**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide feeding assistance at eye-level to one of nine residents (Resident 2) on 8/5/2025 during lunch.This deficient practice had the potential to negatively impact Resident 2's self-esteem and self-worth and increased the risk of aspiration (inhaling or drawing something into the lungs or airways that was not air), which could lead to serious complications (a medical problem that occurred during a disease) such as pneumonia (an infection/inflammation in the lungs).Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis [the loss or impairment of voluntary movement] of the arm, leg, and trunk on the same side of the body), epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness]), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skill for daily living was severely impaired. The MDS indicated Resident 2 was dependent (helper did all the effort) on staff with eating, oral hygiene, toileting hygiene, showering/ bathing self, personal hygiene, and bed-to-chair transferring. During a review of Resident 2's Physician Order Report for 7/2025, the Physician Order Report indicated to give Resident 2 Pureed (food consistency that did not require chewing, often for individuals with swallowing difficulties), Consistent Carbohydrate (CCHO, diet used for individuals with diabetes to manage blood sugar levels), NAS (No Added Salt) diet. During a concurrent observation and interview on 8/5/2025 at 12:38 p.m. with Certified Nursing Assistant (CNA) 4, in Resident 2's room, CNA 4 was sitting in front of Resident 2's Geri chair (specialized chair designed for individuals with limited mobility) while providing feeding assistance to Resident 2. Resident 2's Geri chair was not in an upright position and CNA 4 and Resident 2 were not at eye-level. CNA 4 stated she reclined the Geri chair to prevent Resident 2 from falling forward. During a concurrent observation and interview on 8/5/2025 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 2's room, CNA 4 was not feeding Resident 2 at eye-level. LVN 1 stated Resident 2 was lying on the Geri chair while eating and needed to be positioned more upright to prevent aspiration. LVN 1 stated the food could enter Resident 2's lungs and cause pneumonia. During an interview on 8/7/2025 at 1:02 p.m. with the Director of Nursing (DON), the DON stated residents needed to be positioned upright as much as they could tolerate to prevent aspiration and choking. The DON stated CNAs needed to be at eye-level with residents when providing feeding assistance to maintain residents' dignity. The DON stated that all staff in the facility were responsible for protecting residents' dignity. During a review of the facility's Job Description for CNAs, undated, the Job Description indicated, the CNAs' responsibilities included Provide care in a manner which protects the dignity, respect and self-esteem of the resident. During a review of the facility's Policy and Procedure (P&P) titled Assistance with meals, revised on 10/2009, the P&P indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals. During a review of the facility's P&P titled Quality of life-dignity, revised on 10/2009, the P&P indicated, Residents shall be treated with dignity and respect at all times. ‘Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.em and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool), accurately reflected the oral/dental status for one of six sampled residents (Resident 35). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) regarding Resident 35's oral/dental status and had the potential to negatively affect the resident care plan and delivery of necessary care and services.Findings:During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 35 was originally admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognition (the ability to think and process information) was impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 35 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 8/5/2025 at 8:35 a.m. with Resident 35 in Resident 35's room, Resident 35 was observed sitting on the bed, eating her breakfast. Resident 35 stated it was hard to chew the food because she did not have her natural teeth. During a concurrent interview and record review on 8/6/2025 at 8:10 a.m., with the Minimum Data Set Nurse (MDSN), Resident 35's MDS, dated [DATE], section oral/dental status was reviewed. The MDSN stated the MDS indicated Resident 35 was assessed as not having any oral and/or dental issues. The MDSN stated the coding was inaccurate as it did not reflect the resident's actual oral and/or dental status. The MDSN stated Resident 35 did not have her natural teeth therefore the MDS should have been coded to accurately reflect the resident's oral/dental status. The MDSN stated accurate MDS coding was important for quality measures, which affect quality of care monitoring, outcome measurement, resident perception, and care planning. The MDSN stated inaccuracy of the MDS had the potential to result in the resident's care needs and services not being met. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI), dated 4/30/2025, the P&P indicated the facility would ensure an accurate assessment of residents that would accurately reflect the resident's status. The P&P indicated a registered nurse would sign and certify the accuracy of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to address depression (a mental health disorder) diagnosis for one of six sampled residents (Resident 8). This deficient practice placed Resident 8 at risk of not receiving appropriate care and resident-centered interventions to meet the resident's needs and services related to depression.Findings:During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included depression, dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 8's cognition (the ability to think and process information) was impaired. The MDS indicated Resident 8 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 8/6/2025 at 8:50 a.m., with the Minimum Data Set Nurse (MDSN), Resident 8's MDS, dated [DATE], and care plans, dated 3/2025 through 8/2025, were reviewed. The MDS indicated Resident 8's depression was an active diagnosis. The care plans did not address Resident 8's depression diagnosis. The MDSN stated Resident 8's depression should have been addressed in the care plan with individualized, person-centered interventions to support the resident's emotional and mental health needs. The MDSN stated there were no care plan goals or interventions specific to depression. The MDSN stated the failure to address an identified active diagnosis in the resident's care plan placed Resident 8 at risk for not receiving the necessary care and services related to depression, which could potentially impact the resident's emotional well-being and quality of life. During an interview on 8/7/2025 at 8:58 a.m., with the Director of Nursing (DON), the DON stated care plans were developed to guide the care for each resident. The DON stated all active diagnoses, including depression, must be addressed in the resident's care plan with individualized goals and interventions. The DON stated Resident 8 should have had a care plan developed to address depression to ensure the resident was properly monitored for depression behaviors. The DON stated without a care plan, Resident 8 was at risk for undetected and/or worsening depression behaviors. During a review of the facility's policy and procedure (P&P) titled Care Plans-Comprehensive, revised 12/2010, the P&P indicated the facility would develop and implement an individualized comprehensive care plan that includes measurable objectives to meet each resident's medical, nursing, mental and psychological needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of care for two of two sampled residents (Resident 38 and Resident 40), when Licensed Vocational Nurse (LVN) 2 administered antihypertensive medications (used to treat high blood pressure using blood pressure readings obtained two hours prior to administration. This deficient practice increased the risk for hypotension (low blood pressure), dizziness, and falls for Residents 38 and 40. Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE]. Resident 38's diagnoses included hypertension (HTN, high blood pressure), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/2025, the MDS indicated Resident 38's cognitive skills (ability to think, remember and reason) for daily decision making was moderately impaired. The MDS indicated Resident 38 was independent with walking and transferring from bed to chair. The MDS indicated Resident 38 required setup assistance from staff with eating, oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 38 required partial assistance (helper did less than half the effort) with showering/ bathing. During a review of Resident 38's Physician Order Report for 7/2025, the Physician Order Report indicated to start lisinopril (medication used to treat HTN) 40 milligrams (mg- metric unit of measurement) daily on 6/20/2025. The Physician Order Report indicated to hold lisinopril if Resident 38's systolic blood pressure (SBP- the pressure of blood against artery walls when the heart contracted and pumped blood out) was less than 110 millimeters of mercury (mmHg- the unit used to measure blood pressure) or if the resident's heart rate was less than 60 beats per minute (BPM). During a medication pass observation on 8/5/2025 at 9:28 a.m. with Licensed Vocational Nurse (LVN) 2, observed LVN 2 administer lisinopril 40 mg without checking Resident 38's blood pressure. LVN 2 stated Resident 38's SBP was 150 mmHg at 7:36 am. 2. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included HTN, dizziness and giddiness, and epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 40 was independent with walking and transferring from bed to chair. The MDS indicated Resident 40 required setup assistance from staff with eating, oral hygiene, toileting hygiene. The MDS indicated Resident 40 required supervision from staff with personal hygiene. The MDS indicated Resident 40 required partial assistance (helper did less than half the effort) with showering/ bathing. During a review of Resident 40's History and Physical (H&P), dated 7/18/2024, the H&P indicated Resident 40 had the capacity to understand and make decisions. During a review of Resident 40's Physician Order Report for 7/2025, the Physician Order Report indicated to start amlodipine (medication used to treat HTN) 10 mg daily on 5/29/2025. The Physician Order Report indicated to hold amlodipine if Resident 40's SBP was less than 110 mmHg. The Physician Order Report indicated to start metoprolol (medication used to treat HTN) 50 mg twice a day on 2/16/2024. The Physician Order Report indicated to hold metoprolol if Resident 40's SBP was less than 110 mmHg and/or heart rate was less than 60 beats per minute (BPM). During a medication pass observation on 8/5/2025 at 9:37 a.m. with LVN 2, observed LVN 2 administered amlodipine 10 mg and metoprolol 50 mg to Resident 40 without checking Resident 40's blood pressure. LVN 2 stated Resident 40's SBP was 150 mmHg with heart rate of 77 BPM at 7:36 am. During an interview on 8/5/2025 at 2:01 p.m. with LVN 2, LVN 2 stated she should have taken Resident 38 and 40's blood pressure within an hour of the medication administration time because the blood pressure could fluctuate. LVN 2 stated the risk of administered antihypertensive medications using blood pressure readings obtained two hours prior to administration was hypotension (low blood pressure). LVN 2 stated the residents might have dizziness, weakness, paleness, and fainting spells. During an interview on 8/7/2025 at 10:27 a.m. with the Director of Nursing (DON), the DON stated the nurse should have checked Resident 38 and 40's vital signs (measurable physiological indicators that reflected a person's basic bodily functions and overall health status) prior to medication administration within a reasonable time frame of 15-30 minutes. The DON stated it was common nursing practice because the residents' blood pressure fluctuates and checking vital signs within 15-30 minutes allowed the nurses to make better nursing judgment on antihypertensive medication administration. The DON stated it was not acceptable to check vital signs two hours prior to the antihypertensive medication administration. The DON stated the risk was hypotension, dizziness, fainting, and weakness. The DON stated the practice of checking the resident's blood pressure two hours prior to medication administration did not meet the professional standard of nursing practice. During a review of the facility's Job Description for Medication Nurse, undated, the Job Description indicated the medication nurse's responsibilities included maintaining an acceptable standard of nursing practice. During a review of the facility's policy and procedure (P&P), titled Quality of Care, dated 4/30/2025, the P&P indicated the facility must ensure that residents receive treatment and care in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary gastrostomy tube (GT- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) services for one of nine residents (Resident 47) when, Licensed Vocational Nurse (LVN) 1 did not flush the GT line with the prescribed amount of water before and after medication administration. This deficient practice had the potential to result in Resident 47's GT clogging (blocked), which may lead to Residents 47 not receiving the full dose of medication or feeding as prescribed.Findings: During a review of Resident 47's admission Record, the admission record indicated Resident 47 was originally admitted to the facility on [DATE]. Resident 47's diagnoses included gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/2025, the MDS indicated Resident 47's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 47 was dependent (helper did all the effort) on staff for self-care activities and mobility. During a review of Resident 47's History and Physical (H&P), dated 6/13/2025, the H&P indicated Resident 47 did not have the capacity to understand and make decisions. During a review of Resident 47's care plan titled Altered Nutritional Intake, revised 7/2025, the care plan goal indicated Resident 47 would have adequate nutritional intake with no evidence of weight loss and dehydration daily. The care plan interventions indicated nurses were to provide fluids via GT as ordered. During a medication pass observation on 8/5/2025 at 8:48 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 47's room, LVN 1 flushed 30 milliliters (mL- a unit of volume in the metric system) of water that flowed through Resident 47's GT by gravity (no pushing). LVN 1 then administered one crushed medication and three liquid medications to Resident 47 via the GT. Once complete, LVN 1 flushed another 30 ml of water. During a concurrent interview and record review on 8/5/2025 at 2:26 p.m. with LVN 1, Resident 47's Physician Order Report for 7/2025 was reviewed. LVN 1 stated Resident 47's Physician Order Report indicated to flush the GT with 50 ml of water before and after medication administration. LVN 1 stated she flushed 30 ml of water instead of 50 ml as ordered because she was nervous. LVN 1 stated the licensed nurse was responsible for checking the physician orders before flushing to make sure of the correct amount. LVN 1 stated not flushing the prescribed amount increased the risks of dehydration and the potential of a clogged GT. During an interview on 8/7/2025 at 10:15 a.m. with the Director of Nursing (DON), the DON stated it was important to follow the physician orders. The DON stated the purpose of flushing water before and after medication administration was to prevent the GT from clogging and not working properly. The DON stated when the GT was not working, it affected the GT patency and the resident's ability to receive the prescribed feeding and/or medications. The DON stated even though the facility policy indicated to flush 30 ml of water before and after the medication administration, the nurse needed to follow the current physician order. During a review of the facility's Job Description for Medication Nurse, undated, the Job Description indicated the medication nurse's responsibilities included performing treatments according to the physician's orders accurately and maintaining an acceptable standard of nursing practice. During a review of the facility's Policy and Procedure (P&P), titled Comprehensive resident centered care plan, undated, the P&P indicated it is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare and serve food to meet individual needs for two out of ten sampled residents (Resident 27 and 45) by failing to ensure Residents 27 and 45 received the correct food texture. This deficient practice did not meet Residents' 27 and 45 individual needs and potentially placed Residents 27 and 45 at risk for choking.Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 27's diagnoses included diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 27's History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 27 was confused. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 27's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 27 required moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 27 was dependent on staff for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. The MDS indicated Resident 27 required a mechanically altered diet (modifying the texture of food to make it easier to chew and swallow). During a review of Resident 27's Care Plan for Nutrition related to swallowing and chewing deficit, dated 8/2025, the care plan indicated the goal was for Resident 27 not to have signs of aspiration (the inhalation of food, fluid, or other foreign material into the trachea and lungs) or choking. The care plan interventions indicated to provide a puree texture diet (foods that are blended, mashed, or whipped into a smooth, pudding-like consistency, free of lumps and requiring no chewing) as ordered. During an interview on 8/6/2025 at 8:04 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 27 was to receive a puree diet. CNA 3 stated a pureed diet was not regular textured food, it was food in a liquid consistency (thickness or texture). CNA 3 stated it was important to serve the correct food texture to residents for their safety. CNA 3 stated Resident 27 could potentially choke when eating if the food was not pureed. During a concurrent observation and interview on 8/6/2025 at 8:12 a.m. with CNA 4, observed Resident 27's meal tray. The meal tray consisted of scrambled eggs and pieces of mushy (soft) bread. CNA 4 stated Resident 27's eggs were scrambled. CNA 4 stated puree food was a smooth consistency where residents did not have to chew. During an interview on 8/6/202 at 10:38 a.m. with the Dietary Supervisor (DS), the DS stated during the meal tray line, the dietary staff must check if the correct food and texture was served to the residents. The DS stated on 8/6/2025, Resident 27 did not receive pureed eggs and bread. The DS stated Resident 27 had an order for a puree diet but was not served a puree diet for breakfast. The DS stated it was important for residents to receive their food in a pureed texture because the residents did not have teeth or had swallowing problems. During a concurrent observation and interview on 8/7/2025 at 7:42 a.m. with CNA 4, Resident 27's meal tray was observed. The meal tray consisted of ground (food that has been finely chopped or minced into small pieces) scrambled eggs and bread. CNA 4 stated Resident 27's eggs were grounded to small pieces. CNA 4 stated Resident 27's food always had the same texture and was never pureed. CNA 4 stated she added milk to Resident 27's food to make the food more liquidy (food that has been processed into a liquid or near-liquid state). CNA 4 stated she smashed up the food with a spoon to make it softer to feed Resident 27. CNA 4 stated food should come out of the kitchen in a puree texture in order to safely feed Resident 27. During an interview on 8/7/2025 at 11:23 a.m. with the DS, the DS stated Resident 27 was ordered a puree diet. The DS stated pureed food was food cut in pieces and somewhat liquified. the DS stated residents with swallowing problems,chewing problems and/or missing teeth required a pureed diet so they could safely eat. The DS stated if residents did not receive pureed food they could potentially choke. 2. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 45's diagnoses included dysphagia (difficulty swallowing) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 45's H&P dated 7/18/2025, the H&P indicated Resident 45 did not have the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45's cognitive skills for daily decision making was intact. The MDS indicated Resident 45 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 45 required a mechanically altered diet. During a review of Resident 45's Physician Order report, dated 4/30/2024, the order report indicated Resident 45 had an order for a puree diet. During a review of Resident 45's Care Plan for Nutrition related to swallowing and chewing deficit, dated 8/2025, the care plan indicated the goal was for Resident 45 to not have signs of aspiration or choking. The care plan indicated the interventions were to provide a puree texture diet as ordered. During an interview on 8/6/2025 at 8:04 a.m. with CNA 3, CNA 3 stated Resident 45 was to receive a puree diet. CNA 3 stated Resident 45 could potentially choke when eating if the meal was not pureed. During a concurrent observation and interview on 8/6/2025 at 8:12 a.m. with CNA 4, Resident 45's meal tray was observed. The meal tray consisted of chopped scrambled eggs and bread. CNA 4 stated Resident 45's eggs were chopped into small pieces. CNA 4 stated pureed food was a smooth consistency where residents did not have to chew. During an interview on 8/6/202 at 10:38 a.m. with the DS, the DS stated on 8/6/2025, Resident 45 did not receive pureed eggs and bread. The DS stated Resident 45 had an order for a puree diet but did not receive a puree diet as ordered for breakfast. The DS stated it was important for residents to receive food in puree texture because they did not have teeth or had swallowing problems. During a concurrent observation and interview on 8/7/2025 at 7:50 a.m. with CNA 2, Resident 45's meal tray was observed. The meal tray consisted of ground scrambled eggs and bread. CNA 2 stated Resident 45's food was not pureed because it was too thick. CNA 2 stated it was not safe to give this texture of food to Resident 45 because she could choke. During an interview on 8/7/2025 at 11:23 a.m. with the DS, The DS stated Resident 45's food looked pureed in the kitchen and did not know why it changed when it was delivered to the resident. The DS stated she did not know what happened to the food texture and maybe needed to add more liquid to the food. The DS stated she did not know CNAs added milk to the ground food to make it smoother for residents to easily swallow. The DS stated CNAs should not have to do that, it should come out of the kitchen ready to eat. During an interview on 8/7/2025 at 12:48 p.m. with the Director of Nursing (DON), the DON stated all licensed nurses must check meal trays prior to giving them to residents. The DON stated licensed nurse check the dietary card and compare them to what was served to residents. The DON stated licensed nurses checked the diet being served, the texture of food, and resident dislikes. The DON stated pureed food was blended food. The DON stated blended food was food that was easy to ingest by a resident that had teeth problems or swallowing problems. The DON stated it was important to provide the prescribed diet to residents to prevent swallowing problems and risk for aspiration. During an interview on 8/7/2025 at 1:25 p.m. with the Administrator (Admin), the Admin stated it was important not to serve residents food that was not safe for them. The Admin stated residents could potentially choke when chewing or swallowing food that was not pureed. During a review of the facility's Policy and Procedure (P&P) titled Regular Pureed Diet, dated 2023, the P&P stated a pureed diet was a regular diet that was designed for residents who have difficulty in chewing and/or swallowing. The P&P indicated the texture of the food should be of a smooth and moist consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare and serve food to meet the individualized needs for three out of ten sampled residents (Resident 20, Resident 27, and Resident 45) by failing to: 1. Honor Resident 20's food preferences. 2. Serve Residents 27 and 45 the same food items as other residents. These deficient practices did not meet Resident 20, 27, and 45's individual needs and had the potential to impact the resident's nutritional intake. Findings: 1. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnoses included muscle wasting (the loss or decrease in muscle mass), atrophy (wasting away or decrease in the size of a body part), and scoliosis (abnormal sideways curvature of the spine). During a review of Resident 20's History and Physical (H&P) dated 7/14/2025, the H&P indicated Resident 20 was oriented to person, place and time. The H&P indicated Resident 20's thought process was coherent and insight was good. The H&P indicated Resident 20's higher cognitive (ability to think and reason) functions were intact. During a review of Resident 20's Minimum Data Set ([MDS] a resident assessment tool), the MDS indicated Resident 20's cognitive skills for daily decision making was intact. The MDS indicated Resident 20 was dependent (helper does all of the effort) on staff for toileting hygiene, lower body dressing, and shower/bathing. The MDS indicated Resident 20 required maximal assistance (helper does more than half) for personal hygiene and upper body dressing. The MDS indicated Resident 20 required assistance for eating and oral hygiene. The MDS indicated Resident 20 required a mechanically altered diet (modifying the texture of food to make it easier to chew and swallow). During an observation on 8/6/2025 at 7:59 a.m., Resident 20's meal tray was observed. The meal tray consisted of bacon. The meal tray was uneaten. During a concurrent observation and interview on 8/6/2025 at 8:12 a.m. with Certified Nursing Assistant (CNA) 4, Resident 20's dietary card indicated Resident 20 was not to be served meat. CNA 4 stated Resident 20 usually received meat for breakfast. CNA 4 stated she did not know why Resident 20 was not supposed to receive meat. During an interview on 8/6/202 at 10:38 a.m. with the Dietary Supervisor (DS), the DS stated a dietary card indicated residents' diet, food texture, likes and dislikes. The DS stated if residents received food they did not like, that was not following the resident's food preferences. The DS stated if a food dislike was written on the resident's dietary card, the resident should not receive that food item. The DS stated she was not aware Resident 20 received bacon that morning (8/6/2025). The DS stated it was not appropriate for Resident 20 to receive bacon because she did not like meat. During an interview on 8/6/2025 at 12:47 p.m. with Resident 20, Resident 20 stated she did not eat her breakfast because it had bacon. Resident 20 stated she told dietary staff she did not want any meat as part of her meals but the staff continued to serve her meat. Resident 20 stated when she received meat, she did not eat her meal. Resident 20 stated she did not want meat for her meals because she could not chew the meat. Resident 20 stated she had broken and missing teeth and it made it hard for her to chew. Resident 20 stated she did not want her teeth to be pulled and did not want to wear dentures. 2. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 27's diagnoses included diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 27's H&P dated 6/23/2025, the H&P indicated Resident 27 was confused. During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 27 required moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 27 was dependent on staff for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. The MDS indicated Resident 27 required a mechanically altered diet. During observations on 8/6/2025 at 7:49 a.m., and 8/7/2025 at 7:42 a.m., Resident 27's meal trays were observed. The meal trays consisted of scrambled eggs and bread. During an interview on 8/7/2025 at 11:23 a.m. with the DS, the DS stated all residents were served a vegetable omelet for breakfast (8/7/2025). The DS stated all residents received the same food unless a resident requested something different. The DS stated residents on a puree diet (foods that are blended, mashed, or whipped into a smooth, pudding-like consistency, free of lumps and requiring no chewing) should have also received a vegetable omelet. The DS stated she did not know Resident 27 did not receive the same food as the other residents. The DS stated Resident 27 should have received the same food as the other residents. 3. During observations on 8/6/2025 at 7:54 a.m., and 8/7/2025 at 7:50 a.m., Resident 45's meal trays were observed. The meal trays consisted of scrambled eggs and bread. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 45's diagnoses included dysphagia (difficulty swallowing) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 45's H&P dated 7/18/2025, the H&P indicated Resident 45 did not have the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45's cognitive skills for daily decision making was intact. The MDS indicated Resident 45 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 45 required a mechanically altered diet. During a review of the facility's document titled Breakfast Menu, dated 8/6/2025, the menu indicated on 8/6/2025, the facility was to serve bacon and egg scramble. During a review of the facility's document titled Cooks Spreadsheet, dated 8/6/2025, the spreadsheet indicated on 8/6/2025, the facility was to serve bacon and egg scramble to residents on a puree diet. During a review of the facility's document titled Breakfast Menu, dated 8/7/2025, the menu indicated on 8/7/2025, the facility was to serve baked vegetable omelets. During a review of the facility's document titled Cooks Spreadsheet, dated 8/7/2025, the spreadsheet indicated on 8/7/2025, the facility was to serve baked vegetable omelets to residents on puree diets. During an interview on 8/7/2025 at 11:23 a.m. with the DS, the DS stated she did know Resident 45 did not receive the same food as the other residents. The DS stated all residents must receive the same food to honor the residents' dignity. The DS stated she was responsible for checking what the cooks were cooking and preparing but she did not notice the eggs did not have vegetables. During an interview on 8/7/2025 at 12:48 p.m. with the Director of Nursing (DON), the DON stated all residents must receive food according to their preferences. The DON stated residents had the right to choose what to eat or not to eat. The DON stated all residents must receive the same food and no resident should be treated differently. During an interview on 8/7/2025 at 1:25 p.m. with the Administrator (Admin), the Admin stated all residents should receive the same food. The Admin stated he did not understand why the dietary staff did not provide the same food for all residents. The Admin stated cooks had to pull some food to the side and blend it to make it puree and serve it to the resident. The Admin stated all resident food preferences should be honored. The Admin stated residents should not receive food they do not like. During a review of the facility's Policy and Procedure (P&P) titled Food Preferences, dated 2023, the P&P stated the facility would adhere to residents' food preferences. The P&P indicated substitutes for all disliked foods would be given from the appropriate food group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and properly store food brought by family/ visitors for one out of nine residents (Resident 44), in accordance with the facility's Policy and Procedure (P&P) titled, Foods brought in by family/ visitors. This deficient practice had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and also lead to other serious medical complications and hospitalization for Resident 44. Findings:During a review of Resident 44's admission Record, the admission record indicated Resident 44 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 44's diagnoses