**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change of condition assessment (required assessment of cognitive and functional abilities) in resident status for one of eight sampled residents (Resident 9) when Resident 9 was admitted for hospice (end of life care) services. This failure resulted in Resident 9's change of condition to go unreported to direct care staff (all facility staff who directly provide program and/or nursing services to residents), the Registered Nurse, attending physician, family, interdisciplinary team members, and the Director of Nursing (DON) or Assistant Director of Nursing (ADON) and had the potential for Resident 9's care needs to not be met. Findings: During a concurrent observation and interview on 8/4/2025 at 8:25 a.m. in Resident 9's room, Resident 9 was observed in bed wearing a gown. Resident 9 stated he had been in the facility for a couple of years. Resident 9 stated he had problems with his hands and knees. Resident 9 had hand contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in both hands. Resident 9 stated he could not get up and needed assistance with moving in bed. During a review of Resident 9's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 9 was admitted on [DATE] with diagnoses of paraplegia (paralysis [the loss of the ability to move and sometimes to feel anything] that occurs in the lower half of the body), chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), obstructive and reflux uropathy (when urine cannot drain and backs up into the kidney), adult failure to thrive (a gradual decline in health usually due to one or more medical conditions), and encounter for palliative care (specialized care that focuses on providing relief from pain and other symptoms of a serious illness). During a review of Resident 9's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 6/20/25, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 9 was cognitively intact. During a review of Resident 9's Care Plan (CP), dated 8/6/25, the CP indicated, the resident has a terminal prognosis . admitted under [name of company] Hospice . date initiated: 3/21/25 . During a concurrent interview and record review on 8/7/25 at 9:55 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 9's Order Summary Report (OSR), dated 8/6/25 indicated, . admit to [name of company] Hospice . order date 3/20/25 . LVN 2 stated Resident 9 had orders for hospice care on 3/20/25 and had a hospice consult on 3/25/25. LVN 2 stated she did not see a change of condition assessment (COC) completed for Resident 9. LVN 2 stated Resident 9 should have had a COC assessment when he transferred to hospice care. LVN 2 stated a COC assessment ensured Resident 9 was getting the appropriate treatment to have his needs met. During an interview on 8/7/25 at 3:44 p.m. with the Director of Nursing (DON), the DON stated a resident transitioning to hospice care was considered a change of condition and required a COC assessment, which consisted of a head-to-toe assessment for a change in the resident's condition or for a resident whose condition was declining. The DON stated Resident 9 should have had a COC assessment completed the same day Resident 9's status changed. The DON stated the COC should have been completed immediately so staff were more observant of Resident 9, and more focused on communicating with hospice staff and the hospice physician for changes in Resident 9's status to be sure his needs were being met. During a review of the facility's job description document titled, Licensed Vocational Nurse (LVN), dated 3/1/14, the document indicated, . complete initial and ongoing assessments by gathering data in a timely manner . proficiently and accurately monitor and report resident condition changes to the Registered Nurse, attending physician, family, interdisciplinary team members, and Director of Nursing or ADON . During a review of the facility's policy and procedure (P&P), titled, Change in a Resident's Condition or Status, dated 2/2021, indicated, . our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care . a [significant change] of condition is a major decline or improvement in the resident's status that . will not normally resolve itself . impacts more than one are of the resident's health status . if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personal hygiene for one of the seven sampled residents (Resident 48) when all 10 fingernails were long and had black particles underneath. This failure resulted in Resident 48 feeling worried she would injury or scratch herself and she preferred them short. Findings: During a review of Resident 48's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a chronic condition where the body doesn't properly use insulin, leading to elevated blood sugar levels), muscle weakness and malaise (tiredness). During a review of Resident 48s Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 12 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 48 had moderated cognitive impairment. During a review of Resident 48's MDS, the MDS indicated Section GG-Functional Abilities self-care score (a of 6: independent, 5: setup or clean-up assistance, 4: supervision or touching assistance, 3: partial/moderate assistance, 2: substantial/maximal assistance, 1: dependent) was 2 indicating Resident 48 required substantial/maximal assistance with upper body dressing. During a review of Resident 48's Care Plan Report (a document that outlines a patient's assessed health needs, the care and support they will receive, and the expected outcomes), dated 8/8/25, the Care Plan Report indicated, The patient presents with significant weakness and difficulty performing activities of daily living (ADL - basic self-care tasks that are essential for maintaining independence and quality of life) tasks. During an observation and interview on 8/4/25 at 12:21 p.m. in Resident 48's room, Resident 48 had 10 long fingernails with black particles embedded underneath the fingernails. Resident 48 stated the facility did not offer to cut her fingernails. Resident 48 stated she was worried the long fingernails could have injure or scratch her skin. Resident 48 stated she did not like her fingernails long. Resident 48 stated her fingernails were short at home and she would have liked them cut. During a current observation and interview on 8/4/25 at 2:23 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1stated she was not sure when Resident 48 had her fingernails cut. CNA 1 stated Resident 48 was a diabetic and the nurses were responsible for cutting her fingernails. CNA 1 stated CNAs should have filed and cleaned the fingernails on Sundays. CNA 1 stated Resident 48 should have gotten them cut 8/3/25. CNA 1 stated Resident 48's fingernails looked dirty. CNA 1 stated Resident 48 could have scratched her skin and could have hurt herself. CNA 1 stated the scratches could have caused a skin infection. CNA 1 stated Resident 48 could have been embarrassed from the long fingernails. During a concurrent interview and record review on 8/5/25 at 11:10 a.m. with License Vocation Nurse (LVN) 1, LVN 1 stated Resident 48 fingernails should have been cut on Sundays and as needed. LVN 1 stated cutting fingernails were needed for proper hygiene and safety to prevent scratches to their thin skin. LVN 1 stated the CNA should have made sure fingernails were cleaned underneath. LVN 1 stated long fingernails could have caused fungal (common condition where fungi infect the nail, causing it to become discolored, thickened, and brittle) infections. LVN 1 started on 8/3/25, no logs were done for fingernails care. LVN 1 stated CNAs should have verbally notified the nurses that Resident 48 fingernails needed cutting. LVN 1 stated there was no documentation Resident 48's chart indicating nail care was done. During an interview on 8/7/25 with the Director of Nursing (DON) the DON stated, nurses were responsible for cutting fingernails for residents with diabetes. The DON stated CNAs should have informed the nurses about Resident 48's long fingernails. The DON stated Resident 48 had diabetes and was prone to getting an infection. The DON stated resident 48 with long fingernails could have scratched her skin and caused an infection which could lead to hospitalization. The DON stated nurses should have documented in the chart when the nail care was done. During a review of the facility's policy and procedures (P&P) tilted, Activities of daily Living (ADL), Supporting, dated 3/2018, the P&P indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including.hygiene (.grooming).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a right to a dignified existence when three of 16 sampled residents (Resident 9, Resident 36, and Resident 43) did not have a dignity covering (a bag or holder designed to conceal and protect the catheter drainage bag [a bag that collects urine from a catheter, a tube inserted into the bladder to drain urine], restoring a sense of privacy and dignity for the user) on their catheter drainage bag. This failure had the potential to result in Resident 9, Resident 36, and Resident 43 experiencing embarrassment or shame due to loss of privacy and dignity. Findings: During a concurrent observation and interview on 8/4/2025 at 8:25 a.m. in Resident 9's room, Resident 9 was observed in bed wearing a gown. Resident 9 stated he had been in the facility for a couple of years. Resident 9 stated he had problems with his hands and knees. Resident 9 had hand contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in both hands. Resident 9 stated he could not get up and needed assistance with moving in bed. Resident 9 had a urinary catheter bag on the left side of Resident 9's lower bed frame without a dignity cover. During a review of Resident 9's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 9 was admitted on [DATE] with diagnoses of paraplegia (paralysis [the loss of the ability to move and sometimes to feel anything] that occurs in the lower half of the body), chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), obstructive and reflux uropathy (when urine cannot drain and backs up into the kidney), adult failure to thrive (a gradual decline in health usually due to one or more medical conditions), and encounter for palliative care (specialized care that focuses on providing relief from pain and other symptoms of a serious illness). During a review of Resident 9's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 6/20/25, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 9 was cognitively intact. During a review of Resident 9's Care Plan (CP), dated 8/6/25, the CP indicated, . maintain comfort and dignity . initiated: 3/21/25 . During a concurrent observation and interview on 8/4/25 at 2:13 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 9's room, Resident 9's urinary catheter bag was observed without a dignity covering. CNA 2 stated she was unsure if residents' urinary catheter bags should have a privacy covering but felt it should have had one for Resident 9's privacy. During an interview on 8/4/25 at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated resident's catheter bags should have a dignity covering to protect the resident's privacy and dignity. LVN 3 stated not having a privacy covering could have affected the residents' dignity. During a concurrent observation and interview on 8/4/25 at 8:49 a.m. with Resident 36 in Resident 36's Room, Resident 36 was observed dressed in bed eating his meal. Resident 36 stated he had been at the facility for three years due to being unable to walk. Resident 36 had a urinary catheter bag on the right side of Resident 36's bed with no dignity covering. During a review of Resident 36's AR, dated 8/6/25, the AR indicated Resident 36 was initially admitted from an acute care hospital on 3/10/23 and re-admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), neuromuscular dysfunction of bladder (neurogenic bladder - when a person lacks bladder control due to brain, spinal cord or nerve problems), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and benign neoplasm of brain (an abnormal growth in the brain, which does not invade the surrounding brain tissue, or spread to the spinal cord). During a review of Resident 36's MDS, dated 6/24/25, the MDS section C indicated Resident 36 had a BIMS score of 15, which indicated Resident 36 was cognitively intact. During a review of Resident 36's Care Plan (CP), dated 8/6/25, the CP indicated . position catheter bag and tubing below the level of the bladder and away from entrance room door . initiated: 11/20/23. During an observation on 8/4/25 at 8:03 a.m. in Resident 43's room, Resident 43's catheter drainage bag was observed without a dignity covering. During a review of Resident 43's AR, dated 8/6/25, the AR indicated Resident 43 had a history of urinary retention (inability to completely empty the bladder) and urinary tract infections (a bacterial infection that affects any part of the urinary system, including the kidneys, bladder, ureters, and urethra). During a review of Resident 43's MDS, the MDS indicated a BIMS score of 3 indicating Resident 43 had severe cognitive impairment. During an interview on 8/4/25 at 2:13 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was unsure if resident's catheter drainage bags should have dignity coverings. During a concurrent observation and interview on 8/4/25 at 2:26 p.m. with CNA 3 in Resident 43's room, Resident 43's catheter drainage bag was observed without a dignity covering. CNA 3 stated dignity covers were used only when the residents were out of their rooms. During an interview on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated dignity covers were used only when the residents were out of their rooms. LVN 1 stated the residents catheter drainage bags could be visible to passersby in the hallways and could also be seen by visitors in the residents' rooms. LVN 1 stated residents catheter drainage bags should always have dignity covers. LVN 1 stated leaving residents' catheter drainage bags uncovered would cause a loss of dignity and privacy. LVN 1 stated all nursing staff were responsible to make sure residents' dignity and privacy were provided for. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated dignity covers were not being used while the residents were in their rooms. The DON stated dignity covers should be used in the rooms since the residents' catheter drainage bags could be visible to passersby in the hallways and could also be seen by visitors in the residents' rooms. The DON stated it was the responsibility of all nursing staff to make sure residents' dignity and privacy were provided for. The DON stated the use of dignity bags was important to maintain residents' dignity and privacy. During a review of the facility's job description document titled, Certified Nurse Assistant (CNA) - SNF or Sub Acute, dated 3/1/24, the job description indicated, . provide care in a manner that protects and promotes resident . dignity . During a review of the facility's job description document titled, Licensed Vocational Nurse (LVN), dated 3/1/14, the job description indicated, . assure that the rights of residents are respected and maintained by allowing for privacy and dignity in the provision of care . During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2021, indicated, . demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity . for example . helping the resident to store catheter bags discreetly . During a review of the facility's P&P titled, Resident Rights, dated 2021, indicated, . employees shall treat all residents with kindness, respect, and dignity . these rights include the resident's right to . a dignified existence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure five out of 16 sampled residents (Resident 4, Resident 8, Resident 11, Resident 28, and Resident 40) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when: 1. Resident 8, Resident 11, Resident 28 and Resident 40 were receiving antipsychotic (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions) and psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications and did not sign an informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). 