Based on record review, interview, and facility policy review, the facility failed to ensure 1 (Resident #10) of 5 residents reviewed for unnecessary medications was free from significant medication errors. Specifically, staff failed to hold (not administer) blood pressure medications when blood pressure or heart rate values were outside of ordered parameters for administration. Findings included: A facility policy titled, Administering Oral Medications, dated 2001, specified, 13. Perform any pre-administration assessments. An admission Record indicated the facility most recently admitted Resident #10 on 11/06/2023. According to the admission Record, the resident had a medical history that included a diagnosis of essential primary hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #10's Care Plan Report included a focus area, initiated 12/12/2020, that indicated the resident had altered cardiovascular status related to hypertension. An intervention dated 12/12/2020 directed staff to administer medications as ordered. Resident #10's Order Summary Report, reflecting active orders as of 02/20/2025, contained an order started on 11/06/2023 for carvedilol 12.5 milligrams (mg), one tablet by mouth two times a day for hypertension. The order included instructions to hold the carvedilol if the resident's systolic blood pressure (upper number in a blood pressure reading) was less than 100 millimeters of mercury (mmHg) or if the resident's heart rate was less than 55 beats per minute (bpm). The Order Summary Report also contained an order started on 09/29/2024 for clonidine 0.1 mg, two tablets by mouth two times a day for hypertension. The order included instructions to hold the clonidine if the resident's systolic blood pressure was less than 110 mmHg. Resident #10's Medication Administration Record (MAR) for 01/2025 revealed staff documented the resident's carvedilol was administered on 01/03/2025 at 6:00 PM, when the resident's pulse was 53 bpm, and on 01/15/2025 at 6:00 PM, when the resident's blood pressure was 94/61 mmHg. The MAR also revealed staff documented that clonidine was administered on the following dates and times when the resident's systolic blood pressure was less than 110 mmHg: - 01/05/2025 at 9:00 AM, when the resident's blood pressure was documented as 103/52 mmHg; - 01/09/2025 at 6:00 PM, when the resident's blood pressure was documented as 103/53 mmHg; - 01/15/2025 at 6:00 PM, when the resident's blood pressure was documented as 94/61 mmHg; - 01/28/2025 at 9:00 AM, when the resident's blood pressure was documented as 105/54 mmHg; - 01/29/2025 at 9:00 AM, when the resident's blood pressure was documented as 103/55 mmHg; and - 01/29/2025 at 6:00 PM, when the resident's blood pressure was documented as 109/52 mmHg. Resident #10's MAR for 02/2025 revealed staff documented that carvedilol was administered when the resident's pulse was less than 55 bpm on 02/09/2025 at 9:00 AM, when the resident's pulse was 52 bpm. The MAR also revealed staff documented that clonidine was administered when the resident's systolic blood pressure was less than 110 mmHg on the following dates and times: - 02/01/2025 at 9:00 AM, when the resident's blood pressure was documented as 100/49 mmHg; and - 02/13/2024 at 6:00 PM, when the resident's blood pressure was documented as 105/76 mmHg. During an interview on 02/19/2025 at 9:20 AM, Licensed Vocational Nurse (LVN) #4 stated that when giving medications the nurse should read the order in its entirety to ensure they were following the orders. She stated if a medication had parameters, the nurse needed to hold the medication if the vital signs were outside the parameters. LVN #4 reviewed Resident #10's 01/2025 and 02/2025 MARs and confirmed she had administered clonidine to Resident #10 when the resident's heart rate was outside of ordered parameters for administration on 01/05/2025 at 9:00 AM and 02/01/2025 at 9:00 AM. LVN #4 also confirmed she administered carvedilol to Resident #10 when their heart rate was outside of ordered parameters for administration. During an interview on 02/19/2025 at 2:15 PM, LVN #5 confirmed she administered Resident #10's clonidine on 01/28/2025 and 01/29/2025 when the resident's systolic blood pressure was below the ordered parameters for administration. During an interview on 02/19/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) stated nurses should follow physician orders and not give medication if the residents' blood pressure or pulse were outside of ordered parameters for administration. During an interview on 02/20/2025 at 9:52 AM, the Director of Nursing (DON) stated nurses should ensure they follow any parameters for administration specified by the physician. The DON stated that administering medications when vital signs were outside of ordered parameters for administration could cause the resident's blood pressure or pulse to drop lower if given when it was already low. During an interview on 02/20/2025 at 11:26 AM, the Administrator stated he expected nurses to follow physician ordered parameters for medication administration and not administer medication if the parameters for administration were not met. He stated giving medication outside of the ordered parameters could have an adverse effect on the resident.

Based on observation, interview, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore the proper personal protective equipment (PPE) when providing care for 2 (Resident #30 and Resident #19) of 5 residents reviewed for transmission-based precautions. Findings included: 1. A facility policy titled, Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 [coronavirus disease] Outbreak), revised 09/2021, indicated Equipment and Supplies 1. Respirator masks (disposable N95 filtering facepiece respirators); and 2. Additional PPE as required (gloves, gown and eyewear). A CDC publication titled, Use of Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 06/03/2020, revealed, Preferred PPE - Use (N95 or higher respirator) and Acceptable Alternative PPE - Use (facemask) included wearing a Face shield or goggles. An admission Record indicated the facility admitted Resident #30 on 12/02/2022. According to the admission Record, the resident had a medical history that included a diagnosis of COVID-19. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #30's Care Plan Report revealed a focus area, initiated on 02/14/2025 and revised on 02/17/2025, that indicated the resident required contact and droplet isolation precautions due to COVID-19. An intervention initiated on 02/17/2025 directed staff to use PPE as recommended for the type of infection. Resident #30's Order Summary Report, listing active orders as of 02/18/2025, included an order started on 02/17/2025 for isolation with contact and droplet precautions related to COVID-19. During an observation on 02/17/2025 at 10:08 AM, Licensed Vocational Nurse (LVN) #1 was observed entering Resident #30's room. LVN #1 donned a gown and gloves and was wearing an N-95 mask. A cart with PPE was observed stocked with gowns and gloves; however, there were no face shields or masks on the PPE cart. During an interview on 02/17/2025 at 10:08 AM, LVN #1 stated he entered Resident #30's room to administer a treatment to Resident #30's buttocks. During a follow-up interview on 02/17/2025 at 1:17 PM, LVN #1 stated a face shield was also required when entering a resident's room who was COVID-19 positive. During an interview on 02/18/2025 at 2:50 PM, the Infection Preventionist (IP) stated staff should not enter a COVID-19 positive room without using eye protection. During an interview on 02/20/2025 at 9:10 AM, the Director of Nursing (DON) stated when entering the room of a resident with COVID-19, staff were required don a gown, gloves, an N95 mask, and a face shield. During an interview on 02/20/2025 at 9:34 AM, the Administrator (ADM) stated when staff entered rooms of residents who were positive for COVID-19, they were required to wear a face shield on. 2. An undated facility policy titled, Isolation - Categories of Transmission-Based Precautions indicated 2. Enhanced barrier precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistant organisms] to staff's hands and clothing. The policy revealed, EBP are indicated for residents with any of the following: including, b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The policy also revealed, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, including, f. Changing briefs or assisting with toileting. An admission Record indicated the facility admitted Resident #19 on 03/20/2024. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease (ESRD) and dependance on renal dialysis. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received dialysis while a resident of the facility. Resident #19's Care Plan Report included a focus area, initiated on 03/26/2024, that indicated the resident had an arteriovenous (AV) shunt located in their upper, right arm and had scheduled dialysis appointments each Tuesday, Thursday, and Saturday. The Care Plan Report also included a focus area, initiated on 10/23/2024, that indicated the resident required EBP during high-contact resident care activities due to the presence of an indwelling medical device. An intervention dated 10/23/2024 directed staff to utilize PPE (gown and gloves; face shield as indicated) during high-contact resident care activities (e.g. [exempli gratia, for example], dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care). Resident #19's Order Summary Report, reflecting active orders as of 02/20/2025, contained an order dated 02/16/2025 for EBP during high contact resident care activities secondary to ESRD [and] needing the use of shunt on right upper arm for hemodialysis. A concurrent observation and interview on 02/19/2025 at 8:49 AM revealed signage on Resident #19's door that indicated the resident required EBP. The sign indicated that everyone must clean their hands and wear gloves and a gown for the following high contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, and assisting with toileting. Certified Nursing Assistant (CNA) #3 was observed entering Resident #19's room wearing only an N95 mask. CNA #3 stated she was entering the room to put an incontinence brief on the resident. CNA #3 did not don any additional PPE and proceeded into the resident's room to provide care. During an interview on 02/19/2025 at 8:57 AM, CNA #3 stated she put a brief on Resident #19. She stated the resident also wanted to get up, so she put the resident's socks and shoes on for them. CNA #3 stated that EBP meant staff had to sanitize when going in and out of the room and wash with soap and warm water. She stated she wore gloves but did not wear the gown when providing the resident's care. CNA #3 observed the signage on the resident's door and stated she should have worn a gown, a mask, and gloves when providing care for the resident. During an interview on 02/19/2025 at 2:33 PM, the Infection Preventionist (IP) stated a resident with an indwelling medical device required EBP. She stated if a staff member was attending to a resident on EBP and was providing high-contact care, they should wear a gown and gloves. She stated high-contact activities included changing a resident's brief. During an interview on 02/20/2025 at 9:10 AM, the Director of Nursing (DON) stated when entering a room of a resident on EBP and performing high-touch activities, staff should wear gloves and a gown, which was posted on the door. She stated high-touch activities included changing a resident's brief.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician when Resident 1 continued to have right knee swelling after a fall. This failure resulted in delay of care for Resident 1. Findings: The record for Resident 1 was reviewed on 3/6/24. Resident 1 was admitted to the facility on [DATE] with diagnosis that included Multiple Sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain) and history of leg fractures due to fall. During a review of the Nurse's Notes, the following was noted; 5/1/23 at 12:07 p.m., the Nurse's Notes indicated, During assist from toilet to shower chair nurse had to assist with fall by slowly lowering resident to the ground. No visible injuries were noted. Resident c/o (complain of) pain on R LE (Right Lower Extremity). PA (Physician Assistant) notified. will provide pain management and continue to monitor. 5/7/23 at 10:53 a.m., pt (Patient) R (Right) knee is swollen and pt feels pain to the slightest touch . 5/8/23 at 10:54 a.m., pt still has swelling and c/o pain to the slightest touch . The physician was not notified until 3 days on 5/9/23 at 10:55 a.m., after Resident 1 continued to have swelling and pain to the right leg. During a review of the Physician Progress Note dated 5/9/23 at 11:48 a.m., the Physician Progress Note indicated, Informed by LVN (Licensed Vocational Nurse) that patient is c/o ongoing and worsening pain and swelling to R knee. Extremely tender to slightest touch. Pain medication ineffective. Sending out to ED (Emergency Department) for urgent evaluation. During an interview on 3/7/24 at 12:17 p.m. with MD 1 (Doctor of Medicine), MD 1 stated there was no evidence of receiving calls or notifications from the nursing staff on 5/7/23 or 5/8/23. MD 1 stated the facility had a 24/7 number for MD notification when there was residents change of condition. MD 1 stated the only notification received regarding Resident 1's knee swelling was on 5/9/23, at which time the PA evaluated the resident. MD 1 stated the nurses should have notified the MD when the knee continued to have swelling and pain on 5/7/23. MD 1 stated upon review of the right knee x-ray, there was no new fractures or soft tissue injury. MD 1 stated, Resident 1 returned back to the facility with right leg immobilizer. During a review of the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, with a revision date of March 2018, indicated, 2. In addition, the nurse shall assess and document/report the following baseline information . c. Current level of pain, and any recent changes in pain level . g. Onset, duration, severity . Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status.