included anemia (a condition where the body did not have enough healthy red blood cells) and ulcerative pancolitis (a chronic inflammatory bowel disease). During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 44's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 44 required setup assistance from staff with eating. The MDS indicated Resident 44 required supervision from staff with oral hygiene, toileting hygiene, personal hygiene, bed-to-chair transferring, and walking. The MDS indicated Resident 44 required maximal assistance (helper did more than half the effort) from staff with showering/ bathing. During a concurrent observation and interview on 8/4/2025 at 10:40 a.m., in Resident 44's room, observed an unlabeled, opened ketchup bottle at the bedside. The ketchup bottle indicated Refrigerate after opening. Resident stated she opened the ketchup bottle a few weeks ago and puts ketchup on everything. During a concurrent observations and interview on 8/5/2025 at 8:11 a.m. and 8/6/2025 at 8:23 a.m., with Resident 44, in Resident 44's room, observed an unlabeled, opened ketchup bottle, and an unlabeled, opened jar of red raspberry preserves at the bedside. Both food labels indicated to Refrigerate after opening. Resident 44 stated the jar of red raspberry preserves was brought in by her family member. Resident 44 stated she opened the jar a few weeks ago. Resident 44 stated the staff did not offer to store the opened items in the refrigerator. During a concurrent interview and pictures review on 8/6/2025 at 8:26 a.m. with Certified Nursing Assistant (CNA) 1, pictures of Resident 44's unlabeled and opened ketchup bottle and jar of red raspberry preserves, dated 8/6/2025 at 8:23 a.m., were reviewed. CNA 1 stated the pictures showed the unlabeled and opened ketchup bottle and jar of red raspberry preserves at Resident 44's bedside. CNA 1 stated both food items indicated to Refrigerate after opening. CNA 1 stated the charge nurse should label the date the items were received, the resident's name, and room number. CNA 1 stated the purpose of labeling outside food was to identify the ownership and to indicate expiration dates for items that were only to be kept for a limited number of days. CNA 1 stated Resident 44's outside food needed to be stored in the refrigerator to prevent Resident 44 from getting sick. CNA 1 stated the inappropriate food storage could cause foodborne illness among residents. During a concurrent interview and pictures review on 8/6/2025 at 8:38 a.m. with the Infection Preventionist Nurse (IPN), pictures of Resident 44's unlabeled and opened ketchup bottle and jar of red raspberry preserves, dated 8/4/2025 at 10:40 a.m., 8/5/2025 at 8:11 a.m., and 8/6/2025 at 8:23 a.m., were reviewed. The IPN stated the pictures showed the unlabeled and opened ketchup bottle and jar of red raspberry preserves at Resident 44's bedside. The IPN stated both food items indicated to Refrigerate after opening. The IPN stated the items should be stored in the refrigerator if the label indicated so, to prevent food from spoiling. The IPN stated the residents might get sick from eating the spoiled food. The IPN stated the residents might experience signs and symptoms such as diarrhea, abdominal pain, and nausea/vomiting. The IPN stated staff who had the most contact with the residents should ensure the outside food was stored properly. During a review of the facility's P&P titled, Foods brought in by family/ visitors, revised on 12/2008, the P&P indicated Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the 'use by' date. The nursing staff is responsible for discarding perishable foods on or before the ‘use by' date.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed ten hours of continuing Infection Prevention and Control education on an annual basis. This failure had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control practices.Findings:During an interview on 8/6/2025 at 10:30 a.m., with the facility's Infection Preventionist (IP), the IP stated he was not able to provide documentation indicating the completion of ten hours of continuing education in infection prevention and control for 2024. The IP stated he completed continuing education hours when he renewed his nursing license, however, those hours were not obtained in 2024. The IP stated it was his responsibility to complete ten hours of infection prevention and control education annually to ensure he was aware of any new guidelines or studies that were released and to be up to date with current infection prevention and control practices. During an interview on 8/7/2025 at 8:58 a.m., with the Director of Nursing (DON), the DON stated the IP was responsible for educating staff on current infection prevention and control practices. The DON stated for the IP to effectively educate staff, he must remain current on infection prevention and control updates. The DON stated that failure to complete the required annual ten hours of training could result in the IP missing critical changes in infection control practices, which could lead to inconsistent implementation of current infection prevention measures.A review of the California Department of Public Health All Facilities Letter (AFL), dated 11/4/2020, the AFL indicated, The IP should complete 10 hours of continuing education in the field of [Infection Prevention and Control] on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive care plan (a detailed, resident-centered document outlining all aspects of a person's healthcare needs, including medical, social, and emotional support, and was designed to promote overall well-being) for three out of three sampled residents (Residents 2, 3, and 7) when:1. Resident 2's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) care plan did not reflect the active insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) orders. 2. Resident 3's dementia (a progressive state of decline in mental abilities) care plan did not reflect the active namenda (a medication used to treat dementia) order. Resident 3's antidepressant (medications used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable]) care plan did not reflect the active lexapro (a medication used to treat depression) order.3. The facility did not revise Resident 7's care plan for risk for spontaneous fracture ([pathological fracture]a bone fracture that occurs with minimal or no trauma, often due to underlying bone weakness). These deficient practices increased the potential for staff to be unaware of the interventions required for Residents 2,3, and 7 to maintain their highest practicable physical, mental, and psychosocial well-beings. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included DM and long-term use of insulin. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skill for daily living was severely impaired. The MDS indicated Resident 2 was dependent (helper did all the effort) on staff with eating, oral hygiene, toileting hygiene, showering/ bathing self, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 received insulin daily. During a review of Resident 2's Physician Order Report for 7/2025, the Physician Order Report indicated to start insulin aspart (a fast-acting insulin used to control blood sugar levels for diabetic residents) per sliding scale (a method of administering insulin based on a resident's current blood sugar level) subcutaneously (beneath the skin) before meals on 4/21/2025. The Physician Order Report further indicated to start insulin glargine (a long-acting insulin used to control blood sugar levels for diabetic residents) 30 units subcutaneously daily on 6/25/2025. During a concurrent interview and record review on 8/6/2025 at 12:51 p.m. with the MDS Nurse (MDSN), Resident 2's care plan for diabetes, revised on 6/2025, was reviewed. The MDSN stated the care plan interventions did not reflect the current insulin orders and should reflect. The MDSN stated it would potentially delay the necessary care. The MDSN stated the care plan was a guideline for staff to safely provide resident care. The MDSN stated the care plan should be specific and resident-centered, so the staff would know how to care for the residents. The MDSN stated all licensed nurses could update and revise the care plans when they received the new medication orders and as needed. During a concurrent interview and record review on 8/7/2025 at 9:46 a.m. with the Director of Nursing (DON), Resident 2's care plan for diabetes, revised on 6/2025, was reviewed. The DON stated the care plan intervention, Administer medications as ordered, was too generic. The DON stated the care plan interventions should be resident-centered and individualized because diabetic residents did not get the same medications. The DON stated the MDSN updated the residents' care plans quarterly and as needed. The DON stated the MDSN should have caught it during the care plan reviewed on 6/2025. The DON stated the purpose of the care plan was to show a complete picture of a resident, to address the potential and/or actual problems, to prevent any declines, and to maintain residents' highest practicable well-being. The DON stated residents' medications should be reflected in the care plans to show the staff the plan of care. The DON stated it was better practice for the licensed nurses to update the care plan once they received the order, so the care plan could be more up to date. b. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of dementia and depression. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skill for daily living was severely impaired. The MDS indicated Resident 3 was independent (resident completed the activity by herself with no assistance from a helper) with toileting hygiene and bed-to-chair transferring. The MDS indicated Resident 3 required setup assistance from staff with eating. The MDS indicated Resident 3 required supervision from staff with oral and personal hygiene. The MDS indicated Resident 3 required moderate assistance (helper did less than half the effort) from staff with showering/bathing self. During a review of Resident 3's History and Physical (H&P,) dated 11/8/2024, the H&P indicated Resident3 did not have the capacity to understand and make decisions. During a review of Resident 3's Physician Order Report, dated 7/12/2025-8/12/2025, the Physician Order Report indicated to start namenda 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day on 1/20/2025. The Physician Order Report indicated to discontinue sertraline (medication used to treat depression) 50 mg by mouth daily on 7/17/2025. The Physician Order Report further indicated to start lexapro 20 mg by mouth daily on 7/17/2025. During a concurrent interview and record review on 8/6/2025 at 12:51 p.m. with the MDSN, Resident 3's care plans for dementia and antidepressant, revised on 5/2025, were reviewed. The MDSN stated the care plans interventions did not reflect the current namenda and lexapro order and should reflect them. The MDSN stated she reviewed the care plan on 5/2025 and did not know why she did not include namenda in the care plan. The MDSN stated the nurses would not know if Resident 3 was taking any medications for dementia if she (Resident 3) was acting out (behaved badly, especially when unhappy or stressed). The MDSN stated the antidepressant care plan indicated Resident 3 was taking sertraline and should have been updated to lexapro. The MDSN stated she reviewed the residents' care plans every 90 days. The MDSN stated the nurse who received the order should update the care plan. The MDSN stated it was important to update the residents' care plans for quality of care and quality of life. c. A review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 7's diagnosis included osteoporosis (weak and brittle bones due to lack of calcium [mineral needed for healthy teeth, bones, and other body tissues] and Vitamin D [nutrient that the body needs in small amounts to function and stay healthy]) and an artificial opening of digestive tract (surgically created opening that connects the digestive system to the outside of the body). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 7 was dependent on staff for all activities of daily living. The MDS indicated Resident 7 nutritional approach was a feeding tube (a flexible tube, inserted into the stomach or small intestine to deliver nutrition and fluids). The MDS did not indicate Resident 7's weight. During a review of Resident 7's H&P dated 1/15/2025, the H&P indicated Resident 7's judgement/insight was unable to be determined due to Resident 7 being nonverbal at baseline. During a review of Resident 7's Monthly Record of Vital Signs and Weights, dated 1/2025 - 7/2025, no weight was documented. During a review of Resident 7's Care Plan for Altered Nutrition related to gastric feeding, dated 7/2025, the care plans goals for Resident 7 was for Resident 7 to have adequate nutritional intake with no evidence of weight loss. The care plans intervention was to monitor Resident 7's weight every month and to notify doctor for weight loss of 3% or more. During a review of Resident 7's Care Plan for risk for spontaneous fracture ([pathological fracture]a bone fracture that occurs with minimal or no trauma, often due to underlying bone weakness) secondary fracture to osteoporosis, dated 7/2025, the care plan did not indicate not weighing Resident 7. The care plan did not indicate measuring upper arm circumference (the distance around a circle) instead of monthly weights for Resident 7. During an interview on 8/7/2025 at 12:33 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents must be weighed to determine if residents are gaining or losing weight. LVN 1 stated if residents do not get weighed staff would not know if treatments worked or not know if patient was declining. LVN 1 stated care plan interventions must be followed for all residents for resident's better outcome. LVN 1 stated she did not know Resident 7 did not have a documented weight on her medical record. LVN 1 stated she did not know Resident 7's weight. During an interview on 8/7/2025 at 12:51 p.m. with the DON, the DON stated a care plan included problems that were identified, set goals, and interventions. The DON stated interventions were developed to help residents meet their goals. The DON stated if interventions were not followed residents would not meet their goals. The DON stated if residents do not get weighed staff would not know if the resident was gaining weight due to water retention or if a resident lost weight because they were not eating. The DON stated Resident 7 did not get weighed but instead got her arm circumference measured. The DON stated they do not weigh Resident 7 because she had a history of osteoporosis with pathological fractures. The DON stated the last time Resident 7 got weighed they used a Hoyer lift (mechanical device to safely transfer individuals with limited mobility from one place to another) and Resident 7 sustained a right shoulder pathological fracture due to her position while on the lift. The DON stated staff measured Resident 7's arm to check if Resident 7 lost or gained weight. The DON stated measuring residents' arm was not in their facility policy & procedure. The DON stated Resident 7's care plan should indicate to measure residents' arm instead of checking Resident 7's weight. During a review of the facility's Job Description for Medication Nurse, undated, the Job Description indicated, the medication nurse's responsibilities included assisting with the care plans. During a review of the facility's Job Description for MDS Coordinator (MDSN), undated, the Job Description indicated, the MDSN monitor all of the facility's resident care plan to ensure they were completed appropriately and met standards of practices and clinical guidelines. During a review of the facility's policy and procedure (P&P) titled Care Plans-Comprehensive, revised on 12/2010, the P&P indicated Care plans are revised as information about the resident and the resident's condition change. During a review of the facility's P&P titled Comprehensive Resident Centered Care Plan, undated, the P&P indicated the care plan would be updated and/ or revised for new medications. The P&P indicated Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals.