2. Resident 4 and Resident 40 did not have a listed diagnosis on their consents for antipsychotic and psychotropic medications, and Resident 4's consent did not have the date the physician signed the consent. These failures had the potential to result in Resident 4, Resident 8, Resident 11, Resident 28, and Resident 40 taking medication against their will and not recognizing why the medications were being given and the potential side-effects (unintended or unwanted effects that can occur when taking a medicine) leading to illness or hospitalization. Findings: 1. During a review of Resident 8's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 8 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, thinking, and behavior). The AR indicated Resident 8 was her own responsible party (the individual authorized to make healthcare decisions). During a review of Resident 8's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 8/6/25 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's Order Entry, dated 7/27/25, was reviewed. The Order Entry indicated, [brand name for quetiapine] (antipsychotic) Oral (by mouth) Tablet 25 mg (milligram - a unit of mass or weight) . Give 1 tablet by mouth two times a day for bipolar disorder. Resident 8's Medication Administration Record (MAR - a document used in healthcare facilities to track and record the administration of medications to patients), dated 8/6/25 was also reviewed. The MAR indicated Resident 8 had a dose of quetiapine at 8 a.m. LVN 1 stated she gave Resident 8 her dose of quetiapine. Resident 8's AR, dated 8/6/25, was also reviewed. LVN 1 stated Resident 8 was her own responsible party. LVN 1 stated she did not see a signed informed consent for quetiapine for Resident 8. LVN 1 stated an informed consent should have been signed by Resident 8 prior to giving quetiapine. LVN 1 stated it was important for Resident 8 to sign an informed consent for quetiapine to ensure she understood the risks, benefits, side-effects, and had autonomy over her care. LVN 1 stated she did not check to see if Resident 8 had signed an informed consent for quetiapine prior to giving the medication. LVN 1 stated it would be important to verify if Resident 8 had signed an informed consent prior to giving to ensure Resident 8 was not given a medication against her will. LVN 1 stated Resident 8 could have had a reaction to quetiapine without knowing or understanding the side-effects of the medication which could lead to illness or hospitalization. During an interview on 8/6/25 at 11:45 a.m. with Resident 8, Resident 8 stated she was taking quetiapine for bipolar disorder. Resident 8 stated facility staff did not review the risks, benefits, or side-effects of quetiapine with her. Resident 8 stated she did not sign an informed consent for quetiapine. Resident 8 stated, It makes me feel left out, and like I'm not a part of my care. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated Resident 8 should have signed an informed consent for quetiapine. The DON stated it was important for Resident 8 to sign an informed consent for quetiapine to ensure she understood the risks, benefits, and side-effects. The DON stated Resident 8 had a right to know what medications she was taking and be involved in her care. The DON stated if Resident 8 took quetiapine without signing an informed consent, she would not be aware of the side-effects or know what symptoms to look for if she had a reaction. The DON stated licensed nurses should be verifying an informed consent had been signed by residents prior to giving antipsychotic medications. During an observation on 8/4/25 at 8:43 a.m. in Resident 11's room, Resident 11 was observed in bed sleeping, wearing oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 11 did not wake up when his name was called out. During a review of Resident 11's AR dated 8/6/25, the AR indicated Resident 11 was initially admitted to the facility from an acute care hospital on 8/26/22 with a re-admission on [DATE], with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 11's MDS, dated 6/5/25, the MDS section C indicated Resident 11 had a BIMS score of 13, which suggested Resident 11 was cognitively intact. During a concurrent interview and record review on 8/7/25 at 9:40 a.m. with LVN 2, Resident 11's Order Summary Report (OSR), dated 8/6/25 was reviewed. The OSR indicated, . escitalopram oxalate (medication used to treat depression and anxiety) oral tablet 5 milligrams (mg - a unit of measurement) . order status . active.order date . 1/1/25 .start date 1/2/25 . LVN 2 stated there was no consent in the system for Resident 11 taking escitalopram oxalate. LVN 2 stated Resident 11 should have had a consent for escitalopram oxalate as it was a chemical restraint (any drug that is used for discipline or convenience and not required to treat medical symptoms). LVN 2 stated Resident 11 should have consented for the medication to be sure he was aware of what the medication was given for and what it would do. LVN 2 stated the nurses should have been checking to be sure there was a consent signed by the resident or RP, prior to giving the medication. LVN 2 stated if there was no signed consent, it was a violation of the resident's right. LVN 2 stated the medication could have caused excess sedation and side effects the resident may not have been aware of and did not want. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars (a type of bed rail that provides a handhold) up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated [DATE], the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a concurrent interview and record review on 8/6/25 at 10:20 a.m. with LVN 1, Resident 28's OSR, dated 8/6/28 was reviewed. The OSR indicated, . sertraline HCI (medication used to treat depression and anxiety) oral tablet 25 mg . give 3 tablets by mouth at bedtime for anxiety m/b angry outburst . order status . active . order date 3/27/24 . LVN 1 stated Resident 28's order for sertraline HCI was placed on 3/27/24. LVN 1 stated there was no consent for Resident 28 taking sertraline medication found in system. LVN 1 stated Resident 28 should have had a consent signed and in the system prior to starting the medication. LVN 1 stated a signed consent was important because it showed the resident and/or responsible party (RP) understood why the resident was on the medication, the possible side effects of the medication, both short term and long term, and were in agreement with the resident taking the medication. During a concurrent observation and interview on 8/5/25 at 11:11 a.m. in the hall outside of Resident 40's room, Resident 40 was observed dressed in a wheelchair with a wrist splint on his left wrist. Resident 40 stated he had been at the facility for three years. Resident 40 stated he had ataxia, (poor muscle control that causes clumsy movements and can affect walking and balance, hand coordination, speech and swallowing, and eye movements) and could not walk or use his hands. Resident 40 stated he did not call staff for help as he was self-sufficient. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact. During a concurrent interview and record review on 8/7/25 at 9:47 a.m. with LVN 2, Resident 40's OSR, dated 8/6/25 was reviewed. The OSR indicated, . alprazolam (mediation used to treat anxiety disorders and panic attacks) give 1 tablet by mouth two times a day for anxiety m/b increased tremors . order status .active.order date.2/3/23. LVN 2 stated there was no consent in the system for Resident 40's alprazolam medication. LVN 2 stated Resident 40 should have had a signed consent for alprazolam since it was a chemical restraint. LVN 2 stated Resident 40 should have consented for the medication to be aware of what medication was for and what it would do. LVN 2 stated Resident 40 should have consented to taking the medication prior to administration of the medication so he would have been aware of the possible side effects. LVN 2 stated the nurses should have checked to be sure there was a consent before giving the medication to Resident 40. LVN 2 stated if there was not a signed consent, it was a violation of Resident 40's right to be informed of the possible side effects of excess sedation and other side effects the Resident 40 may not have been aware of and did not want. 2. During an observation on 8/4/25 at 8:44 a.m. in Resident 4's room, Resident 4 was observed wearing a gown, sleeping. Enteral feeding (artificial nutrition - nutrition provided to the body through a vein or a tube inserted in the stomach, when a person can no longer take in food by mouth) pole and pump next to Resident 4's bed with no nutrition bottle or fluids connected. During a review of Resident 4's AR, dated 8/6/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it, caused by an outside force, usually a violent blow to the head) with loss of consciousness, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dysphagia (difficulty swallowing), unspecified speech disturbances, symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 4's MDS, dated 5/9/25, the MDS section C indicated Resident 4 had a BIMS score of 3, which indicated Resident 4 was severely cognitively impaired. During a concurrent interview and record review on 8/6/25 at 10:26 a.m. with LVN 2, Resident 4's OSR, dated 8/6/25 was reviewed. The OSR indicated, . lorazepam (medication used to treat anxiety disorders) 0.5 mg give 1 tablet via G-tube one time a day for anxiety unspecified m/b inability to relax, fidgeting . order status . active . order date 11/22/24 . Divalproex sodium (medication to treat seizures) sprinkles give 1 capsule via g-tube at bedtime for mood stability m/b increased behaviors of aggressiveness toward staff . order status . active . order date . 1/17/23 . quetiapine fumarate (antipsychotic medication) oral tablet 25 mg give 0.5 tablet via g-tube two times a day for schizophrenia, m/b grabbing things, something not there, kicking movements (0.5 tab = 12.5 mg) . order status . active . order date . 1/24/25 . Resident 4's Chemical Restraint Informed Consent (Consent), dated 1/29/22 was reviewed. The Consent indicated, [Brand name quetiapine] 50 mg, 1 tab at bedtime . No diagnosis was indicated. Resident 4's Consent, dated 2/26/22 was reviewed. The Consent indicated no date was entered for the physician's signature. Resident 4's Consent dated 4/19/24 was reviewed. The Consent indicated, no date was entered for the physician's signature. Resident 4's Consent, dated 11/26/24 was reviewed. The Consent indicated, . [brand name lorazepam] 0.5 mg give 1 tab by mouth (p.o.) at noon. No diagnosis was indicated. Resident 4's Consent, dated 6/5/24 was reviewed. The Consent indicated, . [brand name divalproex sodium] 125 mg at bedtime (HS) . No diagnosis was indicated. LVN 2 stated Resident 4's consents all should have had a diagnosis listed. LVN 2 stated the diagnosis on the Consent informed the resident or RP of the indication the medication was being given for. LVN 2 stated the Consent should have had the date the physician signed the Consent. LVN 2 stated the date indicated when the physician discussed the medication, why it was being given, the risks and benefits and possible side effects of the medication with the resident or RP. LVN 2 stated the Consent was not valid without a physician's signature. LVN 2 stated the Resident 4 needed to have a valid Consent prior to nurses administering the medication. During a concurrent interview and record review on 8/7/25 at 9:47 a.m. with LVN 2, Resident 40's Consent, dated 4/22/25 was reviewed. The Consent indicated, .trazadone (used to treat depression and anxiety) 50 mg, give 0.5 tab. [by mouth] HS. No diagnosis was listed on the Consent. LVN 2 stated Resident 40's diagnosis should have been listed on his Consent form for trazadone. LVN 2 stated the diagnosis on the Consent informed Resident 40 of the reasons the medication was being given. LVN 2 stated Resident 40 should have had a completed consent prior to taking the medication so he would have been informed of the reasons why he was being given the medication. During an interview on 8/7/25 at 1:35 p.m. with the Pharmacist Consultant (PC), the PC stated he reviews residents' medications when he is at the facility once a month. The PC stated during his review he will look at the entire medical record and will review consents periodically. The PC stated the consents were reviewed during the facility's psychotropic meetings. The PC stated consents were between the resident and the physician, and it was up to the physician's discretion regarding what was discussed and what was on the consent. During an interview on 8/7/25 at 3:03 p.m. with the Director of Nursing (DON), the DON stated residents who took psychotropic and antipsychotic medications should have had a consent. The DON stated the consent was important because it let the residents know what the benefits and possible side effects were. The DON stated consents should have had a diagnosis to inform the residents why they were taking the medication, for what problem. The DON stated it was the residents' right to know what they were taking and to be involved in their care. The DON it was important to get permission from the residents, and it was the residents' right to decide if they wanted to take the medication or not. The DON stated the doctor needed to review the consent with the resident and sign and date the consent after it was reviewed with the resident or RP. The DON stated it was a risk to residents to have taken a medication they did not consent to. The DON stated the residents might not have been aware of the side effects and could have had hallucinations and not know why. The DON stated the consent form was not valid without a date on the physician's signature. During an interview on 8/7/25 at 4:36 p.m. with the Medical Records (MR) coordinator, the MR stated she checked the resident Consent forms for signatures, diagnoses, and correct dates. The MR stated the consent forms should have had a date of the physician's signature. The MR stated a completed consent was important due to it being a legal document and it should have been dated appropriately. The MR stated the Medical Records department was ultimately responsible for checking to be sure forms were completed prior to scanning them into the resident's chart. The MR stated physician dated Consents were important to verify the resident or RP were educated on the risks and benefits of the medication or treatment before nurses administered the medication or treatment. During a review of the facility's job description document titled, Charge Nurse, dated 3/1/14, the document indicated, .respect rights of residents regarding freedom of choice, consent for care and services .inform the resident in advance about care and treatment . During a review of the facility's job description document titled, Medical Records Director, dated 3/1/14, the document indicated, . establishes and implements policies to ensure that records are complete, accurately documented. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/ Psychotropic Medication Use, (undated), indicated, . the resident . has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers . prior to administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), . a licensed nurse must verify informed consent has been obtained from the resident . prior to administering psychotropic medication.the facility must record the signed written consent in the resident's medical record.the facility must verify the presence of written informed consent in the resident's medical record before initiating treatment with psychotropic medication. During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, Residents . will be informed of the recommendation risks, benefits, purpose and potential adverse consequences of antipsychotic medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for five of 16 residents (Resident 8, Resident 15, Resident 28, Resident 40, and Resident 52) when: 1. Resident 8's care plan was not developed and implemented for the administration and monitoring of anti-psychotic medication (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions). This failure had the potential to result in Resident 8 receiving inadequate medication efficacy (the ability to produce a desired or intended result) and potential side effects to go undocumented and had the potential for Resident 8 to not have his mental and psychosocial needs met. 2. Resident 15 and Resident 28 did not have an individualized care plan developed and implemented for the use of (brand name for acetylsalicylic acid - ASA), an anti-platelet medication (medications that prevent blood cells from sticking together and forming blood clots) and placed Resident 15 and Resident 28 at risk of increased bruising and bleeding. This failure had the potential to result in Resident 15 and Resident 28 to go unmonitored for potential side effects of ASA and an increase in potential bruising and bleeding. 