**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) alternative (call bell) is available for one of three residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for toileting and activities of daily livingDuring a concurrent observation and interview on 8/15/25 at 11:35 a.m., in Resident 1's room. Resident 1 was lying in her bed. There was an overbed table next to her bed and there was no alternative for the call light. Resident 1 stated the call light is not working for two weeks now. Resident 1 stated she doesn't have the call bells. Resident 1 further stated it's okay to ask the staff to check if she has a call bell at bedside. Resident 1 stated she has to call the front desk for help, and it takes time.During a concurrent observation and interview on 8/15/25 at 11:40 a.m., in Resident 1's room with the Treatment Nurse (TN), the TN searched Resident 1's overbed table, drawers, and bedside for a call bell. The TN confirmed there was no call bell for Resident 1. The TN further stated Resident 1 should have a call bell next to her [resident] until they fixed the call lights. The TN confirmed the call lights were not working in Resident 1's room.During a review of Resident 1's admission record on 8/15/2025, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (Hemiplegia and hemiparesis both refer to weakness or paralysis on one side of the body, but they differ in severity. Hemiplegia is a more severe form, characterized by a complete loss of strength or paralysis, while hemiparesis is a weakness or partial loss of strength on one side).During a review of Resident 1's Brief Interview for Mental Status dated 6/25/25 BIMS score is 15 [BIMS, a tool used to assess cognition (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact)]During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Functional Abilities, dated 6/25/25, indicated Resident 1 was Setup or cleaning up assistance with eating, Supervision or touching assistance with oral hygiene, dependent with toileting hygiene and shower/bathing self, substantial/maximal assistance with upper body dressing, dependent with lower body dressing, dependent with putting on/taking off footwear, and partial/moderate assistance with personal hygiene. A further review of Resident 1's MDS Functional Abilities indicated Resident 1 was partial/moderate assistance with rolling left and right and sit to lying, substantial/maximal assistance with lying to sitting on side of bed, dependent with sit to stand and chair/bed-to-chair transfer.During an interview on 8/15/25 at 1:17 p.m., with the Director of Nursing (DON), the DON stated in July 2025 they provided bells to all residents in station AA. The DON stated she expected them [residents] to have a bell at bedside. During a review of the facility's policy and procedures (P&P) titled, Answering the Call Light, revised date 9/ 2022, indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.During a review of the facility's (P&P) titled, Accommodation of Needs, revised date 3/2021, indicated, .2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated and upon admission and reviewed on an ongoing basis. 3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received therapy services as ordered by a physician.The failure decreased the facility's potential to ensure Resident 2 reached his highest rehabilitation potential. During an interview on 7/18/25 at 12:49p.m., with Resident 2, he stated issue with the manpower in therapy, they are skipping on therapy to 4x a week and then until 3x a week. Resident 2 stated the staff said they don't have enough staff in therapy when he spoke to one of the therapists. Resident 2 stated the therapy is helping with self-care and he needed more therapy, and he ran out of Medicare (a health insurance program) days.During a review of Resident 2's admission record on 7/18/2025, dated 5/29/2025 indicated Resident 2 was admitted to the facility with diagnosis including muscle weakness.During a review of Resident 2' s physician's order indicated an order dated 5/30/25 Occupational Therapy clarification: skilled OT (occupational therapy- a therapy aimed at helping individuals perform daily activities and improve functional independence) 5x/week, 8 weeks may include 97166 OT mod complex (moderate complexity needs) 97530 ther act (Therapeutic activities), 97535 self care mgmt. (Management)., 97533 sensory.During a review of Resident 2's Brief Interview for Mental Status (BIMS, a short performance-based cognitive screener for nursing home (NH) residents.), dated 6/5/25 BIMS is 14 (the range of 13-15, which suggests that the person is cognitively intact.)During a review of Resident 2's Occupational Therapy (OT) notes are as follows:Date of Service (DOS), DOS 7/8/25 to 7/14/25-7/14/25-7/11/25-7/10/25-7/8/25 DOS 6/27/25 to 7/3/25 -7/3/25-7/2/25-7/1/25-6/28/25 DOS 6/20/25 to 6/26/2025 -6/26/25-6/25/25-6/24/25-6/23/25DOS 6/13/25 to 6/19/25-6/19/25-6/18/25-6/13/25DOS 6/6/25 to 6/12/25-6/12/25-6/11/25-6/10/25-6/9/25 DOS 5/30/25 to 6/5/25-6/5/25-6/4/25-6/3/25-5/30/25Indicated Resident 2 received OT 4x a week on 5 occasions and 3x a week on 1 occasion.During an interview on 7/18/25 at 1:27 p.m., with the Assistant Director of Rehab (ADOR), the ADOR stated if the order for OT is 5x a week they [resident] will receive 5x a week of therapy. During a concurrent interview and record review on 8/15/25 at 11:48 a.m., with the Director of Rehab (DOR), the DOR reviewed Resident 2's Occupational Therapy notes and confirmed the following date of service (DOS ) is missing, DOS 5/30/35 to 6/6/25, 4 times seen missing 6/2/25 unavailable, DOS 6/6/5 to 6/12/25 missing 6/6/25 unavailable, DOS 6/13/25 to 6/19/25 missing 6/16/25 unavailable no reason, DOS 6/20/25 to 6/26/25 missing 6/20/25 unavailable, DOS 6/27/25 to7/3/25 missing 6/30/25 unavailable no reason, (DOS) 7/8/25 to 7/14/25, The DOR stated missing 7/9/25 unavailable no reason. The DOR confirmed Resident 2's physician's order is OT 5 days a week, The DOR further stated doesn't look like Resident 2 is getting 5x a week OT. During an interview on 8/15/25 at 1:21 p.m., with the Director of Nursing (DON), the DON stated if the OT order is 5x a week they should be following the doctor's order.During a review of the facility's (P&P) titled, Scheduling Therapy Services, revised date 7/2013, indicated, Therapy services shall be scheduled in accordance with the resident's treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 1) when the facility did not report Resident 1's injury of unknown source. This failure resulted in Resident 1's injury of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 1's clinical record titled, admission Record, dated 4/17/2025, indicated Resident 1 was admitted to the facility with diagnoses including COVID-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus, which can be very contagious, and spread quickly), hemiplegia (paralysis of one side of the body), and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (commonly referred to as stroke) affecting right dominant side (refers to the side of the body that tends to be stronger, faster, and more precise for tasks like writing, throwing, or brushing teeth), dysphagia (difficulty in swallowing), and encounter for attention to gastrostomy (a surgical procedure that creates a stoma [an opening] in the stomach, usually for the purpose of inserting a gastrostomy tube [G-tube/GT - this tube allow for the delivery of nutrition, fluids, and medications directly to the stomach]) Review of Resident 1's admission minimum data set (MDS- a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's speech was clear, she had the ability to make herself understood and had the ability to understand others. Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 11 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a phone interview with Resident 1's family member (FM) on 4/2/2025 at 12:54 p.m. Resident 1's FM stated she was called to let her know that Resident 1 had a discoloration to the right side of face, and right side of ear. Resident 1's FM further stated she was told a feeding pump fell on Resident 1's face, and she never believed them because the feeding pump was positioned to the left side of Resident 1's bed. Resident 1's FM stated the bruise could also be seen inside Resident 1's right ear. Review of Resident 1's clinical record titled, SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 3/3/2025, indicated, Describe the problem/symptom: right side of face skin discoloration, right side eye discoloration .pt received with discoloration on right side of face and right ear .pt unaware of what happened .no falls reported. Further review indicated, discoloration to right side of face and ear eye 3.3 x 2.5 [measurement of length by width] ear 4.5 x 3.2. Review of Resident 1's clinical record titled, IDT [interdisciplinary team, a team composed of members from different departments involved in resident's care] - SKIN INTEGRITY (PRESSURE INJURY, OTHER WOUNDS), dated 3/6/2025, indicated Resident 1 had a right ear and right eye discoloration. It further indicated, Risk factors: -MUSCLE WEAKNESS (GENERALIZED) .Chronically bed bound .Fragile compromised skin integrity -High risk for unavoidable d/t [due to] risk factors .IDT determined resident noted to be combative pulling on feeding tubes and GT. Review of Resident 1's clinical record titled, ALERT CHARTING, dated 3/5/2025 at 11:30 a.m., indicated, .Noted before breakfast served swelling on right side of face ice compress applied and monitor patient . Review of Resident 1's medication administration record (MAR - (MAR - a daily documentation record used by a licensed nurse to document medications, treatments given to a resident and resident's monitoring), dated 2/2025 and 3/2025, indicated Resident 1 had a behavior monitoring for verbalization of anxiousness and yelling leading to exhaustion. Further review indicated Resident 1 did not demonstrate these behaviors in 2/2025 and 3/2025. During a phone interview with licensed vocational nurse A (LVN A) on 4/17/2025 at 10:06 a.m., LVN A confirmed she worked with Resident 1 on 3/3/2025, in the evening shift and found Resident 1 with right eye and right ear bruising. LVN A stated, the cause of bruising was undetermined. LVN A further stated, Resident 1 was not even restless during the shift, there was no behavior and Resident 1 told her that she did not know what happened. LVN A confirmed she reported her findings to the doctor and to the unit manager (assistant director of nursing B - ADON B). LVN A confirmed she did not report her findings to the police or to the state because there is nothing suspicious. During a concurrent interview with assistant director of nursing C (ADON C) and record review on 4/17/2025 at 10:17 a.m., ADON C reviewed Resident 1's IDT dated 3/6/2025 and March 2025 MAR. ADON C confirmed she was a part of the IDT on 3/6/2025 and stated the possible contributing factor of Resident 1's discoloration to the face was not included in the IDT notes. ADON C further confirmed she did not know how Resident 1 sustained the discoloration to the right side of the face. ADON C confirmed the following: Resident 1 was not on any anticoagulant medications (AC - medications that prevent blood from clotting too easily which can increase the risk of bleeding or bruising); Resident 1 did not have any documented behavior in March 2025; and there was no care plan related to Resident 1's bruising. When ADON C was asked if she should have reported Resident 1's bruising with no known cause, ADON C stated she did not want to decide if she should have reported it and would just ask the team's decision. ADON C confirmed she was aware that she was a mandated reported [an individual who holds a professional position that is required by law to report suspected or known instances of abuse to state agencies and local law enforcement]. During an interview with ADON B on 4/17/2025 at 10:51 a.m., ADON B confirmed Resident 1's discoloration to the right side of face was reported to her. ADON B stated Resident 1 had a history of pulling the GT and when she asked Resident 1 of what happened, Resident 1 stated she did not know what happened. ADON B confirmed she investigated the possible cause of the discoloration on Resident 1's face and stated Resident 1's feeding pole fell on to Resident 1 and she confirmed nobody witnessed it. When asked why nobody witnessed the incident, ADON B stated Resident 1 was able to pull the feeding pole back up. When asked if she should have reported the unusual bruise on Resident 1's face, ADON B stated this case was new to her, and it should have been reported to CDPH, but she would find out the answer. During an interview with director of nursing (DON) on 4/17/2025 at 11:05 A.M., DON stated ADON B reported Resident 1's bruise, and she would pull her GT. DON further stated, it was a quick decision that it was the pump [feeding pump] that fell on her. DON confirmed it was not reported to state agencies because she heard' from staff that they determined the cause of the injury. During an interview with social services (SS) on 4/17/2025 at 11:19 a.m., SS stated he did not get a report about the bruise with unknown cause. Informed SS that he was a part of the IDT held in 3/6/2025, SS stated he could not recall the IDT because they had a lot. During an interview with the facility's administrator (ADM) on 4/17/2025 at 11:51 a.m., ADM stated ADON B talked to him about Resident 1's bruise and Resident 1 had a history of pulling of tubes, throwing meal trays, and making frantic movements. ADM confirmed that whenever an SBAR was made, the IDT would review them the following day. ADM further confirmed he did not investigate the cause of Resident 1's injury and he did not report it to state agencies. When asked about Resident 1's SBAR was completed on 3/3/2025 which was a Monday, why did the IDT reviewed it on 3/6/2025 (3 days after), ADM stated that he would get back to the nurse surveyor and he would talk to ADON B. During an interview with licensed vocational nurse D (LVN D) on 4/30/2025 at 10:45 a.m., LVN D confirmed he took care of Resident 1, and she did not have any behavior except the refusal to eat. During a concurrent interview with registered nurse E (RN E) and record review on 4/30/2025 at 11:03 a.m., RN E reviewed Resident 1's March 2025 evaluations and nurse's progress notes and confirmed Resident 1 had bluish discoloration on 3/3 to the right side of her face. RN E further confirmed she was not sure how Resident 1 sustained the bruise to her face. When asked if the unknown cause of Resident 1's bruise should have been reported, RN E stated, no, but she was aware that everyone was a mandated reporter. RN E confirmed that no one witnessed that a feeding pole fell on to Resident 1 and if it happened, Resident 1 would not be able to pull the pole back up. During an interview with certified nursing assistant F (CNA F) on 4/30/2025 at 12:21 p.m., CNA F confirmed he was assigned to Resident 1 on 3/3/2025, in the morning shift, and stated Resident 1 had periods of refusal with medications, to be changed and with meals. CNA F further stated, I don't think she can pull her GT because her right side is weak. She can only move the left arm. CNA F confirmed Resident 1 did not have any discoloration on her face in the morning of 3/3/2025. During an interview with licensed vocational nurse G (LVN G) on 4/30/2025 at 12:38 p.m., LVN G confirmed he worked with Resident 1 in March 3/2025 when he was still a CNA. LVN G stated, Resident 1 refused to eat but she never hit anyone. LVN G further stated, he noticed Resident 1 had a purplish discoloration to her face when he helped another CNA to reposition Resident 1 in bed. LVN G stated he did not ask what happened to her face because he assumed it was already reported. During a concurrent interview with licensed vocational nurse H (LVN H) on 7/9/2025 at 10:14 a.m., LVN H reviewed Resident 1's ALERT CHARTING notes on 3/5/2025, and LVN H confirmed she was the one who documented about the swelling and discoloration on Resident 1's face. LVN H stated she did not know how Resident 1 sustained that discoloration, and she did not report it because it was up to the administration's decision. LVN H further stated, nurses just had to do the SBAR and report to MD. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, date revised April 2021, indicated, All reports of resident abuse including injuries or unknown origin) .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse .or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman .d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials . Immediately is defined as: .b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Verbal/written notices are submitted via special carrier, fax, e-mail, or by telephone .Upon receiving any allegations of abuse, .or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents .The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to one of 36 sampled residents (Residents 23) and one unsampled resident (Resident 397) when Resident 23 and Resident 397's personal information and care instructions were posted in the room visible to roommate's visitors. This failure had the potential to compromise resident's rights. Findings: 1. During an observation on 4/14/2025 at 10:08 a.m., inside Resident 23's room, Resident 23 was in bed, with right hand mitten in placed, half naked with upper chest exposed and with caregiver at bedside. Two care instructions were observed posted above Resident 23's head of bed's wall. The first care instruction post indicated, Head of bed elevated at least 40 degrees during feeding. The second care instruction post indicated, -LEFT SIDE WEAKNESS -KEEP LEFT ARM ELEVATED - TURN AND REPOSITION EVERY 2 HOURS. During a concurrent observation and interview with assistant director of nursing I (ADON I) on 4/15/2025 at 9:08 a.m., inside Resident 23's room, the care instructions were still posted above Resident 23's head of bed's wall. ADON I confirmed above observation and stated it should have been covered. 2. During an observation on 4/14/2025 at 10:34 a.m., inside Resident 397's room, Resident 397 was in bed and a care instruction was posted above her head of bed's wall. The care instruction post indicated, CHOKING RISK - NO FOOD BY MOUTH. During a concurrent observation and interview with licensed vocational nurse K (LVN K) on 4/15/2025 at 9:11 a.m., inside Resident 397's room, the care instruction was still posted. LVN K confirmed above observation and stated Resident 397's care instruction should not be posted. During an interview with director of nursing (DON) on 4/18/2025 at 12:11 p.m., DON stated resident's care instructions should be covered when posted. During a review of the facility's policy and procedure titled, Dignity, date revised 2/2021, it indicated, Staff protect confidential clinical information. Examples include the following . b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room . Discreet posting of important information for safety reasons is permissible (e.g. taped to the inside of the closet door).

Based on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurately completed for one of 36 sampled residents (Resident 28). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings: Review of Resident 28's clinical record titled, admission Record, indicated Resident 28 was admitted to the facility with diagnoses including acute respiratory failure (lungs are unable to adequately deliver oxygen to the blood) with hypoxia (a condition where there is an insufficient amount of oxygen in the body's tissues or organs), influenza (a highly contagious respiratory illness caused by influenza viruses), emphysema (a chronic lung disease), and schizotypal disorder (a mental health condition characterized by unusual thoughts and behaviors, difficulty forming close relationships, and a tendency toward odd beliefs and perceptions). Review of Resident 28's clinical record titled, Order Summary Report, dated 4/1/2025, indicated Resident 28 had a prescription of Trazodone (an antidepressant medication used to treat depression, anxiety, or a combination of depression or anxiety) for depression (a common mental health condition characterized by a persistent low mood, loss of interest in activities, and other symptoms that can significantly interfere with daily life) manifested by inability to sleep. Further review indicated, Resident 28 was being monitored for episodes of schizotypal disorder manifested by social anxiety such as 1. more interest of activity done alone or 2. Not wanting to get out of bed. Review of Resident 28's PASARR dated 1/31/2025, indicated Resident 28's Level I Screening was negative for serious mental illness. Further review indicated in question, 9. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? the answer, no was marked. For question, 11. Has the individual been prescribed psychotropic medications for Serious Mental Illness? the answer, no was marked. During a concurrent interview with minimum data set director (MDSD) and record review on Resident 28's admission record, order summary report and PASARR on 4/17/2025 at 9:18 a.m., MDSD confirmed Resident 28's diagnoses of schizotypal disorder, with behavior monitoring and was taking an antidepressant. MDSD confirmed a staff from the hospital was the one who completed Resident 28's PASARR and stated numbers 9 and 11 should have been marked, yes. MDSD stated MDS nurses should always review resident's PASARR for accuracy prior to coding it in resident's comprehensive MDS (a federally mandated resident assessment tool) assessment. During a review of the facility's policy and procedure titled, admission Criteria, date revised 3/2019, indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process .If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plan for one of 36 sampled residents (Resident 23) when a care plan for Resident 23's behavior of pulling off her clothes or facility gown was not developed and implemented. This failure had the potential to result in not having to identify the specific care and services necessary to meet Resident 23's needs. Findings: Review Resident 23's clinical record titled, admission Record, dated 4/16/2025, it indicated Resident 23 was admitted to the facility with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked within the ventricles [fluid-filled spaces] of the brain), benign neoplasm (a non-cancerous growth of cells) of spinal cord, other specified disorders of brain, dysphagia (difficulty swallowing) , and encounter for attention to gastrostomy (a surgical procedure that creates an opening (stoma) into the stomach for the insertion of a feeding tube. Review of Resident 23's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 23's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 00 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an initial observation on 4/14/2025 at 10:08 a.m., inside Resident 23's room, Resident 23 was in bed, with right hand mitten in placed, half naked with upper chest exposed and with caregiver at bedside. During another observation on 4/16/2025 at 9:15 a.m., inside Resident 23's room, the privacy curtain was half drawn and Resident 23 was observed in bed, half naked, and her right upper chest was exposed. Resident 23's bed was located near the bedroom door, and she could easily be seen by her roommates' visitors in beds B and C. During a concurrent interview and observation with certified nursing assistant F (CNA F) on 4/16/2025 at 9:39 a.m. inside Resident 23's room, CNA F confirmed above observation and stated Resident 23 stripped off her facility gown. CNA F further confirmed Resident 23's privacy curtain was half drawn. During an interview with social services G (SS G) on 4/17/2025 at 11:30 a.m., SS G confirmed Resident 23 had a behavior of pulling off her clothes and stated they did not have a plan of care for such behavior. During another interview with CNA F on 4/18/2025 at 8:43 a.m., CNA F stated staff should make sure Resident 23 was checked frequently especially if her family member was not at bedside to prevent her from pulling off her facility gown. During a concurrent interview with registered nurse R (RN R) and review of Resident 23's list of care plans on 4/18/2025 at 10:19 a.m., RN R confirmed Resident 23 had a behavior of stripping off her facility gown and they did not have a plan of care in placed. During an interview with director of nursing (DON) on 4/18/2025 at 12:27 p.m., DON confirmed Resident 23's behavior of stripping off her facility gown and stated the behavior should have been care planned to identify appropriate interventions. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, date revised 3/2022, indicated, The interdisciplinary team [IDT - a group of health care professionals from diverse fields who work toward a common goal for residents], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on interview and record review, the facility failed to ensure one (Resident 241) out of one sampled resident received treatment and care in accordance with professional standards of practice when Resident 241's vital signs were not checked and due medications were not given. This failure had the potential to compromise Resident 241's physical health condition. Findings: A review of Resident 241's medical record indicated diagnoses of, Paroxysmal Atrial Fibrillation (an irregular, fast heartbeat that comes and goes), Acute on chronic combined systolic and diastolic heart failure (a sudden worsening of a long-standing heart condition where the heart muscle has both problems contracting [systolic] and relaxing [diastolic] properly). A review of Resident 241's Physician Orders indicated, Diltiazem Hcl Oral Tablet 30 MG [milligram, unit of measurement] give 1 tablet by mouth three times a day for HTN [hypertension, high blood pressure]. Hold if SBP [systolic blood pressure, the top number in a blood pressure reading, representing the pressure in the arteries when the heart beats and pumps blood throughout the body] is less than 100 or pulse less than 60 on 1/13/25 and Carvedilol oral tablet 25 MG give 1 tablet by mouth two times a day for HTN. Hold if SBP is less than 100 or pulse is less than 60. Given with food. on 1/14/25. A review of Resident 241's Record of Death indicated, date of admission was 1/13/25 and date and time of death was 1/16/25 at 1:05 a.m. During a concurrent interview and record review on 4/17/25 at 3:46 p.m. with the Director of Nursing (DON), the DON verified Resident 241's progress notes indicated that Resident 241 was found unresponsive on 1/16/25 at 12:37 a.m. The DON verified the medication Carvedilol was last given at 9 a.m. on 1/15/25 and Diltiazem was last given at 1 p.m. on 1/15/25. The DON verified Resident 241's blood pressure was last checked on 1/15/25 at 11:09 a.m. and pulse was last checked on 1/15/25 at 6 p.m. and the DON verified pulse was elevated at 103 beats per minutes. The DON verified there was no documentation why Carvedilol and Diltiazem were not given in the afternoon and why vitals signs were not checked in the afternoon of 1/15/25. The DON stated, it should be documented. A review of facility's policy and procedure (P&P) entitled Guidelines for Obtaining Vital Signs revised February 2018, the P&P indicated, the purpose of this procedure is to assure that vital signs are obtained whenever appropriate. Vital Signs will include temperature, blood pressure, respiration and presence or absence of pain . A review of facility's P&P entitled, Charting and Documentation revised July 2017, the P&P indicated, .2. The following information is to be documented in the resident medical record: .b. Medications administered .7. Documentation of procedures and treatments will include care-specific details, including: .e.whether the resident refused the procedure/treatment;

Based on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 36 sampled residents (Resident 215) when the toenails were longer than Resident preferred causing pain and concern for ingrown toenails or infection. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection. Review of Resident 215's clinical records indicated Resident 215 had multiple diagnoses including hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) and hemiparesis (one-sided weakness), and diabetes (high blood sugar). Resident 215's cognitive function is intact Review of Resident 215's order summary, dated 11/14/24, indicated Resident 215 may have Podiatry evaluation, Tx, and follow up every 61 days and prn (as needed). During an interview on 4/14/25 at 9:40 a.m. with Resident 215, Resident 215 stated, she requested to see the podiatrist, they showed her a paper stating saying the podiatrist saw her, but he never did. During a concurrent observation Resident 215's nails were noted to be long, thick and growing inward. During an interview on 4/16/25 at 10:25 a.m. with Social Services (SS) G, the SSG explained, when residents request podiatry services it is noted in a binder at the nurse's station. Resident 215 requested on 4/4/25 and will be scheduled for their next visit. During a concurrent observation and interview with SSG in Resident 215's room with Resident 215, SSG confirmed Resident 215's nails were long and did not look like they were seen on a recent visit by the podiatrist. Resident 215 stated she was not seen by the podiatrist. During an interview on 4/18/25 at 1:28 p.m. with Resident 215, Resident 215 was sitting in the wheelchair with her shoes on. Resident 215 stated she would remember someone working on her toes. They feel the same, the toes are still bothering her, she feels sharp pain, has a history of ingrown toenails so is concerned that will happen and does not want them infected. She is a diabetic. During review of the facility's policy & procedures titled Foot Care dated revised October 2022, indicated, Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (e.g., diabetes, peripheral vascular disease, immobility, etc.) . Trained staff may provide routine foot care ( e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes .Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include corns, neuromas, calluses, hallux valgus (bunions), digiti flexus (hammertoe), heel spurs, and nail disorders.

Based on interview and record review, the facility failed to ensure 1 out of 36 sampled residents (Residents 105) was free from unnecessary medications when there was inadequate monitoring for the resident's vitamin B12 (a supplement to treat vitamin B12 deficiency) and vitamin D (an essential vitamin that your body uses for normal bone development and maintenance) level as ordered. This resulted in inadequate monitoring related to medication management for the resident. Findings: A review of record of Resident 105's admission Record, dated 4/17/25, indicated the resident was admitted with diagnoses including deficiency of other specified B group Vitamins and history of falls. A review of Resident 105's clinical record indicated the following physician's orders: - Cyanocobalamin (vitamin B12) tablet 1,000 micrograms (mcg, unit of measurement) PO once a day for vitamin B12 deficiency, order dated 3/20/22; - Vitamin D3 tablet, 2,000 units by mouth one time a day, dated 3/20/22; - Vitamin D Level every 6 months in April and October of each year, dated 4/12/23. A review of Resident 105's clinical record indicated no laboratory results for vitamin D for April and October 2024; and no vitamin B 12 level since it was ordered on 3/20/22 (more than 2 years ago). During a concurrent interview and record review with Assistant Director of Nursing (ADON) A, on 4/16/25 at 4:26 p.m. ADON A was asked to provide Resident 105's vitamin D level for April and October 2024, a per the physician's order. ADON A reviewed Resident 105's clinical record and stated she could not find any. ADON A also stated she had the help of other staff to look for the vitamin D lab results but there was none. Regarding the vitamin B12, ADON A stated there had not been a vitamin B12 level drawn since it was ordered on 3/20/22. ADON A acknowledged the vitamin D levels were not carried out as ordered; and Resident 105 has a diagnosis of B group vitamins deficiency and received vitamin B12 medication administration without monitoring for vitamin B12 level. A review of facility's policy and procedure titled Medication Utilization and Prescribing - Clinical Protocol, dated April 2018, indicated, The physician and staff will identify significant factors that may affect medication effectiveness and The physician and staff will evaluate the effectiveness and effects of the medication in a resident's regimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for residents when: 1. Resident 23's privacy curtain was not fully drawn when Resident 23 removed her facility gown; 2. Assistant Director of Nursing (ADON) A referred to Resident's clothing protector as bibs in front of approximately 15 residents; and, 3. Certified Nursing Assistant (CNA) B was observed to assist feeding Resident 194 while standing over her. These failures had the potential for adverse effects on the psychosocial well-being and health of Resident 23, Resident 194 and approximately 14 others residents in the dining room during mealtime. Findings: 1. Review of Resident 23's clinical record titled, admission Record, dated 4/16/2025, indicated Resident 23 was admitted to the facility with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked within the ventricles [fluid-filled spaces] of the brain), benign neoplasm (a non-cancerous growth of cells) of spinal cord, other specified disorders of brain, dysphagia (difficulty swallowing) , and encounter for attention to gastrostomy (a surgical procedure that creates an opening (stoma) into the stomach for the insertion of a feeding tube. Review of Resident 23's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 23's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 00 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an observation on 4/16/2025 at 9:15 a.m., inside Resident 23's room, the privacy curtain was half drawn and Resident 23 was observed in bed, half naked, and right upper chest was exposed. There were no family members observed at bedside. Resident 23's bed was located near the bedroom door, and she could easily be seen by her roommates' visitors in beds B and C. During a concurrent interview and observation with certified nursing assistant F (CNA F) on 4/16/2025 at 9:39 a.m. inside Resident 23's room, CNA F confirmed above observation and stated Resident 23 stripped off her facility gown. CNA F further confirmed Resident 23's privacy curtain was half drawn. During an interview with social services G (SS G) on 4/17/2025 at 11:30 a.m., SS G confirmed Resident 23 had a behavior of pulling off her clothes and stated they did not have a plan of care for such behavior. During another interview with CNA F on 4/18/2025 at 8:43 a.m., CNA F stated staff should make sure Resident 23 was checked frequently especially if her family member was not at bedside to prevent her from pulling off her facility gown and exposing herself to other residents and visitors. During a review of the facility's policy and procedure titled, Dignity, date revised 2/2021, it indicated, Residents are treated with dignity and respect at all times . Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior . 2. During an observation on 4/14/25, at 12:21 p.m., in Station 5's second dining room, ADON A was observed assisting residents with set up of lunch time meal. ADON A was observed speaking with other staff members in the second dining room asking, Where are the bibs?, get some more bibs. During an interview on 4/14/25, at 12:22 p.m., with ADON A, ADON stated, she asked the other staff members for more bibs for the residents, to place them on before they eat. 3. During an observation on 4/14/25, at 1:01 p.m., in Station 5's second dining room, CNA B was observed assisting Resident 194 to eat lunch while standing over the resident. During an interview on 4/14/25, at 1:02 p.m., with CNA B, CNA B stated, she assisted Resident 194 to eat lunch while standing, and they are supposed to sit down while assisting residents to eat. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2021, the P&P indicated, Each resident shall be free cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During a review of the facility's P&P titled, Assistance with Meals dated 2022, the P&P indicated, Dining Room Residents: 3. Resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect two of 36 sampled residents (Resident 21 & Resident 445) from physical abuse. When: 1.Resident 231 was observed to physically hit Resident 21 2. Resident 231 was observed to physically hit Resident 445 These failures resulted in Resident 21 & Resident 445 to be physically abused by Resident 231. Findings: 1. During a review of the facility's SOC 341 (mandated report of suspected dependent adult/elder abuse form) dated 4/12/25, indicated an abuse allegation was reported to the California Department of Public Health (CDPH). SOC 341 indicated, Victim [Resident 21].suspected abuser [Resident 231]. SOC 341 indicated, At approximately 8:05 AM on 4.12.25, Resident [231] had hit another resident [Resident 21] in the face and pushed her to the floor. CNA had witnessed the incident and immediately ran over, called for help and separated both residents. SOC 341 indicated, Reported Type of Abuse Physical. Abuse resulted in Minor medical Care During a review of Resident 231's Change in Condition assessment dated [DATE], Assessment indicated, 0715 [7:15 a.m.] received resident awake, alert, and responsive. Ups and ambulates along the hallway of the unit with anger outburst with staff, pacing around the unit.0805 [8:05 a.m.] Resident was walking down the hallway when he struck another resident [Resident 21} in the face and pushed her to the ground. Resident [231] also tried to hit the charge nurse and chased her. Resident is not easily redirectable. Resident becomes very aggressive toward staff and other residents. CNA witnessed the incident. During a review of Resident 21's Change in condition assessment dated [DATE], assessment indicated, Resident was hit in the face by another resident. Redness to the left side of face. During an interview on 4/17/25 at 9:42 a.m, with Certified Nursing Assistant (CNA) C, CNA C stated, she saw Resident 231 walking in the hallway toward the activity room and Resident 21 was walking back to her room. CNA C stated, they crossed paths (Resident 21 and 231) and out of nowhere Resident 231 slapped Resident 21 on the side of the face without being provoked and just kept walking. CNA C stated Resident 21 fell onto the floor from being slapped by Resident 231. CNA C stated, she had witnessed Resident 231 be aggressive in the past, she stated she observed him try to pick up a chair and hit her when cleaning his meal tray after a meal. During a review of the Facility's Investigative Report for Resident 21 and Resident 231's abuse incident dated, 4/15/25, report indicated, from witness account interviews. The incident occurred between Resident [231] and Resident [21] as they crossed paths in the hallway. 2. During a review of the facility's SOC 341 dated 4/15/25, report indicated, Victim [Resident 445] . Suspected Abuser [Resident 231]. At approximately 3:30 PM on 4.14.25. CNA was also present during the time of incident. Here is his account of the events: Resident [231], (perpetrator) was not in activities room. Resident [231] had then ran into the activities room, sat on the table where Resident [445] (victim) was sitting and slapped resident twice on her head. reported type of abuse physical. During a review of Resident 445's Change in condition assessment dated [DATE], assessment indicated, Resident was hit by another resident in the activity room. at approximately 3:15 pm. [Resident 445] was sitting in the activity room watching tv and [Resident 231] went into the room and suddenly without provocation he hit her in the leftforehead [sic]. [Resident 445] sustained a redness on the LEFT forehead. During an interview on 4/16/25, at 3:15 p.m., with Certified Nursing Assistant (CNA) H, CNA H stated, he was in the activity room on 4/15/25 at around 3:15 p.m., and witnessed Resident 231 come into the activity room table where Resident 445 was sitting calmly. CNA H stated, he saw Resident 231 out of nowhere slap Resident 445 several times. During a review of the Facility's Abuse investigation report dated, 4/17/25, report indicated, At approximately 3:30 PM on 4.15.25 Resident [445] was sitting in the activities room participating. CNA was present during the time of the incident and these are his accounts of the event: Resident [231] was not in the dining room participating in activities. Resident [231] ran into the activities room, sat on the table where Resident [445] was sitting and slapped resident [445] twice on her head. During a review of the facility's Policy & Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2021, the P&P indicated, Resident have the right to be free from abuse. this includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse. by anyone including. other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to notify The Office of the State Long -Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) of resident's transfer or discharge in a timely manner when: 1. The Office of the State LTC Ombudsman was not notified for 16 of 51 discharged residents (Residents 151, 166, 237, 233, 183, 408, 103, 409, 410, 411, 404, 412, 414, 415, 416, and 417); and, 2. The facility's notification to The Office of the State LTC Ombudsman for six of 51 discharged residents (Residents 418, 419, 420, 421, 404, 422, and 423) were submitted late. These failures resulted in the State LTC Ombudsman not being informed in a timely manner and removed the opportunity for the State LTC Ombudsman (LTC-O) to advocate on resident's behalf. Findings: During a phone interview with LTC-O on 4/3/2025 at 10:12 a.m., LTC-O stated the facility's resident discharges were not reported to their office since 12/2024. During another phone interview with LTC-O on 4/7/2025 at 8:00 a.m., LTC-O stated she reviewed all the reported resident discharges in their office and revealed they only received less than 10 discharged residents in a month since 7/2024. LTC-O further stated, it was unusual to have less than 10 discharged residents because, this is a big facility. 1A. Review of Resident 151's Medical Record indicated Resident 151 was admitted 2 years ago with multiple diagnoses including osteoarthritis and generalized muscle weakness. The Minimum Data Set (a standardized assessment tool that measures health status in nursing home residents) (MDS) dated [DATE] indicated Resident 151 was cognitively intact. Review of Resident 151's Medical Record, dated 3/20/25, the Social Services progress note indicated Social Services spoke to Resident 151 about discharge planning. Review of Resident 151's Medical Record, dated 3/23/25, the Case Manager progress notes indicated the Resident had been assessed by the team and determined that a lower level of care is appropriate. Review of Resident 151's Medical Record, dated 4/9/25, the Social services progress note indicated Social Services G (SS G) spoke to Resident 151's Power of Attorney (POA) about the right to appeal [the facility initiated discharge]. During an interview on 4/15/25 at 10:48 a.m. with Social Services W, SS W stated she communicated with Resident 151's POA about the pending discharge and filing for an appeal. SS W stated there is a Board and Care that has accepted him and currently holding a bed. During an interview on 4/18/25 at 9:48 a.m. with the Case Manager (CM) N, CM N stated, Do not need to notify ombudsman because we are not sending the Resident 151 out, there was a Board and Care for him as of 4/12/25 but he did not want to go. 1B. Review of Resident 166's Notice of Transfer/discharge date d 4/4/25 indicated Resident 166's Responsible party (RP) was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/7/25. The notification by fax to the Ombudsman was 4/18/25. 1C. Review of Resident 237's Notice of Transfer/discharge date d 4/11/25 indicated Resident 237 was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/13/25. The notification by fax to the Ombudsman was 4/11/25. 1D. Review of Resident 233's Notice of Transfer/discharge date d 4/2/25 indicated Resident 233's RP was notified of the transfer/discharge on [DATE] [to a Board & Care], the effective date of discharge was 4/5/25. The notification by fax to the Ombudsman was 4/11/25. 1E. Review of Resident 183's Notice of Transfer/discharge date d 4/14/25 indicated Resident 183 was notified of the transfer/discharge on [DATE] [to a Board & Care, assisted living group home], the effective date of discharge was 4/15/25. The notification by fax to the Ombudsman was 4/16/25. During an interview on 4/18/25 at 3:46 p.m. with Social Services (SS) G, SS G stated a Notice of Transfer/Discharge is completed 1 day prior to discharge and sent to the ombudsman. During a follow up interview on 4/18/25 at 4:25 p.m. with SS G, SSG stated, The notice of Transfer/Discharge can be faxed to the Ombudsman in 30 days. SS G was not able to explain how the Ombudsman would assist the Resident when notified was 30 days after the discharge. Review of the facility's Policy and Procedure titled, Transfer or Discharge, Facility-Initiated, dated, 10/2022, indicated, Notice of Transfer or Discharge (Planned) A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative 4. If information in the notice changes, the facility will update the recipients of the notice as soon as practicable with the new information to ensure that residents and their representatives are aware of and can respond appropriately. 5. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. During a concurrent interview with both social services G (SS G) and social services V (SS V) on 4/18/2025 at 11:33 a.m., both SS G and SS V stated they notified LTC-O daily with their discharged residents. SS G stated they LTC-O was notified with all their discharged residents regardless of where their destination. Both SS G and SS V further stated, they would fill out a Notice of Transfer/Discharge form and then would fax the form to the LTC-O office. During a concurrent interview with SS G and review of randomly selected residents who were discharged from 7/2024 - 4/2025 on 4/18/2025 at 3:45 p.m., SS G reviewed the list of residents discharged and their fax transaction report. SS G confirmed that the following resident's discharge were not reported to the LTC-O: 1F. Resident 408 was admitted to the facility on [DATE] and was discharged to home or apartment (apt.) with no home health services (HHS - medical care provided to individuals in their own home) on 2/6/2025; 1G. Resident 103 was originally admitted to the facility on [DATE] and was discharged to home or apt. with HHS on 7/1/2024; 1H. Resident 409 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 2/27/2025; 1I. Resident 410 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/16/2024; 1J. Resident 411 was admitted to the facility on [DATE] and was discharged to independent living facility (ILF - a type of senior housing where residents maintain their independence and do not require assistance with activities of daily living [ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] or medical care) on 7/28/2024; 1K. Resident 404 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 3/18/2025; 1L. Resident 412 was admitted to the facility on [DATE] and was discharged to ILF on 7/12/2024; 1M. Resident 414 was admitted to the facility on [DATE] and was discharged to acute care hospital on 9/22/2024; 1N. Resident 415 was admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/31/2024; 1O. Resident 416 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 7/9/2024; and 1P. Resident 417 was re-admitted to the facility on [DATE] and was discharged to home or apt. with no HHS on 10/13/2024. Further interview with SS G, he stated nurses are responsible for the notice of transfers to LTC-O when residents were transferred to the hospital while social services were the ones who notified LTC-O for any planned discharges. Further interview with SS G and review of the list of discharged residents and the facility's fax transaction report, SS G confirmed that the following resident's discharge notification to LTC-O were submitted late: 2A. Resident 418 was discharged to home with HHS on 8/5/2024 and the fax transaction report to the LTC-O was dated 10/24/2024 (two months late); 2B. Resident 419 was discharged to home with HHS on 8/24/2024 and the fax transaction report to the LTC-O was dated 10/24/2024 (two months late); 2C. Resident 420 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2D. Resident 421 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2E. Resident 404 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); 2F. Resident 422 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late); and 2G. Resident 423 was discharged to acute care hospital on [DATE] and the fax transaction report to the LTC-O was dated 1/29/2025 (three months late).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for two residents (Residents 190 and 546) when staff did not turn and reposition the residents every two hours. This failure had the potential to delay wound healing, worsening pressure ulcers and the development of new pressure ulcers for Resident 190 and Resident 546. Findings: 1. During multiple observations on 4/16/25 at 9:38 a.m., 11:40 a.m., 1:45 p.m., and 4:00 p.m., Resident 190 was lying in bed positioned on his back and was not able to turn himself. During multiple observations on 4/17/25 at 8:40 a.m., 10:45 a.m., 12:15 p.m., and 2:30 p.m., Resident 190 was lying in bed positioned on his back and was not able to turn himself. Review of Resident 190's medical record indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (slight or serious difficulty with language or speech) following cerebral infarction (stroke, damage to the brain due to lack of oxygen), chronic respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide, left side hemiplegia and hemiparesis (complete paralysis [inability to move part or all of the body], partial paralysis or muscle weakness on one side of the body), stage 4 (a deep wound reaching the muscles, ligaments, or bones) pressure ulcer (an area of skin that breaks down when something keeps rubbing or pressing against the skin) of the sacral/coccyx (the triangular shaped bone at the base of the spine) region and pressure induced deep tissue damage of left heel. Review of Resident 190's Minimum Data Set (MDS, an assessment tool), dated 3/17/25, indicated he was admitted with pressure ulcers. The MDS also indicated Resident 190 was severely impaired in cognition with communication deficit. The MDS further indicated Resident 190 had impairment of both sides of upper and lower extremities requiring extensive assistance with bed mobility (moving in bed) and non-ambulatory (unable to walk). Review of Resident 190's Weekly Skin Assessment Report indicated on 4/9/25, Resident 190 was noted to have a 7.1 cm (centimeter, a unit of measurement) by 4.7 cm by 0.7 coccyx pressure ulcer. During a wound treatment observation and concurrent interview with the Wound Treatment Nurse (WTN) on 4/18/25 at 9:20 a.m., Resident 190 had an open wound in the coccyx area. The WTN measured the open area and stated the size remained unchanged from observation and treatment on 4/16/25. The WTN also stated recommendations were given to staff to continue turning and positioning of the resident every two hours or as needed to promote healing of the wound. Review of Resident 190's Care Plan dated 1/22/25 and revised on3/4/25 indicated Resident 190 was at risk for pressure injury, development and skin breakdown related to chronic venous insufficiency (leg veins that don't allow blood to flow back up to the heart), hemiplegia and hemiparesis with intervention to turn and position every two hours and as needed. During an interview on 4/17/25 at 1:20 p.m., with Certified Nursing Assistant BB (CNA BB), CNA BB stated residents were supposed to be turned and positioned every two hours to help wound healing but further stated Resident 190, Didn't need it. Review of the CNA Task Log dated 4/16/25 and 4/17/25 for Resident 190 indicated Resident 190 had been turned and repositioned every two hours. During an interview on 4/17/25 at 1:25 p.m., with the Assistant Director of Nursing C (ADON C), the ADON C stated bedridden (unable to get out of bed) residents or residents with pressure wounds were turned and positioned every two hours or as needed as a standard of practice to promote healing of pressure wounds and for prevention of pressure wounds. 2. During multiple observations on 4/16/25 at 8:00 a.m., 10:05 a.m., 12:00 p.m., 2:00 p.m., and 4:00 p.m., Resident 546 was lying on her back in bed and was not able to turn herself. During multiple observations on 4/17/25 at 8:47 a.m., 10:50 a.m., 12:10 p.m., 2:12 p.m., and 4:10 p.m., Resident 546 was lying in bed positioned on her back and was not able to turn herself. Review of Resident 546's medical record indicated Resident 546 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (an infection that affects one or both lungs), respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), diabetes (a condition which affects the way the body processes blood sugar), embolism (blockage of a blood vessel by a clot of blood or an air bubble that has traveled from another location) and thrombosis (formation of a blood clot within a blood vessel) of veins of lower extremities. Review of Resident 546's MDS dated [DATE], indicated Resident 546's cognitive status was severely impaired with communication deficit. The MDS further indicated Resident 546 had impairment of both sides of upper and lower extremities. Review of Resident 546's Weekly Skin Assessment Report dated 4/9/25, indicated Resident 546 was noted to have a pressure ulcer to the coccyx area measuring 4.2 cm by 3.5 cm by 2.8 cm. During a wound treatment observation and concurrent interview on 4/18/25 at 10:45 a.m. with the WTN, Resident 546 had an open wound in the coccyx area. The WTN measured the open wound area and stated the size remained unchanged from observation and treatment on 4/16/25. The WTN stated the wound was very deep and Resident 546 had a history of pressure ulcers closing and re-opening. The WTN stated frequent reminders were given to staff to keep Resident 546 from constantly lying on her back for long periods of time to promote healing of wound tissue. During an interview on 4/18/25 at 11:00 a.m., with (CNA CC), CNA CC stated Resident 546 had not received a wedge pillow (pillow used to relieve pressure points) and was not able to reposition Resident 546 on her side properly using the soft pillows. During an interview on 4/18/25 at 1:00 p.m. with the Director of Staff Development (DSD), the DSD stated an in-service was conducted on 1/24/25 on the topic of skin breakdown and turning and positioning. The DSD stated the evaluation of teaching was discussion only. Review of the facility's policy and procedure titled, Repositioning revised 5/2013, indicated, General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts pressure on tissue that is already compromised and may impede healing. Interventions: .3. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. 4. For residents with a Stage 1 or above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate.

Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for three of 12 sampled residents (residents on oxygen therapy) when: 1. Residents 28's and Resident 152's O2 concentrator's (a device which concentrates the oxygen from ambient air) filters had some grayish substance build up; and, 2. Resident 212 was administered the wrong dosage of oxygen. These deficient practices had the potential for Residents 28, 152, and 212 to have complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 28's clinical record titled, admission Record, indicated Resident 28 was admitted to the facility with diagnoses including acute respiratory failure (lungs are unable to adequately deliver oxygen to the blood) with hypoxia (a condition where there is an insufficient amount of oxygen in the body's tissues or organs), influenza (a highly contagious respiratory illness caused by influenza viruses), emphysema (a chronic lung disease), and schizotypal disorder (a mental health condition characterized by unusual thoughts and behaviors, difficulty forming close relationships, and a tendency toward odd beliefs and perceptions). Review of Resident 28's clinical record titled, Order Summary Report, dated 4/1/2025, it indicated an order of continuous use of oxygen for Resident 28. Further review revealed an order dated 2/1/2025, May use O2 CONCENTRATOR. Check concentrator filter weekly &wash or change every Friday or PRN (as needed). During an observation inside Resident 28's room on 4/14/2025 at 11:17 a.m., Resident 28 was in bed and on oxygen therapy at 2 liters (unit of volume) per minute (lpm) thru a nasal cannula (NC - a tubing used to deliver oxygen from the machine through the nostrils). The oxygen concentrator's filter located at the back of the device was observed with thick grayish substance build up. 1b. Review of Resident 152's clinical record titled, admission Record, indicated Resident 152 was admitted to the facility with diagnoses including pneumonia (infection of one or both lungs), chronic obstructive pulmonary disease (COPD - a disease that affects airflow in the lungs and makes it difficult to breathe), and respiratory failure with hypoxia. Review of Resident 152's clinical record titled, Order Summary Report, dated 4/17/2025, indicated an order of Resident 152's continuous use of oxygen. Further review revealed an order dated 2/14/2025, May use O2 CONCENTRATOR. Check concentrator filter weekly & wash or change every Friday or PRN. as needed AND every night shift every Sat [Saturday] Check & wash or change. During an observation inside Resident 152's room on 4/14/2025 at 10:39 a.m., Resident 152 was in bed, and on oxygen therapy at 2 lpm thru NC. The oxygen concentrator's filter located at the back of the device was observed with thick grayish substance build up. During a concurrent interview with infection preventionist (IP) and photo review of Resident 28 and 152's oxygen concentrator's filters on 4/14/2025 at 11:30 a.m., IP confirmed both resident's oxygen filters had grayish substance build up. IP stated he was not sure who was supposed to check and clean the oxygen concentrator's filters. During an interview with director of nursing (DON) on 4/18/2025 at 12:07 p.m., DON stated the cleaning or changing of oxygen filters should have been done weekly by nurses or the central supply staff. During a review of the facility's policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, date revised 11/2011, indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .among residents and staff .Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 2. During a observation on 4/14/25 at 9:40 a.m., in Resident 212's room. Resident 212 was wearing a nasal cannula (a device that gives you oxygen through your nose.) through an oxygen concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen.) with a dose of 5 liters per minute. During a review of resident 212's Oxygen Order Details dated 3/4/25, order indicated, OXYGEN: May have O2 [oxygen] at 2 L/min [liter per minute] via nasal cannula without humidifier for SOB [shortness of breath] R/T [related to] DX. [diagnosis of] COPD [Chronic Obstructive Pulmonary Disease]. During a concurrent observation and interview on 4/14/25, at 1:52 p.m., with Licensed Vocational Nurse (LVN) J, in Resident 212's room. Resident 212 was observed wearing her nasal cannula with her oxygen concentrator set to 5 L/min. LVN J stated, she knows Resident 212's oxygen should be set to 2 L/min per the order, but it is set to 5 L/min. During a review of Resident 212's Care Plan dated, 12/17/24, Care Plan indication, [Resident 212] has Chronic Obstructive Pulmonary Disease. (COPD) .Interventions Administer oxygen as ordered. During a review of National Institute of Health's National Library of Medicine's article titled, Harms of over oxygenation in patients with exacerbation of chronic obstructive pulmonary disease, dated 2017, article indicated, Too much oxygen can be dangerous for patients with chronic obstructive pulmonary disease (COPD) with (or at risk of) hypercapnia (increased carbon dioxide in the blood). During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physicians orders or facility protocol for oxygen administration.

Based on observation, interview and record review, the facility failed to ensure staff had appropriate competencies to provide nursing care for one (Resident 192) out of seven sampled residents when Resident 192 was not assisted by staff when requested. This failure had the potential for physical injury and psychosocial distress. Findings: During a concurrent observation and interview on 4/14/25 at 10:55 a.m. with Resident 192 in her room, Resident 192 was trying to transfer from the bed to the wheelchair. Resident 192 pressed the call light. Certified Nurse Aide (CNA) X entered the room, turned off the call light button near Resident 192 and left the room. During an interview on 4/14/25 at 10:58 a.m. with CNA X, CNA X verified she did not assist Resident 192 when she entered the room and turned off the call light. During an interview on 4/17/25 at 9:37 a.m. with Case Manager (CM) N, CM N stated they have to ask the residents if they need help before turning off the call light and then assist the residents. During an interview on 4/17/25 at 4:04 p.m. with the Director of Nursing (DON), the DON stated staff must address the needs of residents whenever they press the call light. A review of Resident 192's medical record indicated diagnoses of Primary Osteoarthritis of right and left ankles and feet (a condition where the protective cartilage that cushions the ends of bones in joints wears down over time, causing the bones to rub against each other and leading to pain, stiffness, and limited movement), bilateral primary osteoarthritis of hip, muscle weakness, and difficulty in walking. A review of Resident 192's Minimum Data Set (MDS, an assessment tool), dated 2/14/25, indicated a brief interview for mental status score of 14 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of facility's policy and procedure (P&P) entitled Answering the Call Light revised September 2022, the P&P indicated, .Steps in the procedure 1. Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name a. If the resident needs assistance, indicate the approximate time it will take for you to respond .c. If the resident's request is something you can fulfill, complete the task within five minutes if possible.

Based on observation, interview and record review the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents in a prominent place in each of four nursing stations of the facility. This failure had the potential for residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled and available to care for their needs. Findings: During an observation on 4/16/25 at 10:00 a.m., in Hallway 2, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/25 at 10:05 a.m., in Hallway 3, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/25 at 10:10 a.m., in Hallway 4, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation on 4/16/24 at 10:15 a.m., in Hallway 5, no staff schedule or direct patient care hours were posted and accessible to residents. During an observation and interview on 4/17/25 at 2:10 p.m. with the Director of Nursing (DON), the DON verified the staffing information was not posted in all the hallways and stated the direct daily patient care hours and staffing schedules were posted only in Hall 1 which was closest to the main entrance to the facility. The DON stated the patient care hours and staffing schedules had never been posted anywhere else in the facility.

