**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comprehensive assessments were conducted for one of nine sampled residents (Resident 64) when Resident 64's Nutritional Risk Assessment was not completed on readmission and quarterly in accordance with Minimum Data Set (MDS- a federally mandated resident assessment tool); and Resident 64's Nutritional Risk Assessments and MDS did not include a direct observation and communication with Resident 64. These failure resulted in Resident 64 not receiving an appropriate diet and put Resident 64 at risk of not having her dietary needs met. Findings: During a concurrent observation, interview, and record review on 3/18/25 at 12:40 p.m. with Resident 64, in Resident 64's room, Resident 64 was lying in bed in upright position eating her lunch meal. Resident 64 was awake, alert and oriented to person, place, time and event. Resident 64 was pointing to her food, and stated, . it is a small portion. Resident 64's meal tray ticket indicated portion size small. Resident 64 stated, I want a regular portion . this is not enough for me. Resident 64 stated she had never see or spoke to a dietitian, and she had informed the kitchen manager about disliking her small food portion. During a record review of Resident 64's admission Record (AR), dated 3/20/25, the AR indicated, Resident 64 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. During a review of Resident 64's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/22/25, the MDS section C indicated, Resident 64 had a (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 64 was cognitively intact. During an interview on 3/18/25 at 4:23 p.m. with Resident 64, in Resident 64's room, Resident 64 stated she did not agree about the small portion. Resident 64 stated, I am okay losing weight .they can cut back on different items in my tray, I want my regular portion of my meal. During a concurrent interview and record review on 3/21/25 at 11:57 a.m. with the Director of Nursing (DON), the DON reviewed Resident 64's current physician's order summary report dated 12/30/24, the Physician's order summary indicated diet no added salt, diet regular texture, thin consistency (a diet consisting of liquids that flow like water). The DON stated Resident 64 should be receiving a regular portion based on the physician's order. During an interview on 3/21/25 at 8:44 a.m. with Registered Dietitian (RD) 1, RD 1 stated she completed, nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports with the assistance of Certified Nursing Assistants (CNA) and Licensed Vocational Nurses (LVN). RD 1 stated, [CNA's and LVN's] are my eyes. RD 1 stated she reviewed CNA and LVN documentation for evidence of weight loss, weight gain, muscle wasting, bony prominence and frailness to complete nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports. RD 1 stated she called the nursing station and asked CNA's or LVN's if there was evidence of weight loss, weight gain, muscle wasting, bony prominence and frailness for each resident to complete nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports. RD 1 stated she relied on CNA's, LVN's, and the DM to complete nutritional assessments because she was not physically onsite and could not physically assess the resident. RD 1 stated, I rely on CNA's and LVN's to do the standard of practice of a focused nutritional assessment. RD 1 stated her nutritional assessment was a chart review and CNA's or LVN's completed the physical assessment. RD 1 stated she was responsible in completing all residents' nutritional assessments. During an interview on 3/21/25 at 2:37 p.m. with Dietary Manager (DM), the DM stated she's been a dietary manager at the facility since 4/2024 and was not certified dietary manager. The DM stated Resident 64's was on small portion, and she was aware of Resident 64's disliking small portion. The DM stated she was not informed of change in diet for Resident 64. The stated. I feel bad, she's been getting small portion. The DM stated Registered Dietitian (RD) 1 and nurses communicates with the kitchen verbally or using the diet change form. The DM stated she cannot recall if diet change form was given to the kitchen. During a telephone interview on 3/21/25 at 2:49 p.m. with RD 1, RD 1 stated she was working full time for the facility, and it is 100 percent remote. RD 1 was not aware of diet change, and stated, . there was a communication dropped here. RD 1 stated she completes all residents' nutritional assessments including MDS. During a review of Nutritional Risk Assessment, Resident 64's Nutritional Risk Assessments were completed on 4/27/23 and 4/26/24. The admission assessment, effective date 4/25/23, electronically signed by RD 1 on 4/27/23, the Nutritional Risk Assessment indicated, Diet order: NAS Regular. The Annual Assessment, effective date 4/19/24, electronically signed by RD 1 on 4/26/24, the Nutritional Risk Assessment indicated, Diet order: NAS (no added salt) Regular, Small Portions. During an interview on 3/22/25 at 11:02 a.m. with the DON, the DON stated RD 1 worked 100 percent remotely and was not physically present to assess facility residents. The DON stated RD 1 should have completed a readmission assessment when Resident 64 returned from acute hospital. The DON stated Resident 64's diet order from readmission was a no salt added regular. The DON stated diet form was given to the kitchen during readmission, and stated, .verified with the admission nurse. The DON stated Resident 64's diet was ordered when resident returned from the acute hospital on [DATE]. The DON stated RD 1 should do re-admission, quarterly, annual, and significant change assessments. During a review of facility's policy and procedure (P&P) titled, Comprehensive Nursing Assessment/Reassessment, dated 1/2001, the P&P indicated, .All residents will receive comprehensive assessment by licensed nursing staff upon admission, quarterly, upon significant change of condition and upon readmission as part of the interdisciplinary team; Procedure: 2. The nursing admission data will become part of a multidisciplinary assessment and care plan . During a review of facility's policy and procedure (P&P) titled, Nutrition Screening, Assessment & Re-assessment, revised date 9/18, the P&P indicated, .Nutrition assessment will be performed by an RD within 48 hours of notification and summary documented in the medical record. Data may be gathered from the medical record, patient/family interview and staff responsible for the care of the resident . During a review of Center for Medicare and Medicaid Services (CMS)'s RAI (Resident Assessment Instrument) Version 3.0 Manual CH 1.3: Completion of RAI, dated 10/2024, the reference indicated, The RAI has multiple regulatory requirements . (3) the assessment process includes direct observation, as well as communication with the resident and direct staff on all shifts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent interview and record review on 3/20/25 at 5:07 p.m. with License Vocation Nurse (LVN) 1, Resident 76's Treatment Administration Record (TAR- essential for documenting medication administration details) dated 2/22/2025 was reviewed. The TAR indicated, [box] Order Summary: Treatment-outer left foot DTI (DTI- a serious type of pressure injury, involves damage to underlying soft tissues, potentially leading to a purple or maroon discoloration of the skin) -Paint with [brand name of antiseptic] Solution every day and night shift for Pressure Injury . LVN 1 stated there were no care plan for Resident 76's DTI treatment order. LVN 1 stated a care plan should have been develop the same time the treatment order was done. LVN 1 stated a care plan was important to make sure the DTI was acknowledged. LVN 1 stated, the care plan should have had goals and interventions specific to the DTI. LVN 1 stated without the care plan the DTI could have gotten worse or better and we would not know. LVN 1 stated the nurse who did the treatment order was responsible for developing the care plan. LVN 1 stated all the nurses were responsible to ensure the care were updated. During an interview on 3/21/25 at 11:40 a.m. with the Registered Nurse (RN) 2, RN 2 stated there should be a care plan for the DTI. RN 2 stated, The care plan was our guideline and time bounded [how long the treatment plan should be done] and allow for the nurses to change, update or modify the treatment plan. RN 2 stated the care plan was used to communicate with the Certified Nursing Assistant (CNA). RN 2 stated the care plan allowed the nurses to track the progress of the DTI. RN 2 stated Resident 76's DTI healing process could have been disrupted and gotten worse without the care plan. RN 2 stated the care plan should have been done the same time as the treatment order. During an interview on 3/21/25 at 12:03 p.m. with the Minimum Date Set Nurse (MDSN), the MDSN stated, there should have been a care plan for the DTI. The MDSN stated, the initial nurse should be the one to do the care plan when they got the new order. The MDSN stated, the care plan was needed to guide the care for the resident. MDSN stated, the care plan tells the staff how to provide care for each specific resident. MDSN stated resident goals and interventions would not be tracked. MDSN stated, the DTI could have worsened without the care plan. MDSN stated Resident 76 could have a bad outcome. During an interview on 3/22/25 at 11:27 a.m. with the Director of Nursing (DON), the DON stated, Anytime there is a new wound there should be a care plan. The DON stated all nurses were responsible for making sure care plans were in place. The DON stated the nurse who did the initial treatment order should have initiated the care plan. The DON stated, a Care plan was a guideline and should have been followed. The DON stated the care plan was personalized for each resident and gave specific guidelines on how to care for them. The DON stated the DTI could have gotten worse without the care plan. During a review of Resident 76's admission Record (AR-a document with personal identifiable and medical information), dated 3/21/25 indicated Resident 76 had diagnoses of Hemiplegia (partial weakness or a reduced ability to move on one side of the body, often resulting from stroke (a medical emergency that occurs when blood flow to the brain is interrupted or reduced) and hemiparesis (medical condition characterized by weakness or paralysis on one side of the body) following cerebral infraction (stroke), dysphagia (difficulty swallowing), Parkinsonism (a group of neurological conditions characterized by movement disorders, including slow movements, rigidity, and tremors) and constipation. During a review of Resident 34's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 12/12/2024, indicated the Brief Interview for Mental Status (BIMS) score was 5 out of 15 (a BIMS score of 13-15 indicates cognitively intact (having clear thinking, learning, and memory, which allows someone to perform daily tasks. ), 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 76 had severe impairment. During a record review of the Resident 76's [Facility Name] Order Audit Report (OAR) dated 3/21/2025, the OAR indicated, Order date: 02/22/2025 Order Summary: Treatment-outer left food DTI-Paint with [brand name antiseptic] Solution every day and night shift for Pressure Injury. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan dated 1/21, the P&P indicated, Each resident will have a comprehensive care plan that includes measurable objective and time frame to meet his/her medical nursing, mental and psychological needs. Care plan shall incorporate goals and objective which lead to the resident's highest obtainable level of independence and shall be used in developing daily care needs and routines. Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a detailed approach to care customized to an individual resident's needs) for 2 of 24 sampled residents (Resident 1 and Resident 76) when: 1.The facility did not implement a person-centered care plan for Resident 1, who needed feeding assistance and verbal prompting throughout eating his meal because of blindness. This failure of implementing an individualized care plan for Resident 1 had the potential to place Resident 1's safety at risk and his specific needs not being met. 2.Resident 76 did not have a care plan for a wound treatment for his deep tissue injury (DTI- a serious type of pressure injury, involves damage to underlying soft tissues, potentially leading to a purple or maroon discoloration of the skin) to the outer left foot. This failure placed Resident 76 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed. Findings: 1. 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), dated 3/21/25, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE]. 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 3/6/25, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 11 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately impaired. During a review of Resident 1's Medical Diagnosis (MD), dated 3/21/25, the MD indicated Resident 1 was diagnosed with legal blindness (severely limited vision), epilepsy (a brain disorder that causes recurring seizures, which are sudden bursts of abnormal electrical activity in the brain that can lead to temporary changes in behavior, sensation, or movement), major depressive disorder ( a mental health condition characterized by persistent sadness, loss of interest in activities, and difficulty functioning in daily life) and morbid (severe) obesity (too much body fat). During a review of Resident 1's Social Services Assessment (SSA), dated 12/4/24, the SSA indicated, .Ancillary needs [additional or supporting services and resources that help a patient function better or achieve their goals] . Vision: specify: Legally blind, able to see little . During a concurrent observation and interview on 3/18/25 at 12:10 p.m., with Resident 1, in the dining room, staff members prompted Resident 1 to where each food item was on his plate and what type of food was in his bowls at the beginning of his meal. The staff members were also serving food trays for other residents so Resident 1 was left alone at times. Resident 1 was putting his spoon in his salad thinking it was soup and putting his fingers into the bowls to be able to distinguish what food was where. Resident 1 stated he could not see what food was on his plate and needed staff members to tell him where food items were, or else I'm just guessing while eating. During a concurrent interview and record review on 3/20/25 at 2:42 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Care Plans were reviewed. The care plan indicated Resident 1 had a care plan for insufficient vision due to being legally blind, but nothing in terms of feeding or monitoring Resident 1 for eating safety because of that blindness. The ADON stated she was responsible for resident care plans, but all nursing staff could implement or modify a care plan. The ADON stated care plans are the foundation of care for all residents. The ADON stated care plans need to be person-centered because all residents have different needs and Resident 1's was not person-centered related to blindness and eating. The ADON stated the facility policy and procedure (P&P) Comprehensive Care Plan was not followed. During a concurrent interview and record review on 3/20/25 at 5:13 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 1's Electronic Medical Record (EMR), dated 3/20/25 was reviewed. The EMR indicated Resident 1 did not have a care plan related too his blindness and eating safely. LVN 4 stated Resident 1 should have had a care plan in place that was dedicated to eating and his blindness. LVN 4 stated Resident 1 should require a staff member to be with him at all times and give him instruction while he eats. LVN 4 stated Resident 1 needs this for his safety, as he could burn himself touching his food with his fingers. LVN 4 stated Resident 1 was legally blind and unable to see. LVN 4 stated person-centered care plans are important so residents are properly taken care of and Resident 1 was not. During an interview on 3/21/25 at 2:20 p.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated she knew Resident 1 well and he was blind. CNA 8 stated the facility told CNA's to get Resident 1 into the dining room for every meal due to safety concerns when he is eating, but that was not in his care plan. CNA 8 stated she was never told to prompt him throughout his meal while eating, but that would be helpful for him. CNA 8 stated a care plan for Resident 1's eating specifically would have been helpful for all staff to get on the same page. CNA 8 stated because the care plan was not person-centered Resident 1 could have been in danger of being burned and it makes his life harder. During an interview on 3/22/25 at 9:52 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the nurse for Resident 1 this past week. RN 1 stated Resident 1 was handicapped in terms of vision. RN 1 stated it was important for staff to know Resident 1 needed constant assistance with eating. RN 1 stated the verbal prompting while eating needed to be constant and staff should never leave his side. RN 1 stated Resident 1 could have gotten burned or injured because of the lack of direction. RN 1 stated he could have grabbed something sharp as well. RN 1 stated staff members did not follow the facilities P&P Comprehensive Care Plan. During an interview on 3/22/25 at 10:15 a.m., with the Director of Nursing (DON), the DON stated care plans give staff the structure about what to do with the residents. The DON stated care plans are to give residents consistency of care. The DON stated Resident 1's care plan should have been person-centered and had blindness with eating safety care planned together, with interventions for safety. The DON stated because this was not care planned it was a safety issue for Resident 1. The DON stated a potential outcome of this issue could have been weight loss, frustration, and overall negative affect on his health. The DON stated Resident 1 could have easily caused harm to himself. The DON stated staff were not following the P&P Comprehensive Care Plan for Resident 1. During a review of the facility's P&P titled, Comprehensive Care Plan, dated January 2024, the P&P indicated, .Each resident will have a comprehensive care plan that includes measurable objectives and time frames to meet his/her medical, nursing . needs. Care plans . shall be used in developing daily care needs and routines . PROCEDURE: . The comprehensive care plan has been designed to: a. Incorporate identified or potential problem areas. b. Incorporate risk factors associated with identified or potential problems . Identify the professional services that are responsible for each element of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure one of six sampled resident (Resident 42) grooming was maintained when red patches of dried flaky skin were on top of his scalp and on the front of his shirt and pant. This failure resulted in Resident 42 having dried flaky skin on his skirt and pants which made him feel upset and embarrassed and had this had the potential to cause skin infection. Findings: During a concurrent observation and interview on 3/18/25 at 4:50 p.m. in Resident 42's room Resident 42 had patches of dry, white flakes and redness on his head. Resident 42 had the same dry white flakes on the front of his shirt and pants. Resident 42 stated he had a surgical wound treatment to the abdomen and had been not had shower because he did not want his dressing to get wet. Resident 42 gave permission for a photo of his head to be taken. Resident 42 stated he felt bad, uncomfortable and embarrassed of his head. During a concurrent observation and interview on 3/18/25 at 5:07 p.m. with Certified Nursing Assist (CNA) 1, CNA 1 stated she was assigned to Resident 42. CNA 1 stated she was assigned to Resident 42 two times a week. CNA 1 stated, When I first started, I gave him showers twice a week. CNA 1 stated Resident 42 has been refusing showers due to his surgical incision. CNA 1 stated the white flakes on the top of Resident 42's head looked like dried skin and was not normal for him. CNA 1 stated CNAs should have washed his head during showers or bed bath. CNA 1 stated Resident 42's head should have been brush and lotion should have been applied to prevent the dryness. CNA 1 stated, the dried skin could have caused skin irritation and caused the skin to open. CNA 1 stated the open skin could have caused an infection. CNA 1 stated she should have notified the charge nurse (nurse responsible for care). CNA 1 stated Resident 42 could have felt uncomfortable. CNA 1 stated she agreed when Resident 42 stated he felt embarrassed and ashamed of his appearance. CNA 1 stated CNAs were responsible and should had made sure Resident 42's grooming needs were done daily. During an interview and record review on 3/20/25 at 4:39 p.m., with License Vocation Nurse (LVN) 1, LVN 1 stated Resident 42 returned to the long-term care on 3/11/25. LVN 1 stated, Since he has been back, he has a bed bath .does not want his dressing to be wet. LVN 1 stated CNAs should have applied lotion to Resident 42's head after washing it. LVN 1 stated it was important to keep the skin from being dry and flakey to prevent the skin from opening. LVN 1 stated open skin could lead to an infection. LVN 1 stated. Resident 42 could have felt uncomfortable and embarrassed. During an interview on 3/22/25 at 9:15 a.m., with the Director of Staff Development (DSD) 1, DSD 1 stated CNAs were responsible to check on Resident 42's personal grooming and to check his skin daily. The DSD stated the CNA should have documented that Resident 42 was refusing showers, and notified the charge nurses. The DSD stated skin assessment were completed during showers. DSD 1 stated the CNA should have reported the dried skin to the nurses. DSD 1 stated, I trained the CNAs about documenting the skin at all showers and bathing. The DSD stated the dried skin on Resident 42's head should have been treated. The DSD stated, dried skin had the potential to cause an infection. DSD 1 stated Resident 42 could have felt undignified, embarrassed and uncomfortable. During an interview on 3/22/25 at 11:57 a.m. with the Director of Nursing (DON) the DON was shown a photo of Resident 42's head. The DON stated, It should not look like that. The DON stated Resident 42's skin was a risk for an infection because it was so dry. The DON stated CNAs were responsible for caring for residents who could not care for themselves. The DON stated each resident should be treated appropriately and their grooming needs should be met. The DON stated residents had right to feel comfortable. The DON stated the dried skin on Resident 42's head was a dignity issue. The DON stated Resident 42 could have felt undignified and uncomfortable. The DON stated Resident 42 could have been depressed and upset with his dry skin. During a review of Resident 48's admission Record, (AR) dated 3/21/25, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of rectosigmoid junction ( type of cancer that originates in the junction between the rectum and sigmoid colon( two parts of the large intestine), diabetes Mellitus (DM- chronic metabolic disorder characterized by high blood sugar levels), muscle weakness, unsteadiness on feet, need assistance with personal care. During a review of Residents 42's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [thought process] and physical function) assessment, dated 3/20/25, the MDS indicated Resident 42's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement on a scale of 1-15 with 15 being the highest score) was 15. Resident 42's cognition was assessed as cognitively intact. During a record review of the facility's policy and procedure (P&P) titled, Residents' Right and Responsibilities dated 8/03/2017, the P&P indicated, Patients have the right to: 1. Considerate and respectful care and to be made comfortable . During a review of the facility's policy and procedure (P&P) titled, Resident Grooming dated 01/24, the P&P indicated, To provide daily grooming and grooming as an activity that meets standards for the health and safety of resident and staff by providing and environment which reduces opportunity for injury and infection .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 5, Resident 15, Resident 56, Resident 76) were treated with respect and dignity when: 1.Resident 15's foley catheter bag (a collection bag that attaches to a foley catheter, a type of indwelling catheter [a catheter left in place for a period of time], to collect urine drained from the bladder) had urine visible from the hallway and was not covered with a foley catheter decency bag. This failure resulted in violating Resident 15's right to privacy. 2.Resident 5, Resident 56, and Resident 76 were lined up in the hallway outside of the dining hall and not allowed to enter and eat until other residents were done eating. This failure resulted in Resident 5, Resident 56 and Resident 76 being denied entry to the dining room and having to wait and watch other residents eat before they could be seated. Findings: 1.During a review of Resident 15's admission Record (AR- document containing resident personal information), dated 3/20/25, the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnosis which included Parkinson's disease (chronic, progressive neurological disorder that affects movement, balance, and other bodily functions), muscle weakness and urinary incontinence (involuntary leakage of urine). During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 1/1/25, the MDS assessment indicated Resident 15's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 11 out of 15 which indicated Resident 15 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a concurrent observation and interview on 3/18/25 at 11:05 a.m. with Resident 15 in Resident 15's room, Resident 15's room door was open and next to the dining hall. Resident 15 was observed lying in bed with his foley catheter bag hanging on the right side of the bed with yellow liquid visible from the doorway. Resident 15 stated his room was on a busy corner. Resident 15 stated residents, staff and visitors frequently walked by his room to the dining hall. During an observation on 3/18/25 at 5:10 p.m. in Resident 15's room, Resident 15's room door was open. Resident 15 was observed lying in bed with his foley catheter bag hanging on the right side of the bed with yellow liquid visible from the doorway. During a concurrent observation and interview on 3/19/25 at 8:30 a.m. with Licensed Vocational Nurse (LVN) 5 in Resident 15's room, Resident 15 was observed lying in bed with his foley catheter bag hanging on the right side of the bed with yellow liquid visible from the doorway. LVN 5 stated urine was visible in the foley catheter bag and visible from the hallway. LVN 5 stated all resident's, staff and visitors that walked to the dining room saw Resident 15's foley catheter bag. LVN 5 stated Resident 15 was bed bound and could feel embarrassed. LVN 5 stated the foley catheter bag should be placed on the left side of the bed where it could not be seen from the hallway or covered with a foley decency bag. LVN 5 stated foley catheter decency bags were placed over foley catheter bags to obstruct view of urine in the foley catheter bag. LVN 5 stated foley catheter decency bags provided residents with privacy and dignity. During an interview on 3/20/25 at 4:51 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated it was expected to cover all foley catheter bags with a foley catheter decency bag when visible in a public area. CNA 7 stated foley catheter bags visible from the hallway with urine should be covered with a foley catheter decency bag. CNA 7 stated Resident 15's dignity and privacy were violated when his urine was visible form the hallway. During a concurrent interview and record review on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), Resident 15's Care Plan, dated 3/22/26, was reviewed. The DON stated she expected all foley catheter bags visible from the doorway to be covered with a foley catheter decency bag to maintain resident respect and dignity. The DON stated Resident 15's Care Plan required his foley catheter to be placed in a decency bag. The DON stated Resident 15's Care Plan was not followed. The DON stated Resident 15 was bedbound and on hospice services. The DON stated Resident 15 was moderately impaired and could not consistently make his needs known. The DON stated it was the responsibility of the facility to maintain Resident 15's dignity and privacy at the end of his life. The DON stated Resident 15's respect and dignity were violated when his foley catheter bag was visible from the doorway. During a review of the facility's policy and procedure (P&P) titled, Patients Rights and Responsibilities, dated 5/2023, the P&P indicated, .considerate and respectful care, and to be made comfortable. They have the right to respect .have personal privacy respected . 2.During a review of Resident 5's admission Record (AR- document containing resident personal information), dated 3/20/25, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnosis which included metachromatic leukodystrophy (a disorder that causes fatty substance to build up in cells and causes progressive loss of function), candidiasis (a fungal infection) of skin and nail, muscle weakness and left hand contracture ( shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 1/1/25, the MDS assessment indicated Resident 5's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 00 out of 15 which indicated severe cognitive impairment (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 56's AR dated 3/20/25, the AR indicated, Resident 56 was admitted to the facility on [DATE] with diagnosis which included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.), Aspergers syndrome (A developmental disorder affecting ability to effectively socialize and communicate) and autistic disorder (eurological and developmental disorder that affects how people interact with others, communicate, learn, and behave.) During a review of Resident 56's MDS, dated 1/22/25, the MDS assessment indicated Resident 56's BIMS assessment score was 00 out of 15 which indicated severe cognitive impairment. During a review of Resident 76's AR dated 3/20/25, the AR indicated, Resident 76 was admitted to the facility on [DATE] with diagnosis which included hemiplegia (complete paralysis) and hemiparesis (partial or incomplete weakness) affecting left non-dominant side, muscle weakness, and dysphagia (trouble swallowing). During a review of Resident 76's MDS, dated 1/22/25, the MDS assessment indicated Resident 76's BIMS assessment score was 5 out of 15 which indicated Resident 76 had severe cognitive impairment. During an observation on 3/19/25 at 12:17 p.m. in the dining hall, six tables were observed. Three total residents were observed independently dining and eating their meals at separate tables. Kitchen staff delivered the last meal cart to nursing staff in the dining hall. Three tables had no residents seated at them and were clean. During a concurrent observation and interview on 3/19/25 at 12:20 p.m. with Certified Nursing Assistant (CNA)2 in the dining hall, CNA 2 was observed brining Resident 76 into the dining hall. DSD 2 instructed CNA 2 not to enter the dining hall with Resident 76 until the three other independent feeder (residents who are able to feed themselves independently with no assistance) residents were done eating. CNA 2 was instructed by DSD 2 to line Resident 76 up in the hallway. Resident 5 and Resident 56 were observed lined up in the hallway by two staff members. DSD 2 instructed CNA 2 not to enter the dining hall with Resident 5 and Resident 56 until the three other independent feeder residents were done eating. CNA 2 stated Resident 5, Resident 56, and Resident 76 were not allowed into the dinning hall until the other three other independent feeder residents were done eating. Resident 76 yelled out, come on where's food. CNA 2 stated Resident 5, Resident 56, and Resident 76 had to wait in the hallway until the dining room was empty and the tables were cleaned. CNA 2 stated the three independent eaters in the dining hall needed to finish eating and their tables would need to be cleaned before Resident 5, Resident 56, and Resident 76 could enter and eat. CNA 2 stated Resident 5, Resident 56, and Resident 76 were all dependent feeders (residents who cannot feed themselves and require assistance to eat). CNA 2 stated dependent feeders needed total assist when eating and required one on one assistance. CNA 2 stated dependent feeders often had to wait extended periods of time to eat until independent feeders were done eating. CNA 2 stated she did not think it was right Resident 5, Resident 56, and Resident 76 had to wait outside the dining hall and watch the three independent feeders to finish their meal. CNA 2 stated Resident 5, Resident 56, and Resident 76 rights and dignity were violated when they had to wait outside the dining hall and watch three other residents finish their meal before they could enter. CNA 2 stated the facility had implemented different dining times for independent and dependent feeders for at least 2.5 years but could not state an exact date. During an observation on 3/19/25 at 12:28 p.m. Resident 5, Resident 56, and Resident 76 were brought into the dining hall, served their meals and assisted to eat. During an interview on 3/19/25 at 2:55 p.m. with the Registered Dietician (RD) 2, RD 2 stated she expected all meal trays to be served and fed at the same time. RD 2 stated independent feeders ate first, then the dining hall was cleaned, and then dependent feeders were allowed to enter and eat. RD 2 stated Resident 5, Resident 56, and Resident 76 should not have been lined up in the hallway outside of the dining hall and not allowed to enter and eat with the independent eaters. RD 2 could not state how dining schedules were determined and why independent feeders ate first. RD 2 stated Resident 5, Resident 56, and Resident 76 dignity were violated. RD 2 stated all residents had a right to eat at the same time regardless of dining capabilities. During an interview on 3/20/25 at 8:40 a.m. with Resident 76 in Resident 76's room, Resident 76 stated he had been at the facility for a while, but could not state an exact admission date. Resident 76 stated he was often lined up in the hallway outside of the dining hall and not allowed to enter. Resident 76 stated, it is what it is, when asked how being lined up in the hallway outside of the dining hall made him feel. Resident 76 stated the facility had never asked him what time he wanted to eat or if he wanted to eat in the dining hall. Resident 76 stated he would like to eat when he is hungry. During an interview on 3/20/25 at 11:52 a.m. with RD 1, RD 1 stated dining group one was independent feeders and when they finished eating the dining hall was cleaned. RD 1 stated after the dining hall was cleaned dining group two were allowed to enter and eat. RD 1 stated dining group two were dependent feeders. RD 1 stated she expected if there were empty tables available in the dining hall Resident 5, Resident 56, and Resident 76 should had been allowed to enter and eat. RD 1 stated Resident 5, Resident 56, and Resident 76 should not have been lined up in the hallway and told not to enter. RD 1 stated it was Resident 5, Resident 56, and Resident 76 right to eat when brought to the dining hall by facility staff. During an interview on 3/22/24 at 10:15 a.m. with the Director of Nursing (DON), the DON stated dependent feeders were fed separately to ensure one to one assistance was available. The DON stated Resident 5, Resident 56, and Resident 76 should not have been lined up in the hallway outside of the dining hall and told not to enter. The DON stated Resident 5, Resident 56, and Resident 76 rights and dignity were violated when they were not allowed to enter and eat at the same time as the independent eaters. During a review of the facility's policy and procedure (P&P) titled, Patients Rights and Responsibilities, dated 5/2023, the P&P indicated, .considerate and respectful care, and to be made comfortable. They have the right to respect .have personal privacy respected. During a review of the facility's job duty description document titled, Certified Nursing Assistant I, dated 9/13/23, the document indicated, .assures that the rights of all patients are respected and maintained by allowing for privacy, confidentiality, and dignity in the provision of service. During a review of the facility's job duty description document titled, Licensed Vocational Nurse I, dated 9/13/23, the document indicated, .assures that the rights of all patients are respected and maintained by allowing for privacy, confidentiality, and dignity in the provision of service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise a care plan (a detailed approach to care customized to an individual resident's needs) to reflect assessment and interventions for one of nine sampled residents (Resident 64) when Resident 64's care plans was not reviewed and revised by the Interdisciplinary team (IDT-group professional and direct care staff that development a plan of care for a resident) after re-admission [DATE]). This failure resulted in Resident 64 being served the incorrect diet for her meals and had the potential to place Resident 64 at risk for unintended weight loss. Findings: During a concurrent observation and interview on 3/18/25 at 10:48 a.m. with Resident 64, in Resident 64's room, Resident 64 stated she's been at the facility for two and a half years. Resident 64 stated she had a concern about her food and stated, I want you to comeback when my lunch tray is here. During a record review of Resident 64's admission Record (AR), dated 3/20/25, the AR indicated, Resident 64 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS section C indicated, Resident 64 had a Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) score of 15, which indicated Resident 64 was cognitively intact. During a concurrent observation, interview, and record review on 3/18/25 at 12:40 p.m. with Resident 64, in Resident 64's room, Resident 64 was lying in bed in upright position eating her lunch meal. Resident 64 was awake, alert and oriented to person, place, time and event. Resident 64 was pointing to her food, and stated, . it is a small portion. Resident 64's meal tray ticket indicated portion size small. Resident 64 stated, I want a regular portion . this is not enough for me. Resident 64 stated she had never see or spoke to a dietitian, and she had informed the kitchen manager about disliking her small food portion. During an interview on 3/18/25 at 4:23 p.m. with Resident 64, in Resident 64's room, Resident 64 stated she did not agree about the small portion. Resident 64 stated, I am okay losing weight .they can cut back on different items in my tray, I want my regular portion of my meal. During a concurrent interview and record review on 3/21/25 at 11:57 a.m. with the Director of Nursing (DON), the DON reviewed Resident 64's current physician's order summary report dated 12/30/24, the Physician's order summary indicated diet no added salt, diet regular texture, thin consistency (a diet consisting of liquids that flow like water). The DON stated Resident 64 should be receiving a regular portion based on the physician's order. During an interview on 3/21/25 at 2:37 p.m. with Dietary Manager (DM), the DM stated she's been a dietary manager at the facility since 4/2024 and was not certified dietary manager. The DM stated Resident 64's was on small portion, and she was aware of Resident 64's disliking small portion. The DM stated she was not informed of change in diet for Resident 64. The stated. I feel bad, she's been getting small portion. The DM stated Registered Dietitian (RD) 1 and nurses communicates with the kitchen verbally or using the diet change form. The DM stated she cannot recall if diet change form was given to the kitchen. During a telephone interview on 3/21/25 at 2:49 p.m. with RD 1, RD 1 stated she was working full time for the facility, and it is 100 percent remote. RD 1 was not aware of diet change, and stated, . there was a communication dropped here. RD 1 stated she completes all residents' nutritional assessments including MDS. During a concurrent interview and record review on 3/21/25 at 3:14 p.m. with MDS Nurse (MDSN), the MDSN stated she is responsible for completing the MDS, updates nursing care plans and facilitates care conferences. The MDSN reviewed Resident 64's Electronic Medical Record (EMR - a digital version of patient's chart), and stated Resident 64's last Interdisciplinary team (IDT) weight meeting was 8/13/24 and care conference was 10/21/24. The MDSN stated IDT review care plan on admission, quarterly, and significant change of condition and revised as needed. The MDSN stated Resident 64's small portion diet was removed when she was readmitted back at the facility on 12/27/24. The MDSN stated, . I think there was a miscommunication about her diet. The MDSN stated dietary is responsible for updating the nutrition care plan. The MDSN stated Resident 64 was alert and oriented and has the right to make decision regarding her care and treatment, and stated, .still need to educate her. During an interview on 3/22/25 at 11:02 a.m. with the DON, the DON stated RD 1 worked 100 percent remotely and was not physically present to assess facility residents. The DON stated Resident 64's diet was ordered when resident returned from the acute hospital on [DATE]. The DON stated RD 1 should do re-admission, quarterly, annual, and significant change assessments. The DON stated the dietitian was responsible for developing, revising, and updating nutrition care plan for admission, readmission, quarterly, annual and significant change of condition assessments. The DON stated care plan should be updated to deliver the right services for the residents. During a review of Resident 64's electronic medical record (EMR) titled, Care Plan Report, dated 4/27/23 and 11/20/24, the report indicated, .The resident has nutritional problem or potential nutritional problem .Provide and serve diet/texture NAS (no salt added), Regular, Small Portion .RD (Registered Dietitian) to evaluate and make diet change recommendations [as needed]. During a review of facility's policy and procedure (P&P) titled, Comprehensive Care Plan, revised on 1/24, the P&P indicated, . 5. Care plans are reviewed weekly, upon readmission to the facility following an acute hospital stay, when change of condition dictates, and quarterly with IDT care conferences. They are revised/updated as needed. During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 88's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/21/25, the Face Sheet indicated, Resident 88 was admitted to the facility on [DATE]. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/28/25, the MDS assessment indicated Resident 88's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 88 was cognitively intact. During a review of Resident 88's Medical Diagnosis (MD), dated 3/21/25, the MD indicated Resident 88 was diagnosed with sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), cellulitis (a bacterial infection of the skin and the tissues just beneath it) of the right lower leg, chronic kidney disease (damage and loss of function in the kidneys), anxiety (a feeling of worry, nervousness, or fear, often about things that might happen, and it can involve physical symptoms like a racing heart or sweating) and gastroesophageal reflux disease (GERD- a condition where stomach acid and contents back up into the esophagus (food pipe), causing heartburn and other symptoms). During a concurrent observation and interview on 3/18/25 at 1:05 p.m., with Resident 88, in Resident 88's room, Resident 88 was by himself and there were two white round pills (medications) sitting on his bedside table while he was lying in bed. Resident 88 stated the medications had been there awhile and he did not know what they were. During a concurrent observation and interview on 3/18/25 at 1:15 p.m., in Resident 88's room, Registered Nurse (RN) 1 walked in the room and saw the two white round pills sitting in the medication cup on the bedside table. RN 1 stated she left the pills on his bedside table because he took over fifteen minutes and she didn't have time to wait for him to take them, so she left. RN 1 stated the two pills were simethicone (treats the symptoms of gas, such as fullness, pressure, and bloating) and he takes them daily for his GERD. During an interview on 3/20/25 at 2:42 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 88 should not have had medications sitting at the bedside without nursing staff present. The ADON stated Resident 88 needed to pass an assessment done by staff in order to self-administer medications and staff had never done one. The ADON stated he also needed a physicians order to self-administer medications and he did not have that either. The ADON stated this was a safety issue for Resident 88 due to the lack of assessment and no physicians order. During an interview on 3/22/25 at 9:38 a.m., with RN 1, RN 1 stated she was the nurse for Resident 88 when the medications were observed on the bedside table without staff present. RN 1 stated the medications should not have been left for Resident 88 to take on his own. RN 1 stated the expectation would be for her to watch Resident 88 take the medications. RN 1 stated because she left the pills at his bedside, any resident could have come in his room and took them without any staff knowing. RN 1 stated Resident 88 could have not taken the medication at all, or the medication dropped on the ground and staff would never have known. RN 1 stated Resident 88 usually takes his medication as ordered, but that day he didn't. During an interview on 3/22/25 at 10:15 a.m., with the Director of Nursing (DON), the DON stated Resident 88 would need to qualify to be able to self-administer medications and he did not. The DON stated some issues with the nurse leaving the medication for him to take were Resident 88 might not know the importance of taking the medication on time and he might not take the medication and staff wouldn't know. The DON stated this could have caused a medication error and it was a safety risk for Resident 88. The DON stated a confused resident could have come by and took the medications without staff knowing as well. The DON stated the self-administration medication was not completed for Resident 88 and the facility policy and procedure (P&P) Medication Administration was not followed. During a review of the facility's Self-Administration Assessment (SAA), not dated, the SAA indicated, .Instructions: before performing this assessment, verify that there is a physician order in the residence chart for self-administration of the specific medication under consideration and that the resident has signed the appropriate documents stating the desire to self-administer his own medication . Assessment Criteria: . Can correctly state name of medication and what it is used for . During a review of the facility's P&P titled, Medication Administration, dated January 2025, the P&P indicated, .Medications are administered as prescribed in accordance with . good nursing principles and practices and only by persons legally authorized to do so . Medication Administration: . medications are administered in accordance with written orders of the prescriber . residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care centers interdisciplinary team [IDT] and in accordance with procedures for self-administration of medications and state regulations . the resident is always observed after administration to ensure that the dose was completely ingested . Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of 18 sampled residents (Resident 4, Resident 23, Resident 33, and Resident 88) and follow the policy and procedure when: 1. Certified Nursing Assistant (CNA) 5 and CNA 6 did not file and a reported allegation of abuse to [NAME] President or Long Term Care Designee and notify the appropriate agencies for Resident 23. This failure resulted in Resident 23's allegation to go uninvestigated and had the potential for Resident 23's safety concerns to not be met. 2. Registered Nurse (RN) 1 did not follow the physician's order (PO-a written instruction from a healthcare provider, such as a doctor, that outlines specific medical treatments, tests, or procedures for a residents) for Resident 33 when her systolic blood pressure (SBP- the pressure in your arteries when your heart beats and pumps blood throughout your body, measured in millimeters of mercury [mmHg]) was above 160 mmHg (less than 120 mmHg is recommend) and RN 1 did not accurately document Resident 33's blood pressure in the clinical chart. This failure lead to Resident 33 not received prescribed medication for her elevated blood press and Resident 33's physician was not be notified of Resident 33 blood pressure. 3. Resident 4 was not provided assistive eating devices(foam grips on her fork, spoon and knife. Tools designed to help individuals with physical limitations eat more independently, promoting self-care and improving quality of life) per her diet tray card order. This had the potential for Resident 4 to have a decrease in oral intake, independence and cause frustration during meals. 4. Resident 88 had medication in a medicine cup on his bedside table (serves as a surface for food trays and can hold personal items such as phones, laptops, or books) without a self-administration of medications assessment completed, nor nursing staff present. This failure had the potential to put Resident 88's and other facility residents, safety at risk and his specific needs not being met. Findings: 1.During an interview on 3/19/25 at 3:55 p.m. in Resident 23's room Resident 23 stated [Certified Nursing Assistant 6] came to my room to change my brief. Resident 23 stated, I did not poop. I urinated; he stuck his fingers inside my vagina. Resident 23 stated she told Certified Nursing Assistant (cna) 5 about the sexual abuse allegation. During an interview on 3/19/25 at 3:58 p.m. with CNA 5, CNA 5 stated Resident 23 stated CNA 6 stuck his finger in her vagina. CNA 5 stated, the charge nurse told him to not to fill out a form about the allegation. CNA 5 stated the charge nurse told him Resident 23 had a history of making false accusation against staff members and to not filed out a form. CNA 5 stated People from higher up told me this was normal for her. CNA 5 stated, I was re-assured to not do anything. CNA 5 stated he received training on abuse during his orientation. CNA 5 stated he should have filed and the correct form for notification of the incident. CNA 5 stated staff member were mandated reporters (an individual duty to report known or suspected abuse or neglect). CNA 5 stated Resident 23 could have felt stressed, worried and could have lost trust in facility staff if her allegation was not reported. CNA 5 stated it was all staff members responsibility to report allegation of abuse. CNA 5 stated he should have reported it to the Director of Nursing (DON) and proper authorities. During an interview and record review 3/19/25 at 4:08 p.m. with License Vocation Nurse (LVN) 1, LVN 1 stated she was not aware of the sexual abuse allegation. LVN 1 stated, CNA 5 should have filed out paper work and reported to the supervisor and management. LVN stated, We need to make sure the resident felt safe and assured they are taken care of. LVN 1 stated, Resident 23 could have felt depressed and unsafe. During an interview on 3/19/25 at 5:41 p.m. with CNA 6, CNA 6 stated, I remember I was changing her (Resident 23) and she constantly needed to be changed. CNA 6 stated, I was using the wipes to clean her bottom due to bowel movement. CNA stated Resident 23 accused him of inserting three fingers into her rectum during the brief change. CNA 6 stated he notified the nurse on duty that day but was told to not do anything additional. CNA 6 stated reporting abuse allegation was important for resident safety. During an interview on 3/20/25 at 2: 25 p.m. with the Social Services Director (SSD), the SSD stated CNA 5 or CNA 6 should have reported the sexual abuse allegation to management. The SSD stated law enforcement, California Department of Public Health and Ombudsmen should have been notified. The SSD stated it was important to notify the authorities to protect Resident 23's safety. The SSD stated the Resident 23 could have been depressed withdrawn and isolated. The SSD stated Resident 23 could have had behavioral issues and mood swings. The SSD stated all staff were responsibility to report sexual abuse allegations to proper authorities. During an interview on 3/20/25 at 2:56 p.m. with the Director of Staff Development, the DSD stated, CNA 5 and CNA 6 should have reported to local authority such as, ombudsmen, police. The DSD stated, CNA 5 and CNA 6 should have reported the abuse allegation for Resident 23's well-being and safety. The DSD stated CNA 5 and CNA 6 had training abuse when they both were hired. During an interview 3/22/25 at 12:05 p.m. with the Director of Nursing, the DON stated, CNA 5 and CNA 6 should have notified the ADM or DON about the abuse allegation. The DON stated the staff did not follow their policy regarding reporting abuse. During a review of Resident 23 s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/30/25the MDS section C indicated Resident 23 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 23 was cognitively intact. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition Review dated 01/21, the P&P indicated, Any employee who suspects an alleged violation shall immediately notify the VP [Vice President] or LTC [Long Term Care] or Designee and notify the appropriate agencies not later than 24 hours During a review of the facility's job description and competency evaluation (JD&CE) titled, Certified Nursing Assistant 1, dated no date the JD&CE indicated, Identified patients at risk for abuse and/or neglect, as well as associated signs and symptoms. Adhere to mandatory reporting requirements for healthcare professional per Administrative Policy and Procedure . 2.During a review of Resident 33'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 3/21/25, the AR indicated Resident 33 was admitted on [DATE], with diagnoses of diabetes mellitus (DM- a chronic metabolic disorder characterized by high blood sugar (glucose) levels), end stage renal disease (ESRD- condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood), pain, major depressive disorder, hypertension (high blood pressure) and pain. During a review of Resident 33 s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/1/2025 MDS section C indicated Resident 33 had a Brief Interview for Mental Status(BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 33 was cognitively intact. During a review of Resident's 33's PO, dated 1/22/2025, the PO indicated, [box] Order Summary: [Brand name] tablet 25 mg [milligram-unit of measurement] give 25 mg by mouth every 6 hours as needed for hypertension SBP [systolic blood pressure-the top number in a blood pressure reading, typically expressed in millimeters of mercury (mmHg)] [greater]160 . During an observation at 3/18/25 at 10:36 p.m. in Resident 33's room, Registered Nurse (RN) 1 took Resident 33's blood pressure. RN 1 stated Resident 33's blood pressure reading on the machine was 206/96 mmHg (millimeter/Hg mercury unit of measurement) on the right arm and 186/84 mmHg on the left arm. During an interview on 2/18/25 at 5:46 p.m. with RN 1, RN 1 stated she did not offer [brand name] blood pressure medication per the physicians order. RN 1 stated she should have offered the [brand blood pressure medication] when Resident 33 systolic blood pressure was 206 and 185. RN 1 stated Resident 33 could have a stroke or heart attack because of elevated blood pressure and there could have been additional consequences to her heart. During an interview on 3/22/25 at 11:44 a.m. with the DON, the DON stated the physicians order (PO) should have been followed. The DON stated RN 1 should have followed the PO when the systolic blood pressure was above 160. The DON stated Resident 33 could have complication such as a stroke and heart attack from not having her blood pressure controlled. The DON stated RN did follow professional standard of practice when she did not offer the medication for resident 33's when the systolic blood pressure was above 160. During a review of the facility's policy and procedure titled, Medication are administration General Guidelines dated 01/25, the P&P indicated, Medication Administration: 1. Medication are administered in accordance with written orders of the prescriber . 3. During a review of Resident 4's admission Record (AR- document containing resident personal information), dated 3/20/25, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnosis which included hemiplegia (muscle weakness) affecting right dominant side, seizures (sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness.), pain in right wrist, osteoarthritis (chronic joint disease and breakdown of cartilage) and dementia (decline in mental abilities, including memory, thinking, and reasoning). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/5/25, the MDS Resident 4's diet tray card stated, .devices .foam grips on silverware . The DM stated Resident 4's silverware did not have foam grips on the fork, spoon, or knife and her diet tray card order was not followed. The DM stated foam grips were round, soft tubes placed over silverware to provide assessment indicated Resident 4's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 00 out of 15 which indicated Resident 4 had severe cognitive impairment (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 4's functional abilities (the capacity to perform daily tasks and activities) had no impairments on her upper extremities. During a concurrent observation and interview on 3/19/25 at 11:54 a.m. with the Dietary Manager (DM), in the kitchen during tray line, Resident 4's lunch tray was observed in the tray cart with no assistive eating devices. a comfortable and secure grip when handling silverware. The DM stated Resident 4 required foam grips on silverware to hold her utensils and feed herself. The DM stated all kitchen staff were responsible to ensure trays were plated per the diet tray card order During an interview on 3/19/25 at 2:55 p.m. with Registered Dietician (RD) 2, RD 2 stated she expected all trays to be plated per the diet tray card order. RD 2 stated diet tray cards were an order and were expected to be followed. RD 2 stated it was important Resident 4 received foam grips on her silverware to promote independence when eating. RD 2 stated Resident 4 was at risk for decreased oral intake if she could not hold her silverware to eat. During an interview on 3/20/25 at 11:52 a.m. with RD 1, RD 1 stated foam grips on silverware was an assistive eating device. RD 1 stated all assistive eating devices were listed on the diet tray card order and were expected to be followed. RD 1 stated she expected all kitchen staff to plate trays accurately per the diet tray card order. During an interview on 3/20/25 at 4:51 p.m. with CNA7, CNA 7 stated he was familiar with Resident 4. CNA 7 stated Resident 4 required assistive foam grips on her silverware to feed herself independently. CNA 7 stated Resident 4's assistive eating devices were listed on the diet tray card order. CNA 7 stated kitchen staff were responsible to plate all trays per the diet tray card order. CNA 7 stated it was important Resident 4 received her assistive foam grip silverware to promote independence when eating. CNA 7 stated Resident 4 was at risk for decreased oral intake if she could not hold her silverware. During an interview on 3/20/25 at 5:13 p.m. with LVN 5, LVN 5 stated kitchen staff were responsible to plate all trays per the diet tray card order and ensure assistive eating devices were present on the tray. LVN 5 stated diet tray cards were an order and were expected to be followed. LVN 5 stated Resident 4 had not received her silverware foam grips and was at risk for decreased oral intake and decreased independence. During a concurrent interview and record review on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), a picture of Resident 4's diet tray card order, dated 3/19/25, was reviewed. The facility's policy and procedure (P&P) titled, Adaptive Self Feeding Devices and Diet Tray Cards, dated 1/2021, was reviewed. The DON stated Resident 4's diet tray card stated, .devices .foam grips on silverware . The DON stated all assistive eating devices were placed on the meal ticket as an order to follow. The DON stated per facility policy kitchen staff were responsible to plate Resident 4's assistive eating silverware on the meal tray per the diet tray card order. The DON stated facility P&P was not followed by kitchen staff. The DON stated she expected all diet tray card orders to be followed. The DON stated Resident 4 was at risk for decreased oral intake if she could not hold her silverware to eat. The DON stated Resident 4 enjoyed eating her meals independently and was at risk for decreased independence and frustration if she could not feed herself. During a review of Resident 4's Diet Order (DO), dated 6/10/24, the DO indicated, Resident 4 had an order for, .foam grips . on silverware. During a review of the facility's P&P titled, Diet Tray Cards, dated 1/2021, the P&P indicated, .each resident shall have a diet tray card .the diet tray card must identify .Resident's diet exactly ordered by the physician .Resident's dining abilities . During a review of the facility's P&P titled, Adaptive Self Feeding Devices, dated 1/2021, the P&P indicated, .The Nutritional Services Department will be responsible for sanitizing the utensil safter each use and plating the devices on the resident's tray . During a review of the facility's P&P titled, Tray Assembly, dated 5/2019, the P&P indicated, .A person designated by the Food and nutrition Services Manager is responsible for seeing that all tray assembled meet therapeutic requirements of the diets, constancy, and personal preferences noted on the tray card . During a review of the facility's job description document titled, Nutrition and Food Service Aide, dated 6/1/24, the document indicated, .assembles, prepares and correctly serves items on patient tray line .sets trays with necessary items .set trays completely .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure nursing staff possess the competencies and skill sets necessary to provide restorative nursing services for one of nine sampled residents(Resident 81) when Resident 81 received a restorative nursing service from Certified Nursing Assistant not a certified Restorative Nurse Assistant (RNA-a healthcare worker that assists with rehabilitative care to individuals recovering from illnesses or injuries). This failure had the potential to place Resident 81 at risk for further injury during restorative services. Findings: Based on concurrent observation and interview on 3/18/25 at 9:39 a.m. with Resident 81, in Resident 81's room, Resident 81 was lying in bed, awake, alert and oriented to person, place, time, and event. Resident 81 had a slurred speech during conversation. Resident 81 stated he was getting exercises and walking with the therapist (Certified Nursing Assistant 2). During a record review of Resident 81's admission Record (AR), dated 3/22/25, the AR indicated, Resident 81 was admitted to the facility on [DATE]. During a review of Resident 81's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/28/25, the MDS section C indicated, Resident 81 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 81 was cognitively intact. During an interview on 3/20/25 2:12 p.m. with Certified Nurse Assistant (CNA) 2/Restorative Nurse Assistant (RNA), CNA 2 stated she's been working as RNA at the facility for two months and worked as CNA when needed. CNA 2 stated there were three other RNAs working at the facility. CNA 2 stated she received orientation with other fellow RNAs and stated, . but I am not RNA certified. CNA 2 stated she performs and delivers RNA programs to the residents without supervision from other RNAs. CNA 2 stated RNA programs include range of motion (ROM), and ambulation. CNA 2 stated we received referrals from Physical Therapy (PT) when resident is transition to RNA programs. CNA 2 stated RNA programs meeting held monthly with the director of nursing (DON). During an interview on 3/20/25 at 2:34 p.m. with Director of Staff Development (DSD) 2, DSD 2 stated CNA 2 worked as a CNA and RNA at the facility. DSD 2 stated CNA2 was primarily worked as RNA and worked as CNA when needed. DSD 2 stated RNA competency training was not provided by the facility, and unaware that RNAs needed certification. During a concurrent interview and record review on 3/21/25 at 3:06 p.m. with RNA 1, RNA 1 stated she's been an RNA at the facility for 2 years. RNA 1 stated she was a certified RNA. RNA 1 stated CNA must be RNA certified to be an RNA. RNA 1 reviewed facility's record titled, Restorative Nursing Assignment, dated 3/21/25, the record indicated CNA 2 was assigned to provide RNA services to twelve residents including Resident 81. RNA 1 reviewed electronic medical record (EMR -a digital version of patient's chart), dated 3/21/25 at 9:20 a.m., the EMR indicated Resident 81 walked for 15 minutes. RNA 1stated EMR indicated CNA 2 documented RNA services for six of 12 residents including Resident 81 were completed. RNA 1 stated CNA 2 was scheduled on 3/21/25 as the morning RNA and another RNA was scheduled for the afternoon. During an interview on 3/21/25 at 5:58 p.m. with RNA 1, RNA 1 stated more training are required to become a certified RNA. RNA 1 stated they do not have RNA competency checklist. RNA 1 stated the DON oversees the RNA programs. During an interview on 3/21/25 at 5:58 p.m. with the director of nursing, the DON stated the facility never had a monthly RNA program meeting, and stated, . that is the plan . didn't happen yet. The DON stated she spoke with CNA 2 and validated CNA 2 has been working as RNA. The DON stated CNA 2 should be RNA certified before working as RNA. The DON stated RNA requires training from professional people to deliver restorative nursing services safely. During an observation and interview on 3/22/25 at 12:00 p.m. with Resident 81, at the hallway, Resident 81 was propelling her wheelchair, well groomed and clean. Resident 81 stated CNA 2 walked him yesterday and stated, . she's been walking me. During a review of facility's Job Description and Competency Evaluation for Restorative Nursing Assistant (RNA), unknown date, the document indicated, . Position Summary: Performs various patient/resident care activities and related non-professional services necessary in caring for the personal needs and comfort of patients/residents; assists in maintenance of a safe, clean environment .Position Qualifications: RNA certificate required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for four of 24 sampled residents (Residents 62, 65, 80 and 88) when: 1.Resident 88 had a urinal (a container, often a bottle, used for collecting urine, typically for someone who is unable to get out of bed to use a regular toilet), filled with urine, on his bedside table (serve as a surface for food trays and can hold personal items such as phones, laptops, or books) next to drinking cups, protein shakes and medication in a medicine cup. This failure placed Resident 88 at risk for cross-contamination (the unintentional transfer of harmful substances from one person, object, or place to another) which could result in infections and illness. 2.Licensed Vocational Nurse (LVN) 2 did not clean and disinfect the glucometer machine (a portable device used to measure blood sugar) after using for Residents 62 and 80. This failure had the potential risk in the development and transmission of communicable diseases and infections for Residents 62 and 80. 3. Nursing staff did not wear gloves or a gown during direct patient care to Resident 65 while Resident 65 was on on Enhanced Barrier Precaution (EBP-infection control interventions, primarily used in long-term care facilities, that involve targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs). This failure resulted in the risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and the spread of infection. Findings: 1. During a review of Resident 88's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/21/25, the Face Sheet indicated, Resident 88 was admitted to the facility on [DATE]. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/28/25, the MDS assessment indicated Resident 88's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 88 was cognitively intact. During a review of Resident 88's Medical Diagnosis (MD), dated 3/21/25, the MD indicated Resident 88 was diagnosed with sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), cellulitis (a bacterial infection of the skin and the tissues just beneath it) of the right lower leg, chronic kidney disease (damage and loss of function in the kidneys) and anxiety (a feeling of worry, nervousness, or fear, often about things that might happen, and it can involve physical symptoms like a racing heart or sweating). During an observation on 3/18/25 at 1:05 p.m., in Resident 88's room, there was a urinal filled with urine sitting on his bedside table next to drinking cups, protein shakes and medication in a medicine cup. Resident 88 stated the urine had been there awhile. During an interview on 3/20/25 at 2:42 p.m., with the Assistant Director of Nursing (ADON), the ADON stated there should not have been urine in a urinal on Resident 88's bedside table. The ADON stated his urinal should have never been next too food or shakes. The ADON stated cross-contamination of bacteria (tiny organisms, or living things, that can cause disease) could have occurred. The ADON stated the facility policy and procedure (P&P) Standard Precautions was not followed by staff. During an interview on 3/21/25 at 9:55 a.m., with the Infection Preventionist (IP), the IP stated Resident 88's urinal should not have been on the bedside table. The IP stated Resident 88 eats off of his bedside table and a urinal there would be a big no-no. The IP stated Resident 88 could have bacteria in his urine that could make it contagious (bacteria that can be transmitted or passed on from one person to another). The IP stated cross-contamination could have occurred and the urinal could splash urine onto his drinking cups, protein drinks, or medication and make him sick. The IP stated the facility P&P Standard Precautions was not followed by staff. During an interview on 3/21/25 at 2:20 p.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated urinals should be hung off the resident bed away from food and drinks. CNA 8 stated germs (tiny organisms, or living things, that can cause disease or sickness) could get on a person's food with the urinal so close to it and could have caused an infection for Resident 88. During an interview on 3/22/25 at 9:38 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the nurse for Resident 88 when the urinal was observed on the bedside table filled with urine. RN 1 stated that urinal should never have been on that table. RN 1 stated she, or a CNA, should have emptied the urinal and moved it off of the bedside table. RN 1 stated this was a major infection risk because urine should never be next to food and cups that the resident was using. During an interview on 3/22/25 at 10:15 a.m., with the Director of Nursing (DON), the DON stated the urine on the bedside table was an infection issue. The DON stated urine mixed with food would equate to a low quality of life for Resident 88. The DON stated the urine could have spilled on the floor and caused a safety hazard. The DON stated this issue put Resident 88 at risk for infection and he even could have drank the urine by accident. The DON stated the facility staff did not follow the P&P Standard Precautions. During a review of the facility's P&P titled Standard Precautions, dated May 2024, the P&P indicated, . [Facility name] applies standard precautions to all patients regardless of their diagnosis or presumed infection status .PURPOSE: to provide guidelines on implementing standard precautions, which are the minimum infection prevention practices designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They are applied to all patients, regardless of suspected or confirmed infection status, in any setting where health care is delivered . Standard precautions our practices used to reduce healthcare associated infections and all healthcare settings, and they are applied when interacting with . body fluids, secretions, excretions Patient-Care Equipment and Surface Detection: handle used patient care equipment soiled with . body fluids, secretions and excretions any manner that prevents skin and mucous membrane exposure, contamination of clothing and transfer of microorganisms to other patients and environments . Environmental Control: ensure adequate cleaning and disinfecting procedures for environmental surfaces . bedside equipment and other frequently highly touched surfaces . 3. During a review of Resident 65's admission Record (AR- document containing resident personal information), dated 3/22/25, the AR indicated, Resident 65 was admitted to the facility on [DATE] with diagnosis which included acute respiratory failure with hypoxia (occurs when the lungs fail to adequately oxygenate the blood, leading to dangerously low oxygen levels in the blood [hypoxia]), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways), anemia (a condition where your blood doesn't have enough healthy red blood cells to carry adequate oxygen to your body's tissues, leading to symptoms like fatigue, weakness, and shortness of breath. ) and diastolic heart failure (occurs when the heart's left ventricle stiffens and can't relax properly between beats, preventing it from filling with enough blood, leading to reduced blood flow) During a review of Resident 65's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 1/31/25, the MDS assessment indicated Resident 65's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 00 out of 15 which indicated Resident 65 had severe cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During an observation on 3/21/25 at 5:25 p.m. outside of Resident 65's room, there was an orange dot and an EBP sign next to Resident 65's name. The Director of Staff Development (DSD) 1 was observed entering the room with no gloves or gown. The DSD 1 placed a towel over Resident 65's chest, touched the bed with her body while leaning over Resident 65, and repositioned a pillow under Resident 65's legs. The DSD 1 exited Resident 65's room, performed hand hygiene and walked to the nursing station. During an interview on 3/21/25 at 5:32 p.m. with the DSD 1, the DSD 1 stated she was a Licensed Vocational Nurse (LVN). The DSD 1 stated Resident 65 was on Enhanced Barrier Precaution (EBP) for Methicillin-Resistant Staphylococcus aureus (MRSA - a type of bacteria that's developed resistance to antibiotics and can cause infections, it is spread through direct contact). in her urine. The DSD 1 stated it was a standard of practice and facility policy to wear a gown and gloves when providing direct care to residents on EBP's to prevent the spread of infection. The DSD 1 stated she entered Resident 65's room to prepare Resident 65 for dinner. The DSD 1 stated she was not wearing a gown or gloves when she placed a towel over Resident 65's chest, touched the bed with her body while leaning over Resident 65, and repositioned a pillow under Resident 65's legs. The DSD 1 stated she exited Resident 65's room, performed hand hygiene, and planned to leave the hallway as there were no more meal trays to distribute. The DSD 1 stated not wearing a gown or gloves placed all other residents within the facility at risk for MRSA. The DSD 1 stated EBP's were in place to prevent the risk of cross contamination and the spread of infection. During a concurrent observation and interview on 3/21/25 at 5:38 p.m. with DSD 1, Resident 65's dinner tray was delivered to Resident 65's room by Certified Nursing Assistant (CNA) 4. CNA 4 entered Resident 65's room with no gown or gloves. CNA 4 touched Resident 65's bedside table and meal tray with no gloves or gown. CNA 4 positioned Resident 65's bedside chair next to Resident 65's bed with no gloves or gown. CNA 4 sat beside Resident 65's bed with no gloves or gown and fed Resident 65. CNA 4 was observed touching Resident 65's bed with her right leg and right elbow. CNA 4 was observed feeding Resident 65 with no gloves and continuously leaned over Resident 65. The DSD 1 stated she observed CNA 4 with no gloves or gown and touching Resident 65's while providing direct care. The DSD 1 stated CNA 4 should have placed gloves and a gown on to provide direct care and prevent the risk of cross contamination. During an interview on 3/21/25 at 5:43 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 65 was on EBP for MRSA in her urine. RN 2 stated all staff were expected to wear gloves and a gown when providing direct care. RN 2 stated assisting a resident for meal set up and feeding was direct care. RN 2 stated not wearing a gown or gloves when providing direct care was an infection control issue and placed every resident in the facility at risk for infection. During a concurrent interview and record review on 3/21/25 at 6:05 p.m. with the Infection Preventionist (IP), the facility Enhanced Barrier Precaution Binder dated 3/19/25 was reviewed. The IP stated Resident 65 was on EBP for MRSA in the urine. The IP stated she expected all staff to wear a gown and gloves when providing direct care or touching the environment of a resident on EBP. The IP stated all residents on EBP had an orange dot next to their name and posted EBP signage at the door. The IP stated all staff were trained on orientation and annually on EBP and how to identify residents on EBP. The IP stated she expected all staff to wear a gown and gloves when touching Resident 65 and Resident 65's belongings to prevent the spread of infection to other residents. During a concurrent interview and record review on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), Resident 65's Laboratory Report dated 2/16/23 was reviewed. The DON stated Resident 65 had been on EBP for MRSA in the urine since 2/16/23. The DON stated MRSA in the urine was a multidrug -resistant organism (MDROs- bacteria or other microorganisms that have become resistant to one or more classes of antimicrobial agents, making infections they cause difficult to treat). The DON stated it was facility policy to place all residents with a history of MDRO on EBP to prevent the spread of infection and cross contamination to other residents. The DON stated she expected all staff to wear a gown and gloves when providing direct care to residents on EBP's. The DON stated it was facility policy to wear a gown and gloves when providing high-contact resident care activities to residents on EBP's. The DON stated meal set up and feeding was direct care and was an example of a high-contact resident care activity. The DON stated DSD 1 and CNA 4 did not follow facility policy when providing direct care to Resident 65. The DON stated she expected all staff to follow facility policy and infection control standards of practice. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 9/2024, the P&P indicated, .it is the policy of Oakdale Nursing & Rehabilitation Center facility to implement a process to evaluate the facility and individual resident risk for multidrug-resistant organism (MDROs) and implement interventions to reduce transmission of MDROs to other staff and residents . Enhanced Barrier Precautions (EBP): refer to an infection control intervention designed to reduce transmission of targeted MDROs that employs targeted gown and glove use during high contact resident care activities. EBP is used in conjunction with standard precautions and expands the use of personal protective equipment (PPE) to donning of gowns and gloves during high-contact resident care activities .EBP is to be used for residents with a history of targeted MDROs .High Contact Activity: activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel and occur in the resident's room . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Plan, dated 8/2020, the P&P indicated, .prevent and/or reduce healthcare associated infections by maintain practices that have the potential to reduce healthcare associated infections minimizing the risk of transmitting infections by implementing appropriate precautions . During a review of the facility's job description document titled, Certified Nursing Assistant I, dated 9/13/23, the document indicated, .performs general care activities for patients/residents .in according to Infection Control policies . During a review of the facility's job description document titled, Licensed Vocational Nurse I, 9/13/23, the document indicated, .practices universal precautions while providing care . During a review of the Centers for Disease Control and Prevention article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, the article indicated, .Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality . Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with .MDRO infection or colonization . 2. During a concurrent observation and interview on 3/19/25 at 10:48 a.m. with LVN 2, LVN 2 used [brand name] disinfecting wipe (germicidal disposable wipe) in cleaning and disinfecting the glucometer machine after taking the blood sugar of Resident 62. LVN 2 wiped the glucometer machine from front to back for two seconds, placed the glucometer machine on top of the medication cart without a barrier, and air dried for one minute. LVN 2 stated, . It's been two minutes, it was dry. During concurrent observation and interview on 3/19/25 at 10:50 a.m. with LVN 2, LVN 2 placed the glucometer machine at the medication cart without a barrier after taking the blood sugar of Resident 80. LVN 2 used [brand name] wipe in cleaning and disinfecting the glucometer machine after taking the blood sugar of Resident 62. LVN 2 wiped the glucometer machine from front to back for five seconds, placed the glucometer machine on top of the medication cart without a barrier, and air dried for two minutes. During an interview on 3/20/25 at 2:45 p.m. with the IP, the IP stated they follow the facility's P&P for cleaning and disinfecting of the glucometer machine. The IP stated, [brand name] wipe purple top are used in cleaning and disinfecting glucometer machine and stated, . let it dry naturally for two minutes. The IP was confused with the word kill time/wet time, and stated, I need to review our P&P. The IP stated nurses should place a barrier on top of medication cart before placing the used glucometer machine. The IP stated the glucometer machine was considered contaminated with blood. The IP stated, ' . very important to clean and disinfect the glucometer machine for 2 minutes to prevent cross contamination and infection. The IP was not aware of [brand name] wipe's manufacturer's guidelines. During an interview on 3/21/25 at 11:57 a.m. with the Director of Nursing (DON), the DON stated cleaning and disinfection of glucometer machine required the use of Sani wipe for two minutes. The DON stated she was not aware and trained on properly disinfecting the glucometer machines based on manufacture's guidelines. The DON stated if the glucometer machine was not wet for two minutes, the potential risk for infection is high. The DON stated, .upon reading the Sani wipes manufacture's guidelines, the facility training we received was not accurate. The DON stated, .I need to review again our policy. During the review of facility's P&P titled, Steps for Monitoring Glucometer, unknown date, the P&P indicated, . clean the glucometer with Sani wipe from back to front as instructed by the manufacturer and put it on another clean paper towel .once glucometer is dried after 2 minutes kill time/wet time . During a review of manufacture's guidelines titled, [brand name]-Cloth Germicidal Disposable Wipe, the manufacturer guidelines indicated, Contact time: Use second germicidal wipe to thoroughly wet surface. Allow surface to remain wet two (2) minutes, let air dry. During a review of facility's Policy and Procedure (P&P) titled, Standard Precautions, revised 1/12/2017, the P&P indicated, applies Standard Precaution to all patients regardless of their diagnosis or presumed infection status. Standard precautions are practices used to reduce healthcare associated infections in all health care settings, and are applied when interacting with blood, body fluids, secretions, excretions (except sweat), regardless of whether they contain visible blood, non-intact skin and mucous membranes. Procedure:5. Patient-Care Equipment and Surface Disinfection a. Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretion in a manner that prevent skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients and environment, 6. Environmental Control a. Ensure adequate cleaning and disinfecting procedure for environmental surfaces, . bedside equipment, and other frequently high touch surface with a hospital approved disinfectant.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored when: 1.Registered Nurse (RN) 3, Licensed Vocational Nurse (LVN) 2, LVN 4, and RN 2 left the facility's medication cart unlocked when they walked away from during medication pass. This failure had the potential to place facility at risk for unauthorized access to medication cart and possible drug diversion. 2.Expired over the counter (OTC) medications were stored in medication cart and medication storage room; and eye drops was stored in medication cart beyond use date. This failure had the potential for residents to received expired medications that were no longer effective. 3.Discontinued oral medications, eye drops, inhalation, and injectables medications were stored in drawers of medication storage room. This failure had the potential to result in facility staff using expired medication and a risk a drug diversion. 4.The facility medication storage room temperature was not monitored to ensure medications were kept within acceptable room temperature and in accordance with manufacturer's instructions. This failure had the potential for residents to received medications that were no longer effective. 1. During a concurrent observation and interview on 3/19/25 at 8:26 a.m. with Registered Nurse (RN) 3, in Hallway 1, RN 3 left the medication unlocked and unattended. RN 3 walked away from the medication cart to the nursing station. RN 3 stated she checked Certified Nurse Assistant (CNA) assignment for Resident 13. During a concurrent observation on 3/19/25 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 2, in Hallway 4, LVN 2 left the medication cart unlocked and walked towards the nursing station. Hallway 4's medication cart was facing the hallway with staff member passing by. During a concurrent observation and interview on 3/20/25 at 8:53 with Licensed Vocational Nurse (LVN) 4, in Hallway 1, Hallway 1 medication cart was unlocked and unattended. Hallway 1's medication cart was facing the hallway with staff member passing by. LVN 4 stated, . I was in the resident room. During a concurrent observation and interview on 3/20/25 at 9:10 a.m. with Registered Nurse (RN) 2, in Hallway 4, RN 2 left the medication cart unlocked and unattended. RN 2 stated she received training about keeping the medication cart locked when away from the medication cart to prevent a resident and staff to access the medications. RN 2 stated there is a potential risk of harming the resident and staff when taking medications without doctor's order. During an interview on 3/20/25 at 4:39 p.m. with RN 3, RN 3 stated medication cart should be kept locked when nurses are away from the medication cart. RN 3 stated unlocked medication cart can give easy access for residents and staff to get medications. RN 3 stated, . can cause drug overdose and drug interaction. During an interview on 3/21/25 at 11:57 a.m. with Director of Nursing (DON), the DON stated her expectation for the nurses is to follow the P&P for medication administration. The DON stated medication cart unlocked and unattended is a safety risk for the residents and staff, and stated, .they can take medications accidentally, it can cause med error and negative consequences for resident and staff. The DON stated nurses must keep the medication cart locked when away from the medication cart. The DON stated it is important to follow the P&P for medication administration to prevent harm to the resident. During a review of facility's Policy and Procedure (P&P) titled, Medication Administration General Guidelines, dated 1/25, the P&P indicated, .Medication Administration:17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . 2.During a concurrent observation and interview on 3/19/25 at 10:17 a.m. with LVN 2, in Hallway 4's medication cart, LVN 2 stated a bottle of ibuprofen (medication used to relieve pain) 200 milligrams was stored on the top drawer of the medication and the medication's expiration date was 11/24. LVN 2 stated the medication was expired. LVN 2 stated expired medication can be less effective. During a concurrent observation and interview on 3/19/25 at 10:22 a.m. with LVN 2, in medication storage room, LVN 2 stated a bottle of ibuprofen 200 milligrams was stored in the cabinet of the medication storage room and stated the medication's expiration date was 11/24. LVN 2 stated, . it was expired. LVN 2 placed the expired bottle of ibuprofen in a white container, and stated, . for destruction. During a concurrent observation and interview on 3/21/25 at 9:23 a.m. with RN 3, in Transitional Care Unit (TCU) medication storage room, RN 3 stated a bottle of eye drops was stored in the TCU medication cart with open date of 1/26/25 and stated, the medication was .already expired, . only good for 30 days when opened. RN 3 stated the eyedrops was no longer effective and should be thrown away. During an interview on 3/22/25 at 11:02 a.m. with the DON, the DON stated, expired medications should be destroyed and stated, . expired meds are less effective. The DON stated eyedrops should be destroyed beyond 30 days from the opened date. During a review of facility's policy and procedure (P&P) titled, Medication Storage, dated 1/25, the P&P indicated, . 14. Outdated, Contaminated, . are immediately removed from stock, disposed of according to procedures for medication disposal . 3.During an observation and interview on 3/19/25 at 10:22 a.m. with LVN 2, in medication storage room, two bags of sodium cloride (with pharmacy label) were on top of the counter. LVN 2 stated two bags of sodium chloride requires destruction and stated, .the resident already expired. During an observation and interview on 3/20/25 at 10:09 a.m. with RN 2, in the nursing station, RN 2 discarded an open bottle of sodium chloride irrigation solution [475 millimeter] in the black trash can located at the nursing station. RN 2 stated the bottle of sodium chloride can be thrown in a regular trash can and stated, . there was no resident information in the bottle. RN 2 stated sodium chloride is considered a medication. During a concurrent observation and interview on 3/22/25 at 11:02 a.m. with the DON, in the medication storage room, there were four drawers, one drawer labeled discontinued medication, the drawer contained discontinued medications including oral medications, eye drops, inhalation, and injectables. The DON stated all discontinued medications were placed and stored in the drawers of the medication storage room. The DON stated she will review the P&P for medication disposal. During a review of facility's policy and procedure (P&P) titled, Medication Storage, dated 1/25, the P&P indicated, . 14. Outdated, contaminated, discontinued, . are immediately removed from stock, disposed of according to procedures for medication disposal . During a review of facility's policy and procedure (P&P) titled, Disposal of Medications, dated 1/24, the P&P indicated, Policy 1. Discontinued medications . which do not qualify for return to pharmacy, are identified and removed from current medication supply in a timely manner according to state and federal regulations for disposition; .Procedure 1. The DON and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. a. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. B. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 4. During a concurrent observation and interview on 3/20/25 at 10:38 a.m. with RN 2, in the medication storage room, RN 2 stated there were no temperature monitoring log for medication storage room. RN 2 stated nurses were monitoring the temperature of the medication refrigerator and not the room temperature of the medication room. RN 2 stated nurses were not instructed to check the temperature of the medication room, RN 2 stated the medication room temperature should be check because there are different medications stored in the medication room. RN 2 stated it can affect medications' efficacy when the temperature is high. During a concurrent observation and interview on 3/21/25 at 9:23 a.m. with RN 3, in the medication storage room, RN 3 stated nurses were not instructed to check the temperature of the medication storage room. RN 3 stated the thermometer hanging at the wall inside the storage medication room was not working and stated, . never been working. During an interview on 3/22/25 at 11:02 a.m. with the DON, the DON stated, the medication storage room temperature should be checked and monitored to ensure all the medications were stored following the medications' manufacturer's instructions. During a review of facility's policy and procedure (P&P) titled, Medication Storage, the P&P indicated, . Medications requiring storage at room temperature are kept at temperature ranging from 15C (59F) to 25C(77F) .