3. Resident 28, Resident 40 and Resident 52 did not have an individualized care plan developed and implemented for the use of side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a raised or lowered position) and bed assist rails (a bed rail used to assist the resident with repositioning or getting in and out of bed). This failure had the potential to result in Resident 28, Resident 40 and Resident 52 to be at risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death.Findings: 1. During a review of Resident 8's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 8 had a history of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, thinking, and behavior). During a concurrent interview and record review on 8/6/25 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's Order Entry, dated 7/27/25, was reviewed. The Order Entry indicated, . [brand name for quetiapine] (antipsychotic) Oral (by mouth) Tablet 25 mg (milligram - a unit of mass or weight) . Give 1 tablet by mouth two times a day for bipolar disorder . LVN 1 stated Resident 8 did not have a care plan for her antipsychotic (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions) medication. LVN 1 stated Resident 8 should have had a care plan for antipsychotic medication. LVN 1 stated an antipsychotic care plan would help to identify whether Resident 8 should continue the medication and potential side-effects. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated if a resident was taking an antipsychotic medication, there should be a care plan. The DON stated the licensed nurse should implement the care plan. The DON stated goals and interventions for Resident 8 would be difficult to identify without a care plan for antipsychotics. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 2. During a concurrent observation and interview on 8/4/25 at 8:11 a.m. in Resident 15's room, Resident 15 was observed dressed, in bed with side rails up on both sides of the head of the bed. Resident 15 stated he had been at the facility for one week due to a broken hip from falling off the bed at home. Resident 15 had small areas of bruising on his right arm, which Resident 15 stated he received from his fall. During a review of Resident 15's AR, dated 8/6/25, the AR indicated Resident 15 was admitted from an acute care hospital on 7/29/25 with diagnoses of intertrochanteric fracture of the left femur (a break in the upper bone of the thigh - hip), cerebral ischemia (insufficient blood flow to the brain resulting in damage to brain tissue), and muscle weakness. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/5/24, the MDS section C indicated Resident 15 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 15 was cognitively intact. During a review of Resident 15's Order Summary Report (OSR), dated 8/6/25, the OSR indicated, .[brand name medication for acetylsalicylic acid - (ASA)] 81 (mg) 1 oral tablet chewable give 1 tablet by mouth two times a day for prophylaxis (prevention) status post (S/P) surgery for 6 weeks . order status . active . order date . 7/30/25 . During a concurrent interview and record review with LVN 1 on 8/5/25 at 10:30 a.m., Resident 15's CP, undated and Order Summary Report (OSR), undated were reviewed. The CP' and OSR indicated there was no care plan or orders for monitoring Resident 15 for bruising and bleeding. LVN 1 stated (brand name medication for acetylsalicylic acid - ASA) was a blood thinner Resident 15 took for prevention of blood clots. LVN 1 stated the medication made Resident 15 more prone for bruising and bleeding and staff needed to monitor Resident 15 for discoloration and if his surgical site did not heal. LVN 1 stated bruising meant Resident 15 was bleeding and not healing. LVN 1 stated a care plan for monitoring of Resident 15's use of ASA for increased bruising and bleeding informed other staff Resident 15 was on medication and required additional monitoring. LVN 1 stated if there was no care plan, the night shift may not have known the morning shift gave the medication for the prevention of clotting and would not have known to look for increased bruising on Resident 15. LVN 1 stated a care plan was important for continuity of resident care. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars (a type of bed rail that provides a handhold) up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis the loss of the ability to move and sometimes to feel anything on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated [DATE], the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a review of Resident 28's OSR, dated 8/6/25, the OSR indicated, .[brand name medication for acetylsalicylic acid - (ASA)] 81 (mg) tablet chewable give 1 tablet by mouth one time a day for prophylaxis cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain).order status . active.order date . 3/5/21. During a concurrent interview and record review on 8/5/25 at 10:32 a.m. Resident 28's CP, undated was reviewed. The CP indicated there was no care plan for monitoring Resident 28 for bruising or bleeding. LVN 1 stated there should have been a care plan to monitor Resident 28 for bruising or discoloration, or bleeding. LVN 1 stated (brand name medication for acetylsalicylic acid - ASA) was a blood thinner Resident 28 took to prevent a stroke (CVA). LVN 1 stated the medication made Resident 28 more prone for bruising and bleeding and the staff needed to monitor Resident 28. LVN 1 stated a care plan for monitoring Resident 28 for bruising and bleeding informed other staff Resident 28 was on medication that needed to be monitored. LVN 1 stated a care plan was important for continuity of resident care. During an interview on 8/6/25 at 10:15 a.m. with the DON, the DON stated residents on blood thinners had a standard care plan for monitoring for bleeding and bruising, but they had not had a care plan for residents on anti-platelet medication. The DON stated residents on anti-platelet medication should have had a care plan for monitoring the residents for bleeding and bruising as the medication could have caused the residents to bleed and bruise more easily. The DON stated the resident's CP was not individualize if they did not have monitoring for side effects of their specific medication. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 3. During a record review of Resident 28's CP undated, Resident 28's CP indicated there was no care plan for bed rail use and safety for Resident 28. During a concurrent interview and record review on 8/5/25 at 9:53 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 28's OSR, dated 8/6/25 was reviewed. The OSD indicated, . stationary assist device bilateral to serve as an enabler to promote independence . per resident want bed against the wall . order status . active . order date .4/3/25 . Resident 28's CP, undated was reviewed. The CP indicated there was no care plan for monitoring and for safety of Resident 28's assist rail use. LVN 1 stated there should have been a care plan for Resident 28's assist rail use. LVN 1 stated Resident 28 should have had a care plan for bed rails or assist rail use due to his risk for falls and for his safety when using the assist rails. LVN 1 stated bed rail and assist rail care plans ensured bed rails and assist rails were being used appropriately to avoid injury to the residents. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact During a concurrent interview and record review on 8/5/25 at 9:44 a.m. Resident 40's OSR, dated 8/6/25 was reviewed. The OSR indicated, . stationary assist device bilateral to serve as an enabler to promote independence . order status . active. order date . 2/25/25. Resident 40's CP, undated was reviewed. The CP indicated there was no care plan in place for Resident 40's use of bed rails or assist rails. LVN 1 stated Resident 40 should have had a care plan for assist rail use due to his risk for falls and for his safety when using them. LVN 1 stated assist rail care plans ensured the assist rails were being used appropriately to avoid injury to the residents. During a concurrent interview and record review on 8/5/25 at 9:41 a.m. with LVN 1, Resident 52's Order Entry, dated 6/30/23, was reviewed. The Order Entry indicated, . Order Summary: SIDE RAILS: half rails up as per Dr.'s order for safety during care provision, to assist with bed mobility . LVN 1 stated Resident 52 did not have a care plan for bed rails. LVN 1 stated Resident 52 should have a bed rail care plan for her safety. LVN 1 stated bed rail care plans ensure bed rails are being used appropriately to avoid injury to the resident. During an interview on 8/7/25 at 2:58 p.m. with the DON, the DON stated bed rails were used for resident's safety and helped with positioning the residents. The DON stated the resident's use of bed rails should have been care planned to monitor the resident for their safety when being used and to verify there was no risk of entrapment, which could have caused harm to the resident. The DON stated bed rails and assist rails were considered a restraint and there should have been an order from the physician for monitoring the residents for safety when using the bed rails or assist rails. The DON stated care plans explained what the goal was for the residents and what interventions staff were to take when caring for the residents. The DON stated bed rail care plans helped facility staff assess residents for the ongoing need for bed rails. The DON stated the resident's care plan was not individualized if monitoring the residents for safety when using the bed rail or assist rail was not in the resident's care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of the facility's P&P titled, Goals and Objectives, Care Plans, dated 4/2009, indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives are . resident oriented . goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of practice for two of 15 sampled residents (Resident 4 and 64), when: 1. Resident 4's tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube) flush (water that is pushed through the feeding tube to keep it clean and prevent clogs) bag was not labeled with the date and time it was hung for administration. This failure had the potential to result in Resident 4 receiving an expired tube feeding flush and placed Resident 4 at increased risk of food born illness (any illness resulting from ingesting contaminated/spoiled foods or liquids) and infection. 2. Resident 64 had a 6.2-pound weight gain and the facility did not notify the Registered Dietician (RD) and physician. This failure had the potential for the RD and physician to not be updated and making changes and recommendations for Resident 64's weight gain. Findings: 1. During a concurrent observation and interview on 8/4/25 at 2:21 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 4’s room, enteral feeding and fluid flush bag were observed infusing at a rate of 65 milliliters per hour (ml/hr. – a unit of measurement). Resident 4’s fluid bag for flushes was not labeled and had approximately 450 ml of fluid remaining in a 1000 ml bag. Resident 4’s enteral nutrition bottle was labeled with the date, time and initials of a nurse, with 1000 ml of fluid nutrition remaining. LVN 3 stated Resident 4 was scheduled to be disconnected from his fluid flush every four hours. LVN 3 stated the fluid flushes were connected to the tube feeding as a set and could not be hung separately, so a date was not required on the flush bag. LVN 3 stated a new set was hung every morning with a new flush bag and a new nutrition bottle. During a review of Resident 4’s “admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information”, dated 8/6/25, the “AR” indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it, caused by an outside force, usually a violent blow to the head) with loss of consciousness, schizophrenia (a disorder that affects a person’s ability to think, feel, and behave clearly), dysphagia (difficulty swallowing), unspecified speech disturbances, symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 4’s “Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)”, dated 5/9/25, the “MDS” section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 4 was severely cognitively impaired. During a concurrent interview and record review on 8/5/25 at 10:40 a.m. with LVN 1, Resident 4’s “Order Summary Report (OSR)”, dated 8/6/25 was reviewed. The “OSR” indicated, “… flush g-tube (gastric tube) 150 ml every 4 hours while on continuous feed for 20 hrs. …” LVN 1 stated Resident 4’s flush was hung at noon every day with a new enteral nutrition bottle and new fluids for flushing with 1000 ml of fluids. LVN 1 stated Resident 4’s flush bag should have been labeled with the date and time it was hung. LVN 1 stated a new 1000 ml bag of fluids should have been hung with each new bottle of enteral nutrition. LVN 1 stated the flush bag can be separated from the nutritional feeding. LVN 1 stated it was important for the flush bag to be labeled to be sure it was being changed and so staff knew how long it was up. LVN 1 stated the flush bag could have been a source of infection to Resident 4 since the flush and feeding went directly into Resident 4’s body. During an interview on 8/7/25 at 3:47 p.m. with the Director of Nursing (DON), the DON stated Resident 4’s fluid flush bag should have been labeled with the date, time and initials when it was hung. The DON stated the fluids should have been “fresh”, and she did not want “old” or expired fluids used for flushing Resident 4’s G-tube. The DON stated there was the possibility of contaminants going into the G-tube if “old” fluids were used. The DON stated using “old” fluids put Resident 4 at risk of getting an infection. During a review of the facility lesson plan document titled, “Meal Percentages and Documentation/G-Tube Head of Bed (HOB) 45 degrees”, dated 12/30/24, the document indicated, “… labeling and dating of G-tube supplies (syringe, formula, and water (h2o) spike set …” During a review of the facility’s job description document titled, “Licensed Vocational Nurse (LVN)”, dated 3/1/14, the document indicated, “…provide treatment administration in a proficient manner … proficiently provide and manage the care of technologically dependent residents, including but not limited to … enteral feeding tubes …” During a review of the facility’s policy and procedure (P&P) titled, “Enteral Nutrition”, dated 11/2018, the P&P indicated, “… adequate nutritional support through enteral nutrition is provided to residents as ordered … the nurse confirms that orders for enteral nutrition are complete … administration method … volume and rate of administration … instructions for flushing (solution, volume, frequency, timing and 24-hour volume) …” 2. During a review of Resident 64’s “admission Record” (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 64 was admitted to the facility on [DATE] with diagnoses) severe protein-calorie malnutrition ( serious condition resulting from a deficiency in both calories and protein intake), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness, obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blocked airway) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Resident 64s “Minimum Data Set” (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 64 had no cognitive impairment. During a concurrent observation and interview on 8/4/25 at 3:40 p.m. in the room with Resident 64, Resident 64 was in bed, dressed and lying in bed. Family Member (FM) 1, FM 1 stated she was concerned about Resident 64’s weight loss. FM 1 stated Resident 64 was 130 pounds (lbs.