Based on interview and record review, the facility failed to ensure the accurate accountability of controlled medications (medication with a high potential for abuse and addiction) when: 1. Controlled medications were signed out of the Controlled Drug Record (CDR, an inventory or count sheet) but not documented on the medication administration record (MAR) as administered for four out of five residents (Residents 15, 61, 81, and 114). 2. Records of wasted controlled medications did not contain the co-signature from another nurse for four randomly selected residents (Resident 81, 294, 295, and 296) as per facility policy and procedures. These failures had the potential result to the misuse and abuse of controlled substance medications. Findings: 1. During the survey, the CDRs for five random residents receiving as-needed controlled medications were selected for review. During the interview on 4/16/25 at 10:48 a.m., the Assistant Director of Nursing (ADON) C explained the process of administering a controlled medication. The steps included assessing the resident for pain, checking the physician's order, signing it out of the CDR, administering the medication, and documenting the administration on the MAR. During a concurrent interview and record review with ADON C, the following were identified: a. Resident 114 had a physician's order, dated 1/8/25, for oxycodone (a potent narcotic for pain) 15 milligrams (mg, unit of measurement), 1 tablet every 4 hours as needed (PRN) for moderate pain. On 04/16/25 at 10:51 a.m., a review of Resident 114's CDR for oxycodone 15 mg and the April 2025 MAR with ADON C indicated the nursing staff signed out of the CDR, but did not document on the MAR to show the medication was administered to Resident 114 on two occasions: on 4/1/25 at 1100 and 4/5/25 at 2100. ADON C confirmed this finding and stated it should be documented on the MAR. b. Resident 61 had a physician's order, dated 3/18/25, for oxycodone 5 mg, 2 tablets every 8 hours as needed for mild/severe pain and this dosage was increased to every 4 hours on 4/8/25. On 04/16/25 at 10:54 a.m., a review of Resident 61's CDR for oxycodone 5 mg and the April 2025 MAR with ADON C indicated the nursing staff signed out of the CDR but did not document the medication administration on the MAR on four occasions: on 4/3/25 at 1230; 4/11/25 at 1353; 4/11/25 at 2220; and 4/12/25 at 2100. ADON C confirmed this finding and stated it should be documented. c. Resident 81 had a physician's order, dated 4/26/23, for hydrocodone acetaminophen 5-325 MG (a narcotic medication to treat pain), 1 tablet by mouth every 8 hours as needed for severe pain. On 04/16/25 at 10:58 a.m., a review of Resident 81's CDR for hydrocodone/acetaminophen 5/325 and the March and April 2025 MARs with ADON C indicated the nursing staff signed the medication out of the CDR but did not document the administration on the MAR on three occasions: on 3/20/25 at 0240; 4/5/25 at 0804; and 4/9/25 at 2015. ADON C stated it should be documented. d. Resident 15 had a physician's order, dated 3/5/25, for hydrocodone/acetaminophen 5/325 mg, 1 tab by mouth every 4 hours as needed for moderate to severe pain. On 04/16/25 at 11:02 a.m., a review of Resident 15's CDR for hydrocodone/acetaminophen 5/325 mg and the April 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on the MAR to show the medication was administered to Resident 15 on seven occasions: on 4/6/25 at 1800; 4/9/25 at 0130; 4/10/25 at 2130; 4/11/25 at 1800; 4/11/25 at 2210; 4/12/25 at 0430; and 4/13/25 at 1900. ADON C confirmed this finding and stated it should be documented. During a concurrent interview and record review on 4/16/25 at 11:05 a.m., ADON C verified controlled substance medications were not fully accounted for four out of five residents. A review of the facility's policy and procedures (P&P) titled Administering Medications, dated April 2019, indicated: The individual administering the medication initials the resident's MAR on the appropriate line aftergiving each medication and before administering the next ones. 2. During a concurrent interview and record review with the Director of Nursing (DON), on 04/15/25 at 10:28 a.m., a random review of the controlled medication disposition records, dated 8/29/24 and 11/7/24, indicated wasted medications without a counter signature from another nurse, as follows: a. One tablet of Resident 296's oxyCODONE 5 mg was wasted without a co-signature from another nurse on 5/31/24 at 1100. b. Half tablet of Diazepam (medication to treat anxiety) 5 mg for Resident 295 was wasted without a co-signature from another nurse on 9 occasions: on 7/14/24 at 1700; 7/15//24 at 0830; 7/15/24 at 1700; 7/16/24 at 0830; 7/16/24 at 1700; 7/17//24 at 0830; 7/17/24 at 1700; 7/18/24 at 0849 and 7/18/24 at 1700. c. A film of buprenorphine (a potent pain medication) 900 micrograms for Resident 294 was wasted without a co-signature from another nurse on 6/7/24 at 2020. During the interview and record review with the DON above, she stated that the CDR for wasted medications requires two signatures. The DON confirmed the finding and stated, I did not catch that. d. During an inspection of Station 2 Medication Cart B on 4/15/25 at 12:22 p.m., a review of the CDR for Resident 81's hydrocodone/acetaminophen 5/325 mg with Registered Nurse (RN) D, indicated a tablet was wasted on 2/24/25 at 0808 without a co-signature. RN D confirmed that there should be a double signature on the CDR for this wastage. During a review of the facility's P&P titled, Controlled Substances, dated November 2022, the P&P indicated, The system of reconciling the receipt, dispensing and disposition of controlled substances include Medication Administration Record and the Waste and/ or disposal of controlled medication are done in the presence of the nurse and witness who also signs the disposition sheet.

During an interview on 4/14/25 at 10:55 a.m. with Resident 192, Resident 192 stated food was terrible, and vegetables were mushy. During an interview on 4/15/25 at 9:34 a.m. with Resident 61, Resident 61 stated food did not taste good. During a concurrent dining observation and interview on 4/15/25 at 12:13 p.m. with Resident 192, Resident 192 stated carrot was mushy. Resident 192 did not eat all the carrots on her plate. During a concurrent dining observation and interview on 4/15/25 at 1:00 p.m. with Resident 25 stated food lacked flavor. Resident 25 also stated carrots were overcooked. Resident 25 pressed his fork on the carrots on his plate and were easily mashed. During a lunch test tray conducted on 4/16/25 at 1:32 p.m. with the Dietary Manager (DM), Dietary Director (DD), Registered Dietician (RD) S, and Registered Dietician (RD) L, Regular Diet and Pureed Diet lunch trays were presented and both had mashed potato. DM and DD verified mashed potato lacked flavor. A review of facility's ordered diet list indicated 105 residents were on Regular diet, including pureed texture. A review of facility's policy and procedure (P&P) entitled Food Preparation dated 2023, the P&P indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance . Based on observation, interview and record review, the facility failed to ensure food was palatable for residents when food was served overcooked and lacked flavor for residents on Regular Diet. This failure had the potential to affect meal and food intake which could impair the nutrition status of residents. Findings: During a dining observation on 4/16/25 at 1:10 p.m. in Resident 346's room, Resident 346 open his meal tray to expose a plate that included mash potatoes. Resident 346 tasted the potatoes and immediately said they had no flavor they, Do not taste good. During a concurrent interview Resident 346 stated, I will not eat those, there is no flavor .

Based on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to all residents. This failure had the potential to affect the nutritional and psychosocial wellbeing of residents who may receive snacks at the facility. Findings: During the Resident Council Meeting on 4/16/25, the Residents attending stated they have never have received snacks, the kitchen is closed after 7pm. 1a. During an interview on 4/17/25 at 1:33 p.m. with Resident 17, Resident 17 stated, Dinner comes about 6 p.m. and breakfast comes about 9 a.m., sometimes I want a snack at night, when I ask for one, they do not provide it. 1b. During an interview on 4/18/25 at 7:49 a.m. with Registered Nurse (RN) T, RN T stated, Residents do not ask for snacks, if needed we can get an order. There are no snacks available at night. 1c. During an interview on 04/18/25 at 2:34 p.m. with Resident 83, Resident 83 stated, I request snacks, and they are not provided. 2. During an interview with Resident 400 on 4/14/2025 at 11:07 a.m., Resident 400 stated she was not getting any bedtime snacks. Resident 400 further stated, I am diabetic. I need to have a snack at night. During a concurrent interview with both registered dietician L (RD L) and registered dietician S (RD S) and record review of Resident 400's clinical records on 4/16/2025 at 2:34 p.m., RD L confirmed Resident 400 had diagnosis of diabetes mellitus (DM - a condition which affects the way the body processes blood sugar). RD L stated bedtime snack would come out of the kitchen around 8:00 p.m. and they (both RDs) monitor the bedtime snacks for residents with DM. RD L continued to review Resident 400's order summary report and stated Resident 400's order was just may have HS (at bedtime) snack at bedtime . RD L further stated, nurses should be the one to provide Resident 400's snack if she would ask for it. Both RD L and RD S stated they only prepared snacks for residents with physician's order. During a follow up interview with Resident 400 on 4/18/2025 at 1:37 p.m., Resident 400 complained that she did not get her bedtime snack on 4/17/2025. Resident 400 further stated she asked the certified nursing assistant assigned to her, but she was told that they did not have a bedtime snack for her. Resident 400 confirmed there were two dieticians who spoke to her about her bedtime snacks' preferences on 4/16/2025 but was still not getting her bedtime snacks. During an interview with licensed vocational nurse U (LVN U) on 4/18/2025 at 2:17 p.m., LVN U stated kitchen staff provided resident's bedtime snacks. LVN U confirmed nurse stations did not have a storage for resident's snacks. 3a. During an interview on 4/15/25 at 9:34 a.m. with Resident 61, Resident 61 stated, no snacks were available when it was past 8 p.m. or when the kitchen was already closed. 3b. During an interview on 4/18/25 at 1:30 p.m. with Resident 25, Resident 25 stated snacks at bedtime were never offered. 3c. During an interview on 4/18/25 at 02:09 p.m. with Resident 192, Resident 192 stated, she was not given snacks at bedtime when she asked for it. Resident 192 also stated bedtime snacks were never offered. During an interview on 4/17/25 at 4:27 p.m. with the Dietary Manager (DM), DM stated snacks were delivered to nurse stations at 8:00 p.m. for residents based on their physician orders. The DM also stated there were no kitchen staff by 9:30 p.m. During an interview on 4/18/25 at 12:18 p.m. with Registered Nurse (RN) O, RN O stated, only residents with physician order for bedtime snacks were given snacks at bedtime. RN O also stated bedtime snacks were not available for residents without physician order for bedtime snacks when the kitchen was closed. During an interview on 4/18/25 at 12:20 p.m. with Certified Nurse Aide (CNA) P, CNA P stated bedtime snacks were delivered only for residents with physician order for bedtime snacks. During a concurrent interview and record review on 4/18/25 at 2:53 p.m. with the Dietary Director (DD), the DD verified the list of residents (Total, 41) with orders for snacks at bedtime. The DD stated, Not everyone needs bedtime snacks. A review of facility's policy and procedure (P&P) entitled, Nourishment Policy dated 2023, the P&P indicated, . Bedtime snacks of a nourishing quality will be offered routinely to all residents unless contraindicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation and food storage methods, according to standards of practice and facility policy when: 1. Frozen [NAME] (a type of fish) was stored in the freezer without use by date and opened cereals without open and used by dates. 2. Metal container was stored wet. 3. Pureed food was prepared in a sink These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1a. During the initial kitchen observation on 4/14/25 at 9:11 a.m. with the Dietary Manager (DM), an opened box of frozen [NAME] was found in the freezer without use by date. The DM stated the [NAME] can be used for six months and must be labeled with the use by date. 1b. During an initial kitchen observation on 4/14/25 at 9:22 a.m. with the DM, DM verified two opened cereals in plastic bags without labels for open and use by dates were found in the dry pantry. A review of facility's policy and procedure (P&P) entitled Labeling and Dating of Foods dated 2023, the P&P indicated. Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and date. Procedure: .Newly opened food items will need to be closed and labeled with an open date and use by the date A review of facility document entitled Dry Goods Storage Guidelines dated 2023, the document indicated Ready To Eat Cereals can be stored for six months unopened on the shelf and two months when opened on shelf. 2. During an observation in the kitchen for pureed food preparation on 4/16/25 at 9:56 a.m. with Dietary Aide (DM) M and Registered Dietician (RD) L, DM M took a metal container and drops of water were visible as DM M took it from a stack under a table. RD L verified the container was wet. RD L stated container must be dry when stacked. 3. During an observation in the kitchen for pureed food preparation on 4/16/25 at 9:58 a.m. with Dietary Aide (DM) M, Registered Dietician (RD) L, and Dietary Director (DD), DM M was preparing pureed meat. DM M put a metal container in the food preparation sink and poured the pureed meat into the container. The sink was visibly wet. DD stated it was best practice to scoop pureed food into a container instead of putting the container in the sink. DM M proceeded to scoop pureed food into the container. A review of facility's policy and procedure (P&P) entitled Food Preparation dated 2023, the P&P indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an accurate and systematically organized documentation in accordance with accepted professional standards and practices for one of five sampled residents (residents with peek-a-boo mittens [a type of mitten, often used in healthcare settings, that have a flap on the top that allows for easy inspection of the hand without removing the mitten and designed to prevent patients from removing medical equipment attached to them]) when Resident 23's used of peek-a-boo mitten was not documented in all her weekly summaries (a concise report that provides an overview of a resident's care and progress over the past week). This failure resulted an inaccurate and inappropriate documentation of Resident 23's weekly summaries. Findings: Review Resident 23's clinical record titled, admission Record, dated 4/16/2025, it indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid [CSF - a clear, colorless liquid that surrounds and cushions the brain and spinal cord] is blocked within the ventricles [fluid-filled spaces] of the brain), benign neoplasm (a non-cancerous growth of cells) of spinal cord, other specified disorders of brain, dysphagia (difficulty swallowing) , and encounter for attention to gastrostomy (GT - a surgical procedure that creates an opening (stoma) into the stomach for the insertion of a feeding tube. Review of Resident 23's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 23's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 00 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 23's clinical record titled, Order Summary Report, dated 4/16/2025, indicated an order for the use of Resident 23's peek-a-boo hand mitten for prevention of pulling out her GT. During an initial observation on 4/14/2025 at 10:08 a.m., inside Resident 23's room, Resident 23 was in bed, with right hand peek-a-boo mitten was in placed, half naked with upper chest exposed and with caregiver at bedside. During a concurrent interview with director of nursing (DON) and record review of Resident 23's weekly summaries for peek-a-boo hand mitten used, DON confirmed Resident 23's used of peek-a-boo hand mitten and any related comments for its usage were not documented in the following weekly summaries dated: 2/4/2025; 2/9/2025; 2/16/2025; 2/23/2025; 3/2/2025; 3/9/2025; 3/16/2025; 3/23/2025; 3/30/2025; 4/6/2025; and 4/13/2025. DON stated nurses should have checked the Restraint box because Resident 23 had been using the hand mitten since admission and nurses should have documented any behavior or observations on Resident 23's used of the hand mitten. During a review of the facility's policy and procedure titled, Charting and Documentation, date revised 7/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their infection prevention practices were implemented when: 1. A urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drainage bag touched the floor; 2. Hand hygiene (the practice of cleaning your hands to prevent the spread of germs and illness) and the removal/change of isolation gowns (a type of personal protective equipment (PPE) used in healthcare settings to protect healthcare personnel and patients from the spread of infection or illness, particularly from contact with blood and body fluids) was not completed between tasks; 3. There was no notification to the Dialysis center of the resident's isolation precautions (measures taken to protect both patients and healthcare personnel from infection by isolating individuals who are either infected or potentially infected with a contagious disease) and type of infection. 4. The shared room for Residents 28 and 195 had no appropriate notification from Centers for Disease Control and Prevention (CDC - a set of measures aimed at preventing the spread of infections that can be transmitted through direct or indirect contact with a patient or their environment] Contact Precaution posted on the room entrance door for staff and visitors to be aware of the precaution and there was no easily accessible isolation cart (a cart used in healthcare settings to store supplies needed when caring for patients in isolation to prevent the spread of infectious diseases) placed right outside the room for quick access to needed items; 5. Certified nursing assistant Y (CNA Y) did not don (put on) the proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to entrance to the contact isolation room, and used the purple top Super Sani -Cloth (a disinfectant chemical wipes for cleaning) wipes for hand hygiene after stepping out of the COVID-19 (an infectious disease caused by a virus) isolation room; 6. Registered nurse Z (RN Z) wore a double mask: N-95 (a type of PPE, a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask on top of a surgical mask (known as a face mask, a loose fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) before entrance to a COVID-19 isolation room; 7. Certified nursing assistant AA (CNA AA) did not don the proper PPE prior to entrance in the contact isolation room of Resident 195 with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) infection and did not wash hands with soap and water upon exiting the room; 8. Certified Nursing Assistant B (CNA B) failed to perform hand hygiene when assisting Resident 194 during meal time; 9. Licensed vocational nurse U (LVN) did not wear gloves during Resident 217's urine bag care and did not perform hand hygiene before doing another task; 10. Pulmonary nurse (PN) did not wear proper PPE inside Resident 60's room who was on Contact Precaution; 11. Resident 127's oxygen nasal cannula was esposed and placed at the side of bed; 12. Physical therapy assistant (PTA) did not wear proper PPE during therapy treatment with Resident 60 in the rehabilitation (rehab) therapy room (also called the gym); 13. Resident 31's oxygen tubing observed lying on floor; 14. Resident 50's oxygen tubing observed entangled in wheel of a steel pole; 15. The tips of two Residents (145 and 209) enteral feeding tubing were left uncapped and exposed; and 16. One of three licensed nurses (LVN E) cleaned and disinfected a shared glucometer (a portable devices that measure blood glucose levels) with the appropriate disinfectant. This failure had the potential to result in the spread of bloodborne infections such as hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids), hepatitis C (viral liver infection caused by the hepatitis C virus), human immunodeficiency virus (HIV, is a virus that attacks the body's immune system), and other infections among residents. These failures had the potential to result in the spread of infection throughout the facility. Findings: 1. During an observation and concurrent interview on 4/16/25 at 10:10 a.m. with the Infection Preventionist (IP) (a specialized healthcare professional whose primary role is to prevent and control the spread of infections within a healthcare setting) in the hallway near Resident 346's room, Resident 346 was sitting in the wheelchair with his urinary catheter bag touching the floor, under the wheelchair. The IP immediately adjusted the catheter bag, confirming the bag should not be touching the floor. Review of the facility's policy & procedure titled Catheter Care, Urinary, dated 8/2022, indicated, Infection Control . Be sure the catheter tubing and drainage bag are kept off the floor. 2. During an observation on 4/16/25 at 1:11 p.m., Certified Nursing Assistant (CNA) Q was in the room with Resident 26 and Resident 27. CNA Q was observed in a gown and gloves placing a meal tray on Resident 27's tray table and arranging it within reach of Resident 27. CNA Q then took a tray to Resident 26 and arranged the tray within reach. CNA Q returned to Resident 26, opening a container on her tray. CNA Q removed her gown and gloves and noted there was no trashcan available to dispose of the gown. She removed it from the room to dispose of it, then cleaned her hands with the nearest hand sanitizer. During a concurrent interview CNA Q confirmed she did not change her gown, change her gloves or clean her hands between the residents, also confirming one of the residents were on contact isolation (using specific practices to prevent the spread of infections that are transmitted through direct or indirect contact with a patient or their environment). CNA Q stated she should have had cleaned her hands and removed her gown between residents. Review of the facility's policy & procedure titled, Isolation - Categories of Transmission-Based Precautions, dated 9/2022 revised, indicated, The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., Cohorting, placing with a low risk roommate) Staff and visitors wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). b. Gloves are removed and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 3. During an interview on 4/17/25 at 10:14 with the Infection Preventionist (IP), the IP stated, Resident 398 was positive for COVID -19 (an infectious disease caused by a virus). The IP stated the dialysis center was not notified of Resident 398's infection or isolation status, transport was endorsed and was to communicate with the dialysis center. During an interview on 4/18/25 at 1:02 p.m. with the IP, the IP stated, the dialysis center was not notified of Resident 398's type of isolation and infection because the resident was already on dialysis. Review of Resident 398's Medial Record, dated 4/9/25, the progress notes indicated, Resident 398 was admitted [DATE], after being hospitalized for a traumatic brain injury, was found to have COVID- 19. Resident 398 has a history of End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life)(ESRD), he is on dialysis, (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) that he received while in the hospital. During a review of the facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated Revised August 2013, indicated If the res ident is transported to another unit within the facility or to another facility, the infection preventionist (or designee) will notify the unit or facility of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is also responsible for notifying transport staff of residents that require special care due to infectious conditions. 4. During a concurrent observation and interview with the facility's IP on 4/14/2025 at 11:28 a.m., in front of Residents 28 and 195 shared room, IP confirmed the shared room was on Contact Precaution because Resident 195 was positive for C-diff infection. The following were observed: a. there was no signage of Contact Precaution posted at the entrance door of the shared room, b. there was one signage of the Transmission Based Precautions [TBP - an additional infection control practices, beyond standard precautions, used when patients have documented or suspected infections that can spread through contact, droplet, or airborne routes] posted at the left side of the entrance door, above Residents 28 and 195's name. The signage was in a regular size of paper, which indicated a small, checked mark on Contact, and not easily visible to staff and visitors, c. no isolation cart located outside the shared room. IP confirmed above observations and stated he did not put a sign at the door because the door was always open. IP further stated, staff had access to the PPE located at the hallway's wall wherein staff who cared for a resident in contact isolation had to stepped out of the isolation room and obtain another PPE to care for the other resident. IP confirmed resident's environment inside the contact precaution isolation room were considered contaminated that was the reason staff and visitors should wear the proper PPE before they entered the room. During other observations on 4/15/2025 at 12:50 p.m. and 4/16/2025 at 8:35 a.m., in front of the shared room of Resident 28 and 195, there was still no visible sign of the Contact Precaution posted at the entrance door, and no isolation cart positioned outside the isolation room door for easy accessibility of staff and visitors. During a follow up interview with IP, in the presence of the director of nursing (DON) on 4/16/2025 at 8:37 p.m., IP confirmed they still used the same signage for contact precaution isolation rooms that they had used for years, and no signage posted at the door for contact precautions. IP confirmed they did not put an isolation cart to each of the contact precaution isolation rooms because it would be a lot at the hallway combined with the enhance barrier precaution (EBP - infection control measures that involve using gowns and gloves during high-contact resident care activities, in addition to standard precautions) rooms. During a review of the facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precaution, date revised 9/2022, indicated, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. 5. During an observation on 4/14/2025 at 12:48 p.m., in front of the shared contact precaution isolation room, CNA Y entered the contact precaution isolation room without donning isolation gown and gloves. CNA Y placed Resident 28's lunch tray on his overbed table and moved the overbed table closer to Resident 28. CNA Y stepped out of the room and washed her hands with soap and water at the hallway's sink. At 12:58, CNA Y was observed stepping out of the COVID-19 isolation room and used a purple top Super Sani-Cloth wipes to clean her hands then walked across the room's hallway and performed hand hygiene with the used of the hand sanitizer. During an interview with CNA Y on 4/14/2025 at 1:03 p.m., CNA Y confirmed above observations and stated she did not wear PPE in the contact precaution room because she just served Resident 28's lunch tray. CNA Y stated she used the purple top Super Sani-Cloth to clean her hands because there was no hand sanitizer in the isolation cart, but she used a hand sanitizer which was across the room after. CNA Y confirmed the purple top Super Sani-Cloth wipes should not be used in bare skin. During an interview with DON on 4/18/2025 at 12:34 p.m., DON confirmed the purple top Super Sani-Cloth wipes should not be used for hand hygiene. DON stated the wipes should only be used for surface and equipment cleaning. During a review of CDC's Infection Control guidelines titled, Transmission-Based Precautions, dated 4/3/2024, indicated, Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon entry and properly discarding before exiting the patient room is done to contain pathogens. Review of the purple top Super Sani-Cloth wipes container label indicated it was a germicidal disposable wipe not intended for skin or baby wipe. Review of Super Sani-Cloth Germicidal Wipes Safety Data Sheet date revised 9/7/2023, indicated, Recommended use Use as a disinfectant on hard, non-porous surfaces. Read and understand the entire label before using. Use only according to label directions. It is a violation of Federal law to use this product in a manner inconsistent to label directions. Warning Hazard statements Causes serious eye irritation. May cause drowsiness or dizziness .Precautionary Statements - Prevention Wash face, hands, and any exposed skin thoroughly after handling. Description of first aid measures Skin contact Wash skin with water. Get medical attention if irritation develops or persists. 6. During an observation on 4/15/2025 at 9:21 a.m., outside the COVID-19 isolation room, RN Z donned an isolation gown, gloves and N-95 on top of the surgical mask before she entered the room. RN Z stepped out of the COVID-19 isolation room without her PPE and only the surgical mask left in placed. During an interview with RN Z on 4/15/2025 at 9:48 a.m., RN Z confirmed above observation and stated she wanted to make sure that both masks would give her protection. RN Z confirmed she was fit tested (a test used to confirm the fit of the N-95 to ensure that a tight seal forms on the wearer's face before it is used in the workplace) for the N-95 mask she wore. During an interview with IP on 4/16/2025 at 8:37 p.m., IP confirmed double masking was not allowed. IP stated staff should wear only N-95 mask whenever they entered the COVID-19 isolation room. During a review of CDC's Personal Protective Equipment guideline titled, How to Use Your N95 Respirator, dated 3/12/2025, indicated, Your N95 respirator must form a seal to your face to work properly. Your breath must pass through the N95 respirator and not around its edges .Gaps can also occur if your N95 respirator is too big, too small, or it was not put on correctly. 7. Review of Resident 195's physician order dated 3/25/2025, indicated an order of contact precautions secondary to the diagnosis of C-diff. During an observation on 4/15/2025 at 12:50 p.m., outside the shared contact precaution room of Residents 28 and 195, CNA AA entered the contact precaution room without donning an isolation gown and gloves. CNA AA set up Resident 195's lunch tray on top of his overbed table and moved the overbed table towards Resident 195. CNA AA stepped out of the room and used the hand sanitizer for hand hygiene. During a follow up interview with CNA AA on 4/15/2025 at 12:51 p.m., CNA AA confirmed above observations and stated she just dropped off Resident 195's lunch tray. CNA AA further stated Resident 195 was just on isolation because he was on chemotherapy (medicines used to treat cancer) medications, and she used the hand sanitizer because her hands were not visibly soiled. During an interview with IP on 4/16/2025 at 8:37 a.m. regarding used of hand sanitizer after lunch set up inside a C-diff (+) resident without gloves and gown, IP stated used of hand sanitizer was good enough as long as the staff hands were not visibly soiled. IP further stated staff should only washed their hands with soap and water when their hands were visibly soiled. IP confirmed staff should have worn isolation gown and gloves even when setting up Resident 195's lunch tray. During a review of CDC's guidelines titled, Preventing C. diff, dated 12/18/2024, indicated, Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person .C-diff can live on people's skin. In a healthcare setting *Make sure all healthcare professionals clean their hands before and after caring for you .*While caring for you and other patients with C. diff infection, healthcare professional will use certain precautions like wearing a gown and gloves. This will prevent the spread of C. diff to themselves and other patients. * Wash your hands with soap and water every time you use the bathroom and before you eat, 8. During an observation on 4/14/25, at 1:01 p.m., in Station 5 dining room, CNA B was observed assisting a resident to eat, after a few minutes CNA B assisted Resident 194 without performing hand hygiene. During an interview on 4/14/25. At 1:02 p.m., with CNA B, CNA B stated, we are supposed to use hand hygiene before helping each resident to eat, I did not use hand sanitizer before helping Resident 194 from the previous resident. During an review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene dated, 2019, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .o. Before and after assisting resident with meals. 9. During a concurrent observation and interview on 4/14/25 at 9:47 a.m. with Licensed Vocational Nurse (LVN) U at Resident 217's bedside, LVN U touched Resident 217's urine bag without gloves and proceeded to take Resident 217's water pitcher from the bedside table out of the room. LVN U stated he should have worn gloves before touching a resident's urine bag. LVN U also stated hand hygiene should have been done prior to touching Resident 217's pitcher. A review of facility's policy and procedure (P&P) entitled Handwashing/ Hand Hygiene revised August 2019, the P&P indicated, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. Before and after handling an invasive device(e.g., urinary catheters ) 10. During an observation on 4/14/25 at 9:50 a.m., Pulmonary Nurse (PN) was inside Resident 60's side of the room providing treatment. PN was not wearing gown and gloves inside the room. A sign for Contact Precaution was posted on Resident 60's room by the entrance. The sign indicated, gown, gloves and mask must be worn prior to entry. During an interview on 4/14/25 at 9:55 a.m. with PN, PN stated she should have worn gown and gloves when she entered Resident 60's room. A review of facility's policy and procedure (P&P) entitled Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, the P&P indicated, The following equipment and supplies will be necessary when performing tasks related to this procedure: 2.Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed) . 11. During a concurrent observation and interview on 4/14/25 at 10:53 a.m. with Case Manager N (CM N) at Resident 137's bedside, an oxygen nasal cannula was exposed on Resident 137's side of the bed. Resident 137 stated oxygen was not in use. CM N stated, oxygen cannula not in use must be kept in a Ziploc bag (a type of flexible, plastic bag with a special seal that allows you to close it and reopen it multiple times) and labeled. 12. During a concurrent observation and interview on 4/15/25 at 2:06 p.m. with the DON and IP Resident 60 was in the Rehab Therapy Room getting treatment from a PTA. PTA was not wearing facial mask, gown, and gloves. The DON and IP verified Resident 60 was on Contact Precaution and Personal Protective Equipment (PPE) should have been worn by PTA while providing treatment to Resident 60. The DON verified PTA was in close contact with Resident 60 during the treatment. During an interview on 4/15/25 at 2:20 p.m. with the PTA, PTA stated she was aware that Resident 60 was on Contact Precaution. A review of facility's document entitled Job Description: Infection Control indicated, .Responsibility: Monitoring and surveillance: You will conduct regular inspections and surveillance to identify potential sources of infections, assess compliance with infection control measures . A review of facility's policy and procedure (P&P) entitled Isolation- Categories of Transmission-Based Precautions revised September 2022 indicated .7. Staff and visitors wear gloves (clean, non-sterile) a.While caring for a resident 13. During a concurrent observation and interview on 4/14/25 at 4:20 p.m. in the room of Resident 31 with the Respiratory Therapist FF (RT FF), Resident 31 pointed to the end of her oxygen tubing that connects to her tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) lying on the floor. Resident 31 showed no signs or symptoms of distress. RT FF ran into the room of Resident 31 from the hallway while passing by the room. RT FF stated, Oh no! RT FF immediately checked Resident 31's oxygen saturation (the measurement of how well the lungs are working) then stated the oxygen tubing needed to be replaced with a new one to prevent any infections. 14. During a concurrent observation and interview on 4/14/25 at 2:15 p.m. in the room of Resident 50 with the Certified Nursing Assistant EE (RNA EE) Resident 50's oxygen tubing was observed entangled between the wheel of her roommate's intravenous pole (a medical device typically made of stainless steel used to support medical equipment). RNA EE stated the tubing, Should not be like that. RNA EE immediately untangled Resident 50's oxygen tubing from the wheel of the pole. A review of the facility's policy titled, Oxygen Administration, revised 10/2010, indicated, Steps in the Procedure .7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 15. During an observation on 4/14/25 at 1:38 p.m., the tips of the enteral feeding tubing (a flexible medical device used to deliver liquid food directly into the stomach or intestine) for Resident 145 and Resident 209 were exposed and not covered while feedings were turned off. During a concurrent observation and interview on 4/14/25 at 2:00 p.m. in the room of Resident 145 and Resident 209 with the Assistant Director of Nursing DD (ADON DD), ADON DD confirmed the tips of Resident 145's and Resident 209's enteral feeding tubing were exposed and not covered while feedings were turned off. The ADON DD stated the tips of the tubing should have plastic caps on them when the feedings are turned off to prevent the spread of infections. A review of the facility's policy titled, Infection Prevention and Control Program, revised 10/2018 indicated, .11. Prevention of Infection: a. Important facets of infection prevention include . (3)educating staff and ensuring that they adhere to proper techniques and procedures. 16. On 4/14/25 at 4:25 p.m., at Resident 497's bedside, LVN E was observed pricking the resident's right point finger to obtain a blood sugar reading by using the glucometer. On 4/14//25 at 4:27 p.m., LVN E was observed at the medication cart removing an alcohol wipe from the alcohol prep pad. LVN E used the alcohol wipe to clean and disinfect the glucometer, which she had just used on Resident 497, then placing the glucometer inside the medication cart. During an interview on 4/14/25 at 4:47 p.m., LVN E stated that she just finished the blood sugar checks on 4 residents using a shared glucometer and cleaned it with alcohol wipe between resident uses. During an interview with the Infection Preventionist (IP) on 4/14/25 at 5:12 p.m., the IP stated alcohol wipe cannot be used for glucometer. The IP stated, It's not okay to use the alcohol wipes because it does not kill certain bacteria. They should use purple-top wipe [referring to the Super Sani-Cloth, which is a surface disinfectant cleaner] with 2 minutes dwell time. A review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents. A review of a publication by the United States Food and Drug Administration (FDA) titled Blood Glucose Monitoring Test Systems for Prescription Point-of-Care Use, dated September 29, 2020, it indicated in part, The disinfectant product you choose should be effective against HIV, Hepatitis B, and Hepatitis C viruses. Of these viruses, Hepatitis B virus is the most difficult to kill and prior outbreak episodes associated with blood glucose meters have been due to transmission of Hepatitis B viruses. Therefore, disinfection efficacy studies should be performed to demonstrate effectiveness of the chosen disinfectant against Hepatitis B virus. Please note that 70% ethanol [alcohol] solutions are not effective against viral bloodborne pathogens .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe and orderly discharge for one (Resident 1) out of 2 residents when Resident 1 was discharged without established home health as ordered by the physician. This failure had the potential to put Resident 1 in danger upon returning to his home without a proper care and treatment. Findings: A review of Resident 1's medical records indicated, admission date of 1/7/24 and discharged date of 1/1/25. A review of Resident 1's diagnoses included hearing loss, gastrostomy (a surgical procedure where a tube is inserted through a small opening in the abdomen directly into the stomach) and malignant neoplasm of larynx (a cancerous tumor that forms in the voice box). A review of Resident 1's Interdisciplinary Discharge summary dated [DATE] indicated, .Transportation: Private, pick up by friend .Diet Order and Texture: three times a day enteral bolus feeding via GT [gastrostomy tube] . A review of Resident 1's Physician Orders indicated, May D/C [discharge] home on [DATE] with HH [home health], PT [physical therapy], OT [occupational therapy], ST [speech therapy], RN [registered nurse] with DME [durable medical equipment such as, wheelchair, walker, oxygen tanks, etc.] and feeding supplies. A review of Resident 1's face sheet (document that summarizes a patient's personal and medical information) indicated Resident 1's address was located away in another county very far from the county where the facility is located. During a concurrent interview and record review of Resident 1's medical records with the Social Services Assistant (SSA) on 1/3/25 at 3:13 p.m., the SSA stated Resident 1 was discharged without an approved IHSS (In-Home Supportive Services, a state program that helps low-income, elderly, blind, or disabled people pay for in-home care). The SSA also stated, Resident 1 was picked by her (SSA's) friend (SSAF) via private car on 1/1/25 and SSAF was a certified nurse aide who will look after Resident 1. The SSA verified that Resident 1 had no companion at home. The SSA also stated, Resident 1 cannot talk and used his phone to communicate via text messaging. The SSA provided the contact number for the home health agency (HHA) for Resident 1. During a phone interview on 1/3/25 at 3:30 p.m. with SSAF, SSAF confirmed SSA was her friend. SSAF confirmed she picked up Resident 1 from the facility on 1/1/25 and it was the first time she met Resident 1. SSAF stated that Resident 1's house is seven minutes away from hers. SSAF stated that Resident 1's house was cluttered. SSAF also stated that she will apply for Resident 1's IHSS on 1/6/25. SSAF verified that SSA gave her Resident 1's discharge orders about GT feeding. SSAF stated that Resident 1 cannot feed himself and needed assistance to hold the cup to pour liquid into his GT. During a phone interview on 1/6/25 at 11:53 a.m. with HHA Intake Manager (IM), the IM stated that Home Health Agency (HHA) referral was sent by the facility on 1/3/25 and was also denied on the same day by the HHA. The IM stated they do not provide speech therapy and cannot take Resident 1's case. The IM stated that the HHA spoke with the facility's SSA on 1/3/25 regarding the denial. During a phone interview on 1/6/25 at 12:47 p.m. with SSA, the SSA stated she did not get a confirmation of acceptance of referral from HHA prior to discharging Resident 1. The SSA also stated another home health agency was contacted for Resident 1 and was currently pending approval. SSA confirmed, as of 1/6/25, Resident 1 has no home health agency. During a phone interview on 1/6/25 at 1:04 p.m. with the Director of Nursing (DON), the DON stated that the physician order for discharge must be followed. Resident 1's Post Discharge Plan was requested but was not provided by the facility. A review of facility's policy and procedure (P&P) titled, Discharge Summary and Plan revised December 2016, the P&P indicated, .5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: b. Arrangements that have been made for follow-up care and services; .d. The degree of caregiver/support person availability, capacity and capability to perform care; 10. Residents .who are discharged to a home health agency .will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident1) when: 1. Resident 1's baseline care plan (a basic initial care plan created for a patient upon admission to a healthcare facility, outlining the most essential care needs and instructions until a more comprehensive care plan can be developed) related to dysphagia (difficulty in swallowing) and tube feeding (a flexible tube inserted through nose or belly to provide nutrients) were not developed in a timely manner; 2. Nurses did not notify dietitian or the attending physician when Resident 1 was admitted with tube feeding formula not in facility stocks; and 3. Licensed vocational nurse A (LVN A) signed the IV ATB administered by a registered nurse (RN) for Resident 1. These failures had the potential to compromise Resident 1's quality of care. Findings: 1. Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (primary cancer) of esophagus (a muscular tube that moves food from the throat to the stomach), secondary malignant neoplasm (a primary cancer that has spread to other parts of the body) of unspecified lung, liver, intrahepatic bile duct, and digestive organs, severe protein-calorie malnutrition (a condition that occurs when the body doesn't get enough protein, calories, and other nutrients), dysphagia, and gastrostomy status (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Review of Resident 1's clinical record titled, 48 HR BASELINE CARE PLAN, indicated, the dietary/nutritional status plan of care was completed by the registered dietitian (RD) on 7/8/2024, 72 hours after admission. Further review of the baseline care plan indicated Resident 1's problem with dysphagia and use of tube feeding were developed on 7/10/2024, 5 days after Resident 1's admission. During a concurrent interview with registered dietitian E (RD E), and record review on 10/31/2024 at 1:02 p.m., RD E reviewed Resident 1's baseline care plan and list of care plans. RD E stated baseline care planning should be done 48 hours upon resident's admission. RD E did not validate the other RD's nutritional baseline care plan's completion date. RD E stated, I did not want to speak for the other writer. Whatever is written there is what it is. During a concurrent interview and record review with social worker F (SW F), on 10/31/2024 at 2:05 p.m., SW F reviewed Resident 1's baseline care plan. SW F confirmed he was a member of the baseline care planning team, and he coordinated the meeting with the rest of the team. SW F stated the baseline care plan should be done or completed 48 hours upon resident's admission. SW F confirmed Resident 1's nutritional baseline care plan was signed as completed on 7/8/2024. During interview with assistant director of nursing B (ADON B) on 12/23/2024 at 11:06 a.m., ADON B stated, the admission nurse should have initiated resident's care plan especially if there was an order for tube feeding due to dysphagia. During a review of the facility's policy and procedure titled, Care Plans - Baseline, date revised December 2016, indicated, To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. The Interdisciplinary Team [IDT - a group of health care professionals from diverse fields who work toward a common goal for residents] will review the healthcare practitioner's orders ( .dietary needs, medications .) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: .Dietary orders .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 2. During a phone interview with Resident 1's family member (FM) on 10/31/2024 at 10:49 a.m., Resident 1's FM stated the facility was supposed to provide Resident 1's formula for tube feeding. Resident 1's FM further stated, Resident 1 was admitted in the evening of 7/5/2024 and she learned that the facility did not have the tube feeding formula ordered for Resident 1. Resident 1's FM went back to the hospital and asked for the tube feeding formula. Resident 1's FM stated the hospital provided four bottles. Resident 1's FM further stated the facility staff told her that they would order the formula, but it would take time for it to be delivered. During a review of Resident 1's Order Summary Report, it indicated an order dated 7/5/2024 of TwoCAL HN (2.0 Calories, High Nitrogen liquid formula) to be given at 45 milliliters (ml, volume of measurement) per hour (/hr) for 24 hrs thru GT. During a concurrent observation and interview with director of nursing (DON) on 10/31/2024 inside Station AA's nutritional formula's storage, DON confirmed there was no available TwoCAL HN formula. DON stated the supervisor, or the admitting nurse should have called the registered dietitian (RD) if the ordered formula was not available to obtain an alternative. During an interview with assistant director of nursing G (ADON G) on 10/31/2024 at 3:06 p.m., ADON G stated nurses have a list of formula alternatives that the RD had provided to them. ADON G further stated, the admitting nurse should have called the RD if the alternative in the list was appropriate for Resident 1's use and they should have called the physician to get an order. During an interview with assistant director of nursing B (ADON B) on 12/23/2024 at 11:06 a.m., ADON B stated nurses should have called the doctor upon Resident 1's admission to get an order for an alternative formula for tube feeding. ADON B further stated, the RD should have been called as well. Review of Resident 1's Nutrition/Dietary Progress Notes, dated 7/10/2024, indicated the new tube feeding formula with same calorie and protein contents from the previously ordered formula was just initiated, five days after Resident 1's admission. 3. During a concurrent interview with licensed vocational nurse A (LVN A) and record review on 10/31/2024 at 1:37 p.m., LVN A reviewed Resident 1's July 2024 medication administration record (MAR). LVN A confirmed he initialed the 7/11/2024 Vancomycin administration at 22:28 p.m. LVN A further confirmed the registered nurse (RN) was the one who administered Resident 1's Vancomycin. LVN A stated the RN should have initialed the MAR. During a concurrent interview with DON and record review on 10/31/2024 at 2:23 p.m., DON reviewed Resident 1's July 2024 MAR. DON confirmed LVN A should not have initialed the IV administration in the MAR. DON stated the RN who administered the IV medication should be the one to document the medication administration in Resident 1's MAR. During an interview with ADON G on 10/31/2024 at 3:06 p.m., ADON G stated RNs should be the one to document or initial the administered IV ATB in the MAR. ADON G further stated, Based on what our DON in-serviced us, that RNs should click the medication they administered. During a review of the facility's policy and procedure titled, Administering Medications, date revised April 2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: .The signature and the title of the person administering the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the pharmaceutical services to meet the needs of residents when: 1. Licensed nurses did not administer the ordered intravenous (IV, to deliver a medication into a vein) antibiotic (ATB, a medicine that inhibits the growth of or destroys bacteria) in a timely manner as documented for three of three sampled residents (Residents 1, 2 and 3); and 2. Licensed nurse used other resident's normal saline (NS - a sterile solution containing 0.9% sodium chloride [salt] in water) to mix the Vancomycin for one of three sampled residents (Resident 1). These failures resulted in medication not given to Resident's 1, 2, and 3 as per their scheduled time and had a potential to affect their health and safety. Findings: 1a. Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (primary cancer) of esophagus (a muscular tube that moves food from the throat to the stomach), secondary malignant neoplasm (a primary cancer that has spread to other parts of the body) of unspecified lung, liver, intrahepatic bile duct, and digestive organs, severe protein-calorie malnutrition (a condition that occurs when the body doesn't get enough protein, calories, and other nutrients), dysphagia, and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Review of Resident 1's clinical record titled, Order Summary Report, indicated an order of Vancomycin (a type of ATB) 500 milligrams (mg - unit of measurement) thru IV every 12 hours for infection. Further review indicated, the order was obtained on 7/11/2024 at 12:56 p.m. and with start time at 6:00 p.m. During a phone interview with Resident 1's family member (FM) on 10/31/2024 at 10:49 a.m., Resident 1's FM stated Resident 1 did not receive the ordered IV ATB on 7/12/2024 until 12:30 p.m. During a concurrent interview with licensed vocational nurse A (LVN A) and record review on 10/31/2024 at 1:37 p.m., LVN A reviewed Resident 1's July medication administration record (MAR) and nursing progress notes. LVN A confirmed Resident 1 was on his care on 7/11 and 7/12/2024. LVN A confirmed the first dose of Vancomycin was administered at 10:28 p.m. on 7/11 and the second dose was administered on 7/12/2024 at around 12:00 p.m. as documented in the progress note. LVN A stated both administration times were late. LVN A further stated nurses had a window period to administer the medication which was one hour before or one hour after the medication due time. LVN A confirmed whatever was documented was the real time the medication was administered. LVN A confirmed the Vancomycin was not available on 7/12/2024 at 6:00 a.m. During a concurrent interview with director of nursing (DON) and record review on 10/31/2024 at 2:23 p.m., DON reviewed Resident 1's MAR. DON confirmed the first dose or start dose of Resident 1's Vancomycin should have been on 7/11/2024 at 6:00 p.m. DON stated they have Vancomycin available in their emergency kit (E-Kit). During an interview with assistant director of nursing B (ADON B) and record review on 12/23/2024 at 11:06 a.m., ADON B reviewed Resident 1's MAR and nursing progress notes. ADON B confirmed she was the manager on 7/12/2024. ADON B stated, Resident 1 had an infection and had an order of IV Vancomycin. ADON B confirmed the Vancomycin was administered late on 7/12/2024. ADON B stated medication could be administered one hour before or one hour after the scheduled time. ADON B confirmed Resident 1's scheduled time for Vancomycin administration should have been at 6:00 p.m. on 7/11/2024 and 6 a.m. on 7/12/2024. ADON B stated the facility had an E-Kit for IV ATB and Vancomycin 500 mg was available. ADON B further stated, the registered nurse should have taken one Vancomycin 500 mg from the E-Kit for Resident 1 to receive the ATB on time. During a review of the facility's policy and procedure titled, Medication Ordering and Receiving From Pharmacy Provider dated 9/2010, indicated, New medications, except emergency .are ordered as follows .Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1b. Review of Resident 2's clinical record titled, admission Record, indicated Resident 2 was admitted to the facility with diagnoses including chronic respiratory failure, methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) infection, klebsiella pneumoniae (a type of bacteria that can cause infections to lungs, urinary tract and bloodstream), and Escherichia coli (E. coli - a type of bacteria that is commonly found in the intestines of humans and animals). Review of Resident 2's MAR, scheduled for December 2024, indicated an order dated 12/21/2024 to start at 8:00 p.m. for Vancomycin IV 500 mg every 12 hours for Sepsis (blood infection). During a concurrent phone interview with DON and record review of Resident 2's MAR on 12/24/2024 at 11:49 a.m., DON reviewed Resident 2's MAR. DON confirmed Resident 2's administration time for Vancomycin on 12/21/2024 was at 8:00 p.m. DON further confirmed Resident 2's Vancomycin was given at 10:51 p.m. DON stated she was not aware why the documentation was late. DON stated nurses should follow their policy to document the administration of medication once given to residents. During a phone interview with registered nurse C (RN C) on 12/30/2024 at 11:34 a.m., RN C confirmed she took care of Resident 2 on 12/21/2024. RN C confirmed medication should be given one hour before or one hour after the medication due time. RN C stated Resident 2's IV access was clogged on 12/21/2024 at 8:00 p.m. RN C further stated, she called for an IV nurse to insert a peripherally inserted central catheter (PICC - a thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart) to Resident 2. RN C confirmed she documented everything in alert charting to support her statement. During a review of Resident 2's alert charting documentation dated 12/22/2024 at 12:58 a.m., it indicated no justification of Vancomycin's late administration on 12/21/2024. Further review indicated, there was no PICC line inserted to Resident 2. During a phone interview with medical record director (MRD) on 12/30/2024 at 11:58 a.m., MRD stated she couldn't find any other documentations on 12/21/2024 except the one sent dated 12/22/2024. 1c. Review of Resident 3's clinical record titled, admission Record, indicated Resident 3 was admitted to the facility with diagnoses including chronic osteomyelitis, right ankle and foot, encounter for adjustment and management of vascular (relating to the vessels of the body, especially the arteries and veins, that carry blood and lymph) access device) and personal history of MRSA infection. Review of Resident 3's MAR, scheduled for December 2024, indicated an order dated 12/07/2024 for Vancomycin IV 500 mg once a day for osteomyelitis of foot and to be administered every 9:00 p.m. During a concurrent phone interview with DON and record review of Resident 3's MAR on 12/24/2024 at 11:49 a.m., DON reviewed Resident 3's MAR. DON confirmed Resident 3's administration time for Vancomycin on 12/9/2024 was supposed to be at 9:00 p.m. DON further confirmed Resident 3's Vancomycin was given 12/10/2024 at 01:36 a.m. DON stated she was not aware why the documentation was late. DON stated nurses should follow their policy to document the administration of medication once given to residents. Registered nurse D (RN D) who was assigned to administer Resident 3's IV Vancomycin was contacted on 12/30/2024 at 11:53 a.m. but did not answer. A second call was attempted at 2:08 p.m., RN D did not answer. Review of Resident 3's alert charting on 12/9 and 12/10/2024, indicated there was no documentation of any reasoning when the medication was administered late on 12/9/2024 at 9:00 p.m. During a phone interview with MRD on 12/30/2024 at 11:58 a.m., MRD stated she couldn't find any other documentations on 12/9 and 12/10/2024 except the ones reviewed. During a review of the facility's policy and procedure titled, Administering Medications, date revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience .7. Medications are administered withing one (1) hour of their prescribed time, unless otherwise specified . 2. During a phone interview with Resident 1's FM on 10/31/2024 at 10:49 a.m., Resident 1's FM stated Resident 1 received other IV ATB from another resident. Resident 1's FM further stated she was not sure if it was the right medication for Resident 1 because the IV bag had a different name. During an interview with DON on 10/31/2024 at 2:23 p.m., DON confirmed the nurse used other resident's NS to mixed Resident 1's Vancomycin. DON stated the nurse administered the right ATB ordered but used other resident's NS to Resident 1. During an interview with assistant director of nursing G (ADON G) on 10/31/2024 at 3:06 p.m., ADON G confirmed the nurse used NS from a discharged resident to mixed Resident 1's Vancomycin. During an interview with ADON B on 12/23/2024 at 11:06 a.m., ADON B confirmed she checked Resident 1's IV Vancomycin during infusion due to Resident 1's FM complaint on 7/12/2024. ADON B stated Resident 1 received the right medication, but it was just mixed with other resident's NS. ADON B confirmed the NS bag had another resident's name labeled on it. ADON B stated the nurse should have used the NS available in the E-Kit instead of using another resident's NS. During a review of the facility's policy and procedure titled, Administering Medications, date revised April 2019, indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident .Medication ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician promptly for one of one resident (Resident 1) when Physical Therapist (PT, who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) A did not communicate with Resident 1's charge nurse when the resident fell during her physical therapy session and sustained minor injuries. This failure had the potential to result in a delay of assessment and possible treatment to Resident 1. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) dated 6/11/24 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of oral surgical aftercare, cancer, reduced mobility. Review of Resident 1's SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION (a documentation for change of a resident's conditions) dated 4/24/24 at 3:53 p.m. indicated, Date & Time Problem or Symptom Started: 04/24/2024 12:00 [p.m.], Resident's son informed writer and ADON [Assisted Director of Nursing] that resident fell during therapy outside of the facility. Resident noted with a small excoriation on bilateral knees. Resident denies pain. MD [Medical Doctor] and RR [responsible representative] notified. During an interview on 6/11/24 at 1:02 p.m. with the Director of Rehab (DOR), the DOR stated rehab staff would report to the DOR and let the charge nurse know if a resident fell during a therapy session, a change in condition for fall would be completed, the therapist would complete a rehab post fall assessment. IDT (interdisciplinary team, a group of healthcare professionals) would meet to discuss new interventions, such as rehab recommendations. The DOR further stated the therapist did not reported to the nursing staff because Resident 1's son reported the incident before him. During an interview on 6/11/24 at 1:57 p.m. with ADON B, ADON B stated on 4/24/24, Resident 1 went out with PT A around noon, but Resident 1's fall was reported by a family member a little before 3, it was almost change of shift. The charge nurse and ADON B went to assess the resident for injury right away after they found out the fall, no major injury was noted, they notified the MD and performed treatment to Resident 1's knees. PT A should have informed the nursing department for any changes of a resident right away, not sure why it was not reported timely. ADON B further stated due to the delay of reporting, there could potentially cause a delay of assessment and treatment. During an interview on 6/11/24 at 4:32 p.m. with the Director of Nursing (DON), the DON stated PT A should not expect the family member to notify the nursing staff about the fall, he should have communicated with the nurses. During an interview on 6/12/24 at 3:30 p.m. with PT A, PT A stated Resident 1's PT session was between 11 [a.m.] to 12 [p.m.] on 4/24/24, Resident 1's son was also present. When they were walking outside of the facility, Resident 1 tripped on the sidewalk, she then landed on her hands and knees. PT A checked on the resident, did not notice any injury at that time, Resident 1 did not complain of any pain, so they keep on walking. After the physical therapy session, PT A took the resident back to the nursing station, but he did not notify the charge nurse about the fall because he didn't think it was a reportable event. He further stated rehab therapists should report any changes to the nursing staff as soon as possible. Review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing revised March 2018 indicated, Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to promote respect and dignity for one of one resident (Resident 1) when Social Services (SS) A told Resident 1 she would call 911 (a telephone number for emergencies) for a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) assessment when the resident was trying to advocate for her roommate. This failure had the potential to negatively affect the resident's dignity and psychosocial well-being. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of type 1 diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), pancreatic cancer (cancer that begins in the organ lying behind the lower part of the stomach - pancreas), absence of both upper limbs below elbows and both legs above knees. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/19/24, indicated Resident 1 had a brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 15 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. During an interview on 4/22/24 at 12:00 p.m. with Resident 1, Resident 1 stated she was trying to advocate for her roommate who was having a fever on 4/14/24, however [SS A's name] came to the room and told Resident 1 that she was going to call 911 and tell them Resident 1 was 5150, and they were going to take her away. She also stated [SS A's name]'s statement made her feeling threatened. So she called the police herself because she did not think she should be treated that way. She further stated nobody came to her to clarify anything after the incident, and the management did not address the issue. During an interview on 4/22/24 at 2:04 p.m. with Licensed Vocational Nurse (LVN) B, LVN B stated the resident had to be danger to self and danger to others to qualify for 5150, someone had to have the qualification to assess the resident and to diagnose. She further stated Resident 1 had been sweet to her, she never had any problem taking care of Resident 1. During an interview on 4/22/24 at 2:44 p.m. with SS C, SS C stated Resident 1 was alert an oriented, and very expressive. On 4/14/24, Resident 1's roommate was having a fever, the facility informed the roommate's sister, so the sister came to visit in the afternoon, Resident 1 was telling the sister Everyone here is garbage, everyone is lying, they are not taking care of [roommate's name]! [SS B's name] is lying! SS B and the sister had to step outside of the room to talk because Resident 1 would not stop talking. During an interview on 4/22/24 at 3:03 p.m. with SS A, SS A stated SS C needed help with Resident 1's situation, so she went to the room and told Resident 1, If your behavior continued to persist, I am going to have to call 911, police then will come out and potentially do a 5150 assessment on you, and potentially to send you out. She further stated she was not sure how to deescalate the situation besides bringing up 5150 in that moment, because Resident 1 had made multiple staffs cry that day. And it was like that with her almost every day. During an interview on 4/22/24 at 3:26 p.m. with the SS Director (SSD), the SSD stated she had directed SS A not to have communications with Resident 1, because SS A was not Resident 1's assigned social services staff. She further stated SS A should have not made the 5150 statements towards Resident 1, as it could potentially cause distress. During a review of the facility's policy and procedure (P&P) titled, Resident Rights , revised 12/2016, the P&P indicated, ' 'Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; Based on interview, and record review, the facility failed to promote respect and dignity for one of one resident (Resident 1) when Social Services (SS) A told Resident 1 she would call 911 (a telephone number for emergencies) for a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) assessment when the resident was trying to advocate for her roommate. This failure had the potential to negatively affect the resident's dignity and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure services provided met professional standards of practice when a licensed nurse (LN) did not ensure medications were taken for one of one sampled resident (Resident 1). For Resident 1 LN did not observe medications were taken after giving the medications to the Resident. This finding had the potential to compromise Resident 1's health and safety. Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of unspecified fracture (break in a bone) of the upper end of the right humerus (upper end of the arm bone) and superior rim of the right pubis (bone that forms the front of the pelvis), wedge compression fracture of the third lumbar vertebra (bones located in the middle of the spine), Hyperlipidemia (elevated levels of fats in the blood), Hypertensive Heart Disease (changes in the heart as a result of chronic high blood pressure) and Unspecified Atrial Fibrillation (irregular and often very rapid heart rhythm). Review of Resident 1's Minimum Data Set (MDS, as assessment tool), dated 12/24/23, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 1's Physician Orders, dated 12/19/23, indicated to give the following a.m. meds: a. Acetaminophen (Tylenol, pain medication) 500 mg (mg, a metric unit of measurement) 1 tablet every 8 hours for pain management; b. Amlodipine Besylate (used to treat high blood pressure) Oral Tablet 5 mg 1 tablet one time per day for HTN (HTN, hypertension [high blood pressure]); c. Atorvastatin Calcium (used to lower fats in the blood) Oral Tablet 40 mg 1 tablet one time per day for hyperlipidemia (high levels of fat in the blood); d. Dabigatran Etexilate Mesylate (used to decrease the risk of stroke and blood clots) 1 capsule two times per day for Atrial Fibrillation (irregular heartbeat); e. Docusate Sodium (used to manage and treat constipation) 250 mg 1 capsule two times per day for constipation; f. Fluticasone-Salmeterol Inhalation Aerosol (used to prevent asthma attacks) 2230-21 2 puffs inhale two times per day for wheezing or shortness of breath; g. Furosemide (used to treat high blood pressure) 20 mg 1 tablet two times per day for HTN; h. Hydralazine HCL (used to treat high blood pressure) 100 mg 1 tablet two times per day for HTN; i. Metoprolol Tartrate (used to treat high blood pressure) 25 mg 1 tablet two times per day for HTN; j. Montelukast Sodium (used to treat chronic asthma) 20 mg 1 tablet one time per day for wheezing or shortness of breath; k. Polyethylene Glycol (used to manage and treat constipation) 3350 Powder 17 gram (gm, a metric unit of measurement) one time per day for bowel management; and, l. Sertraline HCL (used to manage and treat major depressive and panic disorder) 50 mg 1 tablet one time per day for depression. Review of Resident 1's Physician Orders, dated 1/4/24, indicated to give Celebrex (used to treat mild to moderate pain) 200 mg 1 capsule two times per day for pain management. Review of Resident 1's Medication Administration Record (MAR) for the period 1/1/24 through 1/31/24, indicated on 1/7/24 all a.m. meds were documented as given. During an interview on, 1/10/24 at 11:40 a.m., with the Case Manager (CM), the CM stated she was notified by Resident 1's family member (FM) medications were found at the resident's bedside. During an interview on, 1/10/24 at 12:19 p.m., with certified nursing assistant A (CNA A), CNA A stated when she went to provide ADL (activities of daily living) care for Resident 1 she saw the pills in a cup at the bedside. CNA stated she left the pills at Resident 1's bedside and she did not report it to anyone. CNA A stated she should have told the nurse. During an interview on, 1/10/24 at 1:00 p.m., with licensed vocational nurse B (LVN B), LVN B stated CNA A came to him that day at around 1:00 p.m. with a cup of pills that were left at Resident 1's bedside. LVN B stated he thinks they were Resident 1's morning pills. LVN B stated he discarded the pills in the drug buster (medication disposal system). LVN B stated while Resident 1 was in the process of taking her pills that morning he was called to attend to another resident. LVN B stated he did not see Resident 1 take her pills. LVN B acknowledged he documented on the MAR Resident 1 took her pills. LVN B stated he should make sure residents take their pills before going on to the next thing and he should have reported it to the physician and the director of nurses (DON). During an interview on 1/10/24 at 1:44 p.m., with the DON, the DON stated she learned about it from the case manager. The DON stated she spoke to LVN B who stated he gave the medications, and it was verified with the MAR. The DON stated licensed nurses should stay and observe residents take their pills after they are administered to ensure they are taken. During a telephone interview on 5/3/24 at 1:52 p.m., with the DON, the DON stated upon further investigation LVN B recalled he was called to attend to another resident and left Resident 1's room during the medication administration. The DON stated LVN B was re-educated on medication administration and observation to ensure medications are taken by residents. Review of the facility's revised April 2019 policy Administering Medications indicated, medications are administered within one hour (1) of their prescribed time . Review of the facility's job description Licensed Nurse/Medication/Treatment Nurse indicated, notify .RN Nurse Supervisor of all drug .discrepancies noted on your shift . and review medication administration records for completeness of information . According to the Board of Registered Nursing Scopes of Practice in its 1973-74 session, amended Section 2725 of the Nursing Practice Act (NPA) indicated direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents necessary to implement a treatment, disease prevention, rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review facility failed to maintain respect and dignity for one out of five sampled Residents (Resident 2) when staff tried to interfere on his right to use his power wheelchair. This failure resulted in psychosocial distress to Resident 2 and his family. Findings: Review of Resident 2 ' s admission Record printed 12/5/23 indicated Resident 2 was originally admitted to the facility on [DATE], readmitted [DATE] with diagnoses including Traumatic Subdural Hemorrhage (pool of blood between the brain and its outermost covering) without loss of consciousness subsequent encounter; Type 2 Diabetes Mellitus (problem with the way the body uses and regulates sugar) with diabetic polyneuropathy (simultaneous malfunction of peripheral nerves throughout the body), generalized muscle weakness, and restless leg syndrome. Review of Resident 2 ' s Minimum Data Set (MDS, an assessment tool) dated 10/27/23 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 15, which meant he was cognitively intact (score or 13-15 = cognitively intact; 8-12 = moderately impaired, and 0-7 = severe impairment). Resident 2 had no physical or verbal behavioral symptoms directed towards others as per Section E of his MDS. Under section GG120 Mobility Devices, his MDS indicated he used a (c) Wheelchair (manual or electric). Review of Resident 2 ' s Intake Information filed with the Department on 11/17/2023 at 8:43 a.m. indicated, I am writing to lodge a complaint against the facility [name of facility] in San [NAME] for a serious violation of the American Disabilities Act (ADA) and improper conduct towards my . [Resident 2], a current resident at the facility. On November 16, 2023, at approximately 6:45 PM, while attempting to return my [Resident 2] to his bed due to discomfort of prolonged wheelchair use, I was confronted by [name of Social Services Assistant (SSA)] in the front walkway of [name of facility]. Despite my attempts to end the conversation quickly for the verbally stated purpose of returning [Resident 2] to his bed to prevent his ongoing wheelchair pain, Ms. [name of SSA] would not let me end the conversation quickly and persistently demanded that my [Resident 2] comply with the facility ' s ban on powered wheelchairs, presumably wanting me to submit to her demands within that very confrontation. She [SSA] disregarded the fact that my [Resident 2] ' s use of a powered wheelchair is medically necessary and that we had received written approval for an ADA accommodation from [name of Administrator (ADMIN)], a facility Administrator. (During the encounter with Ms. [name of SSA], I presented her with a copy of the email from [name of ADMIN], which explicitly granted permission for the wheelchair ' s use and read it out loud word for word.) Despite this, Ms. [SSA name] adamantly and incorrectly insisted that the accommodation did not apply and that my father would need to immediately cease his use of the powered wheelchair. This confrontation occurred publicly in a busy hallway of the building, causing undue distress and humiliation to my father and myself. His ADA accommodation is a private medical matter that should have been addressed in a more private and respectful manner . In response to my ADA accommodation request, we received written approval from [name of ADMIN] a top [name of SNF] administrator) confirming the legitimate use of my father ' s powered wheelchair at the facility . The lack of adherence to ADA protections and the insensitivity shown towards his condition by [name of SNF] staff is not only emotionally distressing but also a violation of his rights . When a resident request an ADA accommodation, they should be patiently listened to instead of discouraged and hushed for the sake of Medicaid Survey results. We would appreciate prompt intervention to protect my [Resident 2] ' s right of accommodation from imminent violation and to protect him from the significant unnecessary suffering that this will inflict on him. They might attempt to confiscate his wheelchair tomorrow, if [name of SSA] ' s predictions prove true . During an interview with the [family member] on 12/28/23 at 11:56 a.m., the family member stated, The facility didn ' t have the ability to communicate. There were few instances the nurses and staff who tried to take away the wheelchair, there was failure of communication, if person is not aware of their rights . I think this is unresolved. During an interview with the SSA on 1/29/24 at 2:27 p.m., she indicated she remembered the incident about the use of power wheelchair and stated, Oh yes, I spoke to his [family member]. Unless it ' s for appointments only, he is not allowed to use the power wheelchair. I said that I believe you ' re only allowed to use to and from medical appointments. When asked if resident can use the power wheelchair from the entrance of the facility to his room, SSA stated, Yes that ' s correct. When asked I she was ever confrontational, SSA stated, No, definitely not. When asked if she was aware of the [ADMIN] email regarding the power wheelchair, SSA stated, I saw a sign at the back of the wheelchair that [family member] pointed to. When asked if she read it out loud, SSA stated, No. Everything was really quick, I was with two other people, then I saw an electric wheelchair, I have to do my (due) diligence to inform him the use of electric wheelchair. The SSA stated there were no witnesses and that she was with an R/P (responsible party) of another patient that passed away. SSA further stated, I have to say it, I ' ve never seen an electric wheelchair aside from that one and it happened. When SSA was reminded that it happened in front of Station 1, SSA maintained it happened in private and that nobody was there. SSA further stated, I was informed by different people to go talk to the patient, that the patient has an electric wheelchair and it ' s not allowed, I said I believe it ' s only for medical appointments . [name of staff] the marketing director and somebody else told me. I believe she ' s the one who told me ' you need to talk to this patient; you will know when you see him. When SSA was asked if she checked with the ADMIN before confronting the patient and his family member, SSA stated, No, It did not occur to me that ' s why I messed up. I should have doubled checked with the ADMIN if it ' s allowed or not instead of just going up to the [family member] and letting him know it ' s only to and from medical appointments . No, the [name of marketing director] she was never around and did not hear the conversation. I did not, I should have checked with the ADMIN before confronting the patient. Review of the facility policy titled, Motorized Device/Scooter, revealed no indication of prohibiting residents on the use of these devices. Instead, review of this facility policy titled, Motorized Mobility Device/Scooter, indicated, Policy Statement: It is the policy of the facility to provide a safe environment for all residents. The purpose of the policy is to promote safety for all residents and yet reasonably accommodate those who use motorized scooters. Policy Interpretation and Implementation: 1.Residents shall operate scooters in a conservative and safe manner, taking special precautions near doorways, at corners, when approaching others, when backing up, and in other situations that present an additional risk of injury or alarm to others in the vicinity. 2. Residents shall not operate their scooters in any way that creates a disturbance or threat of harm to the driver or others, or damage to facility or property. 3. Scooters shall not be driven faster than the natural walking speed of others in the vicinity. 4. Scooters should be maintained in safe operating condition and no unsafe modifications should be made to the scooter. 5. Residents are responsible for not permitting others to operate their scooters in a way that violates the rules. According to the Americans with Disabilities Act website (ADA.gov), . the ADA protects people with disabilities from discrimination. Disability rights are civil rights . the ADA is a law that protects people with disability in many areas of public life . Mobility Devices: Some people with disabilities use mobility to get around, such as walkers, wheelchairs, or other power-driven devices. People with disabilities may use a variety of mobility devices based on their needs . State/local government and businesses must allow a person with a disability who uses a wheelchair or other manually powered mobility aid into all areas where members of the public are allowed to go. A person with a disability who uses a golf cart or other powered option must be allowed to enter businesses and government facilities unless it can be shown that a particular type of device cannot be safely used . Requirements Regarding Mobility Devices and Aids . covered entities must allow people with disabilities who use any OPDMD (Other Power -Driven Mobility Devices) to enter premises unless a particular type of device cannot be accommodated because of legitimate safety requirements. Such safety requirements must be based on actual risks, not on speculation or stereotypes about a particular type of device or how it might be operated by people with disabilities using them . Staff Training: Ongoing staff training is essential to ensure that people with disabilities who use OPDMD for mobility are not turned away or treated inappropriately. Training should include instruction on the types of OPDMD that can be accommodated . The rules for obtaining credible assurance that the device is being used because of a disability, and the rules for the operation of the devices within the facility. Review of facility ' s policy titled, Resident Rights, revised December 2016, indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. 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: a. a dignified existence; b. be treated with respect, kindness, and dignity . f. communication with and access to people and services, both inside and outside the facility . h. be supported by the facility in exercising his or her rights . i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . j. be informed about his or her rights and responsibilities . p. be informed of, and participate in, his or her care planning and treatment .t. privacy and confidentiality . u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear or discrimination or reprisal .