Based on interview and record review, the facility failed to ensure an appropriate pain management and assessment when a PRN (as needed) medication for pain was not administered when Resident 1 complained of pain. This failure resulted in Resident 1 not receiving appropriate pain management. Findings: During a review of the Nurse's Note dated 12/28/23 at 16:55 (4:55 p.m.), the Nurse's Notes indicated, Resident complained of pain on rectum area . Further review of the record indicated there was no documented evidence of pain rating scale and no pain medication administered for Resident 1. During a review of Resident 1's MAR (Medication Administration Record) for the month of December 2023, indicated, Acetaminophen (a pain medication) Tablet 325 MG (milligram) Give 2 tablet by mouth every 6 hours as needed for pain. The MAR did not have documented evidence that the pain medication was given on 12/28/23. During a concurrent interview and record review on 3/7/24 at 3 p.m. with the Director of Nursing (DON), the DON confirmed there was no pain assessment rating scale documented or pain medication given to Resident 1 on 12/28/23 the day Resident 1 complained of pain. During a review of the facility's policy and procedure titled, Pain Assessment and Management with a revision date of October 2022, indicated, 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to three residents (Resident 1, Resident 2 and Resident 23). This failure left the residents or their responsible parties without information related to continuing to receive Part A Medicare services, the cost, and their appeal rights. Findings: During review of Resident 1, Resident 2 and Resident 23's clinical record, there were no signed SNF-ABN forms by the residents or the responsible parties. Additionally, there were no signed NOMNC for Residents 2 and 23. Interview with the Administrator on 4/19/23 at 3:40 pm, he acknowledged lack of signed SNFABN form on Residents 1, 2 and 23. Additionally, there were no NOMNC on Residents 2 and 23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a written grievance decision was issued to one resident (Resident A). This failure had the potential to not ensure Resident A and/or other residents are appropriately apprised of progress and/or decisions on grievances reported to the facility. Findings: Resident A was admitted to the facility on [DATE] with diagnoses that included sepsis (life threatening complication of an infection), chronic kidney disease (progressive damage and loss of kidney function) and gastroenteritis (intestinal infection.) During a review of Resident A's nursing progress notes, dated 4/17/22, the note indicated that the resident wanted to leave due to reported rodents at the facility. During an interview on 7/18/23 at 1:10 PM, with the Director of Nursing (DON), DON explained the facility's grievance officer or designee, was the Social Worker. DON stated the grievance officer involved in Resident A's grievance investigation no longer worked at the facility. DON stated Resident A's grievance, on 4/17/22, was discussed by management at the time. DON stated Resident A's grievance was investigated and recorded on the grievance log. During an interview on 7/18/23 at 1:24 PM, with the DON, DON stated she was not sure if Resident A was notified of the facility's findings and/or resolution on the reported grievance. DON stated she will find out and provide further information. During a concurrent interview and record review on 7/20/23 at 12:33 PM, with the DON, the facility's grievance form related to Resident A's grievance, dated 4/18/22, was reviewed. The grievance form indicated, Resolution: Respond to resident or designee within 7 working days of concern with resolution: Interventions/Action. There was no information on the grievance form about a written decision issued to Resident A pertinent to the grievance. When asked, DON stated, it [response] was not followed through. I'm not seeing that in the documentation. During an interview on 7/20/23 at 12:37 PM, with the DON, DON confirmed there was no documented evidence that the facility notified Resident A, verbally and in writing, of the investigation findings and the facility's decision and resolution on the grievance. DON stated, I couldn't find evidence. I don't see evidence, record of it. DON explained the facility's practice was to provide residents with a report as soon as possible or within 5 days of knowledge of the grievance. During a review of the facility's Policy and Procedures (P&P), titled, Grievances/Complaint, Filing, revision dated 4/2017, the P&P indicated, .Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff . The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within __ [blank] working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office . During a review of the facility's Policy and Procedures (P&P), titled, Resident Rights, revision dated 12/2016, the P&P indicated, .Policy Interpretation and Implementation - 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . v. have the facility respond to his or her grievances .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required period of within 14 days of admission for two of 19 sampled residents (Resident 21 and Resident 90). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 90. Findings: a. During review of Resident 21's clinical record, indicated Resident 21 was admitted on [DATE]. Review of Resident 21's admission MDS assessment indicated, the assessment was completed on 1/11/23, 20 days after admission. b. During review of Resident 90's clinical record, indicated Resident 90 was admitted on [DATE]. Review of Resident 90's admission MDS assessment indicated, the assessment was completed on 4/6/23, 15 days after admission. During an interview on 4/19/23, at 9:48 AM, the MDS Coordinator (MDSC) stated, admission MDS assessment should be completed on the 14th day of admission. MDSC acknowledged the admission MDS assessment for Resident 21 and Resident 90 were late in completion. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . Review of facility policy and procedure titled, MDS Completion and Submission Timeframes, revised July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete significant change in status assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 14) when Resident 14 was discharged from hospice services. This failure could potentially delay the provision of appropriate treatment and services for Resident 14. Findings: Review of Resident 14's profile in the electronic health record (EHR) indicated, was admitted on [DATE] with diagnoses included atrial fibrillation (irregular, rapid heart rate that causes poor blood flow), heart failure, kidney failure, and hypertension (high blood pressure). Review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 2/15/23, indicated, Resident 14 was on hospice care. During an interview on 4/19/23, at 1:39 PM, Licensed Vocational Nurse (LVN) 2 stated, Resident 14 completely stopped eating and was later admitted to hospice due to failure to thrive. LVN 2 also stated, Resident 14 was discharged from hospice care three weeks ago. Review of Client Coordination Note Report dated 3/29/23, indicated, Resident 14 was discharged from hospice care on 3/29/23 due to prolonged prognosis. During an interview on 4/20/23, at 9:40 AM, MDS Coordinator (MDSC) stated, Resident 14 was admitted to hospice on 8/2/22 and was discharged on 3/29/23. MDS C also stated a significant change assessment in the MDS was required to be completed 14 days after Resident 14 was discharged from hospice care. Review of Resident 14's MDS Summary in the EHR indicated, significant change assessment with Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 4/11/23 was in progress. The assessment was 22 days late from the required completion date on the day of the review. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: . 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill . Review of facility policy and procedure titled, MDS Completion and Submission Timeframes, revised July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for six of 19 sampled residents (Resident 6, 21, 62, 14, 80, and 50). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents. Findings: Review of the MDS Summary in the electronic health record (EHR), indicated the following: a. Resident 6 was admitted on [DATE]. Review of Resident 6's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 3/23/23, 16 days after the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). Further review revealed, quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 12/30/22, 25 days after the ARD. b. Resident 21 was admitted on [DATE]. Review of Resident 21's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 4/18/23, 18 days after the ARD. c. Resident 62 was readmitted on [DATE] (original admission [DATE]). Review of Resident 62's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 3/22/23, 20 days after the ARD. d. Resident 14 was admitted on [DATE]. Review of Resident 14's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 3/6/23, 19 days after the ARD. e. Resident 50 was admitted on [DATE]. Review of Resident 50's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 3/29/23, 21 days after the ARD. Further review revealed, quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 12/30/22, 24 days after the ARD. f. Resident 80 was readmitted on [DATE] (original admission [DATE]). Review of Resident 80's quarterly MDS assessment dated [DATE] indicated, the assessment was completed on 2/22/23, 23 days after the ARD. During an interview on 4/19/23, at 1:32 PM, MDS Coordinator (MDSC) stated, quarterly MDS assessment should be completed 14 days after the ARD. MDSC acknowledged the quarterly MDS assessments for Resident 21 and Resident 14 were late. During an interview on 4/20/23, at 4:22 PM, Assistant Regional Director of Clinical Services (ARDCS) acknowledged the quarterly MDS assessments for Residents 6, 21, 62, and 14 were completed late. During an interview on 4/21/23, at 10:10 AM, the Director of Nursing (DON) acknowledged the quarterly MDS assessments for Residents 80 and 50 were completed late. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type . The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . Review of facility policy and procedure titled, MDS Completion and Submission Timeframes, revised July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure complete and accurate assessment for one of 19 sampled residents (Resident 36) when coding in Section M of the Minimum Data Set (MDS, a resident assessment tool) did not reflect Resident 36's actual skin condition as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). The deficient practice resulted in an inaccurate assessment and interventions provided for Resident 36. Additionally, the deficient practice lead to delayed healing and development of a new pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) for Resident 36. Findings: Review of Resident 36's clinical record, indicated Resident 36 was admitted on [DATE] with diagnoses included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood); unstageable (full-thickness skin and tissue loss in which extent cannot be confirmed because the wound bed is covered by a non-viable, dead, or devitalized tissue) pressure ulcer of right hip; and stage 2 pressure ulcer of other site. Review of Resident 36's history & physical (H&P), dated 3/22/23, indicated, .She (referring to Resident 36) received ongoing wound care for ischial and bilateral tibial wounds, present on admission, which do not appear infected . Physical Exam: . SKIN: Sacral pressure injury, unstageable 4.4 x 7.2 cm, 1.8 x .8 cm wound L (left) shin under the knee with slough, 5.2 x 2 cm wound R (right) shin with slough . The H&P indicated no mention of a stage 2 pressure injury on the left medial foot or bunion (a bony bump that forms on the joint at the base of your big toe). Review of Resident 36's MDS assessment dated [DATE], indicated, one unhealed stage 2 pressure ulcer and one unstageable/eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) present on admission and were coded under Section M: Skin Conditions. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. In addition, Section M: Skin Conditions. M1040. Other Ulcers, Wounds and Skin Problems was coded x which indicated None of the above were present. Review of Resident 36's Admission/readmission Evaluation/Assessment dated 3/21/23, indicated the following under Skin Evaluation section: - Right lower leg (front), trauma injury; no wound measurement or description indicated. - Left lower leg (front), trauma injury; no wound measurement or description indicated. - Sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) unstageable pressure; no wound measurement or description indicated. - Left Bunion pressure, no wound measurement or description indicated. Resident 36's Skin & Wound Evaluation V5.0 dated 3/21/23 in the electronic health record (EHR) was also reviewed and indicated the following: - Unstageable PU/PI on right ischial tuberosity (known as Sitz bone, a pair of rounded bones that extends from the bottom of the pelvis) measuring 2.2 centimeters (cm) x 1.0 cm, no description of the wound bed indicated. - Unstageable PU/PI on right ischial tuberosity measuring 4.4 cm x 7.2 cm, 40% of wound filled with eschar. - Stage 2 PU/PI on left medial foot measuring 1.9 cm x 1.6 cm, no description of the wound bed indicated. - Laceration on right shin measuring 5.2 cm x 2.1 cm, wound bed filled with 60% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). - Laceration on left shin measuring 1.8 cm x 1.8 cm, wound bed filled with 50% slough. During an interview on 4/20/23, at 10:24 AM, MDS Coordinator (MDS C) stated, Resident 36 was admitted on [DATE] and confirmed two pressure ulcers/injuries were present on admission. MDS C further stated, it was unclear on the skin & wound evaluation whether the two unstageable PU/PI were both located on the right ischial tuberosity. MDS C added, there was no mention of the unstageable PU/PI on the sacrum as indicated in the admission skin evaluation. MDS C acknowledged Resident 36's MDS dated [DATE] did not reflect two unstageable PU/PI on right ischial tuberosity and lacerations on left and right shin as indicated in the Skin & Wound Evaluation V5.0 completed on admission. Additionally, MDS C was not aware of the unstageable PU/PI on the sacrum as indicated in the Admission/readmission Evaluation/Assessment, thus was not coded in the MDS assessment. During wound care observation and concurrent interview on 4/20/23, at 11:28 AM, in resident's room, Registered Nurse (RN) 1 stated Resident 36 had three wounds located on the sacrum, left shin and right shin. Resident 36's sacrum was observed with pale pink colored, intact skin while the right lower buttock area was observed with irregular shape closed wound covered with black adherent patch. RN 1 pointed towards the right lower buttock, identified it (right lower buttock) as the sacrum, and described the wound as black scab. RN 1 was unable to stage the PU/PI and stated, I'll have to look at the order. RN 1 administered and explained the treatment order for the sacrum was to cleanse with wound cleanser, pat dry, apply skin sealant, and cover with Allevyn (a brand name of foam dressing) dressing. Further wound care observation revealed an oval shape wound covered with black scab on the right and left shin. RN 1 described the wounds on the right and left shin as abrasion but also stated, Both shins were moist and less scabby but now looks like an eschar. RN 1 administered and explained the treatment order was to cleanse with normal saline (NS) solution, apply Medihoney (aids and supports autolytic debridement and moist wound healing environment), and cover with foam dressing. Further observation revealed an irregular shape brownish-black discoloration on left medial foot and big toe. RN 1 was also unable to stage the PU/PI found. During an interview on 4/20/23, at 11:57 AM, RN 1 stated Resident 36 had a stage 2 pressure injury on the left medial foot and thought it was already healed since he did not see a treatment order. RN 1 added that he was also not aware of the discolorations on the left big toe and that it appeared to be new one. On the same interview, RN 1 described the discolorations as brownish scab and stated he had to look at the chart because he was not sure how to stage the discolorations found on the left medial foot and big toe. Review of Resident 36's Order Summary Report dated 3/22/23, indicated the following treatment orders: - Allevyn heel foam for prevention every day shift every Wed, Sat twice a week. - Cam boot for [for] both feet every shift. - Float heel with pillow at all times every shift. - Low air loss bed every shift. - Treatment to R shin wound: after cleaning with NS, pat dry and apply Medihoney HCS (Hydrogel Colloidal Sheet) as needed for soilage AND every day shift every other day. - Treatment to L shin wound: after cleaning with NS, pat dry and apply Medihoney HCS as needed for soilage AND every day shift every other day. - Treatment to sacral pressure injury wound: cleanse with [with] wound cleanser, pat dry then spray area where dressing will be with Cavilon skin sealant then apply an upside down sacral Allevyn dressing as needed for soilage AND every day shift every other day. - Turn and reposition per clinical guideline and place reposition pillow between knees when side lying every shift. Review of Resident 36's undated care plan addressing pressure ulcer, indicated, The resident has pressure ulcer or potential for pressure ulcer development .admitted with right shin laceration, PU to sacrum UTD (unstageable full thickness skin or tissue loss-depth unknown), PU right ischial tuberosity UTD, stage 2 PU left mid foot . Goal: the resident's pressure ulcer will show signs of healing and remain free from infection .The resident will have intact skin , free of redness, blisters or discoloration by/through review date. Further review indicated the following interventions: - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Inform the resident/family/caregivers of any new area of skin breakdown. - Monitor nutritional status. Serve diet as ordered, monitor intake and record. - Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. During an interview on 4/20/23, at 3:04 PM, the Director of Nursing (DON) explained, the admitting nurse is responsible for completing the admission assessments that includes the skin and wound assessment during admission. During a follow-up interview at 3:07 PM, the DON confirmed the admission assessment and wound evaluation were not consistent in identifying, measuring, and describing Resident 36's wounds. During an interview on 4/20/23, at 3:10 PM, the DON acknowledged Resident 36's care plan did not reflect accurate description of the wounds such as type, stage, and current treatment orders. The DON stated, Resident 36's care plan should be updated with accurate and current information to reflect resident's status and current plan of care. During an interview on 4/20/23, at 4:22 PM, Assistant Regional Director of Clinical Services (ARDCS) explained, Section M: Skin Condition of the MDS assessment is completed based on the information gathered from hospital documentation, admission note, H&P, and wound assessments by admission nurse who take photos, measurement, and description of the wound. Additionally, licensed vocational nurse (LVN) completes the nursing sections of the MDS and an RN working remotely will verify all sections are completed before signing and submitting the MDS assessment. Review of Resident 36's Skin & Wound in the EHR (a tab/section for skin and wound assessment that includes photos of the wound) dated 3/21/23 indicated the following: - Medial foot with redness measuring 1.9 cm x 1.5 cm was described as Stage 2 pressure. - Right ischial tuberosity measuring 4.4 cm x 7.2 cm was described as unstageable/eschar. - Right ischial tuberosity measuring 2.18 cm x 0.97 cm was described as unstageable pressure. - Right shin laceration measuring 5.2. cm x 2.09 cm with 60% slough. - Left shin laceration measuring 1.82 cm x 1.84 cm with 50% slough. During an interview on 4/23/23, at 4:34 PM, ARDCS stated the photos shown and description of the wounds (referring to the Skin & Wound assessment above) were taken from an app called Skin & Wound. ARDCS acknowledged the wound assessments recorded on several skin and wound evaluation were not consistent and were not reflected on the MDS assessment. ARDCS also stated that based on the photos, the PU/PI on medial foot should have been coded as unstageable instead of stage 2 as it appears as dark red/brownish discoloration on admission. ARDCS further stated, the wounds were not accurately assessed and coded in the MDS. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . Section M: Skin Conditions - Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program . Steps for Assessment: 1. Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments. 2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident. 3. Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices are present. Assess key areas for pressure ulcer/injury development (e.g., sacrum, coccyx, trochanters, ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles) and skin that is under braces or subjected to pressure (e.g., ears from oxygen tubing).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services for one of 19 sampled residents (Resident 21) when physician's treatment orders for Resident 21's healing burn area on right forearm were not implemented. Failure to implement physician's treatment orders could result to delayed wound healing and the potential for infection. Findings: Review of Resident 21's clinical record indicated, Resident 21 was admitted on [DATE] with diagnoses included but not limited to burn of third degree (full-thickness burn) of right forearm and other site of trunk, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dementia (memory loss), and Parkinson's disease (refers to brain conditions that cause slowed movements, stiffness, and tremors). Review Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/23, indicated, Resident 21 had severe cognitive impairment. The MDS assessment also determined Resident 21 had no impairment on both upper and lower extremities. Section M: Skin Conditions. M1040. Other Ulcers, Wounds and Skin Problems of the MDS assessment indicated, Resident 21 had Surgical wound(s) and Burn(s) (second or third degree). Review of Resident 21's history & physical (H&P) dated 12/24/22, indicated, .Discharge Diagnoses: A 12% total body surface area full-thickness flame burn to right trunk and right arm . Assessment and Plan: [Resident 21] .was hospitalized after sustain a burn to her R (right) arm and torso while cooking. She underwent skin grafting. She is transferred [Facility Name] for therapy. Wound care at outpatient burn clinic . During an observation on 4/17/23, at 10:57 AM, in resident's room, Resident 21 was awake in bed, wearing a short-sleeved pink shirt exposing her pale pink arm and an open wound on the elbow. A wedge pillow (used to elevate the upper or lower body to help improve circulation, reduce snoring, and relieve pressure on sensitive areas) was observed tucked under the bed sheet on both sides of the bedrail. A moist, yellow-colored gauze (a thin, translucent fabric with a loose open weave) and dry crumpled white gauze was observed on the bed sheet by Resident 21's left upper arm. There was no wound observed on Resident 21's left arm. Further observation showed an open wound on the right elbow with no cover or dressing, and red spots on the sheets. During an interview on 4/17/23, at 11:14 AM, Certified Nursing Assistant (CNA) 9 stated, Resident 21's right arm and body got burned. CNA 9 also stated it was her first day taking care of Resident 21 and to ask the charge nurse for more information of the burn on right arm. Review of Resident 21's Order Summary Report dated 4/5/23, indicated the following orders: - Apply Tubigrip (provides firm support for sprains, strains and swelling) size E to right upper arm and apply Tubigrip size D to right lower arm. Check placement q (every) shift. - Topical Tx (treatment) to healing burn area on right forearm - cleanse with wound cleanser, pat to dry, apply collagen dressing and xeroform (non-adherent gauze dressing used on low exudating wounds) cover, then wrap with Kerlix (bandage roll used as primary dressing for exuding wounds, burns, as a cover for surgical wounds and to secure and prevent movement of primary dressing) every other day every 4 hours as needed for Saturation or soiling. - Topical Tx to healing burn area on right forearm - cleanse with wound cleanser, dry, apply collagen dressing and Xeroform cover, then wrap with Kerlix every other day one time a day every other day. - Topical Tx to R (right) elbow/upper arm daily - cleanse with wound cleanser, dry, apply collagen dressing and Xeroform to small open areas right elbow and right upper arm, wrap with Kerlix daily; until healed every day shift for burn areas. - Turning and repositioning as tolerated for wound management q shift. - Wound eval (evaluation)/consult. During an observation on 4/18/23, at 8:48 AM, in resident's room, Resident 21 was awake in bed, scratching and picking the skin on her exposed right arm. During concurrent interview at 8:49 AM, CNA 7 stated, Resident 21 usually scratches the skin on her burned skin. CNA 7 further stated that there should be a cover on her right arm to protect from scratching, I will tell the nurse. During an interview on 4/18/23, at 10:59 AM, Licensed Vocational Nurse (LVN) 2 stated, Resident 21 had a burn on the right arm and body and was admitted to facility for wound care. LVN2 added, a Tubigrip is applied on the right arm to cover and help prevent Resident 21 from scratching or removing the dressing. Further interview, LVN 2 acknowledged Resident 21 had no dressing or cover on her right arm and stated, It should be covered. I will tell the treatment nurse. Review of Resident 21's care plan addressing burn area on right elbow, revised on 3/28/23, indicated the following interventions: - Monitor s/s (signs/symptoms) for pain q shift. - Topical Tx as ordered. Updated 3/28/23 Cleanse with NS (normal saline, a mixture of sodium chloride and water), apply medihoney (aids and supports autolytic debridement and moist wound healing environment), collagen sheet, xeroform, cover with foam daily and PRN (as needed) for soiling and saturation. - Turning and repositioning q 2 hrs (hours). Review of Resident 21's care plan addressing burn area on right torso, initiated on 12/23/22, indicated the following interventions: - Monitor s/s (signs/symptoms) for pain q shift. - Topical Tx as ordered. - Turning and repositioning q 2 hrs. Review of Resident 21's care plan addressing burn area on right forearm, revised on 3/28/23, indicated the following interventions: - Encourage long-sleeved shirts and pants to protect extremities, as indicated. - Keep RP (resident representative) and MD (medical doctor) updated, as indicated. - Monitor for any complaints of pain (location, duration, quantity, quality, alleviating factors, aggravating factors). - Monitor labs as indicated. - Treat area per MD orders. Treatment: Cleanse with NS, apply collagen, xeroform, wrap with kerlix every other day and PRN for saturation and soiling. - Wound specialist MD to follow resident weekly. During concurrent interview and record review on 4/18/23, at 11:23 AM, Director of Nursing (DON) reviewed Resident 21's treatment orders and care plan addressing third degree burn on the right arm and torso. DON stated, Resident 21's burned area should have a dressing and cover including kerlix and Tubigrip on the right arm. DON explained, Tubigrip looks like a cloth sleeve and stated, Resident 21 needs to have it all the time. Check placement every shift. DON added, I don't see it (referring to Tubigrip) in the care plan. Review of Resident 21's care plan addressing skin integrity, initiated and revised on 12/25/22, indicated, Actual and potential for alteration in skin integrity .r/t (related to) s/p (status post) Burn on right arm and right torso . Interventions: .Follow physician orders for skin care and treatment . During a follow-up observation on 4/19/23, at 1:19 PM and 4/20/23, at 11:15 AM, in resident's room, Resident 21 had no dressing or cover on her right forearm. Review of Resident 21's Treatment Administration Record for April 2023, indicated, treatment order, Apply Tubigrip size E to right upper arm and apply Tubigrip size D to right lower arm. Check placement q (every) shift. had check marks and initials on 4/1/23 through 4/20/23. During an interview on 4/20/23, at 11:20 AM, Registered Nurse (RN) 1 stated, the check marks and initials in the Treatment Administration Record indicates treatment order was administered to the resident. Review of facility's policy and procedure titled, Wound Care, revised 10/2010, indicated, . 1. Verify that there is a physician's order . 2. Review the resident's care plan to assess for any special needs of the resident . Review of facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and resident's condition change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide preventive care and treatment to avoid worsening and development of additional pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) on left medial toe (big toe); and promote healing of existing pressure injuries for one of 4 sampled residents (Resident 36) when: 1. The facility did not ensure complete and accurate wound assessment on admission that includes identification, measurement, and description of wound. Additionally, there was no consistency in wound identification, measurement, and description of wound among nursing and physician/practitioner. 2. There was no ongoing wound assessment to monitor the status and progress of Resident 36's multiple pressure injuries. 3. The care plan addressing Resident 36's pressure injuries did not include person-centered wound care and treatment as indicated in the physician orders. These failures resulted in delayed wound healing and development of new pressure injury on left medial toe (big toe) for Resident 36. Findings: 1. Review of Resident 36's History & Physical (H&P), dated 3/22/23, indicated, admitted to facility on 3/21/23 with diagnoses included COVID-19 (Corona Virus 2019 - is an infectious disease caused by SARS-Cov-2 virus) infection; rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood); acute kidney injury (kidney damage that happens within a few hours or a few days); hypertension (high blood pressure); and diabetes mellitus (high blood sugar). Review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/23, indicated, Resident 36 had severe cognitive impairment. The functional status assessment dated [DATE] indicated, Resident 36 required extensive assistance with one-person physical assist with bed mobility and dressing. Resident 36 had impairment on both sides of lower extremities. Further review of the same MDS assessment indicated, Resident 36 was at risk of developing pressure injuries. In addition, the MDS indicated one unhealed stage 2 pressure injury and one unstageable/eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). Review of Resident 36's Admission/readmission Evaluation/Assessment dated 3/21/23, indicated the following under Skin Evaluation section: - Right lower leg (front), trauma injury; no wound measurement or description indicated. - Left lower leg (front), trauma injury; no wound measurement or description indicated. - Sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) unstageable pressure; no wound measurement or description indicated. - Left Bunion pressure, no wound measurement or description indicated. During concurrent interview and record review on 4/20/23, at 10:24 AM, MDS Coordinator (MDSC) stated Resident 36 was admitted to the facility on [DATE] with pressure injuries present. MDSC reviewed Resident 36's Admission/readmission Evaluation/Assessment dated 3/21/23 and confirmed there were two pressure injuries documented on admission. Resident 36's Skin & Wound Evaluation V5.0 dated 3/21/23 in the electronic health record (EHR) was also reviewed and indicated the following: - Unstageable pressure injury on right ischial tuberosity (known as Sitz bone, a pair of rounded bones that extends from the bottom of the pelvis) measuring 2.2 centimeters (cm) x 1.0 cm, no description of the wound bed indicated. - Unstageable pressure injury on right ischial tuberosity measuring 4.4 cm x 7.2 cm, 40% of wound filled with eschar. - Stage 2 pressure injury on left medial foot measuring 1.9 cm x 1.6 cm, no description of the wound bed indicated. - Laceration on right shin measuring 5.2 cm x 2.1 cm, wound bed filled with 60% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). - Laceration on left shin measuring 1.8 cm x 1.8 cm, wound bed filled with 50% slough. MDSC stated it was unclear on the Skin & Wound Evaluation whether the two unstageable pressure injuries were both located on the right ischial tuberosity. MDSC added, there was no mention of the unstageable pressure injury on the sacrum as indicated in the admission Skin Evaluation. In addition, MDSC reviewed Resident 36's MDS dated [DATE] and confirmed only one Stage 2 pressure injury, and one unstageable/eschar were coded/documented. Review of Resident 36's History & Physical (H&P), dated 3/22/23, indicated, .She (referring to Resident 36) received ongoing wound care for ischial and bilateral tibial wounds, present on admission, which do not appear infected . Physical Exam: . SKIN: Sacral pressure injury, unstageable 4.4 x 7.2 cm, 1.8 x .8 cm wound L (left) shin under the knee with slough, 5.2 x 2 cm wound R (right) shin with slough . The H&P indicated no mention of a stage 2 pressure injury on the left medial foot or bunion (a bony bump that forms on the joint at the base of your big toe). During an interview on 4/20/23, at 12:13 PM, Registered Nurse (RN) 1 introduced himself as the treatment nurse and explained that wound assessments are completed using an app (mobile application) called Skin & Wound (an advanced mobile app designed for wound evaluation, documentation, and status communication across the care team for improved care outcomes) wherein measurements of the wound will automatically populate after a photo of the wound is taken. During concurrent record review, Resident 36's Skin & Wound in the EHR (a tab/section for skin and wound assessment that includes photos of the wound) dated 3/21/23 indicated the following: - Medial foot with redness measuring 1.9 cm x 1.5 cm was described as Stage 2 pressure, location (left or right) was not indicated. - Right ischial tuberosity measuring 4.4 cm x 7.2 cm was described as unstageable/eschar. - Right ischial tuberosity measuring 2.18 cm x 0.97 cm was described as unstageable pressure. - Right shin laceration measuring 5.2. cm x 2.09 cm with 60% slough. - Left shin laceration measuring 1.82 cm x 1.84 cm with 50% slough. RN1 confirmed the wound assessments indicated in the Skin & Wound were completed when Resident 36 was admitted to facility on 3/21/23 and that the assessment did not include or mention the unstageable pressure injury on the sacrum. During an interview on 4/20/23, at 3:04 PM, the Director of Nursing (DON) explained, the admitting nurse is responsible for completing the admission assessments that include the skin and wound assessment during admission. The DON stated, the treatment nurse will follow up on the status of the wound and will notify the doctor to obtain treatment orders. The DON also stated that residents with pressure injuries, burns, or surgical wounds are referred to the wound doctor for weekly follow up. The DON added, the wound doctor usually comes every Tuesday to evaluate the progress of the resident's wound. During concurrent interview and record review with the DON on 4/20/23, at 3:07 PM, Resident 36's Admission/readmission Evaluation/Assessment and Skin & Wound Evaluation V5.0 dated 3/21/23 were reviewed. The DON confirmed and stated the admission assessment and wound evaluation were not consistent in identifying, measuring, and describing Resident 36's wounds. The DON stated, Resident 36 was not referred to the wound doctor for her pressure injuries. 2. During wound care observation and concurrent interview on 4/20/23, at 11:28 AM, RN 1 stated Resident 36 has three wounds, located on the sacrum, left shin and right shin. Resident 36's sacrum was observed with pale pink colored, intact skin while the right lower buttock area was observed with irregular shape closed wound covered with black adherent patch. RN 1 pointed towards the right lower buttock, identified it (right lower buttock) as the sacrum, and described the wound as black scab. RN 1 stated he was not sure about stage of the wound, I'll have to look at the order. RN 1 administered and explained the treatment order for the sacrum was to cleanse with wound cleanser, pat dry, apply skin sealant, and cover with Allevyn (a brand name of foam dressing) dressing. Further wound care observation showed an oval shape wound covered with black scab on the right and left shin. RN 1 described the wounds on the right and left shin as abrasion but also stated, Both shins were moist and less scabby but now looks like an eschar. RN 1 administered and explained the treatment order was to cleanse with normal saline (NS) solution, apply Medihoney (aids and supports autolytic debridement and moist wound healing environment), and cover with foam dressing. Further observation showed an irregular shape brownish-black discoloration on left medial foot and big toe. During an interview on 4/20/23, at 11:57 AM, RN 1 stated Resident 36 had a Stage 2 pressure injury on the left medial foot and thought it was already healed since he did not see a treatment order. RN 1 added that he was also not aware of the discolorations on the left big toe and that it appeared to be new one. On the same interview, RN 1 described the discolorations as brownish scab and stated he had to look at the chart because he was not sure how to stage the discolorations found on the left medial foot and big toe. Review of Resident 36's Skin & Wound Evaluation section in the EHR indicated, one wound assessment dated [DATE] was completed since Resident 36 was admitted on [DATE]. The Skin & Wound Evaluation V5.0 dated 4/12/23 indicated the following: right lower leg skin tear measuring 5 cm x 3 cm, left lower leg skin tear measuring 4 cm x 2 cm, sacrum unstageable measuring 6 cm x 4 cm. During concurrent interview on 4/20/23, at 12:21 PM, RN 1 explained he documented skin tear on the assessment for the right and left shin because he cannot find laceration from the choices for the types of wounds. The Skin & Wound Evaluation V5.0 indicated no mention of the brownish-black discolorations on the left medial foot and big toe. Further record review, RN 1 was unable to find wound assessments scheduled for 3/29/23, 4/5/23, and 4/19/23. RN 1 stated, I'm not seeing it right now (referring to the missing weekly wound assessment). I only see one assessment (referring to 4/12/23 wound assessment). RN 1 acknowledged and stated the wound assessment/evaluation was not consistently completed every week to monitor the progress of Resident 36's pressure injuries and stated, I try to complete the [wound] assessments every week if I can. RN 1 further stated, wound assessments should be completed every week on Wednesdays. During an interview on 4/20/23, at 3:14 PM, the DON acknowledged and stated there were no wound assessments on 3/29/23, 4/5/23, and 4/18/23. The DON stated, wound assessments are completed weekly, either on Tuesdays when the wound doctor visits or on Wednesdays. The DON also stated that wound assessment should be completed every week to monitor wound healing, able to see changes in wound appearance, and identify worsening or development of new wounds. In addition, the brownish-black discoloration found on Resident 36's left medial foot and big toe were not identified accurately and timely. 3. During an observation on 4/20/23, at 11:25 AM, in resident's room, Resident 36 was lying on her right side with knees bent rubbing against each other and both feet resting on the mattress with no socks on. Further observation showed an irregular shape brownish-black discoloration on left medial foot and big toe. During an interview on 4/20/23, at 12:05 PM, Certified Nursing Assistant (CNA) 7 stated she was not aware of the brownish-black discolorations on Resident 36's left foot and that nobody told her about it. CNA 7 further stated that Resident 36's legs are stiff. CNA 7 added, resident has a pair of foam booties in the closet and was supposed to wear the foam booties for few hours when in bed. During an interview on 4/20/23, at 12:24 PM, RN 1 stated, Resident 36 does not wear foam protectors or foam booties on both feet. RN 1 further stated that Resident 36 has no treatment orders for the feet. Review of Resident 36's Order Summary Report dated 3/22/23, indicated the following treatment orders: - Allevyn heel foam for prevention every day shift every Wed, Sat twice a week. - Cam boot for [for] both feet every shift. - Float heel with pillow at all times every shift. - Low air loss bed (n air mattress covered with tiny holes) every shift. - Treatment to R shin wound: after cleaning with NS, pat dry and apply Medihoney HCS (Hydrogel Colloidal Sheet) as needed for soilage AND every day shift every other day. - Treatment to L shin wound: after cleaning with NS, pat dry and apply Medihoney HCS as needed for soilage AND every day shift every other day. - Treatment to sacral pressure injury wound: cleanse with [with] wound cleanser, pat dry then spray area where dressing will be with Cavilon skin sealant then apply an upside down sacral Allevyn dressing as needed for soilage AND every day shift every other day. - Turn and reposition per clinical guideline and place reposition pillow between knees when side lying every shift. Review of Resident 36's undated care plan addressing pressure ulcer, indicated, The resident has pressure ulcer or potential for pressure ulcer development .admitted with right shin laceration, PU to sacrum UTD (unstageable full thickness skin or tissue loss-depth unknown), PU right ischial tuberosity UTD, stage 2 PU left mid foot . Goal: the resident's pressure ulcer will show signs of healing and remain free from infection .The resident will have intact skin , free of redness, blisters or discoloration by/through review date. Further review indicated the following interventions: - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Inform the resident/family/caregivers of any new area of skin breakdown. - Monitor nutritional status. Serve diet as ordered, monitor intake and record. - Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X (by) width X depth), stage. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ). During an interview on 4/20/23, at 3:10 PM, the DON stated, the interventions provided for Resident 36's pressure injuries include treatment orders for the wound, low air loss mattress, nutritional supplements, and pillows for positioning. The DON also stated that Resident 36 has no order for booties. During concurrent record review, the DON reviewed Resident 36's care plan in the EHR and stated, the care plan addressing pressure ulcers/injuries was initiated on 3/22/23 and was updated on 3/30/23. The DON acknowledged and stated Resident 36's care plan did not reflect accurate description of the wounds such as type, stage, and current treatment orders. The DON further stated Resident 36's care plan should be updated with accurate and current information to be able to see whether the wound is healing or wound treatments/interventions are effective. During an interview on 4/20/23, at 4:34 PM, Assistant Regional Director of Clinical Services (ARDCS) stated, wound assessments should be completed weekly and residents with any type of pressure ulcer/injury are referred to the wound doctor who also visits weekly. ARDCS further stated, wounds should be re-evaluated every 14 days determine progress of wound healing and effectiveness of wound treatment. Additionally, resident's care plan should be updated or revised to reflect changes in wound status and wound treatment. Review of facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 4/2018, indicated, Assessment and Recognition . 2. In Addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and 3. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer . Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. (a) Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. (b) Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. Review of facility's policy and procedure titled, Wound Care, revised 10/2010, indicated, .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given . 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .

Based on observation, interview and record review, the facility failed to provide trauma informed care for one of three residents (Resident 12) when facility did not identify and address symptoms of PTSD (Post -Traumatic Stress Disorder). This failure to identify symptoms had the potential to result in inaccurate and inappropriate provision of care. Findings: Review of Resident 12's clinical record on 4/19/23 at 1:00 PM, Resident 12 was admitted to facility on 11/16/2016 with diagnoses included bipolar disorder (mood swings disorder) and PTSD. During observation on 4/18/23 at 11:00 AM, Resident 12 was awake and lying in bed. Resident 12 did not respond when greeted. During interview on 4/18/23 at 12:00 pm with CNA 2, CNA 2 stated, 'I have worked with resident since he was admitted , I have worked here over 20 years. He eats by himself, he gets violent if you remove something from his table, he does not talk to strangers, he starts screaming and yelling, and he tends to be forgetful. He refused to go out of bed, even for showers. CNA 2 cleans him up in bed. Resident 12 speaks Spanish and can answer some English. CNA 2 communicates well with him. He was calm and cooperative. His family member used to come and visit but moved back to their country. Activity staff comes to his room. Resident 12 likes to eat while he watches tv. Review of Resident 12's care plan on 4/19/23 at 3:00 PM with DON, DON stated there was no care plan to address trauma specific interventions. During interview on 4/18/23 at 7:53 AM with activity director (AD), AD stated,Resident 12 has been offered activities but refused, not sure of what he wants, he enjoys haircuts, he gets it regularly in his room, he enjoys pet visit, enjoys watching tv, he sometimes yell out but he is better.