Based on observation, interview, and record review, the facility failed to ensure plastic containers of canned fruit stored in the refrigerator were labeled and dated. This deficient practice had the potential to result in improper food safety practices and could lead to possible food-borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 45 of 47 residents who received food from the kitchen.Findings: During a concurrent observation and interview on 8/4/2025 at 8:30 a.m., with the Dietary Supervisor (DS), in the kitchen, observed four large-sized plastic containers, dated 7/30/2025, of canned fruit. The containers of fruit had no use-by date. The DS stated the canned fruit was prepared to substitute dessert or fresh fruit during lunch. The DS stated the fruit should be consumed within three days of preparation to maintain quality and safety. The DS stated the fruit exceeded the three-day period, was not labeled with a use-by date and should have been discarded. The DS stated storing prepared food items without proper labeling and timely disposal increased the risk for bacterial growth, spoilage, and a potential for serving unsafe food to residents, which could result in foodborne illness. During a review of the facility's policy and procedures (P&P) titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the refrigerator would be labeled with an open date and used by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal his/her need for assistance from staff) were within residents' reach while in bed for two out of three sampled residents (Resident 6 and Resident 25). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: a. A review of Resident 6's admission Record indicated the facility readmitted the resident on 9/16/2023 with diagnoses that included encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support), hypotension (low blood pressure), and dysphagia (difficulty swallowing). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/26//2024, indicated Resident 6's cognition (a mental process of acquitting knowledge and understanding) is severely impaired. The MDS indicated Resident 6 is dependent with eating, oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 6's care plan (a written document that summarizes a resident's needs, goals, and care/treatment) titled, Activities of Daily Living (ADL- activities related to personal care)/Self care deficit, reevaluate date 6/2024, indicated an intervention to have call light within reach and answer promptly. During an observation on 8/9/2024 at 7:30 p.m., observed Resident 6's call light was not within reach. Observed Resident 6's call light hanging off Resident 6's right ride rail. During a concurrent observation and interview on 8/9/2024 at 7:58 p.m., with Certified Nursing Assistant 1 (CNA 1), observed Resident 6 in bed and Resident 6's call light not within reach. Observed Resident 6's call light hanging off Resident 6's right side rail. Observed CNA 1 place the call light within Resident 6's reach and stated the residents' call light should be within reach for their safety. b. A review of Resident 25's admission Record indicated the facility readmitted the resident on 7/11/2020 with diagnoses that included hypertension (high blood pressure), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of Resident 25's MDS dated [DATE], indicated Resident 25's had clear speech, made self-understood, and had the ability to understand others. The MDS indicated Resident 25 setup or clean up assistance with eating and oral hygiene, and dependent with toileting hygiene. A review of Resident 25's care plan titled, ADL/Self care deficit, reevaluate date 4/2024, indicated an intervention to have call light within reach and answer promptly. During a concurrent observation and interview on 8/9/2024 at 8:06 p.m., heard Resident 25 yell out help from the hallway. Entered Resident 25's room and asked where Resident 25's call light was and Resident 25 stated, I do not know, I don't have it. During a concurrent observation and interview on 8/9/2024 at 8:07 p.m., with CNA 2, observed Resident 25 in bed and Resident 25's call light on the floor behind Resident 25's headboard, not within reach. Observed CNA 2 picking up Resident 25's call light from the floor behind Resident 25's headboard, placing the call light within Resident 25's reach. CNA 2 stated that call light should always be within reach incase residents need something they can call our attention and for safety. During an interview on 8/11/2024 at 4:42 p.m., with the Administrator (ADM), the ADM stated that residents' call lights should always be within reach in case the resident needs something they can call for assistance and for safety. A review of the facility-provided policy and procedure titled, Answering the Call Light, reviewed 4/17/2024, indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for one of two sampled residents (Resident 36), when on 8/7/24, Resident 32 called Resident 36 an asshole while pointing at Resident 36 in the main dining room. This deficient practice resulted in Resident 36 being subjected to verbal abuse while under the care of the facility. Residents whoa re subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others). Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident on 11/29/2023, with diagnoses including heart failure (occurs when the heart can't pump enough blood and oxygen to support the body's organs). During review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that Resident 36 was independent in performing activities of daily living (ADLs-basic self-care tasks that residents perform every day). During a review of Resident 32's Face Sheet, the Face Sheet indicated the facility admitted Resident 32 on 11/29/2023 with diagnoses including heart failure, dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making was impaired and that Resident 32 the required partial to moderate assistance from staff with showers, dressing and personal hygiene. During an interview on 8/10/24 at 6:30 p.m. with Resident 36, the resident stated that about one and half months ago (Resident unable to recall exact date, the date is later determined to be 8/7/204), Resident 36 informed the Social Service Director (SSD) that Resident 32 was using curse words (a word or phrase that's generally considered blasphemous, obscene, vulgar, or otherwise offensive) when he called Resident 36 an asshole while pointing at Resident 36 in the main dining room. During an interview on 8/11/24 at 1:30 p.m., the SSD stated that he (SSD) was informed by Resident 36 that Resident 32 had called Resident 36 an asshole. The SSD stated that calling somebody an asshole is verbal abuse. During an interview on 8/11/2024 at 2:50 p.m. with the Activity Director (AD), the AD stated that on 8/7/2024 at around 12:30 p.m., while in the main dining room, Resident 32 was cursing and stated, piece of shit, asshole and he (Resident 32)was also looking at the direction of Resident 36. The AD said she (AD) did not see if Resident 32 was pointing his (Resident 32) fingers, but Resident 32 was looking at the direction of Resident 36. The AD stated that she (AD) tried to redirect Resident 32 and told Resident 32 that he (Resident 32) was being inappropriate. A review of the facility`s policy and procedures titled Abuse Prohibition and Prevention Program, last revised on March 2023, indicated that the facility has policies and procedures for . protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal abuse ( at type of abuse that uses language) for one of two sampled residents (Resident 36). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident on 11/29/2023, with diagnoses including heart failure (occurs when the heart can't pump enough blood and oxygen to support the body's organs). During review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that Resident 36 was independent in performing activities of daily living (ADLs-basic self-care tasks that residents perform every day). During a review of Resident 32's Face Sheet, the Face Sheet indicated the facility admitted Resident 32 on 11/29/2023 with diagnoses including heart failure, dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making was impaired and that Resident 32 the required partial to moderate assistance from staff with showers, dressing and personal hygiene. During an interview on 8/10/24 at 6:30 p.m. with Resident 36, the resident stated that about one and half months ago (Resident unable to recall exact date, the date is later determined to be 8/7/204), Resident 36 informed the Social Service Director (SSD) that Resident 32 was using curse words (a word or phrase that's generally considered blasphemous, obscene, vulgar, or otherwise offensive) when he called Resident 36 an asshole while pointing at Resident 36 in the main dining room. Resident 36 stated that after a few days, Resident 36 reported the incident to the SSD. During an interview on 8/11/24 at 1:30 p.m., the SSD stated that he (SSD) was informed by Resident 36 that Resident 32 had called Resident 36 an asshole. The SSD stated that calling somebody an asshole is verbal abuse. The SSD stated that when Resident 36 informed SSD about the allegation of abuse, SSD informed the Administrator (ADM). During an interview on 8/11/2024 at 2:42 p.m. with the Administrator (ADM) the ADM stated that he is the designated abuse coordinator. The ADM stated that on 8/7/2024 Resident 36 told ADM regarding the incident involving Resident 32. ADM stated that she did not report the allegation to the SSA. A review of the facility`s policy and procedures titled Abuse Prohibition and Prevention Program, last revised on March 2023, indicated that Mandated Reporter: any person who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonable appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or is told by and elder or dependent adult that he or she experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonable suspects abuse shall report the known or suspected instance of abuse .the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 4's Face Sheet indicated the facility readmitted the resident on 7/15/2024 with diagnosis that included encephalopathy (brain disease that alters brain function or structure) unspecified, other lack of coordination, and hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side. A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition is severely impaired. The MDS indicated the resident required set up or clean up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and dependent with toileting hygiene. During a concurrent interview and record review on 8/10/2024 at 6:38 p.m., with the Director of Nursing (DON), reviewed Resident 4's care plan for wandering dated 12/12/2023. The DON stated that the care plan has not been updated and should have been updated in 3/2024 and quarterly thereafter. The DON stated care plans are important because it states the problem, the goal of the resident and the interventions towards the goal. The DON stated care plans should be updated every 90 days and/or as needed to see if the interventions that the facility have in place are effective and if the interventions are not working, we have to revise the interventions. When asked who is responsible for updating care plans, the DON stated that MDS nurse is responsible for updating care plan every 90 days. A review of the facility's policy and procedure titled, Care Plans-Comprehensive, reviewed 4/17/2024, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. Based on interview and record review, the facility failed to revise and renew a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of three sampled residents (Resident 18 and 4). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: a. During review of Resident 18's Face Sheet (admission Record) indicated the facility originally admitted the resident on 3/02/2022 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/28/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired and the resident was dependent on staff for toileting, shower, dressing, personal hygiene, and bathing. The MDS Section V (Care Area Assessment [CAA] Summary) dated 8/29/2023 indicated the Care Area for Falls was triggered for continuance of care plan to address the problem (Fall Risk) identified in the assessment. During a concurrent interview and record review on 8/10/2024 at 12:17 p.m., with the Director of Nursing, reviewed Resident 18`s MDS dated [DATE], including Section V. The DON confirmed by stating that Resident 18's CAA Summary was marked for continuance of the Fall Risk care plan due to factors including but not limited to cognitive loss and impaired balance. The DON also confirmed that Resident 18`s Care Plan was last evaluated on 2/2021, was not evaluated on 5/2024 with no other evaluation date after 5/2024. The DON stated that a care plan is a tool wherein the resident`s problems are identified based on contributing factors, treatment goals are defined, and approaches or interventions are identified. The DON stated that care plans are usually re-evaluated every quarter to determine if the resident`s identified problem has been resolved and if not then revise and renew the care plan with new approaches if necessary. The DON stated that if it`s not evaluated then they would not know if the resident`s has made progress or if the problem had been resolved. The DON stated that if not reevaluated the resident will not be provided with the necessary care and services to achieve his treatment goals. A review of the facility's policy and procedure titled, Care Plans-Comprehensive, reviewed 4/17/2024, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed that to ensure that two of three sampled residents (Resident 47 and Resident 45), who were assessed and identified to be a candidate for the facility's bowl (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (a sac-shaped muscular organ that stores the urine secreted by the kidneys) retraining program (when facility staff assist a resident to the restroom at specific timed intervals) , were placed on the bowel and bladder retraining program per facility policy. This deficient practice has the potential for Resident 47 and Resident 45 to not to achieve or restore normal bowel and bladder function. Findings: 1. During a review of Resident 47 admission Record, the admission Record indicated the facility admitted Resident 47 on 9/13/2023 with diagnoses that included arthritis of the right knee (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), muscle wasting and atrophy (gradual decline and loss of muscle), and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/18/2024, the MDS indicated Resident 47's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated that Resident 47 was dependent on staff with toileting hygiene. During a review of Resident 47's Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated that Resident 47 was a candidate for bowel and bladder training. During a concurrent interview and record review on 8/11/2024 at 11:55 a.m. with the MDS Nurse (MDSN), the MDSN stated that the bowel retraining evaluation is done upon admission and quarterly for the residents to evaluate a resident's toileting abilities. The MDSN reviewed Resident 47's Bowel & Bladder assessment dated [DATE] and stated Resident 47 scored a 10 indicating Resident 47 is a candidate for bowl and bladder training. When asked if Resident 47 started his bowel and bladder training, MDSN stated that the facility did not start Resident 47 on a bowel and bladder training program. The MDSN stated that the facility should have initiated Resident 47's bowl and bladder training program. When asked about what negative effects can happen to Resident 47 if a bowel and bladder training program was not initiated, the MDSN stated that Resident 47 may lose more of his bowel and bladder function abilities. 2. A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 9/23/2022 with diagnoses that included hypertension (high blood pressure), depression (disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), and constipation (a condition in which there is difficulty in emptying the bowels). A review of Resident 45's MDS dated [DATE], indicated Resident 45's cognition was intact. The MDS indicated that Resident 45 was dependent on staff with toileting hygiene and personal hygiene. During a review of Resident 45's Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated that Resident 47 was a candidate for bowel and bladder training. During a concurrent interview and record review on 8/11/2024 at 12:11 p.m. with the MDSN, the MDSN reviewed Resident 45's bowel and bladder assessment dated [DATE]. The MDSN stated that Resident 45 scored 17, indicating Resident 45 was a candidate for bowel and bladder training. When asked if Resident 45 was offered bowel and bladder training, the MDSN stated that she was not offered bowel and bladder training because Resident 45 is not ambulatory and is not mobile (able to move). When asked if bowel and bladder training should have been initiated for Resident 45, the MDSN stated that bowel and bladder training should have been initiated because of the result of the bowel and bladder assessment. The MDSN further stated that the facility should have offered and/or initiated the training to Resident 45 and documented any outcomes. A review of the facility's policy and procedure titled Bowel and Bladder Programs reviewed 4/17/2024, indicated it is the policy of this facility to restore resident's normal bowel and or bladder function as much as possible. The purpose of bowl and bladder training toileting program is to ensure that a resident who is incontinent (inability to control) of bowel and or bladder receives appropriate treatment and services .

Based on observation, interview, and record review the facility failed to ensure that one of two sampled residents (Resident 6), was observed to have bed side rails in place despite being evaluated that bed side rails were not recommended for use. This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment (when a person is trapped by the bed rail in a position they cannot move from) and result to injury. Findings: A review of Resident 6's admission Record indicated the facility readmitted Resident 6 on 9/16/2023 with diagnoses that included encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support), degenerative disease of the nervous system (conditions that gradually damage and destroy parts of your nervous system [organized network of nerve tissue in the body] especially areas of the brain), hypotension (low blood pressure), and dysphagia (difficulty swallowing). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/26//2024, indicated Resident 6's cognition (a mental process of acquitting knowledge and understanding) was severely impaired. The MDS indicated Resident 6 is dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 6's Evaluation for Use of Side Rails document dated 6/26/2024, indicated under recommendation: Side rail(s) are not recommended at this time. Reasons for non-use: Totally immobile (inability to move the body). During an observation on 8/11/2024 at 9:25 a.m., observed Resident 6 on her bed with all four side rails up and in place. During an observation and concurrent interview on 8/11/2024 at 9:31 a.m. with the MDS Nurse (MDSN), observed Resident 6 on the bed with all four side rails up and in place. During a concurrent interview and record review on 8/11/2024 at 9:35 a.m. with the MDSN, the MDSN reviewed Resident 6's Evaluation for Use of Side Rails document dated 6/26/2024. The MDSN stated that based on Resident 6's evaluation for side rails, Resident 6 should not have any side rails in place. The MDSN stated that it is the responsibility of the charge nurses to monitor the residents and to make sure side rails are not in place. The MDSN continued to state that she (MDSN) does not believe that there would be any negative outcomes from having all four side rails in place because Resident 25 is unable to be entrapped. A review of the facility's policy and procedure titled Bedrails reviewed 4/17/2024, indicated the facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to implement the facility's policy on medication administration by failing to ensure one of three sampled resident's (Resident 19) administration of Ambien (medication used to treat insomnia [persistent problems falling and staying asleep]) was accurately reflected on the Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on when the medication was administered. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/2/2024, indicated Resident 19's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 19 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, and personal hygiene. During a review of Resident 19's Physician Order dated 5/30/2024 indicated to administer Ambien five milligrams (mg- unit of measure), one tablet by mouth at bedtime (9:00 p.m.) for insomnia manifested by inability to sleep. During a review of Resident 19's Medication Administration History for Ambien dated 8/9/2024, indicated Ambien was scheduled to be administered on 8/9/2024 at 9:00 p.m., however, Licensed Vocational Nurse 3 (LVN 3) documented Ambien was administered on 8/9/2024 at 8:58 p.m. During a review of Resident 19's Controlled Drug Record for Ambien indicated Ambien five mg was administered to Resident 19 on 8/9/2024 at 6:45 p.m. During a concurrent interview and record review on 8/9/2024 at 9:00 p.m. with LVN 3, LVN 3 reviewed Resident 19's Controlled Drug Record dated 8/9/2024. LVN 3 stated that she (LVN 3) administered Resident 19's Ambien five milligrams on 8/9/2024 at 8:58 p.m. however, she (LVN 3) incorrectly documented administering Resident 19's Ambien five mg on Resident 19's Controlled Drug Record. LVN 3 stated that after medication administration, LVN 3 should have documented on both the Controlled Drug Record and the Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional). LVN 3 stated that the time of the medication administration should match (be the same) on both the Controlled Drug Record and the MAR. During an interview on 8/10/2024 at 5:30 p.m. with the Director of Nursing (DON), the DON stated that administration of any controlled drugs should accurately reflect on both the Controlled Drug Record and the MAR to get an accurate representation of the resident's medical records. A review of the facility's policy and procedure titled, Medication Administration-Controlled Substances, last reviewed 4/17/2021, indicated that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, record keeping in the care center, in accordance with federal and state laws and regulations. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage; a. date and time of administration; b. Amount administered; c. Signature of the nurse administering the dose, completed after the medication is actually administered, and documented.