-units of measurement) before coming to the facility. FM 1 sated Resident 64 was getting formula through a tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube). FM 1 stated she called Resident 64’s RD from outside the facility. FM 1 stated she did not realize the facility had a RD in the facility to address her concerns. During a concurrent interview and record review on 8/7/25 at 11:11 a.m. with the Restorative Nursing Assistant (RNA- specialized healthcare professional who works under the supervision of a nurse or therapist to help patients regain and maintain physical function after illness or injury) 1, Resident 64’s “Weights and Vital Summary dated 8/8/25 was reviewed. The Weights and Vital Summary indicate, on 8/1/25 his weight was 125.8 lbs. and on 8/6/25 and 8/6/25 was 132 lbs. The RNA stated Resident 64 had a weight gain of 6.2 lbs. in 5 days. The RNA stated she did not re-check his weight. The RNA stated she gave the weight log to the Assistant Director of Nursing (ADON) and the ADON should have notified the RD and physician. The RNA stated the ADON would have been notified the RD and physician when residents had significant weight changes. The RNA stated she should have re-checked his weight the same day but did not. The RNA stated it was important to recheck his weight to ensure his weight was accurate. The RNA stated an inaccurate reading could have caused Resident 64’s issues to not be addressed or missed diagnosis. During an interview on 8/7/25 at 3:57 p.m. with the ADON, the ADON stated she should have notified the physician about Resident 64’s weight gain. The ADON stated she had not had a chance to do the charting. The ADON stated she should have notified the RD and reviewed the weight gain. The ADON stated the RD and the physician should have been notified within 24 hours after obtaining Resident 64’s weight. The ADON stated it was important to notify the RD and physician in case there were changes needed to address issues like edema (excess of watery fluid collecting in the tissues). The ADON stated not notifying the physician and RD could have been detrimental to Resident 64’s health. During an interview on 8/7/25 at 4:01 p.m. with the DON, the DON stated the RNA should have reweighed Resident 64 to make sure it was accurate. The DON stated the RNA should have done it the same day if possible. The DON stated the ADON should have notified the physician and RD of the weight gain. The DON stated the 6.2 lbs. weight gain could have been from edema (swollen area) or indication of “systemic changes” and the physician should have been notified to make recommendation or changes in the intervention. The DON stated the physician would not have been given the chance to make changes if he was not notified of the weight gain. During an interview on 8/8/25 at 8:45 a.m. with the RD, the RD stated the ADON should have notified her of Resident 64’s weight gain. The RD stated the ADON emailed her twice a week regarding the changes in resident weight. The RD stated she was not notified of Resident 64’s weight gain. The RD stated the facility should recheck the weight. The RD stated the resident was not in the facility long enough to make a recommendation. The RD stated she would have asked to recheck his weigh and ask to check again next week. During a review of the facility’s policy and procedures (P&P) titled, “Nutrition (impaired)/Unplanned Weight Loss-Clinical Protocol” dated 9/2017, the P&P indicated, “…The staff will report to the physician significant weight gains or losses or any abrupt or persistent changes…”

F687 - Foot Care Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice for two of 16 sampled residents (Resident 32 and Resident 48) when Resident 32 and Resident 48 were diabetic (a condition where the body doesn't properly regulate blood sugar levels) and had long, overgrown toenails. This failure had the potential to result in Resident 32 and Resident 48 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization. Findings: During a review of Resident 32's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 1 had a history of type 2 diabetes mellitus (a chronic condition where the body doesn't properly use insulin, leading to elevated blood sugar levels). During a review of Resident 32's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 7 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had severe cognitive impairment. During a review of Resident 48's AR dated 8/7/25, the AR indicated Resident 1 had a history of type 2 diabetes mellitus. During a review of Resident 48's MDS, the MDS indicated a BIMS score of 12 indicating Resident 48 had moderate cognitive impairment. During a review of Resident 48's Care Plan Report (a document that outlines a patient's assessed health needs, the care and support they will receive, and the expected outcomes), dated 8/8/25, the Care Plan Report indicated, The patient presents with significant weakness and difficulty performing activities of daily living (ADL - basic self-care tasks that are essential for maintaining independence and quality of life) tasks. During a concurrent observation and interview on 8/4/25 at 12:21 p.m. with Resident 48 in Resident 48's room, Resident 48's toenails on the left and right feet were long and growing past the top of the toes. Resident 48 stated she would like her toenails to be trimmed. Resident 48 stated she did not like her toenails long and she could scratch herself. During an observation on 8/4/25 at 12:37 p.m. in Resident 32's room, Resident 32's toenails on the left and right feet were long, growing past the top of the toes and curling under towards the skin. During a concurrent observation and interview on 8/4/25 at 2:26 p.m. with Certified Nursing Assistant (CNA) 4 in Resident 32's room, Resident 32's toenails were observed. CNA 4 stated Resident 32's toenails were long and needed to be trimmed. CNA 4 stated a podiatrist (a healthcare professional who specializes in the diagnosis and treatment of foot, ankle, and lower leg conditions) should trim Resident 32's toenails since she was diabetic. CNA 4 stated CNAs should notice if a resident needed their toenails trimmed during ADL care and inform the licensed nurse. CNA 4 stated the licensed nurse should contact the podiatrist. During a concurrent observation and interview on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, a photo of Resident 32's toenails that was taken on 8/4/25 was observed. LVN 1 stated Resident 32's toenails needed to be trimmed. LVN 1 stated Resident 32 was a diabetic and needed a referral to a podiatrist for foot care. LVN 1 stated licensed nurses should look at the resident's feet when they do assessments. LVN 1 stated CNAs should look at resident's feet during ADL care and report long toenails to licensed nurses. LVN 1 stated Resident 32's toenails could cut or scrape her skin, and wounds would be slow to heal due to Resident 32 being diabetic. During a concurrent interview and record review on 8/5/25 at 10:44 a.m. with LVN 1, Resident 32's Care Plan Report, dated 8/6/25, was reviewed. The Care Plan Report indicated, Focus: The resident has Diabetes Mellitus . diabetic foot ulcer history . Date initiated: 2/26/2025 . Interventions: Refer to podiatrist/ foot care nurse to monitor/ document foot care needs and to cut long nails. LVN 1 stated Resident 32 had a care plan for foot care but did not have a podiatry referral. LVN 1 stated referrals orders were made by the physician and referral appointments were made by the Social Services Director (SSD). During a concurrent interview and record review on 8/5/25 at 11:54 a.m. with the SSD, Resident 32's Care Plan Report, dated 8/6/25, was reviewed. The Care Plan Report indicated, Focus: The resident has Diabetes Mellitus . diabetic foot ulcer history . Date initiated: 2/26/2025 . Interventions: Refer to podiatrist/ foot care nurse to monitor/ document foot care needs and to cut long nails. The SSD stated she was not aware of Resident 32's Care Plan Report. The SSD stated, It looks like this resident got lost in the shuffle. The SSD stated Resident 32 and Resident 48 did not have podiatry referrals. During an interview on 8/7/25 at 2:58 p.m. with the Director of Nursing (DON), the DON stated CNAs should report long toenails on diabetic residents to the licensed nurses. The DON stated licensed nurses should report long toenails on diabetic residents to the physician or SSD to get a referral to podiatry. The DON stated if licensed nurses initiated care plans for foot care, they should have followed up with the DON or SSD for a podiatry referral. The DON stated a podiatrist should have seen Resident 32 and Resident 48 prior to 8/7/25. The DON stated diabetic residents are more prone to infection. The DON stated Resident 32 and Resident 48 could scratch themselves with their long toenails, leading to infection and potential hospitalization. During a review of the LVN job description, dated 3/1/14, the LVN job description indicated, Follow through on resident care services needed to meet the individualized needs of each resident. During a review of the SSD job description, dated 3/1/14, the SSD job description indicated, Make referrals and obtain services from outside entities . During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 10/2022, indicated, Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes .). Residents are assisted in making appointments . with . specialists (podiatrist .) as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure four of 16 sampled resident's (Residents 5, 28, 40, and 52) beds were assessed for appropriate bed dimensions, and followed the manufacturers' recommendations and specifications for installing and maintaining the resident's bed side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a raised or lowered position). This failure had the potential to cause entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death to Residents 5, 28, 40, and 52. Findings: During an observation on 8/4/25 at 8:08 a.m. in Resident 5's room, Resident 5 was observed lying on her back with assist bars (a type of bed rail that provides a handhold) up on both sides of her bed. During a review of Resident 5's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/6/25, the AR indicated Resident 5 was initially admitted to the facility from an acute care hospital on 3/8/22 with a diagnosis of cerebral palsy (a disorder that affect a person's ability to move and maintain balance and posture), and stroke (occurs when blood flow to the brain is disrupted). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/6/25, the MDS section C indicated Resident 5 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 5 was cognitively intact. During an observation on 8/4/25 at 8:41 a.m. in Resident 28's Room, Resident 28 was observed dressed in a shirt, sleeping with assist bars up on both sides of his bed. Resident 28 did not wake up when his name was called out. During a review of Resident 28's AR, dated 8/6/25, the AR indicated Resident 28 was initially admitted to the facility from an acute care hospital on 9/8/2010 with a re-admission on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (a disorder that makes it difficult to speak), and a history of falling. During a review of Resident 28's MDS, dated 6/5/25, the MDS section C indicated Resident 28 had a BIMS score of 3, which suggested Resident 28 was severely cognitively impaired. During a review of Resident 28's electronic chart, the electronic chart indicated no baseline assessment or bed assessment for bed rails was observed in Resident 28's chart. Resident 28's Order Summary Report (OSR), dated 3/8/21 was reviewed. The OSR indicated, . Resident is not capable of making and understanding his/her own decisions due to history of (H/o) cerebral vascular accident (CVA) and cognitive issues. Surrogate decision maker is his nephew.order date 3/8/21.stationary assist device bilateral (both sides) to serve as an enabler to promote independence .per resident wants bed against the wall. order date 4/3/25. During an observation on 8/4/25 at 8:49 a.m. in Resident 40's room, Resident 40's bed was observed to be made and had assist bars up at the head of the bed. Resident 40 was not present in his room. During an observation and interview on 8/5/25 at 11:11 a.m. in the hall outside of Resident 40's room, Resident 40 was observed dressed and in a wheelchair with a wrist splint on his left wrist. Resident 40 stated he had been at the facility for three years. Resident 40 stated he had ataxia, (poor muscle control that causes clumsy movements and can affect walking and balance, hand coordination, speech and swallowing, and eye movements) and could not walk or use his hands. Resident 40 stated he did not call staff for help as he was self-sufficient. During a review of Resident 40's AR, dated 8/6/25, the AR indicated Resident 40 was admitted on [DATE] with diagnoses of ataxia, delusional disorders (a mental condition with false beliefs or judgment about external reality), other symptoms and signs involving cognitive functions (functions involving thinking, reasoning and remembering) and awareness, anxiety disorder(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), muscle weakness, and need for assistance with personal care. During a review of Resident 40's MDS, dated 6/20/25, the MDS section C indicated Resident 40 had a BIMS score of 15, which indicated Resident 40 was cognitively intact. During a review or Resident 40's OSR, dated 8/6/25, the OSR indicated, .stationary assist device bilateral to serve as an enabler to promote independence . order date 5/3/22 . 7:39 p.m. There was no bed rail assessment (a process where a resident's need for bed rails is evaluated, considering their physical and cognitive abilities, risk of falls, and potential for entrapment) in the electronic chart for Resident 40. During an observation on 8/4/25 at 10:28 a.m., in Resident 52's room, Resident 52 was observed lying on her right side with assist bars up on both sides of her bed. During a review of Resident 52's AR, dated 8/6/25, the AR indicated Resident 52 was initially admitted to the facility from a skilled nursing facility on 11/12/21 with a diagnosis of unspecified dementia and stroke. During a review of Resident 52's MDS, dated 6/13/25, the MDS section C indicated Resident 52 had a BIMS score of 3, which suggested Resident 52 severely cognitively impaired. During a concurrent interview and record review on 8/5/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 5's MD (Medical Doctor) Order, dated 10/14/22, was reviewed. The MD Order indicated, Order Summary: SIDE RAILS: half rails up x2 to assist with bed mobility and promote independence . LVN 1 stated Resident 5 did not have a bed rail assessment (a process where a resident's need for bed rails is evaluated, considering their physical and cognitive abilities, risk of falls, and potential for entrapment) completed. Resident 52's MD Order, dated 6/30/23, was also reviewed. The MD Order indicated, Order Summary: half rails up as per doctor's order for safety during care provision, to assist with bed mobility . LVN 1 stated Resident 52 did not have a bed rail assessment completed. LVN 1 stated Resident 5 and Resident 52 should have had a bed rail assessment completed at the time the bed rails were ordered and before the bed rails were placed on the bed. LVN 1 stated bed rail assessments were important to ensure they were necessary for the residents and to ensure the equipment was properly installed, safe to use, and to avoid injury to the residents. During an interview on 8/5/25 at 9:53 a.m. with LVN 1, LVN 1 stated the facility did resident assessments for the use of bed rails on admission. LVN 1 stated if there were new bed rail orders she checked with the Director of Nursing (DON) regarding the resident's bed rail assessment. LVN 1 stated she was not sure who physically checked the resident's bed for proper rails and assessments. During a concurrent interview and record review on 8/5/25 at 4:11 p.m. with the Maintenance Director (MAINT), the MAINT stated he went monthly to check resident bed rails for sharp edges and to verify the rails were not loose. The MAINT stated he had a log on his (name brand) electronic system for repair requests and marked it off when the task was done. The MAINT stated there was no form to complete for bed assessments and the system did not specify what was checked on the bed. The MAINT stated it was important for the mattress on the bed to be the proper size. The MAINT stated the resident's bed mattress could not be bigger or smaller than the bed. The MAINT stated if the mattress was not the proper size, the metal parts of the bed frame could have been exposed and caused breaks in the resident's skin, injury to the resident, and if there were gaps between the mattress and the bed rails, the residents could have gotten caught in the gap and been injured. During an interview on 8/7/25 at 3:03 p.m. with the DON, the DON stated residents needed a physician order for the use of bed rails they were considered restraints. The DON stated maintenance did a bed assessment if there was any problem with the mattress or if the bed rail did not go up. The DON stated maintenance should have been looking to be sure the bed rails were secured properly and there was a proper gap between the bed and the bed rails. The DON stated residents used the bed rails for safety and positioning. The DON stated if gaps between the bed rails and mattress were not being checked, it was a safety risk to the residents. The DON stated there was a risk of skin injury, discoloration of the skin, and the residents could have gotten caught in the gaps. The DON stated her expectation was for maintenance to look at the bed mattresses and rails to be sure there were no gaps. The DON stated she also expected the Certified Nursing Assistants (CNA)s to also check the bed and rails for gaps when doing resident care. During a review of the facility's job description (JD) document titled, Maintenance Director, undated, the JD indicated, . the Maintenance Director is responsible to maintain the facility in good repair at all times . ensure that all interior fixtures in good repair . oversee general repair, including . loose handrails or grab bars. During a review of the facility's policy and procedure (P&P) titled, Bed Safety, dated 2001, indicated, . our facility shall strive to provide a safe sleeping environment for the resident . the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement . to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, . and bed accessories) . inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA) (Note: the review shall consider situations that could be caused by the resident's weight, movement or bed position.) . ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit . identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .

Based on observation, interview and record review, the facility failed to ensure medications in one of two surveyed medication carts were labeled and stored according to their Medication Labeling and Storage policy when: one vial of insulin (a hormone that lowers the level of sugar in the blood), and one bottle of melatonin (supplement commonly used to aid in sleep) did not have an open date or expiration date.This failure had the potential for residents to receive expired medication.During a concurrent observation and interview on 8/7/25 at 11:39 a.m. with Licensed Vocational Nurse (LVN) 2 at medication cart two, one vial of insulin and one bottle of melatonin did not have an open date, or an expiration date written on the bottle. LVN 2 stated, there must be an open date on all medication and a visible expiration date to prevent residents from receiving expired medications. During an interview on 8/7/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated, it is my expectation to have all medication dated with an open date and a visible expiration date. During a concurrent interview and record review on 8/7/25 at 12:10 p.m. with the Pharmaceutical Consultant (PC), the facilities policy and procedure (P&P) titled, Medication Label and Storage, dated 2/2023 was reviewed. The P&P indicated, . The medication label includes, at a minimum: expiration date . appropriate instructions and precautions . multi-dose vials that have been opened or assessed (e.g., needle punctured) are dated and discarded within 28 days . The PC stated his expectations were for the staff to label all medications with the date opened and a clear visible expiration date to prevent residents receiving ineffective, expired medications.

Based on observation, interview and record review, the facility failed to follow their Waste Disposal policy when two of four garbage bins had their lids open.This failure had the potential to attract insects and rodents which could transmit disease and infection to the residents in the facility. FindingsDuring an observation and interview on 8/5/25 at 2:46 p.m. with the Housekeeping Supervisor (HSK), outside the facility, two trash bins were observed with their lids open. The HSK stated that the trash bins should always be covered to prevent rodents and insects from getting into the trash and then coming into the facility which could make the residents sick. During an interview on 8/5/25 at 3:45 p.m. with the Maintenance Supervisor (MAINT), the MAINT stated all trash inside and outside of the facility should always be covered to prevent insects, and rodents from getting into the trash and bringing disease into the facility that could infect the residents.During a review of the facility's policy and procedure (PNP), titled, Garbage and Rubbish Disposal dated 2000, indicated, the PNP indicated, .Food Related Garbage and Refuse Disposal indicated . All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent over filling . all containers will be provided with tight-fitting lids or covers, and will be leak proof and water proof . as to be inaccessible to vermin .

Based on interview and record reviews, the facility failed to ensure a Registered Nurse (RN) provided services for at least 8 consecutive hours a day for eight (5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25) of 90 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN . During an interview on 8/6/25 at 3:46 p.m. with the Staff Coordinator (SC), the SC stated no registered nurses (RN)were on working on 5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25. The SC stated she was not responsible for making the schedule for the registered nurses. The SC stated the Director of Nurses (DON) was responsible for the nurse's schedule. During an interview on 8/7/25 at 4:33 p.m. with the DON, the DON stated it was hard to hire an RN. The DON stated having RN on schedule daily could have provided better quality of care for the residents. The DON stated it is important to have RN working. The DON stated a RN could have provided better quality of care to residents and assessments. The DON stated Registered nurses could have provided mediation through intravenous therapy (medical treatment that delivers fluids, medications, or blood products directly into a resident's vein) or peripherally inserted central catheter (PICC line -along, thin, flexible tube inserted into a vein, typically in the upper arm, and threaded into a large vein near the heart). The DON stated residents with IV and PICC line would have required an RN to provide care for antibiotics or other therapy. The DON stated we did not follow our policy and procedure. During an interview on 8/8/25 at 10:12 a.m. with the Administrator (ADM) the ADM stated , We have a revolving RNs. The ADM stated the facility was not able to keep an RN on schedule. The ADM stated staffing an RN for the facility was challenging. The ADM stated RN were more skilled and have higher education. The ADM stated it was important to have an RN each day to provide care for residents that required IV therapy and quality of care. The ADM stated it was in the process of hiring more RNs. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing dated 8/2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with appropriated skills and competency necessary to provide nursing and related care and services for all resident in according with resident care plans and the facility assessment.3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (&) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview, and record review, the facility failed to ensure 58 out of 58 sampled residents had complete nutrition-focused physical exams (NFPE) completed when RD did not follow current standards of practice and the facility's job description titled, Registered Dietitian Nutritionist when she was a part-time remote employee.These failures resulted in incomplete nutrition-focused physical exams and placed residents at risk to not be accurately assessed by identifying nutritional needs.Findings: During an interview on 8/6/25 at 1:03 p.m. with the Dietary Services Manager (DSM) the DSM stated the RD was working remotely and came to the facility one time a month. The DMS stated the RD was not available in person and was available by phone or email. The DSM stated she communicated with the RD through email. The DSM stated the RD did not attend the interdisciplinary team meetings (IDT- a collaborative meeting involving various healthcare professionals to discuss and coordinate residents care) and she did not speak to residents and family members. The DSM stated she was responsible for gathering information regarding resident's food preferences and inputting it into the chart. The DSM stated the RD was responsible for assessing residents' diet. During an interview on 8/7/25 at 2:51 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she worked as an ADON for three years. The ADON stated she emailed the RD the list of new admits. The ADON stated the RD was able to gather information for residents from facility charts and hospital records. The ADON stated the RD would have emailed her recommendation after she reviewed the residents chart. The ADON stated she reached out to the physician about the RD's recommendation. The ADON stated she was responsible for updating any recommendations and new physician orders (instructions given by a physician or other authorized healthcare profession such as a nurse practitioner or physician assistant, regarding the medical care and treatment) after she spoke with the physician. The ADON stated the RD had 72 hours to do her assessment. The ADON stated the RD came to the facility once a month to check on the kitchen but was not sure if she spoke to the residents or family members. The ADON stated the RD was not involved in the IDT meeting. During an interview on 8/7/25 at 4:12 p.m. with the Director of Nursing the DON stated the RD worked remotely. The DON stated the RD had access to the electronic medical records and should have reviewed the charts. The DON stated the RD should have emailed the recommendation to the ADON. The DON stated the RD did not do physical assessment in person and should have done it in person and the nutritional care plan (a document that outlines a patient's health conditions, current treatments, and other relevant information to guide their care) was not comprehensive for all the residents in the facility. The DON stated the RD did not follow professional standard of practice when she did not provide a physical assessment for the residents in person. The DON stated the RD did not provide care planning for nutrition intake and the nurses were the ones doing the care plan. The DON stated the RD could not have done an accurate assessment when she was not seeing the residents in person. The DON stated the RD could have missed things. The DON stated the RD did her 72 hours assessment however she did not visit them in person. The DON stated the RD come in once a month for kitchen duties and did not see the residents before 72 hours in person. The DON stated the RD could have missed early interventions for malnutrition by not seeing residents in person within 72 hours. The DON stated residents with malnutrition had potential for complications such as pressure ulcers and falls and weight loss. The DON stated the RD did not participate in the IDT meeting. DON stated the RD should have been involved in IDT and could have explained to the family member and residents more detailed information about their nutrition plan of care.During an interview on 8/8/25 at 9:45 a.m. with the RD, the RD stated she lived in Monterey County and worked full time at a hospital. The RD stated she worked roughly 40 hours a month as a part-time employee for the facility. The RD stated she checked on the kitchen staff and provided audits when she came into the facility. The RD stated she used a packet she received from a fellow RD to perform her job duties. The RD stated the packet included storage, services observation and tray line (food assembly system, typically used in hospitals and other large-scale food service settings, where meal trays are prepared in a linear, conveyor-belt style fashion). The RD stated she did dinning observation once in the facility and felt she was a distraction for the residents. The RD stated she worked most of the time after 8 p.m. and did not call family members and residents. The RD stated she could have performed her job better if she was on site. The RD stated having a RD on site would have painted a better picture of the residents and added value for the resident and family. The RD stated she did not participate in an IDT meeting. The RD stated she did not complete an in person physical assessment and residents' assessments were done by reviewing hospital records and facility charts. The RD stated she called the nurses to gather more information for the physical assessment. The RD stated she did not communicate with the resident or family member to gather information. The RD stated once she gather her information she would have emailed the ADON about the recommendations. The RD stated she was trained on how to do Nutrition Focused Physical Exam (NFPE) however that was not something she conducts at this facility since she was remote. RD acknowledged she is remote and cannot do the standard of practice of NFPE. During an interview on 8/8/25 at 10:22 a.m. with the Administer (ADM), the ADM stated in the past the facility had contract with the RD working 100 percent remotely. The ADM stated the RD was coming once or twice a month to the facility. The ADM stated the RD did not do physical assessments in person when she came in once a month. The ADM stated the RD did not follow her standard of practice. The ADMS stated she was our in-house employee. The ADM sated, I think it is best to have someone here. During a review of the Commission on Dietetic Registration, the credentialing agency for the Academy of Nutrition and Dietetics document, titled, Revised 2025 Scope and Standards of Practice for the Registered Dietitian Nutritionist in Post-Acute and Long-Term Care Nutrition indicated under Standard 7, Providing Person-Population-Centered Nutrition Care, the RD conducts nutrition assessment and nutrition-focused physical exams (NFPEs) to evaluate nutrition status. It indicated the RD estimates food and fluid intake and history by communicating with resident, caregivers, and interprofessional team. During a review of the facility's job description (J/D) titled, Registered Dietitian Nutritionist dated 11/2017, the J/D indicated, .The Registered Dietitian Nutritionist provides nutritional analysis and guidance to individuals residents to treat and prevent disease.completes nutritional assessment and participated in the interdisciplinary comprehensive assessment.participates with the interdisciplinary team in development of a written, individualized comprehensive plan of care that specifies the services necessary to address the resident's needs.provide resident with ongoing nutritional assessment and outcome-oriented nutritional counseling.works collaboratively with interdisciplinary team to identify appropriate intervention, resources or solutions, implement plan of care with involvement of resident/or family members.participates in Infection Control, Quality Assurance, Resident Care and Safety Committee meetings.must be available and flexible with schedule to work the necessary hours to complete all job functions of the department.