Based on observation, interview and record review, the facility failed to provide medically related social services to attain or maintain highest practicable physical, mental, psychosocial well-being for one (Resident 12) of three residents reviewed when social worker (SW) did not address care plan and progress note on diagnoses of PTSD and history of trauma. This failure can result in staff not recognizing the trauma symptoms can trigger re- traumatization. Findings: Review of Resident 12's clinical record, Long Term Care Psychiatry dated 4/18/23, Nurse Practitioner (NP) indicated, PTSD symptoms after being tortured in Nicaraguan civil war. He is alert, calm pleasant and cooperative, grateful to God. Says he has a lot of memories of his participation in war, dreams about weapons or about killing people from a helicopter, makes him feel like a murderer. Does not like seeing news on tv about war, is concerned about Russia/Ukraine war, he was trained by Russians in Nicaragua. He hopes for International peace. Impression: still has some PTSD symptoms, hard to tell how often or frequent, has dramatic improvement in lability, anger, anxiety, attention-seeking behavior and problem behavior, no need to add any medication at this time. During interview with SW on 4/18/23 at 10:00 AM, SW stated she did not do any care plan or progress notes regarding his behavior.

Based on observation, interview, and document review the facility failed to meet the needs of the residents when unauthorized personnel that had access to the station one medication room. Findings: During an observation on 4/18/23 at 7:00 AM the station one medication room was left unlocked and opened. The deadlock was holding the door open. The deadlock was preventing the door from closing. There were multiple staff and residents that walked by the opened medication room. During an observation and interview on 4/18/23 at 7:00 AM CNA 1 walked past the open medication room. CNA stated that she was not supposed to have access to the medication room. During an observation and interview on 4/18/23 at 7:05 AM Staff 1 walked past the open medication room. Staff 1 stated that she primary does housekeeping and was not supposed to have access to the medication room. During an observation on 4/18/23 at 7:05 AM inside the medication room was multiple prescription medications on the shelves and the medication refrigerator. During an observation on 4/18/23 at 2:00 PM the station two medication room was left unlocked and opened. The door appeared to be sticking but it was clearly visibly opened. A review on 4/18/23 of the undated facility policy entitled Storage of Medications indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Only persons authorized to prepare and administer medications shall have access to the medication room . During an interview on 4/18/23 at 2:05 PM the Director of Nursing stated that only nurses should have access to the medication rooms.

Based on observation, interview, and document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for twenty-six observed opportunities which would equal a medication error rate of eleven percent. Findings: 1. During an observation on 4/18/23 at 8:25 AM LVN 1 prepared 30 mg of Furosemide (diuretic medication used for edema) for Resident 90. LVN 1 had prepared the 30 mg of Furosemide for administration. A review of the physician orders indicated that Resident 90 was to receive 60 mg daily of Furosemide. When asked why LVN 1 was about to administer the 30 mg instead of the 60 mg she stated that the pharmacy label indicated to administer 30 mg. During an interview on 4/18/23 at 8:45 AM Pharmacist 1 stated that Resident 90's pharmacy label was mislabeled. Pharmacist 1 also stated the instruction on the label indicated that the 30 mg daily would be administered instead of the 60 mg daily as ordered by the physician. 2. A review of the Enoxaparin manufacture's' insert indicated Subcutaneous Injection Technique .Introduce the whole length of the needle into a skin fold held between the thumb and forefinger, hold the skin fold throughout the injection During an observation on 4/18/23 at 9:00 AM LVN 1 administered Enoxaparin 40 mg (medication used to prevent blood clots) to Resident 90. LVN 1 did not introduce the needle into a skin fold held between the thumb and forefinger, holding the skin fold throughout Resident 90's injection. It was also observed that there were multiple small bruises (3-5 cm) near the injection site. During an interview on 4/18/23 at 11:30 AM LVN 1 stated that she did not introduce the needle into a skin fold held between the thumb and forefinger, holding the skin fold throughout Resident 90's injection. She also stated she noticed the small bruises and she was concerned about the bruising. 3. A review of the Insulin Aspart Injectable Pen indicated INSTRUCTIONS FOR USE .Insert the needle into the skin. Push down on the plunger to inject your dose .The needle should remain in the skin for at least 6 seconds to make sure you have injected all the insulin . During an observation on 4/18/23 at 11:00 AM LVN 2 administered 2 units of insulin aspart injectable pen (medication use to treat diabetes) to Resident 11. It was also observed that LVN 2 inserted the needle into the skin, however she immediately pulled the needle out of the skin. LVN 2 did not keep the needle into Residents skin for at least 6 seconds.

Based on observation, interview, and record review the facility failed to appropriately label and store medications as evidence by: 1. The facility pharmacy dispensed medications that was mislabeled. The labeling indicated incorrect administration instructions that did not correspond to the physician's orders. 2. The facility station two medication refrigerator was too cold for the medications that were stored inside the refrigerator. Findings: 1. During an observation on 4/18/23 at 8:25 AM LVN 1 prepared 30 mg of Furosemide (diuretic medication used for edema) for Resident 90. LVN 1 had prepared the 30 mg of Furosemide for administration. A review of the physician orders indicated that Resident 90 was to receive 60 mg daily of Furosemide. When asked why LVN 1 was about to administer the 30 mg instead of the 60 mg she stated that the pharmacy label indicated to administer 30 mg. During an interview on 4/18/23 at 8:45 AM Pharmacist 1 stated that Resident 90's pharmacy label was mislabeled. Pharmacist 1 also stated the instruction on the label indicated that the 30 mg daily would be administered instead of the 60 mg daily as ordered by the physician. Pharmacist 1 said that the confusion had to do with only dispensing half tablets and not updating the instruction on the label. During an interview on 4/19/23 at 9:40 AM LVN 1 stated that on 4/17/23 she administered 20mg of Furosemide to Resident 90 instead of 60 mg as ordered by the physician. She also stated that got confused because of the labeling and only gave 20 mg. During an interview on 4/19/23 at 10:50 AM DON stated that LVN 3 had administer the wrong dose on 4/16/23. The DON said that LVN 3 had administer 20mg of Furosemide instead of the 60 mg as ordered. DON also stated that the labeling was wrong, and she had already taken corrective measures to prevent future errors. 2. During an observation on 4/18/23 at 7:06 AM the station two medication refrigerator indicated the internal temperature of the refrigerator was 29 degrees Fahrenheit. During an observation on 4/18/23 at 7:40 AM the station two medication refrigerator indicated the internal temperature of the refrigerator was 30 degrees Fahrenheit. During an observation on 4/18/23 at 10:06 AM the station two medication refrigerator indicated the internal temperature of the refrigerator was 30 degrees Fahrenheit. During an observation on 4/18/23 between the times of 7:06 AM and 10:06 AM the medications that were found in the refrigerator indicated on the labels of the medications to store between 36-46 degrees Fahrenheit. The following are the list of some of medications found in the refrigerator at temperatures below what was recommended by the manufacturer: * PPD vaccine *Influenza vaccine *Ketorolac *Multiple Insulins *Ofloxacin *Xalatan *Retacrit A review of the manufacture's inserts of the medications listed above indicated that they all required storage between 36-46 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. For Resident 62, the undated urinary drainage bag (collection bag) was stored together with the undated urinal (a bottle for urination) in a black bag touching the floor. 2. Resident 25 and Resident 18's oxygen tubing in use were undated. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents. Findings: 1. Review of Resident 62's undated Facesheet indicated, was admitted on [DATE] with diagnoses included spinal stenosis (narrowing of the spinal canal), quadriplegia (paralysis that affects all a person's limbs and body from the neck down), and neuromuscular dysfunction of bladder (a condition where a person lacks bladder control due to brain, spinal cord or nerve problems). During an observation on 4/17/23, at 9:47 AM, in resident's room, Resident 62 was lying in bed watching television (TV). A black open bag was found on the floor that contain an empty urinal with yellowish and light brown discoloration inside; and an undated/unlabeled urinary drainage bag with yellow colored urine. The collecting tube attached to the urinary drainage bag was kinked and the lower part of the tube was touching the floor . During concurrent interview, Certified Nursing Assistant (CNA) 2 stated she used the urinal to empty the urinary drainage bag for Resident 62. The undated/unlabeled urinary drainage bag was brought to CNA 2's attention and she stated, the urinary drainage bag and tubing should not be touching the floor to prevent infection. CNA 2 akcnowledged the drainage bag and urinal were undated/unlabeled and stated, she was unsure of the date it was actually changed. CNA 2 added, the urinal is changed when it becomes dirty (referring to yellowish/light brown discoloration) and drainage bag every week by the charge nurse. During an interview on 4/18/23, at 11:09 AM, Director of Nursing (DON) stated, urinary drainage bags are changed as needed unless specified in the physician's order. DON explained the urinary drainage bag should be inside the black bag and not touching the floor. DON also stated the urinal should not be cleaned after use and not stored togehter with the drainage. Review of the facility policy and procedure titled, Catheter Care, Urinary, revised August 2022, indicated, .General Guidelines . 3. Empty the collection bag at least every eight (8) hours using a separate, clean collection container for each resident. Avoid splashing, and prevent from contact of the drainage spigot with the nonsterile container . Infection Control . 2. Be sure the catheter tubing and drainage bag are kept off the floor . Maintaining Unobstructed Urine Flow 1. keep the catheter adn tubing free of kinks . 2. During an observation on 4/17/23, at 11:19 AM, in resident's room, Resident 18 was lying in bed with oxygen on at 1.5 liters per minute (LPM) via nasal cannula (NC, a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The oxygen tubing was unlabeled/undated. During concurrent interview at 11:20 AM, Licensed Vocational Nurse (LVN) 1 acknowledged and stated the oxygen tubing for Resident 18 was undated. LVN1 further stated, oxygen tubings are changed every three to five days by night shift nurse. During an observation 4/17/23, at 12:40 PM, in resident's room, Resident 25 was in bed asleep with oxygen on at 4 liters per minute (LPM) via NC. The oxygen tubing was unlabeled/undated. During concurrent interview at 12:41 PM, CNA 6 acknowledged and stated Resident 25's oxygen tubing was undated/unlabeled. During an interview on 4/19/23, at 2:11 PM, DON stated oxygen tubings are changed every week by night shift nurses and a label should indicate the date it was changed. Review of facility policy and procedure titled, Oxygen Administration, revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure . 22. Change oxygen tubing weekly and p.r.n. (as needed) .

Based on observation, interview and record review, the facility failed to provide the required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care and may impact their quality of life. Findings: The room measurement indicated multiple resident rooms were less than 80 square feet per resident. Room # # of occupants Space per Resident 1 2 74.27 2 3 74.27 3 2 75.25 4 3 74.27 5 2 76.58 6 3 72.26 8 3 77.19 9 3 74.80 11 3 74.53 12 3 76.13 14 2 76.22 15 2 77.59 16 2 73.61 17 2 76.13 18 3 76.13 19 2 76.13 20 2 77.90 21 3 76.13 22 3 76.13 23 3 76.13 24 3 79.32 25 3 73.66 26 2 76.39 27 3 73.12 28 3 78.36 29 3 73.12 30 2 73.12 31 3 74.00 32 2 75.37 33 2 75.93 34 2 75.93 35 2 75.93 None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and Geri chairs (medical recliners) were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern. Continuance of the room waiver is recommended.