Based on interview and record review, the facility failed to provide laboratory services timely for one of three sampled residents (Resident 45). This deficient practice placed Resident 45's well-being at risk and had the potential for the resident not to receive appropriate care and treatment in a timely manner. Findings: A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 9/23/2022 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) without complications. A review of Resident 45's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/9/2024, indicated Resident 45's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated that Resident 45 required set up or clean up assistance with eating, oral hygiene, and was dependent with toileting hygiene and personal hygiene. A review of Resident 45's Change of Condition (COC- a significant change in a resident's health or functional status that will not normally resolve itself without further intervention) document dated 6/21/2024 at 2:50 p.m., indicated burning sensation upon urination. A review of Resident 45's physician's orders dated 6/21/2024, indicated urinalysis (UA- the physical, chemical, and microscopic examination of urine) and culture (culture is a test to find germs that can cause an infection) and sensitivity (sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) if indicated. During a concurrent interview and record review on 8/11/2024 at 10:43 a.m., with the Infection Preventionist (IP), reviewed Resident 45's COC document dated 6/21/2024 2:50 p.m. The IP stated that Resident 45 complained of burning on urination and labs were ordered. The IP reviewed Resident 45's progress notes from 6/21/2024 - 6/23/2024, and stated that on 6/22/2024 at 7:41 p.m., Resident 45's urine specimen was awaiting pick up. The IP stated that since labs were ordered on 6/21/2024 during the 7 a.m.-3 p.m. shift, the lab specimen should have been obtained and picked up on 6/21/2024. The IP stated that the lab specimen was picked up late. The IP further stated that there is no documented evidence that the facility communicated with the lab indicating that the urine specimen was ready for pick up. The IP stated that licensed nurses should have communicated with the lab so that the specimen would have been picked up timely to minimize bacteria growth. A review of the facility's policy and procedure titled, Laboratory Services, reviewed 4/27/2024, indicated the facility will provide or obtain laboratory services to meet the needs of its residents. The facility will promote practices to ensure the quality and timeliness of laboratory services.

Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) did not willfully falsify (knowingly make a false entry into a resident's medical record) the medication administration of Ativan (brand name for lorazepam, a medication used for anxiety [a feeling of fear, dread, and uneasiness]) on 8/9/2024 for one of two sampled residents (Resident 19). This willful material falsification (WMF - when staff purposefully documents false information in a medical record) resulted in Resident 19's clinical record falsely reflecting the care provided. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/2/2024, indicated Resident 19's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 19 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, and personal hygiene. During a review of Resident 19's Physician Order dated 5/30/2024 indicated to administer Ativan one milligram (mg- unit of measure), one tablet by mouth twice a day (9:00 a.m. and 5:00 p.m.) for anxiety manifested by recurrent feelings of panic that he will not receive medication. During an observation on 8/9/2024 at 6:45 p.m., observed LVN 3 preparing and administering Ativan one mg to Resident 19. During a review of Resident 19's Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for Ativan, dated 8/9/2024, indicated that LVN 3 administered Ativan one mg to Resident 19 on 8/9/2024 at 5:46 p.m. During a review of Resident 19's Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse), the controlled drug record indicated that LVN 3 administered Ativan one mg to Resident 19 on 8/9/2024 at 5:45 p.m. During an interview on 8/10/2024 at 4:42 p.m. with LVN 3, LVN 3 stated that on 8/9/2024 at 6:45 p.m., she (LVN 3) administered Ativan one mg to Resident 19. LVN 3 stated that she did not administer the Ativan one mg to Resident 19 timely (scheduled to be administered at 5:00 p.m.) and instead administered the Ativan one mg to Resident 19 at a later time (6:45 p.m.). When LVN 3 was asked why LVN 3 signed Resident 19's MAR indicating she (LVN 3) administered Resident 19's dose of Ativan one mg on 8/9/2024 at 5:46 p.m. when she did not administer the medication at that time, LVN 3 did not respond. When LVN 3 was asked if Resident 19's Ativan administration on 8/9/2024 was falsely documented, LVN 3 agreed and stated that she (LVN 3) falsely documented Resident 19's Ativan administration on the MAR on 8/9/2024 indicating Ativan was administered at 5:46 p.m. because she administered the Ativan to Resident 19 on 8/9/2024 at 6:45 p.m. LVN 3 further stated that she (LVN 3) also falsely documented Resident 19's Ativan administration on the Controlled Drug Record on 8/9/2024 indicating Ativan was administered at 5:45 p.m. because she administered the Ativan to Resident 19 on 8/9/2024 at 6:45 p.m. During an interview and concurrent record review on 8/11/2024 at 4:43 p.m., with the Administrator (ADM), the ADM reviewed the facility's policy titled Health Information Record Manual and stated that based on the facility's policy, LVN 3 willfully falsified Resident 19's MAR. The ADM stated that LVN 3 should have documented the administration of Resident 19's Ativan at the actual time it was administered and should not have back timed it. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 4/17/2024, indicated that the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. Pour-Pass-Chart is the acceptable method for medication preparation, administration, and documentation. A review of the facility's policy & procedure titled, Chapter III Legal Health Record, last reviewed 4/17/2024, indicated documentation in the legal health record will follow these basic rules: all entries will include date and time as appropriate and will be signed; properly record as the events or observations occur; willful material falsification is any entry in the clinical record made with the knowledge that the record falsely reflects the condition of the resident or the care or service provided.

Based on interview and record review, the facility failed to ensure that hospice care (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) staff was present for two Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who work together to treat a resident) meeting for one of one sampled resident (Resident 18). This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to one of one sampled resident (Resident 18). Findings: During review of Resident 18's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 18 on 3/02/2022 and readmitted Resident 18 on 8/23/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/28/2024,the MDS indicated that Resident 18's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired. The MDS further indicated that Resident 18 was dependent on staff for toileting, shower, dressing, personal hygiene, and bathing. The During a review of Resident 18's IDT Conference notes dated 2/29/2024 and 5/30/2024, the indicated that hospice care services provider representative (hospice nurse) was not in attendance for the IDT meetings. During a concurrent interview and record review on 8/11/2024 at 9:24 a.m., with the Director of Nursing (DON), the DON reviewed Resident 18`s Interdisciplinary Team Conference notes dated 2/29/2024 and 5/30/2024. The DON stated planning the care of a resident on hospice should be a collaboration between the facility`s IDT and hospice nurse representative. The DON stated that there was a breakdown in communication between the facility and the hospice care staff for the IDT meetings on 2/29/2024 and 5/30/2024 since there was no hospice care provider in attendance. During a review of the facility`s Skilled Nursing Facility Contract with Hospice Provider A (HPA) dated 2/27/2017, the contract indicated that, among others, hospice nurse assigned and or RN Supervisor will attend care plan meeting in the skilled nursing facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure that a resident's physician's orders to flush (gently pushing water through the tube to clean it) the gastrostomy tube (G-Tube, a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with five to 10 milliliters (ml-unit of measure) of water in between the administration of each medication for one of 13 sampled residents (Resident 6) was followed. 2. Ensure that facility staff verified tube placement (when a healthcare professional pushes air into the g-tube and listens to hear a gurgling sound in the stomach with a stethoscope [a medical instrument that allows a person to listen to sounds inside the body]; when a healthcare professional aspirates (pulling back of the plunger of a syringe to check if there are contents in the stomach) the syringe to check the stomach contents) when administering medications through a gastrostomy tube (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) for one of three residents (Resident 17). These deficient practices had the potential to place Resident 6 at increased risk for drug interaction (when a drug's effect is changed by taking it with another drug) , and increased the risk for leakage of medication into the abdominal cavity (space) if the tube is dislodged which can lead to subsequent complications like peritonitis (when the peritoneum [the tissue lining the inner wall of the abdomen] becomes inflamed. ) and sepsis (a life-threatening complication of an infection) for Resident 17. Findings: 1. During a review of Resident 6's Face Sheet (a document that summarizes a resident's important medical information), the document indicated the facility originally admitted the resident on 9/16/2022 and readmitted the resident on 3/27/2022 with diagnoses including encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach). During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/26/2024, the document indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for assistance with all activities of daily living (ADLs - the basic tasks that people need to do on their own to live independently). During a review of Resident 6's physician's orders, the following orders were noted: - Flush g-tube with five to 10 ml of water between each medication, with a start date of 9/16/2024. - Ascorbic Acid (Vitamin C- used for the growth and repair of tissues in all parts of the body) 500 milligrams (mg-unit of measure) per five (5) ml (mg/ml-unit of measure) once a day via g-tube; with a start date of 9/16/24. - Aspirin (medication to thin the blood) 81 mg via g-tube once a day; with a start date of 9/16/24. - Liqacel (protein supplement to help with wound healing) 16 grams to 100 kilograms (g-kg: unit of measure) per 30 ml, give 30 ml via g-tube; with a start date of 9/16/24. - Metoclopramide ( medication used to treat slow stomach emptying) 5mg/ml, give a total of 10 ml via g-tube twice a day; with a start date of 9/16/24. - Midodrine (medication to treat low blood pressure) 10mg via g-tube three times a day; with a start date of 9/16/24. - Miralax (medication to treat constipation [inability to have a bowel movement]) 17 grams via g-tube once a day; with a start date of 9/16/24. - Multivitamin with mineral ( used for would healing) 1 tablet via g-tube once a day; with a start date of 9/16/24. - Zinc Sulfate (used for wound healing) 50 mg 1 tablet via g-tube once a day; with a start date of 9/16/24. During an observation on 8/10/2024 at 9:15 a.m., observed Licensed Vocational Nurse 1 (LVN 1) prepare Vitamin C, Aspirin, Liquacel, Metoclopramide, Midodrine, Miralax, Multivitamin with mineral, and Zinc Sulfate for Resident 6: During an observation on 8/10/2024 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 place each of the eight (8) medications (Vitamin C, Aspirin, Liquacel, Metoclopramide, Midodrine, Miralax, Multivitamin with mineral, Zinc Sulfate) in a separate medication cup (small clear measuring cup used during preparation of a resident's medication) and mixed each medication cup with water. Observed LVN 1 pour the first medication cup of medication mixed with water into Resident 6's G-tube. Observed LVN 1 then proceed to do pour each of the seven remaining medication cups mixed with medications and water without flushing the G-tube with five to 10 ml of water between each medication. During an interview on 8/10/2024 at 9:51 a.m., when LVN 1 was asked if LVN 1during an was supposed to flush Resident 6's g-tube with five to 10 ml of water between administering each medication, LVN 1 stated that she (LVN 1) did not flush five to 10 ml of water in between each medication because LVN 1 had mixed each medication in a medication cup with water. During an interview on 8/11/2024 at 3:36 p.m. with the Director of Nursing (DON), the DON stated that LVN 1 should have flushed five to 10 ml of water between administering each medication to Resident 6. The DON stated the purpose of flushing water between each medication is to ensure the g-tube does not get clogged, that the resident actually received all of the medication, and to prevent any interactions between the medications. The DON stated that if the licensed nurse did not flush the g-tube with five to 10 ml of water between administering each medication, then it was possible for the medications to interact with each other which could then, possibly affect the effectiveness of the medications. During a review of the policy and procedure titled, Medication Administration - Enteral Tubes (a soft, flexible plastic tube that is inserted into the gastrointestinal tract to provide nutrients and fluids, or to administer medications), last reviewed on 4/17/2024, the policy indicated that the enteral tube is flushed with at least five (5) ml of water between each medication to avoid physical interaction of the medications. 2. During review of Resident 17's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/21/2024 with diagnoses that included dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 17's MDS dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired. The MDS further indicated that Resident 17 was dependent on staff for oral hygiene, toileting hygiene, shower, dressing, and personal hygiene. During a medication administration observation on 8/10/2024 at 4:24 p.m., observed LVN 2 prepared medications that are due for administration for Resident 17. Observed LVN 2 administering medications through the g-tube of Resident 17 without checking and verifying the placement of the tube. During an interview with LVN 2, LVN 2 stated that he (LVN 2) forgot to check and verify if the G -Tube was in place for Resident 17 prior to administering Resident 17's scheduled medications. LVN 2 stated that verifying the placement of the g-tube is done by auscultating (listening) while infusing air to the tube and by checking the residual (remaining) contents of the stomach. LVN 2 that by not verifying placement of the g-tube prior to using the g-tube puts the resident at risk for leaks into the abdominal cavity which can result to infection and sepsis. During an interview with the DON on 08/11/24 11:49 a.m., the DON stated that before a medication is administered via a g-tube, the nurses` must verify placement by auscultating with stethoscope while infusing air and checking for residual. DON stated that verifying placement of g-tube is to make sure that the tube is in the stomach and prevent leakage which could lead to infection. A review of the facility`s policy and procedures titled Medication Administration-Enteral (into the stomach) Tubes, last reviewed on 4/17/2024, indicated the following administration procedures: - Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. - Aspirate stomach contents with syringe. Allow stomach contents to go back into stomach .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Act upon the pharmacist's recommendation, dated 6/13/2024, to add vitamin B12 (supplement) to a resident's medication regimen for one of 13 sampled residents (Resident 15). 2. Act upon the pharmacist's recommendation, dated 4/29/2024, to discontinue a resident's docusate sodium (stool softener) for one of 13 sampled residents (Resident 15). 3. Document a rationale for why the physician disagreed with the pharmacist's recommendation for one of 13 sampled residents (Resident 8). These deficient practices had the potential to place the residents at increased risk of receiving unnecessary medications or experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 15's Face Sheet (admission record), the document indicated the facility originally admitted the resident on 1/18/2012 and readmitted the resident on 5/29/2020 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 15's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/9/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required maximum assistance from staff for most activities of daily living (ADLs - activities related to personal care). During a review of Resident 15's physician's orders, an order indicated to give the resident metformin (helps lower blood sugar levels in people with type 2 diabetes) 1,000 milligrams (mg - unit of measurement) by mouth twice a day for type 2 diabetes mellitus, ordered on 2/8/2024. During a review of Resident 15's Consultant Pharmacist Recommendations to Physician's, dated 6/23/2024, the document indicated that the resident is on metformin 1,000 mg twice a day with food for diabetes since 2/8/2024. The document indicated that taking metformin for long-term may decrease vitamin B12 absorption. The pharmacist recommended adding vitamin B12 1,000 micrograms (mcg - unit of measurement) daily to Resident 15's regimen. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the Director of Nursing (DON), reviewed Resident 15's Medication Regimen Review (MRR - a thorough evaluation of a resident's medication regimen to identify potential adverse effects and drug reactions). The DON stated she could not find any documentation indicating that the physician had responded to the recommendation or that the recommendation was acted upon. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, the facility should follow up with the physician as soon as possible. The DON stated it was important to act upon the recommendation as soon as possible because it could affect the resident's absorption of medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the policy indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement. b. During a review of Resident 15's Face Sheet, the document indicated the facility originally admitted the resident on 1/18/2012 and readmitted the resident on 5/29/2020 with diagnoses including hemiplegia (a condition that causes partial or complete paralysis on one side of the body) and hemiparesis (a medical condition that causes partial or mild weakness on one side of the body). During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition and required maximum assistance from staff for most activities of daily living. During a review of Resident 15's physician's orders, the orders indicated the following: - Docusate sodium 100 mg, give two capsules by mouth once a day for constipation/stool softener, ordered on 2/16/2021. - Senna (treats constipation) 8.6 mg, give two tablets by mouth in the evening for constipation, ordered on 2/8/2024. - Bisacodyl (treats constipation) 10 mg rectally daily as needed for constipation, ordered on 2/1/2024. - Magnesium hydroxide (treats constipation) 400 mg/5 milliliters (ml - unit of measurement), give 30 ml orally daily as needed for constipation, ordered on 2/1/2024. During a review of Resident 15's Consultant Pharmacist Recommendations to Physicians, dated 4/29/2024, the pharmacist recommended to discontinue the resident's docusate sodium 100 mg two tablets daily since the resident was also receiving senna, magnesium hydroxide, and bisacodyl. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the DON, reviewed Resident 15's MRR. The DON stated she could not find any documentation indicating that the physician had responded to the recommendation or that the recommendation was acted upon. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, the facility should follow up with the physician as soon as possible. The DON stated it was important to act upon the recommendation as soon as possible because it could possibly prevent the resident from receiving unnecessary medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the document indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement. c. During a review of Resident 8's Face Sheet, the document indicated the facility admitted the resident on 9/14/2022 with diagnoses including multiple sclerosis (MS - a chronic neurological disease that affects the brain and spinal cord). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident had intact cognition and was dependent on staff for assistance with all ADLs. During a review of Resident 8's physician's orders, the orders indicated the following: - Daily multivitamin with minerals one tablet by mouth once a day for supplement, ordered on 9/14/2022. - Vitamin D3 5,000 units (unit of measurement) one tablet by mouth once a day for supplement, ordered on 9/15/2022. - Vitamin B one tablet by mouth once a day for supplement, ordered on 9/21/2023. During a review of Resident 8's Consultant Pharmacist Recommendations to Physicians, dated 5/27/2024, the document indicated to consider discontinuing the resident's vitamin B since the resident was already receiving a multivitamin. The document indicated that the physician disagreed with the recommendation but there was no documented rationale. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the DON, reviewed Resident 15's MRR. The DON stated she could not find any documentation providing the physician's rationale for disagreeing with the pharmacist's recommendation. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, and the physician disagreed with it, the physician should document the rationale for disagreeing. The DON stated it was important to act upon the recommendation as soon as possible because it could possibly prevent the resident from receiving unnecessary medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the document indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement.