Based on interview, and record review, the facility failed to ensure dietetic staff had the appropriate skill sets to carry out the functions of food and nutrition services when: 1. The full-time Dietary Manger (DM) did not have the appropriate qualifications to meet the state requirements of the Health and Safety Code 1265.4 when Registered Dietitian (RD) 2 was only working onsite at the facility one day per week: and 2. RD 1 did not follow current standards of practice for nutrition-focused physical exams when she was a full-time consultant who worked remotely in another state and completed nutrition assessments for the facility. These failures resulted in the lack of a full-time qualified DM and RD which led to dietetic staff not having adequate supervision, training, and knowledge to carry out food and nutrition services in a safe and sanitary manner which placed 91 out of 91 resident's dining at the facility at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake, both of which had the potential to result in death and/or nutritional related medical complications. The failure of the remote RD not following current standards of practice had the potential to result in resident's not being accurately assessed with a nutrition diagnosis of malnutrition or at risk for malnutrition. Early nutrition intervention of a patient with malnutrition has the potential to decrease length of stay, falls, pressure ulcers, infections, complications, re-admissions and overall health care costs. Findings: 1. During a review of the State Statue (law), titled Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes seven pathways to be qualified. One of the pathways: (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. During a review of the State requirements titled, Title 22 California Code of Regulations (CCR) section §72333 Dietetic Service -General, indicated Dietetic service means a service organized, staffed and equipped to assure that food service to patients is safe, appetizing and provides for their nutritional needs. During an interview on 3/18/25 at 9:26 a.m. with the DM during the initial kitchen tour, the DM introduced herself as the Dietary Manager, also known as the kitchen supervisor. The DM stated she graduated on 1/24/25 from The University of North Dakota with her Nutrition and Foodservice Professional Training Program certification. The DM stated she had not registered or taken the CDM credentialing exam yet. The DM stated she was not qualified to be kitchen supervisor independently until she had her CDM credential. The DM stated she was working under RD 2 until she obtained her CDM credential. The DM stated RD 2 was her preceptor and responsible to provide oversight and training. The DM stated she had been the acting kitchen supervisor since approximately 4/2024 after the previous DM left. The DM stated RD 2 was full-time at the facility from 2022 to 11/2024. The DM stated RD 2 went per diem (a shift requiring to be onsite one day a week) in 11/ 2024 and was only at the facility once a week on Tuesday's. The DM stated RD 1 was a full-time consultant and worked remotely from another state. The DM stated RD 1 did not provide any physical oversight as she was remote. The DM stated there was no RD on site with her Monday, Wednesday, Thursday, Friday, Saturday, or Sunday. The DM stated RD 1 and RD 2 were available by phone call, text, or email if she had questions. The DM stated she had not received formal training on how to perform her job duties as the DM. During an interview on 3/19/25 at 2:55 p.m. with RD 2, RD 2 stated she was full-time at the facility from 6/2022-11/2024. RD 2 stated she went per diem in 11/2024 and was at the facility once a week, on Tuesday's. RD 2 stated the DM had performed kitchen supervisor duties from 11/24/24 to 3/19/25 with no RD on site Monday's, Wednesday's, Thursday's, Friday's, Saturday's, or Sunday's. RD 2 stated the DM had worked since April 2024 to acquire her CDM certification and had just graduated from The University of North Dakota. RD 2 stated the DM was not qualified to be the DM as she had not taken her CDM credentialing exam yet. RD 2 stated she was the DM's preceptor. RD 2 stated the DM needed a preceptor as she was not qualified to be kitchen supervisor until she passed her CDM credential exam. RD 2 stated RD 1 worked full-time remotely in another state and was not physically at the facility. RD 2 stated RD 1 could not provide direct oversight over the DM as she worked remotely in another state. RD 2 stated RD 1 completed nutrition focused physical examinations (a systematic, head-to-toe approach used by Registered Dietitian Nutritionists (RDs) to evaluate a patient's nutritional status, looking for signs of nutrient deficiencies, malnutrition, and other related issues), annual and quarterly nutrition reports, monthly weight variance meetings. RD 2 stated she could not perform oversight over the DM on Monday's, Wednesday's, Thursday's, Fridays, Saturday's, or Sunday's and ensure the DM completed tasks as required. RD 2 stated RD 1 was the acting Manager of Nutrition and Food Services as she was full-time. RD 2 stated as the Manager of Nutrition and Food Services RD 1 was responsible to oversee kitchen responsibilities. RD 2 stated there was a potential the DM made a mistake without a qualified Manager of Nutrition and Food Services on site overseeing her. During an interview on 3/20/25 at 11:52 a.m. with RD 1, RD 1 stated she had been a remote full-time dietitian for the facility for approximately 3 years. RD 1 stated she was available Monday through Friday 8 a.m. to 5 p.m. for the facility via phone call, text, and email. RD 1 stated she did not perform her job duties on site. RD 1 stated she visited the facility once a year for approximately 2-5 days. RD 1 stated approximately 4/2024 was the last time she was onsite at the facility. RD 1 stated she performed a kitchen audit each year when onsite. RD 1 could not state the date of the last kitchen audit she performed. RD 1 stated as the current full-time RD employed by the facility, she was the acting Manager of Nutrition and Food Services. RD 1 stated her job duties included, but were not limited to, nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports, monthly weight variance meetings, updating care plans, communicating with resident's, their families and the provider to recommend supplements or diet changes. RD 1 could not state what RD 2 responsibilities and tasks were as the RD on site. RD 1 stated RD 2 was responsible to oversee all food and nutrition facility policies. RD 1 stated she .assumed . RD 1 completed all job duty tasks that required being on site at the facility such as kitchen audits and overseeing the DM. RD 1 stated the DM had no direct oversight on Monday's, Wednesday's, Thursday's, Fridays, Saturday's, or Sunday's. During an interview on 3/20/25 at 6:05 p.m. with RD 2, RD 2 stated she completed kitchen audits every Tuesday when on site. RD 2 stated she did not share kitchen audit results with RD 1. RD 2 stated she updated all food and nutrition facility policies before she went per diem in 11/2024 and was not responsible to update policies anymore as she was per diem. RD 2 stated RD 1 was responsible to update all facility food and nutrition polices as the acting Manager of Nutrition and Food Services. RD 2 stated she did not routinely perform or compete nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports, monthly weight variance meetings, updating care plans, communicating with resident's, their families and the provider to recommend supplements or diet changes. During an interview on 3/21/25 at 10:43 a.m. with the DM, the DM stated she registered for her CDM credentialing exam on 3/19/25. The DM stated she did not have an exam date yet. The DM stated it would take approximately 7-14 days to receive an exam date. During an interview on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), the DON stated the DM was the Supervisor Nutrition and Food Services. The DON stated RD 1 was the Manger Nutrition and Food Services. The DON stated RD 1 worked full-time remotely in another state. The DON stated RD 2 was only onsite on Tuesday's. The DON stated the DM was unqualified to be the DM without Manger Nutrition and Food Services direct oversight. The DON stated the DM had not received official training to be the DM. The DON stated without direct oversight from the Manger Nutrition and Food Services the DM had no direct oversight on Monday, Wednesday, Thursday, Friday. Saturday or Sunday. The DON stated the DM was at risk for making an error or not knowing how to perform her job duties with no official training or oversight. During a concurrent interview and record review on 3/22/25 at 11:51 a.m. with the Administrator (ADM), the facility's Human Recourses (HR) document titled, Oak Valley Hospital District (OVHD) Open Positions, dated 1/3/25, 1/10/25, 1/17/25, 1/24/25, 2/7/25, 2/14/25, 2/21/25, 2/28/25, 12/6/24, 12/13/24, 12/20/24, 12/27/24, 11/27/24, 11/22/24, 11/15/25, 11/8/24, 11/1/24, and 10/25/24 was reviewed. The facility's job duty description titled, Manager Nutrition and Food Services,, dated 10/5/23 was reviewed. The ADM stated there was no job recruitment posting for Supervisor Nutrition and Food Services on the HR document. The ADM stated the DM was the acting Supervisor Nutrition and Food Services. The ADM stated the DM had not taken her CDM credentialing exam and was not qualified to be the full-time DM with no full-time RD oversight. The ADM stated RD 2 was pier diem and only onsite Tuesday's. The ADM stated the DM had no oversight on Monday, Wednesday, Thursday, Friday, Saturday, or Sunday. The ADM stated RD 1 was not the Manager Nutrition and Food Services. The ADM stated there was a job recruitment posting for Manager Nutrition and Food Services. The ADM stated until the Manager Nutrition and Food Services position was filled, he was the acting Manager Nutrition and Food Services. The ADM stated he expected all job duty statements to be adhered to and implemented. During a review of the facility's job description for RD 2, titled, Manager Nutrition and Food Services, dated 10/5/23, indicated, .responsible for the operation and management of Nutrition and Food Services .develops and implements related policies and procedures .general accountabilities .the following are essential job functions and accountabilities .demonstrates knowledge of and adheres to, all applicable professional regulatory practice acts, state/federal regulations and policies and procedures of OVHD, including JCAHO, Title XXII and requirements of other regulatory agencies .maintains professional standards .position qualifications .active registered Dietitian (R.D.) status . During a review of the facility's job description for DM, titled, Supervisor Nutrition and Food Services, dated 3/12/08, the document indicated, .supervises Nutrition and Food Services Staff concerned with the planning, preparation and service of food to residents, staff and guests. Orders or oversees the ordering of food and supplies. Maintains continual awareness of resident needs for optimal nutritional care .maintains current professional licenses and/or certifications as and when required by state, regulatory agency, or hospital mandate .demonstrates knowledge of and adheres to, all applicable professional regulatory practice acts, state/federal regulations and policies and procedures of OVHD, including The Joint Commission, Title XXII and requirements of other regulatory agencies .ensures that each resident receives optimal nutritional care within set guidelines .interviews the resident and completes the appropriate screening, and history information .recommends nutrition treatment .intervention . The job description did not list qualifications from the pathways of the HSC 1265.4. 2. During an interview on 3/20/25 at 11:52 a.m. with RD 1, RD 1 stated she had been a remote full-time dietitian for the facility for approximately 3 years. RD 1 stated she was available Monday through Friday 8 a.m. to 5 p.m. for the facility via phone call, text, and email. RD 1 stated she did not perform her job duties on site. RD 1 stated she visited the facility once a year for approximately 2-5 days. RD 1 stated approximately 4/2024 was the last time she was onsite at the facility. During an interview on 3/21/25 at 8:44 a.m. with RD 1, RD 1 stated she completed admission nutrition assessments, annual and quarterly nutrition reports and nutrition focused physical examinations with the assistance of Certified Nursing Assistants (CNA) and Licensed Vocational Nurses (LVN). RD 1 stated, [CNA's and LVN's] are my eyes. RD 1 stated she reviewed CNA and LVN documentation for evidence of weight loss, weight gain, muscle wasting, bony prominences and frailness to complete nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports. RD 1 stated she called the nursing station and asked CNA's or LVN's if there was evidence of weight loss, weight gain, muscle wasting, bony prominences and frailness for each resident to complete nutrition focused physical examinations, admission assessments, annual and quarterly nutrition reports. RD 1 stated she relied on CNA's, LVN's, and the DM to complete nutritional assessments because she was not physically onsite and could not physically assess the resident. RD 1 stated, I rely on CNA's and LVN's to do the standard of practice of a focused nutritional assessment. RD 1 stated her nutritional assessment was a chart review and CNA's or LVN's completed the physical assessment. RD 1 stated she completed the documentation for all nutrition assessments. During an interview on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), the DON stated RD 1 was responsible to perform focused nutritional assessment on residents. The DON stated it was out of the professional scope for CNA's and LVN's to perform a focused nutrition assessment on a resident for RD 1. The DON stated CNA's and LVN's were not trained to perform a focused nutrition assessment. The DON stated she assumed RD 2 completed focused nutritional assessments and all other assessments required for nutrition as she was on site once a week. The DON stated all residents in the facility were at risk for inaccurate assessments, weight loss, weight gain and nutritional deficiencies if RD 1 and RD 2 were not performing duties as assigned and according to standards of practice. During a review of RD 1's job description contract titled, Nutrition Consulting Services Agreement, dated 8/11/09 and signed by RD 1 on 8/21/09, the document indicated, .consultant is a registered dietician .and is qualified to provide nutrition consulting services and medical nutrition therapy to patients .provide nutritional consulting services .consultant shall comply with all policies and procedures of facility .the reporting of incidents affecting the quality of patient care, and the periodic reporting of specific quality control indicators .consultant agrees that all Nutrition Services provided by him/her shall meet or exceed the standards required by facility, including the standards of appropriate licensing agencies, including the State of California and the Joint Commission .on-going quality improvement monitoring activities, such as audits, which shall be conducted annually in the Facility in order to evaluate the appropriateness, timelines, and effectiveness of Nutrition Services provided and to evaluate and enhance the quality of patient care .facility shall employ sufficient support personnel competent to carry out the functions of the Program pursuant to Title 22, California Code of Regulations §72351 . During a review of the State requirements professional reference titled, Title 22 California Code of Regulations (CCR) Section §72351 Dietic Service Staff,, indicated, . (a) A registered dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis and of sufficient duration and frequency to provide continuing liaison with medical and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff of the dietetic service, approval of all menus and participation in development or revision of dietetic policies and procedures and in planning and conducting in-service education programs. During a review of RD 1's most recent kitchen audit checklist titled, Sanitation and Food Safety Checklist, dated 6/30/21, the checklist indicated, RD 1 last completed a kitchen audit on 6/30/21 and not annually as outlined in the Nutrition Consulting Services Agreement. During a review of the Revised 2024 Scope and Standards of Practice for Registered Dietitian Nutritionist (RDN) from the Commission on Dietetic Registration the credentialing agency for the Academy of Nutrition and Dietetics, indicated RDNs (RDs) are the most qualified to provide Medical Nutrition Therapy (MNT), a cost-effective, essential component of comprehensive nutrition care. It indicated RDs in clinical practice provide person centered nutrition care and MNT use the Nutrition Care Process (NCP -NCP is a systematic problem-solving method that credentialed nutrition and dietetics practitioners use to critically think and make decisions when providing MNT or to address nutrition-related problems and provide safe and effective quality nutrition care. The NCP consists of four distinct, interrelated steps: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation). It indicated in Standard 7 (seven) providing person-/population-centered nutrition care, the registered dietitian nutritionist (RDN) conducts nutrition care process and workflow elements to identify and address nutrition-related problems which a RDN is responsible for treating. It indicated the RD: 7.2 Conducts nutrition assessment. 7.2.5 Obtains and assesses findings from nutrition-focused physical exam (NFPE).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored, and served safely in accordance with professional standards of food service safety for 91 out of 91 residents eating at the facility when: 1. An individually wrapped tuna sandwich was expired in the nourishment refrigerator. This failure had the potential to result in the serving of an expired tuna sandwich to 35 out of 35 residents eating regular textured diets at the facility which had the potential to lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). 2. A bottle of wine was not labeled and dated in the resident refrigerator. This failure resulted in the facility not labeling and dating a personal food item per policy for one resident (Resident 28) which had the potential to lead to the growth of microorganisms and result in food borne illness. Findings: 1.During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with the Dietary Manager (DM) in the nourishment refrigerator, an individually wrapped tuna sandwich was observed labeled, Tuna 3/14-3/17. The DM stated the tuna sandwich was expired and should have been removed on 3/17/25 by a dietary aide. The DM stated an expired tuna sandwich could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if consumed by a resident. The DM stated kitchen staff should stock, clean and remove expired food items from the nourishment refrigerator every morning and evening. The DM stated there was no log, record or checklist kitchen staff completed after performing these tasks. The DM stated she did not assign dietary aides to these tasks. The DM stated these tasks were competed by the first available dietary aide in the morning and evening. The DM stated it was her responsibility to ensure kitchen staff completed their assigned tasks. During an interview on 3/19/25 at 2:55 p.m. with Registered Dietician (RD) 2, RD 2 stated kitchen staff were responsible to maintain the nourishment refrigerator. RD 2 stated there was no log, record or checklist kitchen staff completed after performing these tasks. RD 2 stated she expected kitchen staff to remove expired food items from the nourishment refrigerator. RD 2 stated all residents with a regular diet texture were at risk for receiving an expired tuna sandwich from the nourishment refrigerator. RD 2 stated an expired tuna sandwich could result in foodborne illness (illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if consumed. RD 2 stated foodborne illness could make residents sick and cause nausea, vomiting and diarrhea. During an interview on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), the DON stated she expected all expired food items to be removed from the nourishment refrigerator by kitchen staff. The DON stated kitchen staff were responsible to stock, clean and remove expired food items twice a day from the nourishment refrigerator. The DON stated all residents eating a regular texture diet within the facility were at risk for foodborne illness if they ate the sandwich. During a review on the facility's recipe titled, Tuna Salad Sandwich, undated, the recipe indicated, the tuna salad sandwich was made with chilled mayonnaise. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Length of Storage of Foods, dated 1/2021, the P&P indicated, .it is the policy . that food products be stored in a safe manner to prevent food-borne illnesses .length of storage of foods is correlated to food safety .potentially hazardous foods that have been prepared or cooked will have a three day expiration date .examples are the following .salads with mayonnaise . 2.During a review of Resident 28's admission Record (AR- document containing resident personal information), dated 3/21/25, the AR indicated, Resident 28 was admitted to the facility on [DATE] During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/13/25, the MDS assessment indicated Resident 28's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 13 out of 15 which indicated Resident 28 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with the Dietary Manager (DM) in the resident refrigerator, a small bottle of wine was observed with Resident 28's name and room number. No received date was observed on the bottle of wine. The DM stated the bottle of wine was a personal food item. The DM stated all personal food items were expected to have the residents name, room number and received date. The DM stated she did not observe a received date or a manufacture expiration date on the bottle of wine. The DM stated it was important to label personal food items with a received date to determine expiration. The DM stated there was no way to determine how long the wine bottle was stored in the resident refrigerator or when it expired with no received date or manufacture expiration date. The DM stated it was facility policy to keep all personal food items for three days from the received date and then discard the food item. The DM stated Resident 28 was at risk for foodborne illness if the wine bottle was expired and she consumed the beverage. During an interview on 3/19/25 at 2:55 p.m. with Registered Dietician (RD) 2, RD 2 stated it was kitchen and nursing staff responsibility to maintain the resident refrigerator. RD 2 stated nursing staff were responsible to label all food from an outside source with the resident's name, room number and received date. RD 2 stated it was important to include the received date on the personal food item label to ensure food items were discarded after three days. RD 2 stated received date labels ensure food items without a manufacture expiration date are discarded after 3 days. RD 2 stated without a received date label on Resident 28's food item she could not determine an expiration date and could not determine if the food item was expired. RD 2 stated labeling food items ensured Resident 28 would not consume an expired food item. During an interview on 3/20/25 at 4:51 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 Stated it was the responsibility of all nursing and kitchen staff to ensure food items were labeled per facility policy. CNA 7 stated it was the responsibility of the staff member who received the wine bottle to label the food item with the received date. CNA 7 stated all food items that were not labeled with the resident's name, room number and received date should be discarded to prevent serving an expired food item. CNA 7 stated the resident refrigerator was reviewed daily to ensure all foods were discarded in a timely manner. CNA 7 stated there was no log, record or checklist to ensure who reviewed the resident refrigerator. During an interview on 3/21/25 at 9:22 a.m. with Resident 28 in Resident 28's room, Resident 28 stated she had not had wine in a long time and could not remember when the wine was brought into the facility. During a concurrent interview and record review on 3/22/25 at 10:15 a.m. with the Director of Nursing (DON), a picture of Resident 28's wine bottle, dated 3/18/25 was reviewed. The DON stated the wine bottle had no received date or manufacture expiration date. The DON stated she expected all personal food items to be labeled with the resident name, room number and received date, per facility policy. The DON stated the received dated determined an expiration date in the absence of a manufacture expiration date. The DON stated all personal food items were discarded three days after the received date to avoid serving expired food items. The DON stated Resident 28 was at risk for receiving an expired food item which could lead to food borne illness. During a review of the facility's P&P titled, Food from Outside Sources, dated 1/2021, the P&P indicated, food left in the resident's refrigerator shall be labeled with the resident's name and date .food items will be discarded after three (3) days .the night shift .staff member assigned to check the refrigerator shall discard all out-of-date foods . During a review of the facility's job description document titled, Nutrition and Food Services Aide I, dated 6/1/04, the document indicated, .prepares and delivers nourishment's to the proper locations, maintaining nourishment stock levels in utility refrigerators at various nursing units .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 with the known behavior of wandering into other Resident rooms was left unattended on 4/10/24. This failure resulted in Resident 1 entering Resident 2's room where Resident 1 bit the hand of Resident 2. Findings: During a concurrent observation and interview on 4/23/24 at 12:57 p.m. with Resident 1, in Resident 1's room, Resident 1 was seated on her bed. Resident 1 was questioned regarding the altercation on 4/10/24, Resident 1 did not respond to the questions. 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 1/16/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 3 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 had severe cognitive impairment. During an interview on 4/23/24 at 1:01 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 tends to roam into other resident rooms . CNA 1 stated depending on Resident 1's mood, she would attempt to bite her when she did not want assistance with her care. During a concurrent observation and interview on 4/23/24 at 1:12 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 stated Resident 1 entered her room and was going through her belongings. Resident 2 stated she told Resident 1 to leave her room but Resident 1 told her that it was her room and would not leave. Resident 2 stated it made her feel upset and that Resident 1 bit her hand. During a review of Resident 2's MDS dated 3/6/24, it indicated Resident 2's BIMS assessment score was 15. The BIMS assessment indicated Resident 2 was cognitively intact. During a concurrent interview and record review on 4/23/24 at 1:25 p.m. with Registered Nurse (RN) 1, Resident 1 ' s Care Plan (CP) dated 8/18/23 was reviewed. The CP indicated, .The resident is an elopement [wandering] risk outside of facility and wander risk into other resident rooms r/t [related to] Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness Dementia [impairment of at least two brain functions, such as memory loss and judgment] .All staff to be aware of residents location. Res [resident] to be distracted away from exit doors, other resident rooms, and dining room . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . RN 1 stated Resident 1 has dementia and wonders into other resident rooms. During a concurrent interview and record review on 4/23/24 at 1:30 p.m. with RN 1, Resident 2 ' s Progress Notes (PN), dated 4/11/24 was reviewed. The PN indicated, .Resident was verbally and physically abusive to another resident. CNA's were on break and I was in the process of obtaining vitals [measure the basic functions of your body] and doing my med [medication] pass when a resident from [room number] came to the hall saying her neighbor and another resident were about to get into a fight .witnessed her [Resident 1] and another resident [Resident 2] holding each other's wrists being verbally abusive towards each other .gently pulled them apart and [Resident 2] said Get her the F**k [profanity] out of my room .she [Resident 2] was fine just upset and wanted me to keep [Resident 1] away from her and out of her room . RN 1 stated all staff should monitor Resident 1 so she does not go into other resident rooms. During a review of Resident 1's Abuse Investigation Worksheet (AIW) dated 4/12/24 was reviewed. The AIW indicated, .[Resident 1] .entered room of resident [Resident 2] insisting it was her room [Resident 2] asked [Resident 1] to leave and grabbed her to turn her chair away to have [Resident 1] then bit [Resident 2] on her inner hand between thumb and index finger . During a concurrent interview and record review on 4/23/24 at 2:22 p.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Comprehensive Care Plan dated 03/2001 was reviewed. The policy indicated, . Each resident will have a comprehensive person-centered care plan that includes measurable objectives and time frames to meet his/her, medical, nursing, mental and psychological needs . the comprehensive person centered care plan has been designed to . incorporate identified or potential problem areas . goals and objectives are defined as the desired outcome for a specific problem. They are resident oriented, behaviorally stated . Goals and objectives are entered on the person-centered care plan so that all disciplines have equal access to the information . person centered care plans are initiated and maintained in the resident's electronic record . The DON stated the importance of the care plan was so that all staff was aware of the residents specific care needs. The DON stated that if staff were aware of Resident 1's location, the altercation could have been avoided. During an interview on 4/23/24 at 2:35 p.m. with Resident 3, Resident 3 stated Resident 1 had entered her room before. Resident 3 stated on 4/10/24, Resident 1 entered the room and began to go through her belongings then went over to Resident 2's bed. Resident 3 stated she went to inform the nurse that Resident 1 was in their room. During a review of Resident 3's MDS dated 3/21/24, it indicated Resident 3's BIMS assessment score was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During a telephone interview on 4/23/24 at 5:20 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/10/24 Resident 3 informed her that Resident 1 and Resident 2 were going to get into a fight. LVN 1 stated that she entered Resident 2's room and observed Resident 1 and Resident 2 holding each other wrists. LVN 1 stated the CNA assigned to Resident 1 was on break and that she was preparing to begin medication pass. LVN 1 stated the importance of the care plan was to ensure staff were following safety protocols to avoid altercations. LVN 1 stated she was not aware that Resident 1 wondered into other resident rooms and that is it was her first time caring for Resident 1. LVN 1 stated staff should have monitored Resident 1 to prevent her from going into Resident 2's room. During a telephone interview on 4/25/24 at 9:31 a.m. with CNA 2, CNA 2 stated she was Resident 1's assigned CNA on 4/10/24. CNA 2 stated when Resident 1 was out of her room she needed to be monitored to prevent her from entering other resident rooms. CNA 1 stated she communicated to the LVN on shift that she was going on break. CNA 1 stated the altercation could have been avoided if Resident 1 was monitored.