Based on observation and interview, the facility failed to maintain a safe and pest free environment for residents and an effective pest control program, when a rodent was sighted on 4/18/23 in the basement. This failure can result to infection control problem. Findings: During observation on 4/18/23 at 8:15 AM, a running mouse was sighted in the basement near the kitchen. Housekeeping supervisor (HKS) stated, It's a mice [sic]. During interview with kitchen supervisor (KS) on 4/18/23 at 10:00 AM, KS stated, did not see mice in the kitchen today. During interview with Maintenance Supervisor (MS), MS stated, there has been no reports of sighting or droppings this month, but has been in the past month. No logged in report this month. Terminix is the commercial General Pest Control we use, comes in 2 times a month. We had a problem with mice in the building in December 2022, we did what Terminix recommended for us to do, patching the holes, replaced the ceiling with hole in the kitchen, patched the holes with Foam patch to areas with holes as identified by Terminix. To prevent the entry of rodents to the building through the holes in identified areas. We will continue with the scheduled pest control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were consistent with professional standards of care and the residents' comprehensive, person-centered care plan and preferences for 2 out of 2 residents (Resident 60 and Resident 23) who received hemodialysis [a treatment for advanced kidney failure where a machine filters wastes and water from the blood] at an offsite location when: 1.There was no interdisciplinary team (IDT) recommendation to monitor, document, and ensure nutrition and hydration needs related to provision of meals or snacks, including bagged meals were provided to residents before going to dialysis appointments 2.The dialysis care plans were not specific, individualized and implemented to ensure nutrition and hydration needs related to provision of meals or snacks, including bagged meals were provided to residents on dialysis days These failures resulted in Resident 60 and Resident 23 to not consistently receive meals or snacks including bagged meals before their scheduled dialysis appointments. Failure to ensure dialysis residents were monitored and provided with nutrition and hydration prior to dialysis appointments offsite could result in residents' missing their scheduled meals and snacks, feel hungry, potentially lose weight, and may experience clinical complications related to their medical diagnoses. Findings: 1.Resident 60 was admitted to the facility on [DATE] with diagnoses included end stage renal disease (a condition wherein the kidneys fail to function leading to a need for dialysis or kidney transplant). Resident 60's dialysis care plan indicated hemodialysis treatments at an offsite location, three times a week, at 5:45 AM, with transportation pick up at the facility at 5:05 AM. During a review of the Registered Dietitian's (RD) Nutrition/Dietary Note, for Resident 60, dated 1/27/23, the note indicated recommendations that included Provide HS [at bedtime] snack: PB [peanut butter] and jelly sandwich (please keep in resident fridge to give in AM before dialysis MWF [Monday, Wednesday, Friday]). The RD's note also indicated, Give brown bag lunch MWF (include crackers, SF pudding, & fruit) to take with him to dialysis on MWF. During an observation and interview on 4/19/23 at 12:10 PM, in the resident's room, Resident 60 stated he's up at 4 AM during his scheduled dialysis days and got picked up by transportation at around 5 AM. When asked, Resident 60 stated he did not get a bagged meal when he leaves for his dialysis appointments at an offsite location. Resident 60 stated he would like something to eat before he leaves the facility for his dialysis appointments. Resident 60 stated he had informed the nursing staff about this matter but was told that the kitchen was closed. Resident 60 stated the facility's nutritionist spoke to him last week and was also aware of this matter. During an interview on 4/19/23 at 3:20 PM, with the Registered Dietitian (RD), RD stated Resident 60 told her on 4/12/23 that he was not given bagged meals by staff on dialysis days. RD stated prior to meeting with the resident on 4/12/23, she had assumed Resident 60 received dialysis bagged meals. RD stated the expectation was for the Certified Nursing Assistants (CNAs) to get the bagged meal from the Kitchen/Dietary Services Department, and then give it to residents who go offsite for dialysis treatments. RD stated he spoke with the Kitchen Supervisor and mentioned to the IDT last week to make sure Resident 60 got the dialysis bagged meal. RD stated bagged meals were provided to all residents on dialysis treatments offsite. During a review of the Registered Dietitian's (RD) Nutrition/Dietary Note, for Resident 60, dated 4/12/23, the note indicated, He [Resident 60] says he does not receive a bagged meal to take with him to dialysis and misses breakfast since he returns around 10 AM. Will notify nursing to get bagged meal from kitchen before pt [patient] leaves for dialysis and will add 10am nourishment for pt [patient]. During an interview on 4/20/23 at 7:48 PM, with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 60 was very alert and oriented. LVN 4 stated she had not given Resident 60 a bagged snack or meal during dialysis days. LVN 4 stated she had offered Resident 60 snacks before leaving for dialysis appointments, but the resident declined. LVN 4 stated she did not document the dates and times the resident refused or accepted snacks or meals prior leaving the facility for dialysis. During an interview on 4/20/23 at 8:08 PM, with Certified Nursing Assistant (CNA) 5, CNA 5 stated she had given Resident 60 some food to eat but not a bagged meal or snacks prior to dialysis appointments. CNA stated she did not document and did not recall the dates and times she had given Resident 60 with snacks before leaving for dialysis offsite and when the resident refused snacks. CNA 5 stated she had never gone down to the kitchen to get a bagged meal or snack for the resident. CNA 5 stated she did not have access to the kitchen and that the kitchen was closed at the time the resident leaves for dialysis. During a review of Resident 60's medical records, there was only one care plan meeting record, dated 1/16/23, which was participated and signed by the Interdisciplinary Team (IDT) members. The care plan meeting record had no information or recommendation by the IDT on how Resident 60 will be monitored and provided with meals or snacks including bagged meals on dialysis appointment days. Resident 23 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease. Resident 23's dialysis care plan indicated hemodialysis treatments at an offsite location, three times a week, at 1:30 PM to 4:30 PM. The care plan did not indicate the transport pick up time for the resident. During a review of the Resident 23's Nutrition/Dietary Notes, dated 2/24/23 and 4/7/23, the note indicated, dialysis and weight reviews were conducted by the Registered Dietitian (RD). There was no information or recommendation indicated in the RD notes if Resident 23 needed meals or snacks including a bagged meal to take with her on dialysis appointment days. During an interview on 4/19/23 at 1:06 PM, with Resident 23's nursing staff, the Licensed Psychiatric Technician (LPT) stated Resident 23 was picked up between 11:30 AM to 11:50 AM for transport to offsite dialysis three times a week. LPT stated Resident 23's daughter also went with the resident on her dialysis appointments. Lunch meals were typically served at the facility between 12 PM to 1 PM. During an interview on 4/19/23 at 9:40 AM, with Certified Nursing Assistant (CNA) 4, CNA 4 stated she offered snacks or bagged meals during dialysis days to Resident 23 and to Resident 23's daughter but both the resident and the resident's daughter declined. During an interview on 4/21/23 at 11:03 AM, with Resident 23's daughter, with Resident 23 present, in the resident's room, the resident's daughter stated she was not aware of a bagged meal or snacks given to her mother on dialysis days. The resident's daughter stated the staff asked her about a bagged meal or snacks for her mother only that day, 4/21/23. Resident 23 responded she was not given a bagged meal or snacks by staff on dialysis days, when asked by the daughter in her native language. Resident 23's daughter stated she preferred that a bagged meal be provided to her mother on dialysis days. During a review of Resident 23's medical records, there was only one care plan meeting record, dated 1/24/23, which was participated and signed by the Interdisciplinary Team (IDT) members. The care plan meeting record had no information or recommendation by the IDT on how Resident 23 will be monitored for and provided with meals or snacks including bagged meals on dialysis appointment days. During an interview and concurrent record review of Resident 60 and Resident 23's medical records, on 4/19/23 at 4:21 PM with the Director of Nursing (DON), DON explained that dialysis residents were offered and given nourishments or snacks by the nursing staff to take with them on dialysis appointments. DON stated the kitchen staff would prepare the bagged meals or snacks and the nursing staff were responsible to get them from the kitchen staff. When asked, DON stated she did not see information on the residents' records including the residents' dialysis binders wherein licensed nurses and certified nursing assistants offered and provided meals and snacks including bagged meals to Resident 60 and Resident 23 during dialysis days. DON stated she was not aware of dialysis residents not getting bagged meals or snacks. During an interview on 4/20/23 at 9:57 AM, with the Kitchen Supervisor (KS), KS stated he and another kitchen staff would prepare bagged meals or snacks for dialysis residents only when the nursing staff comes down to the kitchen and asked for it. KS stated for the month of April 2023, there was no nursing staff who asked him or the kitchen staff for a bagged meal or snack to be given to dialysis residents. KS stated he did not document dates and times a bagged meal or snack were picked up by nursing staff in the previous months. During an interview on 4/21/23 at 12:03 PM, with the Registered Dietitian, RD stated Resident 23 should receive a bagged meal on dialysis days. RD stated that to her knowledge, all dialysis residents should be getting a dialysis bagged meal prepared by the kitchen staff. During an interview on 4/21/23 at 12:45 PM, with DON, DON stated all dialysis residents should receive a bagged meal on dialysis days. DON stated the nurses were responsible to ensure dialysis residents have their bagged meals with them before leaving the facility for dialysis offsite. During a review of the facility's Policy and Procedures (P&P), titled, Care of a Resident with End-Stage Renal Disease, revision dated 9/2010, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . Policy Interpretation and Implementation - 1.Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: a. The nature and clinical management of ESRD (including . nutritional needs) . b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . 4. Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed, including: a. How the care plan will be developed and implemented .5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care . During a review of the facility's Policy and Procedures (P&P), titled, Care Planning - Interdisciplinary Team, revision dated 9/2013, the P&P indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; C. The Dietary Manager/Dietitian; d. The Social Services Worker responsible for the resident . g. Consultants (as appropriate); h. the Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident . 2. During a review of the Resident 60's Dialysis Care Plan, with date printed 4/19/23, the document did not indicate when the care plan was created. The care plan indicated, Focus - Resident has ESRD [End-Stage Renal Disease], dependence on hemodialysis . Interventions/Tasks . Coordinate meals, activities, medications and treatments with dialysis appointments . Position [Staff/Discipline Responsible] - RN [Registered Nurse], LVN [Licensed Vocational Nurse], LPN [Licensed Practical Nurse] . Frequency/Resolved - Blank . Schedule [for Offsite Dialysis] M-W-F Time: 5:45 AM . Pick Up [by Transportation]: 5:05 AM During a review of the Resident 23's Dialysis Care Plan, with date printed 4/19/23, the document did not indicate when the care plan was created. The care plan indicated, Focus - Resident has ESRD [End-Stage Renal Disease], dependence on hemodialysis . Interventions/Tasks . Coordinate meals, activities, medications and treatments with dialysis appointments . Position [Staff/Discipline Responsible] - RN [Registered Nurse], LVN [Licensed Vocational Nurse], LPN [Licensed Practical Nurse] . Frequency/Resolved - Blank . Schedule [for Offsite Dialysis] M-W-F . [Time] at 13:30 PM - 16:30 PM Time of Pick Up [by Transportation] - Blank . During an interview on 4/21/23 at 12:54 PM, with the Director of Nursing (DON), DON acknowledged there should be an IDT assessment and recommendation to monitor, document, and ensure meals or snacks including bagged meals were provided by nursing staff to all dialysis residents before going to dialysis appointments offsite. DON acknowledged Resident 60 and Resident 23's dialysis care plans were not specific, individualized and implemented by staff to reflect such practice, service, and care standards provided to dialysis residents. DON said, we'll [facility] tighten this process. During a review of the facility's Policy and Procedures (P&P), titled, Comprehensive Person-Centered Care Plans, revision dated 12/2016, the P&P indicated, A comprehensive, person-centered are plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation - 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The Attending Physician; b. A registered nurse . c. A nurse aid . d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative . and f. Other appropriate staff or professional . 7. The care planning process will . b. Include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing goals of care . 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. Describe services that would otherwise be provided above .g. Incorporate identified problem areas . j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care . o. Reflect currently recognized standards of practice for problem areas and conditions .9. Areas of concerns that are identified during the resident assessment will be evaluated before interventions are added to the care plan . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of relationship between the resident's problem areas and their causes, and relevant clinical decision making . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan .

Based on observation, interview, and record review, the facility failed to ensure policies and procedures regarding use and storage of foods brought to residents by family or visitors were implemented when: 1.The temperature inside the refrigerator designated for residents was at 43°F. This temperature was above the acceptable temperature range of 34°F to 38°F as indicated on the food refrigerator temperature log. 2.A food item found inside the refrigerator was not labeled with a resident name and room number. This failure had the potential to cause unsafe food storage, handling, and consumption of foods by residents. This failure could result in the resident not knowing and/or receiving foods brought in by their family or visitor if there was no name and/or identifying information. Findings: 1. During a concurrent observation and interview on 4/20/23 at 10:42 AM, with the licensed psychiatric technician (LPT) present, LPT checked the temperature inside the refrigerator designated for residents only located in Nursing Station 1. LPT read the thermometer and stated the temperature was at 43°F. LPT stated the temperature was out of range and should be within 34°F to 38°F as indicated on the Food Refrigerator Temperature Range log. 2. During a concurrent observation and interview on 4/20/23 at 10:44 AM, with Certified Nursing Assistant (CNA) 3 present, the same refrigerator was inspected. CNA 3 found a food item that was covered and tied close with a green plastic wrapper labeled use by 4/20/23, and today [sic] date 4/18/23. CNA 3 stated there was no name and room number indicated on the food item. CNA 3 stated the resident's name and room number should be included in the label. During a review of the facility's Policy and Procedures (P&P), titled, Food Receiving and Storage, revision dated 11/2022, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . Foods and Snacks Kept on Nursing Units - 1. All food items to be kept at or below 41°F are placed in the refrigerator located at the nurses' station and labeled with a use by date. 2. All foods belonging to residents are labeled with resident's name, the item and the use by date. 3. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1.Packaged food items were not sealed close or secured after opening, had no use by dates, and not stored properly 2.A pitcher was stored wet in the pitcher cupboard 3.Kitchen trays and plate covers or domes were not maintained in good condition 4.Food storage containers and equipment found in the kitchen were not kept clean 5.Kitchen staff did not wear a hairnet in the kitchen 6.Cooling procedures of potentially hazardous foods was not followed (PHF, food that requires time/temperature control for safety to limit the growth of pathogenic microorganisms [such as bacterial or viral organisms] that can cause foodborne illness. Examples of PHF include meat, poultry, chicken, seafood, milk, etc.) 7.Recipe for pureed food was not followed for a lunch menu item on 4/18/23 These deficient practices had the potential to put residents at risk for foodborne illnesses. Failure to ensure foods were correctly prepared may affect the quality and consistency of food provided to 16 residents who received pureed food from the kitchen. Findings: 1. During an initial kitchen tour observation and concurrent interview on 4/17/22, at 9:06 AM, with the kitchen supervisor (KS) present, KS confirmed and acknowledged the following findings: 1.1 A bag of frozen fish fillet, frozen cookies and frozen garlic bread sticks were opened, and not sealed close or secured 1.2 A packet of ground coffee beans was opened, and had no use by date 1.3 A container of bread crumbs was opened, had no use by date, and stored inside a kitchen drawer along with disposable paper cups, stacks of paper and a clipboard 1.4 A bag of corn flake crumbs was opened, not sealed close or secured, had no use by date, and stored inside a kitchen drawer along with disposable paper cups, stacks of paper and a clipboard 1.5 Two containers of sprinkles were opened and had no use by dates 1.6 One bottle of white cupcake topping was opened and had no use by date 1.7 One opened peanut butter jar was opened and had no use by date During an interview on 4/17/23 at 9:55 AM, KS stated the frozen bags of fish fillet, cookies, and garlic bread sticks were supposed to be sealed close or secured once opened. KS stated food items that were opened had to be labeled with use by dates, covered, and sealed close. KS explained the bread and corn flake crumbs were supposed to be stored in a designated location where the salt, sugar, and starch were stored. 2. During a concurrent observation and interview on 4/17/23 at 9:56 AM, in the kitchen, with KS, a pitcher was stored wet along with other clean, dry pitchers in the cupboard. KS stated the pitcher was clean and should be air dried before storage. During a review of the facility's policy and procedure (P&P) titled, Sanitization, revision dated 11/2022, the P&P indicated, .Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. 3. During a concurrent observation and interview on 4/17/23 at 10:22 AM, in the kitchen, with KS, 6 trays used to dry bowls had edges that were chipped, cracked, and open with metal exposed. There were also 12 cranberry-colored plate covers or domes on the drying rack with interior surfaces that were significantly worn out and faded in color. KS stated the trays and plate domes should no longer be used and had to be replaced. During a review of the facility's policy and procedure (P&P) titled, Sanitization, revision dated 11/2022, the P&P indicated, .All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use and proper cleaning . Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded . 4. During a concurrent observation and interview on 4/17/23 at 10:06 AM, in the kitchen, with KS present, KS acknowledged and confirmed the following findings: 4.1 There was a fan on the tile floor placed next to the side of the ice machine. The fan's wire guards had a thick accumulation of dust-like matter and debris. 4.2 A fan by the dishwashing area counter sink had wire guards that had dust-like material. KS stated the two fans were dirty and had to be cleaned. 4.3 The rails of the 4-shelf drying rack for plate covers or domes had orange-brown color residues. The racks were also sticky and had dust-like matter. KS stated the residue on the rails of the drying rack was rust. KS stated the drying rack had to be cleaned. 4.4 The scoop container for the rice bin located in the dry storage room had 2 packets of pepper and a brown-colored substance. 4.5 The scoop container for the flour bin located in the dry storage room had a packet of pepper and an accumulation of several clumps of dried flour. KS stated the scoop containers for the rice and flour bins had to be cleaned. During a review of the facility's policy and procedure (P&P) titled, Sanitization, revision dated 11/2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner . All kitchens, kitchen areas and dining areas are kept clean . All utensils, counters, shelves and equipment are kept clean . During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revision dated 11/2022, the P&P indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Non-refrigerated foods . are stored in a designated dry storage unit . and kept clean . 5.During a concurrent staff observation and interview on 4/18/23 at 9:37, in the kitchen, with KS present, a Kitchen Helper (KH) wore his own beanie (a round, brimless hat), in the kitchen. KS stated staff should wear a hairnet instead of their personal hat in the kitchen. KH stated he worked in the kitchen as a reliever cook and a kitchen helper in addition to performing dishwashing duties. KH stated he forgot to wear a hairnet. During a review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revision dated 11/2022, the P&P indicated, .Hair Nets - Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, lean equipment, utensils and linens . 6.During a concurrent interview and record review, on 4/19/23, at 8:34 AM, with the Kitchen Supervisor (KS), the Food Temperature Cooling Log, for period dated 3/3/23 through 4/13/23 was reviewed. The log indicated the following: At Time of Storage Date Food Item Time/Temp Time/Temp Time/Temp 3/5/23 Roast Beef 10AM, 160(°F) 11AM, 137(°F) 12PM, 98(°F) 3/19/23 Roast Beef 11AM, 161(°F) 12PM, 139(°F) 1PM, 99(°F) 3/27/23 Roast Beef 11AM, 161(°F) 12PM, 138(°F) 1PM, 98(°F) 4/4/23 Pork Loin 10AM, 161(°F) 11AM, 139(°F) 12PM, 99(°F) 4/8/23 Roast Beef 11AM, 160(°F) 12PM, 137(°F) 1PM, 99(°F) KS stated the food items above were not cooled to 70°F after 2 hours. When asked, KS stated he had no evidence that showed proper cooling of foods were followed by staff. KS stated it was important to follow rapid cooling procedures of potentially hazardous foods to prevent rapid growth of pathogenic microorganisms that cause foodborne illness. The Food Temperature Cooling Log, indicated, Cooling Time - 140°F to 70°F within 2 hours . If the hot food is not cooled to 70°F after 2 hours, discard or reheat to 165°F for fifteen seconds within two hours then repeat the cooling procedure. If the food does not reach 70°F after 2 hours again, it must be discarded . Reminder: Danger Zone is between 41°F to 140°F . Cooling tips: 1. remove food item from original container 2. cut in small pieces 3. drain off liquids, if appropriate 4. put in freezer, cover loosely 5. put in shallow pans 6. stir 7. use ice bath 8. Put on upper shelf . During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, revision dated 11/2022, the P&P indicated, .Rapid Cooling 1. Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135°F to 70°F within two hours . 2. Large or dense foods are cooled using special interventions in order to meet the time and temperature requirements for cooling. For example, roasts may be cut in smaller pieces; beans or legumes may be cooled in shallow pans or food containers may be placed in ice baths to expediate cooling . 7. During a review of the Facility Menu for Tuesday, 4/18/23, the lunch menu indicated, Arroz Con [NAME] (Chicken with Rice). During an observation of food production activities in the kitchen on 4/18/23 at 10:23 AM, with the Kitchen Supervisor (KS) present, the Kitchen [NAME] (KC) was observed on the preparation of the pureed recipe for the chicken with rice lunch menu item. KC used an orange-color handle spoodle [a serving utensil, equivalent to 8 ounces] and scooped three portions of diced, cooked chicken that included some cooking juices from a pan in a food processor. KC scooped two portions of cooked vegetables using a gray-color handle spoodle [equivalent to 4 ounces] and one spoon of food thickener using a disposable white plastic spoon into the mixture in the food processor. The mixture was processed continuously. When asked, KC stated she would stop processing the mixture when the texture was completely ground and had no more lumps. KC stated that when the texture was stiff, and not too liquidy or thick then the pureed texture was achieved. KC repeated the procedure five times and stated the completed pureed chicken with rice product was equivalent to 12 to 14 servings. KC stated the KS taught her how to prepare pureed food. During an interview on 4/18/23, at 11:43 AM, with KS, KS provided the surveyor a recipe titled, PUREED Fish/Meat/Poultry - 3oz, Recipe# P15. KS stated this was the recipe used to prepare for the pureed chicken with rice lunch menu item that day. Review of the recipe titled, PUREED Fish/Meat/Poultry - 3 oz, Recipe# P15, the recipe indicated, Ingredients - 15 oz, Meat Product, Cooked; 1 Cup Reserved Cooking Liquid or Broth, Hot; 1 ½ Tsp (teaspoon) Thickener . Diets - Appropriate for Puree . Number of Servings: 5 . Directions: 1. Remove required portion amounts from regular prepared recipe; place in food processor . NOTE: Remember to weight meat only; do not include cooking juices or gravy . Process until meat is smooth in consistency. Gradually add broth or gravy and thickener to meat while processing . Ensure mixture achieves smooth, lump free and extremely thick consistency . During a concurrent interview and record review of the recipe PUREED Fish/Meat/Poultry - 3 oz, Recipe# P15, on 4/19/21 at 8:45 AM, with KS stated the recipe was not followed by the KC during preparation of the pureed chicken with rice lunch menu yesterday. KS stated if the recipe was not followed, the quality, texture and consistency of the food may be affected. KS stated he provided training for the KC on pureed food preparation. During a concurrent interview and record review of the recipe PUREED Fish/Meat/Poultry - 3 oz, Recipe# P15, on 4/19/21 at 3:01 PM, with the Registered Dietitian (RD), RD stated the KC should have followed the recipe to prepare for pureed chicken with rice lunch menu yesterday. RD stated she would use 42 ounces of the cooked chicken for the recipe. RD stated she did not know how KC came up with 15 spoodles total of cooked chicken that was used for the pureed mixture. RD stated she would not add vegetables with the chicken in the food processor. RD stated not following the recipe may affect the quality of the pureed food served.

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed properly when: 1.The dumpster lids for garbage and recycled items were kept open 2.A facility staff did not close the dumpster lid after garbage bags were thrown into the garbage dumpster These failures could result in harborage and feeding of pests in the facility. Findings: 1. During a concurrent observation and interview on 4/18/23 at 9:51 AM, with the Kitchen Supervisor (KS) present, the dumpster site located in the garage area of the facility was inspected. The garbage dumpster lid was propped open by a wooden plank. The recycle dumpster lid was wide open. KS stated both dumpster lids for garbage and recyclables should be closed. KS stated housekeeping and kitchen staff use these dumpsters. KS stated the staff forgot to close the lids and KS closed both the dumpster lids. 2. During a concurrent observation and interview on 4/18/23 at 9:55 AM, with KS present, in the garage area, the Kitchen Helper (KH) disposed garbage bags into the garbage dumpster and left the dumpster lid open. When asked, KH stated he did not close the garbage dumpster lid and kept it open. KH stated the dumpster lid had to be closed to prevent pest infestation. During a review of the facility's Policy and Procedures (P&P), titled, Food-Related Garbage and Refuse Disposal, revision dated 10/2017, the P&P indicated, Food-related garbage and refuse are disposed of in accordance with current state laws . All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use . Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . Outside dumpsters provided by garbage pickup services will be kept closed and free from surrounding litter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure an allegation involving abuse was reported to appropriate authorities immediately but not later than 2 hours for 1 of 21 sampled residents (Resident 36). This failure had the potential to compromise protection of residents from abuse. Findings: Resident 36 was admitted on [DATE] with diagnoses that included intracerebral hemorrhage (bleeding inside the brain caused by a ruptured blood vessel), hemiplegia (paralysis on one side of the body) affecting left non-dominant side, contracture (tightening or shortening of a muscle or joint) on left hand, hypertension (high blood pressure), diabetes mellitus Type II (abnormal blood sugar levels), and depression. Review of Resident 36's Minimum Data Set (MDS, an assessment tool) dated 7/10/19, indicated a Brief Interview for Mental Status (BIMS, a brief scanner to detect cognitive impairment) score of 14, which indicated Resident 36 was cognitively intact. Under section G of the MDS, Resident 36's functional status indicated extensive assistance and two-person physical assist with most activities of daily living such as bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident 36's functional limitation in range of motion assessment indicated an impairment on one side of the upper extremity, and impairment on both sides of the lower extremity. During an observation and concurrent interview on 8/21/19 at 11:30 AM, Resident 36 was awake and lying in bed. Resident 36 was able to move his right arm, and no redness nor bruising was observed on the skin. Resident 36's left arm was observed to be flexed with a towel roll between the upper and lower arm. Resident 36's left arm and hand was resting on his left chest. During an observation with Registered Nurse (RN) 4 and concurrent interview on 8/21/19 at 11:34 AM, RN 4 assisted with checking Resident 36's left arm. Resident 36 started to talk and said, [staff name] pushed very hard on my left arm . I struggled and he started to fight back . Resident 36's left arm did not indicate any redness or bruising. RN 4 gently lifted and inspected the back side of Resident 36's left arm. There was no redness or bruising. Resident 36's left arm remained flexed with the forearm resting on his left chest. Resident 36 was unable to fully open his left hand which appeared to be contracted. Resident 36 said, I was paralyzed on this side. RN 4 asked Resident 36 if he felt safe, and Resident 36 replied he was scared of [staff name]. RN 4 asked the resident if he did not want [staff name] to help him, and Resident 36 said, never. RN 4 asked the resident, are you feeling safe here? Resident 36 said, no. RN 4 asked the resident, what did you want us to do? Resident 36 said, fire everyone else who's violent. RN 4 asked if he had any pain, Resident 36 stated, mental pain. During an interview with RN 4 on 8/21/19 at 11:58 AM, when asked if he had reported Resident 36's statements in the room earlier, he stated he had informed the DON about it. When asked if he had seen the alleged staff [name of staff], RN 4 stated, he's assigned 5B. During an interview with RN 4 on 8/21/19 at 1 PM, when asked if he had spoken to the DON, RN 4 said, DON reported it already .she said she know it already. During an interview with the DON on 8/21/19 at 1:10 PM, with RN 4 present, the surveyor asked RN 4 what he had reported to the DON earlier. RN 4 stated he reported that [alleged staff] was violent with the resident during diaper change. The DON stated she . will certainly investigate about it. During an interview with the DON on 8/22/19 at 9:25 AM, when asked about reporting timelines for the resident's allegation of abuse, the DON stated that if there's no injury [on the resident], it is reported within 24 hours, and if there's injury [on the resident], it is reported within 2 hours. The surveyor showed the DON, the facility's Policy and Procedure on Abuse Investigation and Reporting, which indicated, .Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment .will be reported by .to the following persons or agencies . 2. An alleged violation of abuse, neglect, exploitation or mistreatment . will be reported immediately but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . The DON stated she will call the administrator and clarify. During an interview on 8/23/19 at 10 AM, with RN 1, the staff responsible for the facility's training program related to abuse prevention, investigation and reporting procedures, she stated that an allegation of abuse should be reported as soon as possible, immediately. RN 1 showed the surveyor a 2-page document, CLTCOA (California Long-Term Care Ombudsman Association) Mandated Reporter diagram which illustrated timelines for reporting physical abuse and non-physical abuse. RN 1 stated these guidelines were posted at the nurses' stations. When asked about timeline for reporting an allegation of abuse, RN 1 stated within 2 hours, I have to follow this guideline. Review of facility document addressed to the state agency (CDPH) dated 8/22/19 indicated the facility sent a notification report of suspected dependent adult/elder abuse for Resident 36 on 8/22/19 at 12:28 PM. The notice was reported beyond the prescribed timeframe of 2 hours after the allegation of abuse was made. Review of facility document hand-written on a fax transmission sheet, indicated, Reported, Called San Francisco Police on 8/22/19 at 12:10 PM .Police arrived to the facility on 8/22/19 at 3:48 PM. The notice was reported beyond the prescribed timeframe of 2 hours after the allegation of abuse was made. Review of the facility policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated, As part of the resident abuse prevention, the administration will: . 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; . Review of the facility policy and procedure, titled, Abuse Investigation and Reporting, revised 7/2017, indicated, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment . shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment .will be reported by .to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment . will be reported immediately but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan that reflect the current needs, treatment, and services for one of 21 sampled residents (Resident 130) when the care plan for at risk for fall was not revised to address an actual fall incident. This failure had the potential to result in provision of inaccurate and inadequate care and services that may prevent Resident 130 from achieving and maintaining her highest practicable quality of life/level of functioning. Findings: During a review of the clinical record for Resident 130, the admission Record dated 8/23/19 indicated Resident 130 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, sprain of left ankle, and history of falling. During an observation and concurrent interview on 8/19/19 at 10:19 AM, Resident 130 was in bed, alert, and watching TV. Resident 130 stated, . I fell yesterday. It happened around 4:30 PM . I needed to use the bathroom . I used a walker . the nurse walked me to the bathroom. I told the nurse I'll go in by myself, just wait outside . I was there for about five to six minutes. I got up, had a grip on my walker, pushed against what I thought was a wall and it swung open and I fell. I didn't know it was a door . During an interview with Registered Nurse (RN) 2 on 8/20/19 at 2:23 PM, RN 2 verified Resident 130 had a fall incident at the facility on 8/18/19. In a concurrent review of the clinical record, Resident 130 had a care plan for . At risk for fall and/or injuries . initiated on 8/18/19 with .Goal . Resident will be free of falls through the review date . Target Date: 11/16/2019 . There was no care plan to address the actual fall incident that occurred on 8/18/19. RN 2 stated, .Care plan was not updated yet . I missed that . During an interview with the Director of Nursing (DON) on 8/23/19 at 11:09 AM, when asked about the facility's policy on care planning for a resident who had a fall incident, the DON stated, I believe that was something that was missed . We do the care plan as soon as practicable, the following day or the second day (referring to a fall incident). The DON also stated that the facility create a new care plan for the actual fall after a fall incident and that the care plan should reflect the current plan of care to address the needs of the resident. Review of the facility policy titled, Falls - Clinical Protocol revised on 3/18 indicated, . Cause Identification . 1. For an individual who has fallen, the staff and the practitioner will begin to try to identify possible causes within 24 hours of the fall . Review of the facility policy titled, Care Plans, Comprehensive Person-Centered revised on 12/16 indicated, . Policy Statement . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 14. The Interdisciplinary Team must review and update the care plan: b. When the desired outcome is not met .