Based on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively for 55 of 58 residents who received food from the kitchen when DC 1 could not demonstrate recalibration of the kitchen a thermometer according to the facility's policy and procedure (P&P) title, Thermometer Use and Calibration. This failure resulted in the facility to serve and prepare food without the food temperature taken on a calibrated thermometer for residents who obtained food from the kitchen and had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages). Findings: During an observation and interview on 8/5/25 at 9:10 a.m. in the kitchen with Dietary [NAME] (DK) 1, DC 1 grabbed a cup filled the cup with ice water and inserted a thermometer into the cup with the stem (long narrow part) touching the bottom of cup. DC 1 stated it was fine for the stem of the thermometer to touch the bottom and the side of the cup when calibrating the thermometer. DC1 stated, there was no time frame to leave the thermometer in the ice water cup. DC 1 stated, I don't remember when the last time we had an in service. During an interview on 8/5/25 at 2:39 p.m. with DC 1, DC 1 stated the stem of the thermometer should not touch the bottom of the cup. DC 1 stated the stem touching the bottom of the cup could have caused false reading during the calibration process. DC 1stated food temperature could have been wrong. DC 1 stated the food could be served at the wrong temperature. DC 1 stated residents could have gotten sick from eating food. During a concurrent interview and record review on 8/6/2025 at 12:51p.m. with Dietary Service Manager (DSM), the facility's policy and procedure (P&P) titled, Thermometer Use and Calibration, dated 2023, the P&P indicated, .Checking the Accuracy and Calibrating.2. Put the thermometer stem into the ice water so that the sensing area is completely submerged.Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must remain in the ice water one minute during calibration process. The DSM stated, the stem of the thermometer should not have touched the bottom or the side of the ice water cup. The DSM stated the stem touching the bottom of the ice water cup could have caused inaccurate reading during the thermometer calibration. The DSM stated inaccurately calibrating the thermometer could have caused wrong temperature readings when checking food temperature. The DSM stated food could have been undercooked or overcooked. The DSM stated overcooked food could lose nutritional and caloric value. The DSM stated undercooked food could have caused residents to get sick from foodborne illness. The DSM stated, We did not follow the policy and procedure. The DSM stated DC 1 was not competent. During an interview on 8/7/25 at 9:42 a.m. with the Registered Dietician (RD), the RD stated DC 1 should have gotten a cup of ice and filled it with water. The RD stated DC 1 should have put the thermometer stem into the ice water without touching the tip of the thermometer to the bottom or sides of the cup. The RD stated thermometer calibration was important for food safety. The RD stated inaccurate calibration of the thermometer could have caused false reading of food temperature. The RD stated accurate temperatures were needed to ensure the food was adequately cooked and was safe for residents to consume. The RD stated not calibrating thermometer could have been cause false reading for food and food could have been undercooked. The RD stated undercooked food could have caused foodborne illness. The RD stated DC 1 was not competent.

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices were followed for 55 of 58 sample residents when:1.There was not an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in residents being exposed to contaminated water which could ultimately result in residents getting food born illness.2. A bin of dried macaroni pasta, an open bag of sausage, an open bag of tortillas and a prepared fruit salad were not labeled with open or used by date.3. The resident refrigerator had food that had been brought into the facility that was not labeled with a resident name, an open or used by date.These failures had the potential to cause food-borne illness (known as food poisoning, diseases caused by consuming food or beverages contaminated with harmful bacteria) and hospitalization for all residents receiving food from the kitchen. 1.During a concurrent observation and interview on 08/04/2025 at 10:31 a.m. with Dietary [NAME] (DC) 1, in the facility's kitchen, a three-compartment sink was observed without an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture). DC 1 stated the vegetables are cleaned in the three-compartment sink using food strainers. During an interview on 8/5/25 at 4:19 p.m. with the Dietary Service Manager (DSM), the DSM stated that the three-compartment sink is used to wash vegetables, and the sink does not have an air gap. During an interview on 8/6/25 at 12:51 p.m. with the Registered Dietitian (RD), the RD stated, the three-compartment sink should have an air gap, and it does not. The air gap is necessary to prevent sewage backing up into the sink and contaminating the food being prepared in the sink. RD stated if there is no air gap the contamination could potentially cause food born illness to the residents in the facility. During an interview on 8/7/25 at 3:20 p.m. with the Maintenance Director (MAINT), the MAINT stated, if food is being prepared in the sink, the sink should have an air gap, and the three-compartment sink does not have an air gap. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue . 2.During an observation and interview on 8/4/25 at 7:44 a.m. in the kitchen, an undated opened bag of sausages was on the top shelf of the freezer. The Dietary Chef (DC) 2 stated the bag should have had a label with an open date and a delivered date. During an observation and interview on 8/4/25 at 7:55 a.m. in the storage pantry a dried macaroni pasta bin was not labeled. DC 2 stated the bin was missing a label to indicate opened date and received by date. DC 2 stated Everything in here should have been labeled with an opened date and received date. DC 2 stated It is important to make sure it's not expired. DC 2 stated kitchen staff were responsible for labeling the items in the storage pantry. DC 2 stated dating the items would prevent the kitchen staff from serving expired food to residents. DC 2 stated expired food could cause foodborne illness and gotten residents sick.During an observation and interview on 8/4/25 at 8:29 a.m. in the kitchen with DC 2, a bowl of fruit salad with clear plastic wrapped on top did not have a label with the dates the food was prepared on or when it should be used by. DC 2 stated it should have been labeled with the prepared date and used by date. During an observation and interview on 8/4/25 at 8:40 a.m. in the kitchen with DC 1, an opened bag of tortillas was not labeled with an open date and a used by date. DC 1 stated she was not able to find the label containing the opened date and used by date. DC 1 stated the opened tortilla bag should be labeled to keep track of the expiration date. DC 1 stated the tortillas could have expired and caused residents to get sick. During an interview on 8/6/2025 at 12:27 p.m. with the DSM, the DSM stated the macaroni pasta bin should have been labeled with a received and used by date. The DSM stated it should have been labeled once it was removed from the original package and put side the bin. The DMS stated the kitchen staff were responsible for labeling the bin. The DSM stated using items beyond their used by date could have altered the taste of the food, it could lose its flavor and nutrition value. The DSM stated using items beyond their used by date could cause residents to have foodborne illness. The DSM stated we did not follow the facility policy.During an interview on 8/7/25 at 9:12 a.m. with the RD, the RD stated prepared food should have been labeled before putting the items in the refrigerator. The RD stated kitchen staff should have labeled the fruit salad with the date it was made and the used by date before putting it inside the refrigerator. The RD stated residents could have gotten sick from being served food beyond the used by date.During an interview on 8/7/25 at 9:15 a.m. with the RD, the RD stated the tortilla bag should have been labeled with an opened and used by date. The RD stated everything that goes in the refrigerator should have been labeled with an open and used date to prevent confusion of the life of the product. The RD stated it was important to label the items to ensure safety to prevent cross-contamination and foodborne illness. During an interview on 8/7/2025 at 9:22 a.m. with the RD the RD stated the macaroni bin should have been labeled with the product name, opened and used by date. The RD stated labeling the bins would make it clear for the kitchen staff to know when the product was delivered, opened and the used by date. The RD stated labeling items with all three dates could prevent confusion. The RD stated kitchen staff could serve items past the used by date when items are not labeled. The RD stated residents in the facility were immunocompromised (state where the body's immune system is weakened, making it less effective at fighting off infections and diseases) and at risk for food borne illness. The RD stated if the residents in the facility get a food borne illness it can cause stress on the body and the residents could have been hospitalized . During a review of the facility's policy and procedures (P&P) titled, Labeling and Dating of Foods dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.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 that follows the various storage guidelines.All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray on a tray with masking taped if going to be used for meal service.Leftovers will be covered, labeled and dated.3.During a concurrent observation and interview on 8/6/25 at 9:02 a.m. with the Activities Director (AD), in the activities room, a bottle of soy sauce, mayonnaise, and a container of mashed potatoes, did not have a resident name, open date, or expiration date. The AD stated, she was unaware of when the mashed potatoes were brought in, she smelled them, and they did not smell bad. The resident refrigerator is supposed to be checked daily for old food, and to verify all food is labeled. The mashed potatoes, mayonnaise, and soy sauce did not have a resident label, a date when food was made or opened and they did not have a expiration date. The label is important with the resident identifier so that the food is only consumed by the resident it belongs to, the open date and expiration date are important so that residents are not eating expired food which could lead to food born illness. During an interview on 8/6/25 at 12:37 p.m. with the DSM, the DSM stated the prepared fruit salad was not labeled and dated. The DSM stated it should have been labeled to make sure it was safe. The DSM stated residents could have been served food beyond the used-by date and gotten sick.During an interview on 8/6/25 at 12:47 p.m. with the DSM, the DSM stated the bag of tortillas should have been labeled with open date and used by date. The DSM stated it should have been labeled to make sure it is safe. The DSM stated the residents could have been served the tortilla beyond the used-by date and gotten sick. During an interview on 8/07/2025 9:02 a.m. with the Registered Dietician (RD) the RD stated, Food in freezer should have been labeled with received and opened date. The RD stated the bag of sausages should have been thrown away. The RD stated, the bag of sausages should have been labeled to prevent any confusion and to prevent kitchen staff from using them beyond the use by date. The RD stated the sausages could cause food borne illness and get resident's sick. During an interview on 8/7/25 at 3:25 p.m. with the Infection Preventionist (IP), the IP stated that the resident refrigerator is to be checked be checked once a day to ensure the refrigerator is clean, all food in the refrigerator is labeled and all old food is discarded to prevent ford born illness due to residents eating expired food. The IP stated the food in the refrigerator was not labeled or dated. The resident refrigerator was not up to the facility expectations. During a review of the facility's policy and procedures (P&P), titled, Foods brought by family/visitors, dated 3/2022, indicated, . food brought by family/visitors . is labeled and stored . perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the quality assessment assurance (QAA) committee consisted of the minimum required members when the Medical Director did not attend QAA committee meetings for three consecutive quarters (1/9/25, 4/18/25, and 7/16/25). This failure had the potential to affect the overall medical care provided to all the residents in the facility because the Medical Director was not informed and did not participate in oversite activities that included identifying, analyzing and correcting problems in resident care policies and resident care areas in the facility.Findings: During a concurrent interview and record review on 8/8/25 at 12:11 p.m. with the Administrator (ADM) the Quality Assurance Performance Improvement (QAPI) reports, dated 2025 were reviewed. The administrator stated the QAPI committee met every second Tuesday of the month, and the Continuous Quality Improvement (CQI) committee met every quarter. The ADM stated the CQI committee was the same as the QAA committee. The ADM stated the Medical Director (MD), and Pharmacist Consultant (PC) were not always present during the monthly QAPI committee meetings. The sign-in sheets were reviewed for the CQI committee meetings for 1/9/25, 4/18/25, and 7/16/25, which indicated no MD, and no MD designee was listed on each sheet. The sign-in sheets for the QAPI committee meetings dated 1/25, 6/25 and 7/25 were reviewed with the ADM, which indicated no MD or MD designee was listed on each sheet. The ADM stated the MD did not always attend the CQI quarterly meetings. The ADM stated the MD should have attended the CQI meetings. The ADM stated the Performance Improvement Projects (PIP)s were prioritized by ongoing issues affecting multiple departments, or if the issues affected resident care. The ADM stated some of the PIPs the facility was working on were resident falls and resident urinary tract infections (UTI - an infection in the bladder/urinary tract). The ADM stated if the MD did not regularly attend the CQI meetings, things could have been missed, and the MD would not have known what the issues in the facility were. The ADM stated it was important the MD knew what the PIPs were so he would know what projects were being addressed. The ADM stated the MD was responsible for the physicians working in the facility and how the facility was managed for resident care. During a review of the facility's document titled, QA&A Committee Info:, undated, indicated, . the QA&A Committee meets monthly and quarterly . members: Dr. [name], Medical Director . During a review of the facility document titled QAA/QAPI Meeting Agenda Guide, undated, the document indicated, . the facility is required to have a QAA committee . that meets at least quarterly - and as needed - to coordinate and evaluate activities under the QAPI program . attending . the following members are required to be on the QAA committee . Medical Director .