Based on record reviews, review of the facility policy, and interviews, the facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for 3 (Residents #11, #31, and #89) of 5 sampled residents reviewed for advance directives. Findings included: A review of the facility policy titled, Advance Directives, reviewed in December 2020, revealed, Long Term Care Residents 1. During the admitting process the patient/family and/or surrogate decision maker will be asked if he/she has executed an Advance Healthcare Directive. This information will be recorded on the admission form and forwarded to Social Services. 1. A review of Resident #11's admission Record revealed the facility admitted to the resident on 06/15/2016. Per the admission Record, Resident #11 was their own responsible party. A review of Resident #11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. In an interview on 03/19/2024 at 11:51 AM, the social services (SS) staff person stated she was responsible for offering the advance directive form to the residents and/or their responsible party and for the discussion/education of the details with the resident and/or their responsible party. The SS staff person stated Resident #11 refused to complete the advance directive form and she had no documentation to indicate the resident's refusal. In an interview on 03/20/2024 at 10:22 AM, the Director of Nursing stated she could not speak about the details of the advance directive process. In an interview on 03/20/2024 at 10:40 AM, the Administrator stated he expected SS to offer advance directives information to residents and their responsible party. In an interview on 03/20/2024 at 11:02 AM, Resident #11 stated the facility had not offered information about advance directives. 2. A review of Resident #31's admission Record revealed the facility admitted the resident on 03/20/2021. Per the admission Record, Resident #13 was their own responsible party. A review of Resident #31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. In an interview on 03/19/2024 at 11:51 AM, the social services (SS) staff person stated she was responsible for offering the advance directive form to the residents and/or their responsible party and for the discussion/education of the details with the resident and/or their responsible party. The SS staff person stated Resident #13 declined to complete the advance directive form and she had no documentation to indicate the resident's refusal. In an interview on 03/20/2024 at 10:22 AM, the Director of Nursing stated she could not speak about the details of the advance directive process. In an interview on 03/20/2024 at 10:40 AM, the Administrator stated he expected SS to offer advance directives information to residents and their responsible party. In an interview on 03/20/2024 at 10:49 AM, Resident #31 stated they had not been offered information about advance directives by the facility. 3. A review of Resident #89's admission Record revealed the facility admitted the resident on 10/31/2023. Per the admission Record, Resident #89 was their own responsible party. A review of Resident #89's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. In an interview on 03/20/2024 at 3:25 PM, Resident #89 stated no one from the facility had talked with them about advance directives. In an interview on 03/21/2024 at 8:13 AM, the Director of Nursing stated she did not have much detail about advance directives. In an interview on 03/21/2024 at 8:58 AM, the Administrator stated advance directives should be discussed during the admission progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of six sampled residents (Resident 1) when Resident 1 ' s physician order (PO) for administration of oxygen by nasal canula (tubing used to deliver oxygen to the nose) at the rate of three (3) liters (metric measurement of volume,)was not followed and the oxygen concentrator (machine which uses room air and concentrates it to produce high concentration of oxygen) was routinely set at three and a half (3.5) liters. This failure placed Resident 1 at risk for adverse effects of too much oxygen which can lead to pulmonary edema (excessive accumulation of liquid in the lungs). Findings: During a review of Resident 1's , Physician ' s Orders (PO) (a record which contains resident medical information), dated 1/1/23-2/28/23, the PO indicated, Resident 1 had a diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, group of diseases that cause airflow blockage and breathing-related problems), Heart Failure (condition in which the heart doesn't pump blood as well as it should), Hypertension (high blood pressure), Anxiety disorder (mental condition with irrational fear), shortness of breath (difficulty breathing), chronic respiratory failure with hypoxia (progressive illness of the lungs in which deficient oxygen reaches the body tissues). Resident 1 ' s PO indicated, .Monitor episodes of anxiety .Shortness of breath . The PO indicated, Resident 1 received the following medications: Umeclidinium inhalation Aerosol powder (inhaled medication for chronic respiratory illness), Ipatropium-Albuterol solution (inhaled respiratory medication), Lorazepam (oral medication for anxiety), Proventil Inhaler (inhaled medication for respiratory illness), Montelukast (oral medication to prevent lung irritation), Budesonide/Formoterol inhaler (inhaled medication to prevent lung irritation), and Oxygen via nasal canula 3 [liters] every day and night . During a concurrent interview and record review, on 2/6/23 at 4:50 p.m., with LN 3, Resident 1 ' s nurses notes date 1/29/23 and PO were reviewed. LN 3 stated, she had documented the note and had observed Resident 1 ' s oxygen concentrator was set at three and a half (3.5) liters. LN 3 stated, Resident 1 ' s PO indicated, the oxygen order was for three (3) liters. LN 3 stated, We turn it up, or she turns it up, when she has shortness of breath. LN 3 stated, .I thought we could adjust it up to 5 liters when she was short of breath. We do not have a PRN (as needed) physician ' s order to increase the oxygen .We should follow the doctor ' s order . During an interview, on 2/7/23 at 3:45 p.m., with Resident 1, Resident 1 stated, she was currently at the acute care hospital. Resident 1 stated, she always used oxygen. Resident 1 stated the oxygen was usually set at 3.5 liters. Resident 1 stated, she had asked the CNA to see a nurse on 1/30/23 about 2 a.m. because it was getting hard to breath. Resident 1 stated, LN 1 had come in and helped her. During a review of Resident 1 ' s Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 1/19/23, the MDS assessment indicated, Resident 1 had no mental impairment with a Brief Interview for Mental Status (BIMS, an evaluation of attention, orientation, and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a review of Resident 1 ' s nursing notes, dated 1/31/23, the nursing notes indicated, .11 am, spoke with [physician ' s receptionist] regarding residents SOB (shortness of breath) .Oxygen saturation on 3.5 liters . During an interview on 2/8/23 at 1 p.m., with LN 2, LN 2 stated, she worked on 1/31/23 and was assigned to Resident 1. LN 2 stated, she saw Resident 1 about 9:30 a.m. and gave Resident 1 a breathing treatment. LN 2 stated, when she returned about 10 a.m., Resident 1 had a change in condition and was lethargic (tired and not responding normally). LN 2 stated, Resident 1 was not speaking but would only nod her head. LN 2 stated, she had called the doctor and sent Resident 1 to the hospital. LN 2 stated, she had documented Resident 1 ' s nursing note and validated the oxygen concentrator was set at 3.5 liters. LN 2 stated, she had not looked at the physician ' s order for the oxygen but should have. LN 2 stated, Resident 1 ' s oxygen was usually set at 3.5 liters. LN 2 stated she was responsible for following the physician orders. LN 2 stated, she should have followed the physician order for oxygen at three (3) liters. LN 2 stated, they should have asked the physician for a PRN (as needed) order to increase the oxygen when Resident 1 needed it. During a concurrent interview and record review, on 2/8/23, at 11:29 a.m., with the Director of Nursing (DON), the PO and nursing notes dated 1/29/23 and 1/31/23 were reviewed. The DON stated, Resident 1 had end stage COPD and required continuous oxygen. The DON stated, the PO was for oxygen three (3) liters nasal cannula. The nursing notes indicated, the LN 2 and LN 3 had documented the oxygen was delivered at 3.5 liters. The DON stated, Resident 1 did not have a PRN order to increase the oxygen but should get one. The DON stated, the licensed nurses were responsible for the oxygen settings and the oxygen setting should match the physician order. The DON stated, she would need to train the nurses to turn the oxygen down to three (3) liters when they found it at three and a half (3.5) liters. During a professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886231/ titled, Nurses ' Supplemental Oxygen Therapy Knowledge and Practice in Debre [NAME] General Hospital: A Cross-Sectional Study, dated 2019, the professional reference indicated, .Oxygen therapy is a medical treatment and prescribed to prevent or treat hypoxemia .Nurses are the most responsible health personnel who monitor oxygen therapy and reduce supplementary oxygen risk as soon as possible .Patients can be affected by getting no oxygen or too little or too much oxygen. It is appropriate to provide the optimal concentration of supplemental oxygen . During a review of the facility's policy and procedure (P&P) titled, OXYGEN ADMINISTRATION WITH A NASAL CANNULA, dated 10/22, the P&P indicated, .B. Patient Application .3. Adjust the flow to prescribe flow .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility Licensed Nurses (LN) 1 and 2 failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards and practices for one of six sampled residents (Resident 1) when the Licensed Nurses did not document a complete and accurate assessments for Resident 1 who had a change of condition on 1/30/23 at 2 a.m. These failures resulted in the facility had not maintained clinical records that were complete, accurately documented, and readily accessible for Resident 1. Findings: During a review of Resident 1's Physician ' s Orders (PO) (a record which contains resident medical information), the PO indicated, Resident 1 had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, group of diseases that cause airflow blockage and breathing-related problems), Heart Failure (condition in which the heart doesn't pump blood as well as it should), Hypertension (high blood pressure), Anxiety disorder (mental condition with irrational fear), shortness of breath (difficulty breathing), and chronic respiratory failure with hypoxia (progressive illness of the lungs in which deficient oxygen reaches the body tissues). During a review of Resident 1's Face Sheet (FS) (FS-a record which contains resident personal information at a glance), the FS indicated, Resident 1 was admitted to the facility on [DATE]. The FS indicated, Resident 1 was her own representative. During a review of Resident 1 ' s Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 1/19/23, the MDS assessment indicated, Resident 1 had no mental impairment with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation, and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 2/6/23 at 3:54 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had worked the night shift on 1/31/23 and was assigned to Resident 1. CNA 1 stated Resident 1 began complaining of breathing problems about 2 a.m. CNA 1 stated, Resident 1 had chronic breathing problems and asked to see the nurse. CNA 1 stated, Resident 1 said she wanted to go to the hospital. CNA 1 stated, she had told LN 1 about Resident 1 ' s request. CNA 1 stated, LN 1 had gone to see Resident 1 and had given her a breathing treatment and anxiety medication. CNA 1 stated, Resident 1 had asked again about 4:45 a.m. to see the nurse because she was having trouble breathing. CNA 1 stated, LN 1 had treated Resident 1 for breathing problems both times she had asked. During an interview on 2/7/23 at 3:24 p.m., with LN 1, LN 1 stated, she had worked on 1/30/23 night shift and was assigned to care for Resident 1. LN 1 stated, Resident 1 first complained of difficulty breathing between 1-2 a.m. LN 1 stated, Resident 1 had asked to go to the hospital. LN 1 stated she had talked to Resident 1 and asked that they do the prescribed treatments and medications to see if they helped before sending her to the hospital. LN 1 stated, Resident 1 ' s vital signs were at her baseline and the hospital would not have accepted her. LN 1 stated, Resident 1 had anxiety and frequently asked for breathing treatment and anxiety medication. LN 1 stated, Resident 1 agreed to do the treatments first. LN 1 stated she had administered ipratropium-albuterol (medication to treat lungs and improve oxygen flow) solution 1 vial as needed by nebulizer (machine that turn liquid into mist for inhalation) and Ativan (medication for anxiety) 0.5 milligrams as needed to Resident 1. LN 1 stated around 6 a.m. Resident 1 again requested to go to the hospital. LN 1 stated, she gave another breathing treatment and Proventil (medication to improve lung expansion and decrease irritation) inhalation aerosol solution (handheld inhaler). LN 1 stated, she had reported the changes on shift report to the oncoming nurse assigned to Resident 1. LN 1 stated, she had called the doctor ' s answering service and had left a message, but he had not called back. LN 1 stated, she did not document she had attempted to contact the doctor. LN 1 stated, she had not documented an assessments in Resident 1 ' s clinical record for the night shift on 1/30/23. LN 1 stated, It had slipped my mind. LN 1 stated she was supposed to document assessments when residents had any changes. LN 1 stated, if it was not documented, the people coming on shift could not see the changes for Resident 1 and what happened during the shift. During an interview on 2/7/23 at 3:45 p.m., with Resident 1, Resident 1 stated she was currently at the acute care hospital. Resident 1 stated, she had asked the CNA to see a nurse on 1/30/23 approximately 2 a.m. Resident 1 stated, it was getting hard to breathe and she wanted to go to the hospital. Resident 1 stated, LN 1 had come in and helped her. Resident 1 stated, LN 1 had spoken to her and said they would try the breathing treatments and anxiety medications first and if they did not work, she would send her to the hospital. Resident 1 stated, she agreed with LN 1. LN 1 has given the medications and she did feel better. Resident 1 stated, the trouble breathing came back but she did not know what time. Resident 1 stated, LN 1 had given her another breathing treatment and an inhaler in the morning. Resident 1 stated, LN 2 saw her in the morning, and she was feeling better. Resident 1 stated, she started having trouble breathing again later that morning and LN 2 sent her to the hospital. Resident 1 stated she had gone to the hospital on 1/31/23 but was not sure of the time. During an interview on 2/8/23 at 1 p.m., with LN 2, LN 2 stated, she worked on 1/31/23 and was assigned to Resident 1. LN 2 stated, at the beginning of her shift Resident 1 was sleeping. LN 2 stated she saw Resident 1 about 9:30 a.m. and gave Resident 1 a breathing treatment. LN 2 stated, when she returned about 10 a.m., Resident 1 had a change in condition and was lethargic (tired and not responding normally). LN 2 stated, Resident 1 was not speaking but would only nod her head. LN 2 stated, she had called Resident 1 ' s doctor and was unable to reach him. LN 2 stated, she called the facility ' s medical director and sent Resident 1 to the hospital. LN 2 stated, she had not documented Resident 1 ' s assessment in the electronic medical record (EMR). LN 2 stated, she was supposed to document an assessment for Resident 1 ' s change in condition on 1/31/23 but had not. LN 2 stated, she had forgotten to document an assessment. LN 2 stated, Documentation of the assessment was for people coming in to see what happened with the resident. During a concurrent interview and record review, on 2/8/23 at 11:29 a.m., with the Director of Nursing (DON), Resident 1 ' s nursing notes dated 1/30/23 and 1/31/23 were reviewed. The DON stated, Resident 1 was hospitalized the previous week on 1/20/23 for exacerbation (worsening) COPD and had returned to the facility on 1/24/23. The DON validated Resident 1 ' s nursing notes did not indicate LN 1 had documented an assessment for the night shift on 1/30/23, when Resident 1 first complained of breathing problems. The DON validated Resident 1 ' s nursing notes did not contain an assessment for Resident 1 by LN 2 for the morning of 1/31/23 when change of condition occurred and Resident 1 was hospitalized . The DON stated, the LNs were responsible for documenting assessment when a resident had a change in condition. The DON stated, LN 1 and LN 2 should have documented the assessment for Resident 1. The DON stated, she would need to do training for the LNs on documentation this month. The DON validated Resident 1 was sent to the acute hospital on 1/31/23 for exacerbation of COPD. 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 medical record must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. 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 . An accurate medical record improves the quality of care through enhancing effective communication across the continuum of care for the patient, thus protecting the patient from potential harm Nursing documentation must be time sensitive: To ensure that all nursing documentation is a true reflection of the patient ' s condition and care, the nurse must document at the time of the event or shortly afterward .A failure to maintain a reasonable standard of documentation of nursing interventions administered to a patient could be viewed as professional misconduct .the nurse has an obligation to accurately document. During a review of the facility's policy and procedure (P&P) titled, Patient Documentation, dated 5/22, the P&P indicated, . Documentation of patients depend on the assessment of the licensed nurse . Subjective Information: Chief compliant . 2. Objective Information . Vital sign . Interaction with patient .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of 28 sampled residents (Resident 57, 71 and 83) were treated with dignity and respect when the three residents sat together for lunch and were served at different times. This practice failed to promote the right to a dignified dining experience for Resident 57, 71 and 83. Findings: During an observation on 3/25/19, at 11:45 a.m., in the dining room, four residents shared the same dining room table. Resident 64's lunch meal was served by Certified Nursing Assistant (CNA 1) first. Resident 64 began to eat while Residents 57, 71, and 83 waited to be served. Resident 83 requested to be served lunch and asked CNA 1 about the whereabouts of her lunch. During an observation on 3/25/29, at 11:52 a.m., in the dining room, Resident 83 stated, I am getting hungry. Resident 71's lunch tray was served and waited for a CNA to provide assistance with feeding. Resident 57 was served next and began to eat while Resident 83 continued to wait for her lunch tray to be served. Resident 83's lunch tray was served last at 11:55 a.m., she continued to wait for CNA 2 to assist her with feeding. During an interview with CNA 2, on 3/25/19, at 2:17 p.m., she stated Resident 64, 57 and 71 were served and began to eat before Resident 83 was served. CNA 2 stated, Everybody should be served at the same time. [Staff] should finish serving one table before serving another table. They [residents] shouldn't be looking at other residents eating. I don't think that is right . They will feel neglected. It will affect their dignity. During an interview with Director of Staff Development (DSD) 1, on 3/27/19, at 2:37 p.m., she stated, The RNAs [Restorative Nursing Assistant] and CNAs just grab the food tray in the cart and distribute . there is no system .they just serve whichever tray comes out of the cart. DSD 1 stated it was a dignity issue when residents were not served their meal on the same table at the same time. During an interview with RNA 1, on 3/27/19, at 3:49 p.m., he stated, We are supposed to serve everybody on the same table at the same time. RNA 1 stated it affected the resident's dignity if residents were not served their meals at the same time. During a review of the clinical record for Resident 71, the Minimum Data Set (MDS) assessment (an evaluation of care and functional needs) dated 2/25/19, indicated Resident 71 needed extensive assistance (weight bearing support) and assistance of one-person for eating. During a review of the clinical record for Resident 83, the MDS assessment dated [DATE], indicated Resident 83 needed limited assistance (guided maneuvering of limbs) of one-person physical assist for eating. The facility document titled, MEAL TIME PROCEDURE undated, indicated . ALL NURSING ASSISTANTS NEED TO REPORT TO THE DINING ROOM TO ASSIST WITH PASSING TRAYS AND ASSISTING DINERS IN THE DINING ROOM ON TIME. RESIDENTS NEED SHOULD BE MET PRIOR TO MEALTIME, INCLUDING SET UP FOR MEAL . The facility policy and procedure titled Patients' Rights and Responsibilities dated 5/2003, indicated . Patients have the right to: 1. Considerate and respectful care . 13. Receive care in a safe setting, free from . neglect .