Based on interview and record review, the facility failed to meet the proper transfer and discharge requirements for one of two sampled resident (Resident 61) when Resident 61 did not receive comprehensive care plan goals, the reason for the discharge written by the physician, all special instructions for ongoing care, and a discharge summary containing the required information, such as the resident's post-discharge plan of care and the reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). This deficient practice had the potential to result in a discontinuation of necessary care and services for Resident 61. Findings: A review of Resident 61's admission Records indicated Resident 61 was admitted to the facility, on 7/30/2019, with diagnoses that included cutaneous abscess of abdominal wall (a collection of pus that has built up on, or within, the exterior skin of the abdomen), chronic (long term) kidney disease, diabetes mellitus (a metabolic disorder characterized by high blood sugar levels over a prolonged period), chronic pain syndrome, and opioid abuse (addiction to pain relievers). Resident 61 was responsible for himself. During an interview with Resident 61, on 8/20/19, at 2:52 PM, he stated he was going to be discharged this week. Resident 61 denied receiving a discharge summary or a post-discharge plan of care. Resident 61 stated he was not asked to attend the interdisciplinary team (IDT) meeting to prepare him for discharge. During an interview with Resident 61, on 8/22/19, at 8:06 AM, Resident 61 stated his discharge was scheduled after lunch. Resident 61 stated he was still not asked to attend the interdisciplinary team (IDT) meeting to prepare him for discharge. When asked would he have attended the IDT meeting if he was asked, he answered yes. Resident 61 further stated the meeting would have given him the opportunity to speak with the health care team directly. During a record review and concurrent interview with Social Services Director (SSD), on 8/22/2019, at 11:05 AM, SSD stated the resident will be discharged , at 1 PM, today. SSD denied Resident 61 was provided a post-discharge plan of care, adding the post-discharge plan was in progress. SSD stated she spoke with the resident about the discharge plan without the presence of the other members of the IDT team (e.g. the physician and occupational therapy). SSD reviewed the Post-Discharge Plan of Care - Peninsula Region for Resident 61, dated 8/22/19, and SSD stated, This is the post-discharge plan . it is incomplete . SSD added multiple sections of the post-discharge plan of care, such as the medication section, were empty and unsigned. SSD denied the resident was invited to attend the interdisciplinary team meeting to develop the post-discharge plan of care. SSD acknowledged participating in the IDT meeting gives the resident the opportunity to discuss the resident's concerns and goals with the IDT members directly. SSD stated she was unaware if the discharge summary was given as the Medicare Coordinator (MC), gives the discharge summary to the resident. During an interview with MC, on 8/22/19, at 1:24 PM, MC stated Resident 61 was discharged from the facility without a completed post-discharge plan of care or a discharge summary. MC stated the discharge summary consists of a report from the physician, which was not completed. MC denied Resident 61 was invited to attend the IDT meeting to develop the post-discharge plan of care. During a concurrent record review and interview with Director of Medical Records (DMR), on 8/23/19, at 8:38 AM, DMR reviewed the discharge summary, titled: Physician Discharge Summary, dated 8/22/19, and stated the Physician Discharge Summary, was the discharge summary. DMR reviewed the Post-Discharge Plan of Care - Peninsula Region for Resident 61, dated 8/22/19, and stated the form was Locked (meaning completed and signed by the staff), on 8/22/19, at 3:56 PM, after the resident was discharged . During a record review and concurrent interview with Social Services Director (SSD), on 8/23/19, at 1:25 PM, SSD reviewed the Post-Discharge Plan of Care - Peninsula Region for Resident 61, dated 8/22/19, but could not find a signature indicating the resident received the information. SSD stated she confirmed with the resident his plan was to return home with home care, but SSD denied reviewing the final discharge plan. SSD added the resident did not receive the final post-discharge plan of care prior to discharge, as it was incomplete prior to discharge. SSD denied the resident was invited to participate in the post-discharge plan of care. Further review of the Physician Discharge Summary for Resident 61, dated 8/22/19, indicated a Provisional Diagnosis: Abdominal Wall Abscess. Final Diagnosis: Same, without any additional diagnoses or information. The Pertinent Physical and Laboratory Findings section, had no documentation of pertinent labs related to his medical conditions. For example, the resident had surgery for an abdominal abscess and had a medical diagnoses of chronic kidney failure diabetes, but there weren't laboratory results included to reflect the status of his wound care (if the surgery site was infected or not), his diabetes management or his kidney function. The Course of Treatment section indicated Wound care, Maintenance Medications, and Drug counseling, without additional information. The Condition on Discharge section, indicated, Improved, and the Rehabilitation Potential indicated, Good, but there were no additional details provided. There was no documentation of the course of treatment for his wound care, physical therapy or occupational therapy, Maintenance medications, or drug counseling. The Follow-Up and Discharge Medication Instructions listed to follow up with staff at an outside agency without providing when and who to follow up with. The discharge summary had no documentation of a reconciliation of all pre-discharge medications with the resident's post-discharge medications, the resident's mental and psychosocial status, his dental condition, or his nutritional status. A review of the Progress Notes for Resident 61, indicated the SSD confirmed the discharge plan with the resident, on 8/22/19, at 18:32 (less than 24-hours before discharge). The progress note, dated 8/22/19, indicated MC reviewed the resident's medications; there was no documentation the post-discharge plan of care or discharge summary was given, and the reconciliation of all pre-discharge medications with the resident's post-discharge medications was completed. A review of the facility policy and procedure titled: Discharge Summary and Plan, revised December 2016, indicated the discharge summary and post-discharge will be developed to assist the resident to adjust to his/her new environment. The policy and procedure added the discharge summary will include a recapitulation of the resident's stay at this facility . in accordance with established regulations ., as well as the resident's current laboratory [test results] . Nutritional status and requirements: (1) weight and height (2) Nutritional intake; (3) eating habits Mental and psychosocial status . dental condition . The policy and procedure further indicated developing the post-discharge plan of care involves the participation of the resident and the Care Planning/interdisciplinary Team. Per the policy and procedure, A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure specialized rehabilitative service was provided for 1 of 21 sampled residents (Resident 67), when Resident 67 did not receive physical therapy (PT) on 8/13/19. This failure had the potential for residents to not attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being. Findings: Resident 67 was admitted on [DATE] with diagnoses that included cellulitis (bacterial skin infection) of right lower limb, muscle weakness, hypertension (high blood pressure), and obstructive sleep apnea (a condition in which the throat muscles relax causing airflow blockage during sleep). During an observation on 8/19/19 at 9:55 AM and concurrent interview, Resident 67 was lying in bed, awake, and wearing a mask attached to a CPAP (continuous positive airway pressure) machine (device used for treatment of obstructive sleep apnea). Resident 67 stated he had been at the facility for a couple of weeks, finished course of antibiotics and required to stay until able to transfer [by himself] . When asked about his rehabilitation services, Resident 67 said, .Been only to the gym once .Shifting appointment times around .Don't they want me down in the gym? . What's happening lately, it's not working, I want to get home .Had to perform my requirements for rehab, stand, pivot and transfer, they don't give me practice to help me with that. Review of the Minimum Data Set (MDS, an assessment tool) dated 8/6/19, indicated Resident 67's functional status required extensive assist to full dependence on staff with performance of activities of daily living. Resident 67's range of motion indicated impairment on both upper and lower extremities. Resident 67's special treatment, procedure and program information indicated physical therapy. Review of Resident 67's Physician's Order dated 8/1/19, indicated, PT Clarification: Skilled PT 5x/wk, 4wks . Review of Resident 67's Care Plan, indicated, Focus- PT: Resident with potential for impaired functional mobility, date initiated 08/01/19, Goal: Resident will demonstrate sit to stand . Interventions/Tasks: PT 5x/week, 4 weeks .Position: PT . During an interview on 8/21/19 at 11 AM with Physical Therapist (PT) 1, she stated that Resident 67 was ordered physical therapy 5 times a week. PT 1 stated sessions were typically scheduled Monday through Friday. PT 1 stated that if sessions were missed, they make up on weekends. PT 1 stated the sessions with the resident and the family were between 1:30 PM to 3:30 PM time frame based on the family's preference. When asked how the location of sessions were considered for Resident 67, PT 1 stated this was based on clinical decision of therapist that day depending on goals, e.g., scoot, transfer in room, parallel bars - gym . During an interview on 8/21/19 at 11:16 AM with Resident 67's physical therapy, PT 2 stated, His [resident] main goal is standing. He wants to use parallel bars. We've been bringing him down here . PT 2 further stated the resident's caregiver was aware as to where the sessions were held. Review of Physical Therapy Treatment Encounter Notes from 8/1/19 through 8/20/19 indicated Resident 67's sessions were often held at the facility's gym. Review of Physical Therapy Treatment Encounter Notes for Week of 8/1/19, indicated services were completed on 8/1/19 and 8/2/19. Review of Physical Therapy Treatment Encounter Notes for Week of 8/5/19, indicated services were completed on 8/5/19, 8/6/19, 8/7/19, 8/8/19 and 8/9/19. Review of Physical Therapy Treatment Encounter Notes for Week of 8/12/19, indicated services were completed on 8/12/19, 8/14/19, 8/15/19, and 8/16/19. There was no evidence physical therapy was provided to Resident 67 on 8/13/19. During a record review of Resident 67's Physical Therapy Treatment Encounter Notes from 8/1/19 through 8/20/19, and concurrent interview with PT 1, on 8/22/19 at 10 AM, when asked why the resident missed a session on 8/13/19, she said can't recall on top of my head .will look at specifics and let you know . During an interview with PT 1 on 8/22/19 at 2:01 PM, when asked about the policy for missed therapy sessions, she said, for a missed session, we defer to clinician's judgment if make up session is required. When the surveyor clarified Resident 67's physician's order for physical therapy, PT 1 confirmed 5 times a week. When asked if she can override the physician's order, PT 1 stated we follow a physician's order. During a follow-up interview with PT 1 on 8/22/19 at 4:12 PM, she stated, the therapist is no longer with us so I don't know why that session was missed. It was a missed visit. When asked who was responsible for scheduling, PT 1 stated it was her. When asked how the incident was overlooked, PT 1 stated I don't recall anyone tell me that was missed . They have to let me know . I have no explanation as to why it was missed. PT 1 confirmed Resident 67 was not seen on 8/13/19, and stated the session should have been done. Review of the facility policy and procedure titled, Specialized Rehabilitative Services, revision dated 12/2009, indicated, .Our facility will provide Rehabilitative Services to residents as indicated by the MDS . 1.the facility provides Specialized Rehabilitative Services by qualified professional personnel. 2. Specialized Rehabilitative Services include the following: a. Physical Therapy . 3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a complete and accurate notice before discharge in writing to the resident and the Office of the State Long-Term Care Ombudsman (Office of the State LTC Ombudsman) for two of two sampled residents (Resident 61 and Resident 81). In addition, the facility did not store the written notice in the medical record of Resident 61 and Resident 81. This deficient practice had the potential to result in an unsafe discharge for Resident 61 and Resident 81. Findings: 1. A review of Resident 61's admission Records indicated Resident 61 was admitted to the facility, on 7/30/2019, with diagnoses that included cutaneous abscess of abdominal wall (a collection of pus that has built up on, or within, the exterior skin of the abdomen), chronic (long term) pain syndrome, and chronic kidney disease. Resident 61 was responsible for himself. During an interview with Resident 61, on 8/20/19, at 2:52 PM, he stated he was going to be discharged this week. Resident 61 denied receiving a written notification of his discharge with the reason for his discharge and how to appeal his discharge. When asked if he received any written document with the reason for his discharge, or how to appeal his discharge, Resident 61 replied he .was not given a reason for the discharge other than my insurance coverage was ending, and he .did not receive a form to appeal this decision [for discharge]. Resident 61 stated he received a form yesterday (8/19/19) indicating his insurance coverage ends. During an interview with Resident 61, on 8/22/19, at 8:06 AM, Resident 61 stated his discharge was scheduled after lunch. Resident 61 denied receiving a written notification of his discharge or the post-discharge plan of care. During a record review and concurrent interview with Social Services Director (SSD), on 8/22/19, at 11:05 AM, SSD stated the resident will be discharged , at 1 PM, today. SSD reviewed the Post-Discharge Plan of Care - Peninsula Region for Resident 61, dated 8/22/19, and stated, This is the post-discharge plan. It is incomplete. SSD added multiple sections of the post-discharge plan of care were blank and unsigned. During an interview with Medicare Coordinator (MC), on 8/22/19, at 12:36 PM, MC stated she did not give the resident the 30-day notice, which consisted of the reason for the discharge and the other components of the written notice. MC stated she was unaware of a written notice given. MC stated she gave the resident a different written notification involving his insurance benefits ending. During an interview with MC, on 8/22/19, at 1:24 PM, MC stated Resident 61 was discharged from the facility without a completed post-discharge plan of care. During an interview with Director of Medical Records (DMR), on 8/23/19, at 8:55 AM, DMR was unable to find the written notice of discharge in the resident's medical record. DMR stated the Admission's office stored the written notice before discharge with the admission paperwork. During a concurrent record review and interview with Admissions Coordinator (AC), on 8/23/19, at 12:58 PM, AC stated the written notice of discharge was stored in the admission's office, not in the resident's medical record. When asked how residents receive written notification of their discharge, AC stated the document titled: Notice of Proposed Transfer/Discharge, for Resident 61, dated 7/31/19, was the written notice. AC added the resident received the written notice upon admission. AC added he was given the Notice of Proposed Transfer/Discharge, upon admission, but the resident refused to sign the admission packet. No documentation of the resident's refusal noted on the Notice of Proposed Transfer/Discharge. Per AC, the written notice before discharge was calculated by adding 30 days to the resident's admission date, and the written notice's discharge date of 8/30/19 was not accurate, as the discharge occurred on 8/22/19. AC stated written notice did not include a reason for the discharge, or the email address for the Office of the State LTC Ombudsman, which was required. AC denied the Notice of Proposed Transfer/Discharge was updated and given to the resident prior to discharge. AC was unable to provide an updated written notification of discharge. AC stated the social worker sends the copy of the written notice to the Office of the State LTC Ombudsman. During an interview with Social Services Director (SSD), on 8/23/19, at 1:07 PM, SSD stated Admissions office gives the notice to the resident upon admission and stores it in the Admissions office. SSD added she (SSD) was responsible for sending resident discharge and transfer information to Office of the State LTC Ombudsman, not admissions. When asked for what she had been sending to the Office of the State LTC Ombudsman, SSD was unable to provide the information at that time. During a record review and interview with Social Services Director (SSD), on 8/23/19, at 1:25 PM, SSD stated she sends the Office of the State LTC Ombudsman the resident's post-discharge plan. SSD reviewed the Post-Discharge Plan of Care - Peninsula Region for Resident 61, dated 8/22/19, but could not find a signature indicating the resident received the information. SSD stated the resident did not receive the Post-Discharge Plan of Care, prior to discharge, as it was incomplete prior to discharge. SSD reviewed and denied the Office of the State LTC Ombudsman had received, or was going to receive, the Notice of Proposed Transfer/Discharge. SSD acknowledged the Notice of Proposed Transfer/Discharge for Resident 61 did not give the reason for discharge, and the discharge date did not reflect the actual date of the resident's discharge. SSD acknowledged the Office of the State LTC Ombudsman's email was not recorded. SSD stated she could not provide documentation the Notice of Proposed Transfer/Discharge for Resident 61 was updated to include accurate and complete information. A review of the facility policy and procedure titled: Transfer and Discharge Documentation, revised December 2016, indicated the medical record will contain documentation of the details, including the reason for discharge and the date and time of the discharge. The facility policy and procedure did not include the Office of the State LTC Ombudsman, or the entity who receives appeal rights requests. 2. A review of Resident 81's admission Records indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease. Resident 81 did not have a decision maker. During an interview with Director of Medical Records (DMR), on 8/23/19, at 8:55 PM, DMR stated she was unable to find the written notice before discharge in Resident 81's medical record. DMR stated the Admission's office stored the written notice before discharge with the admission paperwork. During a concurrent record review and interview with Admissions Coordinator (AC), on 8/23/19, at 12:58 PM, AC stated the written notice of discharge was stored in the admission's office, not in the resident's medical record. When asked how residents receive written notification of their discharge, AC stated the document titled: Notice of Proposed Transfer/Discharge, for Resident 81, dated 4/20/19, was the written notice. AC added the resident received the written notice upon admission. Per AC, the written notice before discharge was calculated by adding 30 days to the resident's admission date, and the written notice's discharge date of 5/21/19 was not accurate, as the discharge occurred on 5/29/19. AC stated written notice did not include a reason for the discharge, or the email address for the Office of the State LTC Ombudsman, which was required. AC denied the Notice of Proposed Transfer/Discharge was updated and given to the resident prior to discharge. AC was unable to provide an updated written notification of discharge. AC stated SSD was responsible for sending the copy of the written notice to the Office of the State LTC Ombudsman. During an interview with Social Services Director (SSD), on 8/23/19, at 1:07 PM, SSD stated admissions gave the notice to the resident upon admission and stored it in the Admissions office. SSD added she (SSD) was responsible for sending resident discharge and transfer information to Office of the State LTC Ombudsman, not admissions. When asked for what she had been sending to the Office of the State LTC Ombudsman, SSD was unable to provide the information at that time. During a record review and concurrent interview with SSD, on 8/23/19, at 1:25 PM, SSD stated she sent the Office of the State LTC Ombudsman the resident's post-discharge plan. SSD reviewed the Post-Discharge Plan of Care - V 2 for Resident 81, dated 5/29/19. SSD reviewed and acknowledged the Notice of Proposed Transfer/Discharge, dated 4/20/19, did not give the reason for discharge or the Office of the State LTC Ombudsman's email address. SSD added the discharge date written on the Notice of Proposed Transfer/Discharge, 5/21/19, was inaccurate, as it did not reflect the actual date of the resident's discharge, on 5/29/19. SSD denied the Office of the State LTC Ombudsman had received the resident's Notice of Proposed Transfer/Discharge. SSD stated she could not provide an updated version of the Notice of Proposed Transfer/Discharge for Resident 81 was updated to include accurate and complete information. Further review of the Post-Discharge Plan of Care - V 2 for Resident 81, dated 5/29/19, indicated no documentation of the reason for discharge was written and agreed to by the resident's physician, or signature from the resident on the form indicating they received the information prior to discharge; additionally, there was no documentation of the Office of the State LTC Ombudsman's email, the contact information of the entity which receives the appeals right requests, including their name, address (mailing and email) and telephone number, or the information on the resident's appeal rights, such as how to obtain and submit an appeal form, and how to receive assistance with completing the appeal. A review of the facility policy and procedure titled: Transfer and Discharge Documentation, revised December 2016, indicated the medical record will contain documentation of the details, including the reason for discharge and the date and time of the discharge. The facility policy and procedure did not include the Office of the State LTC Ombudsman, or the entity who receives appeal rights requests.