Based on observation, interview, and record review, the facility failed to ensure to provide a safe, functional, and comfortable environment for residents and staff when: 1. Room (RM) A and B TV cables were dangling; 2. RM B ' s bathroom light fixture was without cover; 3. RM B and C ' s baseboards were missing paint and dusty; 4. RM D and E ' s dresser (furniture with several drawers used to store clothes) drawer handles were broken; and 5. RM F, G, H, I, J, and K ' s dresser drawers were peeling with plastic layer hanging. This failure had the potential to affect the safety of the staff and the comfort of the residents. Findings: During an observation on 1/31/24 at 10:20 a.m. in Room (RM) A and B, the television (TV) cables were exposed and dangling from the ceiling. During an observation on 1/31/24 at 10:25 a.m. in RM B ' s bathroom, the light fixture above the sink was exposed without a cover. During an observation on 1/31/24 at 10:30 a.m. in RM B and C, the baseboards were unkept with missing paint and dusty. During an observation on 1/31/24 at 10:35 a.m. in RM D and E, the handles of the bottom drawers of the built-in dressers were not secured and loosely attached. During an observation on 1/31/24 at 10:40 a.m. in RM F, G, H, I, J, and K, the surfaces of the built-in dressers were peeling off, some of the dressers with plastic layer hanging. During an interview on 1/31/24 at 1:56 p.m. with the Maintenance Manager (MM), the MM stated they were working on the loose cables room by room, the cables should be secured and not to be dangling. The light fixture in RM B ' s bathroom, should be covered, a new light would be put in. Dresser drawer handles should be fixed and the dressers should be free of peeling plastic and painted or replaced. During a concurrent observation and interview on 1/31/24 at 3:11 p.m. with Certified Nursing Assistant (CNA) L, CNA L confirmed above observations, she stated the broken handles affected staff in using the drawers, it was hard to pull the drawers out with broken handles. She further stated the peeling plastic layer on the dressers could potentially cause injuries, staff might get hurt because how sharp it was. During a review of the facility ' s policy and procedure (P&P) titled Quality of life – Homelike Environment, revised May 2017. The P&P indicated, 1. Staff shall provide person-centered care that emphasizes the residents ' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment. During a review of the facility provided job description titled Maintenance Director undated, the job description indicated, as may directed by the Administrator to assure that our facility is maintained in a clen, safe, sanitary and comfortable manner. [ .] Safety and Sanitation, ensure that assigned work areas are maintained in a safe and attractive manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. During an observation on 11/14/23 at 9 a.m., CNA Z was feeding breakfast to Resident 162. Resident 162 was in her bed and CNA Z was standing while feeding the resident. During an interview on 11/14/23 at 9:01 a.m., with the Assistant Administrator (AADM), who was present during the above observation, the AADM verified CNA Z was standing while feeding Resident 162. The AADM stated staff should be sitting while feeding the residents and acknowledged that standing over residents while feeding could be a potential dignity issue. 2b. During an observation on 11/15/23 at 8:52 a.m., CNA CC was feeding breakfast to Resident 104. Resident 104 was sitting on her bed, and CNA CC was standing while feeding the resident. During a concurrent interview with CNA DD, who was present during the above observation, CNA DD verified CNA CC was standing while feeding Resident 104. CNA DD stated staff was supposed to sit while feeding so they could maintain eye contact with the resident. During an interview with the Director of Staff Development (DSD) on 11/15/23 at 9:12 a.m., she explained staff should not be standing while feeding because this might intimidate the residents. The facility's policy titled Dignity, revised 2/2021, indicated residents are provided with a dignified dining experience. The facility's policy titled, Assistance with Meals, revised 3/2022 indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals. Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity for four of 35 residents (28, 53, 104, and 162) when 1. Certified Nursing Assistant W (CNA W) and Certified Nursing Assistant X (CNA X) did not maintain privacy when providing care for Resident 28 and 53; and 2. Certified Nursing Assistant Z (CNA Z) and Certified Nursing Assistant CC (CNA CC) were standing while feeding Resident 162 and Resident 104. These failures had the potential to cause embarrassment and feeling low self-esteem for the residents. Findings: 1a. Review of Resident 28's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 11/13/23 at 8:18 a.m., Resident 28 was sitting on the wheelchair in her room and facing the room door. CNA W was changing her without closing the door or the curtain. Resident 28 was naked from the waist up and could be seen from the hallway. During a concurrent interview with CNA W, she stated she should close the door before changing Resident 28. 1b. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 11/13/23 at 12:50 p.m., CNA X was helping Resident 53 to go to the restroom in the station's lobby. CNA X left Resident 53 in the restroom and walked out without closing the restroom door. Resident 53 pulled down her pants and could be seen from the lobby. During a concurrent interview with CNA X, she stated she should close the restroom door to provide privacy for Resident 53. Review of the facility's policy, Dignity, dated 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 81). Failure to assess had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: Review of Resident 81's medical record indicated he was admitted to the facility on [DATE]. The medical record indicated the facility completed an admission MDS, which was dated 6/19/23. Further review of Resident 81's medical record indicated the facility scheduled a quarterly MDS with a date of 9/15/23. The record indicated this MDS was still In Progress and not Completed. The record further indicated this quarterly MDS was supposed to be completed by 10/3/23 and was 43 days overdue. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 11/15/23 at 12:51 p.m., she reviewed Resident 81's medical record and confirmed the facility did not complete the quarterly MDS dated [DATE]. The MDSC explained the quarterly MDS should have been completed no later than 92 days after the previous MDS. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2023, indicated the quarterly MDS must be completed at least every 92 days following the previous MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 35 sampled residents (Residents 117 and 121). This failure had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: 1. Review of Resident 117's medical record indicated she was admitted on [DATE] and had the diagnoses of anxiety, dementia (mental disorder caused by brain disease or injury), and epilepsy (a brain disorder that causes seizures). Review of Resident 117's SBAR (Situation, Background, Assessment, Recommendation) documentation, dated 6/12/23, indicated Resident 117 had a witnessed fall. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 11/15/23 at 9:56 a.m., she reviewed Resident 117's medical record and confirmed the resident fell on 6/12/23. The MDSC explained this fall should have been coded on the MDS dated [DATE]. The MDSC reviewed Resident 117's MDS, dated [DATE], and confirmed section J1800 was coded No, indicating the resident did not fall during the specified time frame. The MDSC confirmed section J1800 should have been coded Yes, to indicate Resident 117 did fall during the specified time frame. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2023, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame. 2. Review of Resident 121's medical record indicated she was admitted on [DATE] and had the diagnosis of end-stage renal disease (the kidneys cease functioning on a permanent basis). Review of Resident 121's Order Summary Report indicated she had a physician's order, dated 5/19/23, to have dialysis (a procedure used to purify the blood for residents whose kidneys no longer function properly) every Monday, Wednesday, and Friday. Resident 121's MDS, dated [DATE], was reviewed. Section O0110 of the MDS indicated to check (mark) the treatments that were performed for the resident in the last 14 days. The section for dialysis was not checked. Review of Resident 121's dialysis communication forms indicated she went to dialysis on 9/15/23, 9/18/23, 9/20/23, 9/22/23, 9/25/23, and 9/27/23 (all dates that fell within the 14-day time frame indicated in the above MDS). During an interview and concurrent record review with the MDSC on 11/17/23 at 11:14 a.m., she confirmed Resident 121 went to dialysis three times a week. The MDSC reviewed Resident 121's 9/27/23 MDS and verified the dialysis portion of section O0110 did not reflect that the resident received dialysis during the specified time frame. The MDSC acknowledged this section should have been checked to indicate Resident 121 did receive dialysis. The CMS RAI Manual, dated 10/2023, indicated for section O0110, Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. The RAI Manual further indicated to code dialysis which occurs at the nursing home or at another facility.

Based on interview, and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASARR, is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of 35 residents (Resident 32) when a PASARR was not done after Resident 32 had a significant change in condition. This failure resulted in Resident 32 not being evaluated and placed the resident at risk for not receiving the appropriate care or services. Findings: Review of Resident 32's clinical record indicated she was admited to the facility 12/9/20 with diagnoses including dementia (decline in mental capacity affecting daily function) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 32's PASSAR, dated 12/11/20, indicated the evaluation was negative. Review of Resident 32's minimum data sets (MDS, an assessment tool), indicated she had a significant change assessment completed on 8/28/23. There was no documentation that another PASSAR was completed after 8/28/23. During an interview on 11/15/23 at 11:42 a.m., the MDS Coordinator (MDSC) and MDS Coordinator CCC (MDS CCC) stated the facility should have conducted a PASSAR for Resident 32 after her significant change assessment in 8/28/23. MDS CCC confirmed the last PASSAR done for Resident 32 was in 2020. Review of the facility's policy, Pre-admission Screening and Resident Review, dated 1/2016 indicated, The DON or designee has overall responsibility in ensuring the timely completion of the PASSR per guidelines of the CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement interventions to maintain the ability to communicate for one of 35 sampled residents (Resident 104). This failure had the potential to result in Resident 104's needs not being met. Findings: Review of Resident 104's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), diabetes (disease that affects the body's ability to control blood sugar), hypertension (high blood pressure) and depression. Review of Resident 104's Minimum Data Set (MDS, an assessment tool), dated 9/27/23, indicated her speech was clear and she was usually able to make herself understood. The MDS indicated Resident 104's preferred language was a foreign language and she needed an interpreter to communicate with health care staff. The MDS further indicated communication was to be addressed in Resident 104's care plan. Further review of Resident 104's medical record indicated there was no care plan to address the resident's potential communication barriers. During an observation on 11/15/23 at 8:33 a.m., the Director of Staff Development (DSD) and Certified Nursing Assistant CC (CNA CC) were in Resident 104's room. The resident was speaking to the DSD and CNA CC in a foreign language and it appeared as though they did not understand what she was saying. More staff members came to the room and tried to ask Resident 104 what she needed, but the resident kept speaking in a foreign language and it appeared as though the staff did not understand her. Staff tried providing things to the resident, such as a jacket and blanket, but the resident removed them. This interaction between Resident 104 and facility staff lasted almost 20 minutes. There was no communication board (a sheet of symbols or pictures the resident can point to, to communicate her needs) in the resident's room. Staff did not attempt to use any translation services to communicate with Resident 104. During a concurrent interview with CNA CC, she confirmed she did not understand what Resident 104 was saying. CNA CC also confirmed there was no communication board in Resident 104's room. During an observation on 11/15/23 at 8:52 a.m., the Social Services Director (SSD) came into Resident 104's room with a communication board. The SSD asked CNA CC if she knew how to use the communication board, and CNA CC said she did not. The SSD explained how to use the communication board and left it in the resident's room. A few moments later, Resident 104 continued trying to communicate with CNA CC in a foreign language. However, CNA CC still did not attempt to use the communication board. During an interview with the DSD on 11/15/23 at 9:12 a.m., she confirmed staff did not understand what Resident 104 was saying while speaking in a foreign language. The DSD acknowledged the communication board should have been in the resident's room. She also acknowledged staff could have used the facility's translation services to communicate with Resident 104. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 11/15/23 at 9:56 a.m., she reviewed Resident 104's medical record and acknowledged that the 9/27/23 MDS indicated a communication care plan was to be developed. The MDSC confirmed the facility did not develop a care plan to address Resident 104's communication. The facility's policy titled Translation and/or Interpretation of Facility Services, revised 11/2020 indicated, It is understood that providing meaningful access to services provided by this facility requires also that the LEP [limited English proficiency] resident's needs and questions are accurately communicated to the staff. The policy further indicated that information that is not available in written translation shall be provided through the following means: a.) A staff member who is trained in the skill of interpreting; b.) A staff interpreter who is trained and competent in the skill of interpreting; c.) The facility's contracted interpreter service; d.) Voluntary community interpreters; and e.) Telephone interpretation service. The facility's policy titled Accommodation of Needs, revised 3/2021, indicated in order to accommodate individual needs and preferences, maintain adaptive devices and equipment, such as communication boards, for the residents. The facility's policy titled Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an activity program was provided to one of 35 sampled residents (Resident 618). This failure had the potential to affect the overall well-being and quality of life of the resident. Findings: A review of Resident 618's clinical record indicated he was admitted on [DATE] and had diagnoses including surgical aftercare following surgery on the genitourinary system and dementia (a decline in mental capacity affecting daily functioning). His minimum data set (MDS, an assessment tool), dated 10/11/23 indicated he was not able to complete the brief interview for mental status. It also indicated Resident 618 felt it was very important to listen to music he liked and somewhat important to have books, newspapers, and magazines to read for him. During a review of Resident 618's activities care plan, the care plan included interventions to offer a la carte activities, magazines and the newspaper; offer 1:1 visit if unable to attend out of room events. During an observation from 11/13/23 to 11/16/23 in Resident 618's room, there were no books, newspapers, or magazines for the resident observed. During an observation and interview on 11/16/23 at 3:20 p.m. with the Activities Director (AD), there were no books, newspapers, or magazines for the resident. The AD confirmed this observation and agreed that books, newspapers, and magazines should have been available for the resident. During an interview and record review on 11/16/23 at 3:30 p.m. with the AD, she reviewed Resident 618's activity care plan and stated Resident 618 always refused to attend out of room activities. The AD acknowledged that a 1:1 room visit should have been offered for Resident 618 if he did not attend out of room activities. There was no evidence that a 1:1 room visit was offered for Resident 618. The AD stated she could not locate the 1:1 room visit documentation for Resident 618. During a review of the facility's policy and procedure (P&P) titled Activity Program, revised 6/2018, the P&P indicated, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Activities are scheduled 7 days a week. All activities are documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an observation on 11/13/23 at 8:53 a.m., Licensed Vocational Nurse UU (LVN UU) mixed Miralax powder 17 grams (g, unit of measurement) with 4 ounces (oz, unit of measurement) of orange juice in a cup. LVN UU then proceeded to administer the medication by placing the cup near the resident's lips and having the resident take a sip until the cup was empty. The resident was coughing every time he took a sip. During a concurrent interview and record review with LVN UU on 11/13/23 at 9:19 a.m., LVN UU verified Resident 55's diet order was pureed, nectar thick consistency and stated thickener should have been added with the medication. During a review of Resident 55's clinical record, Resident 55 was admitted on [DATE] with clinical diagnoses of dysphagia following cerebral infarction (difficulty swallowing after a stroke), hemiplegia and hemiparesis following cerebral infarction affecting dominant side (paralysis of one side of the body). Review of the Resident 55's Care Plan, dated 11/28/23, indicated, Has swallowing problem-Dysphagia and at risk for aspiration .will have food and fluids provided at a consistency . fluid consistency as ordered. During an interview on 11/14/23 at 10:35 a.m., with Assistant Director of Nursing VV (ADON VV), ADON VV stated thickener should be added when mixing Miralax and use spoon when administering medication. Review of the facility's Administering Oral Medications policy and procedure (P&P) dated October 2010, the P&P indicated Review the resident's care plan to assess for any special needs of the resident. 3. Review of the Face Sheet (a document that provides resident specific information at a quick glance) indicated Resident 193 was admitted on [DATE] with diagnoses that included anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), dependence on respirator (ventilator, a medical device that gives oxygen through a breathing tube), pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), pressure ulcer of left buttock, unspecified open wound of right thumb. Review of Resident 193's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/30/23, indicated Resident 193's cognitive skills for daily decision making was severely impaired. Resident 193 required total dependence from staff with all activities of daily living. Review of Resident 193's Braden Scale (Scale that determine risk for pressure sore), revealed Resident 193 had a Braden scale of 13, was considered a moderate risk for developing pressure ulcers. Resident 193 was confined to bed and had a very limited mobility. Resident 193 made occasional slight changes in body or extremity, but was unable to make frequent or significant changes independently. Review of Resident 193's Initial Change of Condition (COC)/Alert Charting & Skilled Documentation, dated 10/1/2023, indicated, SITUATION .Right ear pressure injury (open wound and redness on the Right ear) . redness on the surrounding and pain in the affected area . Skin/Wound Status . new open wound on rt [right] ear with redness on the surrounding area . Resident always leaning on the rt side, immobile, unable to turn himself and with contacted [contracted] body position . Review of Resident 193's Skin Assessments, dated 10/5/23, 10/12/23, 10/19/23, and 10/22/23, indicated there were no skin assessments regarding Resident 193's right ear open wound. A skin assessment of the right ear wound was not conducted until 10/28/23. Review of Resident 193's Skin Assessment (Pressure Injury), dated 10/28/23, indicated Resident 193's Right Ear Open Wound measured at 3.7 centimeters (cm) in length x 2.1 cm in width x 0.1 cm in depth. Review of Resident 193's Skin Assessment (Pressure Injury), dated 11/4/23, indicated Resident 193's Right Ear Open Wound measured at 4.2 cm in length x 2.9 cm in width x 0.1 cm in depth. During a wound treatment observation with Licensed Vocational BBB (LVN BBB) on 11/15/23, at 1:45 p.m., in thr resident's room, Resident 193 was lying in bed, awake, contracted, and aphasic. LVN BBB performed treatment on Resident 193's right ear wound, there was a moderate amount of bleeding noted from the old dressing. During an interview and concurrent record review with the LVN BBB on 11/16/23, at 1 p.m., LVN BBB stated Resident 193's new right ear wound on 10/1/23 was a change in condition. LVN BBB confirmed the weekly skin assessments for Resident 193's right ear wound was not conducted on 10/5/23, 10/12/23, 10/19/23, and 10/22/23. LVN BBB stated that weekly skin assessment of Resident 193's right ear open wound should have been done weekly. LVN BBB stated on 10/4/23, there was a scab forming on Resident 193's right ear indicated healing and left it open to air. LVN BBB stated monitoring of the right ear wound should have been initiated in the treatment record on 10/4/23, as the right ear wound re-opened on 10/26/23 and was noted to be larger and macerated. Review of the Wound Consult notes with LVN BBB, dated 10/4/23, and 10/6/23, there were no record of assessment done regarding Resident 193's right ear wound. During an interview with Certified Nursing Assistant H (CNA H) on 11/17/23, at 2:45 p.m., CNA H assigned to Resident 193 on 10/1/23 confirmed the presence of redness on Resident 193's right ear prior to that date. The CNA H observed Resident 193's right ear wound on 10/1/23 while providing care and noted that, initially, it affected only the outside portion of the upper and middle parts of the ear. However, the CNA H further stated the Resident 193's right ear wound worsened from the time it was first identified on 10/1/23. Further review of Resident 193's medical record indicated there were no care plans to address the right ear open wound. During an interview and concurrent record review with the Director of Nursing (DON) on 11/17/23, at 12:30 p.m., she reviewed Resident 193's record and confirmed there were no care plans to address resident's right ear open wound. The right ear open area care plan was initiated on 10/26/23. The DON stated the charge nurse was supposed to develop a care plan when Resident 193's right ear open wound was identified on 10/1/23. The DON reviewed the Alert charting notes and confirmed there were no follow up documentations and skin assessments of Resident 193's right ear open wound until 10/26/23. The DON stated weekly skin assessments are conducted by the treatment nurse, the DON further stated that skin assessments should be performed when providing skin treatments to residents. The DON stated nursing staff should have a 72 hour follow up documentation and monitoring of the right ear wound until healed, after it was identified on 10/1/23. Review of Resident 193's Nursing Progress Note, dated 10/4/23, indicated the Nurse Practitioner (NP) was notified of Resident 193's .pressure injury on the right ear. The patient is contracted and bedbound favored on the right side. Ordered wound consult and also ordered try to turn the patient on the left side to relieve pressure. We will continue to monitor . During an interview and concurrent record review with the DON on 11/17/23, at 12:34 p.m., the DON reviewed Resident 193's progress notes on 10/4/23 and COC/Alert Charting & Skilled Documentation, order summary report. The DON confirmed that there were no wound consult order in the Order Summary Report. The DON also confirmed that there was no wound consult ordered until 10/24/23. The DON stated the charge nurse should have carried out the NP's order on 10/4/23. During an interview and concurrent record review with the NP on 11/1/7/23, at 4:45 p.m., the NP stated she was made aware of Resident 193's right ear open wound by the visiting NP on 10/4/23. The NP stated that she saw a picture of the right ear wound on 10/4/23 sent by the visiting NP. The NP described the right ear wound as a stage 2 that time with the epidermis gone, exposing only the dermis. The NP reviewed the nurse progress notes, dated 10/4/23, and NP confirmed that there was an order for wound consult. The NP stated the wound consult order should have been carried out. Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for five of 35 residents (53, 55, 81, 193, and 265) when: 1. Resident 81 did not have treatment orders for the redness like rash on his both arms and a scratch below his left knee; 2. Licensed Vocational Nurse RR (LVN RR) did not follow the physician's order when providing the treatment for Resident 53's pressure ulcer (skin or soft tissue injury that form due to prolonged pressure exerted over specific areas of the body) on her left buttock; 3. For Resident 193, staff did not conduct weekly skin assessments and monitoring, develop a care plan, and implement the wound consultation (consult) order timely for Resident 193's new right ear open wound identified on 10/1/23; 4. For Resident 265, staff did not follow the physician's order for wound treatment and did not implement the wound consult order timely; and 5. Licensed Vocational Nurse UU (LVN UU) administered a medication mixed in thin liquid for Resident 55. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 81's admission Record indicated he was admitted to the facility on [DATE]. During an observation on 11/13/23 at 1:33 p.m., Resident 81 had redness like rashes on both arms and a scratch below his left knee. Review of Resident 81's physician order indicated there were no treatment orders for Resident 81's redness like rashes on his arms and the scratch below his left knee. During an observation on 11/15/23 at 9:32 a.m., Resident 81 still had redness like rashes on both arms and a scratch below his left knee, and he still did not have the physician's treatment orders for the redness on his arms and the scratch below his left knee. During an observation and interview with Licensed Vocational Nurse RR (LVN RR) on 11/15/23 at 9:38 a.m., she confirmed Resident 81 had redness like rashes on both arms and a scratch below his left knee. LVN RR reviewed Resident 81's physician order and confirmed that Resident 81 did not have the treatment orders for the redness on his arms and the scratch below his left knee. Review of the facility's undated policy, Alteration in Skin Integrity, indicated Residents with alteration in skin integrity will be assessed, orders for treatment will be obtained and care plans will be developed. 2. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 53's clinical record indicated she had a pressure ulcer stage 2 (there is partial-thickness skin loss) on her left buttock. Review of Resident 53's physician order, dated 11/7/23, indicated she had an order for the licensed nurse to cleanse the pressure ulcer on her left buttock with normal saline (NS, 0.9% purified salt solution), pat dry, apply Calmoseptine (used to treat and prevent skin irritations), then cover with dry dressing every day and evening shift. During an observation on the treatment for Resident 53's left buttock pressure ulcer, on 11/15/23 at 11:33 a.m., LVN RR cleansed Resident 53's pressure ulcer with NS, patted it dry, then she applied DermaSeptin (skin protectant ointment) to the wound and covered it with dry dressing. During an interview with LVN RR on 11/15/23 at 11:45 a.m., she acknowledged that she should apply Calmoseptine to Resident 53's left buttock pressure ulcer as ordered by the physician and not DermaSeptin. Review of the facility's policy, Administering Medications, dated 4/2019, indicated Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders. 4. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity) and dysphagia (difficulty swallowing). Review of Resident 265's Skin Assessment, dated 7/19/23 indicated the resident had two trochanter (a bony prominence on the thigh bone close to the hip) pressure ulcers. The assessment also indicated the MD was notified and received new treatment orders and wound consult. Review of Resident 265's orders, indicated an order, dated 7/19/23, Wound MD consult for L [left] trochanter wound. Review of Resident 265's Skin Assessment, dated 8/4/23 indicated the two small trochanter pressure ulcers merged into one wound. The assessment also indicated, Notified MD. New order for Wound care consult ordered . Documentation of Resident 265's wound consults in August 2023 were requested. There were no August 2023 wound consults provided. Review of Resident 265's Skin Assessment, dated 9/8/23 indicated, Had wound consult for left trochanter wound this week with NP. Review of Resident 265's wound counsult notes indicated the resident was seen by the wound provider on 9/6/23. Review of Resident 265's orders, indicated an order, dated 8/5/23 to cleanse the wound on left trochanter with normal saline, pat dry, apply Santyl and cover with foam dressing twice a day and as needed. Review of Resident 265's August 2023 Treatment Administration Record, indicated the treatment order to cleanse the wound on left trochanter with normal saline, pat dry, apply Santyl and cover with foam dressing was done once a day. During concurrent interview and record review on 11/20/23 at 8:25 a.m., Wound Treatment Nurse EEE (WTN EEE) stated usually wound consults occur within 48 hours. WTN EEE confirmed Resident 265's treatment order was only done once a day and treatments should have been done twice a day. During an interview on 11/21/23 at 11:33 a.m., the Medical Director (MD) stated a wound consult should occur within a couple of days to one week, depending on the availability of the NP. Review of the undated facility's policy, Alteration in Skin Integrity, indicated, Residents with alteration in skin integrity will be assessed, orders for treatment will be obtained and care plans will be developed . Skin alteration will be assessed by licensed staff to include: a. Description of skin alteration (measurement of affected skin areas) . Development of plan of care . An IDT Conference will be held to discuss any skin problem not responding to treatment and appropriate interventions to promote healing will be implemented, including dermatological consult, etc . Weekly skin progress reports will be completed using non-pressure skin form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 618) had and was wearing his hearing aids (small devices placed in the ear to amplify sound). This failure had the potential to compromise the residents' health, ability to relate to others, and psychosocial well-being. Findings: A review of Resident 618's clinical record indicated he was admitted on [DATE] and had diagnoses including surgical aftercare following surgery on the genitourinary system and dementia (a decline in mental capacity affecting daily functioning). His Minimum Data Set (MDS, an assessment tool), dated 10/11/23 indicated he was not able to complete the brief interview for mental status and had adequate hearing with hearing aids. During an observation and interview from 11/13/23 to 11/14/23 in Resident 618's room, he did not respond to greetings but just stared. During an interview on 11/15/23 at 3:31 p.m. with Resident 618's family member, she stated Resident 618 could not hear without his hearing aids. The family member stated she brought his hearing aids to the facility and gave them to facility staff. Resident 618 was wearing a hearing aid on his right ear. The family member searched for the other hearing aid, and found it in the side table drawer. The family member handed the hearing aid to Resident 618 and the resident put it into his left ear. Resident 618 stated he could hear now. During an interview and record review on 11/16/23 at 9:10 a.m. with the Minimum Data Set Coordinator (MDSC), she confirmed Resident 618's MDS dated [DATE], which indicated his hearing was adequate with hearing aids. The MDSC confirmed there was no care plan for the use of hearing aids regarding hearing difficulty. The MDSC acknowledged that a care plan for the use of hearing aids regarding hearing difficulty should have been developed. During an interview and record review on 11/16/23 at 9:20 a.m. with Assistant Director of Nursing B (ADON B), she confirmed Resident 618's inventory list dated 10/07/23, which indicated he was admitted with one pair of hearing aids. ADON B stated that obtaining a physician's order to apply in the morning, remove at night, and store in the medication cart when not in use was part of the facility's hearing aids management. ADON B stated that staff should have assisted Resident 618 to use his hearing aids. There was no physician's order for the hearing aid management. ADON B stated she could not locate any documentation indicating staff have assisted Resident 618 to use his hearing aids. During an interview on 11/16/23 at 9:30 a.m. with Licensed Vocational Nurse DDD (LVN DDD), he stated he did not know if Resident 618 had hearing aids because there was no physician's order. During a review of the facility's policy and procedure (P&P) titled Assistive Devices and Equipment, revised 1/2020, the P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents. The facility provides the resident with assistance in locating available resources to obtain assistive devices that are not provided by the facility, including: glasses, contact lenses, or magnifying devices, and hearing aids, amplifiers, mittens, splints, etc. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 149's clinical record indicated she was admitted on [DATE] and had diagnoses including left shoulder disorders of bone density and structure (weak bone). During an observation and interview on 11/16/23 at 8:40 a.m., Resident 149 was lying in bed and calling out for help. Her call light was placed on her bed within reach. Resident 149 stated she could not use her call device because it was very hard to press the device due to arthritis in her hands. Certified Nursing Assistant FF (CNA FF) responded to Resident 149's calling out, and the resident asked for help using her TV remote control. Resident 149 stated she could not use the TV remote control. During an interview on 11/16/23 at 8:47 a.m. with CNA FF, she stated that Resident 149 needed assistance with most of her activities of daily living (ADL) due to her hand pain. Review of Resident 149's plan of care note by a nurse practitioner dated 10/05/23 included: 1. Pain management-diclofenac sodium gel apply two times a day for arthritis on affected area. Review of Resident 149's History and Physical (H&P) from the acute hospital included X-ray right hand-extensive degenerative (loss or decline of function) change with multiple joint subluxations (a partial dislocation) noted, 12/30/2021; diagnoses: arthritis-she does have limited hand strength secondary to significant arthritis, 11/11/23. Review of Resident 149's care plan indicated there was no care plan developed for hand arthritis. During an interview and record review on 11/16/23 at 9:01 a.m. with the Minimum Data Set Coordinator (MDSC), she confirmed the above record review. The MDSC stated she could not locate any documentation indicating an intervention for hand arthritis. The MDSC further stated that she was not aware that Resident 149 had difficulty using her call device. The MDSC acknowledged that a care plan for hand arthritis should have been developed for Resident 149. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, revised 10/2010, the P&P indicated, The purpose of the procedure is to respond to the resident's requests and needs. Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. 1b. Review of Resident 65's medical record indicated she was admitted on [DATE] and had the diagnosis of osteoarthritis (degeneration of the joints that causes pain and stiffness). Review of Resident 65's Order Summary Report indicated she had a physician's order, dated 8/16/23, for RNA for range of motion (ROM) to both upper and lower extremities (right and left hands, arms, feet and legs) three times a week. There was no documentation that indicated Resident 65 received RNA from 8/16/23 onward. During an interview and concurrent record review with the DSD on 11/16/23 at 4:02 p.m., the DSD confirmed that RNA treatments should be documented in the resident's medical record. The DSD explained that even if a resident refused RNA treatment, this should still be documented in the medical record. The DSD reviewed Resident 65's record and confirmed there was no documentation that RNA was provided or refused from 8/16/23 onward. During a follow-up interview with the DSD on 11/17/23 at 7:39 a.m., she explained that although Resident 65's RNA order was put in the computer system, there may have been a glitch that caused the inability to document the treatments. The DSD again confirmed that RNA treatments need to be documented, and she acknowledged the staff could have documented Resident 65's treatments on paper while figuring out why they could not document on the computer. Review of the facility's policy, Restorative Nursing Services, dated 7/2017 indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Based on observation, interview, and record review, the facility failed to ensure three of 35 sampled residents (Residents 265, 65, 149) with limited mobility were provided appropriate treatment and services: 1. For Resident 265 and 65, there was no documentation that restorative nursing services (RNA, restorative care for individuals recovering from illnesses or injuries) were provided as ordered; 2. For Resident 149, there was no care plan or interventions developed to address her arthritis (inflammation or swelling in one or more joints that can result in stiffness and pain). These failures had the potential to result in decreases in mobility and complications for residents. Findings: 1a. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity). Review of Resident 265's RNA - Weekly Summary, date 6/9/23 indicated the resident was receiving passive range of motion (PROM) to the upper extremities three times a week. It also indicated, Resident will continue in the RNA Program as written with no change. Review of Resident 265's orders, indicated an order, dated 6/19/23, RNA program for ROM and strength training exercises. 3X/week [three times per week] as tolerated. There was no documentation that indicated Resident 265 received RNA services from July 2023 to October 2023. During a telephone interview on 11/16/23 at 3:18 p.m., restorative nursing assistant AA (RNA AA) stated Resident 265 was in the RNA program in the past. RNA AA stated Resident 265 was hospitalized in June 2023 and when she returned, Resident 265 was not assessed to be put back on RNA. During concurrent record review of Resident 265's RNA order and interview on 11/17/23 at 10:10 a.m., the Medical Records Director (MRD) stated the RNA order was not input into the electronic medical records correctly. During concurrent record review of Resident 265's RNA order and interview on 11/17/23 at 10:13 a.m., the Director of Staff Development (DSD) stated the RNA order was not input correctly, so the staff could not see that there was an order for RNA ROM and exercises for Resident 265. The DSD confirmed there was no documentation that indicated Resident 265 received RNA services after 6/19/23.

Based on observation, interview, and record review, the facility failed to ensure one of 35 residents (Resident 175), with an indwelling catheter (a small, flexible tube that can inserted through the bladder to drain into a urine bag) received care consistent with professional standards when there was no evidence of an order for a indwelling catheter, there was no evidence of catheter care, and there was no evidence of a care plan a indwelling catheter. These failures had the potential to put Resident 175 at risk of not receiving the interventions necessary to maintain their highest level of well-being and at risk of a urinary infection. Findings: Review of Resident 175's clinical record indicated she was admitted to the facility with multiple diagnoses including cerebral infarction (a life-threatening condition that happens when part of the brain doesn't have enough blood flow) and neuromuscular dysfunction of the bladder (lack of bladder control). During an observation on 11/13/23 at 10:45 a.m. in Resident 175's room, Resident 175 was in her bed sleeping, an indwelling catheter bag was on the floor on the left side of the bed. During a concurrent observation and interview on 11/14/23 at 9:43 a.m. with Certified Nursing Assistant MM (CNA MM), in Resident 175's room, Resident 175 indwelling catheter bag was on the floor, CNA MM indicated the catheter bag should be hanging on the side of the bed and should not be on the floor. During a concurrent interview and record review on 11/17/23 at 11:07 a.m. with Minimum Data Set Coordinator NN (MDSC NN), Resident 175's Clinical Record was reviewed. The Clinical Record indicated there was no evidence of an order for an indwelling catheter, no evidence of catheter care and there was no evidence of a care plan for an indwelling catheter. MDSC NN indicated there was no order or specific care plan for the catheter care, she was unsure when the urinary catheter was placed. During a review of Resident 175's Minimum Data Set (MDS, a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 3/8/23, the MDS indicated Resident 175's was unable to complete the interview for the Brief Interview for Mental Status (BIMS) and indicated an indwelling catheter. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person Centered, dated Revised March 2022, indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. During a review of the facility's policy and procedure titled Catheter Care, Urinary dated revised August 2022, indicated, .The following information should be recorded in the resident's medical record: The date and time that catheter care was given. The name and title of the individual(s) giving the catheter care. All assessment data obtained when giving catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for three of 35 sampled residents (Residents 209, 617, and 105) when: 1. For Resident 209 and 617, staff failed to ensure oxygen was administered as specified in the physician's order; and 2. For Resident 617, staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety. Findings: 1.a. Review of Resident 209's clinical record indicated he was admitted on [DATE] and had diagnoses including acute respiratory failure (inability to keep oxygen and carbon dioxide at normal levels) and dependence on supplemental oxygen. Review of Resident 209's physician's order, dated 11/03/17, indicated he was to receive oxygen (O2) at 2 to 3 liters per minute (LPM, rate of oxygen administration) or to keep O2 saturation (sat) above 92% via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) via concentrator. During an observation on 11/13/23 at 10:01 a.m., Resident 209's oxygen concentrator (the machine used to deliver oxygen) was set at 4 LPM. During an observation and interview on 11/16/23 at 1:10 p.m. with the Director of Staff Development (DSD), Resident 209's oxygen concentrator was set at 4 LPM. The DSD confirmed the observation. During an interview and record review on 11/16/23 at 1:14 p.m. with the DSD, she confirmed Resident 209's oxygen order and stated the oxygen concentrator should have been set at 2 to 3 LPM, not 4 LPM. The DSD confirmed staff should have checked Resident 209's concentrator to ensure the oxygen was administered at the prescribed rate. 1.b. Review of Resident 617's clinical record indicated she was admitted on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), acute respiratory failure (inability to keep oxygen and carbon dioxide at normal levels), and dependence on supplemental oxygen. Review of Resident 617's physician's order, dated 11/07/17, indicated she was to receive oxygen at 2 LPM or to keep O2 sat above 92% via nasal cannula via concentrator as needed; humidification: yes. Review of Resident 617's COPD care plan indicated, Give oxygen therapy as ordered by the physician. During an observation on 11/13/23 at 10:18 a.m., Resident 617 was receiving oxygen at 2 LPM via concentrator without a humidifier. During an observation and interview on 11/15/23 at 10:35 a.m. with Licensed Vocational Nurse DDD (LVN DDD), Resident 617 was receiving oxygen without a humidifier. LVN DDD confirmed the observation. LVN DDD stated he was not aware that a humidifier should have been applied to Resident 617. During an interview and record review on 11/15/23 at 10:43 a.m. with Assistant Director of Nursing B (ADON B), she confirmed that a humidifier should have been applied when Resident 617 received oxygen. There was no documentation indicating Resident 617 received oxygen on 11/13/23 and 11/15/23. ADON B acknowledged that oxygen use should have been documented. 2. During observations on 11/13/23 at 10:18 a.m., an oxygen concentrator was placed next to Resident 105's bed, near the window. Review of Resident 105's clinical record indicated she did not have a physician's order for oxygen. During an observation and interview on 11/16/23 at 12:40 p.m. with ADON B, Resident 105 was receiving oxygen in her room. ADON B confirmed the observation. During an interview and record review on 11/16/23 at 12:46 p.m. with ADON B, she confirmed Resident 105 did not have a physician's order for oxygen. ADON B explained that Resident 105 should have had a physician's order that specified the oxygen flow rate (how many LPM), the device used to administer the oxygen (i.e., the nasal cannula), and whether the oxygen was to be administered continuously or only as needed. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, revised 10/2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based observation, interview, and record review, the facility failed to ensure a resident receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of 35 sampled residents (Resident 49) when Resident 49's dialysis access site was incorrectly assessed and documented upon Resident 49's return to the facility and the care plan for dialysis was not specific to Resident 49's hemodialysis. This failure had the risk of causing the resident health complications. Findings: During a review of Resident 49's clinical record, the clinical record indicated Resident 49 was admitted to the facility with multiple diagnoses including end-stage renal disease (ESRD, kidney failure that requires dialysis or a kidney transplant to survive). During an observation and interview on 11/13/23 at 9:44 a.m., in Resident 49's room, Resident 49 was in the bed waiting to be transported to hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood). Resident 49 stated his access site for dialysis was in his right chest. During a review of Resident 49's clinical record, the orders dated 9/9/22 indicated Resident 49 had a Perma Catheter (a tube used for short term dialysis or until a permanent dialysis access can be created) on right subclavian (located below each of your collarbones). During a review of Resident 49's Dialysis Communication form (assessment information between facility and dialysis center before and after dialysis) dated 11/10/23, indicated Resident 49's access site was assessed for a bruit (rumbling or swooshing sound of a dialysis fistula [a connection that's made between an artery and a vein for dialysis access]) and thrill (a vibration caused by blood flowing through the fistula). During a concurrent interview and record review on 11/16/23 at 11:34 a.m. with Assistant Director of Nursing C(ADON C), the Dialysis Communication for Resident 49 dated 11/13/23 was reviewed. The Dialysis Communication form indicated upon return from dialysis, Resident 49's access site was assessed for a bruit and thrill. ADON C confirmed Resident 49's dialysis access site would not be assessed for a bruit and/or thrill since it is in his chest. ADON C indicated she is not sure why that would be filled out. Review of additional dialysis communication forms dated 10/2/23, 10/6/23, 10/13/23, 10/16/23, 10/18/23, 10/20/23, 10/23/23, 10/25/23, 10/27/23, 10/30/23, 11/1/23, 11/3/23, 11/6/23, 11/8/23, and 11/10/23, indicated yes bruit/thrill. During a current interview and record review on 11/16/23 at 12:50 p.m. with ADON C, Resident 49's care plan for dialysis was reviewed. Resident 49's care plan indicated to check percutaneous (catheter is placed in the abdominal cavity) catheter is security sutured . Assess the drained fluid for clarity and color . ADON C confirmed Resident 49 does not have a percutaneous catheter or have fluid drained at the facility. During review of the facility's policy and procedure (P&P) titled, Dialysis Services, revised November 2017 indicated ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, monitoring of the access site (fistula, graft, central venous catheter) for HD for any signs and symptoms of pain, swelling, hypotension, bleeding and infection. During review of the facility's policy and procedure (P&P) titled,Care plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated the comprehensive, person-centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . reflects currently recognized standards of practice for problem areas and conditions.