Based on observation, interview and record review, the facility failed to ensure the residents right to privacy during care for two of two sampled residents (Resident 39 and 65) when: Resident 39 and 65 were provided with care by two Registered Nurses (RN 1 and RN 5) without privacy. This practice violated Resident 39's and 65's right to privacy during the delivery of care. Findings: During a medication administration observation on 3/26/19, at 7:35 a.m., RN 5 entered Resident 65's room and took the resident's blood pressure (measures how hard the blood is pushing against the walls of the arteries) while the maintenance man worked on Resident 65's neighbors bed. RN 5 did not pull the privacy curtain to offer Resident 5 privacy and allowed the maintenance man to see. During an interview with RN 5, on 3/26/19, at 8:15 a.m., she stated she should have pulled the privacy curtain around Resident 65's bed to ensure her privacy was protected from others not involved in her care. During a medication administration observation on 3/26/17, at 12:03 p.m., RN 1 entered Resident 39's room to administer an insulin (medication used to treat high blood sugar) injection. Resident 39's sat in front of the sliding door which overlooked to an outside patio. Resident 39 pointed to her abdomen as her preferred site for insulin injection and lifted her blouse to expose the area. RN 1 proceeded to administer Resident 39's insulin without closing the curtain on the sliding door. During an interview with RN 1, on 3/26/19, at 5:20 p.m., he stated he should have closed the curtain on the glass sliding door to provide the resident privacy during medication administration. During an interview with the director of nursing (DON) on 3/27/19, at 9:55 a.m., she stated the resident's right to privacy should have always been maintained while performing care and procedures. The facility policy and procedure titled, Registered Nurse's Job Description & Competency Evaluation dated 1/16/19 indicated, General Accountabilities: . 3. Assures that the rights of the patients are respected and maintained by allowing for privacy, confidentiality, and dignity in the provision of service . The facility's policy and procedure titled, Patients' Rights and Responsibilities dated 5/2003 indicated, POLICY . Patients have the right to . 11. Have personal privacy respected .examination and treatment are confidential and should be conducted discreetly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a concurrent observation, interview and record review with Rehabilitative Nursing Assistant (RNA)/CNA 9, on 3/26/19, at 10 a.m., CNA 9 demonstrated how sensor alarms (a device that emits sound to alarm staff) were checked daily to verify they were in proper working order. RNA/CNA 9 reviewed the sensor check log for the month of March and stated RNAs were responsible to checked the sensor alarms daily. During a concurrent interview and record review with RN 1, on 3/26/19, at 4p.m., RN 1 reviewed clinical records for Residents' 1,7, 10, 20, 31, 41, 76, 74) who had been using wander alarms and were not assessed prior to its use. RN 1 stated the facility did not perform elopement assessment for residents at risk for elopement. The facility process was for the nurse to place a sensor alarm on residents that were seen going outdoors. RN 1 stated, There is no separate assessment for elopement, it is just a box to check if resident has a history of fall. RN 1 stated if a resident was observed to be at risk for elopement or staff reported a resident was trying to go out of the facility, nurse would apply a sensor alarm. RN 1 stated he does not remember documenting residents risk for elopement in the weekly summary form. RN 1 stated the RNAs (CNA's that provide exercises to resident's) are responsible for checking the sensor alarm daily to ensure the devise is functioning properly. During a concurrent interview and record review with RN 3, on 3/27/19, at 3:03p.m., RN 3 stated the facility did not have an assessment tool for elopement. The RN stated, We just start a behavior monitoring and a care plan and both the charge nurse and the RNA [CNA] will decide if a resident needed a wander alarm (sensor alarm). During an interview with RN 4, on 3/27/19, at 3:49 p.m., RN 4 stated residents were assessed for signs of dementia (a medical condition that causes memory loss), ambulation or mood but unsure if the facility had assessment tool for elopement or any criteria for the sensor alarm. RN 4 stated, I did not see it in the admission packet and elopement is not part of the weekly summary documentation. During an interview with the Director of Nursing (DON), on 3/27/19, at 4:30 p.m., the DON stated the facility did not have an assessment form for elopement, she stated the facility policy mentioned it but there was no assessment form being used at the time of interview. The DON stated it was the responsibility of all the staff in observing the resident's behaviors and notifying the charge nurse. The facility policy and procedure titled Elopement risk and Security Monitoring System dated 1/2018 indicated, .1. Residents are assessed upon admission for individual characteristics that would put them at risk for elopement .2 .Weekly assessment is documented on the weekly summary form by license nurse . After six months of use, the interdisciplinary team (IDT), at a quarterly conference will assess for discontinuance of sensor use . What to do when the alarm sounds .Find the resident and bring him/her inside the facility . 4. During a review of the clinical record for Resident 89, the Physician's Telephone Orders dated 10/31/18 indicated, Transport to ER [Emergency Room] for treatment and evaluation after an unwitnessed fall. The Telephone order document indicated, Physician please sign and return within 72 hours. The telephone order was signed by the physician on 11/19/18 (19 days after the order). During a concurrent interview and record review with the DON and Assistant Director of Nursing (ADON), on 3/26/19 at 9:00 a.m., the DON and ADON reviewed Resident 89's clinical record and stated the physician's verbal/telephone order dated 10/31/19 was not timed, dated or signed by the physician. The ADON stated the telephone order document should be signed within five days from the date of the order. The ADON stated the physician only makes rounds in the facility once a month. During a concurrent interview and record review with the ADON on 3/26/19 at 3:48 p.m., the ADON reviewed the policy titled Verbal or Telephone Orders physician's orders had to be signed within five days of obtaining the verbal/telephone order. The ADON stated, we are not following our policy for verbal/telephone orders. During a concurrent interview and record review with the DON and DSD 2, on 3/26/19, at 5:20 p.m., the DON and DSD 2, stated Resident 74's telephone order was written on 10/31/18 and was timed, dated and signed by the physician on 11/19/18. The DSD 2 stated the telephone order was signed by the physician 19 days after the order was given which was greater than the required five days. The DON stated an order was written on 3/15/19 at 14:00 and signed 3/26/19 at 5:30 [10 days later] should have been signed on 3/20/19 by 14:00. The DON and DSD 2, reviewed clinical records for Resident 42, 64, 74, 89, 90 and stated these clinical records contained multiple telephone orders that had not been signed by the physician within the five-day time frame. The DON stated verbal/telephone orders should have been signed by the five-day time frame from the date the order was received. During a concurrent interview and record review with the Medical Records Clerk (MRC), on 3/27/19, at 9:17 a.m., the MRC verified verbal orders for Resident 64 were signed but not dated and times. The MRC reviewed clinical records for Resident 42, 74, 89, 90 and stated the records contained multiple telephone orders that had not been signed by the physician within the five days from the date the order was received. The MRC stated, We call the Doctor's office if we notice it had been a while, like a month or so. The MRC stated the facility policy required a physician signature within five days of obtaining the verbal/telephone order. The MRC stated, I know they are late a lot. The facility policy titled Verbal or Telephone Orders dated 5/2016 indicated, .Procedure .10. Verbal/Telephone orders obtained at [facility name] must be signed within five days. (authentication must include the date and time of countersignature so that compliance can be verified). 3. During an observation on 3/25/19, at 11:48 a.m., in the dining room, Resident 5 was given his lunch tray. Resident 5's lunch tray contained roast turkey with alfredo sauce, pasta and green beans. Resident 5 stated he was on clear liquids (diet). During an interview with Registered Nurse (RN) 1, on 3/25/19, at 12:05 p.m., he stated, For Resident 5, clear liquids was ordered starting today. He is scheduled for a procedure . All meals ordered is clear liquids. RN 1 stated Resident 5 was served the wrong diet. RN 1 stated Resident 5's lunch should have been clear liquids. During an interview with RN 1, on 3/26/19, at 4:11 p.m., he stated the physician ordered diet was not followed for Resident 5's lunch on 3/25/19. RN 1 stated, Doctor's orders should be followed. During an interview with Director of Staff Development (DSD) 2, on 3/27/19, at 2:49 p.m., she stated, When the CNAs and RNA's hand the trays in the dining room, they will not know the diet order changed. They just go by the meal ticket [slip]. DSD 3 stated physician ordered diets should be followed. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 9:10 a.m., she stated the physician ordered diet should be followed. NSS stated, The ordered diet [Resident 5] was not followed . We [Dietary] made a mistake. My staff did not pay attention. NSS stated Resident 5's scheduled medical procedure would have been cancelled if he ate the regular diet served. NSS stated residents could have a bad outcome if the ordered diet was not followed. During an interview with the Registered Dietitian, on 3/28/19, at 11:42 a.m., she stated, We should follow doctor's ordered diet . We [facility] can have a negative [resident] outcome if we don't follow it. During a review of the clinical record for Resident 5, the Order Summary Report dated 3/15/19, indicated Clear Liquid Diet on 03/25/19, 03/26/19, 03/27/19 unless otherwise noted by MD [Doctor] . The facility policy and procedure titled Therapeutic Diets dated 2/22/17, indicated . Therapeutic diets are prepared and served as prescribed by the attending physician . The professional reference titled California Nursing Practice Act dated 1/1/13, indicated . The practice of nursing . means those functions . including all of the following . (2) Direct and indirect patient care services . necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician . Based on observation, staff interview and record review the facility failed to ensure services provided meet professional standard of quality for 18 of 18 sampled residents (Resident 17, 25, 42, 64 ,74, 89, 90, 1, 7, 10, 20, 31, 41, 76, 74, 5, 89 and 64) when: 1. Registered nurse (RN) 5 did not follow the manufacturer's specifications on an inhaler (inhalers - a portable device for administering a drug which is to be breathed in) inhalation administration use for one of 18 sampled residents (Resident 17). This failure had the potential to place Resident 17's at risk for developing infections in her mouth. 2. RN 2 signed the medication administration record (MAR) prior to the administration of medications to one of 18 sampled residents (Resident 25). This failure had the potential to place Resident 25 at risk for medication errors. 3. The facility failed to follow the physician ordered diet for one of 28 sampled residents in the dining room when Resident 5 was served a regular diet instead of a clear liquids diet (water, broth and plain gelatin - diet that are easily digested and leave no undigested residue in your intestinal tract). This failure resulted in Resident 5 being given the wrong diet which placed Resident 5 at risk of compromising his scheduled medical procedure. 4. The facility failed to implement their policy in signing physician's telephone orders. This failure resulted in an unsigned telephone order for residents (Resident 42, 64, 74, 89, 90) for more than 5 days. This failure placed residents at risk for medication errors. 5. The facility failed to follow the facility policy and procedure on elopement risk assessment and security monitoring system for eight of eight residents (Residents' 1,7, 10, 20, 31, 41, 76, 74) who had been using wander alarm (a type of security monitoring) were not assessed prior to its use. This failure had the potential for these resident's freedom to move around various places in the facility to be restricted when these resident's elopement risk were not assessed. Findings: 1. During a concurrent medication administration observation and interview with Registered Nurse (RN) 5, on 3/26/19 at 8:15 a.m., in Station 2, RN 5 proceeded to Resident 17's room to administer scheduled oral and inhalation medications. Resident 17 requested her inhalation (inhaler) medication first. RN 5 shook and handed the inhaler to the resident without any instruction. Resident 17 self- administered the inhalation therapy, then grabbed her glass of water with straw, sipped some water and swallowed it. RN 5 instructed resident to rinse her mouth and spit the water out on an empty glass. Residents 17 stated she had swallowed the water. Resident 17 stated she did not know why she needed to rinse her mouth with water and spit the water out into an empty glass. Resident 17's physician's order dated 2/26/19 indicated, [Name brand inhaler] Aerosol Powder Breath activated 1 puff inhale orally . RINSE MOUTH AND SPIT AFTER USE The inhaler patient information insert instruction dated 12/2017, indicated, .Step 6. Rinse your mouth . Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water . The facility's policy and procedure titled, Medication Administration dated 12/12 indicated, . Medication Administration .13. Explain to resident the type of medication being administered and the procedure . During an interview with RN 5, on 3/26/19, at 8:15 a.m., RN 5 stated the correct process was for the nurse to first explained the medication procedure and reason why the resident needed to rinse her mouth out after each inhalation administration. RN 5 stated the risk of resident drinking the water and not rinsing her mouth after the inhaler medication could place Resident at risk of getting oral thrush (a painful yeast infection that affects the inside of the mouth). RN 5 stated continuously educating the resident to rinse her mouth out, not swallow the water and spit the water in the empty glass would ensure the manufacturer's specification were followed. During an interview with the director of nursing (DON), on 3/27/19, at 10 a.m., she stated the expectation would be for the nurse to educate Resident 5 regarding the medications and treatments prior to the administration of the medication to ensure the manufacturer's specifications would be followed. During a review of the clinical records for Resident 17, Minimum Data Set, dated [DATE] Section C0500 BIMS (Brief Interview for Mental Status) indicated 15 - cognitively intact. 2. During a medication administration observation on 3/27/19, at 8 a.m., in Station 2, RN 2 prepared the scheduled morning medications for Resident 25 then, signed the medication administration record (MAR) after all the pills were in the medicine cup and prior to the actual administration of medications to Resident 25. During an interview with RN 2, on 3/27/19, at 8:25 a.m., RN 2 stated the correct medication documentation process was for her to sign the resident's MAR after she had actually administered Resident 25's medications. During an interview with the DON, on 3/27/19, at 10:05 a.m., she stated the expectation would be for the nurse to sign the MAR after the medication was administered to the resident. The facility's policy and procedure titled Medication Administration . Documentation: 1. The individual who administered the medication dose, records the administration on the resident's MAR immediately following the medication being given . Review of the professional reference titled Fundamentals of Nursing-[NAME]-Perry dated 2005, page 847 indicated, Recording Medication administration. After administering a medication, the nurse records it immediately on the appropriate record form . The nurse never charts a medication before administering it. Recording immediately after administration prevents errors . Review of the professional reference titled, Clinical Procedures for Safer Patient Care dated 4/4/19 indicated,6.2 Safe Medication Administration . Medication errors are the number -one error in health care (Center for Disease Control [CDC], 2013) . NEVER document that you have given a medication until you have actually administered it .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident who were unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition for two of 28 sampled residents (Residents 83 and 71) when Residents 83 and 71 did not have assistance with their meals. This failure resulted in Residents 83 and 71 having to wait for 10 minutes to receive assistance with their meals which could have the potential to cause unplanned weight loss. Findings: During an observation in the dining room, on 3/25/19, at 11:45 a.m., four residents were seated at the same table. Resident 64 was served her lunch meal by Certified Nursing Assistant (CNA) 1. CNA 1 left and did not serve Resident 71, 83 and 57 their lunch meal. During an observation in the dining room, on 3/25/29, at 11:52 a.m., Resident 71 was served her lunch but did not start eating. Resident 71 waited for assistance. Resident 57 was served her lunch and started eating. At 11:55 a.m., Resident 83 was served her lunch meal. Resident 71 and 83 were assisted with their meals by CNA 2 10 minutes after Resident 64 was served her lunch meal. During an interview with Restorative Nursing Assistant (RNA) 1, on 3/27/19, at 3:49 p.m., he stated, There are only 2 RNAs and 1 CNA assigned to the dining room . We get help from CNAs that are done helping the residents on the floor [resident rooms]. RNA 1 stated residents that needed assistance should be assisted once the meal serving was started. RNA 1 stated, Resident 83 needs to be assisted and fed. If she is not helped, she will not be able to eat enough . Resident 71 needs to be assisted in eating. If she is not helped, she will not be able to eat enough . RNA 1 stated there was no assistance provided in the dining room for Resident 83 and Resident 71 at the start of the meal service. RNA 1 stated, Residents should eat at the same time [on the same table] and be provided assistance. During an interview with RNA 2, on 3/28/19, at 8:25 a.m., she stated there were two RNAs and one CNA assigned to the dining room and there were 8 residents that eat in the dining room that need assistance. RNA 2 stated, They [residents] need a staff to sit with them and assist them. RNA 2 stated they had to wait for CNAs to assist with all the residents that need assistance in the dining room. During an interview with Director of Nursing (DON), on 3/28/19, at 2:05 p.m., she stated residents should not be sitting for more than a couple of minutes in the dining room surrounded by people eating without being assisted. DON stated residents that need to be assisted should receive the required assistance. During a review of the clinical record for Resident 71, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) dated 2/25/19, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 4 indicating severe cognitive impairment and Resident 71 required extensive assistance and one-person physical assist for eating. The care plan for Nutritional Status For Resident 71 dated 5/31/18 indicated . Assist resident with all meals as follows: Dependent . During a review of the clinical record for Resident 83, the MDS dated [DATE], indicated a BIMS score of 8 out of 15 indicating moderate cognitive impairment and Resident 83 required limited assistance and one-person physical assist for eating. The care plan for Nutritional Status For Resident 83 dated 3/7/19, indicated . Assist resident with all meals as follows: Set-up . The facility document titled, MEAL TIME PROCEDURE undated, indicated ALL NURSING ASSISTANTS NEED TO REPORT TO THE DINNG ROOM TO ASSIST WITH PASSING TRAYS AND ASSISTING DINERS IN THE DINING ROOM ON TIME . CNAS ASSIGNED TO THE HALL WILL ASSIST THE DEPENDENT AND ASSISTED DINERS . CHECK TO SEE THAT ALL DEPENDETN DINERS ARE ASSISTED . The facility document titled Job Description . Certified Nursing Assistant undated, indicated . Prepares patients/residents for meals . Assist in feeding .

