, 2022, at 2:05 p.m., in an interview, the Consultant Pharmacist (CP) stated he was at the facility for his monthly visit in September. The CP stated E-Kits were inspected either by him or by the nurse consultant under his supervision. The CP stated during his September visit the Narcotic E-Kits inspection could have been missed by me. On November 1, 2022, at 10:50 a.m., in an interview, the DON stated On October 18, 2022, RX 2 pharmacist notified her of the missing narcotic medication from the RX 2 Narcotic E-Kit. The DON stated there were four tablets of Dilaudid (narcotic pain medication) 2 mg missing from the E-Kit without slips indicating who accessed the medications for the residents. The DON stated she initiated the investigation by making copies of the E-Kit Log for the completed slips and had identified the resident who was on the medication. The DON stated she was not able to continue with the investigation because she was investigating the missing narcotics from the RX 1 Narcotic E-Kit. The DON stated, so far, she was not able to account for all missing narcotic medications from the RX 1 Narcotic E-Kit. The DON also stated she was not able to account for the missing Dilaudid 2 mg tablets from the RX 2 Narcotic E-Kit. On December 2, 2022, at 2 p.m., in an interview, the Administrator stated he was not able to find the DON's investigation into the missing Dilaudid tablets from RX 2 Narcotic E-Kit. The Administrator stated he would have the conclusion of the investigation next week. Review of the facility's result of the investigation provided by the Administrator on December 7, 2022, indicated, .one LVN (licensed vocational nurse), who worked one day a week, appears to have worked on the dates that the medications appeared missing .given the circumstances and poor documentation by this individual the facility has removed her from the schedule . Review of the RX 2's packing slips indicated the narcotic E-Kit was replaced and signed by the facility staff on October 16, October 17, and November 5, 2022. Review of the E-Kit log indicated there was no Dilaudid 2 mg dose removed from the narcotic E-Kit between October 16, 2022 and November 5, 2022. On December 15, 2022, at 10:25 am, in an interview, the Administrator stated the final investigation did not result in the accountability of the missing Dilaudid tablets. The facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits, last revised, June 2016, indicated: .The nurses records the medication use from the emergency kit on the medication order and E-Kit use form and calls the pharmacy for replacement of the kit and flags the kit with a color-coded lock to indicate need for replacement of kit as soon as possible after the medication has been administered . Use of the emergency medication is noted on the resident's medication administration record (MAR) . Before going off duty, the charge nurse indicates the opened status of the emergency kit at the shift change report, and transfers the new medication orders to oncoming staff . Opened kits are replaced with sealed kits within 72 hours of opening . The kits are monitored/inventoried by the consultant pharmacist at least every thirty (30) days for completeness and expiration dating of the contents .

Based on observation, interview, and record review, for one of six residents reviewed (Resident 2), the facility failed to ensure Resident 2's call light was kept within the resident's reach on October 5, 2022. This facility failure had the potential to result in the facility not meeting the resident's needs when she called for help and assistance. Findings: On October 5, 2022, at 10:10 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On October 5, 2022, at 3:15 p.m., an observation of Resident 2's room identified Resident 2's call light was on top of the bedside dresser. Resident 2 was asked if she was able to reach her call light, Resident 2 responded, They (staff) were supposed to put it where I can reach it. Resident 2 further stated that she just yells for help. Resident 2 stated, They don't come when I call for help. On October 5, 2022, at 3:28 p.m., Certified Nursing Assistant 1 (CNA) was interviewed. CNA 1 stated that the call light must have been left by the morning shift on top of the bedside dresser. CNA 1 stated that it was placed where Resident 2 could not reach it. CNA 1 stated that if the resident could not reach the call light, Resident 2 will not be able to call for help. On October 6, 2022, Resident 2's medical record was reviewed. The Minimum Data Set (MDS- a resident assessment tool) Section G - Functional Status, dated August 31, 2022, indicated Resident 2 was limited and requiring extensive to total assistance on: Bed Mobility: 4/total dependence; Transfer: 4/total dependence; Dressing: 3/Extensive assistance; Toilet Use: 4/Total dependence; Personal Hygiene: 4/Total dependence; Bathing: 4/Total dependence; Eating: 1/set up and supervision; and Functional Limitation in ROM, Upper extremity (shoulder, elbow, wrist, hand), 2= impairment on both sides. On October 6, 2022, at 11:50 a.m., the Administrator (ADM) and MDS/Licensed Vocational Nurse 3 (LVN) were interviewed. Both MDS/LVN 3 and ADM stated that the call light should be kept within the resident's reach at all times to ensure they were able to call for help and assistance. A review of the facility's policy and procedure titled, Answering the Call Light, dated October 2010, indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines: .4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .8. Answer the resident's call as soon as possible .

Based on observation, interview, and record review for one of seven residents reviewed (Resident 1), the facility failed to ensure activities were available for residents to participate in when the facility failed to have an Activities Director for approximately six to eight months. This facility failure had the potential to limit Resident 1's engagement into fulfilling activities that promote physical, mental, and social well-being. Findings: On October 5, 2022, at 10:10 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On October 5, 2022, at 12:53 p.m., Resident 1 was interviewed. Resident 1 stated that she used to go to bingo every day but the previous Activity Director 2 (AD) went on maternity leave, and now only comes to the facility part time. Resident 1 stated that no activities were being held for the last six to eight months. Resident 1 stated that the new AD 1 came and said she will put up an activity schedule but she never did. Resident 1 stated that they don't get to do anything. Resident 1 stated, I feel neglected. Resident 1 stated, the so-called new activity director told her that she would post a new activity schedule for bingo, but she never came back. Resident 1 stated, I am beyond disappointed. The rest of us who go to activities feel the same. On October 5, 2022, at 2:27 p.m., AD 1 was interviewed regarding the old September activity schedule posted on the bulletin. AD 1 stated that she was not able to follow through with the months activities because she was still working on the completion of the calendar. AD 1 stated that the previous AD went part time after she was back from her maternity leave. AD 1 stated that if the facility had no planned activities for the residents, the residents would not have anything to keep them occupied and they could end up stressed out. On October 6, 2022, at 11:30 a.m., a follow-up interview was conducted with AD 1. AD 1 stated that people are social in nature and indicated that the residents social needs have not been addressed for the last six to eight months. AD 1 stated, The residents deserved better than that. A review of the facility policy and procedure titled, Activity Programs, dated August 2006, indicated, Policy Statement: Activity programs designed to meet the needs of each resident are available on a daily basis. Policy Interpretation: 1. Our activity programs are designed to encourage maximum individual participation and are geared to the resident's needs. 2. Activities are scheduled 7 (seven) days a week. 3. Our activity programs .are designed to meet the needs and interests of each resident .6. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents .

Based on observation, interview, and record review, for three of seven residents reviewed (Resident 2, 3, and 4), the facility failed to ensure skin care and wound treatments were performed as ordered on October 2 and 5, 2022. This facility failure had the potential for Residents 2, 3, and 4's skin conditions to deteriorate and risk infection. Findings: On October 5, 2022, at 10:10 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On October 5, 2022, the Treatment Administration Record (TAR) for Residents 2, 3, and 4, were reviewed. The TARs failed to indicate that Residents 2, 3, and 4 had their treatments performed when no signature was documented that the wound treatment and skin care had been done on October 2 and 5, 2022. On October 5, 2022, at 3:04 p.m., an interview was conducted with Resident 3 regarding his skin care. Resident 3 stated that his left ankle arthritic pain medication and hemorrhoidal relief cream had not been applied on Saturday, Sunday, Monday, and Tuesday (October 1, 2, 3, and 4, 2022). Resident 3 stated that his left ankle hurts when his arthritic pain relief was not applied and that his hemorrhoid dries out and bleeds when his hemorrhoidal cream relief is not applied as ordered. A review of Resident 3's facility TAR indicated Resident 3 was ordered the following treatments: - Voltaren Gel 1 % (topical gel applied to the skin for the relief of arthritic pain) apply to left ankle topically three times a day for arthritic pain. - Hemorrhoidal Relief Cream 5% (hemorrhoid- a swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding) Apply to Anus topically every day shift. On October 5, 2022, at 3:15 p.m., an interview was conducted with Resident 2 regarding her skin care and wound treatments. Resident 2 stated that she had leg blisters for the last 7 years and when the dressing changes were not done her wounds were not healing and it had caused her pain. Resident 2 stated that the staff only provided her treatments when she had asked for it. Resident 2 stated that her dressing and treatments were not done on Saturday, Sunday, and today (October 1, 2, and 5, 2022). A review of Resident 2's facility TAR indicated Resident 2 was ordered the following treatments: - Calmoseptine Ointment 0.44 - 20.6 % (Protects, soothes, helps promote healing. Prevent and heal skin irritations) Apply to Left buttock topically every day shift for Wound Maintenance . - Cleanse with NS (Normal Saline), pat dry, wrap with Xeroform (an occlusive dressing that keeps air out, which can help to protect the area), wrap with kerlix, tape, daily every shift for Right lower extremity scattered wound . - Cleanse with NS, pat dry, apply Hydrogel (gel that traps and retain water, provides cooling and soothing effect on the skin), wrap with Xeroform, wrap with Kerlix, tape, daily every day for Left lower extremity scattered wound . - Left inferior (lower) buttock pressure wound, cleanse with NS, pat dry, apply Collagen, DD, daily, every day shift. On October 5, 2022, at 3:40 p.m., an interview was conducted with Resident 4 regarding his skin care and wound treatments. Resident 4 stated that his treatments were not done today, October 5, 2022. A review of Resident 4's facility TAR indicated Resident 4 was ordered the following treatments: - Apply Calmoseptine Cream to Peri area extending to bilateral buttocks every shift for skin maintenance. - Voltaren Gel 1 % Apple to both knees topically three times a day for arthritic pain. On October 6, 2022, at 9:54 a.m., the Treatment Nurse/Licensed Vocational Nurse 1 (TXN/LVN) was interviewed. The TXN/LVN 1 stated that Resident 3's medication for his hemorrhoid was not available and that it had been ordered last week. The TXN/LVN 1 stated that Resident 3's medication had not been started. TXN/LVN 1 stated that if Resident 3's treatments were not done, Resident 3 could suffer a lot of pain and/or his hemorrhoid could bleed. A review of the TAR was conducted with theTXN/LVN 1. The TAR indicated treatments were not signed for on residents on the North Station on October 2 and October 5, 2022. The TXN/LVN 1 stated that if the TAR was not signed for it may indicate that the treatment was not done that day. The TXN/LVN 1 stated that if it was a registry nurse that had worked on those days, they may not have known that they were supposed to do the treatment if there was no treatment nurse assigned that day. The TXN/LVN 1 stated that if the residents missed their treatments, they could actually develop pressure ulcers, skin tears, or infection from old dressings where the bacteria could build up and set in. On October 6, 2022, at 11:50 a.m., the Administrator and Minimum Data Set Coordinator (MDS)/LVN 3 were interviewed. The MDS/LVN 3 stated that residents could develop sepsis and a wound could get worst if treatments were not performed as ordered. The MDS/LVN 3 stated that infection could set in and that bleeding could occur, and increased pain and inflammation could result if wound treatments were not done. A review of the facility policy and procedure titled, Administering Medications, dated December 2012, indicated, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .3. Medications must be administered in accordance with the orders, including any required time frame .21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of seven residents reviewed (Resident 1), the facility failed to ensure pain control medications were available and administered as ordered on September 7, 11, 12, 13, and 19, 2022. This facility failure had the potential to result in complications such as withdrawal symptoms, unrelieved pain and discomfort for Resident 1. Findings: On October 5, 2022, at 10:10 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On October 5, 2022, at 12:53 p.m., Resident 1 was interviewed. Resident 1 stated that she had been in the facility for a year. Resident 1 stated that she had been having stomach discomfort. She stated that she had been seen by a doctor and had a scan done, but they had not found anything. Resident 1 stated that she had been having stomach pain for well over a full year and she had been taking pain medication four times a day to treat the pain. Resident 1 stated that she sometimes does not get her medication for pain control when she is scheduled to receive it. Resident 1 stated that the pharmacy had not delivered her pain medication last month. Resident 1 explained that she had suffered in pain, and had experienced withdrawal symptoms. Resident 1 stated, My bones and joints hurt when I go without my medications. On October 6, 2022, Resident 1's record was reviewed. Resident 1 was [AGE] years old, and was admitted to the facility on [DATE], for long term care. Resident 1 diagnoses included Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), hypertension (HTN- high blood pressure), chronic obstructive pulmonary disease (COPD- a group of lung diseases that blocks airflow and make it difficult to breathe), Osteoporosis/Osteoarthritis (a weak and brittle bone), and chronic pain. A review of the Medication Administration Record (MAR) for September 2022, indicated, oxyCODONE HCl Tablet 30 MG Give 1 tablet by mouth every 6 hours for severe pain, was not administered as ordered: On September 7, 2022, at 12:00 p.m. (0000 midnight) and 6:00 a.m. (0600 a.m.), pain scale 7/10 (1 = least amount of pain, 10 severe pain), Medication not on hand. Waiting on pharmacy; On September 11, 2022, at 12:00 a.m., 6:00 a.m., and 12:00 noon, and 6:00 p.m. (18:00), pain scale 6-8/10, not given, awaiting delivery from pharmacy; On September 12, 2022, at 12:00 p.m., 6:00 a.m., 12:00 noon, and 6:00 p.m., pain scale 6/10, not given, awaiting delivery from pharmacy; On September 13, 2022, at 12:00 p.m., 6:00 a.m., and 12:00 noon, pain scale 6-7/10, not given, awaiting delivery from pharmacy; and On September 19, 2022, at 12:00 p.m., 6:00 a.m., 12:00 noon, and 6:00 p.m., pain scale 8/10, not given, awaiting delivery from pharmacy. There was no documented evidence identifed in Resident 1's facility record that indicated the pharmacy's failure to provide the ordered medications had been reported to the physician and/or facility management for the issue to be addressed and acted upon. On October 5, 2022, at 10:51 a.m., Licensed Vocational Nurse 2 (LVN) was interviewed. LVN 2 stated that the medication refill for Resident 1 was not completed when the facility changed pharmacy providers. LVN 2 stated that the physician had failed to signed Resident 1's prescription refill. LVN 2 stated that the physician had to sign for the medication so the residents could receive refills of their ordered narcotics. LVN 2 stated that the residents needed their medication for pain control and management. On October 6, 2022, at 11:50 a.m., the Administrator (ADM) and Minimum Data Set Coordinator (MDS- a resident assessment tool)/LVN 3 were interviewed. The ADM and MDS Coordinator/LVN 3 stated that if residents did not receive their medications on time, their pain could increase and become uncontrolled. The ADM and MDS/LVN 3 stated for those residents that had been on the medication for maintenance for years, the residents could suffer from withdrawal symptoms, and some may suffer increased anxiety that may result in physical and emotional complications. A review of the facility policy and procedure titled, Administering Medications, dated December 2012, indicated, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week for 51 facility residents on October 1, 2 and 4, 2022. This facility failure had the potential to result in delayed identification and treatment of life-threatening medical conditions thus compromising the health and safety of the vulnerable population in the facility. Findings: On October 5, 2022, at 10:10 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. On October 5, 2022, at 10:35 a.m., the Administrator was interviewed. The Administrator verified that the Director of Nursing (DON) had left the facility and that her last day of work had been September 30, 2022. The Administrator stated that the owner was in the facility and had provided RN coverage on October 3, 2022. The Administrator was unable to provide documented evidence that an RN had worked in the facility on October 1, 2, and 4, 2022. The Administrator stated that there should be an RN daily for coverage in the facility. On October 6, 2022, at 1:27 p.m., the Administrator and Minimum Data Set Coordinator/Licensed Vocational Nurse 3 (MDS/LVN) were interviewed regarding the lack of RN coverage and the possible effects to the care provided to the residents. The Administrator confirmed that there were three days this month that the facility had no RN coverage. The Administrator stated that an RN was required on a daily basis to be present and to provide leadership and supervision of the skilled nursing care provided in the facility. A review of the facility's undated Nursing Supervisor Registered Nurse, JOB DESCRIPTION AND PERFORMANCE STANDARDS, indicated, The purpose of this position is to assist the Director of Nursing Service in assessing resident care needs and implementing appropriate action. Implement nursing policies and procedures. Supervise staffing for the nursing department and supervise the quality of nursing care provided to residents .The primary functions and responsibilities of this position are as follows: 1. Direct, evaluate and supervise all resident care and initiate corrective actions. 2. Make daily resident rounds and report status of nursing care to the Director of Nursing Service and Administrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On November 1, 2021, at 11:20 a.m., a concurrent observation and interview was conducted with Resident 35. Resident 35 was observed awake and lying in bed. A three drawer plastic cart was observed at the bedside on top of her bedside dresser. Inside the first drawer of the plastic cart was a quart sized ziplock bag containing 2 bottles of Fungicure (brand name) antifungal solution. Resident 35 stated the antifungal solutions were hers and has been in there a while. On November 1, 2021, at 11:45 a.m., Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE]. The History and Physical, dated September 16, 2020, indicated Resident 35 was .mentally capable of understanding . The Order Summary Report for November 2021 did not indicate Resident 35 had a physician's order for the Fungicure antifungal solution. In addition, there was no physician's order for Resident 35 to self-administer medications. There was no documented evidence an assessment was conducted to determine if Resident 35 was capable of self-administering medications. On November 1, 2021, at 2:30 p.m., a second observation and with a concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1 in Resident 35's room. Resident 35 was observed awake and lying in bed. LVN 1 inspected the two bottles of Fungicure stored inside the first drawer of Resident 35's plastic cart. LVN 1 stated the Fungicure antifungal solution was a medication and it should not have been at Resident 35's bedside. LVN 1 stated medications brought in by residents to the facility should have been checked in with the licensed nurses, and physician's orders should be obtained orders for the use of the medication. LVN 1 asked Resident 35 about the medications. Resident 35 stated she bought the medications from (name of store) sometime in June 2021, and they had been in her drawer since then. On November 1, 2021, at 12:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 35 should have been assessed for self-administration of medications when she brought in the antifungal medications. The IDT (Interdisciplinary Team - a group of staff meeting and working together for the benefit of the resident) would review the assessment. The facility policy and procedure titled, Self-Administration of Medications, dated December 2012, was reviewed. The policy indicated, .Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so .the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications . Self-administered medications must be stored in a safe and secure place, which is not accessible to other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room . Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party . Based on observation, interview, and record review, the facility failed to ensure the residents were safe to self-administer medications, for two of three residents (Residents 4, and 35), reviewed for self-administration of medications. This failure had the potential for Residents 4 and 35 to self-administer medications unsafely. Findings: 1. On November 1, 2021, at 12:18 p.m., an observation with a concurrent interview was conducted with Resident 4. Resident 4 was observed awake, alert and oriented. Observed on his bedside table was one capsule of fish oil (supplement) on top of a container lid. In a concurrent interview, Resident 4 stated he will take the one fish oil capsule later. On November 4, 2021, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. The History and Physical, dated October 28, 2021, indicated Resident 4 was .mentally capable of understanding . The physician's order titled, Order Summary Report for November 2021, indicated Resident 4 had a physician's order for fish oil capsule. There was no documented evidence a self-medication administration assessment was conducted on Resident 4 to determine if the resident was capable of self-administering medications. On November 1, 2021, at 12:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated there was no self-administration of medication assessment conducted for Resident 4. The DON stated Resident 4 should have been assessed for self-administration of medication. The IDT (Interdisciplinary Team - a group of staff meeting and working together for the benefit of the resident) would review the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for one of two residents reviewed (Resident 22), the cause of an injury of unknown origin (purplish skin discoloration on lateral right forearm) was investigated and reported in a timely manner. This failure had the potential to jeopardize the protection, health, and safety of Resident 22. Findings: On November 2, 2021, at 3:51 p.m., an observation with a concurrent interview was conducted with Resident 22. Resident 22 was observed awake, lying in bed, and watching television. A reddish skin discoloration, approximately 5 inches in length, was observed on Resident 22's lateral right forearm. In a concurrent interview, Resident 22 stated when the facility staff helped her out, They are a little bit rough. On November 3, 2021, at 9:49 a.m., a second observation with a concurrent interview was conducted with Resident 22. The previously reddish skin discoloration on Resident 22's lateral right forearm had developed into purplish color. On November 3, 2021, at 2:20 p.m., a concurrent observation, interview, and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 assessed Resident 22's purplish skin discoloration on the right lateral forearm. LVN 1 asked Resident 22 what happened to her right arm. Resident 22 stated, Sometimes they get a little bit rough. LVN 1 stated she was not aware of Resident 22's purplish skin discoloration on the right lateral forearm. LVN 1 stated the Charge Nurse (CN) should have been notified by the Certified Nurse Assistant (CNA) for any skin issues identified on the resident. LVN 1 stated there was no documented evidence Resident 22's purplish skin discoloration on the right lateral forearm was identified and reported by the staff. On November 4, 2021, at 10:08 a.m., Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (narrowing and blockage of the veins). The nursing progress dated November 3, 2021, at 4:36 p.m., indicated Resident 22 had a change of condition identifying the purplish skin discoloration on the lateral right forearm. There was no documented evidence the facility conducted an investigation to determine the cause of the purplish skin coloration and Resident 22's statement about the staff who were a little bit rough. On November 5, 2021, at 2:46 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the CNA should inform the CN for any skin discoloration, concern, or issues identified. The DON stated the CN should assess the skin discoloration, find out the cause of the skin discoloration, monitor the resident for 72 hours, and notify the physician and the RP. The DON stated the cause of Resident 22's purplish skin discoloration on her right lateral forearm should have been investigated. The DON stated he was informed by LVN 1 about Resident 22's lateral right forearm skin discoloration on November 3, 2021. The DON stated he should have made a follow-up, investigated and should have reported to the appropriate agencies. On November 8, 2021, at 11:00 a.m., an interview was conducted with the DON. The DON stated the facility did not conduct an investigation on Resident 22's purplish skin discoloration to the right lateral forearm identified on November 3, 2021. The DON stated he did not report to the State Agency regarding to the Resident 22's right forearm skin discoloration. He stated, I did not know I need to do that. On November 8, 2021, at 2:25 p.m., an interview was conducted with the Administrator Designee (ADMD). The ADMD stated staff should report to the DON or the Administrator any incident of injury of unknown origin. The ADMD also stated the investigation on the cause of Resident 22's skin discoloration on her lateral right arm, should have been conducted and it should have been reported to the State Agency within 24 hours. The facility policy and procedure, titled, ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE AND REPORTING REASONABLE SUSPICION OF A CRIME IN THE FACILITY POLICY AND PROCEDURE, dated October 21, 2020, indicated, .IDENTIFICATION OF ABUSE .Complaints observations, suspicions, or reporting of incidents, falls, bruises, skin tears and injuries of suspicious or unknown origin will be investigated .Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure that resident safety is not compromised and action is taken whenever possible, to avoid future occurrences .The facility will report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property even if no reasonable suspicion .when .Immediately - no later than 2 hours - all abuse (actual, alleged, or potential neglect, mistreatment, misappropriation of property, and injuries of unknown source) AND did not result in serious bodily injury .NO later than 24 hours - all other conduct (actual, alleged, or potential neglect, mistreatment, misappropriation of property, and injuries of unknown source) AND did not result in serious bodily injury .To Whom .State Survey Agency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure on safe smoking practices for two of four residents (Residents 17 and 27) reviewed for smoking when: 1. There was no staff supervision observed during Residents 17 and 27's smoke breaks; 2. There was no fire extinguisher observed in the smoking area. In addition, the fire blanket (sheet made of fire retardant material placed over a fire to smother it) was outdated, and the plastic covering of the fire blanket was observed to be torn and opened; and 3. Unsecured smoking materials such as cigarettes, loose tobacco and lighters, were observed to be in Residents 17 and 27's possession at all times. These failures had the potential to increase the residents' risks for smoking related injuries and accidental fires. Findings: 1. On November 1, 2021, at 10:15 a.m., Residents 17 and 27 were observed smoking without smoking aprons in the designated smoking area, and without a staff present to supervise them. At 3:30 p.m., a second observation was conducted with Residents 17 and 27. Both were observed smoking without smoking aprons (fire resistant aprons used by smokers) in the designated smoking area, and without staff present to supervise them. At 3:50 p.m. the Activities Director (AD) was interviewed. The AD stated if the residents were alert and oriented, they were allowed to keep their smoking materials and they can smoke on their own, without staff supervision, in the smoking area. The AD stated Residents 17 and 27 were alert and oriented, and were allowed to smoke on their own. The AD stated the smoking materials were stored at the nursing station, but he did not collect any smoking materials from the residents after their designated smoke breaks. On November 2, 2021, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included anxiety (a mood disorder), and depression (a mood disorder). The History and Physical, dated September 23, 2021, indicated Resident 27 was able to make decisions. The Smoking- Safety Screen, dated June 8, 2021, indicated .Resident need for adaptive equipment .smoking apron .supervision .Does resident need facility to store lighter and cigarettes? .yes .IDT discussed smoking safety with resident .Resident understands that supervision is needed during scheduled smoke times and an apron must be worn while smoking . The Care Plan for Smoking, dated May 25, 2021, indicated .Resident Goals .Will be able to smoke safely with supervision .Supervise resident when resident is out smoking . On November 2, 2021, Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included liver disease, depression, and anxiety. The History and Physical, dated September 7, 2021, indicated Resident 17 had fluctuating capacity to make decisions. The Smoking- Safety Screen, dated July 3, 2021, indicated .Resident need for adaptive equipment .smoking apron .supervision .Does resident need facility to store lighter and cigarettes? .yes . The Care Plan for Smoking, dated September 7, 2021, indicated .Resident Goals .Will be able to smoke safely with supervision .Supervise resident when resident is out smoking . On November 2, 2021, the facility's undated document titled, (Name of facility) Smoking Schedule, posted around the facility, was reviewed. The document indicated the designated smoke times, the smoking supervisor in charge Receptionist/Screener), as well as reminders including, .It is the resident's right to be allowed to smoke. However, only during the appropriate times and in the designated area, with a supervisor present . On November 5, 2021, at 1:58 p.m., the Administrator (ADM) was interviewed. The ADM stated there should be an assessment conducted on the smokers regarding their ability to smoke safely. The Smoking Schedule, which included the instructions for staff, was concurrently reviewed with the ADM. The ADM stated Resident 17 and 27 should have been supervised during their smoke breaks. The facility's policy and procedure titled, Smoking Policy-Residents, dated December 2007, was reviewed. The document indicated, .This facility shall establish and maintain safe resident smoking practices .Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member .at all times while smoking . 2. On November 1, 2021, at 10:15 a.m., an observation was conducted at Building 5 patio smoking area. There was no fire extinguisher observed in the immediate surroundings of the smoking area. The Building 5 patio closet (labeled with a sign indicating fire blanket) was also inspected. There was no fire extinguisher available for use inside the patio closet. Attached to the inner side of the patio closet door was a wooden box containing a fire blanket dated September 25, 2012. The plastic covering the fire blanket was torn and opened (exposing the fire blanket to the environment). On November 5, 2021, at 2:49 p.m., a concurrent observation and interview was conducted with the facility Owner. The Owner was observed looking for a fire extinguisher in the Building 5 patio smoking area or the immediate surroundings of the smoking area.The Owner was not able to locate the fire extinguisher in the immediate surroundings of the Building 5 patio smoking area. The Owner stated a fire extinguisher should have been placed in the smoking area. The Owner then proceeded to inspect Building 5 patio closet and the fire blanket. The Owner stated the fire blanket, located inside the closet, was outdated, torn, and opened. The Owner stated the fire blanket should have been replaced. According to an article by BestReviews (a consumer-focused website that helps customers simplify their purchasing decisions by providing unbiased recommendations for products and services from industry experts), dated November 2021, indicated, .Tips .Know your fire blanket's expiration date. Like fire extinguishers, fire blankets can expire. If no date is listed, replace the blanket about seven years after it was made .Most fire blankets are not reusable. Even a blanket used to smother a small fire will be weaker in the spot where it was exposed to flames, putting you at risk for the fire to spread . According to the California Code of Regulations, Title 19, Division 1, SS906.5, .Portable fire extinguishers shall be located in conspicuous locations where they will have ready access and be immediately available for use . 3a. On November 2, 2021, at 8:00 a.m., an observation was conducted with Resident 27. Resident 27 was observed awake and lying in bed, with the head of bed elevated and the resident receiving oxygen via nasal cannula (a plastic tube that delivers oxygen through the nose) from an oxygen concentrator (a medical device that concentrates oxygen from environmental air). In a concurrent interview, Resident 17 stated he had shortness of breath last night and that is why he was receiving oxygen now. Observed on his dresser towards the end of the bed was one quart-sized plastic bag containing loose tobacco and rolling paper. A black lighter was observed beside the plastic bag. Resident 27 stated they (smokers) kept their own smoking materials including cigarettes and lighters, and for him, the loose tobacco. Resident 27 stated he was not sure if a smoking assessment was conducted for him by the facility staff. Resident 27 stated he did not have any secured storage container to use for his smoking materials. On November 2, 2021, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included anxiety (a mood disorder), and depression (a mood disorder). The History and Physical, dated September 23, 2021, indicated Resident 27 was able to make decisions. The Smoking- Safety Screen, dated June 8, 2021, indicated .Resident need for adaptive equipment .smoking apron (fire resistant apron used by smokers) .supervision .Does resident need facility to store lighter and cigarettes? .yes .IDT discussed smoking safety with resident .Resident understands that supervision is needed during scheduled smoke times and an apron must be worn while smoking . The Care Plan for Smoking, dated May 25, 2021, indicated .Resident Goals .Will be able to smoke safely with supervision .Supervise resident when resident is out smoking . 3b. On November 2, 2021, at 8:40 a.m., a concurrent observation and interview was conducted with Resident 17. Resident 17 was observed lying in bed, awake. Resident 17 stated he was a smoker and he kept his cigarettes in his shirt pocket and his lighter in his jeans pocket. Resident 17 was observed to remove one pack of [NAME] (brand of cigarettes), containing one cigarette, from the front pocket of his shirt. Resident 17 stated if he had one more pack with him, it would be in stored in his jeans pocket. Resident 17 stated he had his cigarette lighter his jeans pocket, and he was not given any secured storage container to use for his smoking materials. Resident 17 further stated during smoke breaks, We (smokers) usually just watch each other .If there were facility staff in the smoking area, they were there to smoke . On November 2, 2021, Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included depression, and anxiety. The History and Physical, dated September 7, 2021, indicated Resident 17 had fluctuating capacity to make decisions. The Smoking- Safety Screen, dated July 3, 2021, indicated .Resident need for adaptive equipment .smoking apron .supervision .Does resident need facility to store lighter and cigarettes? .yes . The Care Plan for Smoking, dated September 7, 2021, indicated .Resident Goals .Will be able to smoke safely with supervision .Supervise resident when resident is out smoking . On November 2, 2021, the facility's undated document titled, (Name of facility)Smoking Schedule, posted around the facility, was reviewed. The document indicated the designated smoke times, the smoking supervisor in charge (Receptionis/Screener), as well as reminders including, .ALL smoking materials must stay at the Nurse's station in a designated area, each one labeled with the resident's name and room number .Be sure to re-collect all smoking supplies given out once finished .It is the resident's right to be allowed to smoke. However, only during the appropriate times and in the designated areas, with a supervisor present .Smoking aprons are available in the Activities Office . On November 5, 2021, at 1:58 p.m., the Administrator (ADM) was interviewed. The ADM stated there should be an assessment conducted on the smokers regarding their ability to smoke safely. If they were alert and capable, and determined to be competent to handle their own smoking materials, they smoked on their own. The ADM further stated, but we get the materials after they smoke and they should not have lighters with them. The ADM stated the Activities person or the whoever is there to supervise the residents should ensure the lighters were collected after use by the residents. The ADM stated they have not thought about providing secured containers for residents to store their smoking materials. The Smoking Schedule, which included the instructions for staff, was concurrently reviewed with the ADM. The ADM stated the smokers should have been supervised during their smoke breaks, and the smoking materials should have been collected after their smoke breaks. The facility's policy and procedure titled, Smoking Policy-Residents, dated December 2007, was reviewed. The document indicated, .This facility shall establish and maintain safe resident smoking practices .Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member .at all times while smoking .Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct two Gradual Dose Reduction (GDR - a stepwise tapering of a dose) on psychotropic medications (medication capable of affecting the mind, emotions, and behavior) for two of three residents reviewed for GDR (Residents 35 and 38). This failure had the potential for the residents to have excessive duration, dose, and unnecessary use of the psychotropic medications. Findings: 1. On November 2, 2021, at 2:19 p.m., Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a mood disorder), bipolar disorder (a brain disorder), psychosis (a brain disorder), insomnia (inability to sleep), and depression (a mood disorder). The History and Physical, dated September 16, 2020, indicated, Resident 35 was .mentally capable of understanding . The Order Summary Report for November 2021 indicated Resident 35 was on the following medications: - Ambien (a brand name for sleep inducing medication) for Tablet 10 mg (milligram- a unit of measurement) give one (1) tablet by mouth at bedtime for insomnia, ordered on March 14, 2020; - Cymbalta (a brand name for a medication used to treat depression) Capsule Delayed Release Particles 60 mg, give 1 capsule by mouth one time a day for depression, ordered on June 22, 2021; - Lorazepam (a generic name for a medication used to treat anxiety) tablet 0.5 mg, give 1 tablet by mouth two times a day for anxiety, ordered on June 22, 2021; and - Risperdal (a brand name for a medication used to treat bipolar disorder) tablet 0.5 mg (Risperidone [generic name]) give 1 tablet by mouth three times a day for bipolar disorder, ordered on March 31, 2021. On November 5, 2021, the Medication Regimen Review (MRR) for Resident 35, dated September 23, 2021, was reviewed. The document indicated the Pharmacy Consultant (PC) recommended, .Resident has been on the same dose of Cymbalta 60 mg QD (daily), Ativan 0.5 mg BID (twice daily), Risperdal 0.5 mg q8hrs (every eight hours), & (and) Ambien 10 mg QHS (every hour of sleep) since 5/2020 adjustments. Gradual Dose Reduction (GDR) is due if medically warranted . On November 8, 2021, at 12:19 p.m., the quarterly Psychotropic Summary Sheet for June 2021 was reviewed. The document did not indicate an Interdisciplinary Team (IDT) recommendation regarding any medication dose reduction attempts for the medications Cymbalta, Ambien, Risperdal or Ativan. In addition, the document did not indicate IDT participant signatures. There was no evidence a quarterly Psychotropic Summary Sheet was completed for September 2021 in Resident 35's chart. There was no documented evidence the PC's recommendation on September 23, 2021, for a GDR on the use of Cymbalta, Ativan, Risperdal, and Ambien were addressed and discussed with Resident 35's physician and the IDT members. On November 8, 2021, at 2:41 p.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 confirmed the June 2021 document did not indicate a medication dose reduction attempt for the medications Cymbalta, Ativan, Risperdal, and Ambien, and there were no IDT signatures to indicate these were discussed. LVN 3 confirmed there was no quarterly Psychotropic Summary Sheet completed for September 2021 in Resident 35's chart. On November 9, 2021, beginning at 9:02 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated GDRs should be attempted for residents on psychotropic medications on two separate quarters at least one month apart on the resident's first year of admission and at least annually thereafter. The psychotropic medications should be reviewed quarterly by the IDT in conjunction with the quarterly care conference meetings with the resident and/or resident representative. On November 9, 2021, at 9:16 a.m., a concurrent interview and record review was conducted with the DON. The DON stated Resident 35 was currently on the medications Ambien, Cymbalta, Lorazepam, and Risperdal at the same frequency and doses as indicated on the MRR since May 2020. The DON stated there was no documented evidence a follow up was done by the facility to address the PC's recommendation on September 23, 2021, for a GDR attempt on these medications. The DON stated Resident 35's Minimum Data Set (MDS- an assessment tool) dated September 20, 2021, indicated a GDR has not been attempted on the resident's use of psychotropic medications. The DON stated the June 2021 Psychotropic Summary Sheet for Resident 35 did not indicate an attempt at a GDR was discussed or addressed by the IDT. The DON stated an attempt GDR on the use of these psychotropic medications should have been done for Resident 35 in June 2021, especially since the last reduction was conducted more than a year ago in May 2020. 2. On November 8, 2021, at 3:47 p.m., Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a brain disorder), depression (a mood disorder), and anxiety disorder (a mood disorder). The History and Physical, dated March 27, 2020, indicated, Resident 38 was .mentally capable of understanding . The physician orders in the electronic medical record indicated Resident 38 was on the following medications: - Zoloft (a brand name for medication used to treat depression) Tablet 50 MG (milligram- a unit of measurement)(Sertraline HCl) Give 1 tablet by mouth at bedtime for depression, ordered on July 22, 2021; - Xanax (a band name for medication used to treat anxiety) Tablet 0.25 MG (ALPRAZolam) Give 1 tablet by mouth in the evening for anxiety, ordered on March 30, 2021; and - ZyPREXA (a brand name for medication used to treat bipolar disorder) Tablet 2.5 MG (OLANZapine) Give 1 tablet by mouth at bedtime for Bipolar Disorder, ordered on March 27, 2021. The quarterly Psychotropic Summary Sheets for June 2021 and September 2021 were reviewed. The documents did not indicate any Interdisciplinary Team (IDT) recommendations regarding an attempt for dose reductions for the medications Zoloft, Xanax, and Zyprexa. In addition, the document did not indicate IDT participant signatures. On November 10, 2021, beginning at 9:02 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated GDRs should be attempted for residents on psychotropic medications on two separate quarters at least one month apart on the resident's first year of admission and at least annually thereafter. The psychotropic medications should be reviewed quarterly by the IDT in conjunction with the quarterly care conference meetings with the resident and/or resident representative. The DON stated there was no documented evidence a recent GDR attempt was conducted for Resident 38. The DON stated Resident 38's Minimum Data Set (MDS- an assessment tool) dated September 7, 2021, did not indicate a GDR had been attempted. The March 2021, June 2021, and September 2021 Psychotropic Summary Sheets for Resident 38 were reviewed with the DON. The DON stated there wasno docuemnted evidence of IDT recommendations for June 2021 and September 2021 regarding an attempt dose reduction for the medications Zoloft, Xanax, or Zyprexa, since the IDT portion of the form was not completed, and there were no indication of IDT participant signatures. The DON stated an attempt at a GDR should have been done for Resident 38 after the last IDT review on March 2021. The facility's policy and procedure titled, Tapering Medications and Gradual Drug Dose Reduction, dated April 2007, was reviewed. The policy indicated, .All medications shall be considered for possible tapering .Some medications (e.g., antidepressants [medciaitons to treat depression], sedative/hypnotics [sleep inducing medications], opioids [resembling opium in addictive properties or psychological effects]) may need more gradual tapering in order to minimize withdrawal symptoms or other adverse consequences . Residents who use antipsychotic drugs shall receive gradual dose reductions .in an effort to discontinue the use of such drugs .within the first year after a resident is admitted on an antipsychotic medication or after a the resident has been started on an antipsychotic medication (medication to treat psychotic disorders), the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts) . After the first year, the facility shall attempt an GDR at least annually, unless clinically contraindicated .Attempted tapering of psychopharmacologic medications other than antipsychotics or sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefitting from a medication or might benefit from a lower of less frequent dose . During the first year in which a resident is admitted on a psychopharmacological (drugs affecting the mind and behavior) medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has intitiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between the attempts) .After the first year, tapering will be attempted at least annually, unless contraindicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed and/or discarded when: 1. A multi-dose vial of one tuberculin PPD (a test used to detect tuberculosis (TB - an infectious lung disease), was found stored inside the medication refrigerator at the nurse station beyond the discard date. This failure had the potential for the residents to be administered a PPD past the beyond the discard date and could result in an inaccurate TB test results. 2a. Two eardrop medications for Residents 14 and 30 were found stored in the medication cart after the treatments were completed. In addition, a bottle of an opened Milk of Magnesia (MOM - a medication to treat constipation, upset stomach, and heartburn) suspension, labeled for a discharged resident's use, was stored in the medication cart; 2b. Multiple completed, discontinued and/or expired medications were stored in the treatment cart, readily available for use. These failures had the potential for the residents to receive expired and discontinued medications; and 3. For Residents 4 and 30, multiple medications were stored by bedside, unsecured readily available for use. These failures increased the possibility for Residents 4, and 30, to receive medications unsafely. Findings: 1. On November 5, 2021, at 9:57 a.m., an inspection with concurrent inteview of the medication refrigerator at the nurse station was conducted with the Infection Preventionist (IP). Stored inside the medication refrigerator, readily available for use, was an opened multi-dose vial of tuberculin PPD. The vial of PPD had a label open date of August 8. 2021. Included in the label for use on the PPD vial box, was an instruction that indicated, Discard opened product after 30 days. The IP stated the opened multi-dose PPD vial should have been discarderd after the 30 days from the open date of August 9, 2021. The IP stated it should not have been stored in the medication refrigerator readily available for use. 2a. On November 5, 2021, at 10:29 a.m., an inspection of the medication cart with a concurrent interview was conducted with Licensed Vocational (LVN) 2. Stored inside the medication cart readily available for use were the following: - One eardrop medication, labeled for Resident 14's use, with a physician's order to give, Debrox 6.5% OT sol, instill 10 drops in both ears twice daily for 4 days. The physician's order was dated October 30, 2021; - One eardrop medication, labeled for Resident 30's use, with a phsician's order to give, Debrox 6.5% OT sol, place 10 drops in left ear, turn head to drain for 4 days. The physician's order was dated October 29, 2021; and - One used and opened bottle of MOM, labeled for use on a discharged resident. In a concurrent interview, LVN 2 stated the eardrop medications for Residents 14 and 30 should have been discarded and not stored in the medication cart readily available for use. LVN 2 further stated the residents had completed the order for these medications. LVN 2 stated, the opened and used bottle of MOM for the discharged resident should not have been stored in the medication cart. LVN 2 further stated it should have been discarded because the resident did not return to the facility. 2b. On November 5, 2021, at 11:23 a.m., an inspection of the treatment cart with a concurrent interview was conducted with the IP. Stored inside the treatment cart readily available for use were the following: - Nystatin cream 2% (an antifungal medication) labeled for use on a discharged resident; - Nystatin powder (an antifungal medication) labeled for use on a discharged resident; - nystatin powder, with a treatment order that has been completed for Resident 37; and - Triamcinolone 0.1% (a medication used to treat a variety of skin conditions, for example: allergies, rash) treatment order that has been completed for Resident 37. The IP stated the Nystatin treatment medications labeled for use on discharged residents should have been removed from the treatment cart. The IP stated medications such as ointments powder and creams should have been removed from the treatment cart and destroyed once the physician treatment orders were completed or discontinued. On November 5, 2021, at 1:58 p.m., an interview was conducted with the Pharmacy Consultant (PC). The PC stated any treatment medication orders with stop dates for use should have been removed from the medication and/or treatment cart to prevent the Licensed Nurse (LN) from administering it to the resident without an order. The PC stated nurses should have inspected the medication and treatment carts at least once a month and removed discontinued and/or expired medications. 3a. On November 1, 2021, at 12:20 p.m., an observation and concurrent interview was conducted with Resident 4. Resident 4 was observed awake, alert and oriented. One tube of antifungal cream was found at the bedside on top of his bedside dresser. In a concurrent interview, Resident 4 stated the nurses applied the antifungal cream on his body. On November 1, 2021, at 12:35 p.m., an observation was conducted with Certified Nursing Assistant (CNA) 1 in Resident 4's room. CNA 1 took out a wash basin from Resident 4's closet. The wash basin contained the following medications: - One tube of lotrimin cream (medication to treat fungal infection); - One bottle of medicated body powder - (medication to treat minor skin problem); and - One spray bottle of lotrimin (medication to treat fungal infection). On November 4, 2021, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. The History and Physical, dated October 28, 2021, indicated Resident 4 was .mentally capable of understanding . The physician's order titled, Order Summary Report for November 2021 did not indicate Resident 4 had an active physician's order for the use of antifungal cream, lotrimin cream, medicated body powder, and spray bottle of lotrimin. 3b. On November 1, 2021, at 12:16 p.m., an observation with a concurrent interview was conducted with Resident 30. Resident 30 was observed awake, alert and conversant. One tube of antifungal cream (medication to treat fungal infection) and a thick white cream in a medication cup were found on top of Resident 30's bedside dresser. In a concurrent interview, Resident 30 stated the nurses are applied the antifungal cream and the thick white cream on his body. On November 4, 2021, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE]. The History and Physical, dated December 7, 2020, indicated Resident 30 was .mentally capable of understanding . The physician order titled, Order Summary Report for November 2021 did not indicate Resident 30 had an active physician's order for the use of antifungal cream. On November 1, 2021, at 12:45 p.m., the Director of Nursing (DON) was interviewed. The DON was asked regarding the facility's process for storing medications such as antifungal creams, etc. by the resident's bedside. The DON stated there should be no medications stored at the resident's bedside and closet. The facility's policy and procedure, titled, Storage of medications, dated April 2007 was reviewed. The policy indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed . The facility's policy and procedure, titled, Discontinued Medications, dated April 2007, was reviewed. The policy indicated, .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with the facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) information were provided to 11 of 14 residents reviewed (Residents 4,10, 24, 27, 28, 30, 35, 38, 44, 47, and 149). This failure had the potential for Residents 4, 10, 24, 27, 28, 30, 35, 38, 44, 47, and 149 not to be able to exercise their rights to formulate an Advance Directive. Findings: 1. On November 3, 2021, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. The physician's history and physical dated October 28, 2021, indicated Resident 4 was able to make decisions. Resident 4's Physician Orders for Life-Sustaining Treatment (POLST) form indicated Resident 4 did not have an AD. On November 5, 2021, at 11:27 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated she did not provide the AD information to Resident 4; 2. On November 4, 2021, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE]. The physician's history and physical dated November 18, 2020, indicated Resident 10 was mentally capable of understanding. There was no documented evidence Resident 10 had an AD in his records. On November 8, 2021, at 11:10 a.m., an interview was conducted with the SSD. The SSD stated there was no documented evidence the AD information was provided to Resident 10; 3. On November 3, 2021, Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - an assessment tool), dated August 24, 2021, indicated the score for Resident 24's Brief Interview of Mental Status (BIMS) was 10 out of 15 (moderately impaired cognition). Resident 24's POLST dated August 18, 2021 indicated Resident 24 did not have an AD. On November 5, 2021, at 11:47 a.m., an interview was conducted with the SSD. The SSD stated she did not provide Resident 24 the AD information; 4. On November 3, 2021, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE]. The physician's history and physical dated September 23, 2021, indicated Resident 27 was able to make decisions. Resident 27's POLST dated May 25, 2021 indicated Resident 27 did not have an AD. On November 5, 2021, at 11:47 a.m., an interview was conducted with the SSD. The SSD stated there was no documented evidence the facility offered Resident 27 the written AD information; 5. On November 3, 2021, Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the score for Resident 28's BIMS was 15 out of 15 (cognitively intact). Resident 28's POLST indicated Resident 28 did not have an AD. On November 5, 2021, at 11:27 a.m., an interview was conducted with the SSD. The SSD stated she did not provide Resident 28 the AD information; 6. On November 3, 2021, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE]. The physician's history and physical dated December 7, 2020, indicated Resident 30 was mentally capable of understanding. There was no documented evidence Resident 30 had an AD in his medical record. On November 5, 2021, at 11:27 a.m., an interview was conducted with the SSD. The SSD stated she did not provide Resident 30 the written AD information; 7. On November 3, 2021, Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE]. The physician history and physical dated September 16, 2020, indicated Resident 35 was mentally capable of understanding. Resident 35's POLST dated March 14, 2020, indicated there was no AD. On November 5, 2021, at 11:47 a.m., an interview was conducted with the SSD. The SSD stated she did not provide Resident 35 the written AD information. 8. On November 3, 2021, Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE]. The physician's history and physical dated March 27, 2021, indicated Resident 38 was mentally capable of understanding. There was no documented evidence that Resident 38 was provided the written AD information. On November 5, 2021, at 11:27 a.m., an interview was conducted with the SSD. The SSD stated she did not provide Resident 38 the written AD information; 9. On November 3, 2021, Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated Resident 44's score for BIMS was 15 out of 15 (cognitively intact). Resident 44's POLST dated September 24, 2021, indicated Resident 44 did not an AD. On November 5, 2021, at 11:27 a.m., an interview was conducted with the SSD. The SSD stated she did not offer Resident 44 the written AD information; 10. On November 4, 2021, Resident 47's record was reviewed. Resident 47 was admitted to the facility on [DATE]. The physician's history and physical dated September 29, 2021, indicated Resident 47 was able to make decisions. There was no documented evidence Resident 47 had an AD in his medical records. On November 8, 2021, at 11:10 a.m., an interview was conducted with the SSD. The SSD stated there was no documented evidence AD information was provided to Resident 47; and 11. On November 3, 2021, Resident 149's record was reviewed. Resident 149 was admitted to the facility on [DATE]. The physician's history and physical dated October 17, 2021, indicated Resident 149 was able to make decisions. Resident 149's POLST dated October 14, 2021, indicated Resident 49 did not have AD. On November 5, 2021, at 11:47 a.m., an interviewed was conducted with the SSD. The SSD stated she did not provide Resident 149 the written AD information. On November 5, 2021, at 9:10 a.m., an interview was conducted with the SSD. The SSD stated the facility's process was to provide a written AD information to the residents upon admission. The SSD stated if a resident had an AD she or he would be asked to provide a copy and it should be kept in the resident's chart. The SSD stated if the resident did not have an AD and would like to establish one, the SSD would assist the resident to set up an AD. The SSD stated she should have offered the written AD information to Residents 4,10, 24, 27, 28, 30, 35, 38, 44, 47, and 149. The facility's policy and procedure titled, Advance Directives, dated August 2007, was reviewed. The policy indicated, .upon admission of a resident .the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident .

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and home-like environment for six of seven sampled residents (Residents 2, 4, 28, 29, 30, and 38) when: 1. Inside Residents 2, 4, and 30's, shared bathroom, the following were observed: - The bathroom sink was not fully secured or fully attached to the wall; - The bathroom wall on the right side had faux tiles not fully attached to the wall; and - The shower area water drainage cover was not secured to the floor. 2. Inside Residents 29 and 38's shared bathroom in, the following were observed: - The right-side wall in the shower area had an open area approximately five inches (unit of measurement) wide; - The lower section of the bathrom door had chipping paints; and - The bathroom wall had missing tiles approximately 10 inches wide. 3. Inside Resident 28's room the following were observed: - The corner wall of the room near the bathroom entrance had a severe dry wall damage approximately two feet (unit of measurement) wide. 4. Inside Resident 28's bathroom, the following were observed: - The bathroom walls had chipped wall paints; - The bathroom door had two holes approximately two inches wide combined; - The right side bathroom wall had an open area with four and half inches wide; and - The sink had no draining cup. These deficient practices had potential for accidents and increased safety risk on vulnerable residents, allowing bugs and pests into the facility by entering the open space area on the walls and/or bathroom doors. Findings: On November 5, 2021, at 8:55 a.m., an environmental tour observation with concurrent interviews were conducted with the Administrator (ADM), Administrator Designee (ADMD) and the Director of Environmental Services (DES). The following were observed: 1. On November 5, 2021, at 8:57 a.m., inside Residents 2, 4, and 30's, shared bathroom, the following were observed: - The bathroom sink was not fully secured or fully attached to the wall; - The bathroom wall on the right side had faux tiles not fully attached to the wall; and - The shower area water drainage cover was not secured to the floor. In a concurrent interview, the DES stated the environmental issues in Residents 2, 4, and 30's shared bathroom needed to be fixed. 2. On November 5, 2021, at 9:20 a.m., inside Residents 29 and 38's shared bathroom, the following were observed: - The right-side wall in the shower area had an open area approximately five inches (unit of measurement) wide; - The lower section ofthe bathroom door had chipping paints; and - The bathroom wall had missing tiles approximately 10 inches wide. In a concurrent interview the DES stated the environmental issues in Residents 29 and 38's shared bathroom needed to be fixed. 3. On November 5, 2021, at 9:35 a.m., inside Resident 28's room the following were observed: - The corner wall of the room near the bathroom entrance had a severe dry wall damage approximately two feet (unit of measurement) wide. In a concurrent interview, the DES stated the environmental issues in Residents 28's room needed to be fixed. 4. On November 5, 2021, at 9:45 a.m., inside Resident 28's bathroom, the following were observed: The bathroom walls had chipped wall paints; - The bathroom door had two holes approximately two inches wide combined; - The right side bathroom wall had an open area with four and half inches wide; and - The sink had no draining cup. In a concurrent interview the DES stated the environmental issues in Residents 28's bathroom needed to be fixed. A review of the facility documents, Maintenance Log, for the month of November 2021, indicated there was no documented evidence the environmental issues identified during facility environmental tours on November 5, 2021, were identified and reported by the facility staff. On November 5, 2021, at 10:20 a.m., the ADM was interviewed. The ADM stated, The facility is old and it needs fixing. On November 5, 2021, at 10:25 a.m., the ADMD was interviewed. The ADMD stated the facility owner was planning to have a renovation on the residents' rooms & bathrooms. He further stated the facility will undergo a complete renovation. The facility policy and procedure titled, Maintenance Service, dated December 2004, was reviewed. The policy indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment .Maintaining the building in good repair and free from hazards . The facility policy and procedure titled, Maintenance Schedules, dated October 21, 2020, was reviewed. The policy indicated, .The maintenance director is responsible for developing and maintain a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner .

Based on observation, interview, and record review, the facility failed to ensure the Emergency Kits (E-Kit - an emergency storage box containing a small quantity of critical medications used in emergency situations) were not expired and were replaced within 72 hours according to the facility's policy and procedure. This failure had the potential to result in a delay in the administration of medications. In addition, this placed the residents at risk for receiving expired medications. Findings: On November 5, 2021, an observation with concurrent interviews were conducted on the following: - At 8:55 a.m., an inspection of the IV (an injection administered through the veins) E-kit in medication room was conducted with the Director of Nursing (DON). The IV E-kit did not have a lock or an indication it was sealed or unused. In a concurrent interview, the DON stated the IV E-Kit was opened and there was no documented evidence when it was opened, by whom, and what medication was used and taken from it. The DON further stated the opened IV E-Kit should have been secured with a zip tie lock after it was opened. The DON stated, the facility's procedure was for the Licensed Nurse (LN) to seal the E-kit after each use with a color coded zip tie lock and notify the pharmacy for the opened and/or expired E-kits for a replacement within 72 hours of opening. He further stated this procedure was not followed. - At 9:18 a.m., an inspection of the IM (Intramuscular) E-Kit, located in the Nurse Station was conducted with the Infection Preventionist (IP). The IM E-Kit was labeled as IM# (number) 8. The sticker label on IM E-Kit #8 indicated an expiration date of July 2021. IM E-Kit #8 had a yellow zip tie lock indicating it has been opened (yellow zip tie lock indicated an opened E-kit and a red zip tie lock indicated unopened E-Kit). Inside the IM E-Kit #8 was a form that indicated a LN took the medication Valium (a medication to treat anxiety) from the E-Kit on September 3, 2021. In a concurrent interview, the IP stated IM E-Kit #8 expired on July 2021. She further stated the IM E-Kit #8 should not have been used after the expiration date by the LN who opened and took the medication Valium on September 3, 2021. The IP stated the E-Kits once opened should have been replaced within 72 hours and expired E-Kits should have been called in to the pharmacy for replacement before the expiration date. - At 10:25 a.m., an inspection of the E-Kit labeled E-Kit#20, located inside the medication refrigerator at the Nurse Station, was conducted with the IP. E-Kit #20 had a red zip tie lock and the label sticker indicated E-Kit#20 expired on October 2021. In a concurrent interview, the IP stated E-Kit #20 expired on October 2021 and the pharmacy should have been notified for a replacement. On November 5, 2021, at 11:45 a.m., an interview was conducted with the Pharmacy Director (PD).The PD stated the IV E-Kit was last replaced by the pharmacy on October 16, 2021. The PD stated the LN should have called the pharmacy when the IV E-Kit was opened and it should have been replaced within 72 hours. The PD stated all expired E-Kits should have been called to the pharmacy prior to the expiration date for replacement. The PD stated the LN or the Pharmacy Consultant (PC) should call for the replacement of expired E-Kits. The PD further stated, Expired E-Kits are not acceptable. On November 8, 2021, the facility policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated September 2018, was reviewed. The policy indicated, .The provider pharmacy supplies emergency medications in limited quantities in portable, sealed containers in compliance with applicable state regulations .To access medication from the emergency kit secondary to a new order when medication for which there is a current prescription is not readily available . The nurse records the medication use from the emergency kit on the medication order and E-kit Dose Slip (provided in each E-kit). The original E-kit Dose Slip is to remain in the E-kit and the copy is to be taped in the E-kit log book. Nurse is to notify the pharmacy for replacement of the e-kit and flag the e-kit with a color-coded lock to indicate need for replacement of kit as soon as possible after the medication has been administered . Opened kits are replaced with sealed kits within 72 hours of opening .the expiration date of inventory is noted on the outside of the kit .