2. Resident 6 was admitted to the facility with diagnoses including Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and paranoid schizophrenia (a mental disorder in which a person feels distrustful and suspicious of other people and acts accordingly). A review of Resident 6's medical record indicated the resident had been receiving: -Lamotrigine (Lamictal, medication for seizure and mood disorders) 50 mg by mouth two times a day since 3/18/23. -Carbamazepine (Tegretol, medication for seizure and mood disorders) 200 mg 1 tablet by mouth two times a day since 3/18/23. -Benztropine (medication to treatment tremors or movement disorder) 1 mg in the morning and 2 mg at bedtime since 3/18/23. A review of Resident 6's clinical record indicated there were no diagnoses or indications for the above medications. During a concurrent interview and record review on 11/16/23 at 9:06 a.m , with the DON, the DON reviewed Resident 6's physician's orders for Lamictal, Tegretol, and benztropine, and verified there were no diagnoses or indications for them and should have been clarified since admission. During a telephone interview with the facility's CP on 11/16/23 at 10:21 a.m., the CP stated the previous CP sent recommendations to the facility for the past six months, from April 2023 to September 2023, requesting for clarification for the diagnoses of medications including the Lamictal, Tegretol, and benztropine. The CP stated the recommendations were repeated for many months because the previous ones were pending (not acted upon). A review of the CP's MRR recommendations dated April 2023, and June to September 2023, addressed to the facility, asking for diagnoses of the three medications, as follows: Resident has active order for benztropine, tegretol, and lamictal Please make sure to have appropriate diagnosis, behavior monitors and side effect monitors for the use of each medications. During a concurrent interview and record review with the DON on 11/16/23 at 11:03 a.m., the DON stated the CP's recommendations were assigned to an Assistant DON who left the facility in August. The DON acknowledged if CP's recommendations had been followed up, the indications would have been clarified prior to the survey. The DON acknowledged the deficiency regarding not following up on the CP's recommendations timely. Review of the facility's Medication Regimen Review and Reporting policy, dated 5/2016, the policy indicated, Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations, and responded to in an appropriate and timely fashion. Based on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) monthly medication regimen reviews (MRR) for two of five sampled residents (Residents 6 and 175). This failure had the potential for unsafe medication use for these residents. Findings: 1. Resident 175 was admitted to the facility in February 2023 with diagnoses which included schizoaffective disorder (a mental disorder in which people interpret reality abnormally in combination with mood disorder) and major depressive disorder. A review of Resident 175's medical record (MR) indicated the following orders for psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors): - Aripiprazole 5 milligrams (mg, a unit of measurement): Give 2 tablets via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for Schizophrenia m/b (manifested by) visual hallucinations, dated 10/12/23; and - Depakote Delayed-Release (DR, a formulation designed to release in the intestine) 250 mg: Give 1 tablet via G-tube every 8 hours for impulsive behavior, dated 8/11/23 A review of the CP's MRRs, dated August 2023, indicated recommendations were made to monitor Resident 175 for side effects and behaviors related to Depakote DR. Review of the MRRs dated September and October 2023 indicated the CP recommended monitoring for side effects and behaviors for Depakote DR and aripiprazole (brand name: Abilify). The facility had not responded to these recommendations for Resident 175. During a telephone interview on 11/16/23 at 9:33 a.m. with the facility's consultant pharmacist (CP), CP stated the expectation was for the facility to monitor for target behaviors for the use of psychotropic medication as well as their side effects. She stated recommendations had been made to monitor for behaviors and side effects for Resident 175 in August, September and October 2023, but the response was pending. CP stated the facility was expected to follow up with recommendations made by the pharmacist within a 30-day timeline. During an interview on 11/16/23 at 11:28 a.m. with the Director of Nursing (DON), the DON stated the MRRs were distributed to the managers at each nursing station. She stated the managers were expected to review and ensure timely follow up with any recommendations made within 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of five sampled residents (Resident 6 and 175) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 6 received carbamazepine (Tegretol, anticonvulsant; medication used to treat seizures, a medical condition in the brain causing stiffness, twitching or limpness), lamotrigine (Lamictal, anticonvulsant medication) and benztropine (anticholinergics, medication to treatment tremors or movement disorder) without clinical indications for use; and there were no specific behavioral symptoms for auditory and visual hallucinations (what the resident sees or hears), no monitoring for auditory hallucinations for use of Abilify (antipsychotic used to treat mental conditions), and inaccurate Abnormal Involuntary Movement Scale (AIMS; a rating scale designed to measure involuntary movements known as tardive dyskinesia [a condition affecting the nervous system often caused by long-term use antipsychotic medications]) assessment. 2. Resident 175 received Abilify and Depakote (a medication for seizure and mood disorders) Delayed Release (DR, a formulation designed to release in the intestine) without adequate monitoring of target behaviors and side effects. These failures resulted in inadequate monitoring for potential adverse consequences (such as side effects) and unnecessary medications for the residents. Findings: 1. A review of Resident 6's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental disorder in which a person feels distrustful and suspicious of other people and acts accordingly), Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). A review of Resident 6's clinical record indicated he had been receiving: - Aripiprazole (Abilify, antipsychotic) 10 milligrams (mg, unit of measurement) 1 tablet by mouth two times a day for schizoaffective disorder, chronic condition manifested by auditory hallucination since 3/18/23. -Lamotrigine (Lamictal, medication for seizure and mood disorders) 50 mg by mouth two times a day since 3/18/23. -Carbamazepine (Tegretol, medication for seizure and mood disorders) 200 mg 1 tablet by mouth two times a day since 3/18/23. - Benztropine (anticholinergics) 1 mg in the morning and 2 mg at bedtime since 3/18/23. - Divalproex (Depakote, medication for seizure and mood disorders) 500 mg 2 tablet by mouth one time a day and 3 tablets by mouth at bedtime for paranoid schizophrenia manifested by visual hallucination since 6/16/23. During a concurrent observation and interview on 11/15/23 at 8:34 a.m., Resident 6 was sitting up in bed and observed his right hand shaking constantly. Resident 6 stated it might be a side effect from his medications that started two months after he arrived at the facility. During another visit with Resident 6 on 11/16/23 at 08:40 a.m., Resident 6's right hand was observed constantly shaking. He stated the shaking was related to his nerve reacting to the medications and it is involuntary. During a concurrent interview and record review on 11/16/23 at 9:06 a.m., with the Director of Nursing (DON), the DON reviewed Resident 6's physician's order for Lamictal, Tegretol, and benztropine, and verified there were no diagnoses or indications for them and should have been clarified since admission. The DON also reviewed Resident 6's medication orders and agreed that visual and auditory hallucinations monitoring was not specific, such as what resident sees or hears. The DON also reviewed the resident's medication administration record (where nursing documented the behavior monitoring) and verified there had been no monitoring for auditory hallucination associated with the Abilify use, but should have been monitored. A review of Resident 6's AIMS assessment, dated 10/27/23, indicated it had a score of zero, meaning no abnormal involuntary movements. During a concurrent observation and interview with Resident 6 in the presence of the DON on 11/16/23 at 9:25 a.m., Resident 6's right hand was observed constantly shaking while having the conversation with the surveyors and the DON. During an interview with the DON on 11/16/23 at 9:31 a.m., the DON acknowledged the resident's right hand shaking, and stated, Yes, that's not a zero AIMS score. She confirmed Resident 6's 10/27/23 AIMS assessment was inaccurate. A review of the facility's Psychotropic Medication Use policy, dated July 2022, indicated, Psychotropic medication management includes indications for use and monitoring of behavior . Includes evaluation of the resident's signs and symptoms in order to identify underlying causes . Residents receiving psychotropic medications are monitored for adverse consequences, including tardive dyskinesia. 2. Resident 175 was admitted to the facility in February 2023 with diagnoses which included schizoaffective disorder (a mental disorder in which people interpret reality abnormally in combination with mood disorder) and major depressive disorder. A review of Resident 175's Medical Record (MR) indicated the following orders for psychotropic medications (drugs that affect brain activities associated with mental processes and behavior): - Aripiprazole 5 milligrams (mg, a unit of measurement): Give 2 tablets via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for Schizophrenia m/b (manifested by) visual hallucinations, dated 10/12/23; and - Depakote DR 250 mg: Give 1 tablet via G-tube every 8 hours for impulsive behavior, dated 8/11/23 Resident 175's MR indicated the facility was not monitoring for target behaviors and side effects related to Depakote DR. The MR indicated monitoring for behaviors and side effects related to aripiprazole began 11/14/23, over 1 month after the medication was started. During an interview on 11/15/23 at 1:28 p.m. with Assistant Director of Nursing C (ADON C), ADON C agreed side effect and target behavior monitoring for Resident 175's treatment with aripiprazole and Depakote DR should have been initiated when her treatment began. She stated this was important so the facility could evaluate how the medication affected the resident. During an interview on 11/16/23 at 9:33 a.m. with the Consultant Pharmacist (CP), the CP stated the expectation was for the facility to monitor for target behaviors and side effects whenever a psychotropic medication was initiated for a resident.

Based on observation, interview, and record review, the facility had a medication error rate of 5.71% when four medication errors occurred out of 70 opportunities during the medication administration observation for four out of eight residents (Resident 1016, 206, 103 and 109). The failure resulted in medications not given according to the physician's orders and had the potential for residents not receiving the full therapeutic effects of the medications. Findings: 1. During a concurrent observation and interview on 11/13/23 at 8:08 a.m., with Licensed Vocational Nurse A (LVN A), LVN A was observed preparing six medications for Resident 1016. LVN A stated the resident's furosemide (Lasix, medication used to treat high blood pressure and remove extra fluid in the body) was not available, and pharmacy has been notified. Review of Resident 1016's clinical record indicated a physician order of Lasix (furosemide) 20 milligrams (mg, unit of measurement) give 0.5 tablet by mouth one time a day for ascites (abdominal swelling caused by accumulation of fluid) and urinary retention (difficulty urinating and completely emptying the bladder), dated 9/14/23. Review of Resident 1016's Medication Administration Record (MAR) on 11/13/23 at 1:07 p.m., the MAR indicated LVN A documented the code 9 (Other/See progress notes) for furosemide administration on 11/13/23 at 9 a.m. Review of Resident 1016's nursing progress notes, LVN A documented, med n/a [not available] awaiting for delivery on 11/13/23 at 8:15 a.m. 2. During a medication pass observation on 11/13/23 at 4:43 p.m., Licensed Vocational Nurse Y (LVN Y) was observed preparing and administering 10 medications including a tablet of calcium 600 mg + vitamin D 400 (a supplement taken to prevent or treat soft, brittle bones) International Unit (IU, unit of potency for vitamins) to Resident 206. Review of Resident 206's clinical record indicated a physician's order of calcium carbonate-vitamin D 500 mg-10 microgram (mcg, unit of measurement) (400 mg), give 1 tablet by mouth two times a day for supplement, dated 10/22/23. During an interview with LVN Y on 11/13/23 at 5:19 p.m., LVN Y verified the physician's order was for calcium carbonate 500 mg + vitamin D 400 units, and acknowledged the medication given was not the same as the ordered. 3. During a medication pass observation on 11/13/23 at 8:28 a.m. with Licensed Vocational Nurse KK (LVN KK), LN KK was observed preparing 11 medications for Resident 103, including amiodarone (a medication used to treat or prevent heart rhythm disorders) 200 mg, calcium carbonate 500 mg, chlorthalidone (a medication to treat high blood pressure) 50 mg, vitamin D 10 micrograms (mcg, a unit of measurement) Eliquis (a medication to prevent blood clots) 2.5 mg, ferrous sulfate (an iron supplement) 325 mg, isosorbide dinitrate (a medication to treat high blood pressure) 10 mg, furosemide (a medication to treat fluid build-up) 20 mg, pantoprazole delayed-release (a medication to treat chronic heartburn) 40 mg packet for oral suspension, and ClearLax (a medication to treat constipation). Review of Resident 103's medical record indicated a physician's order for potassium chloride extended-release (ER, a long-acting formulation) 15 millequivalent (mEq, a unit of measurement), 1 tablet by mouth in the morning for hypokalemia (low potassium levels), dated 10/24/23. This medication was omitted during the medication pass observed. During a concurrent record review and interview on 11/13/23 at 11:57 a.m. with LVN KK, Resident 103's MAR dated November 2023 was reviewed. LVN KK confirmed she did not administer potassium chloride ER 15 mEq but had documented it as administered. She stated it was not available in the medication cart so she administered one tablet from Resident 103's discontinued order of potassium chloride ER 10 mEq. She stated she did not know how long the resident received 10 mEq instead of 15 mEq. LVN K confirmed nursing staff were expected to follow physician's orders and it was expected to have an active order for a medication in order to administer it. 4. During a medication pass observation on 11/13/23 at 9:49 a.m. with Licensed Vocational Nurse I (LVN I), LVN I was observed preparing six medications for Resident 191. LVN I looked in the medication cart and stated she could not locate the resident's potassium chloride oral solution. LVN I stated she would follow up with the pharmacy. Review of Resident 191's medical record indicated a physician's order for potassium chloride oral solution 20 mEq/15 milliliters (ml, a unit of measurement), give 22.5 ml by mouth one time a day for hypokalemia, dated 10/26/23. During a concurrent interview and record review on 11/13/23 at 12:12 p.m. with LVN I, Resident 191's November 2023 MAR was reviewed. LVN I stated the resident did not receive his potassium chloride scheduled for 9 a.m. on 11/13/23 because it was not available in the medication cart. She stated nursing staff were expected to reorder a resident's medication before they ran out to ensure the resident did not miss any doses. During an interview on 11/14/23 at 11:51 a.m. with Assistant Director of Nursing C (ADON C), ADON C stated nursing staff were expected to verify a physician's order against what was available for the resident to ensure medication was administered accurately and correctly to a resident. During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including required time frame. During a review of the facility's P&P titled, Administering Oral Medications, dated October 2010, the P&P indicated, Check the label on the medication and confirm the medication name and dose with the MAR . Check the medication dose. Re-check to confirm the proper dose.

Based on interview and record review, the facility failed to serve foods that accommodated residents' food allergies for one of 35 sampled residents (Resident 35). Resident 35, who was allergic to mushrooms and wheat products was served mushrooms and wheat products on two separate occasions. This deficient practice had the potential to cause severe allergic reactions and cause harm to the resident. Findings: During an interview and concurrent record review with Resident 35 on 11/13/23, at 1:10 p.m., while in Resident 35's room. Resident 35, was alert and oriented, and stated she was allergic to wheat products and mushrooms. Resident 35 stated she was served wheat bread and cream of wheat yesterday, and meat with mushroom the other day. Resident 35 further stated that she experienced rash and wheezing from wheat products and mushrooms. Resident 35 stated she already informed the Dietary Manager (DM) about her allergies to wheat and mushrooms, but the incident still occurred. Review of Resident 35's tray ticket indicated, Allergies: LACTOSE INTOLERANT, MUSHROOM, WHEAT PRODUCTS. Review of Resident 35's Order Summary Report for the month of November 2023, indicated, Allergies: .Mushroom, wheat products . During an interview with the DM on 11/16/23, at 3:45 p.m., the DM confirmed that Resident 35 had indeed served a meal with mushroom products the other day. The DM stated that she inserviced the kitchen staff, after the incident to read the tray tickets and be aware of Resident 35's allergen information. Review of facility's document, titled, Food Allergies And Reference Sheets,, dated 2023, indicated, .Food allergies may produce adverse, sometimes life threatening, effects and eliminating the allergy causing food is the only way for residents to avoid a reaction. It is important that the resident's entire care team is made aware of the food allergy and its reaction .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of clinical records for Residents 11, 105, 149, 176, and 618, advance directive forms were not located. The residents' POLST forms had check boxes that indicated: if there was an advance directive; if an advance directive was not available; or if there was no advance directive. None of the check boxes were checked for Residents 11, 105, 149, 176, and 618. There was no documented evidence that indicated an advance directives were discussed with Residents 11, 105, 149, 176, and 618 or their legally recognized decision-maker. During an interview on 11/16/23 at 3:06 p.m. with the Social Services Director (SSD), she confirmed the above record review and stated that the advance directive should have been discussed during the care conference with the legally recognized decision-maker. The SSD further stated she was responsible for providing an information about the advance directive to the legally recognized decision-maker. During a review of the facility's policy and procedure (P&P) titled Advance Directives, revised 12/2016, the P&P indicated, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Based on interview and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment should the person be unable to communicate them to a doctor and also allow residents to appoint a health care agent who will have legal authority to make health care decisions in the event that the resident is incapacitated) were discussed with the residents and/or responsible parties for nine of 35 sampled residents (Residents 3, 9, 11, 105, 134, 149, 175, 176, and 618). This failure violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives. Findings: During a review of Resident 3's clinical record, the clinical record indicated Resident 3 was admitted to the facility in June 2021 with multiple diagnoses including acute and chronic respiratory failure with hypoxia (occurs when there is not have enough oxygen in the blood) and anoxic brain damage (occurs when the brain is deprived of oxygen). Resident 3's clinical record also indicated there was another person as the responsible party. There was no evidence of an advance directive in the clinical record. During an interview on 11/14/23 at 11:01 a.m. with Admissions Staff OO (AS OO), AS OO stated if an advance directive is received it is given to social services and there is no documentation to indicate an advance directive is discussed or requested. During a concurrent interview and record review on 11/15/23 at 8:54 a.m. with Interim Sub-Acute Supervisor (ISS), Resident 3's clinical record was reviewed, Resident 3's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician specifying the types of medical treatment they want to receive during serious illness), dated 6/11/21, indicated advance directives were not discussed with the resident or resident's responsible party as it was left blank on the form. ISS indicated to check with social services. During an interview on 11/15/23 at 9 a.m. with Social Services Staff PP (SSS PP), she indicated Resident 3 does not have an advance directive and decisions are made by the responsible party (RP). SSS PP indicated she does not document advance directives in the clinical record. During a review of Resident 134's clinical record, the clinical record indicated Resident 134 was admitted to the facility in September 2023 with multiple diagnoses including diabetes (blood sugar levels are too high) and infection of an amputation (the surgical removal of all or part of a limb or extremity). During a review of Resident 134's clinical record, the POLST dated 9/21/23 indicated Resident 134 has capacity to make decisions, advanced directives were not discussed with the resident as it was left incomplete on the form. There was no evidence of an advance directive on the clinical record. During a review of Resident 175's clinical record indicated she was admitted to the facility in February 2023 with multiple diagnoses including cerebral infarction (a life-threatening condition that happens when part of your brain doesn't have enough blood flow) and acute respiratory failure with hypoxia (a life-threatening illness that can happen when your lungs are not working properly). During a review of Resident 175's clinical record, Resident 175's POLST, dated 8/15/23 indicated an advance directive dated 8/12/23 was available and reviewed. During an interview on 11/16/23 at 4:48 p.m. with SSS PP, SSS PP stated there was not an advance directive available in Resident 175's clinical record. Review of Resident 9's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including spondylosis (condition caused by aging and wear and tear on the spine) and diabetes. Review of Resident 9's POLST, dated 6/6/22 indicated the section regarding advance directives was left blank. There was no documented evidence that indicated Resident 9 had an advance directive or that advance directives were discussed with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of Resident 617's clinical record indicated she was admitted on [DATE] and had diagnoses including stage 3 pressure ulcer (pressure injuries that extend through the skin into deeper tissue and fat) of sacral region (the portion of the spine between the lower back and tailbone). During an observation on 11/13/23 at 10:18 a.m., Resident 617 was lying on a regular mattress and stated that she had a pressure ulcer. During a review of Resident 617's physician order, dated 11/07/23, the order indicated, Apply low air loss mattress for wound management/preventative measures. Check placement, settings and functionality every shift. During a record review on 11/13/23, Resident 617's November 2023 Treatment Administration Record (TAR) indicated that the low air loss mattress had been applied and checked for placement, settings, and functionality since 11/07/23. During an observation and concurrent interview on 11/13/23 at 3:37 p.m. with Assistant Director of Nursing B (ADON B), Resident 617 was lying on a regular mattress, and no low air loss mattress was observed. ADON B confirmed this observation. During an interview and concurrent record review on 11/13/23 at 4:05 p.m. with ADON B, she reviewed Resident 617's physician order and confirmed a low air loss mattress should have been applied for Resident 617 for wound management. The ADON B also reviewed Resident 617's November 2023 TAR, which indicated that the low air loss mattress had been applied and checked for placement, settings, and functionality since 11/07/23. ADON B acknowledged the licensed nurses should not have documented having applied the low air loss mattress and checked for placement, settings, and functionality if it was not performed. 9. Review of Resident 11's clinical record indicated she had a physician's order, dated 10/19/23, to change PICC (peripherally inserted central catheter to deliver medications) line dressing and caps weekly and as needed; dated 10/12/23, to flush PICC line lumen pre and post medication with 10 milliliters (ml, a unit measure dose) of normal saline (NS) every shift. Review of Resident 11's November 2023 Medication Administration Record (MAR) indicated licensed nurses had changed the PICC line dressing and caps on 11/02/23 and 11/09/23. The MAR also indicated licensed nurses had flushed the PICC line lumen with 10 ml of NS every shift. During an observation and concurrent interview on 11/14/23 at 9:19 a.m. with Licensed Vocational Nurse EE (LVN EE), Resident 11 was lying in bed, and no PICC line was observed. LVN EE confirmed this observation. Review of Resident 11's procedure documentation protocol, dated 11/01/23, indicated received order to remove PICC, removed PICC on right upper arm. During an interview and concurrent record review on 11/14/23 at 10:10 a.m. with the Interim Sub-Acute Supervisor (ISS), she confirmed Resident 11's November 2023 MAR, which indicated that licensed nurses had changed the PICC line dressing and caps on 11/02/23 and 11/09/23; licensed nurses had flushed the PICC line lumen with 10 ml NS every shift. The ISS confirmed that Resident 11's PICC line was discontinued on 11/01/23. The ISS acknowledged the licensed nurses should not have documented having changed the PICC line dressing and caps if it was not performed. 10a. Review of Resident 618's clinical record indicated he had a physician's order, dated 10/07/23, to measure the dislodged portion of midline and arm circumference, then document in centimeters (cm, a unit measure dose) during midline dressing change every Monday. During an observation on 11/13/23 at 12:37 p.m., Resident 618 was lying in bed, and one lumen PICC line without a cap on his left arm was observed. The PICC line dressing was dated 10/24/23, and dark-colored bloody drainage inside the dressing was observed. Review of Resident 618's October and November 2023 MAR indicated licensed nurses had measured dislodged portion of midline and arm circumference, then documented in cm during midline dressing change on 10/21/23, 10/28/23, 11/04/23, and 11/11/23. There was no documentation of the measurement for the dislodged portion of the midline and arm circumference. During an observation and concurrent interview on 11/13/23 at 3:58 p.m. with ADON B, Resident 618 was lying in bed and had one lumen PICC line without a cap on his left arm. The PICC line dressing was dated 10/24/23, and there was dark-colored bloody drainage inside of the dressing. ADON B confirmed this observation. During an interview and concurrent record review on 11/13/23 at 4:05 p.m. with ADON B, she confirmed Resident 618's October and November 2023 MAR, which indicated that licensed nurses had measured the dislodged portion of the midline and arm circumference, then documented in cm during midline dressing change on 10/21/23, 10/28/23, 11/04/23, and 11/11/23 without documentation of the measurement for the dislodged portion of the midline and arm circumference. ADON B stated that licensed nurses should have changed Resident 618's PICC line dressing and measured the dislodged portion of the midline and arm circumference, then documented as ordered. ADON B acknowledged the licensed nurses should not have documented having changed the PICC line dressing and measured the dislodged portion of the midline and arm circumference if it was not performed. During a review of the facility's policy and procedure (P&P) titled Organizational Aspects of IV Therapy, effective date 2021, the P&P indicated, Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, changing IV tubing and needleless connection devices. 10b. Review of Resident 105's clinical record indicated she had a physician's order, dated 10/15/23, to change PICC line dressing and caps every week and as needed. During an observation on 11/13/23 at 10:18 a.m., Resident 105 was lying in bed and was on IV medication via PICC line. The PICC line dressing was not dated. Review of Resident 105's October and November 2023 MAR indicated licensed nurses had changed the PICC line dressing on 10/17/23, 10/24/23, and 11/10/23. There was no documentation of the measurement for the dislodged portion of the midline and arm circumference. There was no documentation that the PICC line was flushed from 10/25/23 to 11/11/23. During an observation and concurrent interview on 11/13/23 at 3:50 p.m. with ADON B, Resident 105 was lying in bed and had the PICC line on her right arm. The PICC line dressing was not dated. ADON B confirmed this observation. During an interview and concurrent record review on 11/13/23 at 4:05 p.m. with ADON B, she confirmed Resident 105's October and November 2023 MAR, which indicated that licensed nurses had changed the PICC line dressing change on 10/17/23, 10/24/23, and 11/10/23 without documentation of the measurement for the dislodged portion of the midline and arm circumference. ADON B stated that Resident 105's PICC line dressing should have been changed weekly. ADON B acknowledged that the licensed nurses should have measured the dislodged portion of the midline and arm circumference during the dressing change. ADON B also confirmed there was no evidence that the PICC line was flushed from 10/25/23 to 11/11/23. ADON B acknowledged that the PICC line should have been flushed routinely to maintain patency. During a review of the facility's Policy and Procedure (P&P) titled Infusion Therapy Procedures: Maintaining Patency of Peripheral and Central Vascular Access Devices, dated 8/2016, the P&P indicated, Vascular access devices are flushed and aspirated for a blood return prior to each infusion to assess catheter function and prevent complications. All vascular access devices should be flushed routinely when not in use to maintain patency. 4. Review of Resident 175's clinical record, the clinical record indicated Resident 175 was admitted to the facility with multiple diagnoses including cerebral infarction (a life-threatening condition that happens when part of your brain doesn't have enough blood flow). During an observation on 11/13/23 at 10:45 a.m. in Resident 175's room, Resident 175 was in bed with peek a boo mitts on the left and right hand. During a review of Resident 175's clinical record, the orders dated 3/27/23 indicated Peek a boo hand mitten on right hand every shift for prevent pulling G-tube (a tube inserted through the belly that brings nutrition directly to the stomach), trach (tracheostomy, surgically made opening (called a stoma) in the front of the neck that goes directly into the airway), may take off while doing ADLS (activities of daily living, refer to a person's daily self-care activities). During a concurrent observation and interview on 11/13/23 at 4:27 p.m. with Registered Nurse J (RN J), outside of Resident 175's room, Resident 175 was asleep with peek a boo mitts on the left and right hands. RN J confirmed Resident 175 was sleeping with mitts on both hands, indicating she was unsure when they are removed. During a concurrent observation and interview on 11/14/23 at 11:54 a.m. outside Resident 175's room, with RN WW, Resident 175 had mitts on her left and right hand. RN WW confirmed mitts on both hands and indicated mitts are only removed when doing care. During an interview on 11/15/23 at 9:23 a.m. with Licensed Vocational Nurse (LVN T), LVN T indicated mitts are removed once every shift, he was unsure if there was documentation about the removal. During a follow up concurrent interview and record review on 11/15/23 at 9:34 a.m. with LVN T Resident 175's clinical record was reviewed. Resident 175's orders indicated an order dated 11/14/23 for Peek a boo hand mitten device on right/left hands . replacing the previous order dated 3/27/23 for a right hand peek a boo mitten. LVN T indicated there is no documentation when mitts are placed or removed, or assessment completed prior to placement or when removed. During a concurrent interview and record review on 11/15/23 at 10:35 a.m. with Minimum Data Set Coordinator NN (MDSC NN), Resident 175's clinical record was reviewed. MDSC NN indicated there is no documentation indicating mitts are on or off or assessments completed. 5. During a review of Resident 99's clinical record, the clinical record indicated Resident 99 was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia (occurs when you do not have enough oxygen in your blood) and anoxia brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells). During an observation on 11/14/23 at 12:47 p.m. Resident 99 had a peek a boo mitt on the right hand. Review of Resident 99's clinical records, there was no evidence of an order or documentation for Peek a boo mittens on Resident 99. During an interview on 11/15/23 at 11:20 a.m. with RN XX, RN XX indicated there is no documented monitoring or assessments of the peek a boo mitt. During an interview on 11/16/23 at 4:42 p.m. with the Director of Staff Development (DSD), the DSD indicated she had not provided education on the use of the peek a boo mitts. During a review of the facility's policy and procedure (P&P) titled Hand Mitten Application dated October 2010, the P&P indicated, .Verify physician's order for the use of hand mittens The following information should be recorded in the resident's medical record: The date and time the device was applied. Each time the device is released for resident exercise, toileting, and position change. All assessment data (e.g., bruises, rashes, sores, circulation etc.) observed during the procedure . 6. During review of Resident 195 clinical record, the clinical record indicated Resident 195 was admitted to the facility for multiple diagnoses including pneumonia (common lung infection) and urinary tract infection (infection of the bladder). During a concurrent observation and interview on 11/13/23 at 8:32 a.m. in Resident 195's room, with Resident 195, there was a green capsule in a small clear cup on Resident 195's bedside table. Resident 195 indicated she did not know why it was there. During an interview on 11/13/23 at 8:34 a.m. with Licensed Vocational Nurse YY (LVN YY), in Resident 195 room, LVN YY indicated the capsule may have been a stomach medication, it was not supposed to be left at the bedside. During review of Resident 195's clinical record, Resident 195's orders dated 10/21/23 indicated Omeprazole Oral Capsule Delayed Release 20 mg give one capsule by mouth two times a day for GERD (Gastroesophageal reflux disease - when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). The Medication Administration Record (MAR) dated 11/13/23 indicated Resident 195's Omeprazole was signed off as given at 6:30 a.m. During review of the facility's Policy and Procedure (P&P) titled Administering Oral Medications, dated revised October 2010, the P&P indicated .The purpose of this procedure is to provide guidelines for the safe administration of oral medications Remain with the resident until all medications have been taken. 7. Review of Resident 159's medical record indicated he was admitted on [DATE] and had the diagnoses of diabetes (disease that affects the body's ability to control blood sugar) and malnutrition. Review of Resident 159's Order Summary Report indicated he had a physician's order, dated 6/2/23 for, Cleanse Abrasion on Sacrococcyx [tailbone] with NS [normal saline, solution used to clean wounds], pat dry, apply Hydrogel [substance applied to wounds to promote healing] and cover with dry dressing QD [every day] and PRN [as needed]. Review of Resident 159's Treatment Administration Record (TAR), dated 6/2023, indicated there were 12 days in the month for which there was no documentation that the above wound treatment was provided. Further Review of Resident 159's medical record indicated the facility completed a Skin Assessment for the above sacrococcyx abrasion on 6/2/23, but did not complete another Skin Assessment for this abrasion until 6/28/23 (26 days after the previous Skin Assessment). During an interview and concurrent record review with Wound Treatment Nurse EEE (WTN EEE) on 11/16/23 at 11:15 a.m., she explained wound treatments should be documented on the TAR and wound assessments should be documented in the medical record weekly. LVN EEE reviewed Resident 159's medical record and verified there were multiple wound treatment and wound assessment documentations that were not completed. The facility's policy titled Wound Care, revised 10/2010, indicated to document the type of wound care given, the date and time wound care was given, the name and title of the individual performing the wound care, and 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 care and services in accordance with professional standards of practice for 11 of 35 sampled residents (Residents 265, 32, 172, 175, 99, 195, 159, 617, 11, 618, and 105) when: 1. For Resident 265, a speech therapy consult was not done per physician order; 2. For Resident 32, staff provided the resident with salt while she was on a physician ordered no added salt diet; 3. For Resident 172, a licensed nurse failed to properly administer the resident's tube feeding and there was no order or documented assessments for the use of peek a boo hand mittens; 4. For Resident 175, there was no documented assessments or care plan for the use of peek a boo hand mittens and order for use of peek a boo mittens was not followed as indicated. 5. For Resident 99, there was no documented order, assessments or care plans for the use of peek a boo hand mittens. 6. For Resident 195, staff failed to safely administer medications when a medication was left at bedside. 7. For Resident 159, staff did not complete multiple wound treatment and wound assessment documentations. 8. For Resident 617, staff did not follow a physician's order for the use of a low air loss mattress (a mattress designed to help prevent skin breakdown); 9. For Resident 11, staff documented they administered a treatment to the resident when they did not; and 10. For Resident 618 and 105, staff failed to follow the facility's policy of intravenous (IV) therapy. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity) and dysphagia (difficulty swallowing). Review of Resident 265's SBAR (Situation, Background, Assessment, Recommendation) and Initial COC (Change of Condition), dated 10/24/23 indicated the resident had an episode of choking with fluids during feeding. Review of Resident 265's orders, indicated an order, dated 10/25/23, Urgent SLP [speech language pathologist, speech therapy] consultation. There was no documentation a speech therapy consultation was provided for Resident 265. During an interview on 11/15/23 at 1:42 p.m., the Speech Therapist (ST) stated she did not assess Resident 265 in October 2023. During an interview on 11/15/23 at 1:46 p.m., the Director of Rehabilitation (DOR) stated she did not hear about Resident 265's order for a speech therapy consultation. During an interview on 11/16/23 at 3:47 p.m., the Director of Staff Development (DSD) stated the nurses were supposed to tell rehab about Resident 265's order for a speech therapy consultation. During an interview on 11/17/23 at 9:27 a.m., the DOR stated the best practice for an urgent order is to complete the evaluation within 48 hours. The DOR stated that the order date was 10/25/23, so if she was informed about the order, she would have scheduled a speech therapy consultation for Resident 265 on 10/26/23. Review of the facility's policy, Specialized Rehabilitative Services, revised 12/2009 indicated specialized rehabilitative services include speech pathology and therapeutic services are provided only upon the written order of the resident's attending physician. 2. Review of Resident 32's clinical record indicated she was admitted to the facility 12/9/20 with diagnoses including dementia (decline in mental capacity affecting daily function) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 32's physician orders, indicated she had an order, dated 5/13/22 for No Added Salt (NAS) diet regular texture, thin liquids consistency. During an interview on 11/13/23 at 11:03 a.m., Resident 32 stated she does not get enough salt with her meals. During an observation on 11/13/23 at 1:17 p.m., Resident 32 received her lunch tray and requested a Certified Nursing Assistant (CNA) to provide her with salt. The CNA provided Resident 32 a salt packet. Resident 32 stated, I need more. The CNA provided Resident 32 another salt packet During an interview on 11/14/23 at 10:24 a.m., Certified Nursing Assistant V (CNA V) stated sometimes Resident 32 asks for more salt. CNA V stated she told Resident 32 not to add more salt but Resident 32 did not listen. CNA V stated she gives salt to Resident 32 otherwise she gets mad. During an interview on 11/15/23 at 11:12 a.m., the Registered Dietitian (RD) confirmed Resident 32 was on a No Added Salt (NAS) diet, so staff should ask the RD or doctor first prior to giving Resident 32 salt for meals. Review of the facility's policy and procedure, Meal Service, dated 2018, indicated, Meals that meet the nutritional needs of the resident will be served in an accurate manner. 3. Review of Resident 172's medical record indicated she was admitted to the facility on [DATE] with diagnoses including dependence on respirator (ventilator) status and dysphagia (difficulty swallowing). Review of Resident 172's orders indicated she had a physician order, dated 7/22/23 for Glucerna 1.2 Source at 65 cubic centimeter (cc, unit of volume) per hour continuous via NGT. Turn on at 12 p.m. and off at 8 a.m. or after the dose is completed. During an observation on 11/16/23 at 1:46 p.m., Resident 172 was in bed. The feeding pump was on and attached to Resident 172's nasogastric tube (NGT, a flexible tube inserted through the nose to the stomach for administration of nutrition and medications). Resident 172's formula was leaking onto the bed. During a concurrent interview, Resident 172's visitor stated the assigned nurse (Licensed Vocational Nurse ZZ) was aware the formula was leaking on the bed. The visitor said LVN ZZ said there was a problem with the connector and LVN ZZ would come back to replace it. During a concurrent interview, Licensed Vocational Nurse I (LVN I) stated LVN ZZ went on her lunch break. LVN I checked the connection of Resident 172's NGT and the feeding. LVN I stated there was nothing wrong with the connection. LVN I stated LVN ZZ did not rotate the connector to the on position, so the feeding was flowing onto the bed and not into Resident 172's NGT. LVN I stated the feeding pump indicated 116 cubic centimeter (cc, unit of measurement) has been dispensed but LVN I stated she was unsure how much of the 116 cc leaked on the bed. Review of the facility's policy, Assistance with Meals, revised 3/2022 indicated, Nursing staff will provide feedings to tube-fed residents. During an observation on 11/15/23 at 9:05 a.m., Resident 172 was in bed with a peek a boo mitt (mittens designed to prevent patients from removing medical equipment) on her left hand. Review of Resident 172's clinical record, indicated an order, dated 7/6/23, Place mittens for 24 hours for attempted NGT removal and monitor closely one time only for 1 Day. There was no current order for peek a boo mittens. There was no documentation when the mitten is placed or removed. There were no assessments completed prior to placement or when removed. During an interview on 11/15/23 at 11:33 a.m., the Interim Sub-Acute Supervisor (ISS) stated there was an order for mittens for one time in July. The ISS stated she could not find a current order for peek a boo mittens. During an interview on 11/16/23 at 11:12 a.m., when asked whether Resident 172 had any assessments related to the use of peek a boo mittens, the ISS stated the assessments are now done every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Provide parameters to maintain acceptable nutrition status for a planned weight loss regimen for one sampled resident (Resident 175) with severe weight loss; and 2. Complete a nutrition assessment for one of six sampled residents (Residents 104) with significant weight loss. These failures had the potential to result in undesirable and/or avoidable weight loss for two out of six sampled residents with facility reported significant weight loss. Cross reference F800 Findings: 1. Per the facility's admission Record, Resident 175 was admitted on [DATE] with diagnoses that included cerebral infarction (restricted blood and oxygen to the brain), encephalitis (inflammation of the brain), dysphagia (difficulty swallowing), type 2 diabetes (inability to manage blood sugar), and autoimmune thyroiditis (when the body makes substances to attack it's thyroid gland). Resident 175 experienced a 12.3% weight loss in six months from May 2023 to November 2023. Review of Resident 175's weight and vitals history from March 2023 to November 2023, dated 11/16/23 indicated: March 10, 2023 - 193.4 pounds May 26, 2023 - 187.6 pounds June 3, 2023 - 188.6 pounds June 21, 2023 - 187.6 pounds July 2, 2023 - 184.2 pounds July 20, 2023 - 180.4 pounds July 31, 2023 - 180.6 pounds September 28, 2023 - 169.4 pounds October 9, 2023 - 164 pounds November 1, 2023 - 164.6 pounds During an observation on 11/15/23 at 10:22 a.m , Resident 175 was lying in bed awake. The pole next to the resident's bed with 200 milliliters (ml) of a Jevity 1.5 Cal formula bottle dated 11/14/23. During a record review of Resident 175's Initial/Annual Nutrition Assessment, dated 3/7/23 completed by Registered Dietitian Q (RD Q), the nutrition assessment indicated, Resident's weight = 220 pounds, height = 65 inches, BMI = 37.6; ideal body weight (IBW) = 125 pounds, Goal weight: Maintain/lose; Recommended Energy Needs: 1489-1935 calories, 57-68 grams of protein, and 1489-1935 milliliters (mls) of fluid per day; Enteral tube feeding order: Jevity 1.5 @ 65 cc/hr for 20 hours through a gastro-intestinal (GT) tube to provide 1300 cc/1950 kcal and 83 grams of protein; water flush 150 ml every 6 hours . Goals: Adequate enteral feeding to meet estimated energy needs (EEN), Good tube feed tolerance . No significant weight loss related to nutritional status . During a record review of Resident 175's Quarterly Nutrition Assessment completed by the Registered Dietitian dated 6/1/23, the nutrition assessment indicated, Resident's weight = 187.6 pounds, height = 65 inches, ideal body weight (IBW) = 125 pounds, Goal weight: Maintain; Resident on slight weight loss trend; Enteral tube feeding order: Jevity 1.5 @ 65 cc/hr for 20 hours through a gastro-intestinal (GT) tube to provide 1300 cc/1950 kcal and 83 grams of protein; water flush 150 ml every 6 hours . Goals: Adequate enteral feeding to meet estimated energy needs (EEN) . No significant weight loss related to nutritional status . During a record review of Resident 175's Quarterly Nutrition Assessment completed by the Registered Dietitian, dated 8/16/23, the nutrition assessment indicated, . Resident's weight = 180.6 pounds, IBW = 125 pounds, Goal weight: Lose per MD; Enteral tube feeding order: Jevity 1.5 @ 45 cc/hr for 20 hours through a gastro-intestinal (GT) tube to provide 900 ml/1350 kcal and 57 grams of protein; water flush 150 ml every 6 hours . Goals: Adequate enteral feeding to meet estimated energy needs . Gradual weight loss while maintaining nutrition status . During a record review of Resident 175's Nutrition/Dietary Progress Notes dated 6/5/23, 6/23/23, and 7/19/23, the 6/5/23 progress notes indicated, Resident on slight weight loss trend since admission, MD orders planned weight loss . The 6/23/23 progress notes indicated .BMI still in obese range .may benefit from additional decrease in tube feeding to reduce rate from 65 cc/hr to 50 cc/hr to provide 1500 calories per day and 64 grams of protein. The 7/19/23 progress notes indicated .Continue with previous orders .Meets 100% of RDI (recommended daily intakes) for vitamins and minerals . During an interview on 11/15/23 at 3:29 p.m., RD Q stated Resident 175 was placed on a physician ordered weight loss and the weight loss program involved educating the resident and their family about the gradual weight loss. RD Q stated the weight loss would still provide adequate nutrition but should not go beyond an amount to prevent fatality. RD Q did not know what the parameters of the physician ordered weight loss were for Resident 175 to avoid severe weight loss. RD Q stated the planned weight loss should have parameters to prevent negative affects to the resident's nutrition status. During an interview on 11/16/23 at 10:49 a.m. with Resident 175's physician (PHYS), the PHYS stated Resident 175 was admitted with a high BMI greater than 31, therefore the physician and Registered Dietitian (RD) decided the resident would be placed on a planned weight loss regimen. The PHYS further stated the nurses complained of lifting and moving Resident 175, so weight loss would be beneficial for Resident 175's care. The PHYS stated the amount of weight loss that would be adequate for Resident 175 would be determined by the RD. The PHYS also stated the resident's current weight of 164.7 pounds should be adequate and the planned weight loss may be discontinued but a notice from the RD that the weight is acceptable would have to occur. During an interview on 11/16/23 at 11:39 a.m., the DON stated the resident's weight changes are identified by the RD and then the facility's weight committee would determine the protocol based on the RD's recommendations. The DON stated she was unaware of the parameters of the physician's ordered weight loss program. The DON stated any weight loss program should have been care planned so that it was monitored appropriately because the resident's weight goal would be listed. During an interview on 11/12/23 at 12:20 p.m. with RD Q, she stated Resident 175's goal weight should have been part of the nutrition assessment so the weight could have been monitored. During a record review of Resident 175's care plan review start date 11/13/23, the care plan indicated .Goals: . will maintain weight clinically appropriate/desirable . risk for weight loss will be minimized . Interventions: . Monitor/record/report to MD . significant weight loss of greater than 10% in 6 months . According to an American Family Physician article titled, Evaluating and Treating Unintentional Weight Loss in the Elderly, .Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. [NAME], 2002; 65: pp. 640-50. 2. Review of the Policy and Procedure titled Weight Assessment and Intervention dated 2001, showed resident weights are monitored for undesirable or unintended weight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; c. 6 months - 10% weight loss is significant; greater than 10% is severe. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: a. the resident's target weight range; b. the resident's calorie, protein, and other nutrient needs compared with resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. Review of the Weight Change Protocol dated 2023 showed early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. Residents who experience significant changes in weight or insidious (gradual and continuous) weight loss will be assessed by the facility RD (Registered Dietitian). The recommended assessment included but not limited to: Resident's usual weight and weight goal; Nutrition content of the diet provided and percent of intake for multiple days; General appearance, muscle and fat wasting; Calculate energy, protein, and fluid needs using perimeters as in the initial and annual assessment; Determine if the weight change is expected or desired outcome; Current dietary plan of care is appropriate to meet the goal; Identify reasons for the weight loss. A record review for Resident 104 revealed an [AGE] year old with diagnoses including but not limited to unspecified protein-calorie malnutrition, nutritional anemia, type 2 diabetes, major depressive disorder, schizophrenia, bipolar disorder, and muscle weakness. A record review showed IDT - Weight Variance Notes signed by Registered Dietitian Q (RD Q) and dated 8/19/23, showed Resident 104 weighed 90 lbs on 7/19/23 triggered for significant weight loss in one week. In addition, the note showed Resident 104 had a significant weight loss of 9.5% in 30 days, 7.6% loss in 90 days, and 11.1% loss in 180 days. RD Q wrote Resident 104's weight variance was clinically unavoidable due to predisposing factors including dementia and depression. RD Q also documented Resident 104 was had a decreased intake of meals of 40% to 60% and was receiving multiple supplements/snacks, but there was no RD assessment to show the resident's target weight range and/or weight goal, the resident's calorie, protein, and other nutrient needs compared with resident's current intake, and no general appearance to identify muscle/fat wasting. In an interview with RD Q on 11/17/23 at 11:25 a.m., the weight variance note dated 8/19/23 was reviewed. RD Q confirmed Resident 104 had a significant weight loss in 30 days. She confirmed the there was no documentation of Resident 104's estimated nutrient needs (ENN), no goal weight was to indicate if weight stabilization or weight gain was desired, no general appearance to identify muscle/fat wasting, and there was no comparison of nutrition content provided by the to the resident percent intake to show an estimate of calories the resident was consuming. RD Q stated she did not usually include these things in her assessment for a significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an interview on [DATE] at 12:06 p.m., with the DON, the DON stated that when a resident requested for a PRN (as-needed) controlled medication, the nurse was to assess the resident's condition, review the order, remove the medication from the medication cart, sign out from the CDR, administer the medication, and document the administration on the MAR. a. A review of Resident 94's clinical record indicated she had a physician's order for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5-325 mg, one tablet by mouth every six hours as needed for pain, dated [DATE]. During a concurrent interview and record review on [DATE] at 12:09 p.m., with the DON, a review of Resident 94's CDR for Norco and the 10/2023 MAR indicated the nursing staff removed and signed out one tablet on [DATE] at 9:28 p.m. without documenting the administration on the MAR. The DON verified the finding and reviewed the nursing progress notes but could not find any documentation. b. A review of Resident 168's clinical record indicated she had a physician's order for oxycodone (a controlled medication for pain) 5 milligrams (mg, unit of measurement) one tablet by mouth every six hours as needed for moderate to severe pain, dated [DATE]; and two tablets by mouth once daily for pain management prior to therapy, dated [DATE]. During a concurrent interview and record review on [DATE] at 12:12 p.m., with the DON, a review of Resident 168's CDR for oxycodone and the 10/2023 MAR reflected the nursing staff removed the medication and signed out of the CDR on [DATE] at 5:25 a.m., but did not document the administration on the MAR. c. A review of Resident 111's clinical record indicated she had a physician's order for oxycodone 5 mg by mouth every six hours as needed for severe pain, dated [DATE]. During a concurrent interview and record review on [DATE] at 12:15 p.m., with the DON, a review of Resident 111's CDR for oxycodone and the 10/2023 MAR reflected the nursing staff removed one tablet on [DATE] at 6 a.m. and 12 p.m., and on [DATE] at 12 p.m. and 6 p.m., but did not document the respective administration on the MAR to show they were administered to the resident. The DON verified that a total of four tablets were signed out of CDR and not documented on the MAR to account for the medication. d. A review of Resident 131's clinical record indicated he had physician's order for lorazepam (a controlled medication for anxiety/seizures) 0.5 mg by mouth every two hours as needed for anxiety, dated [DATE]. During a concurrent interview and record review on [DATE] at 12:27 p.m., with the DON, a review of Resident 131's CDR for lorazepam and the 9/2023 and 10/2023 MARs reflected the nursing staff removed and signed out on the following dates with no documentation of administration on the MAR: - [DATE] at 6:50 p.m. - [DATE] at 5 p.m. - [DATE] at 8 p.m. - [DATE] at 2 p.m. - [DATE] at 12:05 p.m. - [DATE] at 2 p.m. - [DATE] at 3 a.m. During an interview with the DON on [DATE] at 12:32 p.m., the DON stated, I see what I see. I don't see any documentation for it after reviewing the MAR and nursing progress notes. The DON verified that seven tablets were unaccounted. She acknowledged controlled medications were not fully accounted for the above residents. During a review of the facility's Administering Medications policy and procedure (P&P), dated [DATE], the P&P indicated The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. 6. During a visit to the Station D Medication Room with Licensed Vocational Nurse A (LVN A), on [DATE] at 10:57 a.m., the injectable emergency kit (e-kit, a kit/box containing medications and supplies for immediate use during a medical emergency) was observed with red seals, indicating it was opened for use. LVN A removed the red seal. A review of the e-kit logs inside the kit indicated two items were taken out on [DATE] and [DATE] (almost a month ago). During an interview with Assistant Director of Nursing B (ADON B) and LVN A on [DATE] at 10:57 a.m., both staff verified the e-kit has not been replaced since it was opened on [DATE]. ADON B stated the e-kit should have been replaced on the same day it was opened. During a visit to the Station A Medication Room on [DATE] at 11:59 a.m., with the Interim Sub-Acute Supervisor(ISS), four out of six e-kits were identified opened. The injectable e-kit was opened on [DATE] (almost a month ago) and the IV supply e-kit (kit containing solutions and supplies for intravenous injection) was opened but no log inside to indicate when it was opened. The ISS confirmed the finding and stated there have been issues with getting the e-kits replaced. During a review of facility's P&P titled, Emergency Medications, dated [DATE], the P&P indicated Medications and supplies used from the emergency medication kit must be replaced. Based on observation, interview and record review, the facility failed to ensure controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for seven of eight randomly selected residents (Residents 94, 111, 131, 168, 184, 189 and 193). Two of two randomly selected medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift. Medications for disposal in the medication storage room and one medication cart were not rendered unusable and irretrievable. Five of 13 emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1a. Resident 189 had a physician's order dated [DATE], for oxycodone (a medication to treat pain) 5 milligrams (mg, a unit of measurement), one tablet by mouth every six hours as needed for mild and moderate pain, and two tablets every six hours as needed for severe pain. Resident 189's CDR indicated one tablet was signed out on [DATE]. The MAR did not indicate that oxycodone was administered to Resident 189 on this date. 1b. Resident 193 had a physician's order dated [DATE], for Percocet (a medication to treat pain) 5/325 mg, one tablet via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) every six hours as needed for pain. Resident 193's CDR indicated one tablet was signed out on [DATE] at 10:10 p.m., one tablet on [DATE], one tablet on [DATE], one tablet on [DATE], and one tablet on [DATE]. The MAR did not indicate Percocet was administered to Resident 193 on these dates or times. 1c. Resident 184 had a physician's order dated [DATE], for Norco (a medication to treat pain) 5/325 mg, give one tablet by mouth every six hours as needed for severe pain. Resident 184's CDR indicated one tablet was signed out on [DATE] at 7:10 a.m., one tablet on [DATE] at 5 p.m., one tablet on [DATE] at 12:08 a.m., and one tablet on [DATE]. The MAR did not indicate Norco was administered to Resident 184 on these dates or times. The MAR indicated one tablet was administered to Resident 184 on [DATE] at 1:01 a.m. but was not signed out on the CDR. During a concurrent interview and record review on [DATE] at 12:24 p.m. with Assistant Director of Nursing C (ADON C), ADON C reviewed the discrepancies between the MARs and CDRs for Resident 189, Resident 193, and Resident 184. ADON C confirmed the discrepancies between the CDRs and MARs and stated nursing staff were expected to document on the CDR as soon as a controlled medication was removed for administration and in the MAR immediately after administration. During an interview on [DATE] at 11:18 a.m. with the Director of Nursing (DON), the DON stated anytime a nurse removed a controlled medication from its package, it was to be documented on the CDR. She stated the administration was to be documented in the MAR immediately after it was given to the resident. 2. On [DATE] at 1:01 p.m., a review of the controlled drug sign-in/sign-out sheet for Station A Medication Cart 2 (Med Cart 2) alongside Licensed Vocational Nurse I (LVN I), identified missing signatures by the outgoing and incoming nurse for each shift (7 a.m., 3 p.m., and 11 p.m.). LVN I acknowledged and confirmed the record was missing signatures between nursing shift changes. A review of the controlled drug sign-in/sign-out sheet, dated [DATE] to [DATE], indicated 50 missing signatures (for the dates indicated) between nursing shift changes. On [DATE] at 1:03 p.m., a review of the controlled drug sign-in/sign-out sheet for Station A Med Cart 3, alongside LVN I, identified missing signatures by the outgoing and incoming nurse for each shift. LVN I stated, We count every morning before starting the shift. LVN I stated the expectation was to sign the sign-in/sign-out sheet to confirm the controlled medications were counted. She stated, If it's [the controlled drug count] off we will not take over, the other nurse can't leave until count is reconciled. A review of the record, dated [DATE] to [DATE], indicated 35 missing signatures between nursing shift changes. During a concurrent record review and interview on [DATE] at 11:49 a.m. with ADON C, the controlled drug sign-in/sign-out sheets were reviewed. ADON C confirmed they were incomplete and stated nursing staff were expected to count the controlled drugs in the medication carts between shift changes and to sign the sheet to indicate they had done so. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated [DATE], the P&P indicated, Dispensing and Reconciling Controlled Substances . 8. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 9. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 3. During a concurrent observation and interview on [DATE] at 10:30 a.m. with ADON C, a tall white plastic container with a blue lid laying sideways on top was observed inside Medication Storage room [ROOM NUMBER]. Inside the plastic container were whole tablets, capsules and four intact intravenous (IV, administered into the vein) bags with pharmacy labels on them. ADON C stated the container was designated for destruction of expired and discontinued medications. She stated nursing staff were expected to remove the pharmacy labels from medications prior to disposal in the container. ADON C stated IV bags should have been cut open and the contents poured out into the bin. During a concurrent interview and inspection on [DATE] at 3:49 p.m. alongside Licensed Vocational Nurse HH (LVN HH), a clear, small, square plastic container with a blue twist off lid was observed inside Med Cart 10. The container had whole tablets, capsules and plastic bags inside with a label on the outside that read, Pill Disposal. LVN HH confirmed the finding and stated nurses were expected to use a disposal system that rendered the medications useless. She looked at the container and stated, Honestly I've never seen this before. You could just open it up and take it back out. During an interview on [DATE] at 11:14 a.m. with the DON, the DON stated nursing staff were expected to remove pharmacy labels from resident's medications prior to disposing them. She stated IV bags should have been cut open and emptied into the bin. She stated refused doses of medication were to be placed in a designated drug disposal system located on the medication carts which contained a substance to deactivate the medication and ensure it was not retrievable. She confirmed the clear plastic container with tablets and capsules inside with a twist off lid was not considered non retrievable and medications could easily be removed. During a review of the facility's P&P titled, Storage of Medications, dated [DATE], the P&P indicated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 4. During an inspection of the Medication Storage room [ROOM NUMBER] on [DATE] at 10:52 a.m. with ADON C, the e-kit containing injectable emergency medications was observed expired 10/2023 and a controlled medication e-kit expired [DATE]. ADON C confirmed the finding and stated the expectation was for the ADONs and nursing staff to routinely check the e-kits to ensure they were not expired and to reorder them as needed. During an interview on [DATE] at 11:18 a.m. with the DON, the DON stated the ADONs were expected to check the e-kits on a regular basis to ensure they were in date and replaced if opened. During a review of the facility's P&P titled, Emergency Medications, dated [DATE], the P&P indicated, The facility shall maintain a supply of medications typically used in emergencies .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/13/23 at 10:32 a.m. in the presence of Licensed Vocational Nurse A (LVN A), an inspection of Station D Medication Cart A identified and verified, in the active stock, a bottle of vitamin B-1 (thiamine, a water-soluble vitamin) 100 mg with an expiration date of 9/2023 and a bottle of zinc (dietary supplement) 50 mg with an expiration date of 10/2023. LVN A stated that any expired medications should be destroyed and put away. LVN A acknowledged both medications had passed its expiration date. On 11/13/23 at 3:41 p.m. in the presence of Licensed Vocational Nurse BB (LVN BB), an inspection of Station C Medication Cart A identified, in the active stock, a bottle of vitamin B12 100 microgram (mcg, unit of measurement) had the expiration date of 10/2023. LVN BB acknowledged the vitamin B12 bottle had passed its expiration date and should be put away. On 11/13/23 at 3:53 p.m. in the presence of ADON C, an inspection of Station E Medication Cart, in the active stock, a bottle of vitamin B12 100 mcg with an expiration date of 10/2023. ADON C acknowledged the vitamin B12 had passed its expiration date. Review of the facility's Storage of Medications policy, dated November 2020, indicated, Discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. 4. During a visit to Station A Medication Room with Interim Sub-Acute Supervisor (ISS) on 11/13/23 at 11:44 a.m., inspection of a medication refrigerator identified a bottle of pharmacy-dispensed gabapentin (used to treat painful nerve diseases) 250 mg per 5 ml solution without the expiration date. The ISS stated there should be an expiration date on the label, and stated he did not know why there was no expiration date. During an interview with the Infection Preventionist (IP) on 11/13/23 at 11:54 p.m., the IP verified the gabapentin solution has no expiration date and stated he did not know why and how it happened. Review of the facility's Labeling of Medication Containers policy, dated April 2019, indicated, Labels for individual resident medications include all necessary information, such as the expiration date. 5. During an inspection of the vaccine refrigerator with the IP on 11/13/23 at 12:07 p.m., the refrigerator was observed to contain four types of vaccines (a preparation used to stimulate the body's immune response against diseases) and numerous bottles of tuberculin (a protein extract used in a skin test to help diagnose tuberculosis [TB] infection). A review of the temperature logs, from January to November 2023, with the IP reflected the refrigerator temperature were monitored twice a day except on weekends. The IP stated there was no temperature monitoring on the weekends except whenever he came in during the weekend. When asked how the facility would identify out-of-range temperatures during the weekends, the IP did not offer a response. The IP stated the products inside the refrigerator are for both residents and staff use. During a telephone interview on 11/16/23 at 10:11 a.m., with the Consultant Pharmacist (CP), the CP stated vaccine monitoring should be conducted twice daily. CP also stated that the previous consultant pharmacist informed the facility that the temperature should be monitored twice daily regardless if it was weekday or weekend. Review of the facility's Storage of Medications P&P, dated November 2020, indicated, Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Temperatures will be . checked twice daily. Based on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date, expired medications were not available for resident use, single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for, vaccine refrigerator temperatures were monitored daily, labeling of pharmacy-dispensed gabapentin with an expiration date, and storage of medication separate from resident food items. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage. Findings: 1. During a concurrent observation and interview on 11/13/23 at 10:18 a.m. with Assistant Director of Nursing C (ADON C), an inspection of Medication Storage room [ROOM NUMBER] identified one box acetaminophen (a medication to treat fever) 650 milligrams (mg, a unit of measurement) suppositories expired 4/2023 and one Novolog Mix 70/30 FlexPen (an insulin to treat diabetes), opened 7/30/23. ADON C confirmed the finding and stated both medications should have been removed from the facility's medication supply. 2. During a concurrent observation and interview on 11/13/23 at 12:27 p.m. alongside Licensed Vocational Nurse LL (LVN LL), an inspection of Medication Cart 6 (Med Cart 6) identified two opened vials Assure Platinum blood glucose test strips (used to test blood sugar levels) and one vial acetylcysteine (medication to thin mucous) 20% solution, and one Basaglar (a long-acting insulin to treat diabetes) 100 unit/milliliter (ml, a unit of measurement) KwikPen, opened and unlabeled with an open date. LVN LL reviewed the manufacturer's labeling on the vial of test strips and confirmed they expired 90 days after opened. He reviewed the manufacturer's labeling on the acetylcysteine vial and stated it was to be discarded after 96 hours once opened. LVN LL stated the Basaglar KwikPen expired 28 days after first use and should have been labeled with an open date. LVN LL confirmed one bottle multivitamin with minerals and one bottle zinc 50 mg tablets, both expired 10/2023, were in the med cart and should have been removed. During a concurrent observation and interview on 11/13/23 at 12:42 p.m. alongside Licensed Vocational Nurse KK(LVN KK), an inspection of Med Cart 5 identified two opened vials Assure Platinum blood glucose test trips opened and unlabeled with an open date. LVN KK confirmed the finding and agreed they should have been labeled with an open date to know when they expired. One vial Humulin N (an intermediate acting insulin) was observed opened with a sticker indicating it was first used on 10/6/23. LVN KK confirmed the finding and stated it expired 31 days after first use and the medication should have been removed from the med cart. One box containing three 30 ml vials acetylcysteine 20% vials were identified in the med cart, expired on 7/2023. LVN KK confirmed the finding and agreed it should not have been available for use in the med cart. During a concurrent observation and interview on 11/13/23 at 12:56 p.m. alongside Licensed Vocational Nurse I (LVN I), an inspection of Med Cart 3 identified five boxes Artificial Tears (an eye drop used to lubricate the eyes) labeled with resident room numbers on the box. LVN I stated nurses wrote resident room numbers on over-the-counter (OTC) items intended for single resident use. Two pouches containing budesonide (a medication to treat asthma) 0.5 mg/2 ml vials for inhalation expired 11/2022, and one GlucaGen HypoKit (an emergency medication to treat dangerously low blood sugar) expired 10/31/23 were observed with LVN I in the med cart. She confirmed they were expired and should have been removed from the medication supply. During an interview on 11/14/23 at 12:24 p.m. with ADON C, ADON C stated nursing staff were expected to label OTC items intended for single resident use with specific resident identifiers, which included resident last name and first initial. She stated it was not acceptable to label an OTC with just a resident room number because they could change rooms. During an interview on 11/16/23 at 11:14 a.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to remove expired drugs from their medication cards and place them in a destruction bin located inside the medication storage rooms. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated April 2019, the P&P indicated, 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name . 6. An observation on 11/14/23 at 4:20 p.m., showed six, 100 milliliter bottles of 0.9% Sodium Chloride Irrigation inside the refrigerator designated for resident food and located in an unsecured location in nursing Station A behind the nursing desk. The refrigerator held belonging to residents, such as fried chicken from a restaurant and deli meat from a grocery store. An observation and interview on 11/14/23 at 4:30 p.m., showed the Consultant Director of Staff Development Infection Preventionist (CDSDIP) looking inside the resident food refrigerator in nursing Station A. The CDSDIP discarded contents inside the refrigerator into a trash can located next to the refrigerator. The items she discarded included the six bottles of Sodium Chloride Irrigation. CDSDIP stated she pulled the saline out because it should not be stored in the food refrigerator. Review of the Policy and Procedure titled Storage of Medications dated 2001 and revised 2020, showed medications requiring refrigeration are stored in a refrigerator located in a drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 11/17/23 at 3:22 p.m., the beds of Residents 105, 617, and 618 were inspected. All three beds had partial side rails bilaterally. During an observation on 11/17/23 at 3:26 p.m., the bed of Resident 149 was inspected. The bed had partial side rails bilaterally. During an observation on 11/17/23 at 3:38 p.m., the beds of Residents 11 and 78 were inspected. The two beds had partial side rails bilaterally. Review of Resident 105's medical record indicated she had a physician's order, dated 10/15/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 105's Side Rails Assessment, dated 10/15/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 617's medical record indicated she had a physician's order, dated 11/06/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 617's Side Rails Assessment, dated 11/07/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 618's medical record indicated he had a physician's order, dated 10/07/23, that she may have 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 618's Side Rails Assessment, dated 10/07/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 149's medical record indicated she had a physician's order, dated 1/05/22, that she may have 1/4 bilateral side rails up when in bed to assist in mobility. Review of Resident 149's Side Rails Assessment, dated 8/07/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 11's medical record indicated she had a physician's order, dated 6/18/23, to put 1/2 (right and left) side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 11's Side Rails Assessment, dated 8/03/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 78's medical record indicated she had a physician's order, dated 6/17/23, that she may have 1/4 bilateral side rails up when in bed to assist resident in bed mobility. Review of Resident 78's Side Rails Assessment, dated 8/11/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails.During an observation on 11/14/23 at 1:40 p.m. in Resident 134 room, there were bilateral partial side rails on the bed. Review of Resident 134's clinical record indicated a physician order, dated 11/4/23, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 134's Side Rails Assessment, dated 11/4/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing side rails. During an observation on 11/14/23 at 10:10 a.m. in Resident 175's room, there were bilateral partial side rails on the bed. Review of Resident 175's clinical record indicated a physician order, dated 2/28/2023, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 175's Side Rails Assessment, dated 8/16/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing side rails. During an observation on 11/17/23 at 3:25 p.m. in Resident 99's room, there were bilateral partial side rails on the bed. Review of Resident 99's clinical record indicated a physician order, dated 10/14/2023, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 99's Side Rails Assessment, dated 10/14/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing side rails. During an observation on 11/17/23 at 3:25 p.m. in Resident 3's room, there were bilateral partial side rails on the bed. Review of Resident 3's clinical record indicated a physician order, dated 8/4/22, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. Review of Resident 3's Side Rails Assessment, dated 9/18/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing side rails. During an observation on 11/17/23 at 3:25 p.m. in Resident 125's room, there were bilateral partial side rails on the bed. Review of Resident 125's clinical record indicated a physician order, dated 8/15/23, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. Review of Resident 125's Side Rails Assessment, dated 8/15/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing side rails. During an observation on 11/16/23 at 1:23 p.m., Resident 49 was sitting in bed with bilateral partial side rails up. Review of Resident 49's clinical record indicated a physician order, dated 9/9/22, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. Review of Resident 49's Side Rails Assessment, dated 11/10/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing side rails. During an observation on 11/17/23 at 3:35 p.m., the beds of Residents 154, 206, 1016, 35, 193, and 79 were inspected. There were partial side rails bilaterally. Review of Resident 154's medical record indicated he had a physician's order, dated 10/20/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 154's Side Rails Assessment, dated 10/20/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 206's medical record indicated he had a physician's order, dated 10/21/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 206's Side Rails Assessment, dated 10/21/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 1016's medical record indicated she had a physician's order, dated 9/13/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 1016's Side Rails Assessment, dated 11/3/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 35's medical record indicated she had a physician's order, dated 10/31/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 35's Side Rails Assessment, dated 10/31/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing bed rails. Review of Resident 193's medical record indicated he had a physician's order, dated 8/24/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 193's Side Rails Assessment, dated 8/25/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 79's medical record indicated she had a physician's order, dated 3/22/23, to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 79's Side Rails Assessment, dated 8/29/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Based on observation, interview, and record review, the facility failed to follow their bed rails (side rails, safety rails and grab/assist bars) policy for 34 of 35 sampled residents (Residents 117, 121, 159, 104, 89, 65, 134, 175, 99, 3, 125, 49, 43, 101, 26, 53, 81, 131, 11, 78, 105, 149, 617, 618, 6, 9, 32, 172, 154, 206, 1016, 35, 193, and 79). The survey team expanded the sample and identified that a total of 198 residents had bed rails. The facility failed to follow their bed rails policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails for 198 of 198 residents; 2. There was no documentation that risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 198 of 198 residents; 3. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to installing bed rails for 198 of 198 residents; and 4. There was no documentation that the facility assessed the bed dimensions to ensure they were appropriate for the residents' size and weight for 198 of 198 residents. The facility also did not obtain informed consent prior to installing bed rails for 160 of 198 residents and follow the manufacturer's recommendations for maintaining bed rails. These failures resulted in the residents and residents' RPs not being fully informed on the risks of the use of bed rails and had the potential to place the residents at risk of entrapment and serious injury. Findings: During an observation on 11/17/23 at 3:33 p.m., the beds of Residents 117, 121, 159, and 104 were inspected. All four beds had partial side rails (part of a whole, [full side rails are attached to the side of a bed along the full or whole length of the bed]) bilaterally (on both sides). During an observation on 11/17/23 at 3:50 p.m., the beds of Residents 89 and 65 were inspected. Both beds had partial side rails bilaterally. Review of Resident 117's physician's order, dated 3/9/23, indicated she may have one quarter (1/4, fraction, one part of a whole divided into four equal parts) bilateral side rails up when in bed to assist in mobility (movement) and/or transfers. Review of Resident 117's Side Rails Assessment, dated 3/29/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 121's physician's order, dated 5/15/23, indicated to put 1/4 bilateral side rails up when in bed to assist in bed mobility and/or transfers. Review of Resident 121's Side Rails Assessment, dated 7/6/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 159's physician's order, dated 6/6/22, indicated he may have 1/4 bilateral side rails up when in bed to assist in bed mobility. Review of Resident 159's Side Rails Assessment, dated 7/14/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 104's medical record indicated there was no physician's order for side rails. There was also no documentation that a Side Rails Assessment was completed for Resident 104. Review of Resident 89's physician's order, dated 11/18/23, indicated she may have 1/3 (one third, fraction, one part of a whole divided into three equal parts) bilateral side rails up when in bed to assist in bed mobility and transfers. Review of Resident 89's Side Rails Assessment, dated 11/18/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 65's physician's order, dated 11/18/23, indicated she may have 1/3 bilateral side rails up when in bed to assist in bed mobility and transfers. Review of Resident 65's Side Rails Assessment, dated 11/18/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. During an observation on 11/17/23 at 3:30 p.m., the beds of Residents 26, 43, 53, 81, 101, and 131 had partial side rails on both sides. Review of Resident 43's clinical record indicated she had no physician order for side rails, no Side Rails Assessment, no documentation that the facility attempted alternatives, explained risks and benefits to the resident or her representative, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. Review of Resident 101's clinical record indicated he had no physician order for side rails. Review of Resident 101's Side Rails Assessment, dated 8/4/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits to the resident or his representative, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. Review of Resident 26's physician order, dated 3/28/23, indicated she may have 1/4 bilateral side rails up when in bed to assist her in bed mobility and/or transfers. Review of Resident 26's Side Rails Assessment, dated 8/10/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits to the resident or her representative, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. Review of Resident 53's physician order, dated 6/26/23, indicated she may have 1/4 bilateral side rails up when in bed to assist her in bed mobility and/or transfers. Review of Resident 53's Side Rails Assessment, dated 9/28/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits to the resident or her representative, assessed for risk of entrapment,obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. Review of Resident 81's physician order, dated 6/13/23, indicated he may have 1/4 bilateral side rails up when in bed to assist him in bed mobility and/or transfers. Review of Resident 81's Side Rails Assessment, dated 6/13/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits to the resident or his representative, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. Review of Resident 131's physician order, dated 8/11/23, indicated he may have (1/3, 1/2) right, left, bilateral side rails up when in bed to assist him in bed mobility and/or transfers. Review of Resident 131's Side Rails Assessment, dated 8/11/23, indicated there was no documentation that the facility attempted alternatives, explained risks and benefits to the resident or his representative, assessed for risk of entrapment, obtained informed consent, or assessed the bed dimensions prior to installing the bed rails. During an observation on 11/17/23 at 3:41 p.m., bilateral partial side rails were observed on the beds of Residents 6, 9, and 32. Review of Resident 6's orders indicated he had a physician's order, dated 3/17/23 that he may have 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 6's Side Rails Assessment, dated 9/7/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 9's orders indicated she had a physician's order, dated 1/27/23 that she may have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. Review of Resident 9's Side Rails Assessment, dated 9/6/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. Review of Resident 32's orders indicated she had a physician's order, dated 12/9/20 that she may have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. Review of Resident 32's Side Rails Assessment, dated 6/28/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. During an observation on 11/17/23 at 3:48 p.m., bilateral partial side rails were observed on the bed of Resident 172. Review of Resident 172's orders indicated she had a physician's order, dated 7/16/23 to put 1/4 bilateral side rails up when in bed to assist resident in bed mobility and/or transfers. Review of Resident 172's Side Rails Assessment, dated 8/16/23 indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. The survey team expanded the sample and identified via observation an additional 164 residents had side rails. Review of the Side Rails Assessments for the 164 residents indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, assessed for risk of entrapment, or assessed the bed dimensions prior to installing bed rails. During concurrent interview and record review of the facility's side rail assessment on 11/17/23 at 4:30 p.m., the Director of Nursing (DON) stated that the facility does not consider side rails as a restraint, so informed consent for the side rails was not obtained. The DON verified the facility's side rail assessment did not address any alternatives that were attempted prior to the use of side rails, the residents' risk for entrapment, and the risks and benefits of side rails. The DON also confirmed the facility's side rail assessment did not address the size and weight of the resident. During an interview on 11/21/23 at 8:34 a.m., the Administrator (ADM) stated the facility's side rail assessment was missing some components and was changed last night. He stated the facility redid all the residents' side rail assessments. During an interview on 11/21/23 at 9:44 a.m., the ADM stated the side rail assessment the facility was using could have been better. He stated the facility's side rail assessment was not similar to other facility's assessments that went line by line with the bed rail regulation. The ADM confirmed the facility completed the missing components of the side rail assessment over the weekend, and it was not completed prior to the survey. During an interview and record review on 11/17/23 at 4:20 p.m. with the Maintenance/Housekeeping Director (MDR), the side rail sections in the facility maintenance log were marked. The MDR stated the side rails should be checked quarterly, but maintenance staff have checked the side rails weekly, at least every ten days. The MDR was not able to verbalize what he did to inspect the side rails. During an interview and record review on 11/20/23 at 11:10 p.m. with the MDR, the facility maintenance log indicated that the side rails in station A were checked on 4/19/23 and 11/04/23; the side rails in station B (from room [ROOM NUMBER] to 230) were checked on 5/05/23 and 11/10/23. There was no evidence that the side rails in stations A and B were checked weekly or quarterly. The MDR confirmed the record review and stated he could not locate any documentation indicating the side rails in stations A and B were checked weekly or quarterly. During a review of the owner's manual provided by the facility titled, Drive: P503 Long Term Care Bed, dated 4/01/2018, the manual indicated, Quarterly Inspection: Inspect all welds for cracks. Check for bed noise and lubricate if appropriate. Check bed for proper function. Inspect all fasteners for looseness, wear or damage. Replace or tighten as necessary. Ensure cables routed in the medical bed, will not be squeezed between parts of the medical bed. Check all electrical cable strain reliefs to ensure there are no cracks or breaks. If bed has a battery backup, unplug power cord from the wall outlet and validate function. Inspect bed and rotating assist bars/rails bolts, if loose tighten and if missing replace. Review of the facility's policy, Bed Safety and Bed Rails, revised 8/2022, indicated the following: Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; Bed dimensions are appropriate for the resident's size; Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit; If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: - An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; - The resident's risk associated with the use of bed rails; The resident assessment to determine risk of entrapment includes, but is not limited to: medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight, sleep habits, medications, ability to toilet self safely, cognition. The resident assessment also determines potential risks to the resident associated with the use of bed rails. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails.