Based on observation, staff interview and record review, the facility failed to implement an ongoing resident centered activities program to support the resident/family's choice of activities to maintaining and/or improve resident's physical, mental and psychological wellbeing for one of four sampled residents (Resident 43). This failure resulted in the activity needs of Resident 43 going unmet. Findings: During a telephone interview with a family member (FM) 1, on 3/25/19, at 9:27 a.m., she stated Resident 43 loves music, like western and pop music and enjoyed being around people. FM 1 stated she had provided the resident with a radio and wanted the radio to be on music for the resident to make sure Resident 43 wound not feel alone. FM 1 stated the last time she was at the facility, she noticed the television owned by another resident was not on. FM 1 stated she was informed the television set was broken. FM 12 stated she recently bought a new television set for Resident 43's visual stimulation. FM 1 stated she asked some of the CNAs (certified nursing assistant) who had been caring for of Resident 43 for a long time to turn on the television set on or to make sure the radio was playing. FM 1 stated this was not happening all the time when she was at the facility visiting the resident. FM 1 stated Resident 1 was non-verbal and could not communicate what she wanted but could respond with smiles and eye contacts. During an observation in Resident 43's room, on 3/25/19, at 8:10 a.m., 11: a.m. and 4 p.m. Resident 43 was on bed and the black & white television set was turned on with no sound and the radio was not playing. During an observation of Resident 43 in her room, on 3/26/19, at 10 a.m., with the medical record assistant (MRA), the television set TV was on with sound muted and no music was playing from the radio cassette. During a concurrent interview and record review of Resident 43's clinical record with the activity director (AD), on 3/26/19, at 10:25 a.m., she stated the resident loved to watch cartoons on television. Resident 43's care plan on Activity last revised on 2/2019 indicated, Provide room or 1:1 visits such as - Music, pet visits. The AD stated she did not know the family wanted music to be provided to the resident and she did not know there was a radio cassette provided by the resident's family in Resident 43's room. During an interview with CNA 41, on 3/26/19, at 3 p.m., she stated the residents loves music, especially western and pop music. CNA 41 stated when she and another CNAs were on duty they saw to it the TV was on for Resident 43's visual stimulations and the radio was on for hearing stimulation. CNA 41 stated Resident 41 was unable to speak but was able to responded by smiling and eye contact. CNA stated there were different staff assigned to the resident and it was possible the family's request for Resident 43's music to be turned on was not passed on to every CNA working at the facility. During an interview with CNA 22, on 3/27/19, at 8 a.m., she stated Resident 43 was unable to speak but could understand and respond to simple cues like holding on the rail when staff provided care. CNA 22 stated Resident 43 was unable to move on her own because she had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity of joints of both upper and lower extremities and was unable to walk. CNA 22 stated she was a new care provider for Resident 43 and did not know the television set or the music radio should be turned on for the resident. During a concurrent interview with the AD and review of the clinical record for Resident 43, the Minimum Data Set (MDS) assessment dated 1/2018 indicated under section F, Interview for activity Preferences While you are at the facility .B. how important is it to you to listen to music you like ? . Very important . how important it is to you to do your favorite activities? . Very important. The AD stated Resident 43's activity preferences should have been implemented for resident to have meaningful activity experiences.