Based on observation, interview, and record review, the facility failed to ensure the supervisory staff carried out the functions of the food and nutrition service, when the Dietary Service Supervisor (DSS) and the facility Registered Dietitian (RD), did not provide management and oversight to ensure food was stored, prepared, and served according to the facility and industry standards. The RD and the DSS did not maintain oversight of the day-to-day operations of the dietetic service. This failure resulted in multiple deficient practices observed in the dietetic service. These deficiencies placed 49 residents, who were on an oral diet, at risk for serious harm from unsafe and unsanitary food handling practices and inadequate nutrition. (Cross reference F803 and F812). Findings: During the standard recertification survey conducted from November 1, through 9, 2021, multiple issues on food safety, food sanitation, food storage, and nutritional needs, were identified. On November 1, 2021, at 10:15 a.m., during a concurrent tour of the facility kitchen and interview with the Dietary Services Supervisor (DSS), Refrigerator 1 was observed to contain a box of 16 fresh shell eggs. The eggs did not have a distinguishing mark to indicate whether the eggs were pasteurized (pasteurized eggs would have a marked with a red letter P on the shell). The box did not indicate whether the 16 unmarked eggs were pasteurized. The DSS verified the 16 fresh shell eggs was unmarked with a letter P on the shell. The DSS asked, What is pasteurized eggs? On November 1, 2021, at 11:30 a.m., during lunch observation, the food items for all residents were observed to have the following: - tuna salad; - tomato salad; - half slice of bread; - cream of mushroom soup (1 cup) with 1 cracker; - milk (4 oz - ounce - unit of measurement); and -juice (8 oz). A review for the facility's planned menu, Week 2 - Fall Menu indicated the following food items: - baked ham; - baked beans; - wheat bread; - pineapple with mandarin oranges; - coffee or tea; and - milk. On November 1, 2021, at 3:50 p.m., during an interview with the Dietary Service Supervisor (DSS), the DSS stated the menu was not followed because the food deliveries did not come on time. The DSS stated she was not aware about the food substitute. The facility was not able to provide a spreadsheet for the planned menu. The facility was not able to provide a documentation or a logbook regarding changes in diet menu. There was no posting on the menu board or consumer board regarding the changes in the planned menu for the day. The facility's policy and procedure titled, MENU PLANNING, dated 2020, was reviewed. The policy indicated, .All daily menu changes, with the reason of changes, are to be noted on the back of the kitchen spreadsheet or a logbook may be kept .Only the Dietitian (RD) or FNS (Food and Nutrition Service) Director can make permanent changes. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. On November 1, 2021, at 9:45 a.m., during the initial kitchen tour with [NAME] 2 and the Dietary Service Supervisor (DSS), the following were observed at the overhead kitchen counter: - one chocolate syrup, with expiration date September 2, 2021; - one can low sodium beef flavored base, unable to distinguish the expiration date. The label indicated keep refrigerated. - three loaves of bread, with no open date; - one large plastic container 36 oz (ounce - unit of measurement) thickener, with expiration date of April 2021; - one gallon of barbecue sauce, with no expiration date; and - one small can of chicken flavor base, with no expiration date. On November 1, 2021, at 10:15 a.m., in an interview with the DSS, the DSS confirmed the food items have no expiration date or no discard date. The DSS stated, they should be discarded. On November 1, 2021, beginning at 10:15 a.m., to 11:30 a.m., during the initial kitchen tour with the DSS, the following were observed, at 10:20 a.m., a) Inside Refrigerator 1, the following food items were observed with no use-by date or discard date: - two liter of soup- no discard date; - one liter of olives- has no discard date; - two liters of blueberries- has no discard date; - two liters of plums- has no discard date; - two liters of jam- has no discard date; - one gallon of sweet pickles- has no discard date. - one gallon of pickle relish-opened on September 14, 2021, but discard date was June 14, 2021; - three liters of gelatin- has no discard date; - one liter of pudding- has no discard date - two liters of pears-has no discard date; - 32 oz of sour cream- has no discard date; and - five lbs. (pounds) of garlic has no discard date. b) Inside Refrigerator 2, the following food items were observed unlabeled (no open date, no prepared date, and no discard date): - eight cups of milk (three 8 oz cups, four 6 oz cups, one 4 oz cup); - three 4 oz cups of orange juice; - six 4 oz cups of strawberry juice; - three 4 oz cups of cranberry juice; - two 8 oz cups of strawberry juice; - three small bowl cup of apple sauce; - one pack of cilantro; - one plastic pitcher of cranberry juice; and - three pounds of fresh mushroom. During a concurrent interview, the DSS confirmed the items inside Refrigerators 1 and 2 were not labeled with the prepared date, opened date, use-by date or discard date. The DSS stated the items should have been labeled with the prepared date, opened date, use-by date or discard date. The facility's policy and procedure titled, LABELING AND DATING OF FOODS, dated 2020, was reviewed. The policy indicated, .Food delivered to facility needs to be marked with a received date .Newly opened food items will need to be closed and labeled with an open date and used by the date follows guidelines .All prepared foods need to be covered, labeled and dated . Produce is to be dated with received date .Leftovers will be covered, labeled and dated . On November 2, 2021, at 10:30 a.m., an observation of the tray line service (the serving of food onto plates) for lunch was conducted with the Dietary Service Supervisor (DSS). [NAME] 1 was observed using tongs (a kitchen tool used to pick up food items) placing one piece of chicken on each plate for Residents 45 and 153. [NAME] 1 was observed scooping 8 oz (ounce - unit of measurement) of shredded chicken on each plate for five residents (Residents 4, 38, 40, 46, and 154). On November 2, 2021, at 12:05 p.m., during an interview, [NAME] 1 stated she would put more butter for the residents with high protein diet order. On November 2, 2021, at 12:20 p.m., the DSS was interviewed. The DSS stated [NAME] 1 should have served one and half or two pieces of oven fried chicken, for all residents on a mechanical soft high protein diet and [NAME] 1 should have served one scoop and a half-shredded oven fried chicken to all residents on a mechanical soft high protein diet. The DSS stated the serving portion size were not followed. A review of the facility documents titled, Diet Type Report, indicated there were two residents (Residents 12 and 45) with a diet type order of High Protein, Regular diet, and there were five residents (Residents 3, 4, 38, 40, and 46) with a diet order of High Protein, Mechanical Soft diet, On November 2, 2021, at 4 p.m., the Registered Dietician (RD) was interviewed. The RD stated she was not aware that menu for yesterday's lunch menu was not followed and no dietary staff member called her yesterday to informed about the changes in the menu. The RD stated she should have been notified when the menu changed. On November 4, 2021, at 4 p.m., during an interview, the RD stated that she conducted quarterly inspections of the kitchen and gave report to the DSS. The RD stated she missed the October 2021, kitchen inspection. She stated she did not verify if the recommendations were followed or carried out. On November 4, 2021, at 4:10 p.m., the RD was interviewed. The RD stated the DSS need to have Dietary Manager training course to become a Certified Dietary Manager. A review of the facility dietary staff in-services dated October 14, 2021, September 13, 2021, August 9, 2021, July 8, 2021, June 12, 2021, May 13, 2021, April 13, 2021, March 8, 2021, February 16, 2021, and January 25, 2021, indicated the January 2021 to October 2021, in-services were conducted by the DSS. There was no documented evidence the RD conducted an in-service to the dietary staff from January to October 2021. A review of the facility document Dietician Agreement, dated November 2, 2017, signed by the RD indicated the following: - Review standardized recipes for all prepared items on the menu will be provided; - Recommendations and provision of a diet manual, as approved dietician and the patient care committee. - In-service training for all dietetic service personnel and other professional staff at least quarterly or as needed; and - Sanitation inspection once a month. In addition, reviews of the Objectives included for this position are as follows: - To maintain high standard of safety and sanitation; - To assure maintenance of accurate records for planning and control of the Dietary Department; - To assist in maintaining high standard of food procurement, production, service and economical use of labor and food; and - To provide a workable nutritional care system that will benefit patients. A review of the JOB DESCRIPTION AND PERFORMANCE STANDARDS, dated July 31, 2021, signed by the DSS indicated the following: - Implement dietary and food service policies and procedures to meet residents needs and in compliance with federal, state, and local requirements; - Implement a monitoring system for the dietary and food service and make recommendations for implementation to assure compliance with federal, state, and local requirements. - Supervise preparation of menus to meet resident's dietary needs; - Assess residents' dietary needs and develop appropriate dietary plans in compliance with physicians' orders; and - Supervise the entire operation of the dietary department. In addition, reviews of the The primary functions and responsibilities, of this position (DSS) were as follows: - Implement diet and menus approved by the consultant; - Supervise food preparation and service; - Document dietary components of residents' care plans; - Maintain files of standardized recipes; - Implement dietary policies and procedures and food service descriptions; - Assume responsibility for compliance with sanitation requirements; - Ensure proper maintenance of equipment; - Maintain menu for required retention period; and - Ability to understand and comply with applicable Federal, State and local regulations and requirements.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of the residents were met when the food portion sizes for seven residents (Residents 4, 38, 40, 45, 46, 153, and 154) on the menu, were not followed. This failure had the potential for 49 of 49 residents on oral diets not to receive the adequate nutrition which can further compromise their medical status. Findings: 1. During an observation of lunch on November 1, 2021, at 11: 30 a.m., during meal tray distribution by the facility staff. The food items for all residents were observed to have the following: - tuna salad; - tomato salad; - half slice of bread; - cream of mushroom soup (1 cup) with 1 cracker; - milk (4 oz - ounce - unit of measurement); and -juice (8 oz). A review for the facility's planned menu, Week 2 - Fall Menu indicated the following food items: - baked ham; - baked beans; - wheat bread; - pineapple with mandarin oranges; - coffee or tea; and - milk. On November 1, 2021, at 3:50 p.m., During an interview with the Dietary Service Supervisor (DSS), the DSS stated the menu was not followed because the food deliveries did not come on time. The DSS stated she was not aware about the food substitute. The facility was not able to provide a spreadsheet for the planned menu. The facility was not able to provide a documentation or a logbook regarding changes in diet menu. There was no posting on the menu board or consumer board regarding the changes in the planned menu for the day. On November 2, 2021, at 10:30 a.m., an observation of the tray line service (the serving of food onto plates) for lunch was conducted with the Dietary Service Supervisor (DSS). [NAME] 1 was observed using tongs (kitchen tool used to pick up food items) placing one piece of chicken on each plate for Residents 45 and 153. [NAME] 1 was observed scooping 8 oz (ounce - unit of measurement) of shredded chicken on each plate of the residents (4, 38, 40, 46, and 154). For the residents with high protein diet order. [NAME] 1 stated, I put more butter. On November 2, 2021, at 12:20 p.m., during an interview, the DSS stated [NAME] 1 should have served one and half or two pieces of oven fried chicken, for all residents with mechanical soft high protein diet, and [NAME] 1 should have served one scoop and a half-shredded oven fried chicken to all residents with order of mechanical soft high protein diet. In addition, she stated the serving portion size were not followed. The facility policy and procedure titled, MENU PLANNING, dated 2020, was reviewed. The policy indicated, .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences .

Based on observation, interview, and record review, the facility's Administrator and governing body failed to exercise the general policy and operating directions to ensure effective oversight, staff competency, and essential resources were provided in order to sustain the necessary care, services and treatment necessary to maintain the highest level of practicable, physical, mental and psychosocial wellbeing of each resident. This systemic failure resulted in several major deficiencies identified in the course of the facility's Recertification Survey. They are as follows: 1. An Immediate Jeopardy (IJ- represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) was called on November 2, 2021, regarding the facility's use of unpasteurized eggs for vulnerable residents in the facility; 2. Multiple issues were identified in the kitchen as a result of inadequate training, as well as ineffective supervision of dietary staff by the Dietary Services Supervisor (DSS) and Registered Dietitian (RD); 3. The RD and DSS did not provide adequate management and oversight of the dietary staff. In addition, there was no sufficient training provided for the DSS in order for her to effectively fulfill her managerial role as DSS; and 4. A second IJ was called on November 5, 2021, regarding Resident 30's multiple skin injuries including an in-house development of pressure ulcers, most notably a Stage III pressure ulcer to Resident 30's left buttock. As a result of the second IJ, an Extended Survey was warranted following the survey team's determination of a Substandard Quality of Care (SQC). Findings: 1. On November 1, 2021, at 9:30 a.m., an unannounced Recertification Survey was conducted at the facility. Following the initial kitchen tour and lunch meal observation, the survey team convened to discuss various observations including: a. The facility's use of unpasteurized eggs and multiple outdated food items found in the kitchen storage areas. Cross reference to F812, examples #1, #2 and #3. b. The lunch meal served to all residents were not in accordance with the facility's menu for the day. The delivery of food supply items did not arrive on time, therefore, the required ingredients for the proposed meal for the day were not available. In addition, the food portion sizes for seven residents (Residents 4, 38, 40, 45, 46, 153, and 154) were not followed. Cross reference to F803, example #1. After further investigation was conducted, and following the process for IJ determination and approval from the State Agency (SA) Supervisor, the survey team declared an Immediate Jeopardy situation on November 2, 2021, at 2:10 p.m. in the presence of Administrator (ADM), Administrator Designee (ADMD), Director of Nursing (DON), and other facility staff. On November 5, 2021, at 1:59 p.m., the ADM, the ADMD and the Owner were interviewed. The Owner acknowledged the lapses in the supervision of the kitchen staff, as well as the lack of training, accountability, and oversight of the DSS and RD regarding their roles and responsibilities. 2. On November 1, 2021, beginning at 9:45 a.m., the following were observed in the kitchen: -Multiple food items in various storage units in the kitchen were found to be outdated; -The stove-oven hood was found to have a thick black substance inside the panel; and -There was no hand soap in the hand washing station. Cross reference to F812, examples #3, #4 and #5. 3. On November 2, 2021, the facility document Dietician Agreement, dated November 2, 2017, and signed by the RD was reviewed. The document indicated multiple RD responsibilities, including periodic kitchen inspections. During a subsequent interview conducted with the RD on November 4, 2021, beginning at 4 p.m., the RD stated she missed the October 2021 kitchen inspection, and did not verify if previous recommendations endorsed to the DSS were followed or carried out. There was also no documented evidence the RD provided in-services to the dietary staff. The RD further stated the DSS needed to have a Dietary Manager training course to become a Certified Dietary Manager. Cross reference to F801. 4. On November 5, 2021, at 10:00 a.m., Resident 30's record was reviewed, including a physician's treatment order of Medi-Honey to Resident 30's pressure ulcer on the right heel. A review of the treatment sheet indicated there was no treatment order record for Resident 30, and he did not receive treatment for his pressure ulcer. Further investigation using observation, interview, and record review revealed multiple skin injuries on Resident 30. Four new pressure ulcers (right malleolus [ankle] right buttock pressure ulcer Stage 2, left buttock pressure ulcer Stage 3, and left posterior knee pressure ulcer Stage 1), and one new skin wound (two infected sites on the right foot) were unidentified by the facility staff. The skin injuries were not reported to the attending physician, therefore no treatment orders for the skin injuries were obtained and carried out. There were no care plans developed as well. Cross reference to F600, F684. On November 5, 2021, at 2:30 p.m., the survey team convened to discuss the situation. Following the process for IJ determination and approval from the State Agency (SA) Supervisor, the survey team declared an Immediate Jeopardy situation on November 5, 2021 at 5:15 p.m. in the presence of the ADM, ADMD, DON, and other facility staff. The facility was also notified of an Extended Survey due to an SQC. On November 5, 2021 at 5:25 p.m., the ADM was interviewed. The ADM acknowledged the facility's system failure leading to multiple deficiencies including the major issues enumerated above. In addition, the above issues have not been identified and included in the facility's Quality Assurance Performance Improvement (QAPI) program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS - a standardized assessment tool) assessment was completed after a significant change in condition (major decline in status that did not resolve on its own and affected at least two areas of health) for one of 16 residents reviewed for assessments (Resident 40). This failure had the potential for Resident 40 to not receive the care and services necessary to maintain her highest possible level of functioning and safety. Findings: On April 22, 2019, at 9:25 a.m., Resident 40 was observed lying in her bed. On April 23, 2019, a review of Resident 40's record was conducted. The record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a type of memory loss). On April 23, 2019, at 9 a.m., an interview was conducted with Resident 40's responsible party (RP). The RP stated Resident 40 could not walk with the walker anymore like she used to and had to use the wheelchair all of the time. The RP stated he did not know why Resident 40 could not walk anymore. On April 24, 2019, at 11: 21 a.m., a review of Resident 40's record was conducted. The MDS Assessment, completed January 8, 2019, indicated Resident 40 required limited assistance to transfer (moving to or from the bed, chair, wheelchair, and standing position) and to walk in the room and in the corridor. The RESTORATIVE NURSING PROGRAM (to assist residents gain strength and mobility) documentation for the months of January and February 2019, indicated Resident 40 stopped walking beginning January 18, 2019. Beginning March 8, 2019, the Restorative Nursing Program documentation indicated the Restorative Nursing Assistant (RNA - an assistant to help residents gain strength and mobility) was assisting Resident 40 to stand only. The LICENSED PERSONNEL WEEKLY PROGRESS NOTES, dated February 11, 2019, at 1 p.m., indicated, Resident shows decrease in function . The PHYSICAL THERAPY EVALUATION, dated February 12, 2019, indicated Resident 40's level of function prior to the evaluation was to walk with a front wheel walker (FWW - a device with wheels to assist with walking). The document indicated Resident 40's level of function at the time of the evaluation was .stand only, unable to take steps using FWW . The document indicated Resident 40 was not safe to walk with the RNA. There was no documented evidence an MDS Assessment for the significant change in Resident 40's functioning in getting up, walking, and transferring was conducted. On April 24, 2019, at 12:25 p.m., an interview was conducted with the MDS Nurse (MDSN). The MDSN stated Resident 40 declined in walking and transferring. The MDSN stated Resident 40 used to get herself up to the bedside commode and the resident was no longer getting up at all and not doing things she used to be able to do. On April 24, 2019, at 2:58 p.m., an interview and concurrent review of Resident 40's record were conducted with the MDSN. The MDSN confirmed the Physical Therapy and RNA documentation indicated Resident 40 lost her ability to walk beginning January 18, 2019. The MDSN confirmed the documentation indicated for the months of February and March 2019, Resident 40 was able to stand, but not able to walk. The MDSN stated Resident 40 lost her ability to walk safely independently and transfer safely independently in January 2019. The MDSN stated an MDS Assessment for a significant change should have been completed in January 2019, when Resident 40 declined in two functional areas of ambulating and transferring. On April 25, 2019, at 9:39 a.m., an interview and concurrent review of Resident 40's record were conducted with the Physical Therapist (PT). The PT stated Resident 40's condition changed in January 2019, when she went from walking with assistance and transferring, to not being able to walk safely independently, and not being able to transfer safely independently. The facility was unable to provide a policy on MDS Assessments for significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment tool) assessment was accurate for one of 16 residents reviewed for assessments (Resident 40). This failure had the potential for Resident 40 to not receive the care and services necessary to maintain her highest level of functioning. Findings: On April 22, 2019, at 9:25 a.m., Resident 40 was observed lying in her bed. On April 23, 2019, a review of Resident 40's record was conducted. The record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a type of memory loss). On April 23, 2019, at 9 a.m., an interview was conducted with Resident 40's responsible party (RP). The RP stated Resident 40 could not walk with the walker anymore like she used to and had to use the wheelchair all of the time. The RP stated he did not know why Resident 40 could not walk anymore. On April 24, 2019, at 11: 21 a.m., a review of Resident 40's record was conducted. The MDS Assessment completed April 5, 2019, indicated in Section G, Resident 40 required limited assistance to transfer (e.g. moving to or from: bed, chair, wheelchair, standing position), and to walk in the room and in the corridor. The RESTORATIVE NURSING PROGRAM (to help residents gain strength and mobility) documentation for the months of January and February 2019, indicated Resident 40 stopped walking beginning January 18, 2019. The RNA Program documentation indicated the Restorative Nursing Assistant (RNA - an assistant to help residents gain strength and mobility) was assisting Resident 40 to stand only, beginning March 8, 2019. The LICENSED PERSONNEL WEEKLY PROGRESS NOTES, dated February 11, 2019, at 1 p.m., indicated, Resident shows decrease in function . The PHYSICAL THERAPY EVALUATION, dated February 12, 2019, indicated Resident 40's level of function prior to the evaluation was to walk with a front wheel walker (FWW - a device with wheels to assist with walking). The document indicated Resident 40's level of function at the time of the evaluation was, .stand only, unable to take steps using FWW . The document indicated Resident 40 was not safe to walk with the RNA. On April 24, 2019, at 12:25 p.m., an interview was conducted with the MDS Nurse (MDSN). The MDSN stated Resident 40 declined in her ability to transfer and to walk. The MDSN stated Resident 40 used to get herself up to the bedside commode and the resident was no longer getting up at all and not doing things she used to do. On April 24, 2019, at 2:58 p.m., an interview and concurrent review of Resident 40's record were conducted with the MDSN. The MDSN confirmed the Physical Therapy and RNA documentation indicated Resident 40 lost her ability to walk beginning January 18, 2019. The MDSN confirmed the documentation indicated for the months of February and March 2019, Resident 40 was able to stand, but not able to walk. The MDSN confirmed the MDS assessment dated [DATE], indicated Resident 40 required limited assistance to walk in her room and to walk in the corridor. When asked if this was an accurate assessment for Resident 40, the MDSN stated, Probably not. The MDSN stated Resident 40's MDS assessment dated [DATE], should have been coded as dependent (full staff performance every time). On April 25, 2019, at 9:39 a.m., an interview and concurrent review of Resident 40's record were conducted with the Physical Therapist (PT). The PT stated Resident 40's condition changed in January 2019, when she went from walking with assistance and transferring to not being able to walk safely independently, and not being able to transfer safely independently. The facility was unable to provide a policy on the accuracy of MDS Assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a care plan was initiated, developed, and implemented, for two of two residents reviewed for smoking (Residents 1 and 31). This failure had the potential to cause Residents 1 and 31 to not receive the necessary care and intervention Findings: 1. On April 22, 2019, at 12:59 p.m., Resident 1 was interviewed. Resident 1 stated, I keep my own cigarettes and lighter in my bedside table. On April 22, 2019, at 1:54 p.m., Resident 1 was observed smoking a cigarette and holding a lighter at the designated smoking area. On April 22, 2019, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including heart failure (the inability of the heart to pump blood effectively), hypertension (high blood pressure), and kidney failure (when the kidneys lose the ability to filter waste from the blood sufficiently). Resident 1's Minimum Data Set (MDS - an assessment tool), completed November 23, 2018, indicated Resident 1 did not use tobacco upon admission. There was no documented evidence a baseline care plan was initiated for Resident 1's smoking since admission. On April 24, 2019, at 2:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 did not have a care plan for smoking. On April 25, 2019, at 12:04 p.m., Resident 1 was interviewed. Resident 1 stated he was smoking prior to being admitted to the facility on [DATE], and was smoking at the time he was admitted to the facility. 2. On April 23, 2019, at 9:01 a.m., Resident 31 was observed to be smoking a cigarette at the designated smoking area. On April 25, 2019, Resident 31's record was reviewed. Resident 31 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease), heart failure, and muscle weakness. There was no documented evidence a baseline care plan was initiated for Resident 31's smoking since admission. On April 25, 2019, at 11:57 a.m., Resident 31 was interviewed. Resident 31 stated, I have been smoking since I was [AGE] years old. The facility policy and procedure titled, COMPREHENSIVE CARE PLANS, dated November 2017, was reviewed. The policy indicated, .The Interdisciplinary Team shall develop and implement a comprehensive person-centered care plan for each resident .Initiated on admission to sufficiently meet the needs of newly admitted residents .A person-centered Baseline Care Plan shall be completed within 48 hours after admission .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure signs and symptoms of bleeding were monitored as indicated in the plan of care, for one of one resident reviewed for anticoagulant (blood thinner) medication side effects (Resident 25). This failure may have contributed to Resident 25 being sent to the general acute care hospital emergency room for rectal bleeding on April 6, 2019. Findings: On April 23, 2019, Resident 25's record was reviewed. The record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses including deep vein thrombosis (DVT - a blood clot in a blood vessel). The record indicated Resident 25 was receiving Eliquis (anticoagulant medication that prevents clots). The document titled, PHYSICIAN and TELEPHONE ORDERS, dated April 6, 2019, indicated, May send out non-emergency to (name of general acute care hospital) ER (emergency room) for rectal bleeding. There was no documented evidence Resident 25 was monitored for signs and symptoms of bleeding in March and April 2019. On April 25, 2019, at 3:20 p.m., an interview and concurrent review of Resident 25's record were conducted with Licensed Vocational Nurse (LVN) 1. The care plan titled, Anticoagulant Agent (medication to prevent clots by thinning the blood), revised August 16, 2018, indicated, Resident has an increased potential for bleeding secondary to use of anticoagulant Eliquis for the Dx (diagnosis) of DVT .Monitor for S/S (signs and symptoms) of excessive anticoagulation (bleeding gums, tarry stools [dark red or black stools caused by blood from the stomach or intestines], bruises on extremities, cuts or scratches that bleed) . The document titled, PHYSICIAN'S ORDERS, dated March 27, 2019, indicated, ELIQUIS 2.5MG (milligrams) (1) (one) TAB (tablet) BY MOUTH 2X (two times) PER DAY DVT 10/11/2016 (October 11, 2016) . LVN 1 confirmed Resident 25 was receiving Eliquis in March and April 2019. LVN 1 confirmed there was no documentation Resident 25 was monitored for signs and symptoms of bleeding in March and April 2019. LVN 1 confirmed Resident 25 should have been monitored for signs and symptoms of bleeding in March and April 2019. LVN 1 confirmed Resident 25 went to the hospital for rectal bleeding on April 6, 2019. The facility policy and procedure titled, COMPREHENSIVE CARE PLANS, dated November 2017, was reviewed. The policy indicated, .The services provided .by the facility shall meet professional standards of quality and shall be provided by qualified persons in accordance with each resident's written plan of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a bedrail was not in use without a physician's order, without completing an assessment for entrapment, and without obtaining a consent from the resident or the resident's responsible party (RP), for one of one resident reviewed for bedrails (Resident 40). This failure resulted in the use of the bedrail for Resident 40 without Resident 40's or Resident 40's RP's knowledge of the potential risks related to the use of the bedrail. This failure also increased the potential for Resident 40 to experience an injury related to the bedrail. Findings: On April 22, 2019, Resident 40 was observed in her bed with a one-quarter (1/4) bedrail elevated on the left side of her bed. On April 24, 2019, Resident 40's record was reviewed. The record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (memory loss). There was no documented evidence an assessment for entrapment related to Resident 40's use of the bedrail was conducted. There was no documented evidence a physician's order was obtained prior to Resident 40's use of a bedrail. There was no documented evidence a consent was obtained from Resident 40 or her RP prior to the use of the bedrail. On April 24, 2019, at 12 p.m., an interview and concurrent review of Resident 40's record were conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated there was no bedrail assessment for entrapment in Resident 40's record. On April 24, 2019, at 12:20 p.m., an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated she was assigned to Resident 40. CNA 1 confirmed Resident 40 had a 1/4 bedrail elevated on the left side routinely. When asked how she knew if Resident 40 was supposed to have an elevated bedrail, CNA 1 stated there was a note on the back of the door to Resident 40's room. On April 24, 2019, at 12:22 p.m., the note from the back of the door for Resident 40's room, titled, ADL (activities of daily living) SHEET, was reviewed with CNA 1. The portion of the document indicating, .Siderails (bedrails) ., had both UP and DOWN checked. When CNA 1 was asked how she knew what to do since both UP and DOWN were checked for the bedrails, CNA 1 stated she did not know. On April 24, 2019, at 12:23 p.m., an interview and concurrent review of the document titled, ADL SHEET, were conducted with the Minimum Data Set (MDS - a standardized assessment tool) Nurse (MDSN). The MDSN stated the document should not have both UP and DOWN checked for bedrails. The MDSN stated there was no physician's order for the bedrails and no consent for the use of a bedrail. The MDSN confirmed that if a bedrail is used, there is supposed to be a physician's order, a consent, and an assessment for entrapment. The facility was unable to provide a policy for bedrails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate accounting of narcotics was maintained for three of five residents reviewed during the medication cart inspection (Residents 29, 3, and 36) when: 1a. For Resident 29, there were 11 (eleven) doses of morphine sulfate (narcotic pain medication) 20 mg (milligrams)/per ml (milliliter) signed out as removed from the medication cart on the DRUG RECEIPT/RECORD/DISPOSITION FORM (Controlled Drug [medications such as narcotics that have restrictions regarding who can have them] Record), and there was no documented evidence the morphine sulfate doses were administered to Resident 29; 1b. For Resident 3, there were two doses of hydrocodone 10 mg/acetaminophen 325 mg (Norco - a narcotic pain medication), signed out as removed from the medication cart on the Drug Receipt/Record/Disposition Form and there was no documented evidence the Norco doses were administered to Resident 3; and 1c. For Resident 36, there was one dose of oxycodone (narcotic pain medication) IR (immediate release) 5 mg, signed out as removed from the medication cart on the Drug Receipt/Record/Disposition Form and there was no documented evidence the oxycodone dose was administered to Resident 36. These failures had the potential for Residents 29, 3, and 36, to receive narcotics incorrectly, and also had the potential for drug diversion. Findings: 1. On April 25, 2019, at 10 a.m., an inspection of the medication cart was conducted with Licensed Vocational Nurse (LVN) 1. 1a. On April 25, 2019, a review of Resident 29's record was conducted. The record indicated Resident 29 was admitted to the facility on [DATE], with diagnoses including fibromyalgia (a condition causing pain in some parts of the body) and chronic pain syndrome (pain over time). The Medication Record indicated Resident 29 had a physician's order for morphine sulfate 20 mg/ml every four hours as needed for severe pain, dated November 20, 2018. Resident 29's Drug Receipt/Record/Disposition Form, dated April 2019, indicated 11 (eleven) doses of morphine sulfate 1 ml of 20 mg/ml were signed out as removed from the medication cart. There was no documented evidence the 11 doses of morphine sulfate were administered to Resident 29. The doses unaccounted for were: - April 18, 2019: Three doses; - April 19, 2019: Two doses; - April 20, 2019: One dose; - April 22, 2019: Two doses; - April 23, 2019: One dose; and - April 24, 2019: Two doses. 1b. On April 25, 2019, a review of Resident 3's record was conducted. The record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a neurological disease that causes difficulty with movement) and history of surgical removal of a brain tumor (growth of abnormal tissue). Resident 3's Drug Receipt/Record/Disposition Form, dated April 2019, indicated four doses of Norco were signed out as removed from the medication cart on April 24, 2019. Resident 3's Medication Record and Nurses Medication Notes for April 2019, indicated two doses of Norco were administered. There was no documented evidence the two doses of Norco were administered to Resident 3. 1c. On April 25, 2019, a review of Resident 36's record was conducted. The record indicated Resident 36 was originally admitted to the facility on [DATE]. Resident 36's Drug Receipt/Record/Disposition Form, dated April 2019, indicated a dose of oxycodone IR 5 mg was signed out as removed from the medication cart on April 25, 2019. There was no documented evidence Resident 36 received the dose of oxycodone IR 5 mg on April 25, 2019. On April 25, 2019, at 10:50 a.m., an interview and review of the Drug Receipt/Record/Disposition Form, Medication Record, and Nurses Medication Notes . for Residents 29, 3, and 36, were conducted with LVN 1. LVN 1 confirmed Resident 29 had 11 doses of morphine sulfate 20 mg unaccounted for, Resident 3 had two doses of Norco 10/325 mg unaccounted for, and Resident 36 had one dose of oxycodone IR 5 mg unaccounted for. LVN 1 stated she did not know why the doses of narcotic medication were unaccounted for. The facility policy and procedure titled, Medication Administration Controlled Substances, dated October 2007, was reviewed. The policy indicated, .Medications .controlled substances are subject to special handling, storage, disposal, and record keeping .in accordance with federal and state laws and regulations .Administer the controlled medication and document dose administration on the MAR (Medication Administration Record) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory blood work was completed as ordered by the physician for one of one resident reviewed for laboratory services (Resident 25). This failure had the potential for Resident 25 to have medical complications such as bruising, bleeding, and hemorrhaging (a large amount of bleeding). Findings: On April 23, 2019, Resident 25's record was reviewed. The record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses including deep vein thrombosis (DVT - a blood clot in a blood vessel). The record indicated Resident 25 was receiving Eliquis (medication that prevents clots by thinning the blood). The document titled, PHYSICIAN and TELEPHONE ORDERS, dated April 6, 2019, indicated, May send out non-emergency to (name of general acute care hospital) ER (emergency room) for rectal bleeding. On April 25, 2019, at 3:20 p.m., an interview and review of Resident 25's record were conducted with Licensed Vocational Nurse (LVN) 1. The document titled, PHYSICIAN AND TELEPHONE ORDERS, dated April 8, 2019, indicated, CBC (complete blood count - a test that indicates the amount of the different types of blood cells) daily . LVN 1 confirmed there was no documented evidence a CBC laboratory blood test was conducted for Resident 25 on April 9, 10, 12, or 13, 2019. LVN 1 confirmed the CBC laboratory testing should have been done and the results should have been in the record. The facility was unable to provide a policy indicating it was necessary to follow physician orders.