Based on observations, interviews, and record reviews the facility failed to ensure: 1. Resident 35 with a wheat allergy received nourishing and palatable meals to meet their needs; 2. The overall day-to-day food and nutrition services operations were carried out in a safe and sanitary manner for food service, preparation, storage, and delivery; equipment sanitation; kitchen staff competency; ineffective pest control; and acceptable parameters of nutrition care to prevent significant and severe resident weight loss for two sampled residents (Residents 104 and 175), according to standards of practice and facility policy. These deficient practices led to 231 residents being exposed to these improper conditions, specifically 197 residents who consume food from the kitchen. Cross reference F692, F802, F804, F812, F813, F908, and F925 Findings: 1. During an observation and interview on 11/13/23 at 1:10 p.m. with Resident 35, the resident stated they were served wheat products yesterday including wheat bread and cream of wheat for breakfast. Resident 35 stated, I get a rash and wheezing when I eat wheat products. Per the resident They don't understand that wheat comes in a lot of products. The other day I was served meat with mushroom, and a lot of their sandwiches have wheat. Resident 35 stated she already informed the Dietary Manager about her allergies to wheat products twice and was told, Rhey will do a better job next time. During a record review of Resident 35's, Resident 35 had a BIMS (Brief Interview for Mental Status) score of 15, which a score of 13-15 means cognitive intactness. Resident 35's allergies in the medical administration record dated 11/13/23, the resident's allergies included: .Lactose (milk sugar) Intolerance .Mushroom, Wheat Products . During a record review of Resident 35's meal tray ticket, the meal tray ticket indicated, Allergies- lactose intolerant, mushroom, wheat products. During an interview on 11/15/23 at 3:30 p.m. with Registered Dietitian Q (RD Q), the RD Q stated it was important for residents with food allergies to receive the correct food items because they could have a harmful allergic reaction to the food. During an interview on 11/16/23 at 3:45 p.m. with the Director of Dietary Services (DDS), the DDS confirmed that Resident 35 was recently served a meal with mushroom products. The DDS stated, A CNA informed me, and I changed it right away. It was written on the tray ticket about her allergy to wheat and mushrooms. It is important for the staff to read the tray ticket correctly. And it's important for residents to receive foods without stuff they're allergic to like wheat products. 2a. During the initial kitchen tour observations and interviews on 11/13/23 at 8:02 a.m., the kitchen staff had served the breakfast meal on Styrofoam plates with a dome that partially covered the plates. [NAME] D stated the regular ceramic plates were not clean in the dish room, so she decided to serve the breakfast on the Styrofoam plates. During an interview on 11/13/23 at 8:55 a.m. with the DDS, the DDS stated the staff should have used any ceramic plates available to serve the breakfast meal. The DDS stated the only concern from using Styrofoam plates is a dignity issue. The DDS did not mention the palatability and poor temperature regulation from the use of Styrofoam plates. During the kitchen observations on 11/13/23 at 8:10 a.m. and 11/14/23 at 10:30 a.m., many other food safety concerns were identified including milk cartons on trayline stored without ice or in a cooler to maintain temperature; cooked meat sauce was found in a large sauce pan on the stove that would be used for lunch; the [NAME] not following the recipe for the regular diet lunch meal; cucumber salad was not safely stored after preparation; and the peanut butter and jelly sandwich recipe was not followed. b. During observations of the kitchen staff on 11/13/23 and 11/14/23, the kitchen staff were unable to demonstrate competency in correctly carrying out their job tasks for safely storing milk at safe temperatures, sanitizing dishes in the dish machine and in the three-compartment sink. c. During an observation on 11/13/23 of the facility's dish machine in the kitchen's dishroom, the dish machine had a large puddle of water leaking behind it. The three-compartment sink had handkerchiefs stuffed inside the drain with rubber stoppers to plug the water, and the garbage disposal had a bucket full of water underneath because of a water leak. During an observation on 11/13/23 of the facility's main ice machine, the ice machine had black dirt and grime particles inside the ice cubes from the ice bin. The inside ice curtain and ice chute had dark brown, black and pink slime residue around the perimeter of the hole where the ice comes down. During the ice machine vendor's visit at the facility on 11/13/23, the ice machine vendor stated the main ice machine had not been cleaned in several years. d. During the initial resident screening process on 11/13/23, observations and interviews from the residents were stated about the food being cold or lukewarm, food not having flavor or any taste, and food being soggy. Other concerns included residents receiving items they stated they disliked. During a test tray observation and interview on 11/14/23 at 9:28 a.m., with the DDS and RD Q of the breakfast meal, several food items were cold or lukewarm and did not meet the facility's food temperature policy. e. During observations and interviews on 11/15/23 and 11/16/23, two sampled residents were identified with significant and severe avoidable weight loss within the last 6 months. f. During observations, staff interviews, and record reviews on 11/14/23 and 11/15/23, the facility did not have a policy or process to safely store food brought in from the outside. During an interview on 11/16/23 at 12:20 p.m. with RD Q, RD Q stated her expectation is for the food to be safely prepared and stored in the kitchen, the kitchen equipment to be correctly cleaned and sanitized, the resident's food to be safely stored in the facility, and prevent avoidable significant and severe weight loss among residents. During a record review of the facility's monthly kitchen sanitation checks titled Quality Assessment for Performance Improvement for April 2023, May 2023, July 2023, September 2023, and October 2023, completed by the Registered Dietitian (RD Q), the sanitation checks indicated: Meals were not delivered to residents at appropriate temperatures, skill checks not complete for kitchen workers, weekly weights were not monitored consistently by the RD, and other concerns. Review of the facility's policy and procedure (P&P) titled Food preparation dated 2023, indicated Food shall be prepared by methods that conserve nutritive value, flavor, and appearance . Review of the facility's policy and procedure (P&P) titled Ice Machine Cleaning Procedures dated 2023, indicated The ice machine needs to be cleaned and sanitized monthly . Review of the facility's policy and procedure (P&P) titled Sanitation dated 2023, indicated The Food & Nutrition Services Department shall have equipment of the type and amount necessary for the proper .serving and storing of food .All equipment shall be kept maintained as necessary and kept in working order . During a review of the Registered Dietitian (RD) Job description dated 8/24/20, the job description duties and responsibilities indicated .The primary purpose of the job is to plan, organize, develop, and direct the overall operation of the Food Services Department in accordance with federal, state, and local standards, guidelines and regulations .that quality nutritional services are being provided on a daily basis and the food services department is maintained in a clean, safe, and sanitary manner .Monitor food service personnel to assure they are following established safety precautions in the use of equipment and supplies . During a review of the Director of Dietary Services (DDS) Job description dated 10/12/21, indicated the job description duties and responsibilities included . Assist in planning, developing, organizing, implementing, evaluating, and directing the Dietary Department, it's programs and activities . Assist the dietary staff in the use of departmental policies, procedures, equipment, and supplies . Assume administrative authority, responsibility, and accountability of supervising the Dietary Department . Ensure all food storage rooms, preparation areas, are maintained in a clean, safe, and sanitary manner . Make periodic rounds to check equipment and assure necessary equipment is available and working properly . Ensure that all personnel operate dietary service equipment in a safe manner .

Based on observations, interviews, and record reviews the facility failed to ensure the kitchen staff had the competencies and training to perform their job duties and tasks according to standards of practice and facility policy when: 1. A Dietary Aide did not safely store milk on the trayline served to residents. 2. Two Dietary Aides did not know how to correctly test the sanitizer in the three-compartment sink. These failures had the potential to expose 197 residents who receive food from the kitchen to contamination from food and chemicals that may harm their health and nutrition status. Findings: 1. During the initial kitchen tour on 11/13/23 at 8:03 a.m., Dietary Aide K (DA K) was observed on the trayline adding 8-ounce milk cartons and cold drinks to the breakfast meal trays. There was a food utility cart with two gray milk crates half full of fat-free 8-ounce milk cartons on top and a large rectangle sized tan colored rubber bin on the middle shelf with 4-ounce strawberry protein shakes, and other flavors. The milk crates and rubber bins did not have ice in them or around the milk to retain the temperature. During a kitchen observation and interview on 11/13/23 at 8:31 a.m. with DA K, DA K stated she took the temperatures of the milk cartons at 7:10 a.m. before the breakfast trayline started, and the temperature was 36 degrees Fahrenheit (F, a scale of temperature at which water freezes at 32 degrees and boils at 212 degrees under standard conditions). The surveyor and DA K took the temperature of a fat-free milk from the trayline milk crate, and it was 53.4 degrees F. DA K stated she was not told to place the milk cartons on ice or to maintain the cold temperature when serving the milk to residents. During an interview on 11/13/23 at 8:41 a.m. with DA K in the kitchen, DA K stated she forgot to write the milk temperatures in the Trayline Temperature log this morning. During a review of the facility's Food Temperature Meal Trayline log dated 11/13/23 and 11/12/23, the breakfast milk temperature was blank without a temperature for both dates. During an interview on 11/13/23 at 8:50 a.m. with the Director of Dietary Services (DDS), the DDS stated the trayline milks should be held at a temp of at least 41 degrees F, so they are served at a safe temperature. The DDS acknowledged the 53.4-degree F milk and stated it was not okay to serve it. The DDS stated DA K should have placed the milk in a bin on ice to hold the temperature at below 41 degrees F. During a review of the Dietary Aide's Job description dated 2003, the job description duties and responsibilities indicated . Assist in the preparation and serving of meals and snacks . Serve food in accordance with established portion control procedures . Assist [NAME] in preparing meals . Prepare and deliver snacks . as instructed . According to the 2022 Federal FDA Food Code, section 3-201.13, titled Fluid Milk and Milk Products, indicated, Milk, which is a staple for people . with incomplete immunity to infectious diseases, is susceptible to contamination with a variety of microbial pathogens . and provides a rich medium for their growth . Dairy products are normally perishable and must be received under proper refrigeration conditions. Review of the facility's policy and procedure (P&P) titled Food Preparation, dated 2023, indicated .7. Hold foods prior to service for as short a time as practical .cold foods at 41 degrees F or below . 2. During an observation and interview on 11/13/23 at 8:57 a.m. with Dietary Aide N (DA N), DA N stood next to the three-compartment sink in the kitchen dish room. The middle and last sinks (rinse and sanitize sinks) were full of water. The middle second sink had a pink rubber stopper with a white handkerchief stuffed in the drain, and the third sink had a light blue rubber stopper to plug the water in those drains. DA N stated the three-compartment sink compartments are used to wash the food carts and other equipment items. DA N stated the sanitizer chemicals in the third sink compartment should be tested daily and she was not sure what the concentration should be. DA N stated she did not test the sanitizer that day or other days she worked. During a review of the November 2023- Quaternary Ammonia Log hung on the wall above the three-compartment sink in the dish room, the log document was blank. During an observation and interview on 11/13/23 at 9:06 a.m. with DA N in the dish room, DA N stated she checked it in the morning and the sanitizer was 200 ppm (parts per million) and that was good. DA N demonstrated how she checked the sanitizer in the dish machine by dipping a test strip from the container and dipped it into water solution at the end of the dish machine and compared it against the test strip container. The test strip container had a color code and concentration system of lavender-10 ppm, light purple-50 ppm, purple- 100 ppm, and dark purple-200 ppm. During an interview with DA N and record review of the November 2023- Dish machine temperature Log hung on the wall in the dish room, the log had three sections of Breakfast, Lunch, and Dinner and a column for test strip. On 11/13/23, the breakfast test strip concentration indicated 100. DA N stated the strip was 100 ppm this morning. During an observation and interview with the DDS on 11/13/23 at 9:13 a.m., the DDS acknowledged the three-compartment sink Quaternary Ammonia log was blank and stated should be checked daily and recorded on the log. The DDS stated the dish machine sanitizer concentration should be between 50-100 ppm on the test strip, and 200 ppm was too high. The DDS further stated it was important for the three-compartment sink and dish machine chemicals to have the correct sanitizer concentrations, so it doesn't affect the resident dishes. The DDS further acknowledged DA N did not know the correct temperatures of the three-compartment sink or the sanitizer concentrations for the third compartment sink and the dish machine. During an observation and interview with Dietary Aide S (DA S) on 11/14/23 at 9:45 a.m. in the kitchen dish room, DA S stated she doesn't use the middle sink in the three-compartment sink but does use the last one for sanitizing the food carts. DA S also stated she was unsure what the temperatures of the wash and rinse sink compartments should be. DA S further stated she was unsure what the sanitizer concentration should be for the third compartment sink. During an interview with the DDS on 11/14/23 at 9:55 a.m., the DDS acknowledged DA S did not know how to correctly use the three-compartment sink including the correct temperatures in the wash and rinse sinks, and the sanitizer concentration of the third sink. During a review of the Diet Aide's Job description dated 2003, the job description duties and responsibilities indicated . Assist in cleaning and sanitizing work areas, equipment and floors, dishes, and utensils . Perform dishwashing/cleaning procedures . During an interview with Registered Dietitian Q (RD Q) on 11/15/23 at 3:28 p.m., RD Q stated it was important for the Dietary Aides and kitchen staff to know how correctly use the three-compartment sink and test the sanitizer in both the three-compartment sink and dish machine. Review of the facility's policy and procedure (P&P) titled Sanitation dated 2023, indicated, 1. The FNS (Food & Nutrition Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . 4. The FNS Director is responsible for instructing Food & Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area . Review of the facility's policy and procedure (P&P) titled Dish Washing dated 2023, indicated . All dishes will be properly sanitized through the dishwasher . 3. Appropriate chemicals will be used to wash, de-stain, and rinse dishes . 9. The dishwasher will run the dish machine . Low-temperature machine . the chlorine should read 50-100 ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes. If you do not achieve the proper chlorine level . resort to manual dish washing .

Based on observations, interviews, and record reviews the facility failed to ensure the recipes were followed, and food was served at a safe and palatable temperature according to facility policy and resident complaints. These failures had the potential to negatively affect the nutritional status due to poor food intake of 197 residents on a therapeutic diet and who may consume a snack from the kitchen. Cross reference F800 Findings: 1. During the initial kitchen tour on 11/13/23 at 8:03 a.m., an observation of an extra-large metal pot was on the stove with meat sauce, uncovered without a lid. The stove was turned off. During an observation and interview on 11/13/23 at 10:14 a.m. with [NAME] D, [NAME] D was preparing the meatballs for the meatball sandwich lunch entrée. [NAME] D placed several frozen pre-made meatballs from a large box on an extra-large baking sheet. [NAME] D stated she was cooking the meatballs for the lunch meal meatball sandwich. She stated she would use the frozen meatballs for the regular diet meals and the meat sauce she prepared earlier in the large pot, for the textured pureed and mechanical soft diets. [NAME] D stated it would take too long to make meatballs from scratch. [NAME] D stated she made the meatball meat mixture in the morning between 6 and 7 a.m. Review of the facility's Fall Menus dated 11/13/23 indicated the lunch meal for the Regular diet texture included Meatball sandwich with three meatballs and a hotdog bun, 1-ounce spaghetti/marinara sauce, 1-ounce shredded cheese, 1/2 cup of creamy cucumber & celery salad, 1/3 cup of pudding with whipped topping, and a 4-ounce carton of milk. Review of the facility's Recipe titled, Meatball Sandwich indicated the ingredients were: ground beef, breadcrumbs, milk, parmesan cheese, pasteurized eggs, Italian seasoning, salt, garlic powder, parsley, and shredded cheese. Review of the ingredients of the meatballs by [Brand Name] included textured soy protein, beef, caramel color, butterfat, propylene glycol, xanthan gum. During an interview on 11/13/23 at 10:20 a.m. with the Director of Dietary Services (DDS), the DDS acknowledged [NAME] D did not use the original meatball recipe for the meatball sub sandwich to be served at the lunch meal on 11/13/23. The DDS stated [NAME] D should have made the meat sauce later and closer to the time of the lunch meal preparation, and used the recipe because the ingredients were available. During a review of the Cook's Job description dated 2011, the job description duties and responsibilities indicated .Prepare and serve food and meals in accordance with planned menus, diet plans, recipes, portion and temperature control procedures and facility policies .Prepared food in accordance with standardized recipes . Review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, indicated, .Food shall be prepared by methods that conserve nutritive value, flavor, and appearance .2. Recipes are specific to portion yield, method of preparation, quantities of ingredients, and time and temperature .5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness, and to prevent overcooking . 2. During an observation and interview on 11/14/23 at 10:10 a.m. with Dietary Aide O (DA O) in the kitchen, DA O stated she was making 15 peanut butter and jelly sandwiches. DA O poured a purple liquid syrupy mixture from a 4-quart container labeled Peanut butter into a large metal bowl. DA O stated the purple mixture was both peanut butter and jelly combined but she stated it appeared to have more jelly than peanut butter and was like liquid. DA O used a large ladle spoon to scoop out 3 ounces of the syrupy mixture on slices of white bread. During a review of the facility recipe titled Peanut Butter and Jelly, the recipe indicated: Mix 3 cups+ 2 tablespoons of peanut, 1 1/2 - 3 cups of jelly, and spread on 50 slices of wheat bread. Can combine the peanut butter and jelly and blend (2 parts PB & 1 part jelly), 1 sandwich = 1 gram of Protein. During an interview on 11/14/23 at 10:16 a.m. with the DDS in the kitchen, the DDS acknowledged the purple liquid syrupy mixture in the metal bowl and stated it appears to have a lot more jelly than peanut butter in it. The DDS stated it didn't appear the peanut butter and jelly sandwich recipe was followed. The DDS stated her expectation is for the facility's peanut butter and jelly recipe to be followed as printed. During a review of the Diet Aide's Job description dated 2003, the job description duties and responsibilities indicated .Assist in the preparation and serving of meals and snacks .Serve food in accordance with established portion control procedures .Assist [NAME] in preparing meals .Prepare and deliver snacks .as instructed . During an interview on 11/15/23 at 4:30 p.m. with Registered Dietitian Q (RD Q), RD Q stated it was important for the Cooks and Dietary Aides to follow the facility's recipes approved by the Registered Dietitian for the department's use. RD Q stated if the kitchen staff use different recipes, it could affect the resident health status in a negative way. A nutrient analysis of the facility's daily menus was requested on 11/15/23 but was not provided by the facility. Review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, indicated, .Food shall be prepared by methods that conserve nutritive value, flavor, and appearance .1. The facility will use approved recipes, standardized to meet the resident census .2. Recipes are specific .to portion yield, method of preparation, quantities of ingredients .5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness, and to prevent overcooking . 3. During a test tray observation on 11/14/23 at 9:20 a.m. with the DDS and RD Q, the temperatures of the regular breakfast meal included the French toast entrée = 110 degrees F, sausage =109. 2 degrees F, oatmeal 141.3 degrees F, and the milk = 52 degrees F. The Puree meal temperatures included the French toast entrée = 120 degrees F and the sausage = 114 degrees F. The Regular diet French toast was partially wet and tasted soggy and the pureed diet French toast tasted more like regular toast and not French toast. The DDS and RD Q both acknowledged the low food temperatures for each food item, and taste. And the DDS further stated the food temperatures were out of range for palatability, but the flavor was okay. During a review of the facility's May 2023, June 2023, and October 2023 Test Tray evaluations completed by the DDS, the evaluations for the lunch meal test trays indicated the entrée, starch and vegetable temperatures ranged from 122 to 138 degrees F, and milk temperatures from 48 to 52 degrees F. Review of the past three months - August 2023, September 2023, and October 2023, resident council meeting minutes was conducted. The August 2023 and September 2023 meeting minutes indicated the temperature of the breakfast foods specifically the eggs, waffles, and pancakes were reported as always cold. In addition, they indicated the waffles and pancakes were always soggy and the pancakes tasted like rubber. Furthermore, the September 2023 council meeting minutes indicated meals are served and come out late. During the Resident Council Meeting on 11/14/23 at 2:00 p.m., a group of four confidential residents stated food temperatures at all meals have been a high concern and unacceptable to the residents for a long time. The residents indicated the food is always cold, especially the breakfast meals. Review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2018, indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures .3 Hot food serving temperature must be at or above minimum holding temperature of 140 degrees F .Food item: meat .pastas .vegetables .Service temperature: 160-180 degrees F .milk 41 degrees F or less .Resident preferences for .food temperatures shall be honored.