Based on observation, interview, and record review, the facility failed to: 1. Ensure licensed nurse did not leave two medicine cups with medications unattended. This deficient practice has the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2. Ensure an open multi dose vial of Lidocaine 1% (local anesthetic agent [causes a loss of feeling in one small area of the body]) was labeled with an open date. This deficient practice had the potential to compromise the therapeutic effectiveness of the medication. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave prepared medications unattended at a resident's bedside for one of 13 sampled residents (Resident 6). This deficient practice had the potential to result in unauthorized personnel or residents having access to the unattended medications. Findings: 1. During an observation on 8/9/2024 6:12 p.m., observed two medicine cups with medications on top of a medication cart, left unattended. During a concurrent observation and interview on 8/9/2024 at 6:20 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that she left the medications for two (2) minutes while she went into the activity room. LVN 3 stated that she should always have all medication with her at all times for safety. LVN 3 further stated that she should not have left the two medicine cups with medications on top of her medication cart unattended. A review of the facility's policy and procedure titled, Medication Administration, reviewed 4/17/2024, indicated medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications. 2. During a concurrent observation and interview on 8/9/2024 at 6:24 p.m., with LVN 2, observed in Medication Cart 1 a multi-use vial of Lidocaine 1 %, opened and undated. LVN 2 stated that all opened multi use vials should be dated with the open date for safety. A review of the facility's policy and procedure titled, Injectable Vials and Ampules, dated 4/17/2024, indicated vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. Under procedures indicated: 1. Vials and ampules sent from the provider pharmacy in a box or container with the label on the outside are kept in the box or container. 2. The date opened and the initials of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label of fixed for that purpose). 3. During a review of Resident 6's Face Sheet (admission record), the document indicated the facility originally admitted the resident on 9/16/2022 and readmitted the resident on 3/27/2022 with diagnoses including encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach). During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/26/2024, the document indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for assistance with all activities of daily living (ADLs - t activities related to personal care). During a medication administration observation on 8/10/2024 at 9:15 a.m., observed LVN 1 prepare the following medications: - Ascorbic Acid (Vitamin C- used for the growth and repair of tissues in all parts of the body) 500 milligrams (mg-unit of measure) per five (5) ml (mg/ml-unit of measure) once a day via g-tube; with a start date of 9/16/24. - Aspirin (medication to thin the blood) 81 mg via g-tube once a day; with a start date of 9/16/24. - Liqacel (protein supplement to help with wound healing) 16 grams to 100 kilograms (g-kg: unit of measure) per 30 ml, give 30 ml via g-tube; with a start date of 9/16/24. - Metoclopramide (medication used to treat slow stomach emptying) 5mg/ml, give a total of 10 ml via g-tube twice a day; with a start date of 9/16/24. - Midodrine (medication to treat low blood pressure) 10mg via g-tube three times a day; with a start date of 9/16/24. - Miralax (medication to treat constipation [inability to have a bowel movement]) 17 grams via g-tube once a day; with a start date of 9/16/24. - Multivitamin with mineral (used for would healing) 1 tablet via g-tube once a day; with a start date of 9/16/24. - Zinc Sulfate (used for wound healing) 50 mg one tablet via g-tube once a day; with a start date of 9/16/24. During an observation on 8/10/2024 at 9:37 a.m., observed LVN 1 leave the prepared medications at Resident 6's bedside while she went into the bathroom to wash her hands. The medications were not within eyesight. Observed LVN 1 once again leave the medications unattended while she returned to her medication cart. The medications were behind the privacy curtain, not within eyesight. Observed LVN 1 again leave the medications unattended and out of eyesight as she returned to the bathroom to wash her hands again. During an interview on 8/10/2024 at 9:51 a.m., with LVN 1, LVN 1 stated she should not have left the medications unattended at the bedside because anyone can come by and take the medications. During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated that nurses should never leave medications unattended at the bedside. The DON stated that, if medications were left unattended at the bedside, then the nurse may not know if the resident had already received the medication. The DON stated that other residents could also have access to medications that was not theirs. The DON stated that, either way, the resident could possibly experience a negative outcome, such as experiencing unwanted side effects. During a review of the facility's policy and procedure titled, Storage of Medication, last reviewed on 4/17/2024, the policy indicated that, in order to limit access, only licensed nurses, the consultant pharmacists, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, cabinets, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to: 1. Ensure there was no moldy food inside the designated resident refrigerator. 2. Ensure a bag of prepared French toast found inside the refrigerator in the kitchen was labeled with the date it was prepared. 3. Ensure that food found inside the designated resident refrigerator was labeled with a resident identifier and the date it was placed inside the refrigerator. These deficient practices had the potential to place 44 out of 48 residents living in the facility at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 8/9/2024 at 6:17 p.m., observed the kitchen refrigerator with Dietary Aide 1 (DA 1). Certified Nursing Assistant 1 (CNA 1) provided translation assistance. Inside the refrigerator, observed an unlabeled clear plastic bag with something wrapped in foil inside it. When DA 1 opened the bag and the foil, DA 1 stated it contained prepared slices of French toast. DA 1 stated it should have been labeled with the date it was prepared and placed inside the refrigerator. Observed the designated resident refrigerator for outside food in the staff break room with CNA 1. Observed a plastic bag inside the refrigerator labeled with a resident's name but not the date it was placed inside the refrigerator. Upon opening the bag, CNA 1 confirmed it contained moldy unidentifiable food inside it. CNA 1 stated it should have been labeled with the date it was placed inside the refrigerator. Observed an unlabeled clear plastic bag inside the refrigerator containing refried beans. CNA 1 stated it should have been labeled with a resident identifier and the date it was placed inside the refrigerator. During an interview on 8/11/2024 at 1:48 p.m., with the Dietary Supervisor (DS), the DS stated the bag of French toast should have been labeled with the date of when it was prepared. The DS stated it was a charge nurse's or CNA's responsibility to label the food that goes inside the designated resident refrigerator. The DS stated food should be labeled with the date it was placed inside the refrigerator because it should only be kept in the refrigerator for 72 hours. The DS stated that, after 72 hours, food should be discarded because it can possibly be spoiled. The DS stated that food should also be labeled with a resident identifier, so staff would know to whom it belonged. The DS stated that residents can possibly get a foodborne illness from eating potentially spoiled food. During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was important to label food with the date it was stored or prepared so that staff know it's not spoiled or expired. The DON stated that food that goes into the designated resident refrigerator should be labeled with a resident identifier so that staff know to whom it belonged. The DON stated that residents can develop and upset stomach or a foodborne illness if they ate food that was spoiled or expired. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, last reviewed on 4/17/2024, the policy indicated that all food items in the storeroom, refrigerator, and freezer need to be labeled and dated .Leftovers will be covered, labeled, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1.Ensure a resident's urinal was not placed hanging on a trash receptacle for one of two sampled residents (Resident 7). 2. Ensure a resident's urinal had the residents' name on the urinal for two of two sampled residents (Resident 7 and Resident 33). This deficient practice had the potential to result in contamination of the residents' care equipment and place residents at risk for and place the residence at risk for infection. 3. Ensure staff did not store their personal food inside the kitchen refrigerator along with the residents' food. This deficient practice had the potential to place 44 out of 48 residents living in the facility at increased risk of infection. Findings: a. A review of Resident 7's admission Record indicated the facility admitted the resident on 3/3/2024 with diagnoses that included fracture (broken bone) of unspecified part of neck of right femur (thighbone), age related osteoporosis (a condition in which bones become weak and brittle) with current pathological (caused by, or of the nature of a physical or mental disease) fracture, right femur, subsequent encounter for fracture with routine healing, and personal history of urinary tract infections (an infection in the part of the urinary system). A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated the Resident 7's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated Resident 7 required setup or clean up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and dependent with toileting hygiene. During a concurrent observation and interview on 8/9/2024 at 8:01 p.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 7's room, observed an unlabeled urinal hanging on a trash receptacle right next to Resident 7's bed. When asked who the urinal belongs to, CNA 2 stated that the urinal belongs to Resident 7. When asked why the urinal is placed hanging on the side of the trash receptacle, CNA 2 stated that Resident 7's wife wants it there. When asked if a resident's urinal should be placed hanging off a trash receptacle, CNA 2 stated that urinals should be stored in the resident's restroom with their name on it. When asked about the importance of having the resident's name of the urinal, CNA 2 stated that it is important to have a resident's name on the urinal so that staff know who the urinal belongs to. b. A review of Resident 33's admission Record indicated the facility readmitted the resident on 3/16/2022 with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles in the blood), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems) due to excess calories, and fatty liver. A review of Resident 33's MDS dated [DATE], indicated the Resident 33's cognition was intact. The MDS further indicated Resident 33 required setup or clean up assistance with eating and oral hygiene, personal hygiene and independent with toileting hygiene. During a concurrent observation and interview on 8/9/2024 at 8:05 p.m., with CNA 2, in Resident 33's room, observed an unlabeled urinal hanging on Resident 33's right side rail, with liquid contents in the urinal. When asked who the urinal belongs to, CNA 2 stated that the urinal belongs to Resident 33. CNA 2 stated that the contents of the urinal should be discarded in the toilet and flushed. CNA 2 continued to state that the urinal should be stored in the resident's restroom with their name on it. CNA further stated that resident's name should be on the urinal for infection control. During an interview on 8/11/2024 at 4:43 p.m., with the Administrator (ADM), the ADM stated that urinals should not be placed hanging on a trash receptacle. The ADM stated urinals should be placed near the resident where it is reachable. The ADM continued to state that residents' name should be placed on urinals so staff know who the urinal belongs to and should be dated to ensure the facility changes the urinal for infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, reviewed 4/17/2024, indicated to provide guidelines for disinfection of bedpans and urinals. Cover and return bedpan or urinal to resident's bedside cabinet. Disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. c. During a concurrent observation and interview on 8/9/2024 at 6:17 p.m., observed the kitchen refrigerator with Dietary Aide 1 (DA 1). Certified Nursing Assistant 1 (CNA 1) provided translation assistance. Inside the refrigerator, observed an unlabeled plastic container of chilies. DA 1 stated it belonged to a staff member. During an interview on 8/11/2024 at 1:48 p.m., with the Dietary Supervisor (DS), the DS stated the container of chilies found inside the kitchen refrigerator belonged to a staff member. The DS stated staff food should have been kept separate from residents' food but could not explain why. During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was not the facility's practice to store staff food inside the kitchen refrigerator along with residents' food. The DON stated it was important to keep them separate because they did not know where the staff's food came from, so they wanted to prevent cross contamination with the residents' food. The DON stated that residents could possibly develop a foodborne illness if they ate contaminated food. During an interview on 8/11/2024 at 5:49 p.m., with the DON, the DON stated she could not find a policy specifically addressing the separation of staff food from