Based on observation, interview, and record review, the facility failed to offer and serve an appropriate meal alternative with comparable nutritive value to the entrée served for residents. This failure had the potential to affect resident's nutritional status and further compromise their medical status for 43 of 43 residents who received food from the kitchen. Findings: 1a. On April 23, 2019, at 10:53 a.m., [NAME] 1 was observed preparing peanut butter and jelly sandwich. [NAME] 1 used a flat spatula to scoop out the peanut butter from the container and spread it on the bread. In a concurrent interview with [NAME] 1, [NAME] 1 stated she did not measure how much peanut butter or jelly she puts on each sandwich. [NAME] 1 further stated she just spreads the peanut butter on the bread. On April 23, 2019, at 1:42 p.m., the facility Registered Dietitian (RD) was interviewed. The RD stated there were residents in the facility who requested for peanut butter and jelly sandwich to replace the main entrée for lunch or dinner. On April 24, 2019, at 12:44 p.m., Resident 29 was interviewed. Resident 29 stated she preferred peanut butter jelly sandwich as an alternate for the main entrée at least once a week for lunch or dinner. 1b. On April 23, 2019, at 11:07 a.m., [NAME] 3 was observed preparing a salad. [NAME] 3 was observed placing shredded cheese on top of the lettuce using tongs. [NAME] 3 did not measure the amount of shredded cheese to place on top of the lettuce. In a concurrent interview with [NAME] 3, [NAME] 3 stated the chef's salad (can consist of hard- boiled eggs, meat, tomatoes, cucumbers, and cheese placed on a bed of tossed lettuce or other leaf vegetables) was a request from Resident 30 for lunch. [NAME] 3 stated Resident 30 often only received a salad for lunch. [NAME] 3 stated she made it with ingredients the resident requested. [NAME] 3 further stated she did not know how much cheese was placed on top of the lettuce. [NAME] 3 confirmed she did not measure the amount of the ingredients she placed on the salad. On April 24, 2019, at 12:41 p.m., Resident 30 was interviewed. Resident 30 stated she requested for Chef's salad for lunch every day. Resident 30 stated she preferred meat, cheese, or eggs on the Chef's salad. On April 24, 2019, at 4:30 p.m., the RD was interviewed. The RD stated residents who request for alternate for their meals should receive the same amount of protein as the main entrée. The RD was not able to say if the dietary staff have guidance on how much protein to provide to a resident who request for alternate meal. On April 25, 2019, at 11:55 a.m., a follow up interview with the RD was conducted. The RD stated protein value for alternate entrees should be three ounces of meat protein equivalent. The RD stated there was no system in place for kitchen staff to follow regarding how much protein content an alternate meal should receive if a resident request for meal replacement. The RD stated the peanut butter for the peanut butter and jelly sandwiches should be two tablespoons. The RD further stated Resident 30 tells the kitchen staff what she wanted on her salad and confirmed Resident 30 did not indicate the measurement or amount of protein she liked. The RD stated the cheese had to be measured as it was placed on a salad and the salad was a substitute for the main entrée. The facility document titled, Request for Alternate Meal, was reviewed. The document indicated peanut butter and jelly sandwich or chef salad as alternates if resident did not prefer the main meal. The facility document titled, List of Menu Substitutes, dated 2011, was reviewed. The document indicated, .Entree substitutes .Sandwiches, tuna, peanut butter, egg, cheese .Chef's salad . The facility policy and procedure titled, MENU ALTERNATES, dated 2011, was reviewed. The policy indicated, .Menu alternates will be of similar nutritive value as the original menu item .Residents/patients who refuse their meal during meal service should be offered another food item of similar nutritive value, i.e., the menu alternate or other item of their choice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure policies were established and implemented regarding smoking safety, for two of two residents reviewed for smoking (Residents 1 and 31) when: 1. Resident 1 was observed to have his cigarettes and a cigarette lighter in his possession; and 2. Resident 31 was observed to have cigarettes in her possession. These failures increased the potential for accidents and injuries to residents in the facility. Findings: 1. On April 22, 2019, at 12:59 p.m., Resident 1 was interviewed. Resident 1 stated, I keep my own cigarettes and lighter in my bedside table. On April 22, 2019, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including heart failure (the inability of the heart to pump blood effectively), hypertension (high blood pressure), and kidney failure (when the kidneys lose the ability to filter waste from the blood sufficiently). There was no documented evidence a smoking assessment for Resident 1 was completed. On April 22, 2019, at 1:54 p.m., Resident 1 was observed smoking at the designated smoking area. On April 25, 2019, at 10:45 a.m., LVN 3 stated resident's cigarette lighters are locked up in the nurse's station cabinet, and residents are able to keep their own cigarettes, if they are alert and oriented. On April 25, 2019, at 12:04 p.m., Resident 1 was interviewed. Resident 1 stated he was smoking prior to being admitted to the facility on [DATE], and was smoking at the time he was admitted to the facility. 2. On April 23, 2019, at 9:01 a.m., Resident 31 was observed smoking at the designated smoking area. During a concurrent interview with Resident 31, she stated, I keep my own cigarettes, but the staff keep my lighter. On April 25, 2019, Resident 31's record was reviewed. Resident 31 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD - lung disease), heart failure, and muscle weakness. There was no documented evidence a smoking assessment for Resident 31 was completed. On April 25, 2019, at 11:57 a.m., Resident 31 was interviewed. Resident 31 stated, I have been smoking since I was [AGE] years old. The facility policy and procedure titled, Smoking Policy & Procedure, updated July 21, 2016, was reviewed. The policy indicated, .This facility is a non-smoking facility for residents and residents may not carry smoking materials . The facility was unable to provide a policy on conducting a smoking assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents were provided written information about advance directive (a written statement of a person's wishes regarding his/her medical treatment) for four of 16 residents reviewed (Residents 40, 29, 9, and 27). This failure had the potential for Residents 40, 29, 9, and 27, to not make their wishes known regarding their medical treatment. Findings: 1. On April 23, 2019, Resident 29's record was reviewed. Resident 29 was originally admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a lung disease). The document titiled, Physician Orders for Life-Sustaining Treatment (POLST- a form identifying patients' wishes regarding medical treatment that included physician's orders), dated March 26, 2018, did not indicate if Resident 29 had an advanced directive or if information was given to her regarding advance directives. There was no documented evidence the facility provided information about advance directives to Resident 29. On April 25, 2019 at 1 p.m., Resident 29's record was reviewed with the Social Service Director (SSD). In a concurrent interview with the SSD, the SSD confirmed there was no documentation information about advance directive was given to Resident 29. The SSD stated if she had discussed the advance directive with Resident 29, she would have documented it. 2. On April 23, 2019, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE]. The POLST, dated October 26, 2017, did not indicate if Resident 29 had an advanced directive or if information was given to her regarding advance directive. There was no documented evidence the facility provided information about advance directive to Resident 27. On April 25, 2019, at 1:05 p.m., Resident 27's record was reviewed with the SSD. In a concurrent interview with the SSD, the SSD confirmed there was no documentation the information about advance directive was provided to Resident 27. The SSD stated if she had discussed the advance directive to Resident 27, it would have been documented. 3. On April 23, 2019, Resident 9's record was reviewed. The record indicated Resident 9 was admitted to the facility on [DATE], with a diagnosis of cancer of the penis. The POLST, dated November 27, 2018, did not indicate if Resident 9 had an advanced directive or if information was given to him regarding advanced directives. On April 24, 2019, at 11:55 a.m., an interview and concurrent review of Resident 9's record were conducted with the SSD. The SSD confirmed there was no documentation the information was given to Resident 9 regarding advanced directives. The SSD stated her process was to give information on advanced directives to the residents or to their responsible party (RP) only if they asked for it. 4. On April 23, 2019, Resident 40's record was reviewed. The record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a disease affecting memory). The POLST, dated January 30, 2017, indicated Resident 40 did not have an advanced directive. There was no documented evidence indicating information on advanced directives was given to Resident 40 or her RP. On April 24, 2019, at 11:47 a.m., an interview and concurrent review of Resident 40's record were conducted with the SSD. The SSD confirmed there was no documentation Resident 40 or her RP were given information on advanced directive. The SSD stated her process was to give residents or their RP the information on advanced directive only if they asked for it. The facility's policy and procedure titled, Advance Directives, dated 2013, was reviewed. The policy indicated, .Residents who are admitted to the facility will be offered information about Advance Directives .Upon admission, residents will receive Advance Directive information and an Advance Directive Acknowledgement form .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) was transmitted to the Centers for Medicare and Medicaid Services (CMS-a federal agency within the United States Department of Health and Human Services) within 14 days of completion, for nine of nine residents reviewed for MDS assessment transmission (Residents 5, 6, 1, 9, 3, 8, 7, 4, and 2), when; 1. Resident 5's quarterly assessment was completed on February 15, 2019, and was not transmitted; 2. Resident 6's quarterly MDS assessment was completed on March 1, 2019, and was not transmitted; 3. Resident 1's quarterly MDS assessment was completed on February 4, 2019, and was not transmitted; 4. Resident 9's quarterly MDS assessment was completed on March 11, 2019, and was not transmitted; 5. Resident 3's quarterly MDS assessment was completed on February 5, 2019, and was not transmitted; 6. Resident 8's quarterly MDS assessment was completed on March 8, 2019, and was not transmitted; 7. Resident 7's annual MDS assessment was completed on March 8, 2019, and was not transmitted; 8. Resident 4's annual MDS assessment was completed on February 12, 2019, and was not transmitted; and 9. Resident 2's annual MDS assessment was completed on January 22, 2019, and was not transmitted. These failures resulted in the MDS assessments for Residents 5, 6, 1, 9, 3, 8, 7, 4, and 2 to not be transmitted to CMS. Findings: According to the Long Term Care Facility Resident Assessment Instrument (RAI-guidance and information gathering for resident's strengths, need, care plan, and tracking of changes in residents' condition) 3.0 Users Manual, dated October 2018, the quarterly and annual MDS assessments should be transmitted to CMS within 14 days after the MDS assessment was completed. 1. On April 25, 2019, at 3:52 p.m., Resident 5's record was reviewed with the Minimum Data Set Nurse (MDSN). Resident 5 was admitted to the facility on [DATE], with diagnoses which included atherosclerosis heart disease (hardening of the blood vessels of the heart). Resident 5's quarterly MDS assessment was completed on February 15, 2019. There was no documented evidence Resident 5's quarterly MDS assessment was transmitted to CMS within 14 days after it was completed on February 15, 2019 (69 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 5 was not transmitted to CMS. The MDSN stated the quarterly MDS assessment should have been transmitted within 14 days after the MDS assessment was completed. 2. On April 25, 2019, at 3:58 p.m., Resident 6's record was reviewed with the MDSN. Resident 6 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure). Resident 6's quarterly MDS assessment was completed on March 1, 2019. There was no documented evidence Resident 6's quarterly MDS assessment was transmitted to CMS within 14 days after the MDS was completed on March 1, 2019 (55 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 6 was completed on March 1, 2019, but it was not transmitted within 14 days of completion. 3. On April 25, 2019, at 4:04 p.m., Resident 1's record was reviewed with the MDSN. Resident 1 was admitted to the facility on [DATE], with diagnoses which included heart failure (inability of the heart to pump blood effectively) and hypertension. Resident 1's quarterly MDS assessment was completed on February 4, 2019. There was no documented evidence Resident 1's quarterly MDS assessment was transmitted to CMS within 14 days after the MDS was completed on February 4, 2019 (80 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 1 was completed on February 4, 2019, but it was not transmitted within 14 days of completion. 4. On April 25, 2019, at 4:08 p.m., Resident 9's record was reviewed with the MDSN. Resident 9 was admitted to the facility on [DATE], with diagnoses which included gastroesophageal reflux disease (GERD-acid reflux). Resident 9's quarterly MDS assessment was completed on March 11, 2019. There was no documented evidence Resident 9's quarterly MDS assessment was transmitted to CMS within 14 days after the MDS was completed on March 11, 2019 (45 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 9 was completed on March 11, 2019, but it was not transmitted within 14 days of completion. 5. On April 25, 2019, at 4:10 p.m., Resident 3's record was reviewed with the MDSN. Resident 3 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a slowly progressive nerve disease). Resident 3's quarterly MDS assessment was completed on February 5, 2019. There was no documented evidence Resident 3's quarterly MDS assessment was transmitted to CMS within 14 days after the MDS was completed on February 5, 2019 (79 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 3 was completed on February 5, 2019, but it was not transmitted within 14 days of completion. 6. On April 25, 2019, at 4:14 p.m., Resident 8's record was reviewed with the MDSN. Resident 8 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar). Resident 8's quarterly MDS assessment was completed on March 8, 2019. There was no documented evidence Resident 8's quarterly MDS assessment was transmitted to CMS within 14 days after the MDS was completed on March 8, 2019 (48 days from completion). In a concurrent interview with the MDSN, the MDSN stated the quarterly MDS assessment for Resident 8 was completed on March 8, 2019, but it was not transmitted within 14 days of completion. 7. On April 25, 2019, at 4:06 p.m., Resident 7's record was reviewed with the MDSN. Resident 7 was admitted to the facility on [DATE], with diagnoses which included hypotension (low blood pressure). Resident 7's annual MDS assessment was completed on March 8, 2019. There was no documented evidence Resident 7's annual MDS assessment was transmitted to CMS within 14 days after it was completed on March 8, 2019 (48 days from completion). In a concurrent interview with the MDSN, the MDSN stated the annual MDS assessment for Resident 7 was completed on March 8, 2019, but it was not transmitted within 14 days of completion. 8. On April 25, 2019, at 4:12 p.m., Resident 4's record was reviewed with the MDSN. Resident 4 was admitted to the facility on [DATE], with diagnoses which included hypertension. Resident 4's annual MDS assessment was completed on February 12, 2019. There was no documented evidence Resident 4's annual MDS assessment was transmitted to CMS within 14 days after it was completed on February 12, 2019 (72 days from completion). In a concurrent interview with the MDSN, the MDSN stated the annual MDS assessment for Resident 4 was completed on February 12, 2019, but it was not transmitted within 14 days of completion. 9. On April 25, 2019, at 4:16 p.m., Resident 2's record was reviewed with the MDSN. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic pain and generalized anxiety (mood disorder). Resident 2's annual MDS assessment was completed on January 22, 2019. There was no documented evidence Resident 2's annual MDS assessment was transmitted to CMS within 14 days after it was completed on January 22, 2019 (93 days from completion). In a concurrent interview with the MDSN, the MDSN stated the annual MDS assessment for Resident 2 was completed on January 22, 2019, but it was not transmitted within 14 days of completion. The MDSN stated the MDS assessment should be transmitted based on the guidelines in the RAI manual. The facility was not able to provide a policy for the transmission of the MDS assessment to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement or update the plan of care when: 1. For one of four residents reviewed for falls (Resident 142), the facility failed to ensure the screening by the rehabilitation staff (Physical Therapy) was completed after the episodes of falls on February 13, 2019, and March 25, 2019; This failure increased the risk for Resident 142 to experience another fall; and 2. For one of two residents reviewed for bathing (Resident 3), the facility failed to ensure showers were provided as indicated in the plan of care during the month of April 2019. This failure caused Resident 3 to not feel clean. 3. For one of two residents reviewed for a decline in the activities of daily living (ADL's - things normally done in daily life such as eating, bathing, and dressing) (Resident 40), the facility failed to ensure the care plan was updated to reflect the change in Resident 40's functional status. This failure increased the potential for Resident 40 to not receive the care and services necessary to maintain the highest level of functioning. Findings: 1. On April 23, 2019, at 1:07 p.m., Resident 142 was observed in her bed. Resident 142 gestured to her left hip. On April 24, 2019, Resident 142's record was reviewed. The record indicated Resident 142 was readmitted to the facility on [DATE], after a surgical repair of her left hip which was broken after a fall. The care plans titled, .POST FALL, dated February 13, 2019, and March 25, 2019, included an intervention indicating, Post (after) fall screening by Rehab (Rehabilitation - Physical Therapy) . There was no documented evidence post fall screening by Physical Therapy was completed as indicated in the care plans. On April 25, 2019, at 4:40 p.m., an interview and concurrent review of Resident 142's record were conducted with the Director of Nursing (DON). The DON confirmed Resident 142 had episodes of falls on February 13, 2019, and March 25, 2019. The DON confirmed the care plans, dated February 13, 2019, and March 25, 2019, included interventions for Resident 142 to receive .post fall screening by Rehab. The DON confirmed there was no documentation Resident 142 received post fall screening by Physical Therapy as indicated in the February 13, 2019, and March 25, 2019, care plans. The DON confirmed Physical Therapy should have completed a post fall screening after the fall on February 13, 2019, and after the fall on March 25, 2019. The DON confirmed Resident 142 had another fall on April 2, 2019, and sustained a broken hip which required surgical repair. 2. During the Resident Council Meeting on April 23, 2019, at 2 p.m., Resident 3 stated she did not always get two showers a week and she did not like it when she did not get two showers a week because she did not feel clean. On April 25, 2019, Resident 3's record was reviewed. The record indicated she was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a neurological disease that caused difficulty with movement). The HISTORY AND PHYSICAL, indicated Resident 3 had weakness, failure to thrive (weight loss and physical inactivity), and surgical removal of a brain tumor. The care plan titled, ACTIVITIES OF DAILY LIVING ., dated November 8, 2018, indicated Resident 3 required extensive to maximum assistance to bathe. The care plan indicated, .BATHING .Shower at least 2x/week (two times per week) . The NURSE ASSISTANT NOTES, dated April 2019, indicated Resident 3 received one shower for the week beginning March 31, 2019, and one shower for the week beginning April 7, 2019. There was no documented evidence Resident 3 received a shower on Monday, April 22, 2019, as scheduled. On April 25, 2019, at 12:23 p.m., an interview and concurrent review of Resident 3's record were conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated Resident 3 was scheduled to receive showers on Mondays and Thursdays. CNA 1 confirmed Resident 3 did not receive two showers a week for the weeks beginning March 31, 2019, and April 7, 2019. CNA 1 confirmed Resident 3 did not receive a shower on Monday, April 22, 2019, as scheduled. On April 25, 2019, at 12:57 p.m., an interview and review of Resident 3's record was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed Resident 3 required extensive to maximum assistance to shower. LVN 1 confirmed Resident 3's care plan indicated she was scheduled to receive showers two times a week, every Monday and Thursday. LVN 1 confirmed Resident 3 did not receive two showers a week for the weeks beginning March 31, 2019, and April 7, 2019. Additionally, LVN 1 confirmed Resident 3 did not receive a shower on April 22, 2019, as scheduled. LVN 1 confirmed Resident 3 should have received showers two times a week as indicated in the plan of care. 3. On April 22, 2019, at 9:25 a.m., Resident 40 was observed lying in her bed. On April 23, 2019, a review of Resident 40's record was conducted. The record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a type of memory loss). On April 23, 2019, at 9 a.m., an interview was conducted with Resident 40's responsible party (RP). The RP stated Resident 40 could not walk with the walker anymore like she used to and had to use the wheelchair all of the time. The RP stated he did not know why Resident 40 could not walk anymore. On April 24, 2019, at 11: 21 a.m., a review of Resident 40's record was conducted. The MDS Assessment completed January 8, 2019, indicated in Section G, Resident 40 required limited assistance to transfer (moving to or from bed, chair, wheelchair, and standing position), and to walk in the room and in the corridor. The RESTORATIVE NURSING PROGRAM (a program to assist residents gain strength and mobility) documentation for the months of January and February 2019, indicated Resident 40 stopped walking beginning January 18, 2019. Beginning March 8, 2019, the Restorative Nursing Program documentation indicated the Restorative Nursing Assistant (RNA - an assistant to help residents gain strength and mobility) was assisting Resident 40 to stand only. The LICENSED PERSONNEL WEEKLY PROGRESS NOTES, dated February 11, 2019, at 1 p.m., indicated, Resident shows decrease in function . The PHYSICAL THERAPY EVALUATION, dated February 12, 2019, indicated Resident 40's level of function prior to the evaluation was to walk with a front wheel walker (FWW - a device with wheels to assist with walking). The document indicated Resident 40's level of function at the time of the evaluation was, .stand only, unable to take steps using FWW . The document indicated Resident 40 was not safe to walk with the RNA. There was no documented evidence Resident 40's care plan was updated when Resident 40 experienced a decline in her ability to transfer and to walk. On April 24, 2019, at 12:25 p.m., an interview was conducted with the MDS (Minimum Data Set - a standardized assessment tool) Nurse (MDSN). The MDSN stated Resident 40 declined in her ability to transfer and to walk. The MDSN stated Resident 40 used to get herself up to the bedside commode and she was no longer getting up at all and she was not doing things she used to do. On April 24, 2019, at 2:58 p.m., an interview and concurrent review of Resident 40's record were conducted with the MDSN. The MDSN confirmed the Physical Therapist and RNA documentation indicated Resident 40 lost her ability to walk beginning January 18, 2019. The MDSN confirmed the documentation indicated for the months of February and March 2019, Resident 40 had the ability to stand with assistance, but not to walk. The MDSN stated Resident 40 lost her ability to walk safely independently and transfer safely independently in January 2019. On April 25, 2019, at 9:39 a.m., an interview and concurrent review of Resident 40's record were conducted with the Physical Therapist (PT). The PT stated Resident 40's condition changed in January 2019, when she went from walking and transferring to not being able to walk safely independently, and not being able to transfer safely independently. On April 25, 2019, at 11 a.m., an interview and concurrent review of Resident 40's record were conducted with the MDSN. The MDSN confirmed Resident 40's care plan titled, Activities of Daily Living ., revised January 7, 2019, indicated she required limited assistance to transfer and to walk. The MDSN confirmed the care plan was not accurate. The MDSN confirmed the care plan should have been updated when Resident 40's condition changed in January 2019. The facility policy and procedure titled, COMPREHENSIVE CARE PLANS, dated November 2017, was reviewed. The policy indicated, .The interdisciplinary Team (a group of professionals working towards the common goals of the resident) shall .implement a comprehensive person-centered care plan for each resident .The services provided .shall be provided .in accordance with each resident's written plan of care .

Based on observation, interview, and record review, the facility failed to ensure food served was palatable, and nutritive value was not compromised and not destroyed when vegetables were overcooked. This failure resulted in residents to receive meals which were not palatable and appetizing. Furthermore, this failure had the potential to affect the residents' nutritional status and quality of life, and can lead to insufficient food intake. Findings: On April 22, 2019, at 12:33 p.m., an observation of tray line service (the serving of food onto plates) for lunch was conducted with the Dietary Manager (DM). The sliced zucchini was observed in a large pot of water standing in on a small steam table. [NAME] 2 was observed placing zucchini from the pot of water onto the plate and as the trayline continued the zucchini became mushy and was falling apart. In a concurrent interview with the DM, the DM stated the sliced zucchini was mushy and overcooked. On April 25, 2019, at 12:45 p.m., the facility Registered Dietitian (RD) was interviewed. The RD stated the vegetable should not sit in water for prolonged period of time during trayline. The RD stated if the vegetables were cooked in water for a prolonged time, there was the potential for the appetite of the resident to be diminished, and the nutrients will leak out into the water. The facility policy titled, Food Preparation dated 2001, was reviewed and indicated, Employees will prepare foods by methods that conserve nutrients, enhance flavor, and maintain attractive appearance . 2. On April 22, 2019, at 1:05 p.m., during trayline observation, the fish entrée ran out and chicken nuggets were substituted. The DM was observed to place half bag of chicken nuggets in the microwave. The DM measured the temperature of one chicken nugget with his calibrated thermometer. The temperature of the chicken nugget was 146 Fahrenheit (F). [NAME] 2 placed the chicken nuggets on a resident's plate. The surveyor measured the temperature of several chicken nuggets on the plate and the temperature taken were 125 F, 73 F, and 145 F. In a concurrent interview with the DM, the DM stated the chicken nuggets should have a temperature of 165 F when cooked. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated when cooking food in the microwave, the temperature should be taken of a few chicken nuggets to ensure they were hot enough due to the uneven heating of microwaves. According to the 2017 Federal FDA Food Code, the food must attain a temperature of 165 F in all parts of the food when cooked in the microwave.

Based on observation, interview, and record review, the facility failed to ensure the residents on puree diet received the correct texture and consistency according to the diet order, for six of 43 residents. This failure had the potential for the resident to choke on the food. Findings: The facility menu spreadsheet for lunch on April 24, 2019, indicated residents on puree diet was to receive pureed chicken tetrazzini as the main entree. On April 24, 2019, at 12:24 p.m, a test tray for puree diet was requested from the Dietary Manager (DM). The puree diet test tray contained pureed chicken tetrazinni (a dish made with chicken, noodles, and vegetables) as the entrée. The pureed chicken tetrazzini was observed to have chunks of vegetables. The pureed chicken tetrazzini was tasted by the two surveyors and noted not to be smooth and had pieces of vegetables in it that were not pureed. Concurrently, the DM tasted the pureed chicken tetrazzini and confirmed the pureed chicken was not smooth and had vegetable pieces in it. In a concurrent interview with the DM, the DM stated the puree consistency should be like mashed potato. The DM further stated they were not able to reach the correct consistency because the blender was not a good industrial blender. On April 24, 2019, at 2:48 p.m., the facility Registered Dietitian (RD) was interviewed. The RD stated the texture and consistency of pureed diet should be smooth, and not grainy and watery. The RD further stated the texture and consistency of pureed diet should be like mashed potato. The undated facility diet manual section titled, PUREED TEXTURE, was reviewed. The manual indicated, .Foods are pureed to smooth consistency unless already in a comparatively smooth form such as mashed potatoes .