Based on meal plating observation, interview, and record review, the facility failed to accommodate the food preferences of six of 81 residents (Residents 28, 55, 78, 69, 74, and 36) during meal distribution. This failure had the potential for loss of appetite which may lead to decreased food intake and could potentially cause unintentional weight loss to the residents who receive food from the facility kitchen. Findings: During tray line (a cafeteria-style of food distribution) observation and concurrent interview on 8/21/19 beginning at 12 PM, Kitchen Staff (KS) 1 began plating meals for multiple residents. The plated meals were placed on the trays inside the food delivery cart by KS 2. KS 3 stated the meals were ready for distribution to the residents. During observation with the Dietary Supervisor (DS), on 8/21/19 at 12:14 PM, of the contents of the trays in the food delivery carts ready for distribution to the residents, showed each tray inside the food delivery carts included the plated meal and an undated diet card (a printed copy of the resident's physician prescribed diet order, and a list of allergies, food preferences, etc) for each resident. Concurrent review of the diet cards with the plated meals showed the following: - For Resident 28, it indicated, . Lunch . Standing Orders .1 Each Boiled Egg . Chicken [NAME] Soup . There was no boiled egg and chicken rice soup included in the meal for Resident 28; - For Resident 55, it indicated, . Lunch . Standing Orders . 1/2 (half) Sandwich . Ham and cheese . There was no ham and cheese sandwich included in the meal for Resident 55; - For Resident 78, the diet card indicated, . Lunch . Notes: Resident request mashed potatoes with gravy . Standing Orders . 2 fl (fluid) oz (ounces) Gravy (Extra) . 1/2 cup Mashed Potatoes& Gravy . There were no mashed potatoes and gravy included in the meal for Resident 78; - For Resident 69, the diet card indicated, Lunch . Standing Orders .Ham Sandwich (Mo [Monday], We [Wednesday], Fr [Friday]) . There was no ham sandwich included in the meal for Resident 69; - For Resident 74, the diet card indicated, . Lunch . Standing Orders . Mashed Potatoes (w/ [with] extra gravy . There were no mashed potatoes and extra gravy included in the meal for Resident 74; and - For Resident 36, the diet card indicated, . Lunch . Standing Orders: . Fresh Fruit and Cottage Cheese Plate . Grilled Ham and Chse [cheese] Snd [sandwich] (Mo, We, Fr) . There were no cottage cheese, and no grilled ham and cheese sandwich included in the meal for Resident 36. During concurrent interview, the DS verified the above observations. During an interview with KS 1 on 8/21/19 at 12:52 PM, KS 1 stated, . Residents will not receive nutrients needed . if the meal tray contents are not accurate. During an interview with the DS on 8/21/19 at 1:17 PM, when asked about the missing items on the meal trays of the residents, the DS stated, residents will complain . (Residents) will receive inadequate nutrients . and may affect the residents . During an interview with the Registered Dietitian (RD) on 8/23/19 at 10:44 AM, the RD stated that the Standing Orders written on the diet cards refer to the food preferences of the resident. The RD also stated that if the resident's food preferences were not accommodated, that could potentially lead to weight loss of the resident. Review of the facility policy titled, therapeutic Diets revised on 10/17 indicated, . Policy Interpretation and Implementation . 1. Diet will be determined in accordance with the resident's . preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to distribute meals in accordance with the physician ordered therapeutic diet for one of 67 residents (Residents 78) when Resident 78 was plated with a whole cheeseburger sandwich during lunch meal distribution. Failure to follow physician ordered diets may further compromise the medical status of residents which may lead to unnecessary hospitalizations, and in severe instances may result in death. Findings: During a review of the clinical record for Resident 78, the admission Record indicated Resident 78 was admitted on [DATE]. The Order Summary Report dated 8/1/19, indicated, . Dietary -Diet . Mechanical Soft (a diet that is easy to chew and easy to swallow, and includes foods that readily break apart without a knife) with chopped meat texture . Start date 07/12/2019 . The . Speech Therapy . Evaluation and Plan of Treatment . Start of Care: 7/11/19 . Precautions: Diet: . m/s (mechanical soft) chopped . Patient Goals: . slow rate of feeding, small bite size .during PO (oral) intake . During tray line (a cafeteria-style of food distribution) observation on 8/21/19 beginning at 12 PM, Kitchen Staff (KS) 1 began plating meals for multiple residents. The plated meals were placed on the trays inside the food delivery cart by KS 2, including the plated meal for Resident 78. During an interview and concurrent observation on 8/21/19 at 12:23 PM, KS 3 stated the meals were ready for distribution to the residents. The tray for Resident 78 included the plated meal and a diet card (a printed copy of the resident's physician prescribed diet order, and a list of allergies, food preferences, etc). The diet card for Resident 78 indicated, .Texture: Mechanical Soft/chopped meats . Standing Orders: 1 Each Cheeseburger on Bun . The plated cheeseburger was not chopped. The DS verified the observation. During an interview with KS 1 on 8/21/19 at 12:52 PM, KS 1 stated, . Not good for the resident . if Resident 78 was served and ate the incorrect texture of food. During an interview with the Registered Dietitian (RD) on 8/23/19 at 10:44 AM, the RD stated, . there could be possible consequences to the patients . if the physician prescribed diet was not followed. Review of the facility policy and procedure titled, Therapeutic Diets, revised on 12/17 indicated, . Policy Statement . Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences . Policy Interpretation and Implementation 1. Diet will be determines in accordance with the resident's informed choices, preferences, treatment goals and wishes .

Based on observation, interview, and record review, the facility failed to display the total and actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) each shift, and the actual hours worked by the Certified Nursing Assistants (CNAs) each shift. This deficient practice had the potential to misinform residents and visitors on the facility's staffing levels, and the deficient practice had the potential to lead to inadequate RN, LVN, and CNA staffing levels. Findings: During an initial tour observation, on 8/19/19, at 8:36 AM, a double-sided sheet of paper titled: Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 8/19/19, was displayed in the bulletin board and at the reception desk. The DHPPD, and other posted information, did not contain the total and actual hours worked by RNs and LVNs each shift, or the actual hours worked by the CNAs each shift. During an observation, record review, and interview with the Admissions Coordinator (AC), on 8/20/19, at 9:06 AM, AC found staffing information in the bulletin board, and on the front lobby reception desk and on the nursing station desk. AC reviewed the DHPPD, dated 8/20/19, and a document titled: [Facility Name] AM shift, dated 8/20/19, attached to a face-down wooden clip board on nursing station's desk. AC stated none of staffing information displayed the total or actual hours worked by the LVNs or RNs each shift, or the actual CNAs hours worked each shift. During an observation and interview with the Unit Manager 1 (UM 1), on 8/20/19, at 9:10 AM, UM 1 found staffing information in the bulletin board, on the desks at the front lobby reception area and at both nursing stations: Unit 1 and Unit 2. UM reviewed the DHPPD, dated 8/20/19, and the [Facility Name] AM shift, dated 8/20/19. UM stated there was posted information on the total or actual staffing hours worked by the LVNs or RNs on each shift, or the actual hours worked by CNAs on each shift. During an interview and record review with the Medicare Coordinator (MC), on 8/20/19, at 9:14 AM, MC referred to document titled: [Facility Name] AM shift, dated 8/20/19, as a nursing assignment sheet. MC reviewed that morning shift's nursing assignment sheet, for both units, and a collection of both unit's nursing assignment sheets for different days and shifts. MC reviewed the DHPPD and stated the DHPPD reported the actual hours worked by a CNA for a 24-hour period, not for each shift in the 24-hour period. When asked if the facility posted the actual and total LVN and RN hours on a daily basis per each shift, and the actual hours worked by the CNAs for each shift on a daily basis, MC stated, No. During a record review and interview with the Director of Nursing (DON), on 8/20/19, at 9:20 AM, DON reviewed records of DHPPD, between 8/18/19 and 8/20/19, and the [Facility Name] AM shift sheets for both nursing stations, dated 8/20/19, and could not provide the total and actual hours worked by the LVNs or RNs hours on a daily basis per shift. DON stated, We don't record those hours [the total and actual LVN or RN hours worked each shift and the actual CNA hours worked each shift], adding the hours were to display in order to inform the residents and visitors of the staffing levels. During an observation, interview, and record review with Administrator (Admin), on 8/20/19, at 9:35 AM, Admin located and reviewed the staffing information posted, but could not provide additional staffing information posted. Admin then stated, We didn't post it [the total and actual hours worked by RNs and LVNs on a daily basis for each shift, or the actual hours worked by the CNAs on a daily basis for each shift] . We'll add them. A review of the policy and procedure titled: Posting direct care daily staffing numbers, revised July 2016, indicated, Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . Within two (2) hours of the beginning of each shift, the number of licensed nurses (RN, LPNs [Licensed Practical Nurses], and LVNs) and the total number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to store foods in accordance with accepted professional standards of practice when: 1. Five cartons of Glucerna Therapeutic Nutrition (medical nutritional beverages meant for people with diabetes) were stored beyond expiration date; and 2. One opened container of Parsley Flakes was undated. This deficient practice may put the residents at risk for food borne illnesses, and may affect the appetite of the residents due to loss of potency and flavor of expired seasonings. Findings: 1. During an observation of the kitchen and concurrent interview with the Dietary Supervisor (DS) on 8/19/19 at 9:30 AM, there were five cartons of Glucerna Therapeutic Nutrition with expiration date of 7/1/19 stored in the kitchen cabinet. The DS stated, . They (referring to kitchen staff) have to throw it away . if given to patients, they're gonna affect the resident . 2. During an observation of the kitchen and concurrent interview with the DS on 8/19/19 at 9:12 AM, there was one unlabeled opened container of parsley flakes stored in the kitchen cabinet. The DS stated if opened food items were unlabeled, . We will not know how long they're good for . maybe they (referring to the kitchen staff) forgot to label it . During a review of the policy provided by the facility (when requested for a policy on labeling of opened containers of food items), titled, Food Receiving and Storage, revised on 12/17, it did not address labeling of opened containers of food items stored in their original packaging. During an interview with the Registered Dietitian (RD) and concurrent review of the facility titled, Food Receiving and Storage, revised on 12/17, on 8/23/19 at 10:44 AM, the RD stated, . Expired food items must be disposed on the day of (referring to the expiration date) . The RD also stated that expired food items should not be stored beyond expiration date and should not be available for use by the kitchen staff. The RD acknowledged that the policy mentioned above did not indicated specific guideline on disposal of expired food items.

Based on observation, interview and record review, the facility failed to provide the required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care, and may impact their quality of life. Findings: During the entrance conference interview and record review with the Administrator (Admin), on 8/19/19, at 8:40 AM, Admin stated and presented the written room waiver request for resident rooms one through six, eight through 12, and rooms 14 - 35. During the initial tour observation, on 8/19/19, at 9:03 AM, there were more than one resident in all of the resident rooms noted on the room waiver request. Residents in the aforementioned rooms were observed and interviewed by members of the survey team and the residents had no concerns about the quality of life, quality of care, and safety related to the room size. During a concurrent interview and record review with Admin, on 8/23/19, at 11:56 AM, Admin presented and submitted the Client Accommodation Analysis, dated 8/23/19, indicating more than one resident was in the following resident rooms: Room # # of Occupants Space per Resident 1 2 74.27 2 3 74.27 3 2 75.25 4 3 74.27 5 2 76.58 6 3 72.26 8 3 77.19 9 3 74.80 11 3 74.53 12 3 76.13 14 2 76.22 15 2 77.59 16 2 73.61 17 2 76.13 18 3 76.13 19 2 76.13 20 2 77.90 21 3 76.13 22 3 76.13 23 3 76.13 24 3 79.32 25 3 73.66 26 2 76.39 27 3 73.12 28 3 78.36 29 3 73.12 30 2 73.12 31 3 74.00 32 2 75.37 33 2 75.93 34 2 75.93 35 2 75.93