Based on observation, interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of 59 sampled residents (Resident 4) when the linoleum (hard, washable floor covering) flooring by the door to Resident 4's bathroom was lifted and peeling off the floor base. This failure resulted in a hazardous environment for Resident 4 that could lead to falls. Findings: During a concurrent observation and interview with Resident 4, on 3/28/19, at 11:23 a.m., she stated, In July of last year, I fell going in the bathroom . There is a lip [peeling linoleum] on the floor. My feet get caught on it . See how you get your toes under there? There was peeling of the linoleum flooring going to the bathroom. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 3/28/19, at 1:56 p.m., in Resident 4's room. LVN 3 felt the floor by the bathroom door with her foot. LVN 3 stated, It [peeling linoleum flooring] catches my foot. It is a fall risk. The floor shouldn't be like that. LVN 3 stated the floor was an accident hazard and should not be left like that. During an observation and concurrent interview with Director of Nursing (DON), on 3/28/19, at 2:25 p.m., DON felt the floor by the bathroom door. DON stated, There is a lip [peeling linoleum flooring]. DON stated it was an accident hazard and a fall risk. During an interview with Administrator (ADM), on 3/28/19, at 2:36 p.m., he stated, The floor should be fixed. ADM stated the peeling linoleum flooring was a fall risk for the resident. During a review of the clinical record for Resident 4, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) dated 3/5/19, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 12 indicating moderate cognitive impairment. During a review of the clinical record for Resident 4, the Post Fall Summary dated 2/4/19, indicated . Date/Time of fall: 2/1/19 [at] .[1:15 p.m.] Summary of Fall: Res [Resident] found on the floor . resident states that she was walking to the BR [bathroom] . No injuries noted . During a review of the clinical record for Resident 4, the Post Fall Summary dated 11/26/18, indicated . Date/Time of fall: 11/24/18 [at] . [12:35 p.m.] Summary of Fall: Res [Resident] was found sitting on buttock on floor . Res states she was transferring food items from lunch tray to small table . and fell to the floor. No injuries noted . The facility policy and procedure titled Fall Risk Assessment dated 4/2018, indicated . [Facility Name] will ensure the resident environment remains as free of accident hazards as possible while allowing maximum mobility . The facility policy and procedure titled In-Room Furniture Furnishings dated 1/24/18, indicated . Safety Management Program provides our residents . and visitors a physical environment free of hazards our goal top manages activities proactively to reduce the risk of injuries .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional principles and ensure all drugs and biologicals were securely stored and permit only authorized personnel to have access to these medications when: 1. An insulin medication vial was not labeled with a change of direction sticker for one of 12 sampled residents (Resident 63). 2. Registered nurse (RN) 5 left an inhaler on top of the med cart unattended. 3. RN 2 left the medication cart unlocked and unattended. These failures placed all residents' health and safety at risk when drugs were inappropriately labels and drugs were left unattended and accessible to unauthorized individuals. Findings: 1. During a concurrent medication administration observation and interview Registered Nurse (RN) 1, on 3/26/19 at 12 p.m., RN 1, held the bottle of the insulin and read the pharmacy label, Humalog [insulin - medication to treat diabetes (a medical condition that causes high blood sugars) 100 units/ml (milliliter) vial, inject 10 units every morning and evening daily . RN 1 stated there was a new order for the insulin does. During an interview with RN 1, on 3/26/19, at 12:15 p.m., he stated there should have been a change of direction sticker attached to the Humalog insulin vial and the box. He stated it was the responsibility of a licensed nurse on duty to attach a change of direction sticker on the medication. RN 1 obtained a change of direction sticker which indicated, DIRECTION CHANGED REFER TO CHART [medical record]. During a review of the clinical record for Resident 66, the physician's telephone order dated 3/6/19, indicated, Change insulin with sliding scale medium [refers to the progressive increase in pre-meal or nighttime insulin doses]. The medication administration record dated 3/6/19, indicated, .Medium dose using Humalog insulin, Follow hypoglycemia (deficiency of glucose in the bloodstream) protocol. During an interview with the Director of Nursing (DON), on 3/27/19, at 10;10 a.m., she stated the expectation would be for the nurses to ensure a change of direction sticker be placed on the insulin bottle and containers as soon as the direction change for its use was received by the licensed nurse to ensure safety in the administration of medications. The facility's policy and procedure titled Medication administration dated 12/12 indicated, . PROCEDURES Medication Preparations . 3 .Apply a direction change sticker to label if directions have changed from the current label . The facility's policy and procedure titled MEDICATIONS AND MEDICATION LABELS' dated 12/12 indicated, POLICY . Medications are labeled in accordance with currently accepted professional principles . to promote safe medication use . PROCEDURES . 6. a. If the prescriber's direction for use change or the label is inaccurate, the nurse may place direction change, change of order-check chart or similar label on the container indicating there is a change in direction for use, taking care not to cover label information. b. When such a direction change label appears on the container, the medication nurse checks the resident's medication record (MAR) or the prescriber's order for current information. 2. During a medication administration observation on 3/26/19 at 8:55 a.m. in Station 2. RN 5 left an inhaler (an oral inhalation for asthma) unattended while RN 5 placed a call to the pharmacy to follow up the eye drops supply for another resident. During an interview with RN 5, on 3/26/19, at 9:10 a.m., she stated the inhaler should have been securely stored inside the med cart after use and should not have been left unattended on top of the med cart to avoid the potential risk of residents and others having access to the inhaler. During an interview with the DON, on 3/27/19, at 10:03 a.m., she stated the expectation would be for all nurses to make sure all medications were secured inside the medication cart prior to the nurse leaving the area. The facility's policy and procedure titled Medication Administration dated 12/12 indicated, . PROCEDURES Medication Administration: . During administration of medications medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart 3. During a medication administration observation on 3/27/19, at 8:20 a.m., in Station 2, RN 2 left the medication cart unlocked and unattended in front of room [ROOM NUMBER] while she was in room [ROOM NUMBER] attending to a resident behind a curtain. RN 2 stated she was unable to see the unlocked medication cart from behind the closed privacy curtains. RN 2 stated the medication cart should have been locked. During an interview with the DON, on 3/27/19, at 10:04 a.m., she stated the medication cart should never have been left unlocked and unattended to prevent unauthorized access to the medications. The facility's policy and procedure titled Medication Administration dated 12/12 indicated, . PROCEDURES Medication Administration: 17. During administration of medications medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked .

Based on observation, interview and record review, the facility failed to follow the physician ordered diet for one of 28 residents (Resident 5) in the dining room when Resident 5 was served a regular meal instead of a clear liquid. This failure resulted in Resident 5 being given the wrong diet which had the potential to compromise his scheduled medical procedure. Findings: During an observation on 3/25/19, at 11:48 a.m., in the dining room, Resident 5 was given his lunch tray. On Resident 5's tray was roast turkey with alfredo sauce, pasta and green beans. Resident 5 stated he was on a clear liquid diet. During an interview with Registered Nurse (RN) 1, on 3/25/19, at 12:05 p.m., he stated, For Resident 5, clear liquids was ordered for today. He is scheduled for a procedure . All meals ordered today is clear liquids. RN 1 stated Resident 5's lunch should have been clear liquids. During an interview with RN 1, on 3/26/19, at 4:11 p.m., he stated the physician ordered diet was not followed for Resident 5's lunch on 3/25/19. RN 1 stated, Doctor's orders should be followed. During an interview with Director of Staff Development (DSD) 2, on 3/27/19, at 2:49 p.m., she stated, When the CNAs and RNA's hand the trays in the dining room, they will not know the diet order changed. They just go by the meal ticket [slip]. DSD 3 stated physician ordered diets should be followed. During an interview with the Nutritional Services Supervisor (NSS), on 3/28/19, at 9:10 a.m., she stated the physician ordered diet should be followed. The NSS stated, The ordered diet [Resident 5] was not followed . We [Dietary] made a mistake. My staff did not pay attention. The NSS stated Resident 5's scheduled medical procedure would have been canceled if he ate the regular diet served. During an interview with the Registered Dietitian, on 3/28/19, at 11:42 a.m., she stated, We should follow doctor ordered diet . We [facility] can have a negative outcome if we don't follow it. A review of the facility document for Resident 5, the meal ticket dated 3/25/19, indicated, . Lunch . Diet: CCHO [Controlled Carbohydrate] . Consistency: Regular . During a review of the clinical record for Resident 5, the Order Summary Report dated 3/15/19, indicated, Clear Liquid Diet on 03/25/19, 03/26/19, 03/27/19 unless otherwise noted by MD [Doctor] . The facility document titled, . NURSING DEPARTMENT SCOPE OF SERVICE dated 8/3/17, indicated, . All care is provided by licensed professionals under the general direction of a physician . The facility document titled, Job Description . Supervisor Nutrition and Food Services undated, indicated, . Position Accountabilities . 4. Monitor tray-line to ensure the correct foods are served according to menu and diet orders . The facility policy and procedure titled, Therapeutic Diets dated 2/22/17, indicated, . Therapeutic diets are prepared and served as prescribed by the attending physician . The facility policy and procedure titled Food Preparation and Service dated 2018, indicated . If the Dietary Service Manager is not available, the manager's designee assumes the responsibility for dietary activities, to include but not limited to: a . c. Checking of resident's trays . The facility policy and procedure titled Diet Orders/ Changes dated 2/22/17, indicated . The Nutrition and Food Services . are also responsible for accurately completing the change of diet procedure-recording all information in the resident's profile card . and the meal card.

Based on observation, interview and record review, the facility failed to provide a safe and homelike environment for residents when: loud alarms and overhead paging was frequently used in the facility and Resident 4's restroom floor was in disrepair. These failures created an environment that was not homelike for residents. Findings: During an observation on 3/25/19, at 8:50 a.m., in the kitchen, the Dietary [NAME] (DC) 2 overhead paged the Maintenance Engineer (ME). During a concurrent observation and interview with Assistant Director of Nursing (ADON), on 3/26/19, at 9:32 a.m., at the nurses' station, a very loud alarm turned on with a light by a wall at the nurses' station. The alarm was heard in the whole facility. The ADON stated, [The alarm turns on] when the residents push on the exit doors [when they are] trying to go out. The ADON stated some residents with wander guard wrist bands (a system to alert staff when a resident is exit seeking or exits a building) triggered alarms to alert staff when they got close to exit doors. During an observation on 3/26/19, at 10:17 a.m., at the nurses' station, Licensed Vocational Nurse (LVN) 4 was paged overhead to report to the nurses' station. During an observation on 3/26/19, at 10:21 a.m., at the nurses' station, LVN 4 was paged overhead to report to the nurses' station. During an observation on 3/26/19, at 11:33 a.m., at the nurses' station, overhead paging was done from the dining room for Certified Nursing Assistants (CNAs) to assist for lunch. During an observation on 3/26/19, at 11:51 a.m., overhead paging was used for CNA's to assist in the dining room. During an observation on 3/26/19, at 12:09 p.m., overhead paging was used for CNA's to assist in the dining room. During an observation on 3/26/19, at 4:28 p.m., at the nurses' station, overhead paging was done from the dining room for CNAs to assist residents for dinner. During an observation on 3/26/19, at 4:47 p.m., overhead paging was done for CNAs to assist with dinner being served in the dining room. During an observation on 3/26/19, at 4:50 p.m., overhead page was done for a staff to call the nurses' station. During an interview with Resident 30, on 3/27/19, at 8:50 a.m., he stated the noise form the excess alarms and overhead paging bothered him. Resident 30 stated it was a part of living in the facility. During a concurrent observation and interview with Registered Nurse (RN) 4, on 3/27/19, at 8:55 a.m., at the nurses' station, a loud beeping occurred every second and continued to beep loudly for two minutes. RN 4 stated. It is not super loud . the door alarm is louder. RN 4 stated the loud alarms and beeping was normal in the facility. During an observation on 3/27/19, at 9:00 a.m., at the nurses' station, overhead paging was done for a nurse to report to the station. A loud beeping started which happened every 4 seconds and continued for 10 minutes. During an observation on 3/27/19, at 9:27 a.m., overhead paging was done to announce the start of group exercise. During an observation on 3/27/19 at 9:31 a.m., overhead paging was done to announce the start of a group activity. During an interview with the Administrator (ADM), on 3/27/19 at 12 p.m., the ADM stated the facility did not have a policy and procedure to control noise levels or loud overhead paging in the facility. During a concurrent observation and interview with Resident 4, on 3/28/19, at 11:23 a.m., in Resident 4's room, a portion of the linoleum floor on the doorway entrance to the bathroom was peeling. Resident 4 stated, In July of last year, I fell going in the bathroom . There is a lip [peeling linoleum] on the floor. My feet frequently get caught on it . See how you get your toes under there . During a concurrent observation and interview with LVN 3, on 3/28/19, at 1:56 p.m., in Resident 4's room, LVN 3 looked at the peeling linoleum floor to the bathroom entrance. LVN 3 used her foot to gauge the extent of the peeling linoleum. LVN 3 stated, It [peeling linoleum flooring] catches my foot. The floor shouldn't be like that . It is not homelike LVN 3 stated it was the resident's home. During a concurrent observation and interview with DON, on 3/28/19, at 2:25 p.m., in Resident 4's room, DON looked at the peeling linoleum floor to the bathroom entrance. The DON used her foot to gauge the extent of the peeling linoleum. The DON stated, There is a lip [peeling linoleum flooring]. The DON stated it was an accident hazard and it was not homelike. During an interview with Administrator, on 3/28/19, at 2:36 p.m., he stated, The floor should be fixed. The facility policy and procedure titled In-Room Furniture Furnishings dated 1/24/18, indicated . Safety Management Program provides our residents . and visitors a physical environment free of hazards our goal top manages activities proactively to reduce the risk of injuries .to promote a home-like environment .

Based on staff interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was for 17 of 21 Certified Nursing Assistants (CNAs). These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews. Findings: During employee records review with the Director of Staff Development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19, at 2:50 p.m., the following CAN records indicated: 1. CNA 31 with a hire date (HD) of 3/22/17, was evaluated on 11/19/18, eight months and 18 days late. 2. CNA 32 with a hire date of 7/1/13, was evaluated on 11/20/18, four months and 19 days late. 3. CNA 62 with a hire date of 2/21/17, was evaluated on 3/7/18, 14 days late. 4. CNA 65 with a hire date of 1/26/17, was not evaluated on 1/2018 and 1/2019. 5. CNA 2 with a hire date of 5/26/16, was evaluated on 11/21/18, seven months and 21 days late. 6. CNA 28 with a hire date of 3/28/16 was evaluated on 5/17/18, two months and 19 days late. 7. CNA 17 with a hire date of 1/6/17 was evaluated on 10/22/18, 10 mos. 21 days late. 8. CNA 42 with a hire date of 9/8/16 was evaluated on 11/21/18, two months and 13 days late. 9. CNA 51 with a hire date of 2/21/17 was evaluated on 5/14/18, three months and 23 days late. 10. CNA 41 with a hire date of 1/4/05 was not evaluated on 1/2019. 11.CNA 66 with a hire date of 10/20/16 was evaluated on 11/21/18, one months late. 12. CNA 10 with a hire date of 9/19/16 was evaluated on 11/20/18, two months late. 13. CNA 12 with a hire date of 2/11/17 was evaluated on 11/15/18, nine months and 14 days late. 14. CNA 37 with a hire date of 5/31/17 was evaluated on 11/28/18, five months and 28 days late. 15. CNA 34 with a hire date of 9/25/17, was evaluated on 11/26/18, two months and one day late. 16. CNA 45 with a hire date of 3/22/16 was evaluated on 11/20/18, eight months and 20 dates late. 17. CNA 48 with a hire date of 8/16/10 was evaluated on 11/19/18, four months and 11 days late. During an interview with the VP for HR, on 3/25/19, at 3:30 p.m., he stated the competency evaluations of the CNAs should have been done every 12 months from the CNA's hire date. The facility's policy and procedure titled Employee performance appraisal dated 11/13 indicated, . It is the policy of [name of facility] to review each employee's performance during the first ninety (90) days of a new position and annually thereafter. PURPOSE: To provide for a comprehensive and systemic review of the employees' performance in order to define expectations and assure competence . PROCEDURE . Annual anniversary Performance Appraisal . Schedule the performance appraisal session before the employee's anniversary review date . RESPONSIBILITY: The manger/supervisor is responsible for conducting performance appraisals on a timely basis, prior to the due date . The Human Resource Department is responsible for monitoring and ensuring compliance of the Performance Appraisal program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed when incorrect portions of beef stew were served to 21 of 22 residents receiving small portion diets. This failure resulted in residents receiving incorrect servings and amount of nutrients in their meals which could potentially result to negative outcome to the residents. Findings: During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/26/19, at 11:38 a.m., in the kitchen, trayline [meal service on trays] was started. There was a pan of regular beef stew with red and blue ladle. A pan of mechanical beef stew had red and blue ladle. A pan of pureed beef stew had red and blue ladle. DC 2 stated, The blue ladle is 6 oz. [ounce - unit of measure] and red ladle is 8 oz. During an interview with DC 4, on 3/26/19, at 1145 a.m., she stated the regular and mechanical beef stew pan both had blue and red ladles. DC 4 stated, They are 8 oz. [red] and 6 oz. [blue]. During an interview with DC 3, on 3/28/19, at 8:14 a.m., she stated, We have to follow the menu and the recipe . We also follow the right size scoop [measurement]. DC 3 stated if the food amount on the menu was not followed the patient would not get the right amount of nutrients. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 8:34 a.m., she stated there were 22 residents on small meal portions with one resident on clear liquids diet. NSS stated, Menus are supposed to be followed, also food items and measurement. NSS stated there could be negative resident outcomes if the menu was not followed. NSS stated, They [residents] won't get sufficient calories . they can have weight loss, get sick, poor wound healing, weight gain, obesity . If the menu says 5 oz., then we serve 5 oz. During an interview with the NSS, on 3/28/19 at 1048 a.m., she stated there were 21 residents that was served 6 oz. of beef stew. During an interview with Registered Dietitian (RD), on 3/28/19, at 11:42 a.m., she stated menus were used to ensure nutritional adequacy of the meal for the residents. RD stated, Menus should be followed . Also for variation that meets the nutritional requirement. The scoops and measurement should be followed. RD stated residents could have negative outcomes if the menu was not followed. RD stated, You can have malnutrition, skin break down and weight gain. The facility document titled Spring Cycle Menus Week 3 Tuesday dated 3/26/19, indicated . Regular . [NAME] Beef Stew . Small . 5 oz . Mech Soft [mechanical soft- ground] . [same portions as regular diet] . CCHO [Controlled Carbohydrate] . [NAME] Beef Stew . Small . 5 oz . The facility document titled Compact Roster by Room [Diet List] dated 3/26/19, indicated 22 residents on small portions diet. The facility document titled Job Description . Supervisor Nutrition and Food Services undated, indicated . Position Accountabilities . 4. Monitor tray-line to ensure the correct foods are served according to menu and diet orders . 8. Supervises food preparation . Ensures that portion control standards are followed . The facility policy and procedure titled Menus dated 2018, indicated . It is the policy of the [facility name] to provide residents with sufficient and adequate nutrition . Menus are provided . to meet all nutritional guidelines and resident need according to the RDA [Recommended Daily Allowance]. The facility policy and procedure titled Food Preparation and Service dated 2018, indicated . If the Dietary Service Manager is not available, the manager's designee assumes the responsibility for dietary activities, to include but not limited to: a . b. Following the written menus .

Based on interview and record review, the facility failed to provide sufficient staffing to residents when the dining room was left with insufficient staff to meet the needs of the residents requiring assistance for two of three meals on Saturday, March 23, 2019. This failure resulted in residents not having care and socialization needs met. Findings: During a resident council meeting interview, on 3/26/19, at 10:00 a.m., nine residents (Residents 8, 11, 12, 13, 14, 27, 40, 67 and 86) and two family members attended the resident council meeting and 11 out of 11 attendees at the resident council meeting expressed they were not happy with the short staffing situation in the facility dining room. During an interview with Resident 86, on 3/26/19, at 10:01 a.m., he stated staffing was an issue on holidays, weekends and flu season. He stated the facility would close the dining room prior to the weekend because of insufficient staffing. During an interview with Resident 42's wife (RW42), on 3/26/19, at 10:01 a.m., she stated the facility was understaffed and questioned why her husband only gets out of bed twice a week. She stated her husband was not receiving the care he needed. RW42 stated one Certified Nursing Assistant (CNA) was assigned to her husband's hallway with 14 residents on the hall require assistance. During an interview with Resident 40, on 3/26/19, at 10:02 a.m., she stated her call light had been on for 30 minutes before a CNA tended to her needs. During an interview with Staffing Coordinator (SC), on 3/27/19, at 9:45 a.m., SC stated on 3/23/19 Saturday the facility had two day-shift licensed nurse and one CNA who called in sick and the facility did not replace the three staff members. SC stated some of the effects of being short staffed were not providing good patient care, dining room were closed when they did not have enough CNA's and Restorative Nursing Assistant's (RNA's). SC stated the dining room unavailability affected resident rights, they did not get their meals timely. SC stated it was not written anywhere that the facility needed a total of eight RNA's and CNA's to open the dining room, it was just known that if the number dropped below eight the dining room was closed. SC stated, Residents are upset when dining room is closed because they like to socialize and eat with friends. The facility document titled Daily Schedule dated 3/23/19, indicated an LVN, an RN and a CNA called in, did not come to work and were not replaced on the schedule. During an interview with Director Staff Development (DSD) 1, on 3/27/19, at 3:00 p.m., she stated the dining room had been closed depending on how many RNA's are working. DSD 1 stated, The facility need a minimum number of RNA's and CNA's working for the dining room to remain open, when there are sick calls the dining room might be closed. DSD 1 stated there was no policy regarding dining room closing process related to staffing. DSD 1 stated, It is a resident's right to have access to the dining room for all meals. During an interview with Director of Nursing (DON), on 3/27/19, at 3:40 p.m., she stated in her staffing plan the facility needed a minimum of eight RNAs/CNAs for the dining room to be open. The DON stated, Less staff makes it hard to deliver trays in a timely manner. The DON stated the plan regarding staffing and the dining room was not written in a policy. The DON stated it was her goal to schedule enough staff so that the dining room was open for breakfast, lunch and dinner 365 days a year. The DON stated, It is not good if we close the dining room related to staffing. The DON stated she was not aware the dining room had closed on 3/23/19 due to staffing. The facility policy and procedure titled Nursing Department, Scope of Service undated, indicated . Staffing, Adjustment to staffing in the Nursing Department . is based upon residents' needs and acuity.