Based on observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment and utensils were not maintained clean and/or in good condition including: a. Two of three ice machines; b. Pans, pitchers, mixing bowls; c. A meat slicer; d. An industrial can opener; e. Cutting boards; f. Knives; and g. A microwave. 2. Kitchen storage equipment were not clean and/or in good repair including: a. Food storage racks in the walk-in refrigerator were rusty; b. Drawers holding food preparation/serving utensils; c. A rack holding food preparation equipment/utensils; d. A cart holding items such as cooking oil and gloves; and e. A cart holding clean cutlery. 3. Floor drains were not maintained clean; 4. Kitchen floors were not clean and were not maintained in good repair; 5. Walls were not maintained clean and in good repair in the kitchen and in the dry food storeroom; 6. Non-food contact equipment in the kitchen was not maintained clean including; a. Stove hood filters; b. A large floor fan; c. The top of a free standing oven; and d. A booster heater box under a dish machine counter. 7. Food thickener stored in a bulk bin was not protected from contamination from other foods; 8. Refrigerated food in the kitchen was not maintained at safe temperatures; 9. Refrigerated food belonging to residents was not stored safely in: a. Resident food refrigerators in nursing stations; and b. A refrigerator located in a staff breakroom. 10. Thawing meat was not stored safely in the walk-in refrigerator; 11. There were no air-gaps equipment including: a. Food preparation sink in the kitchen; and b. An ice machine. These failures had the potential to result in contamination of food leading to food-borne illness, as well as contamination of utensils used by residents leading to pathogenic causing illness for 197 residents who received food from the kitchen out of a census of 231. Findings: 1. Review of the policy and procedure titled Sanitation dated 2023, showed all utensils and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch, and surfaces are to be smooth. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, and other debris; and are to be designed and constructed to allow easy cleaning and to facilitate maintenance. a. During observation of an ice machine located in Station D and concurrent interviews with the Maintenance/Housekeeping Director (MDR), Maintenance Staff G (MS G), the Administrator (ADM) and the Infection Preventionist (IP) on 11/14/23 at 11 a.m., showed the ice machine ice bin was filled with ice cubes. Three ice cubes found in the ice bin had pieces of black bits inside the ice cubes. The ice chute (where the ice is transferred from the upper part of the ice machine where the ice is made to the bin where the ice is stored) surface was wiped with a paper towel and black residue came off onto the paper towel. The MDR opened the top of the ice machine to view the inside where the ice was formed. The top plastic cover had dark brown residue on the inside surface and when the residue was wiped with a paper towel, the residue transferred to the towel. There was yellow and black residue at the top of the chute. There was black and pink residue on the plastic surrounding the evaporator plate (a metal grid where the ice is formed), and there was as significant amount of a thick dark yellow and black residue build-up on the metal grid of the evaporator plate. When wiped with a paper towel, the yellow and black residue transferred to the paper towel. The ADM and the IP confirmed there was residue inside the ice machine. MSG stated he cleaned the ice machines and showed two bottles of cleaner he used to clean the machine. Both cleaners MSG stated he used were nickel safe Ice Machine Cleaner. MSG stated he filled a spray bottle with water and one of the nickel safe cleaners. He used this solution to clean the bin and the outside of the machine. He stated he used the other cleaner for the inside of the ice machine. He said he filled a small plastic cup (the cup markings showed it held two tablespoons) with the cleaner and poured it in the ice machine trough and set the machine to the wash cycle. He stated he also removed all the ice from the ice machine and drained the machine. In a consecutive observation of the Station D ice machine and interview with the MDR, on 11/14/23 at 11 a.m., showed a white polyvinyl chloride (PVC) drainpipe attached to the back of the ice machine. The end of the PVC pipe led to the inside of a black/white plastic box. The MDR stated the PVC pipe drained the ice machine into the black/white plastic box. The surface of the PVC pipe had a significant amount of black residue on the surface. The MDR stated the ice machine drainpipe was not clean. When the PVC pipe was wiped with a paper towel, moist, chunky, black residue transferred to the paper towel. During an observation of the ice machine drain in Station D and interview with the MDR on 11/15/23 at 1:18 p.m., the MDR stated he cleaned the plastic box that held the water from the ice machine drainpipe. The MDR opened the box, and the box was filled with murky water and a significant amount of yellow particles floating in the water. The inside of the end of the PVC drainpipe had black residue on the inside of the drain. When the inside of the pipe was wiped with a paper towel, black, slimy residue transferred to the paper towel. The MDR stated he thought the black residue could be mold. During an observation of an ice machine located in Station B and concurrent interview with the MDR, ADM, and IP on 11/14/23 at 12:10 p.m., the MDR opened the top of the machine to view the inside. There was black residue over the surface of the evaporator plate grid. When wiped with a paper towel, chunks of slimy, black residue transferred to the paper towel. The ADM and IP confirmed there was black residue inside the ice machine. In an interview on 11/15/23 at 1:32 p.m., the Director of Dietary Services (DDS), the DDS stated the ice from the ice machines was used for ice water for residents and to keep food/beverage items cold for residents. Review of undated ice machine maintenance instructions titled Maintenance located on a metal panel inside the ice machine. The instructions showed the frequency of cleaning required is depended on water quality, the appliance's environment, and local sanitation regulations. The cleaning procedures were very detailed and showed the ice machine company's brand of chemicals to clean the machine. It was noted the two cleaners the ADM stated he used, were not the ice machine manufacturer's brand. In addition to detailed cleaning procedures, there were also detailed sanitizing procedures which showed to use a 5.25% sodium hypochlorite solution (chlorine bleach) with warm water to sanitize the ice machine. Review of the policy and procedure titled Ice Machine Cleaning Procedures dated 2023, showed to clean the ice machine per manufacturer's recommendations. b. An observation in the kitchen dish room on 11/13/23 at 8:18 a.m., showed a metal storage rack holding cooking utensils and equipment including: - Seven pans with a black on the cooking surface which appeared to be a nonstick coating that was worn off and/or black residue build-up. The cooking surface of the pans were scratched and were greasy to the touch. One pan was wiped with a paper towel and black, greasy residue transferred onto the paper towel. - A cheese grater with yellow, dry, rough to the touch residue on the grating surface. - Three metal bowls with dried residue resembling dried food, on the inside surface of the bowls. - A square metal pan with white residue on the inside surface. - A metal pitcher with white residue on the inside surface. In an interview on 11/13/23 at 9:34 a.m., the DDS confirmed the metal storage rack in the dish room was for storing clean items. She stated the pans, cheese grater, metal bowls, the small square metal pan, and the metal pitcher were dirty. c. An observation in the kitchen dish room on 11/13/23 8:31 a.m., showed a meat slicer covered with a torn plastic bag. The surface of the plastic bag had brown residue on the surface. The plastic bag was removed, and the surface of the meat slicer had residue on the surface resembling dried food. In an observation of the meat slicer and concurrent interview with the DDS on 11/13/23 at 9:33 a.m., the DDS confirmed the meat slicer was dirty. In an interview on 11/15/23 at 4:20 p.m., Registered Dietitian Q (RD Q) stated everything in the kitchen should be clean. She stated it was not okay to store equipment, such as the meat slicer, with food build-up. Review of the policy and procedure titled Electrical Food Machines dated 2023, showed to keep and maintain all food machines in sanitary condition. The food slicer is to be cleaned after each use, and when not in use it should be covered. d. An observation in the kitchen and concurrent interview with the DDS on 11/13/23 9:19 a.m., showed an industrial can opener stored in a holder attached to a preparation table. The can opener blade surface was covered with a thick, wet, yellowish residue. Also on the blade, in the seam where the blade attached to the can opener, and on the cogwheel (the part of the can opener that helps turn the can), there was a thick, black/brown residue. The shaft (handle) of the can opener was sticky to the touch. The DDS stated the can opener was dirty. Review of the policy and procedure titled Can Opener and Base dated 2023, showed proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. e. An observation on 11/13/23 at 9:29 a.m., showed plastic cutting boards stored in a rack on the bottom shelf of a cart located across from the stove. Two cutting boards had deep cut marks and the surface had peeling bits of plastic. Another cutting board also had significant cut marks on the surface as well as black residue and what resembled food residue on the cutting surface. In addition, the shelf holding the cutting board rack had black and orange, wet residue on the surface. The DDS stated the cutting boards were in poor condition, and the holding rack for the cutting boards was dirty. In an interview on 11/15/23 at 4:20 p.m., RD Q stated everything in the kitchen should be clean and when equipment was worn, like cutting boards, they should be replaced. f. An observation in the kitchen and a concurrent interview with DDS on 11/13/23 at 9:17 a.m., showed multiple knives stored in a knife holder located across from the stove. Five of the knives stored in the knife holder had orange residue on the knife blade surface. Also, three of the five knives had white greasy residue on the blade surface. DDS stated the knives were dirty and should not be stored in the knife rack if they were not clean. She stated knives were hand washed and should be rewashed until they were clean. g. An observation and concurrent interview with Housekeeping Staff L (HK L) on 11/14/23 4:44 p.m., showed a microwave oven located in the Station E activity room. The ceiling, and back wall inside the microwave, had a significant amount of orange and brown splatter residue on the surfaces. In addition, dark brown residue was imbedded along the side edge of the bottom and corners inside the microwave. HK L stated (Activities Assistant M translated) housekeeping staff were responsible for cleaning the microwave ovens in the activity rooms. She stated the housekeeping staff responsible for cleaning the microwave in Station E activity room had a shift that ended at 2:30 p.m. HK L stated the microwave was supposed to be cleaned every day. HK L stated the microwave was not clean. In an interview on 11/14/23 at 5:35 p.m., the DDS stated Food and Nutrition Services did not have oversight of the microwaves located outside of the kitchen. In an interview on 11/14/23 at 5:40 p.m., RD Q stated she did not monitor microwaves outside of the kitchen. 2. Review of the policy and procedure titled Sanitation dated 2023, showed all equipment shall be kept clean, maintained in good repair and shall be free from corrosions. In addition, the FNS Director will write the cleaning schedule in which he/she designates by job title and/or employee who is to do the cleaning task. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch, and surfaces are to be smooth. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, and other debris; and are to be designed and constructed to allow easy cleaning and to facilitate maintenance. a. An observation and a concurrent interview with the DDS on 11/13/23 10:18 a.m., showed metal racks used to store food in the kitchen's walk-in refrigerator was covered with orange residue. The DDS stated the racks were covered with rust. b. An observation in the kitchen and concurrent interview with the DDS on 11/13/23 at 9:43 a.m., showed cooking utensils stored in two drawers under a preparation table across from the stove. Both drawers were had a significant amount of debris resembling food crumbs on the inside bottom surface. The cooking utensils came into contact with the debris. The DDS confirmed the drawers were dirty. When asked if there was a cleaning schedule to clean areas such as drawers, The DDS stated she did not currently have a cleaning schedule for staff to follow. Review of the policy and procedure titled Cabinets and Drawers dated 2023, showed to clean cabinets and drawers on a weekly basis. c. An observation in the dish room and concurrent interview with the DDS on 11/13/23 at 8:18 a.m., showed a metal rack holding food preparation equipment such as pans and mixing bowls, was lined with plastic mesh that had spots of brown residue on the surface. In an interview on 11/13/23 at 9:34 a.m., DDS confirmed the metal storage rack in the dish room was for storing clean items. She stated the lining for the dishrack was not on a cleaning schedule, but it should be. d. In a consecutive observation and interview on 11/13/23 at 9:34 a.m., a rolling cart was stored adjacent to the metal storage rack. The rolling cart had plastic tableware racks on the top shelf which held spoons, forks, and knives. The top shelf of the rolling cart was covered in debris that resembled food crumbs. The DDS stated the tableware was clean and the rolling cart was covered with food residue and was not clean. e. An observation in the kitchen and concurrent interview with the DDS on 11/13/23 9:30 a.m., showed a rack across from stove holding items such as gloves and cooking oil. The legs of the rack had brown residue build-up on the surface. The DDS confirmed the residue build-up and said it was not clean. 3. Review of the policy and procedure titled General Cleaning of Food & Nutrition Services Department dated 2023, showed Food and Nutrition Services (FNS) staff should remove large debris as it accumulates from drains, and staff are encouraged to clean drains weekly. According to the 2022 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. According to the 2022 Federal Food Code Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. An observation in the kitchen dish room on 11/13/23 at 8:36 a.m., showed a long floor drain in the middle of the dish room. The removable grates over the drain had thick gray build-up on the surface. An observation in the kitchen on 11/13/23 at 8:38 a.m., showed a floor drain next to the stove filled with black sludge and standing liquid. An observation in the kitchen on 11/13/23 at 8:42 a.m., showed a floor drain near the staff lockers and the walk-in refrigerator with debris inside the drain such as a shoe, a plastic spoon, and black bits. In an interview and observation on 11/14/23 at 8:53 a.m., the DDS looked at the long floor drain in the dish room and confirmed there was residue build-up on the drain grates. She stated kitchen staff were responsible for cleaning the grates. The DDS stated there was no documentation or schedule to show how often it was done. In an interview and observation on 11/14/23 at 9:55 a.m., showed the floor drain near the stove was covered. The DDS stated the drain was clogged. She said maintenance did not know where the water in the drain came from. In an interview an observation of the floor drain near the stove on 11/14/23 at 10:15 a.m., the MDR stated the drain was for an old steamer that was removed. He stated he just covered the drain today. He removed the cover which the MDR secured with foam sealant and tape to keep it from moving off the drain. Inside the drain there was thick black residue build-up and some standing water. The MDR stated he did not think the drain was clean. The MDR stated he was responsible for cleaning drains. 4. Review of the policy and procedure titled General Cleaning of Food & Nutrition Services Department dated 2023, showed floors are to be maintained in good condition. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. An observation in the kitchen on 11/13/23 at 8:16 a.m., showed the floor between the dish room and the kitchen food preparation room was cracked and detached so it was raised. The area around the cracked, raised flooring had brown residue build-up. In addition, the metal floor threshold between the dish room and the kitchen preparation room had, black residue build-up on the surface. In an interview on 11/13/23 at 9:41 a.m., the DDS confirmed the floor was cracked and in poor condition. An observation in the kitchen dish room and concurrent interview with the MDR on 11/13/23 at 9:39 a.m., showed the tile floor under the dish machine was covered with a black residue. The MDR confirmed the floor was dirty. An observation and interview with the DDS on 11/14/23 at 9:55 a.m., showed the kitchen floor surface was rough, uneven and had black residue build-up through- out the surface of the floor. In addition, the floor felt sticky when walking on it. The DDS agreed the floor felt sticky and stated we do our best to clean it. During and observation of the kitchen floor and concurrent interview with the MDR on 11/14/23 at 10:15 a.m., the MDR confirmed there was black residue build-up throughout the floor surface. 5. Review of the policy and procedure titled Storage of Food and Supplies dated 2023, showed the storeroom should be clean at all times. According to the 2022 Federal Food Code, indoor walls and ceiling surfaces under conditions of normal use shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted. In addition, attachments to walls are to be easily cleanable and wall covering materials are to be attached so they are easily cleanable. An observation in the kitchen on 11/13/23 at 8:16 a.m., showed the doorway from the dish room to the food preparation room had metal molding surrounding the doorway and the metal molding was bent and pulled away from the wall creating gaps between the molding and the wall. In an interview on 11/13/23 at 9:41 a.m., the DDS confirmed the metal molding around the doorway was becoming detached. She stated she did not inform maintenance about this issues. During an observation and interview with the MDR on 11/13/23 at 10:50 a.m., he stated he was responsible for fixing the doorway molding. An observation in the kitchen on 11/13/23 at 8:39 a.m. showed the wall by the stove and doorway out to a hallway had brown, dried reside down the wall resembling dried drip marks. Also, there was brown residue on the light switch, and light switch cover located next to the doorway in the same area. In addition, a large black plug for the for the steamer and the outlet it was plugged into, adjacent to the light switch, had brown residue on the surface. Along the same wall was metal conduit (a tube covering to protect electrical wiring). The metal conduit was covered with a light gray, fuzzy substance. An observation in the kitchen dish room on 11/13/23 at 9:39 a.m., showed the wall, close to the floor behind the dish machine had a rough, bubbled appearance, and was covered with a black residue. There was also long, white pieces up to two inches in length, of a substance hanging from a strip of molding behind the dish machine in the area where the wall was rough and black. The wall was wiped with a paper towel, the surface felt hard and rough, and black residue wiped off. An observation in the dry food storeroom and concurrent interview with the DDS on 11/13/23 at 10:32 a.m., showed cracked and peeling paint more than two feet in length on a back wall above a food storage rack. Also, there was orange residue on the ceiling and wall in the same area of the dry storeroom. In addition, there was a dime size hole with exposed drywall in a wall above a food storage rack. There were black dots on the wall surrounding the hole resembling very small, dead insects. The DDS stated she did not report the cracked/peeling paint to maintenance, but it was something she would report if she noticed it. She also confirmed there was orange and black residue on the walls and ceiling, and stated kitchen staff were responsible for cleaning. In an interview with the MDR and concurrent observation of the wall behind the dish machine on 11/13/23 at 10:53 a.m., the MDR confirmed the wall had black residue build-up and he was responsible for cleaning that area. In an interview with the DDS and concurrent observation of the wall by the stove on 11/14/23 at 9:55 a.m., the DDS stated the conduit was dusty and the wall, light switch, light switch cover, and the plug and outlet for the steamer were dirty and had to be cleaned. An observation in the kitchen dish room and interview with the DDS on 11/14/23 at 9:57 a.m., showed a metal kickplate/molding (a wide metal strip along the bottom of a wall to protect the wall from damage) along the bottom of the wall adjacent to the hallway. The kickplate had brown residue build-up along the surface. The DDS stated she did not think the kickplate was cleaned very often and it needed to be cleaned. 6. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, and other debris. a. Review of the policy and procedure titled Hoods, Filters, and Vents dated 2023, showed due to potentially high fire hazard, it is important that hood filters be part of a strictly enforced cleaning schedule (every two weeks). According to the 2022 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. Exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials. An observation in the kitchen and interview with the DDS on 11/13/23 at 9:18 a.m., showed the removable filters in the hood of the stove had visible black build-up on the filter surfaces. The DDS stated the filters were cleaned every three months by an outside company and confirmed the filters looked dirty. Review of the most recent invoice for cleaning the stove hood vents/filters titled [Company Name] Restaurant Grease Exhaust Specialists showed exhaust cleaning was performed on 5/30/23. b. An observation in the kitchen dish room and concurrent interview with the DDS on 11/13/23 at 9:32 a.m., showed a large standing fan next to the 3-compartment sink with gray, fuzzy residue covering the guard over the fan blades. The DDS stated the large fan was used and it was dusty. c. An observation in the kitchen and interview with DDS on 11/13/23 at 8:37 a.m., showed a standing oven with a thick layer of gray, fuzzy residue, as well as particles that resembled food crumbs on the top, outside surface of the oven. In addition, there was a pile of black, dry reside on top of the oven, under an insulated oven vent, indicating black residue was falling from the oven vent onto the top of the oven. The DDS looked at the top of the oven and sated it was dusty and it was time to call maintenance. d. An observation in the kitchen dish room and concurrent interview with the DDS on 11/14/23 at 10 a.m., showed a metal box under the dish machine covered with wet, black, and yellowish residue. The DDS stated the metal box under the dish machine was the booster heater for the dish machine. She stated the kitchen staff did their best to clean the booster heater. 7. An observation on 11/13/23 at 10:29 a.m., showed large, white food storage bins stored in a row. One bin labeled potatoes contained large white onions. A bin next to the bin with onions was labeled thickener. The bin labeled thickener was filled with a white, granular substance. In addition, there were onion skins and debris from onions inside the bin labeled thickener, combined with the white granular substance. In a consecutive interview and observation on 11/13/23 at 10:31 a.m., the DDS confirmed there was food thickener (used to thicken foods and sometimes beverages) in the bin labeled thickener. She stated onion debris should not be inside the thickener bin. According to the 2022 Federal Food Code, food that is adulterated (the addition of another ingredient/foreign substance lessening the purity of the food) shall be discarded. 8. Review of the policy and procedure titled Procedure for Refrigerated Storage dated 2023, showed refrigerators were to be 41 degrees F or lower. Also, to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees lower. For example, to hold chicken at 41 degrees F, the air temperature must be 39 degrees F. According to the 2022 Federal Food Code, when food is held when time is not used as the public health control, TCS food is to be maintained at 135 degrees F or above or at 41 degrees F or less. An observation in the kitchen and interview with Dietary Aide E (DA E) on 11/13/23 at 8:55 a.m., a large pan of creamy cucumber salad was stored in the walk-in refrigerator. The temperature of the salad was measured with a calibrated thermometer and was 48.6 degrees Fahrenheit (F). DA E stated (Cook D translated) she made the cucumber salad between five and six a.m. that morning (11/13/23). An observation on 11/13/23 at 9:20 a.m., showed the pan containing the cucumber salad was taken out of the refrigerator and placed on a preparation table to be portioned for lunch. The temperature was measured with a calibrated thermometer and was 46.6 degrees F. In a consecutive interview with DDS on 11/13/23 at 9:22 a.m., when the time and temperatures of the cucumber salad was described to the DDS, she stated the cucumber salad had to go back in the refrigerator. In an observation and interview on 11/13/23 at 9:56 a.m., showed the cucumber salad was removed from the refrigerator to portion for lunch. The temperature of the salad was measured with a calibrated thermometer and was 46.8 degrees F. The recipe for the creamy cucumber salad was reviewed and the recipe showed the salad was to be stored at 41 degrees F. Then the DDS stated the cucumber salad should be placed in a shallow pan to cool it down more quickly. Review of the undated recipe titled Recipe: Creamy Cucumber and Celery Salad showed ingredients which included sour cream. In addition, the recipe showed to hold at less than 41 degrees F until service. During an observation in the kitchen and interview with the DDS on 11/13/23 at 10:05 a.m., the temperatures of food, the DDS confirmed were stored in the refrigerator overnight and were not removed from the refrigerator that day, were measured with a calibrated thermometer. The temperatures were as follows (some of the food measured was measured with a facility calibrated thermometer and a surveyor calibrated thermometer): -A carton of milk stored in the back of the refrigerator 44.1 degrees F (Surveyor) - Tuna salad 44.2 degrees F (Surveyor) and 42.9 degrees F (facility) - Sliced deli meat ham 43.0 degrees F (Facility) - Sliced deli meat turkey 44.4 degrees F (Surveyor) and 43.1 degrees F (Facility) In an interview with the DDS on 11/14/23 at 9:55 a.m , the DDS stated the temperature of food stored in the refrigerator should be 41 degrees F or under. She stated the temperature of the refrigerator was currently 40 degrees F. She stated she did not take temperatures of food to determine the food was at an appropriate temperature. 9. Review of the policy and procedure titled Procedure for Refrigerated Storage dated 2023, showed Refrigerator 41 degrees F or lower and to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees lower. For example, to hold chicken at 41 degrees F, the air temperature must be 39 degrees F. According to the 2022 Federal Food Code, when food is held when time is not used as the public health control, TCS food is to be maintained at 135 degrees F or above or at 41 degrees F or less. a. In an interview on 11/14/23 at 4:10 p.m., Certified Nursing Assistant H (CNA H) stated food brought in for residents by visitors, was sometimes stored in the resident food refrigerator located in nursing Station A. In an observation and concurrent interview with Registered Nurse J (RN J) on 11/14/23 at 4:40 p.m., RN J stated resident food could be stored in the resident food refrigerator in the nursing station for two to three days. She stated nursing staff monitored the refrigerator temperature and temperatures were documented on a temperature log. RN J stated the food refrigerator temperatures were documented under the Large Refrigerator on the log and refrigerator temperatures were recorded twice a day. The temperature log documentation was reviewed and showed temperatures up to 46 degrees F were recorded for the food refrigerator. RN J stated she documented temperatures at 44 and 46 degrees F, and up to 46 degrees F was okay. She stated if the food refrigerator went above 46 degrees, maintenance had to be contacted. Review of untitled document dated November 2023 which was provided as the refrigerator documentation log for the food refrigerator located in Nursing Station A, showed the document had Acceptable Range: 36 degrees F - 46 degrees F typed at the top of the log. From 1/11/23 to 11/14/23, there were four temperatures recorded at 44 degrees and one temperature recorded at 46 degrees F. An observation and interview with the Director of Staff Development (DSD) and the DDS on 11/14/23 at 5:35 p.m., showed a resident food refrigerator located in the medication room in Nursing Station E. The refrigerator temperature log was reviewed with the DSD, and she stated it the food refrigerator temperatures should be 36 to 46 degrees F. The DDS stated Food and Nutrition Services did not conduct training for nursing regarding appropriate food refrigerator temperatures [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to have a policy pertaining to the safe storage of resident food brought in from the outside. This failure had the potential to expose 197 residents who consume food, to contamination from the unsafe storage of the resident's food from outside stored in three facility refrigerators, including an employee refrigerator where resident and employee food were comingled. Findings: During an interview on 11/14/23 at 4:08 p.m., with Certified Nurse Assistant U (CNA U), CNA U stated residents can bring food in from outside and the food is stored in the refrigerator inside the staff breakroom in Station C. CNA U stated the CNAs would label the resident's food with their name and room number before it is placed in the refrigerator. During an interview on 11/14/23 at 4:10 p.m. with Certified Nurse Assistant H (CNA H), CNA H stated there were two residents he knew of that had food brought in by visitors. CNA H further stated he thought food like sandwiches can be held in the refrigerator for four to five hours. He stated sometimes residents do not want the food brought in from the outside right away, so it would go in the fridge at Station A. During an interview on 11/14/23 at 4:13 p.m. with Certified Nurse Assistant X (CNA X), CNA X stated the resident's family can bring food into the facility from the outside, and the food is stored in the refrigerator inside the employee breakroom. During an interview on 11/14/23 at 4:15 p.m. with Licensed Vocational Nurse I (LVN I), LVN I stated food brought in by visitors can be held in the fridge for up to 12 hours, then it goes in the trash. CNA H did not state how the food in the fridge was monitored and who threw it in the trash after 12 hours. During an interview on 11/14/23 at 4:20 p.m. with Registered Nurse J (RN J), RN J stated resident food brought in from the outside can be stored in the resident's fridge at nursing Station A for two to three days. RN J further stated the resident's fridge is checked every Friday to throw away all food inside. During an interview on 11/14/23 at 4:35 p.m. with Registered Dietitian Q (RD Q), RD Q stated food could be brought in from the outside for residents, and it is stored in the refrigerator inside the medication room at nursing Station C. RD Q stated she was unaware of the facility's policy which stated resident's food could not store food in the facility. RD Q further stated the resident's food should be stored safely with the correct labeling of their name, room number, and date so that it could be safely monitored. During an observation and interview on 11/14/23 at 4:48 p.m. with Housekeeping Staff L (HK L) in the employee breakroom, HK L stated she cleans the refrigerator in the employee daily and throws the food out that looks old and has an expired date. Activities Assistant M (AA M) translated for HK L. Review of the facility's undated policy and procedure (P&P) on 11/13/23 titled, Bringing in Food for a Resident indicated, . Non-perishable food or beverage items without a manufacturer's expiration date will be thrown away after at most, 30 days. Prepared foods, beverages, or perishable foods that require refrigeration will be discarded after 1 hour. [NAME] Post Acute does not provide a refrigerator for resident use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. During a concurrent observation and interview on 11/13/23 at 8:38 a.m. with Licensed Vocational Nurse (LVN A), LVN A put on gloves at Resident 165's bedside, removed the medication patch on the right shoulder of Resident 165 and applied topical ointment to the right upper arm and shoulder using the same gloves. LVN A stated she should have changed gloves and performed hand hygiene. During an interview on 11/14/23 at 11:58 a.m., with the DON, the DON stated hand hygiene should be done before and after each medication, and after each procedure. Review of the facility's Administering Medications policy, dated April 2019, indicated Staff follows established facility infection control procedures (e.g., handwashing .) for the administration of medications. Based on observation, interview and record review, the facility failed to implement infection control practices for 10 of 35 sampled residents (Residents 11, 78, 26, 43, 53, 131, 177, 117, 79, and 165) when: 1. For Resident 11, staff did not follow the facility's handwashing/hand hygiene policy; 2. For Resident 78, staff did not keep her urinary catheter drainage bag (a bag used to collect urine from a flexible tube inserted into the bladder) off the floor; 3. Resident 177's urinals were dirty and had dry yellow residue around their necks; 4. Certified Nursing Assistant JJ (CNA JJ) put her finger in Resident 131's box of milk to pull it completely opened; 5. Resident 53's oxygen tubing was not covered and hung on the portable oxygen tank. The filters of Resident 53's and Resident 26's oxygen concentrators were dusty, and the cover bags for their oxygen tubings were undated; 6. Certified Nursing Assistant SS (CNA SS) walked out of Resident 43's room with gloves on, and Certified Nursing Assistant TT (CNA TT) did not wash or sanitize her hands before feeding Resident 43; 7. Licensed Vocational Nurse RR (LVN RR) did not wash her hands before doing the treatment for Resident 53's wound; 8. For Resident 117, staff did not keep her oxygen tubing off the floor; 9. For Resident 79, facility staff failed to properly discard an uncapped normal saline (NS, sodium chloride) flush syringe; and 10. For Resident 165, staff did not perform hand hygiene for the administration of medications. These failures had the potential to spread infection in the facility. Findings: 1. During a wound treatment observation on 11/14/23 at 1:25 p.m., Licensed Vocational Nurse BBB (LVN BBB) provided wound treatment for Resident 11 without performing hand hygiene or changing his gloves after removing the previous dressing or after cleansing the wound. LVN BBB then applied the dressing to her right-hand wound. LVN BBB started the wound treatment on Resident 11's coccyx (the tailbone) area without performing hand hygiene or changing his gloves. LVN BBB continued the wound treatment on the coccyx area without performing hand hygiene or changing his gloves after removing the previous dressing or after cleansing the wound, then he applied the dressing. During the after-wound treatment observation on 11/14/23 at 1:36 p.m., Certified Nursing Assistant AAA (CNA AAA) touched a pillow on Resident 11's bed and fixed her bed sheets without gloves. CNA AAA cleaned Resident 11's buttocks with a wet towel after hand hygiene and wearing gloves. Then CNA AAA applied a diaper without performing hand hygiene or changing her gloves. During an interview on 11/14/23 at 1:40 p.m. with LVN BBB, he confirmed the above observation. LVN BBB stated he should have performed hand hygiene and changed his gloves during the wound treatment procedure, as well as before starting another wound treatment for infection control. During an interview on 11/14/23 at 1:46 p.m. with CNA AAA, she confirmed the above observation. CNA AAA stated she should have performed hand hygiene and wore gloves before starting the care. CNA AAA also stated she should have performed hand hygiene and changed her gloves during the care. During a review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after direct contact with residents; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects in the immediate vicinity of the resident. 2. Review of Resident 78's clinical record indicated she was admitted on [DATE] and had diagnoses of neuromuscular dysfunction of bladder (the bladder may not fill or empty properly as a result of the nerves and muscles not working together) and pressure ulcer (injury to the skin and underlying tissue from prolonged pressure) of sacral region (the portion of the spine between the lower back and tailbone). During a review of Resident 78's physician order, dated 11/07/22, the order indicated, Indwelling Foley catheter due to diagnosis of neurogenic bladder, wound management. During an observation and interview on 11/14/23 at 9:30 a.m. with Licensed Vocational Nurse EE (LVN EE), Resident 78 was lying in bed, and her urinary catheter drainage bag was placed on the floor. LVN EE confirmed the observation and immediately relocated the urinary catheter drainage bag off the floor. LVN EE stated the urinary catheter drainage bag should have been kept off the floor because of infection control. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, revised 8/2022, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. 9. Review of Resident 79's Face Sheet (a document that provides resident specific information at a quick glance) indicated Resident 79 was admitted on [DATE] with diagnoses that included dysphagia (swallowing disorder) following cerebral infarction (stroke), hemiplegia (symptom that involves one-sided paralysis) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction, dependence on respirator (ventilator, a medical device that gives oxygen through a breathing tube). During an observation and concurrent interview on 11/15/23, at 10:30 a.m., in Resident 79's room. Resident 79 was lying in bed, asleep, tracheostomy in place. Registered Nurse WW (RN WW) was inside Resident 79's room, standing near the overbed table. There was a 10 milliliter (ml, unit of measure) pre-filled NS flush without the white tip cap attached, loosely wrapped in facial tissue, and was placed on top of Resident 79's overbed table. RN WW stated that she will administer the IV (intravenous, within a vein) antibiotic (ATB, medicines that fight bacterial infections). After a few minutes, LVN I entered Resident 79's room, and RN WW began setting up the IV medications. The IV site located on Resident 79's left hand was cleaned by RN WW, who then requested LVN I to hand her the uncapped, 10 ml pre-filled NS flush syringe wrapped in facial tissue on the overbed table. The surveyor intervened, questioning the use of the syringe without the white tip cap attached. The RN WW acknowledged the concern, removed a new, properly capped NS syringe from her pocket, and administered it to Resident 79. The RN WW stated that the uncapped syringe should not be administered to Resident 79. During an interview with the Director of Nursing (DON) on 11/16/23, at 2:11 p.m., the DON was made aware of the above incident. The DON stated that the uncapped NS syringe should be discarded and not be used to flush Resident 79's IV site. The DON stated the NS syringe could be contaminated because the tip cap was not attached. The DON further stated RN WW should open a new NS syringe to flush Resident 79's IV site. 8. Review of Resident 117's medical record indicated she was admitted on [DATE] and had the diagnoses of chronic obstructive pulmonary disease (COPD, a disease that obstructs airflow and causes difficulty breathing) and chronic respiratory failure (a condition in which not enough oxygen travels from the lungs into the blood). Review of Resident 117's Order Summary Report indicated she had a physician's order, dated 3/29/23, to receive oxygen by way of nasal cannula (NC, flexible tubing placed in the nostrils and connected to an oxygen source). During an observation on 11/14/23 at 9:12 a.m., Resident 117 was lying in bed. Her NC was attached to an oxygen concentrator (machine that delivers oxygen). The part of the NC that was meant to be placed in the resident's nostrils was on the floor. During an observation on 11/14/23 at 10:18 a.m., Certified Nursing Assistant FF (CNA FF) was tending to Resident 117 in the resident's room. The NC was still on the floor. After tending to Resident 117, CNA FF turned off the resident's light and left to provide care to another resident. CNA FF did not pick up Resident 117's NC before leaving the room. During an observation on 11/14/23 at 10:47 a.m., Resident 117's NC was still on the floor. During an observation and concurrent interview with Registered Nurse GG (RN GG) on 11/14/23 at 10:49 a.m., Resident 117's NC was still on the floor. RN GG confirmed this observation and acknowledged the NC should not have been on the floor. RN GG acknowledged that staff who provided care to Resident 117 should have identified that the NC was on the floor.3. Review of Resident 177's admission Record indicated he was admitted to the facility on [DATE]. During an observation and interview with Certified Nursing Assistant II (CNA II) on 11/13/23 at 12:20 p.m., Resident 177 had two urinals on his bed side table; they were dirty and had dry yellow residue around their necks. CNA II stated Resident 177 used the two urinals and confirmed they were dirty. CNA II stated the urinal should be washed every two hours and changed if it was dirty. During an interview with the Infection Preventionist (IP) on 11/17/23 at 8:59 a.m., he stated the urinal should be washed after it was used. The resident's urinal should be kept clean and changed if it was dirty. Review of the facility's policy, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated 6/2011, indicated . Steps in the Procedure: . Measuring Graduates/Urinals: 1. Rinse measuring graduate/urinal with warm water after each use. 2. Disinfect measuring graduates/urinals weekly using EPA-registered and facility approved low-level disinfectant solution . 4. Review of Resident 131's admission Record indicated he was admitted to the facility on [DATE]. During an observation on 11/15/23 at 12:15 p.m., CNA JJ brought lunch tray to Resident 131 in his room and opened the lids of food plate and drinks for Resident 131. CNA JJ opened Resident 131's box of milk then put her finger inside the box opening to pull it completely opened. During a concurrent interview, CNA JJ stated she should not put her finger inside the box of milk to open it. During an interview with the IP on 11/17/23 at 9:02 a.m., he stated staff should not put their fingers inside the box of milk to open it. Review of the facility's policy, Food Handling, dated 2023, indicated Food will be prepared and served in a safe and sanitary manner. 5a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 53's physician order, dated 6/27/23, indicated she had an order for oxygen at 2 liters (L, a metric unit of volume) per minute continuously via oxygen concentrator every shift and as needed. During an observation and interview with Licensed Vocational Nurse QQ (LVN QQ) on 11/13/23 at 12:39 p.m., Resident 53 was sitting in the station lobby. A portable oxygen tank was next to her, and the oxygen tubing was hanging on the oxygen tank without a cover bag. LVN QQ stated Resident 53's oxygen tubing should be covered in a bag. During an observation and interview with LVN QQ on 11/13/23 at 12:41 p.m. in Resident 53's room, the cover bag of her oxygen tubing was not dated, and the filter of her oxygen concentration was dusty. The filter had a layer of dust on it. LVN QQ stated the cover bag for the oxygen tubing should be dated, and the filter of the oxygen concentration should be kept clean. 5b. Review of Resident 26's admission Record indicated she was admitted to the facility on [DATE] with respiratory failure diagnosis. Review of Resident 26's physician order, dated 10/24/23, indicated she had an order for oxygen at 2 L per minute as needed for shortness of breath/wheezing. During an observation and interview with LVN QQ on 11/13/23 at 12:45 p.m. in Resident 26's room, the cover bag of her oxygen tubing was not dated, and the filter of her oxygen concentration was dusty. The filter had a layer of dust on it. LVN QQ stated the cover bag for the oxygen tubing should be dated, and the filter of the oxygen concentration should be kept clean. During an interview with the IP on 11/17/23 at 9:09 a.m., he stated the oxygen tubing should be stored in a bag if not in use, and the filter of the oxygen concentrator should be kept clean. During an interview with the Director of Staff Development (DSD) on 11/17/23 at 9:15 a.m., she stated the cover bag of the oxygen tubing should be dated. Review of the facility's oxygen concentrator, User Manual, dated 2009, indicated Remove the filter and clean at least once a week depending on environmental conditions. Notes: Environmental conditions that may require more frequent cleaning of the filters include but are not limited to high dust, air pollutants, etc. 6a. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 11/13/23 at 9:29 a.m., Certified Nursing Assistant SS (CNA SS) helped Resident 43 in her room and walked out of the room with the gloves on. During a concurrent interview with CNA SS, he stated he should remove the gloves before walking out of Resident 43' room. During an interview with the IP on 11/17/23 at 9:13 a.m., he stated the staff should remove their gloves before exiting the residents' room. Review of the facility's policy, Personal Protective Equipment - Using Gloves, dated 9/2010, indicated . 2. Discard used gloves into the waste receptacle inside the examination or treatment room. 6b. During an observation on 11/14/23 at 9:21 a.m., Certified Nursing Assistant TT (CNA TT) was in Resident 43's room. Resident 43's breakfast tray was on her overbed table. Since the chair could not fit in the space on the side of Resident 43's bed, CNA TT moved the bed to the other side, pushed the chair into the space of this side, sat down, and fed Resident 43 her breakfast without washing or sanitizing her hands. During an interview with CNA TT on 11/14/23 at 9:31 a.m., she stated she should sanitize her hands before feeding Resident 43 her breakfast. During an interview with the IP on 11/17/23 at 9:13 a.m., he stated the staff should wash or sanitize their hands before feeding the residents. Review of the facility's policy, Handwashing/Hand Hygiene, dated 8/2019, indicated This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . q. Before and after assisting a resident with meals. 7. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review or Resident 53's clinical record indicated she had a pressure ulcer (skin or soft tissue injury that form due to prolonged pressure exerted over specific areas of the body) stage 2 (there is partial-thickness skin loss) on her left buttock. Review of Resident 53's physician order, dated 11/7/23, indicated she had an order for the license nurse to cleanse the pressure ulcer on her left buttock with normal saline (NS, 0.9% purified salt solution), pat dry, apply Calmoseptine (used to treat and prevent skin irritations), then cover with dry dressing every day and evening shift. During an observation on the treatment for Resident 53's left buttock pressure ulcer, on 11/15/23 at 11:33 a.m., Licensed Vocational Nurse RR (LVN RR) was in Resident 53's room and planned to start the treatment. LVN RR noticed that she forgot to bring the NS with her. LVN RR walked back to the treatment cart, opened the cart to get the bottle of NS, came back in, put on gloves, and started to cleanse the pressure ulcer on Resident 53's left buttock and apply treatment without washing her hands. During an interview with LVN RR on 11/15/23 at 11:45 a.m., she stated she should wash her hands before putting on gloves to cleanse the wound and apply treatment for Resident 53. During an interview with the IP on 11/17/23 at 12:20 p.m., he stated the licensed nurses should wash their hands before doing the wound treatment for the residents. Review of the facility's policy, Handwashing/Hand Hygiene, dated 8/2019, indicated This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . h. Before handling clean or soiled dressings, gauze pads, etc. m. After contact with objects . 9. The use of gloves does not replace hand washing/hand hygiene.

3. During an observation and interview on 11/13/23 at 9:05 a.m. with Dietary Aide N (DA N), two compartments (rinse and sanitize sinks) inside the three-compartment sink had pink rubber stoppers with a white handkerchief stuffed in between the drain and the stopper to plug the water. DA N stated the rubber stoppers have been used for a while to stop the water from draining out the sinks because the piece under the three-compartment sink to stop the water was broken. DA N stated the rinse and sanitize sinks in the 3-compartment sink was used to wash the food carts and other equipment items. During an observation and interview with the DDS on 11/13/23 at 9:31 a.m., the DDS stated the three-compartment pink rubber stoppers in the rinse and sanitize sinks with white handkerchief should not have been used to plug the water. The DDS stated the lever under the first wash sink did not work or close to stop the water from draining. During an interview with RD Q on 11/15/23 at 3:25 P.M., RD Q stated the three-compartment sink should have the correct stoppers to plug the drain in each sink to allow for safe cleaning, rinsing, and sanitizing. According to the 2022 Federal FDA Food Code, section 4-501.11, titled Good Repair and Proper Adjustment, Part (A) indicated Equipment shall be maintained in a state of repair and condition that meets requirements . (B) Equipment components such as doors, seals, hinges . shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. Review of the facility's policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing dated 2023, indicated Supplies Needed: . drain stoppers . Step 4: the second compartment is for rinsing. Fill the second sink with clean, clear hot water (110-120 degrees F). Record temperature on log . Step 5: The third compartment is for sanitizing. Fill the third compartment with clean, clear water to the fill line . The add . oz. of . sanitizer. Test the concentration with the appropriate test strip . Record on log . Temperatures and test strips need to be retaken every 30 minutes . Based on observation, interview, and facility document review, the facility failed to maintain kitchen equipment in safe operating condition when: 1. Water was dripping onto the floor from the dish machine; 2. A sink/garbage disposal drain was leaking; and 3. A three-compartment sink did not have appropriate drain plugs to allow the sinks to be filled with water. The failure to maintain the equipment working in the way intended had the potential to lead to contamination of food, utensils, and equipment for 197 residents who received food from the kitchen. Findings: Review of the policy and procedure titled, Sanitation dated 2023, showed in the Food and Nutrition Services (FNS) Department, all equipment shall be maintained as necessary and kept in working order. In addition, employees are to alert the FNS Director immediately to any equipment needing repair. Also, the FNS Director will report any equipment needing repair to the maintenance man. The Maintenance Department will assist FNS as necessary in maintaining equipment. 1. An observation and interview with the Maintenance/Housekeeping Director (MDR) on 11/13/23 at 10:53 a.m., showed a stream of water was dripping onto the floor from the bottom of the dish machine. There was a significant amount of murky water pooled under the dish machine area. The MDR stated he was not aware the dish machine was dripping. In an interview on 11/14/23 at 8:53 a.m., the Director of Dietary Services (DDS) stated staff were supposed to inform her when equipment needed maintenance or repair. She stated staff did not inform her about the leaking dish machine. An observation and interview with the DDS on 11/14/23 at 9:55 a.m., showed a stream of water was dripping from under the dish machine onto the floor and there was a significant amount of standing water under the dish machine area. The DDS stated she thought the dish machine leak was fixed. On 11/14/23 at 3:18 p.m., the Administrator (ADM) provided an outside vendor invoice showing the dish machine was serviced earlier in the day. An observation and interview on 11/16/23 at 10:40 a.m., showed staff were washing dishes using the dish machine. A stream of water was dripping from the bottom of the dish machine onto the floor. Murky water was pooled on the floor under the dish machine. The DDS stated she was not aware the dish machine was still leaking. 2. An observation and interview with the MDR on 11/13/23 at 10:53 a.m., showed a sink/garbage disposal area on the dirty side of the dish machine. A bucket was on the floor under the sink/disposal drain. The bucket was half filled with murky water. The drain had thick white and black slimy residue on the outside surface. The MDR stated he was not aware the sink/disposal drain was leaking. In an interview on 11/14/23 at 8:53 a.m., the Director of Dietary Services (DDS) stated staff were supposed to inform her when equipment needed maintenance or repair. She stated staff did not inform her about the leaking sink/disposal drain. An observation and interview with the DDS on 11/14/23 at 9:55 a.m., the sink/disposal drain was leaking water onto the floor. The DDS stated she thought the drain leak was fixed. The DDS stated that would explain the standing water under the dish machine. In an interview with Registered Dietitian Q (RDQ) on 11/15/23 at 4:20 p.m., RD Q stated she did not report the dripping sink/disposal drain but she often saw maintenance in the kitchen working on the sink. An observation and interview with the DDS on 11/16/23 at 10:40 a.m., showed a bucket was on the floor under the sink/disposal drain. The bucket was half full of murky water. DDS stated the sink must still be leaking because there was murky water in the bucket.

Based on observation, interview, and facility document review, the facility failed to maintain the facility: 1. Free of flies; and 2. In a manner to keep pests from entering the kitchen. This failure had the potential to result in pest transferred disease to residents for a census of 231. Findings: Review of the Policy and Procedure titled Pest Control dated 2001, showed the facility shall maintain and effective pest control program. Review of the Policy and Procedure titled Sanitation dated 2023, showed on a monthly basis, a pest control company will inspect and service the Food and Nutrition Services Department. If at any time additional servicing is needed, the pest control company will be notified. According to the 2022 Federal Food Code, perimeter walls of a food establishment shall effectively protect the establishment from the entry of insects, rodents, and other animals. In addition, the premises is to be maintained free of insects, rodents, and other pests. 1. On 11/13/23 at 9:39 a.m., a small fly was observed in the kitchen preparation area. On 11/13/23 at 10:40 a.m., five small flies were on a wall in the hallway outside of the dish room. In an interview and concurrent observation on 11/14/23 at 9 a.m., a Vendor Day Pest Control Technician (VDPCT) stated he was at the facility to do pest control for the exterior of the facility. The VDPCT he was not aware of flies inside the facility and said pest control for flies was done by the Vendor Night Pest Control Technician (VNPCT). The VDPCT observed the hallway outside of the kitchen dish room where there were 12 small flies on the ceiling and walls and the VDPCT stated he thought could be fungus gnats and stated they might be coming from outside due to the open hallway door to the outside. Then the VDPCT looked in the dish room and noted there were two fly lights, meant to attract and kill flies, attached to the wall adjacent to the hallway. He confirmed one light was not working or turned on. There were more than 13 insects on the ceiling by the door in the dish leading out to the hallway. The VDPCT stated he thought these insects could also be fungus gnats and/or another type of insect he could not remember the name of. The VDPCT stated fungus gnats were attracted to organic cellulose (plant) matter, residue build-up, grime, and moisture. He pointed to an old grease trap under the 3-compartment sink, which was covered in orange and brown residue resembling rust and food residue and stated the flies could be attracted to it. There were areas multiple areas inside the kitchen and kitchen dish room with built-up residue and standing water (Cross-reference F812 and F908). In an interview on 11/14/23 at 9:55 a.m., a small fly was in the food preparation area. The Director of Dietary Services (DDS) stated if she noticed flies, she reported them. She stated she did not notice flies in the hallway or the dish room. An observation on 11/15/23 at 3:22 p.m., showed 10 small flies on the walls and ceiling in the hallway outside the dish room, and two small flies in a resident room hallway directly next to the hallway of the dish room. In an interview on 11/16/23 8:55 a.m., the Administrator (ADM) stated the pest control service company was called to service for flies on Tuesday (11/14/23). Review of an email from the VDPCT to the ADM dated 11/16/23, showed the VDPCT stated he was contacted by the facility on Tuesday of this week (11/14/23) regarding flies. He stated the type of fly in the kitchen was a fungus gnat which fed on organic matter and come in from the outside. It was noted the VDPCT stated on 11/14/23 he was not aware of flies in the facility when he was interviewed on 11/14/23 at 10:40 a.m., and he stated during this interview he was not the pest control technician who conducted inside pest service for flies in the kitchen. In a phone interview with the VNPCT on 11/16/23 03:05 6:59 p.m., the VNPCT stated the facility called him today to check for flies inside the facility. In a phone interview with the VNPCT on 11/17/23 at 7:51 a.m., the VNPCT stated he went into the facility last night and found evidence of flies in the hallway outside the kitchen dish room. The VNPCT stated the flies he observed were drain flies which he stated were attracted to things that were not clean such as dirty drain and standing water. VNPCT sated he did a walk-through of the kitchen with the Administrator (ADM) and the DDS and showed them a drain that was not clean, standing water, as well as additional dirty areas. The VNPCT stated the facility should be cleaning and keeping everything clean in the kitchen. Pest reports from an outside pest service vendor titled [Company Name] Service Report were reviewed. While the most current reports provided dated 10/11/23, 10/25/23, and 11/8/23, showed the facility maintained regular pest control service visits, the documentation showed the facility was serviced for roach and rodent control and not for flies. 2. An observation and interview on 11/14/23 at 9:55 a.m. with the DDS showed the back door to the kitchen which led to the outside was closed and had a more than a one inch gap at the top of the door and at the side of the door. DDS confirmed there were gaps in the door to the outside. In an observation and interview with the Maintenance/Housekeeping Director (MDR) on 11/15/23 1:40 p.m., the MDR confirmed the kitchen back door was not tight fitting and had to be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice for one resident (Resident 1) when: 1. There was no documentation that the facility communicated with the dialysis center to check on the resident ' s well-being when the resident did not return as anticipated after dialysis treatment (a treatment for people whose kidneys are failing), and 2. There was no documentation that the facility assisted the resident ' s transportation arrangement when it was cancelled. These failures had the potential to compromise the resident ' s health and well-being. Findings: A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including end stage renal disease (ESRD, a medical condition in which a person ' s kidneys cease functioning) and dependence on renal dialysis. During a review of Resident 1 ' s physician's order, dated 8/16/23, the order indicated hemodialysis at [name of the dialysis center], M/W/F, (Monday, Wednesday, Friday) transportation booked by [insurance name], every day shift every Mon, Wed, Fri. Please call in AM to confirm transportation booked on time. During a review of Resident 1's nurses note, dated 9/02/23 at 3:28 a.m., the note indicated, The resident was to be returned from dialysis around 6:30 p.m. No return ride came to pick him up. He called his responsible party around 8 p.m., who called PM supervisor. Around 9 p.m., dialysis reached the transport and found out it was cancelled. The staff at dialysis called 911 to pick up the resident. 911 declined to pick him up. The resident returned and was visited by his family around 1215 a.m. During a review of Resident 1's medical record, the record indicated there was no documentation that the facility communicated with the dialysis staff when the resident did not return to the facility as anticipated after the dialysis treatment. There was also no documentation that the facility assisted the resident ' s transportation arrangement when it was cancelled. During an interview on 10/27/23 at 3 p.m. with the Director of Staff Development (DSD), she stated the facility staff should communicate with the dialysis staff to check on their residents ' well-being if residents did not come back as anticipated after the dialysis treatment. The DSD further stated that the facility should assist residents ' transportation arrangements in the event of its cancellation. During an interview and record review on 10/27/23 at 4:40 p.m. with the Director of Nursing (DON), she confirmed the above record review. The DON acknowledged that the facility staff should have communicated with the dialysis staff to ensure the resident ' s well-being and assisted with the resident ' s transportation arrangements. During a phone interview on 11/07/23 at 11:20 a.m. with Licensed Vocational Nurse A (LVN A), he stated he was Resident 1 ' s charge nurse in the AM (morning) shift on 9/01/23, but he did not confirm the resident ' s transportation for dialysis treatment. During an interview and record review on 11/07/23 at 11:25 a.m. with Assistant Director of Nursing B (ADON B), she confirmed the order to confirm the transportation and stated she usually confirmed Resident 1 ' s transportation for dialysis treatment, but she was not sure if she confirmed on 9/01/23. ADON B stated she could not locate any document that confirmed the transportation. During an interview and record review on 11/07/23 at 11:55 a.m. with the medical record (MR), she confirmed there were no dialysis communications for Resident 1. The MR acknowledged that the facility should have maintained Resident 1 ' s dialysis communications. During a review of the facility ' s policy and procedure (P&P) titled Transportation, Social Services, revised 12/2008, the P&P indicated, Our facility shall help arrange transportation for residents as needed. During a review of the facility ' s contract with [name of the Dialysis Center] titled LTSF-Dialysis (ESRD) Compliance Agreement, effective date 8/17/16, the agreement indicated, E: The parties desire to promote continuity of care and treatment appropriate to the needs of their patients, to use the skills and resources of their facilities in a coordinated and cooperative fashion to facilitate the provision of care to residents requiring dialysis, and to assure communication of information between the facility and the dialysis provider. 2. Control of Care: The facility retains primary responsibility for the development and implementation of the resident ' s overall plan of care. Coordination of care may include the following: b. Transportation arrangements 8. Patient Transfer: The facility will be responsible for arranging transportation to and from the dialysis provider for treatment or clinic visits, and will be responsible for the patient during transfer to and from dialysis provider ' s location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management, and 2. The care plan for diabetes was not developed. These failures had the potential to compromise residents' care and well-being. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus. During a review of Resident 1's physician's order, dated 10/04/23, the order indicated Humulin N subcutaneous suspension 100 unit/ml inject 14 unit subcutaneously in the morning for DM, given 30 minutes before breakfast. A further review of Resident 1's order, dated 10/06/23, indicated Check FSBS (finger stick blood sugar) before breakfast and dinner, If BS <70, follow hypoglycemia guideline and notify MD, If BS is 300 and greater, call MD two times a day. During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated blood sugar was 72 milligrams per deciliter (mg/dL, a unit of measure) on 10/06/23 at 6:30 a.m. and recorded as 16 (Hold/FSBS below parameters). During a review of Resident 1's progress note, there was no evidence the physician was notified of BS 72 mg/dL and ordered to hold the insulin. During an interview and record review on 10/26/23 at 1:30 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 1's BS was 72 mg/dL on 10/06/23 at 6:30 a.m., and the nurse held the insulin. The DON further confirmed that there was no document indicating that the physician was notified and ordered to hold the insulin. The DON acknowledged that the nurse should not have held the insulin. The DON stated that the insulin order should have parameters. The DON further stated the nurse should have notified the physician if there was a need to hold the insulin regarding BS 72 mg/ml and documented it. During a review of Resident 1's care plans, the review indicated a DM care plan was not developed for Resident 1. During an interview on 10/26/23 at 5 p.m. with the DON, the DON acknowledged that a DM care plan should have been developed for Resident 1. During an interview and record review on 10/26/23 at 5:05 p.m. with the Medical Record (MR), the MR reviewed Resident 1's care plans and confirmed that there was no DM care plan for Resident 1. During a review of the facility's policy and procedure (P&P) titled Diabetes-clinical Protocol, revised 9/2017, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. During a review of the facility's policy and procedure (P&P) titled Insulin Administration, revised 9/2014, the P&P indicated, The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and physician ' s order. During a review of the facility's policy and procedure (P&P) titled Care Plans-Preliminary, revised 8/2006, the P&P indicated, The interdisciplinary team will review the attending physician ' s order, and implement a nursing care plan to meet the resident's immediate care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services was provided to meet professional standard of practice for Resident 1 when the licensed nurses (LNs) did not initial and document the time, level of pain, and effectiveness of the medication given for pain. This failure may affect the health and safety of Resident 1. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including multiple fractures of right side of the ribs. Review of Resident 1's physician order dated 8/26/23 indicated give 2.5 milliliter (ml, unit of measurement) Morphine Sulfate oral solution (narcotic pain medication) 10 milligrams/5 milliliters (mg/ml, unit of measurements) orally as needed for pain. Review of Resident 1's controlled drug inventory sheet done on 9/11/23 indicated Morphine Sulfate oral solution were given by licensed vocational nurse A (LVN A) on 8/27/23 at 12 MN; LVN B on 8/30/23 at 12 MN; and LVN C on 9/9/23 at 12:10 a.m. There was no written record in Resident 1's medication administration record (MAR) that licensed nurses who gave the medication on the above dates signed, and documented the level of pain, and the effectiveness of the medication. During an interview with LVN A on 10/9/23 at 2:10 p.m., she confirmed she gave the Morphine Sulfate oral solution to Resident 1 on 8/27/2023 at 12 MN but forgot to initial and put the time it was given in the MAR. She acknowledged she should have initialed and put the time in the MAR. During an interview with LVN B on 10/9/23 at 2:25 p.m., she confirmed she administered Morphine Sulfate to Resident 1 on 9/9/23 at 12:10 a.m., but forgot to sign and put the time it was given in the MAR. She acknowledged she should have documented the time and her initial in the MAR. During an interview with the director of nursing (DON) on 10/11/23 at 3:25 p.m., she acknowledged LVN A, B, and C should have recorded their initials and put the time in the MAR including the pain level assessments before and after the medication is administered. She further stated the LVNs should have assessed the effectivity of the medication after one hour and recorded it in the MAR. Review of the revised facility's policy and procedures dated 4/2019, Administering Medications indicated the individual administering the medication initials the resident's MAR on the appropriate line after each medication. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; any complaints or symptoms for which the drug was administered; and any results achieved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure residents were free of accidents and hazards for one of two sampled residents (Resident 1) when: 1. Staff did not develop and/or implement resident-centered interventions to prevent falls, and 2. Care Support Team Members (CSTM) were not supervised by their supervisor during resident care. These failures resulted not prevent further falls for Resident 1. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes (high blood sugar), dementia, restlessness and agitation, hypertension (high blood pressure), and psychotic disorder with hallucination (a perception of having seen, heard, or touched something that was not actually there). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/29/23, the MDS indicated a brief interview for mental status (BIMS, a structured cognitive test) scoring 04 (severe impairment). Resident 1 required limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person physical assist for transfer and locomotion on/off units. The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance for moving from seated to standing positions and surface to surface transfers. During a review of Resident 1's clinical record, the Morse fall assessments, dated from 4/07/23 to 7/11/23, indicated that the Morse fall risks were high. Resident 1 had a fall on 4/23/23, 4/25/23, 5/05/23, 5/13/23, 5/22/23, 5/23/23, 5/24/23, 6/02/23, 6/04/23, 6/13/23, 6/28/23, and 7/11/23 in the facility. During a review of Resident 1's fall risk care plan, initiated on 1/09/23, the care plan indicated she was at risk for falls and injuries due to the following: psychotic disorder with hallucinations, dementia (a decline in mental capacity affecting daily function), other amnesia (memory loss), restlessness and agitation, and osteoporosis (bone disease). Some interventions on the fall care plan included encouraging the resident to use a call light for assistance; providing educational teaching/safety reminders to the resident to ask for help; educating the resident on the importance of the relationship between activity and rest, safety awareness; and tilting the resident's wheelchair when sitting up for comfort. During a review of Resident 1's IDT falls progress notes, the notes, effective date 6/28/23, indicated that root cause analysis: new staff put reclined wheelchair for resident who is confused on upright position. Staff was immediately educated regarding different kind of wheelchair used by resident, positioning . Educated new staff to ask CN/experienced CNA if he is unsure of what to do. The notes, effective date 7/13/23, indicated that root cause analysis: Staff did not properly position resident while sitting on her wheelchair and resident diagnosis of dementia with poor safety awareness. During an interview and record review on 7/19/23 at 4:30 p.m. with the Director of Nursing (DON), she confirmed Resident 1's fall intervention: encourage the resident to use call light for assistance; provide educational teaching/safety reminders to the resident to ask for help; educate the resident on the importance of the relationship between activity and rest, safety awareness was not proper for the resident because the resident could not remember to do so. The DON acknowledged that care plans should be resident-centered. During an interview on 8/31/23 at 1:38 p.m. with Registered Nurse A, she stated Resident 1's wheelchair should be reclined when she was sitting in it, but the new staff put her wheelchair in an upright position. RN A further stated that the new staff was not aware of proper positioning in a wheelchair for the resident. During an interview and record review on 8/31/23 at 3 p.m. with Assistant DON B (ADON B), she confirmed the IDT falls progress notes and stated that the staff were certified nurse assistant (CNA) students, and the CNA student did not know Client 1's wheelchair needed to be tilted. During an interview on 9/15/23 at 12:01 p.m. with the Director of Staff Development (DSD), she stated the CNA student was not a CNA, they were a Care Support Team Member (CSTM) who had not received their CNA certification yet. The DSD further stated they could provide only customer service, not physical assistance. The DSD acknowledged that the CSTM should be under staff supervision. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, Psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's document titled Care Support Team Member, created 6/09/15, the document indicated, The primary purpose of your job position is to provide residents with quality Customer Service and assist CNAs and Licensed Nurses as appropriate and as may be directed by your supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders regarding pressure ulcer order treatment for sacrum (bone in the lower back ), implement the care plan intervention regard pressure ulcer (PU, injury to the skin and the underlying tissue resulting from prolonged pressure on the skin, complete the weekly skin assessment, and conduct interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) meeting to discuss Resident 1's PU condition and progress for one of three sampled residents (1) when: 1. Facility did not follow the acute hospital discharge order for low air loss (LAL, a type of therapy mattress designed to help prevent and treat pressure wounds) and avoiding the use of adult absorbent brief for Resident 1's wound management. 2. Facility did not follow doctor's order for Resident 1's PU treatment, 3. Facility did not implement the PU care plan intervention for LAL mattress and update the care plan to include intervention to avoid the use of incontinent briefs for Resident 1's wound management. 4. Facility did not complete Resident 1's weekly skin assessment to monitor Resident 1's PU condition and progress. 5. Facility did not conduct the IDT meetings to discuss Resident 1's PU condition and progress. These failures could result in Resident 1's wound deterioration and complications. Findings: Review of Resident 1's admission record indicated she was originally admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra (is the most common form of vertebral infection) on lumbar region (lower back) and pressure-induced deep tissue damage/injury ((DTI, pressure ulcers that are purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) of sacral region (between lower back and tailbone), diabetes mellitus type 2 (is a disease in which your blood glucose, or blood sugar, levels are too high) and long term use of insulin(medication to lower blood sugar). Review of Resident 1's admission Braden Scale (an assessment tool for predicting pressure ulcer risk), dated 4/15/23, indicated a score of 12 or at high risk for developing PU. Review of Resident 1's nurse practitioner's progress notes for wound care, dated 5/19/23, indicated, Resident 1 had a wound debridement (the removal of damaged tissue or foreign objects from a wound.) of his sacrum wound on 5/18/23 in the facility. Review of Resident 1's acute hospital Emergency Department (ED, the department for life-threatening illnesses or accidents which require immediate, intensive treatment) notes, dated 5/25/23, indicated Resident 1 developed a DTI of the left sacrum on 4/6/23. Her wound was infected since 5/22/23 with starting on antibiotics for wound infections. Further review the ED notes indicated Resident 1's wound was gradually worsen at the rehab (facility where Resident 1 resided). Review of Resident's Situation-Background-Assessment-Recommendation (SABR, a communication tool for change in condition) indicated Resident 1 was transferred to the hospital on 5/25/23 due to the wound infection. Review of Resident 1's acute hospital inpatient wound care notes, dated 5/26/23, indicated her wound measurement was 12 centimeters (cm, a unit of measurement) in length, 17 cm in width and 5 cm in depth. Wound bed was full thickness, 40% pink non granulating tissue. Full thickness, dusky discolored wound bed. Peri-wound was well -defined and did not attach to wound bed, one plus erythema and violaceous. Surrounding skin was erythema. Scant amount of serosanguinous. Full odor. Under comments documented bone is palpable. A review of Resident 1's minimum data set (MDS, an assessment tool), dated 4/21/23, indicated she was incontinent (insufficient control) of urine and feces. 1. Review of Resident 1's discharge summary notes, dated 4/11/23, indicated Resident 1 was mostly bed bound status. Review of Resident 1's skilled nursing facility (SFN) orders, dated 4/15/23, indicated, low air loss (LAL) therapy mattress . and avoid adult absorbent briefs ., were ordered for Resident 1's wound management. Review of Resident 1's physician telephone encounter progress notes, dated 5/1/23, indicated the physician progress notes documented, There was an order for low-air-loss mattress but per case manager patient refused to place. Talk to patient discussed the importance. She agreed to place it in. During an interview on 7/20/23, at 2:05 p.m., with the assistant director of nursing (ADON A), she stated, the order for LAL mattress was placed for Resident 1 on 4/27/23, staff should have carried out the discharge order from the acute hospital upon her admission to the facility on 4/15/23. The ADON also stated, delayed implementation of preventive measures such as LAL mattress would affect wound healing. During interviews on 7/20/23, at 4:20 p.m. and 7/31/23, at 2:30 p.m., with the case manager D (CM D), she confirmed it was a mistake to delay the implementation of preventive measures (LAL mattress) for Resident 1. CM D confirmed that Resident 1's pressure injury wound was stable without worsening at the beginning upon admission, one week later 4/24/23, she noticed Resident 1's wound started to have drainage with worsening until 5/18/23 received wound debridement at the facility. CM D further stated, LAL mattress was provided to Resident 1 upon admission, but since 4/17/23 had room changes, the LAL mattress was not switched to her new room until 4/27/23. During an interview on 7/31/23, at 1:55 p.m., with the certified nursing assistant E (CNA E), she stated, she had been assigned to care of Resident 1 and she stayed in bed most of the time, had been wearing adult diaper for incontinence of bowel and bladder. Further review of Resident 1's activities of daily living (ADL, eating, dressing, toileting .) tasks from 4/2023 to 6/2023, indicated the ADL record documented p which meant Resident 1 wore incontinent briefs from 4/16/23 to 5/18/23. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, in 2019, the P&P indicated, Review the interventions and strategies for effectiveness on an ongoing basis. 2. A review of Resident 1's physician's order, dated 4/17/23, indicated, Cleanse (Pressure Injury) on (Sacrum) with NS, pat dry, apply Medihoney (wound treatment that supports the removal of necrotic tissue) + Xeroform) and cover with Mepilex QOD (every other day) and PRN (as needed). A review of Resident 1's physician's order, dated 4/18/23, indicated, Cleanse (Pressure Injury) on (Sacrum) with NS, pat dry, apply Santyl (is a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) and cover with Mepilex QOD and PRN. A review of Resident 1's physician's order, dated 4/19/23, indicated, Cleanse (Pressure Injury) on (Sacrum) with NS, pat dry, apply Santyl and cover with Mepilex QOD and PRN. A review of Resident 1's treatment administration record (TAR) in April 2023, it indicated treatment were not done on 4/17/23, 4/19/23, 4/21/23, 4/26/23. A review of Resident 1's physician's order, dated 5/3/23, indicated, Cleanse (Pressure Injury) on (Sacrum) with NS, pat dry, apply Santyl and cover with Mepilex QD (every day) and PRN. A review of Resident 1's physician's order, dated 5/19/23, indicated, Cleanse (Pressure Injury) on (Sacrum), cleanse with Dakin's ½ solution and, pack with wet to dry dressing and cover with Mepilex BID (twice a day) and PRN. Assess and evaluate during treatments and during weekly rounds with wound MD for progress/ worsening/ treatment effectiveness and notify MD if treatment is ineffective PRN. A review of Resident 1's physician's order, dated 5/20/23, indicated, Cleanse pressure injury on sacrum with NS, pat dry, pack with Dakin's ¼ moistened gauze and cover with dry dressing QD and PRN. A review of Resident 1's physician's order, dated 5/23/23, indicated, Cleanse pressure injury on sacrum with NS, pat dry, pack with Dakin's ¼ moistened gauze and cover with dry dressing BID and PRN. Assess and evaluate during treatments and during weekly rounds with wound MD for progress/ worsening/ treatment effectiveness and notify MD if treatment is ineffective PRN. Review of Resident 1's May 2023 TAR indicated there were missed treatments on 5/2/23 5/4/23, 5/5/23, 5/8/23, 5/10/23, 5/11/23, 5/12/23, 5/15/23, 5/16/23, 5/17/23, 5/18/23, 5/19/23, 5/22/23, 5/23/23, 5/24/23. During a record review and concurrent interview with CM D, on 7/31/23, at around 3 p.m., upon her review of the May 2023 TAR, CM D confirmed there were missed treatments on 5/2/23 5/4/23, 5/5/23, 5/8/23, 5/10/23, 5/11/23, 5/12/23, 5/15/23, 5/16/23, 5/17/23, 5/18/23, 5/19/23, 5/22/23, 5/23. During an interview on 7/17/23, at 2 p.m. and 7/20/23, at 2:05 p.m., with ADON A, she stated, she was not aware of Resident 1's wound treatment being missed multiple times from April to June, because the wound treatment nurse never reported to her. During the ADON A's review of Resident 1's treatment record, she confirmed that wound treatment nurse B (WTN B) did not document if Resident 1 refused the wound treatment. ADON A stated, if Resident 1 refused any treatment, then the physician and responsible party (RP, the person who make medical decisions to sign consents) should be notified and documented as soon as possible. During an interview on7/20/23, at 4:50 p.m., with the assistant administrator (AA), he stated, facility would require having at least three full time wound treatment nurses. During a telephone interview on 7/21/23, at 10:16 a.m., with the wound treatment nurse C (WTN C), he confirmed once resident refused to have wound treatment then should be documented and reported to the physician and RP. Review of the facility's policy and procedure (P&P) titled, Wound care, revised 10/2010, the P&P indicated, If the resident refused the treatment and the reason(s) why. The signature and title of the person recording the data. Should be recorded in the resident's medical record. Notify The supervisor if the resident refuses the wound care. 3. A review of Resident 1's Care Plan for, Pressure Injury on Coccyx (7 cmx 7 cm), dated 4/16/2, it indicated the care plan included interventions to apply LAL mattress to relieve pressure points and pressure relieving device, assessing /recording/monitoring wound healing regularly. Measure Length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress If the resident refuses treatment, confer with the resident, IDT, and family to determine why and try alternative methods to gain compliance. Document alternative methods. The care plan did not include avoiding the use adult brief for Resident 1, and staff also did not consistently provide LAL mattress as an intervention for Resident 1's PU management. During an interview on 8/17/23, at 9:35 a.m., with the primary physician (PP), she confirmed the importance of LAL mattress for Resident 1's wound management. The PP was not informed that staff did not follow 4/15/23's discharge order (to avoid providing brief or diaper for Resident 1's wound management). 4. A review of Resident 1's clinical record indicated, Skin Assessment was completed on 4/16/23, the day after her initial admission, and during her readmission on [DATE], and the following week on 6/16/23. There was no documented of evidence that the weekly skin assessment for pressure injury and wound measurements were done during the week of 4/23/223, 4/30/23, 5/7/23, 5/14/23, 5/21/23 and 6/22/23. The weekly skin assessment of 4/16/23, 6/8/23 and 6/16/23 did not include wound description being documented, and there was no wound measurement being documented on 6/8/23 and 6/16/23's weekly skin assessment. During a concurrent interview and record review on 7/13/23, at 3:45 p.m., with the director of nursing (DON), she confirmed staff had missed Resident 1's weekly skin assessments on 4/23/223, 4/30/23, 5/7/23, 5/14/23, 5/21/23 and 6/22/23, and her weekly skin assessment completed of 6/8/23 and 6/16/23 did not include the wound description and characteristics. During an interview on 7/20/23, at 2:05 p.m., with the assistant director of nursing (ADON A), she stated, on 6/16/23's skin assessment was done by herself, and she forgot to measure Resident 1's wound that would indicate its size (length, width, and depth) including the wound description during the weekly skin assessment. She further stated, Resident 1's wound assessment with measurement should have been completed on a weekly basis to reflect the wound condition indicating wound progression, healing or deterioration, and whether the treatment was effective or not. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, in 2019, the P&P indicated, Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Evaluate, report and document potential changes in the skin. 5. During a review of Resident 1's clinical record, it indicated there was no documented of evidence that a Skin/Wound IDT meeting being conducted for Resident 1. During an interview on 7/20/23, at 4:20 p.m., with CM D, she admitted that facility did not conduct any Skin/Wound IDT for Resident 1. CM D further stated, the missing wound treatment and weekly skin assessments should have been identified and addressed if an IDT meeting was conducted. During an interview on 7/31/23, at 9:45 a.m., with DON, she confirmed that facility did not have wound IDT meeting.