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings when a Certified Nursing Assistant (CNA) 1 used Resident 1's debit card without his consent or permission and charged $376.38. This failure resulted in Resident 1 loss of $376.38 from his bank account. Findings: During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During an interview on 1/6/25 at 1:30 p.m., with the Director of Nurses (DON), DON stated Certified Nursing Assistant (CNA) 1 was using Resident 1's debit card without his permission or consent to order food on the phone delivery application for herself, stepmother and sister. The sum of 12 delivery transactions charged to Resident 1's debit card was $376.38. The DON stated CNA 1 had saved Resident 1's debit card number on her personal phone and used it for the 12 transactions. The DON stated the facility expectation was that the Activity Director (ACTDIR) is allowed to make approved purchases for residents with permission of their responsible parties (RP-person who is responsible for paying the patient's account). The DON stated no other staff are allowed to make purchases, handle resident cash or resident debit cards. The DON stated the facility did not have a protocol in place prior to this incident to reinforce that the ACTDIR was the only one to make purchases on behalf of residents. The DON stated no formal education or training was provided to staff regarding using residents personal funds. The DON stated she considered CNA 1s unauthorized use of Resident 1's debit card as stealing. The DON stated CNA 1 was terminated due to financial elder abuse and law enforcement was notified. During an interview on 1/6/25 at 2:30 p.m., with the Activity Director (ACTDIR), ACTDIR stated Resident 1 approached her for some assistance regarding money missing from his account. The ACTDIR stated while reviewing Resident 1's financial records, it was identified that unauthorized purchases were made on the food delivery application under the name of CNA 1 in the sum of $376.38 the transactions were verified with Resident 1, and 12 out of of the 13 purchases made were not approved by Resident 1. The ACTDIR stated she is in charge of making purchases for residents in the facility. The ACTDIR stated Resident 1 had asked CNA 1 to make a purchase of food on the food delivery application, CNA 1 made the purchase through her own account and had saved Resident 1's debit card number and continued to make unauthorized purchases. The ACTDIR stated when CNA 1 made additional purchases and used Resdent 1's debit card number without his permission it was stealing. The ACTDIR stated CNA 1 also failed to notify leadership prior to making a purchase for Resident 1. During an interview on 1/6/25 at 3:02 p.m., with the Social Service Director (SSD), the SSD stated the facility did not have policy or procedure in writing to educate staff on proper protocols or guidelines concerning purchasing items on behalf of the residents. SSD stated It wasn't until after CNA 1 made unauthorized purchases for Resident 1 that staff received education regarding purchases for residents. During an interview on 1/7/25 at 10 a.m., with Resident 1, Resident 1 stated he initially asked CNA 1 to assist him with making a phone delivery application order online but since he didn't have a phone CNA 1 used her phone and her food delivery account to assist him. Resident 1 stated he provided her with his debit card number and the order was completed. Resident 1 stated it wasn't until a few weeks later he noticed his bank funds decreasing without making any purchases, he requested the assistance of ACTDIR and that's when he found out that CNA 1 was stealing from him by using his card to make unauthorized purchases for herself. Resident 1 stated the total sum of money spent was close to $400 dollars. Resident 1 stated he was reimbursed his money by the facility once the investigation was completed. During a review of facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, indicated, .Facility-wide commitment and resource allocation to support .develop and implement policies and protocols to prevent .theft, exploitation or misappropriation of resident property . During a review of facility's policy and procedure titled, Investigating Incident of Theft and/or Misappropriation of Resident Property dated April 2021, indicated, .Residents have the right to be free from exploitation, theft and/or misappropriation of person property .implementing policies that strictly prohibit . staff or employee theft or misappropriation of resident property .providing measures to safeguard resident valuables .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appropriately discharge on e of three sampled residents (Resident 1) when on 8/1/24 Resident 1 went on a leave of absence from the facility at 11:09 am and the facility Administrator (ADM) decided Resident 1's leave was against medical advice (AMA- -when a resident leaves a healthcare facility against medical advice from a physician) and he would be discharged . This failure resulted in Resident 1 being discharged on 8/1/24 without his belongings. Findings: During a review of Resident 1 ' s admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with alcoholic cirrhosis (the destruction of normal liver tissue), chronic kidney disease (gradual loss of kidney function), hereditary and idiopathic neuropathy (condition that causes numbness, tingling and muscle weakness in the limbs), unspecified and personal history of other disease of the musculoskeletal system and connective tissue (disease that affects the parts of the body that connect the structures of the body together). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated 6/2024, Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During a review of Resident 1 ' s Psychosocial note, dated 8/1/24 at 11:09 a.m., Resident 1 ' s Progress Note indicated .Held meeting with resident, Administrator and [social service director]due to resident leaving the facility without signing out and in and not having a Dr order to leave, Administrator told [Resident 1] that when he wants to leave he needs to have the Nurse call the Dr to give the ok . Administrator explained again that the Nurse needs to get a Dr order for him to go out on pass and if he leaves without getting the order it would be against medical advice . During a review of Resident 1 ' s Psychosocial note, dated 8/1/24 at 11:39 a.m., Resident 1 ' s Progress Note indicated .Due to resident leaving the Facility without Dr Order to leave, resident left [Against Medical Advise-AMA-when a resident leaves a healthcare facility against medical advice from a physician], Residents belongs was packed up, resident came back about 2 hours later, [Administrator] ADM and [Social Service Director] SSD went and talked with him that we just had the meeting about him leaving without a Dr order and you left anyway, so we have packed up your belongings and you have been discharged against medical advice . During an interview on 8/12/24 at 1:55 p.m., with the License Vocational Nurse (LVN), 1 stated she didn ' t know on 8/1/24 Resident1 was required to have a doctors order prior to him leaving the facility since, Resident 1 had left the facility before without one. LVN 1 stated he wasn ' t aware Resident 1 was out of the facility on 8/1/24. LVN 1 stated he had administered Resident 1 ' s medications in the morning. LVN 1 stated the Director of Nurses (DON) and the SSD let her know Resident 1 was considered to be AMA. LVN 1 asked the ADM if she should provide his scheduled noon medication to Resident 1. LVN 1 stated the ADM told her not to give medication to Resident 1 because the facility was discharging him. During an interview on 8/12/24 at 5 p.m., with the Social Service Director (SSD), SSD stated she spoke to Resident 1 on 8/1/24 regarding him leaving and returning to the facility. SSD stated Resident 1 was told he needed a doctor ' s order to leave the facility. SSD stated after she met with Resident 1 he left the facility. SSD stated the facility then discharged him. SSD stated the ADM let her know Resident 1 was not allowed back. SSD stated Resident 1 came back later that day and resident was stopped outside in the patio area of the facility by the ADM and SSD and was told he was no longer a resident of the facility and his belongings had been packed for him because he left AMA. SSD stated Resident 1 then came back again on 8/6/24 to pick up and sign for his personal belongings. SSD stated she also had him sign an AMA form. SSD stated the AMA facility form indicated Resident 1 signed it on 8/1/24. SSD stated the date of 8/1/24 on Resident 1 ' s AMA facility form was incorrect Resident 1 did not sign form until 8/6/24. SSD stated the date of 8/1/24 was pre-filled in. During an interview on 8/13/24 at 11:20 a.m., with the Director of Nurses (DON), the DON stated on 8/1/24, the ADM and SSD told Resident 1 he had left AMA and would no longer be allowed back in facility. DON stated there is no policy that Resident 1 needed an order to leave the facility. DON stated she could not answer what medical advice Resident 1 was going against when he left the faciity on 8/1/24. DON stated it was the ADM who determined that Resident 1 left AMA. The DON stated Resident 1 was not provided any medications after he left the facility. DON stated Resident 1 had left the facility before and returned and felt this was a liability for the facility. DON stated she believed Resident 1 did not need any care from the facility for skilled care needs because Resident 1 was independent with all ADL care needs. During an interview on 8/15/24 at 12:11 p.m., with the ADM, ADM stated he told Resident 1 on 8/1/24 he needed to have a doctors order to leave the facility. ADM stated Resident 1 signed out on 8/1/24 and left the facility. The ADM stated once Resident 1 left that the building she would discharge Resident 1. ADM stated she documented Resident 1 was AMA because Resident 1 did not get a doctor ' s order to leave the facility. The ADM stated she had Resident 1 sign the AMA form on 8/6/24. The ADM stated as far as he knew the facility only had to notify ombudsman of the AMA discharge which was done on 8/1/2024 by the SSD via email on 8/1/2024 . During a review of facility's policy and procedure titled, Transfer or Discharge, Facility-Initiated dated October 2022, indicated, . Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences . Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge . During a review of Resident 1 ' s Order Summary Report dated 9/3/2024, the Order Summary Report did not indicate, an order for discharge of Resident 1 on 8/1/24. During a review of facility's policy and procedure titled, Signing Resident ' s Out dated August 2006, indicated, . Each resident leaving the premises (excluding transfers/discharges) must be signed out . During a review of facility's job description titled, Job Description Charge Nurse Department: Nursing, dated 3/1/14, indicated, . Administer medications, treatments and provide direct care to residents on unit according to physician orders and in compliance with facility policies and procedures . Promptly consult with nursing supervisor and Social Worker if unsure of proper course of action that respects resident's rights, comply with facility policies and procedures that is consistent with county, state and federal laws and regulations . A review of the All Facilities Letter (AFL 23-37) Summary, dated 12/22/23, indicated that effective 12/2023.Pursuant to Title 22 CCR section 72527(a)(6), residents have the right to be transferred or discharged only for medical reasons, the resident's welfare, the welfare of other residents, or for nonpayment for their stay .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #39) of 1 sampled resident reviewed for physical restraints was free from a physical restraint. Findings included: A facility policy titled, Use of Restraints, revised 04/2017, revealed, Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for disciple or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation: 1. Physical Restraints are defined as an manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Per the policy, 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. An admission Record revealed the facility admitted Resident #39 on 03/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, dementia, repeated falls, difficulty in walking, and dependence on wheelchair. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2024, revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. s The MDS indicated the resident was dependent on staff to come from a sitting to stand position and for chair/bed-to-chair transfers. Per the MDS, the resident used a trunk restraint daily. Resident #39's care plan included a focus area initiated 11/14/2022, that indicated the resident used a physical restraint, lap buddy, related to confusion and falls. Interventions directed staff to ensure the resident was positioned correctly with proper body alignment while restrained (initiated 11/14/2022). Resident #39's Order Summary Report with active orders as of 08/01/2024. included an order dated 04/17/2022, for a lap buddy while up in the wheelchair for safety due to frequent falls. During an observation on 07/29/2024 at 10:47 AM, Resident #39 was a wheelchair in activities, with a padded lap pad in place. During an observation on 07/29/2024 at 2:07 PM, Resident #39 was in their wheelchair with a padded lap pad in place, being wheeled by staff to activities. During an interview on 07/31/2024 at 3:02 PM, the Director of Nursing (DON) stated the lap buddy used by Resident #39 had been in place since 03/2022 due to the resident having sustained frequent falls out of their wheelchair. Per the DON, the medical symptom for the use of the physical restraint was falls. The DON confirmed a lesser restrictive device had not been attempted and there was no ongoing monitoring of physical restraint. During a follow-up interview on 08/01/2024 at 11:44 AM, the DON confirmed falls were not a medical symptom for the use of the physical restraint. During an interview on 08/01/2024 at 11:51 AM, the Administrator stated the facility needed to try to use the least restrictive device first and have a true medical symptom for the use of the restraint. During an interview on 08/01/2024 at 1:00 PM, Certified Nursing Assistant (CNA) #1 stated Resident #39 had the lap buddy ever since she worked in the facility for the past two years. CNA #1 stated the only time the lap buddy was removed was during showers and when the resident was placed in their bed. During an interview on 08/01/2024 at 1:02 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #39 had the lap buddy ever since she worked at the facility for the past two years. LVN #2 stated to her knowledge the lap buddy had never been removed. During an interview on 08/01/2024 at 1:09 PM, the Physical Therapist stated he knew Resident #39 had the lap buddy, but to his knowledge therapy was not consulted about the use of it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when the Certified Nursing Assistants (CNA) did not complete accurate documentation for Resident 1 every two hour repositioning and truing schedule. This failure resulted in inaccurate documentation for Resident 1. Findings: During a review of Resident 1's, admission Record (AR) (AR-a record which contains resident personal information), the AR indicated, Resident 1 was a [AGE] year old female who was re-admitted to the Skilled Nursing Facility (SNF) on 10/14/22. Resident had a diagnosis of .hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on side of the body) During a review of Resident 1 ' s care plan, dated 9/27/23, the care plan indicated .Focus .The resident has an [activities of daily living] self-care performance deficit [related to] Dementia (loss of thinking, remembering and reasoning) Disease Process, Fatigue, Musculoskeletal impairment .total dependent (dependent on others for all care needs) .Goal .Needs will be met .Interventions .Bed Mobility: The resident is total dependent on staff for repositioning and turning in bed every 2 hours and as needed . During a concurrent interview and record review on 11/2/23 at 4:45 p.m. with Certified Nursing Assistant (CNA) 4, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning September 2023 indicated, there were missed documentation for Resident 1 turning and repositioning. CNA 4 stated, she worked PM shift (2 p.m. -10:30 p.m.) on 9/8/23, 9/9/23, 9/21/23 and 9/22/23.CNA 4 stated on 9/8/23, she did not document turning and reposition for Resident 1 every 2 hours. CNA 4 stated on 9/9/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated on 9/21/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated on 9/22/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated it is expected for staff to chart tasks as soon as possible once they have been completed. CNA 4 stated it was important for Resident 1 to be turned and repositioned every 2 hours to help maintain skin integrity because Resident 1 cannot reposition or turn herself. During a concurrent interview and record review on 11/2/23 at 5:03 p.m. with Certified Nursing Assistant (CNA) 5, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning dated September 2023 indicated there was missed documentation for Resident 1 ' s turning and repositioning. CNA 5 stated, turning and repositioning should be documented in Resident 1 ' s electronic record at least every two hours. CNA 5 stated staff were trained to document once the task was completed. During a concurrent interview and record review on 11/2/23 at 5:12 p.m. with CNA 6, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning dated September 2023 indicated there was missed documentation for Resident 1 ' s turning and repositioning. CNA 6 stated turning and repositioning should be documented every two hours for Resident 1. CNA 6 stated documentation of Resident 1 Turing and Repositioning for the month of September 2023 had missed documentation. During an interview on 11/2/23 at 5:26 p.m. with Assistant Director of Nurses (ADON), the ADON stated Resident 1 ' s care plan interventions had missed documentation for September 2023. The ADON stated staff had been instructed on where and how often to document interventions for residents. The ADON stated staff did not document interventions. The ADON stated it is important to document interventions, to keep residents healthy and safe. The ADON stated there is missed documentation for Resident 1 ' s turning and reposition every two hours for September 2023. During a professional reference reviewed retrieved from https://bok.ahima.org/doc?oid=301868 titled, Ethical Standards for Clinical Documentation Imporvement (CDI) Professionals dated June 2016, the professional reference review indicated, .Ethical Standards .Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding and reporting of high-quality healthcare data used for both individual patients and aggregate reporting . During a professional reference reviewed retrieved from https://journals.lww.com/cns-journal/Fulltext/2014/11000/Quality_Nursing_Documentation_in_the_Medical.4.aspx titled Quality Nursing Documentation in the Medical Record, dated December 2014, the professional reference review indicated, .Current healthcare systems require that documentation ensures continuity of care, provides legal evidence of the process of care delivered by all disciplines, and supports evaluation of quality of patient care. Healthcare professionals should fully understand the principles of maintaining a legally sound health record .Documentation is regulated by both state and federal statutes. Poor standards of documentation have been linked to the failure to detect patients who were clinically deteriorating All providers of healthcare for the patient are responsible for knowing the required documentation and are held accountable for their entries and for missing information in the medical record .