Based on observation, interview and record review, the facility failed to store and handle food safely when: 1. There were red bell peppers with a black organic substance and past their storage guidelines. 2. There was black and yellow substance inside the ice machine. 3. Trayline (meal service) food temperatures were taken in an unsanitary way. These failures resulted in unsafe food storage and handling that could lead to contamination and potentially negative outcome to all residents who consumed food from the kitchen. Findings: 1. During an observation and concurrent interview with Dietary [NAME] (DC) 2, on 3/25/19, on 8:22 a.m., there was a bin of red bell pepper that had a black substance in the walk in refrigerator. DC 2 stated the date on the bin was 3/14/19 and there were 10 bell peppers inside. DC 2 stated, It is mold. During an interview with DC 3, on 3/28/19, at 8:16 a.m., she stated, Fresh bell pepper is good for 7 days. DC 3 stated it was not good to use moldy bell pepper. DC 3 stated, Sometimes it [red bell pepper] gets rotten . It has to be fresh to use for the residents. DC 3 stated the patients could get sick if fed with moldy food. DC 3 stated, Expired food have to be thrown away. During an interview with Nutritional Services Supervisor (NSS), on 3/28/19, at 9:02 a.m., she stated, Red bell peppers should be good for 7-10 days. NSS stated it was not good to use a moldy bell pepper. NSS stated, It should be tossed and not served to the residents . They could get sick. The facility policy and procedure titled, Guidelines for Length of Storage of Foods dated 2/22/17, indicated, . It is the policy of [facility name] that food products be stored in a safe manner to prevent food-borne illnesses. PURPOSE . To provide guidelines for food storage in the absence of a manufacturers expiration date . The facility document titled, Produce Storage Guidelines dated 8/15, indicated, . [NAME] or red peppers . 7 to 10 days . 2. During an observation and concurrent interview with the Maintenance Engineer (ME), on 3/25/19, at 8:56 a.m., in the staff breakroom, the ice machine had a black and yellow substance by the bottom part of the evaporator. The ME stated he did not know what it was. The ME stated, It is something. The ME examined the bottom part of the evaporator (the part that cycles water to form ice cubes) with a white paper towel. The ME stated, I got a little something. There was a yellowish-substance on the paper towel from the ice machine evaporator. During an interview with Certified Nursing Assistant (CNA) 2, on 3/28/19, at 8:34 a.m., she stated ice was placed in the water pitchers for the residents. CNA 2 stated, Seven residents don't like ice or can't have ice . The rest like ice in their water. During an interview with ME, on 3/28/19, at 1:50 p.m., he stated the ice machine was not clean. ME stated, I don't know what the black and yellow substance is . I would not use the ice and water from it. ME stated the ice machine was not safe for use for the residents. ME stated, The residents could get sick. During an interview with Director of Nursing (DON), on 3/28/19, at 2:16 p.m., she stated she did not consider the ice machine with the black and yellow substance clean and safe for use. The DON stated, I wouldn't want to drink it [water/ice] . I don't know what the black and yellow substance is. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . Follow the manufacturer's instructions for cleaning and maintaining the equipment . The facility document titled, [Ice machine brand] Installation, Use & Care Manual undated, indicated, . Maintenance . Clean the ice machine every six months for efficient operation. If the ice machine requires more cleaning and sanitizing, consult a qualified service company . CLEANING/ SANITIZING PROCEDURE . The ice machine and bin must be disassembled, cleaned and sanitized . remove mineral deposits from areas or surfaces that are in direct contact with water . 3. During an observation and concurrent interview with DC 1, on 3/26/19, at 11:24 a.m., in the kitchen, DC 1 was taking the temperatures for the food on the steam table. The thermometer handle touched the food when taking of temperatures was done with the mechanical (ground) beef stew, pureed beef stew, pureed corn bread and the white bean soup. DC 1 stated the plastic handle of the thermometer should not touch the food. During an interview with DC 3, on 3/28/19, at 8:18 a.m., she stated, When doing the temp [food temperature], the handle should not touch the food . The handle is not sanitized. DC 3 stated the thermometer handle was not supposed to touch the food. DC 3 stated, If the handle touches the food, the food gets contaminated. During an interview with the Registered Dietitian (RD), on 3/28/19, at 11:42 a.m., she stated the thermometer handle should not touch the food. RD stated, 'I can't say for sure that the handle got sanitized. RD stated the food could potentially get contaminated. The facility document titled, Job Description . Supervisor Nutrition and Food Services undated, indicated, . Position Accountabilities . Ensures food safety guidelines are followed for receiving, storage, preparation and service of foods. Follows established policies and procedures for safe food handling and storage The facility policy and procedure titled Food Storage dated 2/22/17, indicated . Sufficient storage facilities are provided to keep food safe . Food is stored, prepared . by methods designed to prevent contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a policy regarding the use and storage of foods brought to residents by family and visitors from outside of the facility when there were unlabeled and incorrectly labeled resident food items in the resident refrigerator. This failure had the potential of giving unlabeled or incorrectly labeled food items to the wrong resident which could result in negative outcome to the residents. Findings: During an observation and concurrent interview with Registered Nurse (RN) 1, on 3/25/19, at 4:06 p.m., in the medication room, there was a resident refrigerator with resident food items. RN 1 stated, We just put the room number on the residents' food items. There were three 12 oz. (ounce - a unit of measure) cans of beer labeled 27C, one 8 oz. can of Lime A [NAME] ([NAME] drink) labeled 6A, three unlabeled 8 oz. cans of Lime A [NAME], four 12 oz. can of Keystone Light labeled 32A and five 12 oz. cans of Michelob Ultra labeled 6A. During an interview with RN 1, on 3/25/19 at 5:05 pm, he stated, The Nurses label the food items and put it in the fridge [resident's]. RN 1 stated if the food item was labeled with just room numbers resident food items could get mixed up if the resident changed rooms. RN 1 stated, I couldn't remember if we had any in-service in food handling of resident food . There is a possibility of giving the food item to the wrong resident. During an observation of the resident refrigerator and concurrent interview with the Assistant Director of Nursing (ADON), on 3/27/19, at 9:35 a.m., in the medication room, she stated there were 3 unlabeled beverage drinks (Lime A [NAME]) and there were 3 beer cans labeled 27C. The ADON stated, We don't have a resident in 27C . Resident might have been discharged or moved to another room. The ADON stated she doesn't know how they should label the resident food items. The ADON stated, It is not a good practice to just put the room numbers . There is a chance it will be given to the wrong resident. During an interview with the Director of Nursing (DON), on 3/28/19 at 2:10 p.m., she stated they did not have a policy for food brought in from home by family or visitors. The DON stated, It [resident food items] should labeled with the resident's name. The facility policy and procedure titled, Food from Outside Sources dated 2/22/17, indicated, Food brought in by visitors for residents is discouraged doe to problems of infection control .

Based on interview and record review, the facility failed to use staff development resources effectively and efficiently to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual training when 57 of 59 Certified Nursing Assistants (CNAs) did not complete one or more of the annual five required dementia training in-services. This failure had the potential for the residents to be cared for by CNA's inadequately trained. Findings: During a concurrent interview and record review with Director of Staff Development (DSD 2), on 3/28/19 at 11:30 a.m., DSD 2 stated the dementia in-service training sign-in sheets indicated there were missing CNA signatures on all five dementia training in-services. DSD 2 stated the following CNA's did not complete one or more of the required five dementia training modules, CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65. During a concurrent interview and record review with DSD 1, on 3/27/19, at 5:08 pm, she stated four hours of Dementia training were done on the first day of orientation for new hires and one hour of dementia training was completed using the five hand on hand training videos during the year. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 3/28/19, at 11:15 a.m., the ADON stated the facility did not have a policy on dementia training. The ADON stated the in-services for all five modules were incomplete and not all of the CNA's attended the dementia in-service training. During a concurrent interview and record review with DSD 2, on 3/28/19, at 11:30 a.m., DSD 2 stated the dementia in-services sign-in sheets indicated there were missing signatures on all five dementia training in-services. During an interview with the DON on 3/28/19 at 11:45 a.m., the DON stated five dementia training in-services were required annually. Review of the facility record titled, Resident Matrix (a listing of residents by medical conditions) [undated], indicated there were twenty-six residents diagnosed with Alzheimer's/Dementia (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The professional reference titled, Center for Clinical Standards and Quality/Survey and Certification Group dated 9/14/12, indicated, The Affordable Care Act: Section 6121 requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created this training program to address the requirement for annual nurse aides training on these important topics.

Based on interviews and record review, the facility failed to assess the demographic composition of its resident population and location as part of the required facility assessment when there was no water management program for the facility. This failure resulted in the facility not having a water management program which could potentially expose the residents to Legionella in an event of an outbreak. Findings: During an interview with Maintenance Engineer (ME), on 3/27/19, at 10:52 a.m., ME stated he was aware of the All Facilities Letter 18-39 that was issued on September 17, 2018 requiring facilities to develop and implement a water management program. ME stated, We do not test for Legionella. ME stated he had not tested for Legionella and the facility did not have any water testing results. ME stated he did not have a map of the water system and do not have a policy regarding testing the water for Legionella or a water management plan. During an interview with Administrator (ADM), on 3/27/19, at 10:55 a.m., ADM stated he had just become aware of the All Facilities Letter 18-39 that was issued on September 17, 2018 requiring facilities to develop and implement a water management program. ADM stated it was a brand new regulation and the facility does not have a contract for water testing. During an interview with ME, on 3/27/19, at 11:50 a.m., ME stated he had not tested the water yet. ME stated someone tested the water in the main facility (hospital) but did not test the Nursing and Rehabilitation building. During an interview with Chief Engineer (CE), on 3/28/19, at 11:10 a.m., CE stated they were using the guidelines from The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) to develop their water management plan. CE stated we have started the water testing procedure without having a full fledged policy or water management plan. During an interview with CE and concurrent record review, on 3/28/19, at 11:10 a.m., the facility document titled, Legionnaires and Other Waterborne Diseases Management Plan for Prevention dated 2/14, CE stated the water management plan was not included in the Legionnaires and Other Waterborne Diseases Management Plan for Prevention and there should be a policy for the facility's water management plan.

5. During an interview with the Maintenance Engineer (ME), on 3/27/19, at 10:52 a.m., the ME stated he was aware of the All Facilities Letter 18-39 that was issued on September 17, 2018, which required facilities to develop and implement a water management program. The ME stated they had not tested for the presence of Legionella (bacteria). The ME stated, I do not have any water testing results. I do not have a map of our water system. I do not think we have a policy regarding testing the water for Legionella or a water management plan. During an interview with the Administrator (ADM), on 3/27/19, at 10:55 a.m., the ADM stated he had just become aware of the All Facilities Letter 18-39 that was issued on September 17, 2018, which required facilities to develop and implement a water management program. The ADM stated it was a new regulation and facility did not have a contract for water testing. During an interview with the ME, on 3/27/19, at 11:50 a.m., the ME stated they had not tested the water yet. During an interview with the Chief Engineer (CE), on 3/28/19, at 11:10 a.m., he stated they were using the guidelines from The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) to develop their water management plan. CE stated they had started the water testing procedure without having a full-fledged policy or water management plan at this time. During an interview with the CE and concurrent record review, on 3/28/19, at 11:10 a.m., the facility document titled, Legionnaires and Other Waterborne Diseases Management Plan for Prevention dated 08/03/2007, CE stated the water management plan was not included in the Legionnaires and Other Waterborne Diseases Management Plan for Prevention and there should be a policy for the facility's water management plan. 6. During an observation on 3/25/19, at 8:40 a.m., in the resident's room, Resident 18 was sitting in bed with a nasal cannula attached to oxygen. A continuous positive airway pressure(CPAP) machine (used to keep the air sacs of the lung inflated) was located on the bedside stand with one end of the tubing attached to the CPAP machine and the other tubing attached to an oxygen source was in use and had touched the ground. During an interview with Registered Nurse (RN) 1, on 3/25/19, at 9:50 a.m., RN 1 stated the filter of the CPAP machine was dirty and needed to be replaced. RN 2 stated, I got it from the storage room. During an interview with the ME, on 3/25/19, at 2:17 p.m., he stated nursing staff and housekeeping staff were responsible for keeping the concentrator clean. During an interview with ADON, on 3/26/19, at 3:48 p.m., she stated the CPAP tubing came in a plastic bag and should have been stored in a plastic bag. The ADON stated, If it is not stored in a plastic bag it needs to be cleaned and put into a larger plastic bag for storage. During an interview with DSD 1, on 3/27/19 at 3:08 p.m., she stated CPAP and oxygen tubing should be stored in a bag at the bedside when not in use. DSD 1 stated if tubing was exposed and on the floor it should be discarded. DSD 1 stated if the end of the tubing that connected to the oxygen concentrator touched the ground it was contaminated and should not be reused by the resident. DSD 1 stated it was an infection control issue. During an interview with the DON, on 3/27/19 at 3:55 p.m., she stated when the CPAP tubing was not in use, it should be kept neatly rolled around the machine. The DON stated CPAP tubing should not be on the floor. The DON stated, It is an infection control issue. 7. During an observation on 3/25/19, at 8:40 a.m., in a Resident 18's room, Resident 18 was sitting in bed with a nasal cannula attached to an oxygen concentrator. The air filter located on the back of the oxygen concentrator had black particles covering the entire filter surface. During an interview with RN 1) on 3/25/19, at 9:50 a.m., he stated patient equipment tubing needed to be bagged and stored with the machine when not in use. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . use barrier protective coverings (i.e. table paper, probe covers, etc.) as appropriate . 4. During an observation and concurrent interview with Resident 14, on 3/25/19, at 9:36 a.m., in Resident 14's room, a nasal cannula was hanging by the oxygen concentrator gauge exposed and close to the floor. Resident 14 stated, I am using that. Resident 14 stated there was no storage bag for her nasal cannula. During an observation and concurrent interview with LVN 1, on 3/25/19, at 9:38 a.m., in Resident 14's room, Resident 14's nasal cannula was hanging by the oxygen concentrator gauge exposed and close to the floor. LVN stated, It [nasal cannula] should have been stored in a bag if not being used. During an interview with LVN 1, on 3/25/19, at 5:05 p.m., she stated, I changed the nasal cannula because it is an infection control issue. During an interview with DSD 1, on 3/27/19, at 3:07 p.m., she stated, Nasal cannula should be kept in a ziploc [resealable] bag for storage . If it is on the floor it should be tossed. If left exposed it should be discarded. DSD 1 stated it [nasal cannula] was contaminated. DSD 1 stated, It is an infection control issue. During an interview with the DON on 3/28/19, at 2:01 p.m., she stated there was a risk of contamination when a nasal cannula hung close to the floor. During a review of the clinical record for Resident 14, the Minimum Data Set (MDS- a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) Assessment, dated 12/18/18, indicated the Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) score of 15 indicated no cognitive impairment. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . use barrier protective coverings (i.e. table paper, probe covers, etc.) as appropriate . Based on observation, interview and record review, the facility failed to effectively implement and maintain an infection prevention and control program for 11 of 59 sampled residents (Resident 46, 63, 39, 11, 238, 63, 32, 36, 43, 14 and 18) when: 1. Registered nurse (RN) 5 and RN 1 failed to perform hand hygiene prior to placing on gloves when care was delivered to residents during a physical assessment and a finger stick procedure to test blood for blood sugar levels for (Resident 46, 63, and 39). 2. Licensed vocational nurse (LVN) 4 and RN 1 used a contaminated pair of gloves in the performance of the finger stick procedure on three residents (Resident 11, 238, and 63), and touched objects in the resident room without changing the gloves LVN 4 wore to perform the finger stick procedure. 3. RN 5 used a contaminated pair of gloves in the provision of care to Resident 43. 4. Resident 14's nasal (nose) cannula (a plastic tubing used for the delivery of oxygen through the nose) was exposed and left hanging low draped over the regulator dial of the oxygen concentrator. 5. The facility did not have a water management program for Legionella (a waterborne bacteria). 6. Resident 18's continuous positive airway pressure (CPAP- therapy is a common treatment for obstructive sleep apnea) tubing was disconnected from the oxygen and the exposed end of tubing was touching the ground. 7. Resident 18's oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) filter was covered in a black fluffy substance. These failures placed the residents' health and safety at potential risk for cross-contamination, spread of infections, and water borne bacteria. Findings: 1. During a medication pass observation on 3/26/19 at 10:55 a.m. in Station 2, RN 5 did not sanitize or wash hands before donning gloves in the performance of the skin assessment of Resident 46's buttocks for pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a medication administration observation on 3/26/19 at 11:54 a.m., in Station 2, RN 1 did not sanitize or wash hands before placing on gloves when a finger stick (a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) was performed on Resident 63. On 3/26/19 at 12:03 p.m., in Station 2, RN 1 did not wash hands before placing on gloves when a finger stick procedure was performed on Resident 39. 2. During a medication administration observation on 3/26/19 at 11:24 a.m., LVN 4 sanitized her hands, donned (placed on) a pair of gloves, opened the medication administration record, used a key to open the medication cart and prepared the materials for a finger stick procedure for Resident 11. LVN 4 then sanitized her hands, donned a pair of gloves and documented the result of Resident 11's finger prick test. LVN 4 then opened the medication administration record, used a key to open the medication cart and prepared the materials for a finger stick procedure for Resident 238. LVN 4 wore the same pair of gloves in performing finger sticks on Resident 11 and Resident 12. During a medication administration observation on 3/26/19 at 11:54 a.m., in Station 2, inside Resident 63's room, RN 1 wore a pair of gloves flipped on the overhead lights in the resident's bed and then performed the finger stick. RN 1 used the same pair of gloves in the performance of the finger stick procedure on Resident 63. RN 1 then, without removing the gloves, turned off the overhead light on the resident's bed, and turned down a t.v. in the room for one of the residents. 3. During a medication administration observation on 3/26/19 at 12:25 p.m. in Station 2, after the skin assessment was done on Resident 43, without removing gloves and sanitizing hands and donning a pair of new clean gloves, RN 5 repositioned the resident with the assistance of a staff, arranged the pillows and bedding and obtained a mouth swab and cleaned the resident's mouth. During an interview with LVN 4 on 3/26/19 at 4:46 p.m., she stated she should have sanitized her hands before and after performing the finger stick on the resident and changed to a clean pair of gloves before doing the finger stick procedure. LVN 4 stated she had thought sanitizing hands should be done in between patient care only. During an interview with RN 5 on 3/26/19 at 5:09 p.m., she stated she should have sanitized her hands before the use of gloves when performing procedures. RN 5 stated she should have changed gloves and sanitized her hands after performing a procedure and going from a dirty part to a clean part in providing care to the resident. During an interview with RN 1 on 3/26/19 at 5:25 p.m., he stated he should have sanitized his hands before the use of gloves when he did the finger stick procedure on the resident. RN 1 stated after the finger stick procedure was done, he should have changed gloves and sanitized his hands before touching objects inside the resident's room to prevent cross contamination of different body sites. During an interview with the director of nursing (DON) on 3/27/19 at 9:40 a.m., she stated the expectation would be to sanitize hands and use the gloves according to the standard precaution policy. The DON stated the licensed nurses (LNs) should have removed gloves, sanitized hands before donning a pair of clean glove for another procedure. The DON stated the LN should have removed the used gloves, sanitized hands before touching objects in the resident's room to prevent the potential of cross contamination (exposing germs from a dirty site to a clean site) and potential spread of infection. The facility policy and procedure titled, Registered Nurse's Job Description & Competency Evaluation dated 1/16/19 indicated, General Accountabilities: . 8. Practice Universal precautions while providing care and performing other hospital services . The facility's policy and procedure titled, Standard Precaution dated 4/5/17 indicated, PROCEDURE 1. Hand Hygiene . b. Wash hands or use alcohol based hand hygiene product: i. Before patient contact ii. After patient contact iii. After contact with items in the patient's environment iv. After removing gloves v. Between glove changes vi. after any procedure. c. Wash hands, or use alcohol based hand hygiene product, between task and procedures on the same patient to prevent cross contamination of different body sites. 2. Gloves . c. Change gloves between task and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms.

Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition when: 1. There was ice build-up on the door frame and on a copper pipe inside the walk-in freezer. 2. There was black and yellow substance in the ice machine at the bottom part of the evaporator. These failures had the potential for the residents to use ice and food that was unsafe for consumption that could lead to negative outcome. Findings: 1. During an observation on 3/25/19, at 8:24 a.m., in the kitchen, there was ice build-up on the top frame of the freezer door and copper pipe by the top, right corner toward the back of the walk-in freezer. During a concurrent observation and interview with the Dietary Aide (DA), on 3/28/19, at 8:09 a.m., in the kitchen, the freezer door was not fully closed. Inside the freezer, there were water drops along a strip of plastic by the side of the freezer door. The DA stated he had noticed the ice buildup in the freezer. The DA stated it water drips happened when the freezer door was not fully closed or left open for a while. During an interview with the Maintenance Engineer (ME), on 3/28/19, at 1:40 p.m., he stated he went inside the walk-in freezer a few times and used a heat gun to thaw the ice build up. The ME stated, I do not do any maintenance check in the freezer, I only regularly check the coil on the roof. The ME stated ice buildup indicated something was not working properly with the freezer. The ME stated, If the freezer temperature goes up, the food could spoil. The ME stated there should be no ice build-up in the freezer. During an interview with Administrator (ADM), on 3/28/19 at 2:35 p.m., he stated the ice buildup was because there was a problem with the gasket which caused the ice build-up. The ADM stated, It brings moisture inside and it freezes . It could ruin food. 2. During a concurrent observation and interview with the ME, on 3/25/19, at 8:56 a.m., in the staff breakroom, the ice machine had black and yellow substance by the bottom part of the evaporator. The ME stated he did not know what the yellow substance was. The ME examined the bottom part of the evaporator with a white paper towel and stated, I got a little something. There was a yellowish-substance on the paper towel from the ice machine evaporator. During an interview with the ME, on 3/28/19, at 1:50 p.m., he stated the ice machine was not clean. The ME stated, I don't know what the black and yellow substance is . I would not use the ice and water from it. The ME stated the ice machine was not safe for use for the residents. During an interview with Director of Nursing (DON), on 3/28/19 at 2:16 p.m., she stated she did not consider the ice machine with the black and yellow substances to be clean and was not safe for use. The DON stated, I wouldn't want to drink it [water/ice] . I don't know what the black and yellow substance is. The facility policy and procedure titled, Equipment, Care and Cleaning of dated 9/13, indicated, . [Facility name] maintains an environment to prevent spread of infection. PURPOSE . To provide guidance to employees on the proper care and cleaning of equipment to prevent transmission of infection . PROCEDURE . Follow the manufacturer's instructions for cleaning and maintaining the equipment . Review of the facility document the, [Ice machine brand] Installation, Use & Care Manual undated, indicated, . Maintenance . Clean the ice machine every six months for efficient operation. If the ice machine requires more cleaning and sanitizing, consult a qualified service company . CLEANING/ SANITIZING PROCEDURE . The ice machine and bin must be disassembled, cleaned and sanitized . remove mineral deposits from areas or surfaces that are in direct contact with water . The facility policy and procedure titled, Inventory and Inspection of New Equipment dated 2/16, indicated, . It shall be the responsibility of the Engineering Department to routinely inspect all . equipment to determine its safe operation .

2. During a concurrent interview and record review with DSD 1, on 3/27/19, at 5:08 pm, she stated four hours of dementia training were done on the first day of orientation for new hires and the remainder of the hours annually for dementia using the five hand-on-hand training videos. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 3/28/19, at 11:15 a.m., the ADON stated the in-services for all five modules were not completed, and not all the CNAs attended the dementia in-service training. During a concurrent interview and record review with DSD 2, on 3/28/19 at 11:30 a.m., DSD 2 stated the dementia in-service training sign-in sheets indicated there were missing CNA signatures on all five dementia training inservices. DSD 2 stated the following CNA's did not complete one or more of the required five dementia training modules, CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65. During an interview with the DON on 3/28/19 at 11:45 a.m., the DON stated five dementia training in-services were required annually. Review of the facility record the, Resident Matrix (a listing of residents by medical conditions) [undated], indicated there were twenty-six residents diagnosed with Alzheimer's/Dementia (an irreversible, progressive brain disorder that slowly destroyed memory and thinking skills and eventually the ability to carry out the simplest tasks). Review of the professional reference titled, Center for Clinical Standards and Quality/Survey and Certification Group dated 9/14/12, indicated, The Affordable Care Act: Section 6121 requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia .CMS created this training program to address the requirement for annual nurse aides training on these important topics. Based on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNAs) employed by the facility receive annual mandated training to keep competencies in the delivery of care when: 1. Three of 21 CNAs (CNA 1, 2 and 3) completed less than 12 hours of mandatory training per year. 2. 57 of 59 CNAs (CNA 3, 4, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64 and 65) did not complete the five dementia training modules offered by the facility. This failure resulted in CNA's insufficient training which placed the resident at risk to not have quality of care needs met. Findings: 1. During employee records review with the director of staff development (DSD) 1 and 2, the vice president for human resource (VP/HR) and the VP/HR Assistant on 3/25/19 at 2:50 p.m., stated from 3/16/18 to 3/24/19: 1. CNA 1 was provided in-service training's for five of 12 hours. 2. CNA 2 was provided in-service training's for seven of 12 hours. 3. CNA 3 was provided in-service training's for eight of 12 hours. During a concurrent interview with DSD 1 and DSD 2, on 3/25/19, at 3:40 p.m., both stated, the expectation was for the CNAs to have 12 hours of in-service training to ensure their competency met the need of the residents in the facility.