Based on observation, interview, and record review, the facility failed to ensure comfortable and safe temperature levels for one of five rooms (Room A) when room air temperatures were not maintained in the range of 71° Fahrenheit (°F, a scale of temperature) to 81°F. This failure had the potential to result in an unsafe environment for the residents. Findings: During a phone interview on 6/27/23 at 4:10 p.m. with Resident 1's family member, she stated, My mother's room was too hot. During an interview on 6/28/23 at 11:55 a.m. with Licensed Vocational Nurse A (LVN A), she stated some residents and/or family members requested a fan for hot weather. During a concurrent interview and observation on 6/27/23 at 12:30 p.m. with the Maintenance Supervisor (MS), the MS checked the air temperature with a thermogun (a device to check room temperature). The temperature in room A was in the range of 84°F to 85°F. The MS stated that room temperature should be in the range of 71°F to 78°F. During an interview on 6/28/23 at 12:33 p.m. in room A, Resident 2 was sitting in her bed and fanning herself with her hand. Resident 2 stated her room was very hot, always hot in this room. A floor fan observed in the room was on. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 4/03/23, the MDS indicated Resident 2's brief interview for mental status (BIMS, cognition level) score was 15 (a score of 13 to 15 indicates intact cognition). During an interview on 6/28/23 at 2 p.m. with the director of nursing (DON), she acknowledged the facility room temperature should have been in the range of 71°F to 81°F. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, revised 2/2021, the P&P indicated that The facility staff and management maximizes the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71-81F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's skin tear was not treated timely: there was no document regarding the skin tear and staff administered skin tear treatment without a physician's order. These failures had the potential to compromise the residents' health and well-being. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases), epilepsy (a disorder in the brain causing seizures), schizophrenia (a mental disorder), and polyneuropathy (malfunction of many nerves). During a concurrent observation and interview on 6/06/23 at 9:39 a.m. in the resident room, Resident 1 was lying in bed, and there was a bandage on her left forearm noted. Resident 1 stated she got a cut on her left arm on 6/04/23, and a nurse applied the bandage on 6/05/23. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 4/04/23, the MDS indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 15 (cognitively intact). A review of Resident 1's clinical record revealed there was no document regarding the skin tear and there was no physician's order to treat it. During a concurrent interview and record review on 6/06/23 at 11 a.m. with Treatment Nurse A (TN A), he stated that Registered Nurse B (RN B) reported Resident 1's skin tear on the left forearm on 6/05/23, and he applied the bandage. TN A confirmed that there was neither a documention found regarding Resident 1's skin tear nor a physician's order to treat the skin tear. TN A stated a physician's order to treat the skin tear should have been obtained before doing the treatment. During an interview on 6/06/23 at 11:50 a.m. with the Certified Nursing Assistant (CNA C), she stated that Resident 1's skin tear on the left forearm was observed on 6/04/23, and she reported it to RN B the same day. During a concurrent interview and record review on 6/06/23 at 1:10 p.m. with Assistant Director of Nursing D (ADON D), she reviewed Resident 1's clinical record and confirmed there was neither a document regarding the skin tear nor a physician's order to treat the skin tear. ADON D stated that nurses should have documented the skin tear and obtained a treatment order. ADON D further stated that the residents should not wait one day for their treatment. During a phone interview on 6/09/23 at 12:40 p.m. with RN B, he stated that Resident 1's skin tear on her left forearm was reported to him on 6/05/23, and he informed TN A. RN B confirmed that he did not document the skin tear or obtain a physician's order to treat the skin tear. RN B stated Resident 1's skin tear should have been documented, and a physician's order should have been obtained before the treatment of Resident 1's skin tear. During a review of the facility's policy and procedure titled Change in a Resident's Condition or Status, revised 5/2017, the policy indicated Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. During a review of the facility's policy and procedure titled, Medication and Treatment Orders, revised 7/2016, the policy indicated Orders for medications and treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a baseline care plan within 48 hours of a resident's admission for three of three sampled residents (Residents 1, 2, and 3). This failure had the potential to result in the facility being unable to promote continuity of care, meet the resident's immediate needs, and ensure the resident and representative are informed of the initial plan for delivery of care and services. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] and had the diagnoses including dementia (a group of conditions with impairment of brain function) without behavioral disturbance, hypertension (high blood pressure), and hyperthyroidism (overactive thyroid). During a review of Resident 1's facesheet (a document that summarizes a resident's information), the facesheet indicated her responsible party (RP, a person empowered to make decisions for the resident/person legally responsible and liable for a decision or an action) was 'daughter ' . During a review of Resident 1's 48 Hour Baseline Care Plan, dated 4/27/23, it indicated 'in progress' and missing information on the following sections: 3. Rehab (PT [Physical Therapy]); 4. Rehab (OT [Occupational Therapy]/ST [Speech Therapy]); 7. Resident or Resident Representative (RR) signature; and 8. Copy of Baseline Care Plan (A copy of the 48 Hour Baseline Care Plan was offered/given to the resident/RR). During a concurrent interview and record review on 5/16/23 at 11:15 a.m. with the Director of Nursing (DON), the DON confirmed Resident 1's 48-Hour Baseline Care Plan dated 4/27/23 had not been completed yet. The DON stated that a 48 Hour Baseline Care Plan should be completed within 48 hours of the resident's admission, the resident/RP should be informed regarding the care plan, and a copy should be given to the RP. The DON further stated there was no evidence that indicated Resident 1's RP was informed regarding the resident's care plan and/or a copy of the baseline Care Plan was given to Resident 1's RP. During a concurrent interview and record review on 5/16/23 at 11:35 a.m. with Assistant Director of Nursing A (ADON A), she reviewed Resident 1's 48 Hour Baseline Care Plan dated 4/27/23 and confirmed the 48 Hour Baseline Care Plan was 'in Progress '. ADON A stated that all sections of the Baseline Care Plan should be completed within 48 hours of the resident's admission. 2. A review of Resident 2's clinical record indicated she was admitted to the facility on [DATE]. Resident 2's facesheet indicated her RP was 'other ' . During a review of Resident 2's 48 Hour Baseline Care Plan, dated 4/29/23, it indicated 'in progress' and missing information on the following sections: 1. Nursing; 2. Social services; 7. Resident or RR signature; and 8. Copy of Baseline Care Plan. During a concurrent interview and record review on 5/16/23 at 11:20 a.m. with the DON, the DON confirmed Resident 2's 48 Hour Baseline Care Plan dated 4/29/23 had not been completed yet. The DON stated there was no evidence that Resident 2's RP was informed regarding the resident's care plan and/or a copy of the baseline Care Plan was given to Resident 2's RP. 3. A review of Resident 3's clinical record indicated he was admitted to the facility on [DATE]. Resident 3's facesheet indicated his RP was 'wife '. During a review of Resident 3's 48 Hour Baseline Care Plan, dated 4/26/23, it indicated 'in progress' and missing information on the following sections: 2. Social services; 3. Rehab (PT); 4. Rehab (OT/ST); 7. Resident or RR signature; and 8. Copy of Baseline Care Plan. During a concurrent interview and record review on 5/16/23 at 11:20 a.m. with the DON, the DON confirmed Resident 3's 48 Hour Baseline Care Plan dated 4/26/23 had not been completed yet. The DON stated there was no evidence that Resident 3's RP was informed regarding the resident's care plan and/or a copy of the baseline care plan was given to Resident 3's RP. A review of the facility's policy and procedure titled, Care Plans - Baseline, revised 12/2016, indicated A baseline plan of care to meet the resident ' s immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident; a summary of the resident ' s medications and dietary instructions; any services and treatments to be administered by the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the plan of care for Resident 1 was individualized and revised to reflect the resident's current care needs and interventions. This failure had the potential to result in not meeting the residents' needs. Findings : Review of Resident 1's clinical record indicated he was readmitted on [DATE] and had the diagnoses of hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) affecting left nondominant side, persistent vegetative status (a chronic state of brain dysfunction), diabetes (high blood sugar), and hypertension (high blood pressure). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/08/22, indicated his brief interview of mental status (BIMS, a structured cognitive test) was marked 'resident rarely/never understood.' Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/08/22, indicated his self-performance for bed mobility, dressing, eating, toilet use, and personal hygiene were marked 'total dependence' . Review of Resident 1's fall care plan dated 9/16/22, included: Educate resident on importance of relationship between activity and rest: safety awareness and proper use of assistive devices; Encourage to use call for help before attempting to transfer to ambulate; sensor pad on wheelchair and/or bed as monitoring devices. Review of Resident 1's fall care plan dated 5/08/22, included: Sensor pad on wheelchair and/or bed as monitoring devices. Review of Resident 1's clinical records indicated there was no physician's order and/or consent for the sensor pad. During an interview and record review with licensed vocational nurse A (LVN A) on 3/21/23 at 2:55 p.m., she confirmed the above record review and stated the resident was not able to use call devices. LVN A stated that the fall care plan was not proper for Resident 1 because the resident was not able to remember even if staff educated and/or encouraged him. LVN A further stated there was no sensor pad on the resident's wheelchair and/or bed. During an interview and record review with director of nursing (DON) on 3/21/23 at 5:40 p.m., she confirmed the above record review and stated the sensor pad was included in his care plan, but the sensor pad was not applied because the physician did not order the sensor pad. The DON acknowledged that the fall care plan should have been revised with current interventions. The DON stated that the fall care plan was not proper for Resident 1 because the resident was not able to use call devices or remember what staff educated and/or encouraged. The DON further stated that the fall care plan should have been individualized and person-centered. Review of facility's policy Care Plans-Comprehensive, revised 10/2010, indicated An individualized comprehensive care plan . is developed for each resident. Care plan is designed to reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the care plan interventions for one of two sampled residents (Resident 2) related to rash like multiple redness on Resident 2's back and extremities. This failure had the potential to negatively impact Resident 2's quality of life. Findings: Review of Resident 2's clinical record, indicated resident was admitted on [DATE]. Diagnoses included, but were not limited to, Cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), Type 2 Diabetes Mellitus with Diabetic Neuropathy (is a type of nerve damage that can occur if you have diabetes), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Review of Resident 2's Care plan, indicated, Resident 2 has rash like multiple redness on Left lower extremity and right lower extremity. Intervention: Apply Resident 2's treatment as ordered by MD. Review of Resident 2's Care plan, created 6/2/2021, Rash like multiple redness on back. Intervention: Cleanse rash to back with Normal Saline (NS, mixture of sodium chloride and water), pat dry, and apply (Lotrisone cream) twice a day. Monitor and assess during treatment for any worsening, signs and symptoms of infection, skin breakdown, or if treatment is ineffective and notify MD. Review of Resident 2's Shower Day Skin Inspection Form, dated 12/12/2022, indicated, Skin Assessment: Rashes, redness. During an interview and concurrent record review of Resident 2's clinical record with the Assistant Director of Nursing A (ADON A) on 2/27/2023, at 2:45 p.m., ADON A stated Resident 2's rashes started in 2021 and has been on and off. ADON A stated Resident 2's rashes were on his back and lower extremities. According to ADON A, Resident 2 had an episode of cellulitis on his back which started on 12/21/2022. During an interview with the Certified Nursing Assistant (CNA) on 3/17/2023, at 9:25 a.m., surveyor informed CNA about the Shower Day Skin Inspection Form on 12/12/2022, which indicated rashes and redness was noted on Resident 2's skin. CNA, who is familiar with Resident 2's care, stated Resident 2's rashes were on his back and was reported immediately to the treatment nurse. CNA stated Resident 2 always has rashes on his back and legs. During an interview and concurrent record review with the Treatment Nurse (TN) on 3/17/2023, at 10:45 a.m., TN stated he's new and started when the previous treatment nurse left. TN confirmed there was no assessment and monitoring started in relation to the rashes and redness reported on 12/12/0222 by the CNA. TN stated there were nurse's notes, but nothing specific to Resident 2's rashes and redness. TN further stated an assessment and monitoring should have started when CNA reported rashes and redness on 12/12/2022, even if Resident 2's rashes has been on and off. Review of Resident 2's Treatment Administration Record (TAR), dated December 2022, indicated, Lotrisone cream 1-0.5% (Clotrimazole-Betamethasone, a prescription medication used to treat fungal skin infections). Apply to extremities, back, chest topically every 12 hours as needed for rash. There was no documented evidence that the medication was applied on 12/12/2022 when it was reported by the CNA. During interview and concurrent record review with the ADON B on 3/23/2023, at 11:30 a.m., surveyor informed ADON B about the rashes and redness on 12/12/2022 as indicated on the Shower Day Skin Inspection form. ADON B reviewed the TAR and confirmed there was no evidence that the treatment was provided to Resident 2 when the CNA reported the rashes and redness on 12/12/2022. Review of facility's policy, revised 12/2016, Care plans, Comprehensive Person-Centered, 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. 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. Receive the services and/or items included in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to transcribe the pacemaker (an electronic device that is implanted in the body to monitor heart rate and rhythm) care orders and the nursing preventive measure orders on the Treatment Administration Record (TAR) for one of two sampled residents (Resident 1) that were initiated on admission. This resulted in care not being provided that was ordered to Resident 1 while in the facility. Findings: 1. Review of Resident 1's clinical record, Resident 1 admitted to the facility from the hospital on [DATE]. Diagnoses included, but were not limited to Ventricular Tachycardia, monomorphic (a type of irregular heart rhythm (arrhythmia) that happens when the lower chambers of your heart beat at a dangerously fast pace), presence of Automatic Implantable Cardiac Defibrillator (AICD or pacemaker), Heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Myocardial Infarction (heart attack, happens when one or more areas of the heart muscle don't get enough oxygen), Review of Resident 1's admission Skin Assessment, dated 11/23/2022, indicated, Observations/Data: Site: Left Chest, Type: Surgical Incision Review of Resident 1's Pacemaker discharge instructions from the hospital, dated 11/23/2022, indicated, After a new ICD implantation: Activity Care: Avoid raising the involved arm above the head and should refrain from heavy lifting or straining for 4-6 weeks . Bathing and Showers: .No bath or swimming immersion for 2 weeks. Do not peel away or pick at the glue; it will slough off by itself within 2 weeks. Wound Care: Dressing change to the wound is performed once per day for 10 days. Wash hands, remove old dressing then cover the incision with a folded gauze pad . Review of Resident 1's Order Summary Report, dated 11/23/2022, there were no pacemaker order care and instructions indicated related to Activity, Bathing and Showers, and Wound Care on incision site. Review of Resident 1's Care Plan, initiated 11/25/2022, indicated, Resident 1 has an ICD related to atrial fibrillation, dysrhythmias. Intervention: Monitor and report to MD as needed any signs and symptoms of infection at incision site: redness, drainage, warmth. The admission Nurse assigned on 11/23/2023 was unable to be reached by phone. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 3/21/2023, at 4:20 p.m., upon review of Resident 1's medical record. ADON confirmed the pacemaker care discharge instructions were not recorded on the Order Summary Report and Treatment Administration Record (TAR). ADON stated Resident 1's pacemaker care should have been transcribed on the Order Summary Report and TAR. 2. Review of Resident 1's Order Summary Report, order date 11/23/2022, indicated the following: Nursing Preventive Measure Orders to apply A&D ointment (topical cream) to left heel and right heel as preventive measure for skin breakdown every shift Nursing Preventive Measure Orders to apply Dermaseptin (topical moisture barrier cream) to intact skin on coccyx (tailbone), left buttock, right buttock, and Sacrococcyx (relating to the sacrum (bottom of spine) as preventive measures from skin breakdown every shift and after every incontinent care. Review of Resident 1's TAR for November 2022, indicated no order data found on Nursing Preventive Measure treatments for the left heel, Right heel, coccyx, left buttock, right buttock, and Sacrococcyx. During an interview and concurrent record review with Licensed Vocational Nurse (LVN), on 3/21/2023 at 4:00 p.m., LVN confirmed there were no treatment orders on the TAR. LVN stated if there's an order on the TAR, then skin treatments should have been done. During an interview and concurrent record review with the ADON on 3/21/2023, at 4:30 p.m., ADON confirmed the Nursing Preventive Measures were not transcribed on the TAR. ADON stated she's not sure why it was not recorded on the TAR. Review of the facility's policy, Medication and Treatment Orders, revised February 2014, Drugs and biologicals must be recorded on the Physician's order sheet in the resident's chart.

Based on interview and record review, the facility failed to ensure accurate documentation of administered medications for one of two sampled residents (Resident 2). This failure had the potential to affect the physical well-being of residents in the facility. Findings: Review of Resident 2's Medication Administration Record (MAR), dated 12/2022, Keflex (used to treat a wide variety of bacterial infections) capsule 500 milligrams (mg, a unit of mass or weight). Give 1 capsule by mouth every 8 hours for early cellulitis of back for 10 days. Keflex was not documented as given on 12/21/2022 at 10:00 p.m.; and 12/22/2022 at 08:00 a.m. Review of Resident 2's Treatment Administration Record (TAR), dated 12/2022, Clotrimazole Cream 1% (a medicated antifungal cream). Apply to back topically two times a day for rashes to back for 30 days. Clotrimazole cream was not documented as given on 12/21/2022 at 5:00 p.m.; 12/22/2022 at 5:00 p.m.; 12/23/2022 at 5:00 p.m.; 12/24/2022 at 9:00 a.m.; 12/25/2022 at 05:00 p.m.; 12/26/2022 at 5:00 p.m.; 12/27/2022 at 5:00 p.m.; 12/29/2022 at 05:00 p.m. and 12/31 at 9:00 a.m. During an interview and concurrent record review with the Director of Nursing (DON) on 3/9/2023, at 1:00 p.m., upon review of Resident 2's MAR and TAR, DON stated that she expects the licensed staff and contract staff to document the administration of medication at the time it was given. Review of facility's policy on, dated 4/2007, Documentation of Medication Administration, A Nurse or Certified Medication Aide shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a second dose of COVID-19 booster shot (additional dose or doses of a vaccine given after the protection provided by the original shot(s) has begun to decrease over time) when requested by one of three sampled residents (Resident 1). This failure had the potential to affect Resident's 1 health and well-being against COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). Findings: A review of complaint intake dated 10/27/22, indicated Resident 1 repeatedly requested to get a second dose of COVID-19 booster upon her admission but received no response from the facility. During a review of Resident 1's electronic health record (EHR) indicated she was a [AGE] year-old female and was admitted to the facility on [DATE] with complete COVID-19 vaccination including first booster shot. Her brief interview for mental status (BIMS, a quick test for cognitive functioning, a score of 13 to 15 mean cognitively intact, a score of 8 to 12 mean moderately impaired, score below 8 means severe impaired) score was 15. During an interview on 11/14/22, at 1:50 p.m., with the infection preventionist (IP), he confirmed he was aware of Resident 1's request for second dose of COVID-19 booster shot. He also stated Resident 1 would need to wait until all residents received influenzas vaccination because the pharmacy would take time to process her COVID-19 booster shot. During an interview on 11/14/22, at 3:30 p.m., with Resident 1, in her room, she stated she had requested to have her second COVID-19 booster several times to several different nursing staff since her admission in 5/2022. She was feeling disappointed that no one came back to her in spite of repeated request. During an interview on 11/16/22, at 10 a.m., with the assistant administrator (AADM), she confirmed the facility had COVID-19 positive residents currently in the red zone. During a follow-up interview on 11/16/22, at 10:25 a.m., with IP, he confirmed all residents should have offered a COVID-19 vaccine including booster shot upon admission. He also stated he had checked on Resident 1's EHR and noted that staff did not document her request for booster shot. During a review of the facility's policy and procedure titled, COVID Vaccination of Residents, updated on 6/2022, it indicated, All residents will be offered vaccines that aid in preventing COVID-19 infection unless the vaccine is medically contraindicated Additional COVID booster dose/s will be offered when the resident is already eligible according to the latest Centers for Disease Control and Prevention (CDC)

Based on observation, interview, and record review, the facility failed to follow its policy and resident plan of care for one non-sampled resident (Resident 150) by not ensuring an adaptive device was available for Resident 150. Resident 150's eyeglasses were kept in the social service office instead of by the bedside. This deficient practice had the potential to delay provision of services and could have resulted in the resident's needs not being met. Findings: Review of Resident 150's admission Record indicated he was admitted to the facility with a diagnosis including unspecified glaucoma (a group of eye conditions that can cause blindness). Review of Resident 150's Minimum Data Set (MDS, an assessment tool), dated 1/13/2021, indicated he had a BIMS (Brief interview of mental status) score of eight (8-12 indicates moderate cognitive impairment). Review of Resident 150's care plan, dated 10/10/2018, indicated Resident 150 had altered visual function due to impaired vision, and the interventions indicated to keep eyeglasses clean and within easy reach. Review of Resident 150's undated inventory list indicated one pair of eyeglasses. During an observation on 4/22/21 at 8:05 a.m., Resident 150 was sitting in bed eating breakfast without wearing eyeglasses. During another observation on 4/22/21 at 10:17 a.m., Resident 150 was in the lobby watching a movie on a tablet. During an interview with certified nursing assistant Y (CNA Y) on 4/22/2021 at 12:04 p.m., CNA Y stated Resident 150 did not have eyeglasses since moving to Station A. CNA Y confirmed he could not locate Resident 150's eyeglasses at bedside. During an interview and concurrent record review with assistant director of nursing F (ADON F) on 4/22/21 at 12:15 p.m., ADON F confirmed Resident 150's care plan and inventory list indicated Resident 150 had eyeglasses. ADON F said Resident 150's eyeglasses should be available as indicated in the care plan. During an interview with social service L (SS L) on 4/22/2021 at 12:45 p.m., SS L acknowledged Resident 150's eyeglasses were found in the social service office in another station. SS L stated she was not aware Resident 150's eyeglasses were not at bedside since Resident 150 was moved to Station A for quite a while. SS L said Resident 150 refused to wear his eyeglasses as of 4/22/2021. Review of the facility's revised 8/2009 policy, Quality of Life - Accommodation of Needs, indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, should be evaluated upon admission and reviewed on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 140) was free from physical restraints when staff placed both of Resident 140's feet into a single pressure relief boot (device strapped to the foot in order to reduce pressure on the heels). This practice impaired Resident 140's ability to move both lower extremities (feet and legs) and had the potential to negatively affect his physical and psychosocial well-being. Findings: Review of Resident 140's clinical record indicated he was admitted on [DATE] and had the diagnoses of respiratory failure (the body is unable to effectively transfer oxygen and carbon dioxide) and myoclonus (muscle jerks). Review of Resident 140's Minimum Data Set (MDS, an assessment tool), dated 1/6/21, indicated he was totally dependent (staff provide full assistance) and required physical assistance from two or more people for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed). Review of Resident 140's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) Progress Notes, dated 2/8/21, indicated Resident 140 was on a video call with his family member on Saturday afternoon (2/6/21 based off the date of the IDT Progress Notes). The notes indicated Resident 140's family member asked to see the resident's body head to toe and noticed that he only had one booty on for both feet and called the attention of the charge nurse on duty. The notes further indicated the restorative nursing assistant (RNA) assisted the charge nurse in unstrapping the pressure relief booty and repositioning the resident. Review of Resident 140's undated Event Summary indicated the facility conducted an investigation of the above incident. The Event Summary indicated certified nursing assistant HH (CNA HH) openly discussed that it was her that took care of [Resident 140] and placed both his feet in a single booty.According to the Event Summary, CNA HH did this because Resident 140 kept repositioning his legs and swinging them off the bed. The Event Summary indicated the administrator (ADM) explained to CNA HH that this was not an appropriate practice and that devices should never be used in such a manner. The Event Summary further indicated this practice resulted in unintentionally restraining the resident's feet to a single booty. During an observation on 4/21/21 at 12:10 p.m., Resident 140 was lying in bed with his feet spread apart. Both feet were hanging slightly over the edges on either side of the bed, but Resident 140 did not appear to be in danger or distress. He was wearing one pressure relief boot on each foot. During an interview with restorative nursing assistant II (RNA II) on 4/23/21 at 11:48 a.m., he confirmed Resident 140 was able to move his lower extremities without staff assistance. During an interview with the ADM on 4/23/21 at 12:10 p.m., he confirmed CNA HH applied a restraint to Resident 140 when she placed both his feet in a single pressure relief boot. The ADM acknowledged this was a restraint because it impaired Resident 140's ability to move his lower extremities. The ADM stated this was not a correct practice. During an interview with registered nurse E (RN E) on 4/23/21 at 12:29 p.m., she stated CNA HH admitted that she placed both of Resident 140's feet in a single pressure relief boot. RN E confirmed Resident 140 did not have a physician's order for physical restraints, nor was it part of the resident's plan of care. RN E also confirmed the facility did not have consent to restrain Resident 140. Review of the facility's policy titled Use of Restraints, revised 12/2008 indicated, Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. The policy further indicated, Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy for one of two sampled residents (Resident 25) when they did not report an injury of unknown source to the Ombudsman (an advocate for the residents) and law enforcement. This failure had the potential to delay investigation of the incident in order to rule out abuse. Findings: Review of Resident 25's clinical record indicated she was admitted on [DATE] and had the diagnoses of respiratory failure (the body is unable to effectively transfer oxygen and carbon dioxide), osteoporosis (condition that causes weak and brittle bones) and quadriplegia (both arms and legs are paralyzed). Review of Resident 25's situation, background, assessment, recommendation (SBAR, a communication tool) documentation, dated 2/23/21, indicated she had swelling on the left knee. Review of Resident 25's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) Progress Notes, dated 2/24/21, indicated the swelling on Resident 25's left knee increased from the previous day. Resident 25's physician ordered an X-ray, which revealed an acute fracture of the medial cortex of the medial femoral condyle (cracked or broken bone in the knee). Review of Resident 25's undated Event Summary indicated, Upon investigation with direct care staff, there was no incident prior to finding the swelling of the knee. During an interview with registered nurse E (RN E) on 4/23/21 at 8:20 a.m., she explained the facility interviewed staff who cared for Resident 25 in the last three days prior to the discovery of her left knee fracture. RN E confirmed there were no reports of rough handling, falls, or any other incidents that may have caused Resident 25's fracture. During a concurrent interview with the administrator in training (AIT), he confirmed the facility reported Resident 25's incident to the California Department of Public Health (CDPH), but did not report it to the Ombudsman or law enforcement. Review of the facility's policy titled Abuse Investigation and Reporting, revised 12/2016 indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: b. The local/State Ombudsman; e. Law enforcement officials. During a follow-up interview with the AIT on 4/23/21 at 9:44 a.m., he acknowledged the facility's policy that injuries of an unknown source should be be reported to the Ombudsman and law enforcement. The AIT stated, That's probably what we should have done.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when: 1. The patio door in Station A leading to the parking lot was open; and 2. Staff did not keep the bed in its lowest position for one of six sampled residents (Resident 73) as indicated in the care plan. These failures could potentially result in serious injury to the residents in the facility. Findings: 1. During an observation in Station A on 4/19/2021 at 12:15 p.m., Resident 160 was standing near an open automatic door and was attempting to go to the patio. Assistant director of nursing F (ADON F) and licensed vocational nurse EE (LVN EE) were standing next to Resident 160 and redirecting her to go back inside the unit. During a concurrent interview with LVN EE and ADON F, LVN EE stated she saw Resident 160 going to the patio and immediately tried to stop and redirect the resident's behavior. According to ADON F, they had many residents who wandered frequently. During an observation in Station A with ADON F on 4/22/2021 at 10:41 a.m., the patio door leading to the parking lot was open and the alarm did not activate. During a concurrent interview with ADON F, she confirmed the above observation and stated the patio door leading to the parking lot should always be kept closed. During an interview with the maintenance supervisor (MS) on 4/22/2021 at 10:44 a.m., the MS stated the patio door should be kept closed and confirmed the door alarm did not work. A review of the facility's policy titled Wandering and Elopements, revised on 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. Review of Resident 73's admission record indicated she had diagnosis of central pontine myelinolysis (CPM, a neurological disorder characterized by acute paralysis [loss of ability to move], difficulty speaking, and other neurological symptoms). Review of Resident 73's care plan, dated 2/5/21, indicated Resident 73 was at risk of falls/further falls due to poor safety awareness. Care plan interventions included having the bed in the lowest position to lessen the impact of a fall. During an observation on 4/19/21 at 11:07 a.m., Resident 73 was lying in bed and the bed was in the high position. During an observation and concurrent interview with assistant director of nursing K (ADON) K on 4/21/21 at 9:34 a.m., Resident 73 was lying in bed and the bed was in high position. ADON K demonstrated how the bed could be lowered and she agreed the bed was positioned high. ADON K stated Resident 73 had been refusing to have the bed lower. During an interview and concurrent record review with ADON K on 4/22/21 at 8:51a.m., she confirmed Resident 73's bed should be in the lowest position as indicated in the care plan and the care plan, should be updated to reflect Resident 73's refusal to have the bed lower.

Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice and facility's policy and procedure for four of 13 sampled residents (Residents 106,111, 36 and 164) when: 1. For Residents 106, 36 and 111, facility staff failed to ensure oxygen was administered as specified in the physician's order. Residents 36 and 111 did not have the oxygen sign posted outside of the room. 2. For Resident 164, facility staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 106's order summary report, dated 12/20/2020, indicated oxygen at 2 liters/min (liters per minute, LPM, unit of measurement) via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) continuously via concentrator (machine used to deliver oxygen) every shift. During an observation on 4/19/21 at 9:47 a.m., Resident 106 was lying in bed receiving oxygen at 2.5 LPM via nasal cannula. During another observation on 4/20/21 at 7:31 a.m., Resident 106 was lying in bed receiving oxygen at 2.5 LPM via nasal cannula. Review of Resident 111's physician order, dated 8/7/2020, indicated oxygen at 2 LPM or to keep O2 (oxygen) sat (saturation, blood oxygen level) above 92% via nasal cannula humidification continuously via concentrator every shift. During an observation on 4/19/21 at 10:16 a.m., Resident 111 was lying in bed receiving oxygen at 2.5 LPM via nasal cannula. The room did not have an oxygen sign posted. Review of Resident 36's physician order, dated 3/24/21, indicated oxygen at 2 LPM or to keep 02 sat above 92% via nasal cannula continuously via concentrator every shift. During an observation on 4/19/21 at 10:32 a.m., Resident 36 was lying in bed receiving oxygen at 3 LPM via nasal cannula. The room did not have an oxygen sign posted. During another observation on 4/20/21 at 7:37 a.m., Resident 36 was lying in bed receiving oxygen at 3 LPM via nasal cannula. During a follow-up interview with registered nurse N (RN N) on 4/19/21, RN N confirmed Residents 111 and 36 did not have the oxygen sign posted. During an interview and concurrent record review with assistant director of nursing K (ADON K ) on 4/20/21 at 8:27 a.m., ADON K confirmed Residents 106, 111 and 36 physician orders for oxygen were not followed. 2. During an observation on 4/26/2021 at 8:04 a.m., Resident 164 was lying in bed. The oxygen concentrator next to Resident 164's bed was set to deliver oxygen at a rate between 2.5 and 3 LPM. There was a clear flexible tube connected to the oxygen concentrator, with the other end of the tube connected to a clear covering over Resident 164's tracheostomy (a surgical incision in the front of the neck and into the windpipe). During an observation on 4/26/2021 at 10:13 a.m., Resident 164 was lying in bed, still receiving oxygen between 2.5 and 3 LPM. Review of Resident 164's tracheostomy care plan, dated 3/30/2021 indicated, Provide humidified O2 as ordered. Review of Resident 164's Order Summary Report, dated 4/26/2021, indicated she did not have a physician's order for oxygen. During an interview and concurrent record review with licensed vocational nurse T (LVN T) on 4/26/2021 at 10:47 a.m., LVN T confirmed Resident 164 was receiving oxygen between 2.5 and 3 LPM. When asked how he would know if Resident 164 was receiving the right amount of oxygen, LVN T explained the oxygen order should be in the resident's record. LVN T reviewed Resident 164's record and confirmed she did not have an order for oxygen. Review of the facility's policy titled Oxygen Administration, revised 10/2010 indicated, Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. The policy further indicated, Place an 'Oxygen in Use' sign on the outside of the room entrance door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 68's clinical record indicated he was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. He had diagnoses that included anxiety. Review of Resident 68's physician's order dated 4/3/2021 through 4/20/2021 indicated Lorazepam (anti-anxiety medication) 0.5 mg orally every 12 hours as needed for anxiety. Further review of Resident 68's clinical record indicated Lorazepam 0.5 mg tablet was given on 4/4/2021, 4/6/2021, 4/9/2021, 4/11/2021, 4/12/2021, 4/16/2021, and 4/20/2021. There was no evidence of written documentation that non-pharmacological nursing interventions were provided including it's effectiveness prior to administration of Lorazepam. During an interview with registered nurse E (RN E) on 04/22/2021 at 10:52 a.m., she confirmed there was no evidence of written documentation that non-pharmacological interventions were tried first by facility staff before giving Lorazepam on above dates. RN E acknowledged that licensed nurses should have documented non-pharmacological interventions provided and evaluated the results before giving Lorazepam for Resident 68. Review of the facility's policy and procedures revised 1/2020, Guidelines for Psychotropic Medication and Monitoring indicated the medical record must contain clear documentation that non-pharmacological approaches have been attempted and evaluated in any attempts to discontinue the psychotropic medication. Based on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 5, 74 and 68) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Residents 5 and 74, staff did not monitor target behaviors (behavior intended to be reduced or eliminated by administering the psychotropic medication); and 2. For Resident 68, staff did not provide non-pharmacological interventions (interventions that do not involve the use of medications) before administering as needed (PRN) psychotropic medication. These failures had the potential to compromise the facility's ability to determine the effectiveness of the psychotropic medications. These failures also had the potential to increase the residents' risk for adverse effects from the medications. Findings: 1. Review of Resident 5's clinical record indicated she had the diagnosis of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 5's Order Summary Report indicated she had a physician's order, dated 3/25/21, for Fluoxetine (medication used to treat depression) 40 milligrams (mg, unit of dose measurement) one time a day for depression manifested by excessive worrying over medical condition. She also had a physician's order, dated 3/25/21, to Document number of episodes per shift of target behavior 1. episode of excessive worrying about medical condition. Review of Resident 5's 4/21 medication administration record (MAR) indicated from 4/1/21 to 4/21/21, there were 29 shifts during which staff did not document the number of times Resident 5 exhibited the target behavior of excessive worrying over medical condition. Review of Resident 74's clinical record indicated she had the diagnosis of major depressive disorder. Review of Resident 74's Order Summary Report indicated she had a physician's order, dated 3/5/21, for Fluoxetine 30 mg one time a day for major depressive disorder manifested by excessive worrying of medical condition. She also had a physician's order, dated 3/4/21, to Document number of episodes per shift of target behavior 1. excessive worrying of medical condition 2. tearfulness. Review of Resident 74's 4/21 MAR indicated from 4/1/21 to 4/21/21, there were 29 shifts during which staff did not document the number of times Resident 74 exhibited the target behaviors of excessive worrying of medical condition and tearfulness. During an interview with licensed vocational nurse C (LVN C) on 4/22/21 at 11:51 a.m., she explained that for residents receiving psychotropic medication, licensed nurses were supposed to monitor target behaviors every shift and document the number of episodes on the MAR. LVN C reviewed the MARs for Residents 5 and 74 and acknowledged there were many shifts during which staff did not document the number of episodes of their target behaviors. LVN C confirmed if it was not documented, it was not done. Review of the facility's policy titled Medication Monitoring Medication Management, dated 1/2021 indicated, After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms must be reevaluated periodically to determine the effectiveness of the medication and the potential for reducing or discontinuing the dose. The policy further indicated the residents' clinical records must reflect whether there is adequate monitoring for the effectiveness of the medication in treating the specific conditions.

Based on observation, interview and record review, the facility had a 19.23% medication error rate with five medication errors during 26 opportunities during the medication passes (med pass, licensed nurses administer medication to residents) for two of nine observed residents (Residents 117 and 118). This failure had the potential to jeopardize the residents' medical condition and health. Findings: 1. During a med pass observation in Resident 118's room on 4/20/21 at 6:04 p.m., licensed vocational nurse KK (LVN KK) administered the mixture of water and famotidine (medication for digestive disease), mixture of water and sennosides (medication for constipation) to Resident 118 via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use). After LVN KK finished med pass for Resident 118, white residue particles of famotidine and brown residue particles of Sennosides remained on the bottom and side of the medication cups. Both medications were not completely dissolved with water and Resident 118 did not receive the full dose of famotidine and sennosides. During an interview with LVN KK on 4/20/21 at 6:31 p.m., LVN KK stated she did not administer the full doses of famotidine and sennosides to Resident 118 because the medications were not fully dissolved. LVN KK stated she should have administered the full doses of the two medications to Resident 118 per physician's order. Review of Resident 118's physician order dated 3/5/21, indicated to give famotidine 20 milligrams (mg: measure unit) via GT two times a day for GERD (Gastroesophageal reflux disease: digestive disease when stomach acid flows back to the mouth and stomach). The physician order dated 3/5/21 indicated to give sennosides one tablet via GT two times a day for bowel regularity. 2. During a med pass observation in Resident 117's room on 4/20/21 at 6:34 p.m., LVN KK administered the following medications: a. LVN KK crushed one iron tablet of 325 mgs and mixed it with water. LVN KK administered part of the iron mixture to Resident 117 via GT. LVN KK spilled part of the iron mixture on the medication tray during the med pass. Black and white iron particles were observed on the bottom and side of the medication cup after LVN KK finished the med pass. b.LVN KK administered the mixture of water and metoprolol (medication to treat high blood pressure). [NAME] particles of metoprolol remained on the bottom and side of the medication cup after LVN KK completed the med pass; c. LVN KK administered the mixture of the water and Vitamin C (medication for supplement) to Resident 117. [NAME] particles of Vitamin C remained on the bottom and side of the medication cup after LVN KK completed the med pass. Iron tablet, metoprolol and Vitamin C were not completely dissolved with water and Resident 117 did not receive the full dose of these medications. During an interview with LVN KK on 4/20/21 at 6:50 p.m., she stated she spilled Iron medication during med pass and did not administer the full doses of iron, metoprolol, and Vitamin C to Resident 117. LVN KK stated she should have administered the full doses of these medications to Resident 117 per physician's order. Review of Resident 117's physician's order dated 3/21/21, indicated to give one tablet of iron (also called Ferrous sulfate) 325 mgs via GT two times a day for supplement; Physician's order dated 4/13/21, indicated to give metoprolol 25 mgs via GT every six hours for hypertension (high blood pressure); physician's order dated 3/21/21, indicated to give vitamin C 250 mgs via GT two times a day for supplement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five resident beds (Room F beds a, b and c; Room G bed b and Room H bed c) were in safe operating condition when these five beds were found not locking properly. Two of the five beds were occupied by Residents 18 and 27. This failure can put residents and staff at risk for accidents. Findings: During a dining observation on 4/19/21 at 12:32 p.m., Resident 18 was being served his lunch tray by certified nursing assistant A (CNA A). A clean folded diaper pad was noted under the bed of Resident 18. During a concurrent interview with CNA A, he stated, The diaper is placed under the bed to keep it locked as it moves even when locked, maintenance is fixing the bed. During a concurrent observation and interview on 4/20/21 at 10:32 a.m., CNA A stated, Yesterday I took the (diaper) pad off from [Room F bed a] after you left. I tested it again today and it still moves. CNA A then showed surveyor all beds in Room F (beds a, b and c) were still moving even though they were in locked position. All the beds in [Room F] moves even if locked, maintenance is aware yesterday. I reported it to the supervisor nurse yesterday after you [surveyor] left. During a record review at nursing Station C, the red maintenance logbook was reviewed. There was no entry for 4/19/21 and 4/20/21 for the beds. The last entry was dated 4/14/21 for a broken remote control. During an interview with the maintenance supervisor (MS) on 4/20/21 at 10:39 a.m., he pointed to the red logbook and stated nursing has this red book to list the problem. The MS further stated he was not aware of the problems of the beds in room F. During a concurrent interview and observation on 4/20/21 at 10:42 a.m. with CNA B, she showed the MS and surveyor the beds that were still moving even when locked. CNA B stated all of the beds in Room F (beds a, b and c), Room G bed b, and Room H bed c were still moving even when locked. CNA B further stated, When we pull up and transfer the patient, it is dangerous and when we are not there maybe the patient will move and fall. She also stated, When we know we report to the nurse, the nurse has to put in the red logbook. CNA A reported to the nurse supervisor yesterday. During a concurrent interview with the MS, he stated, We have to change the beds, we have to put the patient out of the bed to fix the break; my maintenance guy checks the red logbook every day; yesterday it was my other guy who was here. During an interview on 4/20/21 at 10:49 a.m. with licensed vocational nurse C (LVN C), she stated she was aware of the red logbook when there was a need for maintenance, but said, No, I am not aware of the locked beds moving in [Rooms F, G and H]. She also stated, No one reported to me, they did not report to me, yes I was here yesterday. LVN C then proceeded to write in the red logbook form and went with LVN D to check the beds. During an interview on 4/20/21 at 10:55 a.m., with registered nurse E (RN E), she stated, It was reported to maintenance yesterday, they came to check, they said it was fixed when I asked them. RN E was made aware that the beds were still moving even when in locked position at this time. Review of facility policy and procedure titled Work Orders, Maintenance, revised 9/11/2015, indicated work orders must be filled out and forwarded to the Maintenance Director. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. A supply of work orders is maintained at each nurses' station . Work orders are picked up daily. Emergency requests will be given priority in making necessary repairs. Review of facility policy titled Bed Safety, revised December 2007, indicated to try to prevent deaths/injuries from beds and related equipment (including frame, mattress, side rails, headboard, footboard and bed accessories) the facility shall promote the following: a) Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . c) Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation in Station A on 4/20/2021 at 12:34 pm., the case manager (CM) was standing up while feeding Resident 143 at bedside. Resident 143 was looking up and not at eye level with the CM during meals. During a concurrent interview with the CM, she confirmed the above observation and stated she should have sat down while feeding Resident 143. During an interview with assistant director of nursing F (ADON F) on 4/26/2021 at 3:21 p.m., she stated the CM should have sat down while feeding Resident 143. Review of the facility's revised 7/2017 policy, Assistance with Meals, indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example: a. Not standing over residents while assisting them with meals. Based on observation, interview and record review, the facility failed to maintain dignity and privacy for five of 33 sampled residents (Residents 102, 73, 36, 143 and 66) and one non-sampled resident (Resident 72). For Residents 102, 73, 36, 143 and 66, staff provided feeding assistance while standing over the residents. For Resident 72, staff did not provide privacy during the finger stick blood sugar check (FSBG, medical device is used to prick the resident's fingertip to collect a blood sample and test the blood sugar level). These failures to maintain dignity may impact the residents' quality of life and lower residents' self-esteem. Findings: Review of Resident 102's Minimum Data Set (MDS, an assessment tool), dated 2/26/21, indicated cognitive skills for decision-making were severely impaired and the resident was totally dependent on staff with eating. Review of Resident 73's MDS, dated [DATE], indicated she needed assistance from staff with eating. Review of Resident 36's MDS, dated [DATE], indicated cognitive skills for decision-making were severely impaired and the resident was dependent on staff with eating. During consecutive observations on 4/19/21 at 12:54 p.m., certified nursing assistant G (CNA G) was observed standing while feeding Resident 102 in bed. CNA G then proceeded to Resident 73, and provided spoon-feeding to Resident 73 while standing next to the bed. During a follow-up interview with CNA G on 4/19/21, CNA G stated she should have been sitting down while feeding Residents 102 and 73. During consecutive observations on 4/20/21 at 8:01 a.m., CNA H was standing while feeding Resident 102 in bed. CNA I was observed standing while feeding Resident 73 in bed. Restorative Nursing Assistant J (RNA J) was observed standing while feeding Resident 36 in bed. During an interview with the director of staff development (DSD) on 4/22/21 at 9:35 a.m., the DSD stated staff should be in a sitting position at eye level with the residents while assisting them with meals. Review of Resident 66's MDS, dated [DATE], indicated her cognition was severely impaired. She required extensive and one-person assistance with eating. During an observation on 4/20/2021 at 8:05 a.m., Resident 66 was sitting upright in a low positioned bed. CNA BB was standing at bedside while feeding Resident 66. CNA BB was not at Resident 66's eye level. During a concurrent interview with CNA BB, she confirmed the observation. CNA BB acknowledged she should have sat down while feeding Resident 66. During an interview with the DSD on 4/26/2021 At 10:19 a.m., he stated CNA BB should have sat down when she fed Resident 66 to provide dignity. During an observation in Resident 72's room on 4/20/2021 at 11:15 a.m., registered nurse GG (RN GG) did not close Resident 72's door or privacy curtain while RN GG checked Resident 72's FSBG. Staff and visitors walked by Resident 72's room in the hallway. Resident 72 was exposed to the public view when RN GG pricked Resident 72's fingertip to get drops of blood for the FSBG check. During an interview with RN GG on 4/20/2021 at 11:30 a.m., RN GG stated she should have pulled the privacy curtain and closed the door for Resident 72 for the privacy during FSBG. Review of the facility's revised policy Quality of Life-Dignity dated August 2009 indicated .Residents shall be treated with dignity and respect at all times .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. The clinical record for Resident 100 was reviewed. He was admitted on [DATE] with diagnoses including cerebral edema and acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). His care plan included behavior episodes of undressing self and pulling trach tubing. His physician orders included, Behavior Monitoring: document number of episodes per shift of target behavior (specify) 1. Undressing self, 2. Pulling trach tubing, date started [DATE]. A record review of the behavior monitoring record per the above order for [DATE], indicated the licensed nurses on all shifts were charting YES or NO answers to the record instead of monitoring how many times behavior 1 or 2 occurred. During an interview on [DATE] at 12:55 p.m. RN Z, she reviewed the [DATE] charting for Behavior Monitoring for Resident 100 and stated document number of episodes should specify which behavior 1 or 2 not yes or no; the problem is, it is not marking how many times he is doing 1 or 2. RN Z further stated, They are putting that behavior is present on their shift, but when asked can you monitor how many times, she stated No, not how many times per shift. 9. The clinical record for Resident 4 was reviewed. He was admitted on [DATE], readmitted on [DATE] with diagnoses including hemiplegia (complete loss of strength or severe paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body, leg, arm or face) following cerebral infarction affecting right dominant side. His orders included Enteral feeding: (nutrition taken through the tube directly to the stomach) Suplena at 50 cc/hr. for 20 hours via GT. During an observation on [DATE] at 4:03 p.m. with LVN AA, she checked the tube feeding hanging on the pole attached and running on Resident 4. LVN AA stated and confirmed Resident 4 had Glucerna 1.0 running at 50 cc/hr. started at 12:00 noon today. LVN AA checked the order on her computer and stated the order is Suplena; I will stop it and change it to Suplena. Review of the facility's policy on Enteral Nutrition, revised [DATE], indicated adequate nutritional support is provided to residents as ordered. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. Review of the California Board of Vocational Nursing website, California Business and Professions Code, Division 2, Chapter 6.5, Article 2, Section 2859, indicated licensed vocational nurses should follow the physician orders. 6. Review of Resident 7's order summary report indicated he was admitted to hospice service on [DATE]. Resident 7 had orders for the following: Potassium Chloride (a type of mineral supplement) ER (Extended Release) 20 milli equivalent (meq, a unit measurement) by mouth once daily for supplement dated [DATE], NAS CCHO (No added salt, consistent (or controlled) carbohydrate) diet Mech (mechanical) Soft ground texture, and nectar thick liquids dated [DATE]. Review of Resident 7's care plan dated [DATE], indicated oxygen at 2 liters/min (minute) or to keep O2 (oxygen) sat (saturation) above 92% via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) continuously via concentrator (machine used to deliver oxygen) every shift PRN (as needed) for shortness of breath. During an interview and concurrent record review with assistant director of nursing (ADON) K on [DATE] at 11:42 a.m., Resident 7's hospice binder included an InterDisciplinary (IDT) Care Plan with the certification period indicated from [DATE] to [DATE]. When asked about the current recertification period documents that included the list of current medications and treatments, ADON K was not able to provide. ADON K stated Resident 7 was currently under hospice. Review of Resident 7's Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update, which the facility provided on [DATE], indicated the benefit period was from [DATE] to [DATE]. The list of medications included did not have the Potassium Chloride ER 20 meq. Further review of the document did not have the order for Resident 7's oxygen and diet. During an interview and concurrent record review with ADON K on [DATE] at 8:50 a.m., she confirmed the above findings. During a follow-up interview and record review with ADON K, together with RN M on [DATE] at 12:10 p.m., RN M confirmed the Hospice Visit Note Report conducted on [DATE] for recertification and for the facility to have, did not include the list of medications, order for oxygen and diet. RN M acknowledged the hospice's new system had issues resulting in documents not being readily available for the facility to review timely. Review of the facility's Nursing Facility Services Agreement, effective [DATE] indicated, Information from Hospice. Obtaining the following information from Hospice: Plan of Care, Medications and Orders. The most recent Hospice Plan of Care, medication information and physician orders specific to each Hospice Patient. Creation and Maintenance of Records indicated each clinical record should completely, promptly and accurately document all services provided to and events including evaluations, treatments .physician orders entered pursuant to this Agreement and discharge summaries. 7a. Review of Resident 36's order summary report dated [DATE], indicated soft booty to left foot QS (every shift) when in bed as preventative measures. Residents 36's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated she was dependent on staff for activities of daily living (ADLs, basic tasks of everyday life, i.e., eating, bathing, dressing) and had severe cognitive impairment. Her MDS also indicated she had high risk for developing pressure ulcers. Review of Resident 36's care plan, dated [DATE], indicated Resident 36 was at risk for skin breakdown/further skin breakdown due to decreased mobility/immobility and intervention included treatment/med (medication) as ordered. During an observation and concurrent interview with certified nursing assistant P (CNA P) on [DATE] at 12:17 p.m., Resident 36's legs were contracted and a pillow was under the legs. CNA P confirmed Resident 36 had boots and CNA P started to look but failed to find the boots. During an interview with LVN Q on [DATE] at 12:26 p.m., LVN Q stated Resident 36 had an order for a boot on her left foot and it should be in place. 7b. Review of Resident 162's order summary report indicated bilateral booties at all times, dated [DATE], and hand roll to L (left) hand QS (every shift) monitor placement, dated [DATE]. Review of Resident 162's MDS, dated [DATE], indicated he had severe cognitive impairment, was totally dependent on staff for ADLs, and had high risk for developing pressure ulcers. During an observation on [DATE] at 9:58 a.m., Resident 162's hands and fingers were contracted. There was no hand roll in his left hand. During an observation and concurrent interview with CNA R on [DATE] at 10:58 a.m., Resident 162 did not have a hand roll in his left hand, and he had no booties on his feet. CNA R stated the booties might be in the laundry. During another observation and concurrent interview with CNA R on [DATE] at 8:12 a.m., Resident 162 did not have a hand roll in his left hand, and he had no booties on his feet. CNA R stated most of the time Resident 162 did not have the booties and hand roll. Review of Resident 162's treatment administration record (TAR), dated [DATE] to [DATE] on all shifts (morning, evening and night), indicated licensed nurses documented booties and hand roll in place. During an interview and concurrent record review with RN S on [DATE] at 8:29 a.m., RN S acknowledged booties and hand roll should be in place for Resident 162 as evidenced by licensed nurses signing the TAR. 2. Review of Resident 11's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing). He had a GT for enteral feeding. His physician's order, dated [DATE], indicated Glucerna (liquid nutrition) at 75 cubic centimeter (cc, unit of liquid measurement) per hour for 20 hours via GT. During an observation on [DATE] at 1:43 p.m., Resident 11's Glucerna feeding bottle was labeled at 85 cc per hour. LVN C confirmed this observation. LVN C acknowledged the rate of flow should have been 75 cc per hour, not 85 cc per hour as ordered by the physician. Review of the facility's policy and procedure revised 11/2018, Enteral Nutrition, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete that includes volume and rate of administration. 3a. Review of Resident 68's clinical record indicated he was readmitted to the facility on [DATE] with diagnoses that included retention of urine, dysfunction of urinary bladder, and urethral stricture (narrowing of the tube that carries urine out of body). He was under hospice care. During an observation on [DATE] at 9:43 a.m., Resident 68 was observed with an indwelling foley catheter (FC, a flexible tube that drains urine from the urinary bladder into a bag outside the body) connected to a drainage bag. Review of Resident 68's facility physician order sheet on [DATE] indicated there was no evidence of written order for the placement of an indwelling FC. During an interview and record review with the registered nurse E (RN E) on [DATE] at 8:24 a.m., she confirmed she did not find any active or current physician's order regarding placement of an indwelling FC in Resident 68's facility clinical record. RN E stated per facility practice, placement of an indwelling FC requires a physician order. Further review of Resident 68's hospice plan of care (POC) indicated the hospice physician ordered placement of an indwelling FC for Resident 68 on [DATE]. The facility received the hospice physician order regarding placement of indwelling FC on [DATE], but it was not carried over into Resident 68's facility clinical record. During another interview with RN E on [DATE] at 3:33 p.m., she confirmed the facility's licensed nurse missed incorporating the hospice physician order regarding the placement of an indwelling FC for Resident 68. She acknowledged the facility's licensed nurse should have incorporated the hospice physician order to Resident 68's facility clinical record. Review of the agreement between the facility and Resident 68's hospice agency indicated the facility shall consult with the hospice to assist in developing and updating the hospice POC, which will identify which provider is responsible in performing the respective function that have been agreed upon and included in the hospice POC. If there are physician orders that are inconsistent with the hospice POC or protocols, a registered nurse with the facility shall notify hospice. An authorized representative of hospice shall resolve differences directly with the physician and secure the necessary orders. 3b. Review of Resident 68's clinical record indicated he was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. He had diagnoses that included atrial fibrillation (abnormal heart rhythm), ischemic heart disease (narrowing of arteries of the heart), glaucoma (an eye disease), depression (a mood disorder characterized by persistent feeling of sadness and loss of interest), and anxiety (intense feeling of unease, worry, and nervousness). Review of Resident 68's physician's orders, dated [DATE], indicated Artificial tears (eye lubricant) one drop to both eyes three times a day, Metoprolol Tartrate (medication used to treat high blood pressure), 25 milligrams (mg, unit of measurement) orally two times a day and hold for systolic blood pressure (BP) less than 110 millimeter Mercury (mmHg, unit of measurement) or heart rate below 60 beats per minute, Zoloft (anti-depressant) 100 mg orally every day, and Apixaban (medication used to prevent blood clots) 2.5 mg orally two times a day. Further review of Resident 68's physician's orders, dated [DATE], indicated monitor and document the episodes of verbalization of helplessness and side effect (S/E) every shift for the use of Zoloft and monitor S/E every shift for the use of Apixaban. Review of the Resident 68's medication administration record (MAR), dated [DATE], indicated there were no licensed nurse initials for administration of Artificial tears at 100 p.m. on [DATE], [DATE], 4/11 to [DATE], and [DATE]; no licensed nurse initials for the monitoring of verbalization of helplessness on day shift for the use of Zoloft on [DATE], [DATE], 4/8 to [DATE], 4/11 to [DATE], [DATE] and for afternoon shift on [DATE], [DATE], and [DATE]; no licensed nurse initial for the monitoring of the side effects for the use of Zoloft on day shift on [DATE], 4/8 to [DATE], 4/12 to [DATE], [DATE] and on afternoon shift on [DATE], [DATE], and [DATE]; no BP and pulse taken and no licensed nurse initials for the administration of Metoprolol Tartrate on day shift on [DATE], [DATE], [DATE], 4/11 to [DATE] and on afternoon shift on [DATE]; and no licensed nurse initials for the monitoring of the S/E for the use of Apixaban on day shift on [DATE] and [DATE]. During an interview and record review with LVN C on [DATE] at 11:10 a.m., she confirmed there were no licensed initials on the administrations, parameters, behavior monitoring and side effects monitoring for the above medications as ordered by the physician for Resident 68 on the above dates and shifts. During an interview with RN E on [DATE] at 2:30 p.m., she acknowledged the licensed nurses should have consistently documented their initials and chart codes in Resident 68's MAR for the administration of medications, parameters, side effects, and behavioral monitoring on the above dates and shifts in a timely manner. Review of the facility's policy titled Administering Medications, revised 12/2012 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy further indicated, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility's policy and procedures revised 1/2020, Guidelines for Psychotropic Medication and Monitoring indicated the facility assures that residents are being adequately monitored for adverse consequences. 4. Review of Resident 170's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia (insufficient blood flow to the brain), atrial fibrillation, and dementia (long term brain disorder causing impaired memory, reasoning, and social function). Her advanced health directive indicated do not resuscitate (DNR, an instruction for health care providers not to do cardiopulmonary resuscitation [manual chest compression and artificial breathing to patients in cardiac arrest]) and comfort measures only. She expired (died) in the facility on [DATE]. Further review of Resident 170's clinical record indicated there was no evidence of written documentation of the events prior to Resident 170's actual death. During an interview and record review with RN E on [DATE] at 2:27 p.m., she confirmed there was no evidence of written documentation regarding prior events before the actual death of Resident 170 in the facility on [DATE]. RN E acknowledged the licensed nurse should have documented the events prior to Resident 170's death. Review of the facility's policy and procedure revised 5/2017 titled Change in a Resident Condition or Status indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition status. 5. Review of Resident 167's clinical record indicated she had diagnoses that included fracture of the right arm. Her physician orders, dated [DATE], indicated keep sling and brace on right arm at all times except for showering and skin checks. During multiple observations on [DATE] at 1:46 p.m., [DATE] at 10:52 a.m. and 3:59 p.m., Resident 167 was not wearing sling and brace on the right arm. During an interview and record review with restorative nursing assistant J (RNA J ) on [DATE] at 9:35 a.m., he confirmed there was no written documentation that the sling and brace were applied for Resident 167 on the above dates. RNA J further stated he did not apply sling and brace whenever he was assigned to Resident 167. During an interview and record review with the medical records supervisor (MR) on [DATE] 10:06 a.m., she confirmed there were no RNA treatment sheets for Resident 167 for the months of March and [DATE]. During an interview with assistant director of nursing K (ADON K) on [DATE] at 11:10 a.m., she acknowledged RNAs should have still applied the sling and brace to Resident 167 as ordered by the physician. Review of the facility's policy and procedure dated [DATE], Restorative Nurse Assistant: Duties and Responsibilities, indicated performs duties as assigned by Restorative Manager which may included: restorative adaptive devices and documents daily and weekly on each resident in the restorative program. Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for ten of 33 sampled residents (Residents 74, 5, 11, 68, 167, 7, 36, 162, 100 and 4), one non-sampled resident (Resident 170), and three of four nurse stations when: 1. For Residents 74 and 5, licensed nurses did not administer and/or document medications and supplements as ordered by the physician; 2. For Resident 11, staff incorrectly labeled the gastric tube (GT, tube inserted through the abdomen into the stomach to deliver nutrition) formula bottle; 3. For Resident 68, licensed nurses failed to incorporate a hospice order into the resident's facility clinical record; also for Resident 68, licensed nurses did not implement and/or document medications, medication side effects monitoring, behavior monitoring, and vital signs monitoring as ordered by the physician; 4. For Resident 170, the licensed nurse did not document the events regarding her death in the facility; 5. For Resident 167, staff did not apply a right arm sling and brace as ordered by the physician; 6. For Resident 7, medication, oxygen and diet orders were not included in the hospice assessment and plan of care; 7. For Residents 36 and 162, staff did not apply protective booties (device secured to the foot to reduce pressure) and hand rolls (device placed in the palms of the hands to prevent contractures) as ordered by the physician; 8. For Resident 100, licensed nurses did not document behavior monitoring as ordered by the physician; 9. For Resident 4, licensed nurse did not follow the physician's order for GT feeding; and 10. Licensed nurses failed to ensure the glucometer (device used to check blood sugar) daily quality control record (documentation that the glucometer's function was tested) was completed on multiple days for three of four nurse stations. These failures had the potential to compromise the residents' health and well-being. Findings: 1a. Review of Resident 74's clinical record indicated she had the diagnoses of hypertension (high blood pressure), dysphagia (difficulty swallowing) and diabetes (disease that causes high blood sugar). Review of Resident 74's physician's order, dated [DATE], indicated she was to receive Metoprolol Tartrate (medication used to lower blood pressure) 25 milligrams (mg, unit of dose measurement) every 12 hours. Review of Resident 74's physician's order, dated [DATE], indicated she was to receive half a tablet of Amlodipine Besylate (medication used to lower blood pressure) 5 mg one time a day. Review of Resident 74's physician's order, dated [DATE], indicated she was to receive a healthshake (nutritional supplement) every morning. Resident 74's 4/21 medication administration record (MAR) was reviewed. From [DATE] to [DATE], there were eight doses of Metoprolol Tartrate that were not documented as given. During the same time period, there were five doses of Amlodipine Besylate that were not documented as given. From [DATE] to [DATE], there were nine healthshakes that were not documented as given. During a record review and concurrent interview with licensed vocational nurse C (LVN C) on [DATE] at 11:51 a.m., LVN C reviewed Resident 74's MAR and acknowledged there were several doses of the above blood pressure medications and several healthshakes that were not documented as given. LVN C confirmed if it was not documented, it was not done. 1b. Review of Resident 5's clinical record indicated she had the diagnosis of diabetes. Review of Resident 5's physician's order, dated [DATE], indicated she was to receive sugar free Med Pass (nutritional supplement) 60 milliliters (ml, unit of measurement) three times a day. Resident 5's 4/21 MAR was reviewed. From [DATE] to [DATE], there were six doses of sugar free Med Pass that were not documented as given. During a record review and concurrent interview with LVN C on [DATE] at 11:51 a.m., LVN C reviewed Resident 5's MAR and acknowledged there were several doses of sugar free Med Pass that were not documented as given. LVN C confirmed if it was not documented, it was not done. Review of the facility's policy titled Administering Medications, revised 12/2012 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy further indicated, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 10. Review the facility's glucometer' daily quality control records, dated from [DATE] to [DATE] for Station B, indicated there was no documentation that the nurse staff checked the accuracy of the glucometers on [DATE], [DATE], [DATE]; [DATE], [DATE], and [DATE] to [DATE]. During a record review with ADON K on [DATE] at 11:00 a.m., ADON K reviewed Station B's glucometer daily quality control records and acknowledged the above mentioned missing dates. ADON K stated the night shift nurses should have checked the glucometer daily quality control. Review the facility's glucometer daily quality control records, dated from [DATE] to [DATE] for Station C, indicated there was no documentation the nurse staff checked the accuracy of the glucometers on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] to [DATE]. Review of the facility's glucometer daily quality control record, dated from [DATE] to [DATE] for Station D and its 9 medication carts (Med Cart), indicated there was no documentation that the nurse staff checked the following dates for the accuracy of the glucometers: a. Did not check for [DATE] to [DATE] for all 9 Med Carts; b. Med Cart 8: [DATE], [DATE], [DATE], and [DATE]; c. Med Cart 9: [DATE], [DATE], [DATE], and [DATE]; d. Med Cart 10: [DATE], [DATE], and [DATE]; e. Med Cart 11: [DATE] to [DATE]; f. Med Cart 12: [DATE] to [DATE]; g. Med Cart 13: [DATE], [DATE], [DATE], [DATE] and [DATE]; h. Med Cart 14: [DATE], [DATE], [DATE], [DATE] and [DATE]; i. Med Cart 15: [DATE], [DATE], and [DATE]. During an interview with the registered nurse E (RN E, who also worked as director of nursing) on [DATE] at 1:45 p.m., she reviewed the above glucometer quality control records for Station D and acknowledged the above mentioned missing dates. RN E stated the medical record department could not find the glucometer daily quality control records from [DATE] to [DATE] for Station D. RN E further stated the night shift nurses should have checked the glucometers daily quality control.