Based on interview and record review, the facility failed to ensure the facility-wide assessment addressed the facility resources such as supplies and equipment necessary in the food and nutrition services to carry out food service for the residents. In addition, the facility-wide assessment did not include the hours needed for the dietitian to conduct dietetic services. These failures had the potential to affect the 43 residents to maintain their highest practicable well being while residing in the facility out of a facility census of 43. Findings: During the facility annual recertification survery from April 22, 2019 to April 25, 2019, multiple equipment and food service items in the kitchen were observed to be not in good repair (Cross Reference F812 1a, 1b, 1c, 1d, 1e, 1g, 1i, and F908). In addition, there were essential supplies needed in the kitchen that were not included in the facility assessment. On April 23, 2019, at 1:42 p.m., the facility Registered Dietitian (RD) was interviewed. The RD stated the condition of the kitchen microwave to have rust and crack had been identified and was reported to the administrator several months ago. The RD also stated the ice build up in the reach-in freezer in the dry storage room was referred to the administrator more than a year ago. On April 24, 2019, at 12:20 p.m., during lunch observation, there were five residents' tray that did not have bases on the plates (used to cover plates during food service). In a concurrent interview with the DM, the DM stated there were not enough plate dome and bases in the kitchen. The DM stated as soon as the residents in the dining room are done eating, the dietary staff would immediately wash the plate dome and lid for the dietary staff to use for the residents who eat in their rooms. On April 24, 2019, at 3:26 p.m., a follow up interview was conducted with the DM. The DM stated the kitchen had 46 domes and 37 bases. The facility census on April 24, 2019, was 43 residents. The facility had a maximum capacity of 64 residents. On April 25, 2019, at 10:21 a.m., a follow up interview was conducted with the DM. The DM stated the food preparation, food storage, and the food service items (i.e. pots and pans, plate dome and base, measuring cups, and storage bins for bulk food) and equipment (i.e. reach-in freezer, microwave, refrigerator, and drying rack) were identified by him since he first started as the DM (about two years ago). The DM stated the kitchen equipments and food service items were really old and needed to be replaced. The DM stated he reported equipment and food service items needed for repair and replacement during the facility daily meeting. The DM was not able to provide documentation of the meeting. The DM stated he did not report the equipment and food service items needed in the kitchen because they had a strict budget the facility alloted to the food and nutrition services. The DM further stated the facility administrator would question him if the he would go above the alloted budget. On April 25, 2019, at 11:53 a.m., the RD was interviewed. The RD stated she would prioritize the equipment and food service items needed in the kitchen based on the budget the facility had alloted for the food and nutrition services. When the RD was asked if anything identified by the surveyors during the survey were projects currently in Quality Assurance and Performance Improvement (QAPI), she stated she did not know if there were current kitchen projects in QAPI. The RD stated she was not involved in the QAPI meetings because there was not enough hours the facility had authorized for her services. A review of the facility assessment tool, reviewed January 21, 2019, indicated the number of residents the facility was licensed to provide care for was 64 and the average daily resident census was 57-60 residents. There was no documented evidence the facility risk assessment included the supplies and resources needed in the food and nutrition services. There was no documented evidence the process to ensure adequate supply and appropriate maintenance or replacement of kitchen equipment were addressed in the facility risk assessment. In addition, there was no documented evidence the facility risk assessment included the necessary hours the RD was needed to conduct her job duties and responsibilities based on the contract. On April 25, 2019, at 3:30 p.m., the administrator was interviewed. The administrator stated he did not include the analysis of equipment and supplies needed in the food and nutrition services in the facility risk assessment. The administrator further stated there was no assessment conducted to determine the hours neccesary for the RD to do her job duties and responsibilities.

Based on observation, interview, and record review, the facility failed to ensure supervisory staff carried out the functions of the food and nutrition service when the Dietary Manager (DM) and the facility Registered Dietitian (RD) did not provide management and oversight to ensure food was stored, prepared, and served according to facility and industry standards, and ensure equipment and food service items were in good working condition and available for use by the dietary staff. These failures had the potential for 43 residents, who consumed food from the kitchen, to result in food borne illness and nutritional related health complications out of a facility census of 43. Findings: 1. According to the facility document Dietician Agreement, dated November 2, 2017, by the RD, the RD conducted a sanitation inspection of the kitchen one time per month with the objective of maintaining a high standard of safety and sanitation in the kitchen. In addition, the RD assisted the Dietary Manager (DM) in providing nutritionally sound meals. During the facility annual recertification survey from April 22, 2019 to April 25, 2019, it was found that the RD did not ensure residents received a comparable in nutrient content alternate when one was requested in place of the main entrée (Cross-reference F806). Also, during the facility annual recertification survey, the RD did not ensure safety and sanitation for meal service when she did not identify and report the poor condition of the domes and bases (covers for plates during meal service). (Cross-reference F812, 1i) Review of the Food Safety and Sanitation audit form, updated November 28, 2016, that was provided by the RD as the form she used for her monthly sanitation inspection, showed the RD looked to ensure hair restraints were worn by everyone in the kitchen, fans were clean, the can opener was clean, freezers and refrigerators were clean, foods were protected from contamination when being transported to the residents, cutting boards were clean, and pans were clean. During the facility annual recertification survey multiple issues were noted in the kitchen that were areas the RD inspected on the monthly sanitation inspection including: 1a. The can opener was rusty (Cross-reference F812,1b). In an interview with the RD on April 23, 2019, at 1:42 p.m., the RD stated she did not observe the can opener was rusted even though she inspected it monthly. Review of the last Food Safety and Sanitation Audit, completed by the RD, showed it was dated March 28, 2019. It was noted that this audit was conducted less than a month from the survey and the significantly rusty can opener was not documented. 1b. The cutting boards were not in good condition (Cross-reference F812, 1c). In an interview with the RD on April 25, 2019, at 11:55 a.m., she stated she checked the cutting boards in her monthly inspection but did not feel the film peeling off the back was an issue. She stated they needed to be replaced at some point but they were not high on the priority list. She stated she was not sure if she reported them to administration. The surveyor asked if she would provide documentation that the cutting boards were reported and the RD did not provide the documentation. 1c. Multiple cooking pans had thick black build up on the inside surface and the rubber handles were not intact (Cross-reference F812,1d). In an interview with the RD on April 23, 2019, at 1:42 p.m., she stated the pans needed to be newer and in better condition and the current ones used were old and very well used. She stated she was concerned about staff using the pans but they were in that condition in almost every facility. She stated they should be replaced but she did not report them to administration to be replaced because of the budget. 1d. The window air-conditioner had debris build-up (Cross-reference F812, 1f). In an interview with the RD on April 24, 2019, at 1:42 p.m., she stated she was not aware of who cleaned the air-conditioner in the kitchen and she did not check it for cleanliness. 1e. There were not enough domes and bases (a cover for plates of food) to serve all resident trays (Cross-reference F838). On April 24, 2019, at 12:20 p.m., during lunch observation, there were five residents' tray that did not have bases on the plates (used to cover plates during food service). In a concurrent interview with the DM, the DM stated there were not enough plate dome and bases in the kitchen. On April 24, 2019, at 3:26 p.m., a follow up interview was conducted with the DM. The DM stated the kitchen had 46 domes (cover the top of the plate) and 37 bases (cover the bottom of the plate). The facility census on April 24, 2019 was 43 residents. The facility had a maximum capacity of 64 residents. In an interview with the RD on April 25, 2019, at 11:55 a.m., she stated she was not aware of the amount of domes and bases the kitchen had in order to cover the plates during foodservice. 1f. The DM did not cover his facial hair (Cross-reference F812, 6). In an interview with the RD on April 23, 2019, at 1:42 p.m., the RD stated she would not expect facial hair that was closely cut to be covered. 1g. The combination refrigerator/freezer used to hold resident food located in the East Wing nursing station area was rusty and cracked (Cross-Reference F812, 1g). In an interview with the RD on April 23, 2019, at 1:42 p.m., the RD stated she inspected the nourishment room and refrigerator and looked for cleanliness on her monthly inspection. The RD stated she did not notice the rust and cracks in the refrigerator and stated but it's old. Review of the last Food Safety and Sanitation Audit, completed by the RD, showed it was dated March 28, 2019. It was noted that this audit was conducted less than a month from the survey. 2. According to the undated job description titled, Dietary Manager, and signed by the DM, responsibilities for the DM included developing cleaning schedules, inspecting storage areas for proper order, submitting written reports to administration as necessary, assuring that supplies are available for use by dietary personnel, and inspecting the Dietary Department regularly to ensure that it is safe and sanitary. During the facility annual recertification survey from April 22, 2019 to April 25, 2019, multiple day to day operation issues were found that the DM was aware of and responsible for according to the job description, including: 2a. Food was stored in the dry storeroom less than six inches off the ground. It was noted that the RD identified food stored less than six inches off the ground in her monthly inspection report (Cross-reference F812, 8). In an interview on April 22, 2019, at 9:10 a.m., the DM stated he was aware that food was supposed to be stored six inches off the ground and confirmed the RD identified the issue in her sanitation report. In an interview with the RD on April 23, 2019, at 1:42 p.m., the RD stated the DM received a copy of each of her reports. 2b. Food items were outdated and not discarded (Cross-reference F812, 4). In an interview with the DM, the DM stated that he used the manufacturer's best by date open soy sauce although the facility storage guidelines indicated it was good for one year after opening and the open date on the container was over one year. 2c. Holding food temperatures during food service were not maintained at a proper temperature when the DM heated food frozen chicken nuggets in the microwave and did not ensure the temperature was the proper temperature for holding food during food service (Cross-reference F812, 3b). 2d. Cooking equipment was dirty. The DM was aware that the kitchen toaster was broken and borrowed a toaster from the administration office. The toaster was not cleaned before it was made available for use in the kitchen (Cross-reference F812, 1e). 2e. The window air conditioner was dirty and not on the cleaning schedule and the DM was aware that the window air conditioner was greasy and dirty (Cross-reference F812, 1f).

Based on interview and record review, the facility failed to ensure staff was competent in performing safe and effective food preparation practices when a dietary staff was not able to explain the cool down process (procedure for cooling of hot foods that will not be served immediately). This failure had the potential to result in food not adequately cooled, which could lead to bacteria growth in the food and food borne illness for the 43 residents who eat food from the kitchen out of facility census of 43. Findings: On April 23, 2019, at 10:25 a.m., a concurrent interview and record review were conducted with the Dietary Manager (DM). The DM stated the facility did not usually practice cool down of hot foods because they serve the food cooked the same day. The DM stated the cooks were knowledgeable in the cool down process. The DM stated the facility used the form titled, Cooling of Cooked Foods, to document the cool down process. The form was written in English and Spanish language. The DM further stated the cooks had received in-service training on how to cool down hot foods. When the cool down log was reviewed, it was noted that foods were documented that were cooled. On April 23, 2019, at 10:50 a.m., [NAME] 1 was interviewed. [NAME] 1 explained in Spanish the procedure the facility practice for cooling down hot food. When [NAME] 1 was asked (with the DM interpreting) at what temperature should the food be reheated to if the food did not reach 70 degrees Fahrenheit (F) within 2 hours, she pointed to 135 degrees on the cool down instructions and stated 135. The DM confirmed her answer to reheat the food to was 135 F. The facility document titled, Cooling of Cooked Foods, was reviewed. The document indicated, .If food does not reach < (less than) 70 F in 2 hours, or < 41 F in 4 hours, reheat cooked food to 165 F for 15 seconds and restart cooling process . On April 24, 2019, at 8:55 a.m., a concurrent interview and record review was conducted with the DM. The DM showed an in-service training was conducted to Cooks 1 and 3 on the cool down process on March 2, 2018. The DM stated in-service training was conducted in English and Spanish for the dietary staff to be able to understand. The DM stated there was no written documentation to show that the staff understood the training.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs of the residents were met when: 1. Food portion sizes on the menu were not followed; and 2. Recipe was not followed. These failures had the potential for 43 residents on oral diets out of facility census of 43 not to receive the adequate nutrition which can further compromise their medical status. Findings: 1a. On April 22, 2019, at 11:55 a.m., an observation of the tray line service (the serving of food onto plates) for lunch was conducted with the Dietary Manager (DM). [NAME] 2 was observed using tongs (a kitchen tool used to pick up food items) to place the pasta onto the plates. A review of the facility menu spreadsheet for lunch on April 22, 2019, titled, Spring/Summer 2017, indicated the pasta for regular portion was 1/2 (one-half) cup. The menu spreadsheet also indicated pasta for small portion was 1/4 (one-fourth) cup. The menu spreadsheet indicated pasta portion for mechanical soft CCHO (controlled carbohydrate usually prescribed for residents with diabetes) diet was 1/2 cup. On April 22, 2019, at 12:13 p.m., during tray line observation conducted with DM, the pasta on a regular portion diet (which included two trays: one for residents on a regular diet and one for a residents on a CCHO diet) and small portion diets were measured with the DM. The pasta on the regular portion diet and the CCHO diet was measured by the DM at one cup. During a concurrent interview, the DM stated according to the menu a regular portion diet (including regular diets and CCHO) should receive 1/2 cup of pasta. The pasta on the small portion diet was measured by the DM at what he stated was just under 3/4 cup. The DM stated the small portion diet should receive 1/4 cup of pasta per menu. In an interview on April 23, 2019, at 1:42 p.m., the Registered Dietitian (RD) stated kitchen staff should follow the portion size on the menu spreadsheet. 1b. On April 22, 2019, at 11:55 a.m., an observation of the tray line service for lunch was conducted with the DM. [NAME] 2 was observed to place pureed fish onto the plate. Cream sauce was not observed on the plates served with pureed diets. A review of the facility menu spreadsheet for lunch on April 22, 2019, titled, Spring/Summer 2017, indicated puree diet should have two ounces of cream sauce over the pureed fish. In a concurrent interview with the DM, the DM stated the pureed and mechanical soft diet should have cream sauce on the fish entrée per menu spreadsheet. Subsequently, [NAME] 2 placed cream sauce on all the diets including regular and CCHO (controlled carbohydrate) diet. According to the menu spreadsheet, only puree diets should receive cream sauce on the fish entrée. In an interview on April 23, 2019, at 1:42 p.m., the RD stated kitchen staff should follow the menu spreadsheet. 2. On April 22 at 12:13 p.m., the DM stated the kitchen had only one measuring cup. The DM stated the measuring cup had increments of one cup portion and did not have other liquid measurements. The DM stated the kitchen needed more measuring cups to use to be able to measure recipe ingredients. On April 22, 2019, at 3:35 p.m., [NAME] 1 was observed preparing chicken salad for dinner. The recipe titled, CHICKEN SALAD SANDWICH 2OZ (ounces) ., was reviewed. The recipe for the chicken salad indicated 1/4 cup of lemon juice or vinegar was needed for 50 servings. In a concurrent interview with [NAME] 1 and the DM on April 22, 2019, at 3:35 p.m., [NAME] 1 stated she used the metal measuring cup with one cup increment to measure the lemon juice. [NAME] 1 stated she approximated 1/4 cup using the only measuring cup they had and did not have a measuring cup meant to measure 1/4 cup that the recipe required. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated food portions on the menu should be followed menu. She also stated the kitchen should have the necessary measuring equipment to use to measure ingredients and portion sizes. On 4/25/19 at 10:21 a.m., the DM confirmed he did not ask administration to order more measuring cups. The facility policy and procedure titled, FOOD PREPARATION, dated 2011, was reviewed. The policy indicated, .Standardized recipes will be used to ensure meals are attractive, palatable and provide necessary nutritive value. All menu items will have standardized recipes .