residents' food. During a review of the facility's policy and procedure titled, Food and Nutrition Services, last reviewed on 4/17/2024, the policy indicated that the facility will store, distribute, and serve food in accordance with professional standards for food service safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/9/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that Resident 1 was totally dependent on staff for self-care and mobility. A record review of Resident 1's Change of Condition Form (COC- a documentation to show when there is a physical or mental change in the resident), dated 4/15/2023, timed at 6:00 a.m. indicated Resident 1 had a light-yellow discoloration (any change in natural skin tone) with edema (swelling) on right upper and lower arm, and the right shoulder. A record review of Resident 1's Physician's Orders, dated 4/15/2023, timed at 9:30 a.m. indicated that the physician ordered for X-radiation (x-ray- creation of pictures of the inside of the body) of Resident 1's right shoulder and humerus (long bone of the upper arm). A record review of Resident 1's X-ray report dated 4/16/2023, indicated that Resident 1 had a nondisplaced (bone breaks into pieces that stay in their normal alignment) right humeral fracture (broken bone in upper arm). During an interview and concurrent record review on 1/25/2024 at 12:40 p.m., the DON reviewed Resident 1' care plans dated 1/7/2024 for Activities of Daily Living (ADL) assist for bed mobility, dressing, toilet use, personal hygiene, and bathing was not updated or revised at any point to reflect the resident's sustained right arm broken bone on 4/15/2023. A review of the facility's policy and procedure titled Baseline/Comprehensive Care Plan lastly reviewed on 4/26/2023, indicated, The facility will develop a comprehensive, person-centered care plan for each resident Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened) that occurred on 4/15/2023 and 12/12/2023 for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: 1. A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/9/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that Resident 1 was totally dependent on staff for self-care and mobility. A record review of Resident 1's Change of Condition Form (COC- a documentation to show when there is a physical or mental change in the resident), dated 4/15/2023, timed at 6:00 a.m. indicated Resident 1 had a light-yellow discoloration (any change in natural skin tone) with edema (swelling) on right upper and lower arm, and the right shoulder. A record review of Resident 1's Physician's Orders, dated 4/15/2023, timed at 9:30 a.m. indicated that the physician ordered for X-radiation (x-ray- creation of pictures of the inside of the body) of Resident 1's right shoulder and humerus (long bone of the upper arm). A record review of Resident 1's X-ray report dated 4/16/2023, indicated that Resident 1 had a nondisplaced (bone breaks into pieces that stay in their normal alignment) right humeral fracture (broken bone in upper arm). During an interview on 1/25/2024 at 10:00 a.m. with the Director of Nursing (DON), the DON stated that Resident 1's broken bone in the right arm that was discovered on 4/16/2023 was an injury of unknown origin because the resident is unable to describe how the injury happened, and that there were no witnesses who could describe how Resident 1 sustained the injury. During an interview on 1/25/2024 at 1:40 p.m. with the Administrator (ADM), when the ADM was asked if the facility reported to the SSA Resident 1's injury of unknown origin discovered on 4/16/2023, the ADM stated that Resident 1's injury of unknown origin was not reported. The ADM stated that all injuries of unknown origins should be reported within two (2) hours from the identification of the injury to the SSA. 2. A review of Resident 2's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (a feeling of fear and uneasiness). A review of Resident 2's MDS dated [DATE], indicated the resident's cognition was moderately impaired. The MDS further indicated that Resident 2 was able to wheel themselves independently at least 150 feet (ft - unit of measure) once seated in the wheelchair. A record review of Resident 1's COC Form dated 12/12/2023, timed at 11:38 a.m. indicated that Licensed Vocational Nurse (LVN 1) observed that Resident 2 was holding Resident 1's left hand inside Resident 1's room. The COC Form further indicated that LVN 1 noted that Resident 1's left arm was slightly swollen during the body assessment. The COC Form went on to indicate that Resident 1 had an increased swelling on the left arm and elbow with purplish discoloration. A record review of Resident 1's Physician's Orders, dated 12/12/2023, timed at 1:00 p.m. indicated that the physician ordered for x-rays of Resident 1's left shoulder, arm, and elbow. A record review of Resident 1's X-ray report dated 12/12/2023, indicated that Resident 1 had no fracture (broken bone) or dislocation (a separation of two bones where they meet at a joint). During an interview with Resident 2 on 1/11/2024 at 4:02 p.m., Resident 2 was unable to recall the incident with Resident 1 on 12/12/2023. During an interview on 1/11/2024 at 4:06 p.m. with LVN 1, LVN 1 stated that on 12/12/2023 Resident 2 was found holding Resident 1's hand. LVN 1 stated that after Resident 2 released Resident 1's hand, there were no initial discoloration or bruises observed. LVN 1 stated that approximately one hour later, Resident 1 had discoloration and swelling to the left upper arm. During an interview on 1/11/2024 at 5:26 p.m. with the DON, the DON stated that Resident 1's discoloration and swelling to the left upper arm identified on 12/12/2023 was an injury of unknown origin. The DON stated that Resident 1's left upper arm discoloration and swelling noted on 12/12/2023 was an injury of unknown origin because Resident 1 was unable to explain what had happened. During an interview on 1/11/2024 at 5:36 p.m. with the ADM, the ADM stated that the injury Resident 1 sustained on 12/12/2023 which included discoloration and swelling to the left upper arm was not reported to the SSA or the local law enforcement until 12/28/2023. A review of the facility's policy and procedure titled Abuse Prohibition and Prevention Program revised March/2023, indicated that the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but not later than two [2] hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials including to the SSA.

Based on observation, interview, and record review, the facility failed to ensure Resident 36's call light was within reach for one of 44 sampled residents. This deficient practice had the potential for residents not being able to summon health care workers for assistance when needed. Findings: A review of the admission record indicated Resident 36 was admitted to the facility, on 3/04/2021, with diagnoses that included diabetes mellitus (chronic condition characterized by high blood sugar), hypertension (elevated blood pressure), and repeated falls. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/04/2021, indicated Resident 36 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 36 required supervision from staff with toileting and one-person limited assistance with dressing and personal hygiene. A review of Resident 36's Care Plan titled, Activities of Daily Living (ADL)/Self Care Deficit, reviewed on 12/2021, indicated an intervention to have the resident's call light within reach and for staff to answer promptly. During an observation, on 1/11/2022 at 10:15 a.m., Resident 35 was laying in bed and call light was out of reach of the resident. The call light was observed hanging behind the headboard of the resident's bed. During an observation and interview, on 1/11/2022 at 10:28 a.m., Certified Nursing Assistant 3 (CNA 3) confirmed the call light was behind the headboard of Resident 36's bed and out of reach of the resident. CNA 3 stated the call light should be next to or within reach of the resident to allow Resident 36 to call for help. During an interview, on 1/13/2022 at 5:05 p.m., the Director of Nursing (DON) stated all staff were responsible for answering call lights as soon as possible and should place call lights within reach of residents. The DON confirmed call light should be placed within reach for residents to call for assistance when needed to accommodate the resident's needs and for safety. A review of the facility's policy titled, Answering the Call Light, last reviewed and approved on 4/18/2021, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect Resident 14's use of oxygen according to the Minimum Data Set (MDS - an assessment and care screening tool) for one out of 13 sampled residents investigated addressing accuracy of MDS assessments. The failure to accurately assess Resident 14's oxygen use had the potential to negatively affect the resident's plan of care and delivery of necessary care and services. Findings: A review of the admission record indicated Resident 14 was admitted to the facility, on 11/28/2012 with a readmission of 07/08/2021, with diagnoses that included angina pectoris (chest pain caused by reduced blood flow to the heart), chronic atrial fibrillation (irregular rapid heart rate), and moderate persistent asthma (condition in which a person's airway become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). A review of the MDS, dated [DATE], indicated Resident 14 had the ability to make self-understood and the ability to understand others. The MDS did not indicate that resident received oxygen during the 14-day look-back period (time frame for observation). A review of Resident 14's physician's orders indicated an order for oxygen at two LPM (liters per minute) via nasal cannula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) continuously, ordered on 07/08/2021. During a concurrent interview and record review, on 01/13/2022 at 11:12 a.m., with the MDS Nurse, Resident 14's quarterly MDS dated [DATE] was reviewed. The MDS Nurse verified the MDS indicated Resident 14 was not on oxygen and stated it should have been marked for oxygen use. The MDS Nurse stated the MDS was a tool used for care planning. A review of the facility-provided Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated 10/2016, indicated oxygen therapy: code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item.

Based on observation, interview, and record review, the facility failed to ensure Resident 29's low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was properly set per resident's weight, for one of two sampled residents investigated under the care area of pressure ulcer/injury. This deficient practice placed Resident 29 at risk for skin breakdown and development of pressure ulcers. Findings: A review of the admission record indicated Resident 29 was admitted to the facility, on 06/17/2013 with a readmission date of 09/17/2021, with diagnoses that included quadriplegia (paralysis of all four limbs), gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 11/29/2021, indicated Resident 29 rarely/never made self-understood and the ability to sometimes understand others. A review of Resident 29's Monthly Record of Vital Signs and Weights indicated in 01/2022, Resident 29's weight was 101 pounds. A review of the Braden Scale for Predicting Pressure Sore Risk (an assessment tool for predicting the risk of pressure ulcers) indicated Resident 29 was at high risk for pressure ulcers. A review of Resident 29's physician's orders, dated 12/08/2021, indicated an order for low air loss mattress for high risk skin breakdown. During an observation, on 01/11/2022 at 09:59 a.m., Resident 29's LALM was set to four (4). Four indicated weight of 175 pounds. During a concurrent observation and interview, on 01/12/2022 at 10:44 a.m., Licensed Vocational Nurse 2 (LVN 2) verified Resident 29's LALM was set to nine (9) which indicated a weight of 350 pounds. LVN 2 stated Resident 29's LALM was set to the wrong setting and the LALM setting was based on the resident's weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 3's environment remained free from accident hazards by failing to have padded side rails per physician's orders, for one of two sampled residents investigated under the care area of accidents. This deficient practice had the potential to cause injury to Resident 3. Findings: A review of the admission record indicated Resident 3 was admitted to the facility, on 07/04/2014 and readmitted on [DATE], with diagnoses that included Huntington's disease (progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability), dementia (loss of cognitive functioning- thinking, remembering, and reasoning), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/05/2022, indicated Resident 3 rarely/never made self-understood and usually understood others. The MDS indicated Resident 3 needed total dependence with activities of daily living. A review of Resident 3's physician's orders, dated 12/29/2020, indicated an order for half padded side rails. During a concurrent observation and interview, on 01/11/2022 at 10:28 a.m., Licensed Vocational Nurse 2 (LVN 2) verified Resident 3's side rails were not padded. LVN 2 stated Resident 3 had padded side rails because she moved a lot and her side rails should be padded for safety. During an interview, on 01/14/2022 at 09:04 a.m., the Director of Nursing (DON) stated Resident 3 had Huntington's disease and jerking movements. The DON stated the side rails should have been padded because the side rails were being used for prevention of injury. A review of Resident 3's Evaluation for Use of Side Rails indicated side rails were being considered for safety and uncontrolled movement related to Huntington's chorea. The record indicated an intervention to minimize risk when using side rails had side rail pads. A review of the facility's policy titled, Proper Use of Side Rails, last reviewed and updated on 04/18/2021, indicated the resident will be checked periodically for safety relative to side rail use .Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders.