Based on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two randomly selected residents (Residents 6 and 7). The facility failed to ensure the controlled substance was disposed properly for one randomly selected resident (Resident 91). Nurse staff stored Resident 569's opened controlled medication in medication cart 12 (Med cart 12). These failures had the potential to result in residents not getting the controlled medications per physician's order and potential to cause misusing and abusing the controlled medications. Findings: 1. Review of Resident 6's physician order, dated 1/8/21, indicated to administer one tablet of one milligram (mg, measure unit) lorazepam (medication for anxiety) by mouth every 24 hours as needed for anxiety. Review of Resident 6's CDR and MAR from 1/15/21 to 1/26/2020 indicated nurse staff removed one tablet of lorazepam from the controlled medication storage area in the medication cart on 1/24/21 at 4 p.m. and 1/25/21 at 4 p.m. However, there was no evidence on the MAR indicating the nurse administered the medication to Resident 6 on 1/24/21 and 1/25/21. 2. Review of Resident 7's physician order, dated 10/21/2020, indicated to administer one tablet of two mgs Hydromorphone (controlled medication for pain) by mouth every four hours as needed for moderate to severe pain or short of breath. The physician's order, dated 4/14/21, indicated to administer one tablet of two mgs Hydromorphone by mouth every four hours as needed for moderate pain. Review of Resident 7's CDR and MAR from 10/5/2020 to 10/20/2020 and 4/1/21 to 4/15/21, indicated nurse staff removed one tablet of Hydromorphone from the controlled medication storage area in the medication cart on 4/7/21 at 10 a.m., 4/14/21 at 10 p.m., and 4/15/21 at 9 p.m. However, there was no evidence on the MAR indicating the nurses administered hydromorphone to Resident 7 on 4/7/21, 4/14/21 and 4/15/21. 3. Review of Resident 91's physician's order, dated 2/25/21, indicated to administer one tablet of Norco 5-325 mgs via GT (gastrostomy tube, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use) every four hours as needed for moderate pain. Review of Resident 91's CDR and MAR from 3/1/21 to 3/24/21 indicated nurse staff removed one tablet of Norco from the controlled medication storage area in the medication cart on 3/1/21 at 9 p.m. and 3/2/21 at 9 a.m. CDR indicated nurse staff wasted the Norco on 3/1/21 at 9 p.m. and 3/2/21 at 9 a.m. by one nurse. There was no evidence on the MAR that Norco was administered to Resident 91 on 3/1/21 and 3/2/21. During an interview with the registered nurse E (RN E, who also worked as director of nursing, DON) on 4/23/21 at 2:22 p.m., RN E stated the nurse staff should have wasted the controlled medication with two nurses and documented on CDR. RN E stated when the nurse staff removed the controlled medication and signed on CDR and MAR; The controlled medication should be accounted on CDR and MAR for the residents. 4. During an inspection of med cart 12 with licensed vocational nurse WW (LVN WW ) on 4/21/21 at 2:30 p.m., Resident 569's Norco 5-325 milligrams tablet packet (Norco, controlled medication for pain) #16 tablet opened and taped with a clear tape. LVN WW stated nurse staff just taped the opened #16 tablet of Norco and continued to count each shift. Review the facility revised policy Controlled Substances dated December 2012, indicated The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and document of s II (schedule II) and other controlled substances.

Based on observation, interview, and record review, the facility failed to employ dietary staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check the dish machine's sanitizer correctly; 2. Dietary staff did not know how to check the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes) at three compartment sinks area (3 sinks used to manually sanitize dishes with quaternary sanitizer); 3. Dietary staff did not know how to calibrate the temperature thermometers correctly; the registered dietitian (RD) did not know how to calibrate the temperature thermometers correctly; and 4. RD was not aware how kitchen function and did not supervise the kitchen or provide in-service to dietary staff. The lack of knowledge of the RD created the potential for dietary staff to be inadequately trained and supervised to carry out their job functions properly; the lack of knowledge of dietary staff had the potential to compromise their ability to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1a. During an observation and interview on 4/19/21 at 9:55 a.m., dietary aide OO (DA OO) demonstrated how to wash a tray of dishes via the dish machine. Her wet gloved fingers removed one test strip from the test strip bottle, then dipped the test strip into the sanitizer solution on the counter table next to the dish machine. DA OO dipped the test strip into the solution on the table for four seconds and checked the test strip with the color chart on the test strip bottle to obtain the dish machine sanitizer concentration. The test strip did not change color, which indicated the dish machine sanitizer concentration was zero. 1b. During an observation and interview on 4/19/21 at 10:00 a.m., DA UU demonstrated how to wash a tray of dishes and check the dish machine's sanitizer. She dipped the test strip in the sanitizer solution on the plate for 10 seconds, then checked the test strip with the color chart on the test strip bottle. The test strip did not change color, which indicated the dish machine concentration was zero. DA UU stated the dish machine sanitizer concentration should be between 50 parts per million (ppm: liquid concentration measurement unit) to 100 ppm. During an interview with the dietary manager (DM) on 4/19/21 at 10:10 a.m., she stated the dish machine's sanitizer was ok in the morning, but it was not good now and she would call the dish machine company to fix it immediately. During an interview with DM on 4/19/21 at 11:28 a.m., she stated the dish machine company came to fix the sanitizer around 11:00 a.m. Review of the dish machine sanitizer test strip guide indicated to use dry fingers to remove the test strip of paper from the vial, dip strip into solution to be tested. Test time is one second. Compare strip with color chart on the label to obtain the sanitizer concentration. During an interview with the administrator (ADM) on 4/20/21 at 8:35 a.m., he stated the dish machine sanitizer was still not working and the facility was working on fixing it. He stated the DM was on medical leave from 4/20/21 and 4/26/21. 1c. During an observation and interview with DA SS on 4/20/21 at 12:00 p.m., DA SS demonstrated how to wash dishes via dish machine and dipped the test strip into the sanitizer solution on the plate for five seconds. She compared the test strip with color chart and stated the sanitizer concentration was 50 ppm. DA SS stated she did not know she should test the sanitizer for one second. 1d. During an observation and interview with DA QQ on 4/22/21 at 2:44 p.m., she demonstrated how to wash dishes via dish machine and dipped the test strip into the sanitizer solution that dripped on the counter table for two seconds and compared the strip with color chart and stated the sanitizer concentration was between 10 ppm to 50 ppm. DA QQ stated the normal range of sanitizer was 100 ppm to 200 ppm. DA QQ stated she did not know how long she should dip the strip into the sanitizer. 1e. During an observation and interview on 4/22/21 at 2:35 p.m., with DA UU's translation assistance, DA RR demonstrated how to wash dishes via dish machine. He dipped the test strip into the sanitizer for 3 seconds and said the sanitizer concentration was 200 ppm. He stated he was not sure if the test was correct. DA RR pulled out another test strip and did not know where to dip the strip to check the sanitizer. He touched the small corner of the test strip on the plate and then compared the dot spot color on the test strip to the color chart. DA RR stated the sanitizer was 10 ppm and the dish machine sanitizer was okay. 2a. During an observation and interview with DA UU on 4/22/21 at 3:30 p.m., she dipped the test strip into quaternary sanitizer for one minute and compared the strip with color chart. DA UU stated she normally dipped the strip into the sanitizer for 30 seconds to test. 2b. During an observation with DA QQ on 4/22/21 at 3:53 p.m., she dipped the test strip into the quaternary sanitizer for one minute and then compared the test strip with the color chart. 2c. During an observation and interview with DA VV on 4/22/21 at 3:57 p.m., he threw the test strip into the quaternary sanitizer for one minute and then took the wet strip out to compare it with the color chart. He stated the sanitizer was 400 ppm. DA VV said the normal range for quaternary sanitizer was 200 ppm to 400 ppm. He stated there was no need to hold the strip to dip into the sanitizer. DA VV stated he just threw the whole strip into the sanitizer for one minute to test the concentration. Review of the quaternary sanitizer test strip guide on the strip bottle indicated PRECISION QAC QR5 . Use dry fingers to remove strip paper from vial. Remove one strip and dip strip for one second into solution to be tested. Allow 5 to 10 seconds to develop, then compare to color chart below . 3a. During an observation and interview with cook LL on 4/22/21 at 3:16 p.m., she demonstrated thermometer calibration. [NAME] LL inserted the thermometer tip into the glass of ice cubes and water mixture and stated she was the one to calibrate the thermometer prior to checking the food temperature. The ice temperature read as 20 Fahrenheit (F, temperature measure unit). [NAME] LL stated it was okay to use the thermometer to check the food temperature and there was no need to calibrate the thermometer. 3b.During an observation and interview with cook MM on 4/23/21 at 11:06 a.m., she demonstrated thermometer calibration. [NAME] MM inserted the thermometer tip into a glass of ice cubes and water mixture and stated if the ice water temperature was not 32 F, then she needed to calibrate the thermometer to 32F. [NAME] MM stated there was no need to crush the ice when mixed with water for the calibration. 3c. During an observation and interview with the registered dietary (RD) on 4/24/21 at 11:17 a.m., she mixed a small paper cup of ice cubes and water, and inserted thermometer tip into the ice water. RD stated if the ice water temperature was not 32 F, then need to calibrate the thermometer. When asked how she calibrated the thermometer to 32F, RD stated she did not know how to calibrate the thermometer. RD stated it was not her job to calibrate the thermometer. She stated she did not know the thermometer policy and did not know she needed to crush the ice and form slush for the calibration. Review of the facility's policy THERMOMETER USE AND CALIBRATION dated 2018, indicated Food thermometers are to be used properly and calibrated to ensure accurate temperature reading. The policy also indicated .Checking the Accuracy and Calibrating .Fill a large glass with crushed ice and add clean tap water until slush is formed. Stir the mixture well .Put the thermometer's stem into the ice water so that the sensing area is completely submerged .If the thermometer does not read 32 F, then the thermometer must be calibrated or discarded . 4. During an interview with the RD on 4/22/21 at 4:26 p.m., she stated she was new to the facility (started to work with the facility in August 2020) and she did not supervise the kitchen or DM. RD stated she did not know much about dish machine, quaternary sanitizer, and thermometer calibration. RD stated she did not audit kitchen logs such as sanitizer logs, temperature logs nor train kitchen staff. During an interview with ADM on 4/23/21 at 9:54 a.m., he stated the RD was supervising the kitchen and the kitchen manager.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. Toaster had multi-colored substances; 3. Refrigerator (fridge) had multi-colored substance; 4. Electrical pipes on the wall near the kitchen table had black sticky substance; 5. The can opener had multi-colored substances; 6. Multi-colored substance noted on the top of the dish washer; 7. There was no space (air gap) between dish machine (same as dish washer) and food preparation sink drain pipes and floor sink drain; 8. Two of three ice machines (Ice machine B and C) had black substance at the interior and exterior of the ice machines; 9. There was no evidence that the facility identified and addressed the multiple out of range dish machine temperatures (per the dish machine temperature log). These failures had the potential to cause food-borne illness for residents. Findings: 1a. During an initial kitchen tour with the dietary manager (DM) on 4/19/21 at 9:14 a.m., the DM, dietary aides UU (DA UU), DA NN, DA OO, DA TT, DA PP worked in the kitchen. Their hair on the sides and back were not completely covered with a hairnet. During an interview with DM on 4/19/21 at 9:15 a.m., she stated dietary staff should have covered their hair completely with a hairnet. 1b. During an observation in the kitchen on 4/19/21 at 3:32 p.m., cook LL and DA QQ's hair on the sides and back were not completely covered with a hairnet. 1c. During an observation in the kitchen on 4/22/21 at 2:34 p.m., DA UU, DA TT, and DA QQ's hair on the sides and back were not completely covered with a hairnet. Review of the facility's policy, DRESS CODE FOR WOMEN AND MEN, dated 2018 indicated, .Appropriate dress in the Food & Nutrition Department Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department. The policy indicated women should wear .Hair net or hat which completely covers the hair . and men should wear .Hat for hair, if hair is short .Hair net for hair, if hair is long (over the ears or longer) . 2. During an initial kitchen tour with DM on 4/19/21 at 9:20 a.m., one toaster had black and white sticky substances on the exterior area. Yellow, white, and black sticky substances were noted in the interior of the toaster. During an interview with the DM on 4/19/21 at 9:25 a.m., the DM stated there was only one toaster in the kitchen and staff should clean the toaster after each use. Review of the facility policy, ELECTRICAL FOOD MACHINES, dated 2018, indicated Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, slicers, and toasters. The policy indicated to clean the toaster daily and .Remove crumbs from the crumb tray daily and wipe the toaster case with a soft damp cloth. If the case is greasy, use non-abrasive cleaning compound to clean it . 3. During an initial kitchen tour with the DM on 4/19/21 at 9:30 a.m., it was observed the metal tray/shelf inside the fridge had black, orange, and yellow substances; 2 x 1.5 inches of irregular shape torn patch with the yellow, black, and white color on the bottom of the interior of the fridge. White, yellow, orange, and black substances were noted in the interior of the fridge. The DM stated the fridge was old and the dietary staff should clean the fridge. Review of the facility policy, REFRIGERATOR AND FREEZER, dated 2018, indicated Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods .Refrigerator and freezer should be on a weekly cleaning schedule .Periodically inspect shelves and replace if coating is chipped away exposing metal shelves . 4. During an initial kitchen tour with the DM on 4/19/21 at 9:40 a.m., electrical pipes on the wall next to the kitchen table had black sticky substance. The DM acknowledged this. 5. During an initial kitchen tour with the DM on 4/19/21 at 9:42 a.m., orange and black substances were observed on the can opener blade and surrounding area. The DM stated dietary staff should clean the can opener after each use. The DM further stated the facility bought a new can opener but the kitchen did not yet replace the old one. Review of the facility policy, CAN OPENER AND BASE, dated 2018, indicated Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn out cogwheel .The can opener must be thoroughly cleaned each week shift and, when necessary, more frequently . 6. During an observation with the DM in the kitchen on 4/19/21 at 10:15 a.m., yellow, grey, and white substances were observed on the top of dish washer. The DM acknowledged this. 7. During an observation with the DM in the kitchen on 4/19/21 at 3:44 p.m., there were no air gaps between the dish machine drain pipe and floor sink drain. There was no air gap between the food preparation sink drain pipe and the floor sink drain. The DM stated the dish machine and food prepare sink drain pines were one inch below the floor level and one inch inside the floor sink drain. The DM stated the dish machine and food preparation sink drain pipe should have air gap between the floor sink drain to avoid back flow. Review of the facility policy, ACCIDENT PREVENTION-SAFETY PRECAUTIONS, dated 2018 indicated .An air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch . 8. During an ice machine inspection with the maintenance supervisor (MS) on 4/19/21 at 3:53 p.m., based on white paper towel wipe test, ice machine B was noted with a small amount of black substance inside the ice machine bin wall area and the black substance noted on the exterior of the ice machine. Ice machine C had black substance at the exterior frame and the door area. During an interview with the MS on 4/19/21 at 4:00 p.m., he stated there were a total of three ice machines in the facility. The MS stated the staff just cleaned the ice machines two days ago and should ensure the ice machines were clean. 9. During an interview with the DM on 4/19/21 at 9:56 a.m., she stated the facility had the low temperature dish machine and the temperature should maintain at least 120 Fahrenheit (F, temperature measure unit). Review of the facility's DISH MACHINE TEMPERATIRE LOG for January 2020 and February 2021 to April 2021, indicated the dietary staff checked the dish machine temperatures (T) three times a day on breakfast (B), lunch (L) and dinner (D). The dish machine temperatures were out of range on the following days: 1) 1/7/2020 B,T=110F; 1/8/2020 B,T=110F; 1/9/2020 B,T=115F; 1/10/2020, B,T=100F; 1/13/2020, D,T=100F;1/14/2020, D,T=100F; 1/17/2020, L and D, T=100F; 1/18/2020, L,T=100F; 1/21/2020, D,T=100F; 1/22/2020, D,T=100F; 1/29/2020, D,T=100F; and 1/31/2020, D,T=100F; 2) 2/1/21, D,T=100F; 2/4/21,D,T=100F;2/7/21,D,T=100F; 2/8/21, D,T=100F; 2/10/21, D,T=100F; 2/11/21, D,T=100F; 2/12/21, D,T=100F; 2/14/21, D,T=100F; 2/15/21, D,T=100F; 2/22/21, D,T=100F. There was no evidence the facility identified and addressed the above mentioned multiple out of range dish machine temperatures. During an interview with the administrator (ADM) on 4/20/21 at 8:35 a.m., he stated the DM was on medical leave from 4/20/2021 to 4/26/2021 and the registered dietitian (RD) supervised the kitchen. During an interview with the RD on 4/22/21 at 4:26 p.m., she stated she was new to the facility (started to work with the facility in August 2020) and she did not supervise the kitchen or DM. RD stated she did not know much about dish machine, quaternary sanitizer, and thermometer calibration. RD stated she did not audit kitchen logs such as sanitizer logs, temperature logs nor train kitchen staff.

Based on observation, interview, and document review, the facility failed to maintain sanitary conditions for the dumpsters when four of five dumpsters were overflowed with disposable food plates and utensils, dumspters were not covered with lids, garbage bags were overflowed from the side of the dumpster, and used gloves were on the ground next to the dumpsters. These failures had potential to harbor or feed the pests. Findings: During an observation at the dumpster's area near the parking lot with the maintenance supervisor (MS) on 4/22/21 at 4:50 p.m., two dumpsters were overflowed with disposable food plates and utensils. These two dumpsters were not covered with lids. One dumpster contained cardboard without a lid covering. One dumpster had garbage bags overflowed from the side of the dumpster. Multiple used gloves were noted on the ground next to the dumpsters. During an interview with the MS on 4/22/21 at 4:55 p.m., he stated the dumpsters should be covered with a lid and the dumpsters should not be overflowing. Review of the facility's revised policy, Storage Area, Maintenance, dated 9/11/2015, indicated Maintenance storage area shall be maintained in a clean and safe manner .All storage areas must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store medications in a safe and sanitary condition when: 1. Fifteen of fifteen medication carts (Med Carts 1-15) had multi-colored and sticky substances; medication pills were spilled inside the med carts; med carts stored expired medications; med carts stored unlabeled medications; med carts had improperly stored medications; and 2. Three of five medication rooms (Med Rooms E, D, and B) stored staff's personal items; the medication refrigerator temperatures in two med rooms (Med Rooms D and B) were out of range; and the refrigerator temperature log was incomplete for one med room (Med Room E); These failures had the potential for the residents to receive used, contaminated, and/or deteriorated medications. Findings: 1a. During Med Cart 10 inspection with registered nurse GG (RN GG) on 4/19/21 at 10:33 a.m., observed the following: 1) Pill crusher (device to crush the medication) had black, grey, and white substances. 2) Applesauce (for residents' use) dated 4/18/21; RN GG stated applesauce was old and should be discarded. 3) Water pitcher had sticky black and grey substances. Water pitcher was labeled as water 8pm. There was no indication when the water was prepared. RN GG stated the water should be dated properly and the water pitcher should be cleaned. 4) One pink pill was spilled inside the med cart. 5) Resident 112's Lantus insulin (injection medication for high blood sugar) with open date of 3/18/21; Resident 112's Insulin Aspart (Novolog) with an open date of 3/14/21; RN GG stated Resident 112's insulins were expired and should be discarded in 28 days after they were opened . 6) Resident 271's insulin aspart with a date of 4/14/21, there was no indication if it was the open date or the discard date. Resident 271's Latanoprost 0.005% (eyedrop medication for eye disease) with a date of 2/16/21 and Brimonidine 2% (eyedrops for eye disease) with date of 2/15/21; neither eyedrops indicated if it was the open date or the discard date. RN GG stated the eyedrops should be discarded in 42 days after they were open. 7) Resident 271's opened Lantus insulin had no date. Artificial tears (eyedrops for the dry eye) with date of 2/17/21, there was no indication if it was the open or discard date. 8) Resident 40's Cromolyn 4% (eyedrop medication for eye disease) with a date of 3/17/21, there was no indication if it was the open date or the discard date. 9) Resident 40's opened artificial tears had no date. 10) Six eyedrop medication bottles were stored together with one resident's breathing inhaler medication. RN GG stated the eye medication and breathing medication should not be stored together in the med cart. 11) Yellow, white, and grey substances were noted inside the med cart. 12) Opened Iron liquid medication had an orange sticky substance on the bottle. There was a pink sticky substance noted on one liquid medication bottle. During an interview with RN GG on 4/19/21 at 11 a.m., she stated nurse staff should keep the med cart clean, should check if medications were expired, and should store medications properly. 1b. During Med Cart 9 inspection with licensed vocational nurse V(LVN V) on 4/19/21 at 11:05 a.m., the following were observed: 1) Water pitcher had black substances with a label of 8pm/water. LVN V stated the kitchen should update the water to 4/19/21. 2) Pill crusher had sticky black, orange, and white substance. 3) One pink pill and one white pill spilled inside the med cart. 4) Red, orange, black, white, and grey substances, and a sticky pink substance were noted inside the med cart. Red sticky substance noted on an opened oral liquid bottle. 5) One bottle of insulin injection medication was stored with two bottles of oral medications. 6) Small pill cutter had white, black, and grey sticky substance. 7) Resident 72's insulin aspart with an open date of 3/18/21, Basaglar Kwikpen insulin with open date of 3/7/21, and opened Semglee insulin glargine pen had no date. LVN V stated the insulin was expired and should be discarded in 28 days after it was opened. LVN V further stated nurse staff should label the insulin with an open and discard date; Lexi-comp online (www.[NAME].com), a nationally recognized drug information resource, indicated a Novolog, Basaglar insulin pen, and Lantus Solostar pen could be used for up to 28 days at room temperature storage. Lexi-comp indicated to store intact bottles of latanoprost under refrigeration. Once opened, the container may be stored at room temperature up to 6 weeks. 1c. During Med Cart 6 inspection with LVN EE on 4/19/21 at 2:29 p.m., the following were observed: 1) Pill crusher had black, grey, and white substances. 2) Orange, black, grey, and white substances were noted at the storage tray that contained med cups, spoons, and hand sanitizer. 3) Sticky red liquid spilled inside med cart; black, grey, and white substances were noted inside the med cart. 4) One bottle of eyedrops were stored with three insulin bottles and four bottles of oral medications. LVN EE stated these medications should not be stored together. 5) Resident 86's insulin lispro was dated with 3/21/21 and LVN EE stated the resident's insulin was expired and should not be stored in the med cart. During an interview with LVN EE on 4/19/21 at 2:50 p.m., LVN EE stated nurse staff should keep the med cart clean, should check if medications were expired, and should store medications properly. 1d. During Med Cart 5 inspection with LVN ZZ on 4/19/21 at 3 p.m., an observed pill crusher had orange and white substances. Orange, grey, yellow, black and white substances were noted inside the med cart. During an interview with LVN ZZ on 4/19/21 at 3:20 p.m., she stated the nurse staff should keep the med cart clean. 1e. During Med Cart 3 inspection with LVN C on 4/20/21 at 10:14 a.m., the following were observed: 1) Two water pitchers had sticky black and grey substances. 2) Pill crusher had orange and black substances; 3) Inhaler medication, oral medication, and lubricating jelly medications were stored together inside the med cart. 4) Eyedrops were stored with lubrication jelly. 5) Nasal spray, inhalation solution, and oral medication were stored together. 6) Injection medication was stored with oral medication. 7) Hair and torn paper was observed inside the med cart. During an interview with LVN C on 4/20/21 at 10:30 a.m., she stated nurse staff should keep the med cart clean and should store the medication properly. 1f. During Med Cart 7 inspection with LVN T on 4/20/21 at 11:38 a.m., the following were: 1) Pill cutter and pill crusher had black, white, orange, and grey substance. 2) Orange, black, grey, and white substances were noted inside the med cart. 3) Resident 164's opened insulin injection had no date. During an interview with LVN T on 4/20/21 at 11:50 a.m., he stated nurse staff should keep the med cart clean. 1g. During Med Cart 1 inspection with LVN X on 4/20/21 at 1:31 p.m., the following were observed: 1) Pill crusher had sticky black, orange, grey, and white substances. Pill cutter had grey, white, and black substances. 2) Black, orange, yellow, grey, and white substance were noted inside the med cart. 3) Nasal spray medications were stored with oral medications During an interview with LVN X on 4/20/21 at 1:45 p.m., she stated nurse staff should keep the med cart clean and store the medications properly. 1h. During Med Cart 8 inspection with LVN T on 4/20/21 at 1:46 p.m., the following were observed: 1) Pill crusher had black, orange, grey, and white substances. 2) Black, orange, grey, and white substances were noted inside the med cart. 3) Suppository and transdermal med were stored together. 4) Injection medications and oral medications were stored together. During an interview with LVN T on 4/20/21 at 1:55 p.m., he stated nurse staff should keep the med cart clean and store the medications properly. 1i. During Med Cart 2 inspection with RN N on 4/21/21 at 12:42 p.m., the following were observed: 1) Pill crusher had black, white, and grey substances. 2) Moderate amount of black, white, grey, pink (sticky), and orange substances were noted inside the med cart. 3) One white tablet, one pink tablet, and one orange tablet of pills were spilled inside the med cart. 4) Hair and torn paper were noted inside the med cart. During an interview with RN N, he stated nurse staff should keep the med cart clean and store the medications properly. 1j. During Med Cart 4 inspection with LVN C on 4/21/21 at 1:14 p.m., the following were observed: 1) Pill crusher had black, white, and grey substance. 2) Four white pills were spilled inside the med cart. 3) White, black, grey, pink, and orange substances were noted inside the med cart. A white sticky liquid substance was noted on the oral liquid bottle. During an interview with LVN C on 4/21/21 at 1:20 p.m., she stated nurse staff should keep the med cart clean. 1k. During Med Cart 15 inspection with LVN EE on 4/21/21 at 1:48 p.m., the following were observed: 1) Injection medications and oral medications were stored together. 2) Pill crusher had black, grey, white, and orange substances. 3) Black, grey, white, and yellow substances were noted inside the med cart. 4) Pill cutter had yellow, black, grey, and white substances. During an interview with LVN EE on 4/21/21 at 2 p.m., she stated nurse staff should keep the med cart clean. 1l. During Med Cart 14 inspection with LVN EE on 4/21/21 at 2:07 p.m., the following were observed: 1) Suppository medications and oral medications were stored together. 2) Pill crusher and pill cutter had black, orange, yellow, grey, and white substances. 3) Black, orange, yellow, grey, and white substances were noted inside the med cart. During an interview with LVN EE on 4/21/21 at 2:15 p.m., she stated nurse staff should keep the med cart clean and store the medications properly. 1m. During Med Cart 11 inspection with LVN AAA on 4/21/21 at 2:18 p.m., the following were observed: 1) Pill crusher had black, orange, yellow, grey, and white substances. 2) Black, orange, yellow, grey, and white substances were noted inside the med cart. 3) [NAME] pills were spilled inside the med cart. During an interview with LVN AAA on 4/21/21 at 2:25 p.m., she stated nurse staff should keep the med cart clean. 1n. During Med Cart 12 inspection with LVN WW on 4/21/21 at 2:30 p.m., the following were observed: 1) Nasal spray medications were stored with oral medications. 2) Pill crusher and pill cutter had orange, yellow, black, grey, and white substances. 3) Black, orange, yellow, red, white, and grey substances were noted inside the med cart. During an interview with LVN WW on 4/21/21 at 2:38 p.m., she stated nurse staff should keep the med cart clean. 1o. During Med Cart 13 inspection with LVN EE on 4/21/21 at 2:05 p.m., the following were observed: 1) Injection medications and oral medications were stored together. 2) Pill crusher had black, grey, white, and orange substances. 3) Black, grey, white, and yellow substances were noted inside the med cart. 4) Pill cutter had yellow, black, grey, and white substances. Review of the facility's policy, Medication Storage, dated 09/18 indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations . Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories . Intravenously administered medications are stored separately from orally administered medications .Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock . All medication storage areas should be kept clean . 2a. During Med Room E inspection with the assistant director of nursing F (ADON F) on 4/19/21 at 4:51 p.m., the following were observed: 1) One backpack and one lunch bag belonging to facility staff were placed on the counter table inside the med room, one bag was hung on the door; there was an unlocked cabinet for staff items, staff's drinking bottles, snacks and paper tissues were stored in the cabinet. 2) Inside the medication refrigerator, two unopened suppository (medication for constipation, administer via anal area) boxes, two unopened insulin pens stored with one bottle of opened tuberculin (tuberculosis: TB: high contagious infection cause by the bacterium) TB skin test medication. 3) There was no evidence that the staff checked the refrigerator temperature for 1/17/21 at 6:00 p.m., 1/18/21 at 6:00 p.m., 1/24/21 at 6:00 p.m., 1/28/21 at 6:00 a.m., 1/29/21 at 6:00 a.m., 1/30/21 at 6:00 a.m., 4/10/21 at 6:00 a.m.; 4/11/21 at 6:00 a.m., and 4/17/21 at 6:00 p.m. During an interview with ADON F on 4/19/21 at 5 p.m., she stated staff's personal items should not be stored in the med room and staff should complete the refrigerator temperature check. 2b. During Med Room D inspection with RN Z on 4/20/21 at 1:55 p.m., it was observed the medication refrigerator's temperature was 56 Fahrenheit (F, temperature measure unit). Anti-anxiety injectable medication and insulin injection were stored inside the refrigerator. RN Z stated the temperature of the refrigerator should be 36 F to 46 F. 2c. During Med Room B inspection with ADON K on 4/20/21 at 2:38 p.m., it was observed the medication refrigerator temperature was 24 F. Insulin injection medication, eyedrops, and Tylenol suppository were stored inside the refrigerator. ADON K stated the refrigerator temperature should be 36 F to 46 F. Review facility's policy Medication Storage dated 09/18 indicated .Medications requiring refrigeration or temperature between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring .A daily recorded temperature should be documented and signed off .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The clinical record for Resident 4 was reviewed. He was admitted on [DATE], readmitted on [DATE] with diagnoses including hemiplegia (complete loss of strength or severe paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body, leg, arm or face) following cerebral infarction affecting right dominant side. His orders included Enteral feeding (nutrition taken through the tube directly to the stomach) with Suplena at 50 cc/hr for 20 hours via gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach). During observations on 4/19/21 at 10:24 a.m., and during the rest of the survey, Resident 4 was in a room with a contact precautions sign at the door. During an enteral feeding observation on 4/23/21 at 1:03 p.m., with LVN X for Resident 4, LVN X after preparing all her materials, rolled her cart to Resident 4's room. LVN X put on her PPE (gown and gloves) at the door, knocked, went to Resident 4, and explained to Resident 4 she was going to give his tube feeding. During the tube feeding process, LVN X was observed with her gloved hands placed her TF bag on the pole, took the syringe from its bag, filled syringe with air, and checked the GT placement of Resident 4 by auscultation with her stethoscope. After GT placement confirmation, LVN X removed the syringe, placed it on the table and stated, I will get some water. Without changing her gloves, LVN X with an empty cup proceeded to the bathroom, touched the bathroom sink knob to get some water from the bathroom sink faucet. LVN X returned to the bedside with a cup of water and without changing her gloves, proceeded to start touching the tube feeding bag, and looped tubing hanging on the pole for Resident 4. She was then stopped by surveyor and asked if she was going to change her gloves. LVN X immediately stopped and stated yeah and agreed she had touched the bathroom sink knob with the same gloves when she got some water. Since LVN X had no extra gloves and hand sanitizer with her in the room, LVN X proceeded to go to the door by her cart, removed her used PPE (gloves & gown) at the door, did hand hygiene (HH), put on a new gown and took a box of gloves and hand sanitizer to a table at the foot of Resident 4's bed. LVN X then proceeded by doing HH, applied new gloves and proceeded with the rest of the tube feeding process. Review of the Hand Hygiene Guidance from the Centers for Disease Control and Prevention (CDC) www.cdc.gov/handhygiene/providers/guideline.html indicated: Healthcare personnel use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, .after touching a patient or the patient's immediate environment, .after contact with blood, body fluids, or contaminated surfaces, .immediately after glove removal. Healthcare facilities should require personnel to perform hand hygiene in accordance with CDC recommendations .Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Review of CDC Guidelines on Glove Use indicated: Wear gloves according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, potentially contaminated skin or equipment could occur .Change gloves and perform hand hygiene during patient care, if gloves become damaged, moving from work on soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. 5a. During an observation on 4/20/21 at 7:49 a.m., social service O (SS O) was inside the room of Resident 73 and checked on Resident 73's call light. SS O proceeded to Resident 78's room and checked on Resident 78's call light. During these observations, SS O did not perform hand hygiene in between touching both residents' call lights. During a follow-up interview with SS O on 4/20/21, she acknowledged she should have performed hand hygiene but she forgot. 5b. Review of Resident 162's order summary report, dated 9/9/19, indicated an enteral feed order for Jevity 1.2 at 100 cc/hr. x 20 hours via GT pump, on at 12:00 noon and off at 8:00 a.m. or until dose completed. During observations on 4/19/21 at 9:58 a.m. and 1:19 p.m. respectively, Resident 162's tube feeding pole had a syringe with no label and the feeding tube attached to the feeding pump did not have a label. During an interview with ADON K on 4/20/21 at 8:32 a.m., ADON K confirmed the syringe and tube feeding should have been dated. During an observation on 4/21/21 at 10:52 a.m., certified nursing assistant R (CNA R) put on gloves and checked Resident 162's legs and arms. CNA R did not perform hand hygiene before applying gloves. During a follow-up interview with CNA R on 4/21/21, he acknowledged he forgot to do hand hygiene. During an observation and concurrent interview with RN S on 4/22/21 at 8:43 a.m., RN S put on gloves and checked on Resident 162's placement of hand roll and booties. RN S did not perform hand hygiene before applying gloves and she stated she forgot. During an interview with the DSD on 4/22/21 at 8:19 a.m., the DSD stated staff should perform hand hygiene before applying gloves. 4a. During an initial tour of the facility on 4/19/21 at 9:21 a.m., Residents 30, 33, and 75 surgical masks were observed on top of their bedside tables exposed and uncovered. During a concurrent interview with Resident 30, she stated she wore the surgical mask located on top of her bedside table when she left her room. During a concurrent interview with the assistant director of nursing K (ADON K) and LVN CC, they both confirmed the above observations. ADON K and LVN CC both stated the surgical masks should have been put inside a clean paper bag or plastic bag. During an interview with the DSD on 4/26/21 at 10:19 a.m., he acknowledged surgical masks for the above residents should have been kept inside a clean paper bag or should have been disposed by facility staff. Review of the Centers for Disease Control and Prevention (CDC) guidelines, dated 10/28/2020, indicated masks can be stored and reused later. Keep in dry, breathable bag (like paper or mesh fabric bag) to keep it clean between uses. Review of the California Department of Public Health All Facilities Letter (CDPH-AFL), dated 11/4/2020, indicated if the facility determines that PPE should be disposed of into the solid waste, used gloves, facemask, coveralls, etc. should be placed in a lined container, preferably with lid/cover. Tightly close off the bag before disposing the solid waste items into the solid waste bin. 4b. Review of Resident 16's clinical record indicated she had a diagnoses that included hypoxemia (low level of oxygen in the blood) and chronic obstructive pulmonary disease (COPD, diseases that cause airflow blockage and breathing problems). Her physician order indicated oxygen administration via nasal cannula (a lightweight plastic tube used to deliver oxygen to a patient) as needed to keep oxygen saturation (the amount of oxygen within a blood cells) above 92%. During an observation on 4/19/21 at 10:23 a.m., Resident 16's oxygen cannula tubing was observed exposed, uncovered, and wrapped around the small oxygen tank at the back of wheelchair. ADON K confirmed the observation and she stated the oxygen tubing should have been kept inside a clean plastic bag. During an interview with the DSD on 4/26/21 at 10:19 a.m., he acknowledged facility staff should have put the oxygen cannula tubing inside a clean plastic bag. 4c. Review of Resident 68's clinical record indicated he had a history of COVID-19 (a new strain of virus that can cause mild to severe respiratory illness) on 1/18/21. His physician order dated 2/11/21, indicated to screen for signs and symptoms of respiratory illness every shift such as elevated temperature 99 degrees Fahrenheit and above, dry cough, sore throat, congestion or runny nose, shortness of breath, fatigue/increased weakness, chills, generalized pains/aches, headache, loose watery stool, chest tightness, change of level of consciousness, loss of appetite, and loss of smell, if any notify the physician. Review of Resident 68's medication administration record (MAR) for 4/2021 indicated there were no licensed nurse written entries and chart codes for the screening for signs and symptoms of respiratory illness for day shifts on 4/3/21, 4/6 to 4/16, & 4/20-4/21; for afternoon shifts on 4/5 to 4/6, 4/11- 4/12, 4/14-4/16, & 4/19/21. During an interview with LVN C on 4/26/21 at 11:05 a.m., she confirmed there were no licensed nurse initials and chart code entries for the screening for signs and symptoms of respiratory illness on the above dates and shifts for Resident 68. She stated the licensed nurses should have documented their initials and chart codes in Resident 68's MAR as ordered by the physician. 3. During an interview with registered nurse Z (RN Z) on 4/19/21 at 1:42 p.m., she explained that GT syringes were supposed be changed every 24 hours. RN Z added that the nurses on the afternoon (PM) shift were responsible for changing the GT syringes. During an observation on 4/20/21 at 9:14 a.m., Resident 126 was lying in bed. His GT pump (device used to deliver formula to the resident through the GT) was next to his bed. There was a GT syringe on a table near Resident 126's bed that was dated 4/19/21. However, there was an outdated syringe, dated 4/18/21, on a table next to Resident 126's GT pump. During an observation and concurrent interview with the director of staff development (DSD) on 4/20/21 at 9:33 a.m., he looked at Resident 126's outdated GT syringe that was dated 4/18/21. The DSD acknowledged this syringe should have been discarded. Review of Resident 126's physician's order, dated 7/4/2020, indicated Change enteral [GT] syringe Q [every] 24hrs. Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Nurse staff did not follow infection control practices during medication passes (med pass, nurse administered the medications to residents per physician's order) for four of nine observed residents (Residents 114, 151, 30, and 72). 2. Housekeeping staff did not follow infection control practices when cleaning residents' rooms; 3. An outdated gastric tube (GT, tube inserted through the abdomen into the stomach to deliver nutrition, hydration and medication) syringe (tube with a nozzle and piston used to suck and eject liquid) was not discarded for Resident 126; 4. Surgical masks were not stored properly for Residents 30, 33 and 75; a nasal cannula was not stored properly for Resident 16; screening for signs and symptoms of respiratory illness was not consistently done for Resident 68; 5. Staff failed to perform hand hygiene after touching potentially contaminated objects for Resident 78; staff failed to label GT tubing and syringe for Resident 162; staff failed to perform hand hygiene before applying gloves for Resident 162; and 6. Staff did not change gloves and perform hand hygiene during tube feeding for Resident 4. These failures had the potential to result in cross-contamination and the spread of infections among the residents and staff. Findings: 1a. During an observation on 4/19/21 at 12:58 p.m., licensed vocational nurse T (LVN T) pushed a used blood pressure (BP) machine and BP cuff from Resident 114's room to the hallway and left the BP machine and cuff in front of Station D. LVN T stated he was looking for the disinfectant wipes to disinfect the used BP machine and cuff. After LVN T found the disinfectant, he sprayed bleach on the BP cuff and machine and wiped the bleach off right away with a paper towel. LVN T continued the process of administering medications to Resident 114. LVN T washed the medication tray (a tray to hold the medications during med pass) and did not disinfect the tray after med pass. During an interview with LVN T on 4/19/21 at 1:29 p.m., he stated he did not have any disinfectant in the medication cart and he had to push the used BP machine in the hallway and left it at the nursing station to look for the disinfectant. He stated he wiped off the disinfectant with a paper towel after he sprayed the bleach disinfectant on the BP machine and cuff. LVN T stated he should have left the bleach wet on the BP machine and cuff for two minutes (contact time) in order to kill the bacteria or virus. LVN T further stated he should have disinfected the med tray after med pass for Resident 114. 1b. During an observation on 4/19/21 at 4:31 p.m., LVN YY removed gloves after checking Resident 151's finger stick blood sugar (used a medical device to prick the resident's fingertip to get blood drops to check the blood sugar level). LVN YY did not perform hand hygiene and continue to wear a new pair of gloves to wipe the glucometer (medical device to check the resident's blood sugar level) and did not disinfect the medication tray, which was used to hold the glucometer in the resident's room during blood sugar check. LVN YY did not perform hand hygiene and continued to prepare insulin injection (medication for high blood sugar). During an observation on 4/19/21 at 4:38 p.m., LVN YY stored the prepared insulin injection medication next to the oral medications inside medication cart 6 (Med Cart 6) and looked for Resident 151 for the medication administration. At 4:39 p.m., LVN YY pushed Resident 151's wheelchair to the room and touched Resident 151. LVN YY did not perform hand hygiene and wore a pair of gloves to inject the insulin for Resident 151. LVN YY wore the same pair of gloves to continue to wipe the medication tray after injecting the insulin to Resident 151. During an interview with LVN YY on 4/19/21 at 4:53 p.m., she stated she forgot to perform hand hygiene after removing the gloves, before preparing the insulin, before administering insulin, and after touching the resident and the wheelchair. She stated she should not wear the same gloves to perform different tasks for Resident 151. LVN YY further stated she should not store the prepared insulin injection next to oral medications inside the medication cart. 1c. During a med pass observation in Resident 30's room on 4/20/21 at 9:34 a.m., LVN X touched Resident 30's bed remote control to raise up the bed for the oral medication administration. LVN X did not perform hand hygiene and continued to administer oral medication to Resident 30. Two oral tablets of the medication dropped on Resident 30's gown, LVN X put the two tablets of medication back to the medication cup and continued to administer these two medications with a spoon to Resident 30. During an interview with LVN X on 4/20/21 at 9:30 a.m., she stated she should have performed hand hygiene after she touched the resident's bed remote control and prior to administering medication to Resident 30. 1d. During an observation in Resident 72's room on 4/20/21 at 11:15 a.m. registered nurse GG (RN GG) disinfected Resident 72's fingertip with an alcohol pad before checking the finger stick blood sugar. RN GG fanned back and forth with her gloved hand over Resident 72's disinfected fingertip. At 11:20 a.m., RN GG fanned back and forth with her gloved hand over Resident 72's disinfected abdomen area prior to inject insulin. During an interview with RN GG on 4/20/21 at 11:30 a.m., she stated she should not fan with her gloved hand over Resident 72's disinfected fingertip and abdomen area during med pass. RN GG stated she should let the resident's disinfected areas to be air dried. Review of the facility's revised policy Handwashing/Hand Hygiene, dated August 2019, indicated All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents .Before preparing or handling medications .Before performing any non-surgical invasive procedures .After handling used dressings, contaminated equipment, etc.After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .After removing gloves . 2a. During an observation on 4/22/21 from 10:36 a.m. to 10:55 a.m., housekeeper XX (HS XX) performed the following tasks at Room D. Resident at C bed lied in bed with a tracheostomy tube (trach tube: medical procedure to insert a tube into the resident's windpipe via an opening in the neck for breathing): 1) HS XX removed gloves without hand hygiene and put wet floor sign at Room D; 2) Wore the same pair of gloves to wipe Resident B bed's bedside table, wiped Resident C bed's bedside rails, windows and blinds, removed dirty trash bags, put in new trash bags, cleaned the sink, brought a clean roll of paper towel in the room to wipe the sink and then brought the clean roll of paper towel back to the cleaning cart, swept and mopped the floor, picked the paper on the floor, and sprayed air fresher at the door of Room D. 2b. During an observation in Room E on 4/22/21 at 11:00 a.m., the Residents at beds A and B were lying in the beds with trach tubes. HS XX wore the same pair of gloves to put the wet floor sign in Room E, removed the dirty trash bag at A bed, sprayed bleach disinfectant in the trash can, cleaned the trash can with disinfectant wipes, put a new trash bag in the trash can, pushed the B bed's bedside table to the side to pick up the trash bag at B bed. During an observation in Room E on 4/22/21 at 11:05 a.m., HS XX wore the same pair gloves to wipe Resident A bed's bedside rail, wiped B bed's table, wiped A bed's bedside rail, wiped B bed's bedside rail and then B bed's nebulizer machine (the machine for the breathing medication), cleaned the sink, toilet bowel and seat, touched bathroom doorknob, swept and mopped the floor. 2c. During an interview with HS XX with the activity director's (AD) assistance for language translation on 4/22/21 at 11:19 a.m., HS acknowledged the above mentioned infection control practice concerns. HS XX stated she did not perform hand hygiene after removing gloves. She stated she wore the same pair of gloves for the above mentioned tasks in Rooms D and E. HS XX stated she did not know how long these disinfectants should remain wet (disinfectant contact time) on the surfaces during Room D and E cleaning tasks. She stated she was trained by another housekeeper to use one pair of gloves for each room's cleaning.