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. Multiple equipment and food service items were dirty and not in good repair: 2. Ready to eat food was stored in the refrigerator next to raw eggs and raw meat; 3. Food was not held up at a safe temperature during tray line; 4. Food was not discarded according to the use by dates; 5. Food item was stored near chemicals; 6. Facial hair was not covered; 7. Cooking and food service items were not air dried; and 8. Food was stored less than six inches off the ground. These failures had the potential to result in cross contamination and foodborne illness in a medically vulnerable population of 43 residents who consumed food from the kitchen and the nourishment rooms out of a facility census of 43 residents. Findings: 1a. On April 22, 2019, at 9:10 a.m., an observation of the facility kitchen and concurrent interview with the Dietary Manager (DM) were conducted. The microwave was opened and the inside was observed to have a brown discoloration at the bottom two corners and the plastic covering toward the front was not intact and had a crack. In a concurrent interview with the DM, the DM stated the brown discoloration on the microwave was rust. The ceiling of the inside of the microwave was observed to have scattered orange/yellow residue. The DM stated the microwave had splashes of food particle and was dirty. The DM stated the microwave had to be cleaned after every time it was used. In a concurrent interview, the DM stated the facility Registered Dietitian (RD) indicated the microwave needed replacement on the previous kitchen inspection report . The facility document titled, FOOD SAFETY AND SANITATION AUDIT, dated February 4, 2019, was reviewed with the DM and indicated the RD inspected the microwave and noted corrosion inside and needs replacement. On April 23, 2019, at 1:42 p.m. the RD was interviewed. The RD stated the microwave should be kept clean. The RD stated the condition of the microwave was included in her monthly kitchen inspection report and the microwave needed replacement. On April 24, 2019, at 9:50 a.m., the Chief Financial Officer (CFO) and Assistant Administrator (AA) were interviewed. The CFO and AA stated they were aware of the kitchen microwave needed replacement. The CFO and AA stated the microwave was not a top priority in the facility budget. According to the 2017 Federal Food Code, food-contact surfaces are to be smooth, free of breaks, open seams, cracks, and inclusions, and are to be clean to sight and touch. Also, nonfood-contact surfaces of equipment that require frequent cleaning are to be constructed of corrosion-resistant, smooth material. Nonfood-contact surfaces are to be kept free of food residue and other debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1b. On April 23, 2019, at 9:29 a.m., the can opener was observed to have brown residue on the blade and the cogwheel (the wheel that turns the can) had an orange/brown discoloration. The residue on the blade wiped off easiliy when the surveyor wiped it with a paper towel. In a concurrent interview with the DM, the DM confirmed there was residue on the blade and stated the food particles on the blade should have been cleaned after each use. The DM stated the cogwheel was rusty and really old. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated the can opener needed to be cleaned and free from food particles and rust. On April 25, 2019, at 10:21 a.m., a follow up interview was conducted with the DM. The DM stated he observed the can opener to be rusty about a month ago. The DM stated he had not requested for a new one because it was not part of the kitchen budget. The facility policy and procedure titled, CLEANING SMALL APPLIANCES/EQUIPMENT, dated 2011, was reviewed. The policy indicated, Can Openers will be cleaned after each use and sanitized daily . According to the 2017 Federal Food Code, food-contact surfaces are to be clean to sight and touch. Also, nonfood-contact surfaces of equipment that require frequent cleaning are to be contstructed of corrosion-resistant, smooth material. Nonfood-contact surfaces are to be kept free of food residue and other debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1c. On April 22, 2019, at 9:29 a.m, the cutting boards were inspected. There were three small and thin cutting boards observed to have a film peeling off at the back side. On April 22, 2019, at 1:15 p.m., the DM was interviewed. The DM confirmed the three cutting boards had a film peeling off the backs. According to the 2017 Federal Food Code, food-contact surfaces are to be smooth, and free of inclusions. Also, nonfood-contact surfaces of equipment that require frequent cleaning are to be constructed of corrosion-resistant, smooth material. The facility policy and procedure titled, FOOD PREPARATION, dated 2011, was reviewed. The policy indicated cutting boards are to be in good condition. 1d. On April 23, 2019, at 9:29 a.m., the metal colander, muffin pans, sheet pans (large flat rectangular pans), hotel pans (large rectangular pans) and frying pans, were inspected. The metal colander was observed to have yellowish brown residue in the holes and the bottom surface. There were four muffin pans observed to have yellow residue build up on the inside surface. There were three sheet pans observed to have thick black residue build up on the sides of the inside surface. There were four frying pans with thick black residue build up in the inside surface. The rubber handles of the frying pans were observed to be not intact and had missing pieces and the surface was not smooth. In a concurrent interview with the DM, the DM confirmed the colander had residue build up and stated the muffin pans, sheet pans, hotel pans, and frying pans had residue build up and needed to be replaced. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated the colander and pans had to be cleaned and free from any residue. The RD stated the pans were very old and well used and needed to be replaced. On April 25, 2019, at 10:21 a.m., a follow up interview was conducted with the DM. The DM stated he did not report to the RD or the administrator the pots and pans needed replacement. According to the 2017 Federal FDA Food Code, the food-contact surface of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Also, nonfood-contact surfaces are to be constructed of corrosion resistant, smooth materal. 1e. On April 22, 2019, at 9:10 am, a two-slotted bread toaster was observed to have greasy residue on the outside of the toaster. There was a brown residue and crumbs inside the toaster. In a concurrent interview with the DM, the DM stated the two-slot bread toaster was taken from the facility office to use as the four-slot bread kitchen toaster was broken. The DM showed the four-slot bread toaster and only two slots were working. The DM stated the kitchen toaster was broken since last week. The DM further stated the toaster needed to be replaced. According to the 2017 Federal Food Code, food-contact surfaces are to be clean to sight and touch. Also, nonfood-contact surfaces of equipment are to be kept free of food residue and other debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1f. On April 22, 2019 at 1:12 p.m., the window air conditioner was observed with the DM. The window air conditioner was observed to have a layer of gray and black, fuzzy residue on the slots where air blows out and on the sides of the the air conditioner. The residue had a thick, greasy feel when it was touched. In a concurrent interview with the DM, the DM stated the air conditioner unit was dusty and greasy. The DM stated the air conditioner unit was cleaned by the dietary staff. The facility documents titled, COOKS CLEANING SCHEDULE and DISHWASHERS CLEANING SCHEDULE, for the month of April 2019, was reviewed. The cleaning schedule for the cooks and dishwashers did not indicate a schedule to clean the air conditioner unit. According to the 2017 Federal Food Code, nonfood-contact surfaces are to be kept free of debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1g. On April 22, 2019, at 3:40 p.m., a room by the East Nursing Station with a door sign of Diet Kitchen/Electrical Panel Room was inspected. The Diet Kitchen Room was observed to have a white combination freezer/refrigerator labeled Resident Refrigerator (RR). The top of the RR was observed to have a fuzzy, gray residue over the surface. The RR freezer had a significant amount of bits of brown residue on inside bottom surface and black residue at the back inside surface. The RR freezer contained a large bag of ice in a ripped plastic bag and ice was exposed. The ripped bag had a sticker label of a resident's name on it. The RR freezer also contained a pint of ice cream labeled with a resident's name with ice build up covering the outside of the container and one frozen water bottle. Two cracked racks with orange discoloration on the surface were inside the RR refrigerator. The bottom ledge of the inside surface of the refrigerator was not intact and was cracked and had an orange discoloration. On April 22, 2019, at 3;53 p.m., the Director of Nursing (DON) was interviewed. The DON stated the housekeeping staff cleaned the RR. The DON stated there was brown and black residue in the freezer. On April 22, 2019, at 4:03 p.m., the DM was interviewed. The DM stated housekeeping cleaned the RR. The DM stated the bottom of the refrigerator was cracked and with rust around it. The DM stated whoever discovered the equipment not in good repair was to report to maintenance or administrator. On April 23, 2019, at 10:04 a.m, the Director of Environmental Services (DES) was interviewed. The DES stated the top of the RR was dusty and the bottom of the RR had cracked with an orange discoloration. The DES stated the RR was cleaned by the housekeepers every Monday. The DES stated the RR did not appear it was cleaned yesterday (Monday) as scheduled. The DES further stated the crack and rust on the bottom of the RR was not reported to her. The undated facility policy and procedure titled, HOUSEKEEPING, was reviewed. The policy indicated: - .In order to ensure the health and safety of residents, staff, and visitors, it is critical that the facility be kept clean, sanitary, and in good repair at all times . - .Make sure that each room, area, piece of furniture, or equipment is cleaned properly and thoroughly with the correct equipment and cleaning product . - .The housekeeping supervisor shall provide orientation for new housekeeping staff within the first three days of employment, ensuring that orientation includes at the least the following .The basic housekeeping responsibilities and methods of cleaning, disinfecting . - .The housekeeping staff is responsible for completing the daily, weekly, monthly, and annual cleaning procedures posted by the housekeeping supervisor . - .The housekeeping supervisor holds housekeeping in-service training classes at least twice a month for all housekeepers . In-service for housekeeping includes: a. Procedures for cleaning . On April 24, 2019, at 9:30 a.m., a follow up interview was conducted with the DES. The DES stated there was no cleaning schedule for the housekeeping staff. The DES stated there was no documentation training was provided to the housekeeping staff on cleaning the refrigerator in the East Nursing Station area. The undated facility policy titled, Sanitation and Infection Control, indicated, Reach-in freezers will be cleaned and sanitized once a week . According to the 2017 Federal Food Code, food-contact surfaces are to be smooth, free of breaks, open seems, cracks, inclusions and are to be clean to sight and touch. Also, nonfood-contact surfaces of equipment that require frequent cleaning are to be contstructed of corrosion-resistant, smooth material. Nonfood-contact surfaces are to be kept free of food residue and other debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1h. On April 23, 2019, at 9:07 a.m., the ice machine was inspected with the DES. The DES removed the covering of the ice machine. The evaporator panel (the component of the machine where water flows over to make ice) of the ice machine was observed to have a black residue in the corner of the plastic around the evaporator panel. The top of the evaporator panel was observed to have a yellow and black gelatinous residue around the plastic of the evaporator panel. The residue was removed easily when wiped with a paper towel. In a concurrent interview with the DES, the DES confirmed there was residue around the evaporator plate. According to the 2017 Federal Food Code, food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of food residue and other debris and are to be cleaned at a frequency necessary to preclude the accumulation of residue. 1i. On April 22, 2019, at 9:10 a.m., during the initial kitchen inspection, all (83 total) plate domes and bases (covers for plates of food) were observed to be discolored, had pits, had areas where the plastic was melted, had cracks, and were not intact. One dome had plastic missing from the handle area and yellow substance was exposed. In a concurrent interview with the DM, the DM stated the plate dome and base lids were old and needed to be replaced. In an interview on April 23 at 1:42 p.m., the RD stated the domes and bases should not have any scratches so food did not get stuck on them. According to the 2017 Federal Food Code, food-contact surfaces are to be smooth, free of breaks, open seems, cracks, inclusions and are to be clean to sight and touch. 2. On April 22, 2019, at 9:29 a.m., the reach-in refrigerator was inspected with the DM. The following food items were observed on the bottom shelf of the refrigerator stored beside each other: - Ground meat in a box; - Ground beef in a pan (thawing); - A package of bacon in plastic bag container; - A box of corn tortillas; - A box of pasteurized eggs; and - A box of diced pork. In a concurrent interview with the DM, the DM stated the corn tortillas should not be stored on the bottom shelf with the meat. On April 23, 2019, at 1:42 p.m, the RD was interviewed. The RD stated the ready to eat foods (corn tortillas) should be stored above the thawed meat and the eggs. According to the 2017 Federal FDA Food Code, cooked ready-to-eat food should be stored separately from raw animal food. The facility policy and procedure titled, Sanitation and Infection Control Subject: Refrigerated Storage, dated 2011, was reviewed. The policy indicated, .All frozen uncooked meat, poultry and fish should be placed on the bottom shelf for proper thawing .Cooked foods will be stored on shelves above raw food to prevent contamination from drippings . 3a. On April 22, 2019, at 12:30 p.m., during the tray line food service observation, a pan of chicken nuggets was observed placed on top of the pan of pasta on the grill. [NAME] 2 served chicken nuggets on a resident's plate. The surveyor measured the temperature of the chicken nuggets with a calibrated thermometer and the temperature registered at 123.3 Fahrenheit (F). The DM measured the temperature of the chicken nuggets with his calibrated thermometer and the temperature registered at 125 F. In a concurrent interview with the DM, the DM stated the chicken nuggets should have a temperature of 135 F and above when served. The facility policy and procedure titled, FOOD PREPARATION, dated 2011, was reviewed. The policy indicated, .Prepared food will be stored at proper temperature until serving time .Hot foods at above or equal to 140 F . According to the 2017 Federal Food Code, when time is not monitored after removing food from hot holding, such as on trayline, the food is to be at least 135 degrees F when it is removed from hot holding. 3b. On April 22, 2019, at 1:05 p.m., during trayline observation, the fish entrée ran out and chicken nuggets were substituted. The DM was observed to place half bag of chicken nuggets in the microwave. The DM measured the temperature of one chicken nugget with his calibrated thermometer. The temperature of the chicken nugget was 146 F. [NAME] 2 placed the chicken nuggets on a resident's plate. The surveyor measured the temperature of several chicken nuggets on the plate and the temperature taken were 125 F, 73 F, and 145 F. In a concurrent interview with the DM, the DM stated the chicken nuggets should have a temperature of 165 F when cooked. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated when cooking food in the microwave, the temperature of a few chicken nuggets should be taken to ensure they were hot enough due to the uneven heating of microwaves. According to the 2017 Federal FDA Food Code, the food must attain a temperature of 165 F in all parts of the food when cooked in the microwave. 4. On April 22, 2019, at 9:10 a.m., during kitchen inspection with the DM, one gallon bottle of soy sauce with an open date of January 23, 2018, was stored on a shelf. In a concurrent interview with the DM, the DM confirmed the open dates of the soy sauce. The facility policy and procedure titled, SUGGESTED DRY GOODS STORAGE GUIDELINES, dated 2011, was reviewed. The policy indicated sauces (steak, soy, etc.) were to be discarded one year after it was opened. The reach-in refrigerator was inspected. The following opened food items were stored inside the refrigerator: - Cooked ham, with an open date of April 15, 2019; and - Cooked sliced roast beef, with an open date of April 16, 2019. In a concurrent interview with the DM, the DM stated the cooked ham had a use by date of five days once opened. The DM stated the cooked ham should have been discarded on April 20, 2019. The DM stated the sliced roast beef had a use by date of five days. The DM further stated the sliced roast beef should have been discarded on April 21, 2019. The DM stated everyone in the kitchen was responsible for discarding and it should have been discarded by the end of the fifth day. The facility policy and procedure titled, SUGGESTED REFRIGERATED STORAGE GUIDELINES, dated 2011, was reviewed. The policy indicated ham and luncheon meats should be discarded after five days. On April 22, 2019, at 10:20 a.m., the dry storage room was inspected with the DM. There were eight packs of English muffin, dated April 4, 2019. In a concurrent interview with the DM, the DM stated the date on the muffins was the date they were delivered and the English muffin should be discarded in seven days. The storage guidelines for bread was requested from the DM. The DM was not able to provide the storage guidelines for bread. On April 22, 2019, at 3;40 p.m, the Diet Kitchen/Electrical Panel Room beside the East Nursing Station was inspected. The residents' refrigerator was observed to have an opened two-quart cranberry juice labeled with a resident's name and room number and an open date of November 29, 2018. Inside the cabinet of the Diet Kitchen Room, there were two loose bottles and a box (six bottles/box) tube feeding formula with an expiration date of November 1, 2018. On April 22, 2019, at 3:53 p.m., Licensed Vocational Nurse (LVN) 4 and the DON were interviewed. LVN 4 stated the date on the cranberry juice bottle was the date it was opened. LVN 4 stated she thought it should be discarded two weeks after opening. The DON stated she looked at the manufacturer's use-by or best-by date to determine when opened items were discarded. The DON stated she would talk to the resident before discarding anything. The DON stated the tube feeding formulas were expired and should have been discarded. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated food items stored in the refrigerator and the dry storage room were to be discarded based on the food storage guidelines. The RD further stated that the manufacturer date should be followed for discarding bread (it was noted the bread did not have a manufacturer use-by-date or best-by-date.) On April 24, 2019, at 3:50 p.m., the Business Office Manager (BOM) was interviewed. The BOM stated the housekeeping staff was responsible in discarding unlabeled and undated food items in the RR. The BOM further stated the dietary staff was responsible in discarding food items in the RR with past use by dates. The BOM stated the tube feeding formula were usually kept in the storage room beside the East Wing Nursing Station. The BOM stated nursing staff were responsible in discarding tube feeding formulas when expired. The undated facility policy and procedure titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, was reviewed. The policy indicated non-perishable foods brought in for the resident must be dated when opened and disposed of by the best-by date or after 30 days, whichever came first. The facility policy and procedure titled, CANNED AND DRY GOODS STORAGE, dated 2011, was reviewed. The policy indicated, .Commercial Formulas, such as enteral feedings (tube feedings) or supplements, must be checked routinely for expiration dates . 5. On April 22, 2019, at 9:10 a.m., during the kitchen inspection, there were one unopened box and one opened box of onions stored under the sink. The opened box of onions contained whole onions and one onion was partially used and wrapped in plastic. The box of onions were stored beside chemicals (oven cleaner, disinfectant, and dish soap). On April 22, 2019, at 1 p.m, the DM was interviewed. The DM stated the box of onions should not be stored under the sink together with chemicals. The DM stated the box of onions should have been stored in the dry storage area. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated the onions or non-refrigerated produce should have been stored in the dry storage area. The RD further stated the onions should not have been stored close to any chemicals. The facility policy and procedure titled, CANNED AND DRY GOODS STORAGE, dated 2011, was reviewed. The policy indicated, .No chemicals or cleaning products may be stored with food items . 6. On April 22, 2019, at 9:10 a.m., during the initial kitchen tour with the DM, the DM was observed to have a mustache and beard approximately one inch long. The DM was not wearing a beard net (a cover for facial hair) while kitchen inspection was conducted. On April 22, 2019, at 11:55 a.m., during the tray line observation, the DM measured the pasta from the plate to be served. The DM was observed to have a mustache and beard without beard net. As the DM was measuring the pasta, there was what appeared to be a strand of short black hair on the plate with the pasta. In a concurrent interview with the DM, the DM confirmed there was a strand of hair on the plate and stated where did that come from? On April 22, 2019, at 1:15 p.m., the DM was interviewed. The DM stated the facility policy was to have facial hair covered with a beard net but he usually kept his beard short. On April 23, 2019, at 10:25 a.m, the DM was observed working in the kitchen. The DM was observed with beard and mustache not covered with a beard net. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated the DM should have covered his beard with a beard net anytime the DM was in the kitchen and the food area. The RD further stated it depended on the length of the hair whether or not it should be covered. According to the 2017 Federal Food Code 2-402.11, .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD . 7. On April 22, 2019, at 9:10 a.m., during kitchen inspection with the DM, the following cooking and food service items were observed stored and stacked wet on top of one another: - Three hotel pans; - Three 1/4-sized pans; - Four 1/8-sized pans; - Two 1/2-sized pans; - 78 plate domes and bases (used to cover plates of food during food service); and - Five serving trays. In a concurent interview with the DM, the DM confirmed the items were stacked and stored wet. The DM stated the cooking and food service items were stacked wet because they did not have a rack to dry them. The DM stated all the items should be air dried. On April 22, 2019, at 3:40 p.m., the Diet Kitchen Room beside the East Nursing Station was inspected. Inside the cabinet were 54 plastic water pitchers and four plastic drinking cups observed to be stacked wet inside each other. On April 22, 2019, at 3:50 p.m., LVN 4 was interviewed. LVN 4 stated the plastic water pitchers and drinking cups were used for the residents' water. LVN 4 further stated the water pitchers and drinking cups should not be stacked wet. On April 22, 2019, at 4:03 p.m., the DM was interviewed. The DM stated the water pitchers and drinking cups should have been air dried before it was stored in the cabinet stacked on top of each other. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated cooking equipment and food service items should be air dried before they were stacked. On April 24, 2019, at 3:26 p.m., a follow up interview was conducted with the DM. The DM stated he informed the administrator of the need for a drying rack when he first started as the DM (about 2 years ago). According to the 2017 Federal FDA Food Code, .After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried The facility policy and procedure titled, DISHWASHING PROCEDURES (DISHMACHINE), dated 2011, was reviewed. The policy indicated, .Allow racks of dishes/trays/utensils to air dry. If drying space is not ample for dishes to air dry, use utility carts .Do not rack and stack wet dishes or trays . 8. On April 22, 2019, at 10:20 a.m., the dry storage room was inspected with the DM. There were bulk containers of flour, sugar, oatmeal, bread crumbs, and rice stored one and a half (1.5) inches off the floor on the bottom shelf of the storage room. In a concurrent interview with the DM, the DM stated food items should be stored six inches off the floor. On April 23, 2019, at 1:42 p.m., the RD was interviewed. The RD stated the food items should be stored six inches off the floor. On April 24, 2019, at 8:55 a.m., a follow up inspection of the dry storage room was conducted with the DM. The bulk supply of flour, sugar, oatmeal, bread crumbs, and rice were observed transferred to smaller bins and stored on the second shelf (more than six inches off the floor). In a concurrent interview with the DM, the DM stated the smaller bins were not food safe. According to the 2017 Federal FDA Food Code, food in packages and working containers may be stored at least six inches above the floor. The facility policy and procedure titled, FOOD/CLEANING SUPPLY RECEIVING AND STORAGE, dated 2011, was reviewed. The policy indicated, .Food will be stored at least 6 inches off the floor .

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment were maintained in a safe operating condition when the reach-in freezer in the dry storage room had significant ice build up. This failure had the potential for compromised food palatability, quality, and safety. Findings: On April 22, 2019, at 10:20 a.m., during the dry storage room inspection, the white reach-in freezer was inspected. The reach-in freezer was filled with packages of frozen vegetables. The freezer had a significant amount of ice build up on the ceiling and racks, and icicles hanging off inside door. The frozen vegetables were observed to have frost inside the bags and on the surface of the vegetables. In a concurrent interview with the Dietary Manager (DM), the DM stated the freezer was defrosted every two weeks due to the ice build up. On April 23, 2019, at 1:42 p.m., the facility Registered Dietitian (RD) was interviewed. The RD stated she noticed the ice build up in the smaller freezer in the dry storage room about two months ago. The RD stated the frozen vegetables should not have frost inside the bags and should have been tossed away. The RD further stated the smaller freezer was not a commercially acceptable freezer. The facility document titled, FOOD SAFETY AND SANITATION AUDIT, dated February 22, 2018, was reviewed. The document indicated the RD included in the report the white freezer in the dry storage room was covered with frost. On April 24, 2019, at 9:52 a.m., the Chief Financial Officer (CFO) was interviewed. The CFO stated the administration was aware of the ice build up in the reach-in freezer in the dry storage room. On April 25, 2019, at 10:21 a.m., a follow up interview was conducted with the DM. The DM stated he did not ask for a replacement of the reach-in freezer because it was not a priority in the facility budget. On April 25, 2019, at 11:53 a.m., a follow up interview was conducted with the RD. The RD stated the ice build up in the reach-in freezer inside the dry storage room was an on-going problem since last year. The RD stated she had notified the administrator about the problem with the reach-in freezer. On April 24, 2019, at 3:31 p.m., the manufacturer's manual was requested from the Business Office Manager (BOM) in order to review the maintenance required for the freezer. The facility did not provide the manual. According to the 2017 Federal FDA Food Code, equipment shoud be maintained in a state of repair. Failure to properly maintain equipment according to the manufacturer instructions could lead to health and safety risk.