Based on observation, interview, and record review, the facility failed to store food, in accordance with professional standards for food service safety when: 1. An employee's large beverage container, half consumed, was stored on the shelf in the freezer with residents' food. 2. A baking pan full of green Jell-O was stored in the refrigerator uncovered and available for resident consumption. These deficient practices had the potential for food to become contaminated with harmful microorganisms causing foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), placing residents at an increased risk of being exposed to infectious agents. Findings: 1. During a concurrent observation of the kitchen freezer and interview with the Director of Dietary Services (DDS), on 9/17/19, at 9:38 a.m., a large plastic beverage container with a half consumed drink was stored on the shelf in the freezer with residents' food. The DDS stated, It [large beverage container] should not be here. Employee personal items of any kind were not allowed to be stored in this [resident] freezer, they [dietary staff] know better. The DDS disposed the container into the garbage. During an interview with Dietary Aide (DA) 1, on 9/17/19, at 10:13 a.m., she stated employee personal food and drinks items were not allowed to be stored in the kitchen refrigerator and freezer because those food items could contaminate resident food stored and served to residents. DA 1 stated employee should use the refrigerator in the employee lounge to store their personal food items and never in the kitchen because of the risk of contaminating resident food items. During an interview with [NAME] 1, on 9/18/19, at 9:10 a.m., she stated staff should not store personal item, drink or food in the kitchen freezer and refrigerator because of the risk of contaminating resident food stored in the refrigerator. [NAME] 1 stated the facility had an employee refrigerator with a freezer that was available and designated for staff use to store their food and drinks. 2. During a concurrent observation in the kitchen refrigerator and interview with the DDS, on 9/17/19, at 9:42 a.m., a large baking pan full of green Jell-O was stored on the shelf in the refrigerator uncovered. The DDS stated, It [pan of green Jell-O] should be covered . it should still have a cover. During an interview with [NAME] 1, on 9/18/19, at 9:10 a.m., [NAME] 1 stated the pan of green Jell-O should have been covered to avoid food contamination and food borne illness. [NAME] 1 stated all food and drinks stored in the freezer and refrigerator for resident should be covered and dated. The facility policy and procedure titled, Preventing Foodborne Illness - Food Handling dated 7/14, indicated, Policy Statement Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet (Sq. Ft) per resident in eleven resident rooms (Room - Rm. # 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15). This failure resulted in inadequate space for staff to deliver care, insufficient space for resident's personal belongings, wheelchairs and could impact the residents' quality of life or quality of care. Findings: During an observation between 9/17/19 through 9/20/19, the following rooms did not provide the minimum square footage in Rm # 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15. During an interview with Resident 14, on 9/17/19, at 10:02 a.m., she stated she had enough space in her room area and the staff helped her in bed and transferring to her wheelchair. During an interview with Resident 31, on 9/17/19, at 1:47 p.m., she stated her room felt crowded for her. Resident 31 stated she had a difficult time getting to her belongings in the nightstand that were between her bed and the bed next to her. Resident 31 stated she was unable to have her wheelchair next to her bed because it blocked the pathway to the bathroom. Resident 31 stated staff moved the wheelchair against the sliding glass door when she was in bed in order to open the pathway to the bathroom. Resident 31 stated when staff removed her wheelchair from her bedside she was unable get out of bed unassisted and had to wait for staff to get her wheelchair for her from in front of the sliding glass door. Resident 31 stated the limited space made her feel crammed in the room. During a concurrent observation in room [ROOM NUMBER] and interview with Certified Nursing Assistant (CNA) 5, on 9/17/19, at 2:37 p.m., CNA 5 stated rooms with four beds, Get challenging to move around to do my work and give care to the residents in those room . [the room space] is worse when we have to use the (mechanical lift - device used to move those who were unable to stand on their own or whose weight made it unsafe to move or be lifted manually) or the shower chair that was bulky enough that we need to move furniture around in the room to make more space. [The room space] is tight with [the resident] wheelchairs . CNA 5 stated when CNAs were providing care they had to move the room furniture from one side of the room to have sufficient space to provide safe care to that resident. CNA 5 stated when CNAs finished providing care to one resident they moved to the other and again had to move all of the furniture to the other side of the room. CNA 5 stated, Meaning one side [of the room] we make wider so we move the furniture closer on one side of the room so that on that side of the bed there is a wider space and we tell the resident to use that side of the bed [where the furniture was removed] to be able to maneuver around to and from their wheelchair. During a concurrent observation in room [ROOM NUMBER] and interview with CNA 3, on 9/17/19, at 2:52 p.m., she stated rooms with four beds did not have enough space to complete resident care. CNA 3 stated Resident 32 used a mechanical lift for transfers and she had to resort to moving Resident 32's bed out of its position to fit the mechanical lift in the room. CNA 3 stated Resident 19 also used a mechanical lift for transfers on shower days and she would have to move the bed out of its position to safely fit the mechanical lift inside the room. During a concurrent observation in room [ROOM NUMBER] and interview with CNA 3, on 9/17/19, at 2:55 p.m., she stated room [ROOM NUMBER] did not have enough space to safely accomodate and use the mechanical transfer lift inside the room for Resident 2 and Resident 25. CNA 3 stated she had to move Resident 2's bed to the side of the room in order to fit the mechanical lift in the room when transferring Resident 25. CNA 3 stated CNAs moved the bed next to Resident 34 blocking Resident 34's path to make the space needed between the beds to fit the wheelchair close enough to assist residents safely into the wheelchair. During an interview with Resident 33, on 9/17/19, at 3:32 p.m., she stated, It is a little tight with four beds in the room. I have to ask somebody to give me more space, move the other bed over to get my wheelchair close to where I want it to be. It's hard to get to my bedside cabinet . I can't get to it . my wheelchair won't fit in the room. Resident 33 stated her wheelchair was taken away from her and placed in an area she was unable to access and had to wait for staff to bring her the wheelchair when she needed to get out of bed. During a concurrent observation in room [ROOM NUMBER] and interview with the Director of Nursing (DON), on 9/19/19, at 4:15 p.m., the DON stated the room was a little bit crowded. The DON stated Resident 31's wheelchair could be moved closer to her, but the wheelchair would block the pathway to the bathroom for all residents in the room. The DON stated the wheelchair should not be out of Resident 31's reach. The DON stated the room space was not sufficient to accommodate having Resident 31's wheelchair accessible to her. During a concurrent observation in room [ROOM NUMBER] and interview with the DON, on 9/19/19, at 4:20 p.m., she stated the room was a little crowded. The DON stated Resident 9's bathroom access was blocked by the floor mat in front of the bathroom pathway used for Resident 32. The DON stated the room did not have sufficient space to accommodate the residents' needs. During a concurrent observation of room [ROOM NUMBER] and interview with CNA 8, on 9/20/19, at 9:15 a.m., a folded wheelchair was observed leaning against the sliding glass door. CNA 8 stated she had assisted Resident 31 to the bathroom. CNA 8 stated Resident 31's wheelchair was removed from her [resident] and was placed against the sliding glass door because if the wheelchair remained close to Resident 31 the wheelchair blocked access to the bathroom. During an interview with CNA 8, on 9/20/19, at 11:02 a.m., she stated Resident 31's wheelchair was normally placed on the side of the closet space next to the sliding glass door. CNA 8 stated the wheelchair was far from Resident 31 when placed next to the closet space and Resident 31 would not have access to the wheelchair. CNA 8 stated Resident 31 was able to transfer from bed to wheelchair on her own without staff assistance and would have to ask staff for assistance when the wheelchair was taken away from her. The residents' bedroom measurements were as follows: Rm. # Bed Capacity Sq. Ft. Per Resident 1 4 73.62 2 4 73.62 3 4 73.62 4 4 73.62 6 4 73.62 7 4 73.62 8 4 73.62 9 4 73.62 10 4 73.62 14 4 73.62 15 4 73.62 Recommend, room waiver for rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15. __________________________________ Health Facilities Evaluator Supervisor Signature & Date Request waiver. ________________________________ Administrator Signature & Date

Based on interview and record review, the facility failed to conduct a facility wide risk assessment specific to the needs of the facility and resident population for 39 of 39 residents when the facility assessment did not include a water management plan. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak. Findings: During an interview with the Maintenance Supervisor (MS), on 9/20/19, at 8:49 a.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature weekly. During an interview with the Administrator (ADM), on 9/20/19, at 9:02 a.m., the ADM stated she was not aware of the AFL (all facilities letter -is a letter from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C. The information contained in the AFL include changes in licensing requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the healthcare facility) 18-39 regarding, Reducing Legionella Risks in Health Care Facility Water System. The ADM stated she was not aware of the requirement to have a water management program and did not include a water management program in the facility assessment. During a review of the professional reference, CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements . The facility policy and procedure titled, Facility Assessment for [name of facility] dated 7/30/19, indicated .Services Waste management, hazardous waste management, telephone, HVAC, dental, barber/beauty, pharmacy, laboratory, radiology, occupational, physical, respiratory, and speech therapy, religious, exercise . The facility assessment did not have information regarding the facility's need for a water management program. The facility policy and procedure titled, Facility Assessment dated 7/17, indicated . 4. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population .

2. During an interview with the Maintenance Supervisor (MS), on 9/20/19, at 8:49 a.m., he stated the facility did not have a water management program in place. The MS stated he only checked the water temperature weekly. The MS stated the facility did not have a system to detect the potential for legionella (bacterium found in both potable and non-potable water systems [showers, sinks and water fountains]) outbreak or other waterborne bacteria. During an interview with the Administrator (ADM), on 9/20/19, at 9:02 a.m., the ADM stated she was not aware of the AFL (all facilities letter - is a letter from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C. The information contained in the AFL include changes in licensing requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the healthcare facility) 8-39 regarding, Reducing Legionella Risks in Health Care Facility Water System. The ADM stated she was not aware of the requirement to have a water management program and did not include a water management program in the facility wide risk assessment. During a review of the professional references, CMS Quality, Safety & Oversight (QSO) letter, dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements . Based on observation, interview, and record review, the facility failed to have an effective infection control and prevention program for three of six sampled residents (Resident 25, Resident 32 and Resident 35 when: 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene for three of six sampled residents (Resident 25, Resident 32, and Resident 35) after touching Resident's wheelchair, her clothing, and food containers and proceeded with providing feeding assistance to Resident 32, Resident 35 and Resident 25. This failure had the potential to cross contaminate (the process by which bacteria or other microorganisms [bacterium, virus, or fungus] are unintentionally transferred from one substance or object to another) residents' food and cause infections to residents. 2. The facility did not develop and implement a water management program to monitor for bacterial organisms in the water system used for 39 of 39 facility residents population. This failure had the potential risk for residents to become infected with legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) or other water borne bacteria. Findings: 1. During an observation in the dining room on 9/17/19, at 11:37 a.m., CNA 2 was feeding Residents 25, 32, and 35 their lunch. CNA 2 used her ungloved hands and adjusted her clothing multiple times, touched the table, touched residents' trays, and touched residents' food containers while feeding Residents 32, Resident 35 and Resident 25 without washing her hands in between actions. During an interview with CNA 2, on 9/18/19, at 11:38 a.m., CNA 2 stated, I am not supposed to get up when I start feeding these residents . I am supposed to only touch the spoons. I didn't realize that I was touching other things . CNA 2 stated she should have wash her hands when she touched more than the residents' spoons. CNA 2 stated, I know that. I should be more conscious, I guess. During an interview with the Registered Dietitian (RD), on 9/17/19, at 11:53 a.m., she stated the dining room had a sanitizer dispenser. The RD stated CNA 2 should have washed her hands before feeding Resident 32 and Resident 25 and in-between tasks in the dining room. The RD stated staff who assist with feeding should only be handling the spoon to feed the residents. The RD stated, If touching more than that, I expect them to wash or sanitized their hands. During an interview with the Director of Nursing (DON), on 9/17/19, at 11:55 a.m., she stated staff who assisted with feeding more than one resident in a table were not supposed to get up until after the staff were finished with feeding the residents. The DON stated the staff were supposed to only touch the spoon. The DON stated if the CNA was touching other things besides the spoon then she needed to repeat her hand sanitation. The facility policy and procedure titled, Hand Washing/Hand Hygiene during feeding in the Dining Room dated 2018, indicated, .Procedure . CNA may touch feeding utensils ONLY while assisting residents with eating. If contact is made with the table, wheelchair, resident body, or any other object, CNA must sanitize/wash their hand .