Based on interview and record review, the facility failed to test two out of eight sampled unvaccinated staff (Certified Nursing Assistant 1 [CNA 1] and Certified Nursing Assistant 2 [CNA 2]) twice per week for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) during the sampled period of 01/03/2022 to 01/09/2022. This deficient practice had to potential for unvaccinated staff, who are at higher risk for contracting COVID-19, to spread infection within the facility. Findings: During a concurrent interview and record review, on 01/14/2022 at 12:14 p.m., with the Infection Preventionist (IP), the IP reviewed the COVID-19 test results for Certified Nursing Assistant 1 (CNA 1) and confirmed that she was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP also reviewed the COVID-19 test results for Certified Nursing Assistant 2 (CNA 2) and confirmed that CNA 2 was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP stated all unvaccinated staff are required to be tested twice a week per current guidelines. The IP stated CNA 1 and CNA 2 should have been tested twice per week. A review of the facility's COVID-19 Mitigation Plan revised 01/07/2022, indicated the following: Additional testing requirements for non-fully vaccinated staff (unvaccinated, partially vaccinated) and booster-eligible staff who have not received their booster dose, including those who have an exemption to COVID-19 vaccination and/or booster doses: Non-fully vaccinated staff and booster-eligible staff who have not received their booster dose working more than one shift per week should test at least twice per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of the admission record indicated Resident 8 was admitted to the facility, on 4/1/2021 with diagnoses that included encounter for orthopedic (branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the musculoskeletal system) aftercare, pain in left lower leg, and contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of a joint) of the left hand. A review of the MDS, dated [DATE], indicated Resident 8 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 8 was to receive Hydrocodone-acetaminophen (Norco, a controlled pain medication used to relieve moderate to severe pain) tablet 5-325 mg one tablet oral for moderate to severe pain every 4 hours as needed (PRN), ordered on 12/31/2021. A review of Resident 8's Care Plan titled, Actual Alteration in Comfort: Pain, revised on 1/2022, indicated the following interventions: Assess level of pain, frequency, site, and factors that trigger the pain, medication as ordered and note effectiveness, and to document/notify physician of increasing and/or unrelieved pain. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., LVN 3 reviewed Resident 8's CDR and PRN Medication Flowsheet and verified the following: - One dose of Norco 5-325 documented on the CDR for 1/4/2022 was not documented on the PRN Medication Flowsheet. - One dose of Norco 5-325 documented on the CDR for 1/6/2022 was not documented on the PRN Medication Flowsheet. - Pain assessment and reassessment for Norco 5-325 administered on 1/6/2022 were not documented on the PRN Medication Flowsheet. LVN 3 stated the process was to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions were ineffective, then the license nurse would check the physician orders to see what pain medications could be given. LVN 3 stated license nurse would then remove the medication from the bubble pack, document on the Controlled Drug Record, administer the ordered pain medication, and document on PRN Medication Flowsheet. LVN 3 stated the pain assessment was documented on the back of the PRN Medication Flowsheet every time a PRN pain medication was given that included the date, time, name of the medication, pain location, and the pain intensity using a pain scale of 1-10. LVN 3 further stated residents who received pain medication were reassessed for pain one hour later and the reassessment was documented on the back of the PRN Medication Flowsheet. LVN 3 confirmed that the doses of PRN Norco given on 1/4/2022 and 1/6/2022 should have been documented on the PRN Medication Flowsheet to reflect that the PRN pain medication was administered. LVN 3 further stated a pain assessment and reassessment should have been completed and documented on the PRN Medication Flowsheet for the dose given on 1/6/2022 to evaluate Resident 8's pain level and location and to determine if the pain medication given was effective. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., the DON verified the missing entries on the PRN Medication Flowsheet for the PRN Norco administered on 1/4/2022 and 1/6/2022 as well as the missing pain assessment and reassessment for the dose given on 1/6/2022. The DON explained that the process was for license nurses to conduct a pain assessment and initiate nonpharmacological interventions when a resident complained of pain. The DON stated licensed nurses would then check the physician's order, administer the ordered pain medication, and document the pain assessment on the back of the PRN Medication Flowsheet. The DON confirmed the license nurse should document entries from the CDR on the PRN Medication Flowsheet and conduct a pain assessment prior to after administering pain medications on the back of the PRN Medication Flowsheet. The DON stated it was important to document the administered doses of PRN Norco on Resident 8's PRN Medication Flowsheet to match the CDR and to accurately reflect what was given. The DON further stated that pain assessments and reassessments should be done to monitor the resident's pain level and for staff to relay to the physician if pain medication was effective. The DON explained pain affected the resident's quality of life and residents should be free of pain as much as possible. d. A review of the admission record indicated Resident 144 was admitted to the facility, on 12/30/2021, with diagnoses that included unilateral primary osteoarthritis (joint disease in which the tissues in the joint break down over time) of left knee and presence of left artificial knee joint. A review of the MDS, dated [DATE], indicated Resident 144 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 144 was to receive Oxycodone (pain medication is used to help relieve moderate to severe pain) 5 mg one tablet by mouth every four hours PRN for moderate pain 4-6/10, ordered on 12/31/2021. - Resident 144 was to receive Oxycodone 10 mg one tablet by mouth every four hours PRN for severe pain 7-10/10. A review of Resident 144's Care Plan titled, Actual Alteration in Comfort: Pain, initiated on 1/2/2022, indicated the following interventions: Assess level of pain, frequency, site, and factors that trigger the pain, medication as ordered and note effectiveness, and document and notify physician of increasing and/or unrelieved pain. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., LVN 3 reviewed Resident 144's Controlled Drug Record (CDR) and Medication Administration Record (MAR) for 01/2022 and verified the following: - One dose of Oxycodone 10 mg documented on the CDR for 1/4/2022 at 10:30 p.m. was not documented on the MAR. - Pain assessments and reassessments for Oxycodone 10 mg given on 1/3/2022 at 9 a.m., 1/4/2022 at 2 a.m., and 1/4/2022 at 10:30 p.m., were not documented on the MAR. - Resident 144 received Oxycodone 5mg on 1/5/2022 at 9 a.m. for pain level of 7/10. LVN 3 stated the process was to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions were ineffective, then the license nurse would check the physician orders to see what pain medications could be given. LVN 3 stated license nurse would then remove the medication from the bubble pack, document on the Controlled Drug Record, administer the ordered pain medication, and document on the MAR. LVN 3 stated the pain assessment was documented on the back of the MAR every time a PRN pain medication was given that included the date, time, name of the medication, pain location, and the pain intensity using a pain scale of 1-10. LVN 3 further stated residents who received pain medication were reassessed for pain one hour later and the reassessment was documented on the back of the PRN Medication Flowsheet. LVN 3 confirmed that the dose of PRN Oxycodone 10 mg given on 1/4/2022 at 10:30 p.m. should have been documented on the MAR to reflect that the medication was administered. LVN 3 stated that a pain assessment should have been conducted for Resident 144 since the resident had an order specifying how much Oxycodone should be given based on the resident's pain level. LVN 3 reviewed Resident 144's physician's order and verified that the resident had an order for Oxycodone 5 mg for moderate pain of 4-6/10 and Oxycodone 10 mg for severe pain of 7-10/10. LVN 3 then reviewed Resident 144's MAR and confirmed Oxycodone 5mg was given on 1/5/2022 for pain level of 7/10. LVN 3 clarified that Resident 144 should have received Oxycodone 10 mg instead of 5 mg on 1/5/2022 based on the resident's pain level of 7/10 and the parameters set by the physician that indicated to give 10 mg for pain level of 7-10 out of 10. LVN 3 stated it was important to reassess residents for pain upon administering a pain medication to make sure that the medication was effective and to monitor for side effects. LVN 3 further stated there was potential for the resident to still be in pain by not following the parameters ordered by the physician. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., the DON verified Resident 144's CDR indicated Oxycodone 10mg was given on 1/4/22 at 10:30 pm but did not reflect on the Resident 144's MAR. The DON also confirmed the missing pain assessments and reassessments on the MAR for Oxycodone 10 mg administered on 1/3/2022 at 9 a.m., 1/4/2022 at 2 a.m., and 1/4/2022 at 10:30 p.m. The DON explained that the process was for license nurses to conduct a pain assessment and initiate nonpharmacological interventions when a resident complained of pain. The DON stated licensed nurses would then check the physician's order, administer the ordered pain medication, and document the pain assessment on the back of the MAR. The DON confirmed the license nurse should document entries from the CDR on the MAR and conduct a pain assessment prior to after administering pain medications on the back of the MAR. The DON stated it was important to document the administered dose of PRN Oxycodone 10 mg on Resident 144's MAR to match the CDR and to accurately reflect what was given. The DON further stated that pain assessments and reassessments should be done to monitor the resident's pain level and for staff to relay to the physician if pain medication was effective. The DON explained pain affects the resident's quality of life and that residents should be free of pain as much as possible. The DON reviewed Resident 144's MAR from 01/2022 and confirmed that Resident 144 received Oxycodone 5 mg instead of 10 mg on 1/5/2022. The DON also reviewed Resident 144's physician's order and verified Resident 144 should have received Oxycodone 10 mg since Resident 144's pain level was 7/10 and the order was to give 10 mg for severe pain of 7-10/10. The DON stated the importance of following physician's order and administering the correct dose according to the resident's pain level. A review of the facility's policy titled, Pain Management Program, last reviewed and approved on 4/18/2021, indicated it is the policy of this facility to assess all residents for pain upon admission, first complaint or symptoms of discomfort. The policy further indicated that residents on a pain management regimen will be monitored daily or as needed for changes in pain intensity. A review of the facility's policy titled, Medication Administration,' last reviewed and approved on 4/18/2021, indicated medications are administered in accordance with written orders of the attending physician. The policy further indicated the following: When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral), and, if applicable the injection site. Complaints or symptoms for which the medication is given. Results achieved from giving the dose and the time results were noted. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. Based on observation, interview, and record review, the facility failed to ensure residents' effective pain management by failing to: 1. Document pre and post pain assessments for four of five sampled residents (Residents 4, 13, 8, and 144) investigated under the care of pain management. 2. Administer pain medication for the appropriate pain scale as indicated by the physician's orders for one of five sampled residents (Resident 144) investigated under the care area of pain management. These deficient practices may lead to inaccurate pain assessment and mismanagement of residents' pain. Findings: a. A review of the admission record indicated Resident 4 was admitted to the facility, on 09/28/2021, with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/05/2022, indicated Resident 4 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 4 was to receive Hydrocodone-acetaminophen (controlled strong pain medication) 5-325 mg (milligram - unit of measurement) one tab for moderate pain every six hours PRN (as needed). - Resident 4 was to receive Hydrocodone-acetaminophen 5-325 mg two tabs for severe pain every six hours PRN. During an inspection of Medication Cart, on 01/12/2022 at 02:46 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 4's Controlled Drug Record (CDR), Medication Administration Record (MAR), and Pain Assessment Flow Sheet (PAFS) were reviewed. LVN 1 verified the following: - One dose of hydrocodone-acetaminophen 5-325mg two tabs documented on the CDR for 01/08/2022 was not documented on the PAFS and pre and post pain evaluation was not done. - One dose of hydrocodone-acetaminophen 5-325mg two tabs documented on the CDR for 01/09/2022 was not documented on the Pain Assessment Flow Sheet (PAFS) and pre and post pain evaluation was not done. b. A review of the admission record indicated Resident 13 was admitted to the facility, on 04/01/2021, with diagnoses that included hypertension, cardiomegaly (enlarged heart), and heart failure (heart is not pumping as well as it should be). A review of the MDS, dated [DATE], indicated Resident 13 had the ability to make self-understood and to understand others. A review of the physician's orders indicated Resident 13 was to receive an order for tramadol 50 mg (controlled strong pain medication) every 12 hours as needed. During an inspection of Medication Cart, on 01/12/2022 at 03:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 13's CDR, MAR, and PAFS were reviewed. LVN 1 verified one dose of tramadol 50 mg documented on the CDR for 01/02/2022 was not documented on the PAFS and pre and post pain evaluation was not done. LVN 1 stated the process when giving pain medications was to assess the resident to try non-pharmacological interventions first. LVN 1 stated if that did not work she would check the resident's physician orders and medicate the resident according to pain scale. LVN 1 stated she would then take out the medication from the bubble pack and sign the CDR. Then LVN 1 would medicate the resident and document on the MAR and document the pain assessment. LVN 1 stated she would reassess the resident after 30 minutes to an hour and document pain effectiveness. LVN 1 stated pain assessment and evaluation should have been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 8's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic (branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the musculoskeletal system) aftercare, pain in left lower leg, and contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of a joint) of the left hand. A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/4/2022, indicated that Resident 8 has the ability to make self-understood and has the ability to understand others. A review of Resident 8's physician's orders indicated the following: - Hydrocodone-acetaminophen (Norco, a controlled pain medication used to relieve moderate to severe pain) tablet 5-325 milligrams (mg - unit of measurement) one tablet oral (by mouth) for moderate to severe pain every 4 hours as needed (PRN), ordered on 12/31/2021. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Resident 8's Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) and PRN Medication Flowsheet (the report that serves as a legal record of the PRN medication administered to a resident) and verified the following: - One dose of Norco 5-325 mg documented on the CDR for 1/4/2022 was not documented on the PRN Medication Flowsheet. - One dose of Norco 5-325 mg documented on the CDR for 1/6/2022 was not documented on the PRN Medication Flowsheet. LVN 3 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions are ineffective, then the license nurse will check the physician orders to see what pain medications can be given. LVN 3 stated license nurse will then remove the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), document on the Controlled Drug Record, administer the pain medication, and document on the PRN Medication Flowsheet upon giving the medication. LVN 3 confirmed that the doses of PRN Norco given on 1/4/2022 and 1/6/2022 should have been documented on the PRN Medication Flowsheet to reflect that the medication was administered and should match the CDR. LVN 3 explained that if it is not documented, then it will appear as if the medication was not given. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., with the Director of Nursing (DON), the DON verified the missing entries on the PRN Medication Flowsheet for the PRN Norco administered on 1/4/2022 and 1/6/2022. The DON stated the license nurse should document entries from the CDR on the PRN Medication Flowsheet to accurately reflect what the resident received for pain. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and approved on 4/18/2021, indicated, the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. The policy further indicated the person administering the medications reviews the MAR to ensure necessary doses were administered and documented at the end of each medication pass and in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. d. A review of Resident 144's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that include unilateral primary osteoarthritis (joint disease in which the tissues in the joint break down over time) of left knee and presence of left artificial knee joint. A review of Resident 144's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/6/2022, indicated Resident 144 has the ability to make self-understood and has the ability to understand others. A review of Resident 144's physician's orders indicated the following: - Oxycodone (pain medication is used to help relieve moderate to severe pain) 5 milligrams (mg - unit of measurement) one tablet by mouth every four hours as needed (PRN) for moderate pain 4-6/10. - Oxycodone 10 mg one tablet by mouth every four hours PRN for severe pain 7-10/10. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Resident 144's Controlled Drug Record (CDR) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional)) for January 2022 and verified the following: - One dose of Oxycodone 10 mg documented on the CDR for 1/4/2022 at 10:30 p.m. was not documented on the MAR. LVN 3 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions are ineffective, then the license nurse will check the physician orders to see what pain medications can be given. LVN 3 stated license nurse will then remove the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), document on the Controlled Drug Record, administer the pain medication, and document on the MAR upon giving the medication. LVN 3 confirmed that the dose of PRN Oxycodone 10 mg given on 1/4/2022 at 10:30 p.m. should have been documented on the MAR by the licensed nurse to reflect that the medication was administered and should match the CDR. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., with the Director of Nursing (DON), the DON verified the missing entry on the MAR for PRN Oxycodone 10 mg. The DON stated the CDR indicated Oxycodone 10 mg was given on 1/4/2022 at 10:30 p.m. but did not reflect on the MAR. The DON stated the license nurse should document entries from the CDR on the MAR to accurately reflect what the resident received for pain. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and approved on 4/18/2021, indicated, the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. The policy further indicated the person administering the medications reviews the MAR to ensure necessary doses were administered and documented at the end of each medication pass and in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. Based on observation, interview, and record review, the facility failed to ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records for four of five sampled residents (Resident 4, 13, 8, and 144). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: a. A review of Resident 4's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of Resident 4's Minimum Data Set (MDS - an assessment and care screening tool) dated 01/05/2022 indicated the resident has the ability to make self-understood and has the ability to understand others. A review of Resident 4's physician's orders indicated the following: - Hydrocodone-acetaminophen (a controlled strong pain medication) 5-325 milligrams (mg - unit of measurement) one tablet (tab) for moderate pain every six hours as needed (PRN). - Hydrocodone-acetaminophen 5-325 mg two tabs for severe pain every six hours PRN. During an inspection of Medication Cart #2 in Station 1 on 01/12/2022 at 02:46 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 4's Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) were reviewed. LVN 1 verified the following: - One dose of hydrocodone-acetaminophen 5-325 mg two tabs documented on the CDR for 01/08/2022 was not documented on the MAR. - One dose of hydrocodone-acetaminophen 5-325 mg two tabs documented on the CDR for 01/09/2022 was not documented on the MAR. LVN 1 stated the process when giving pain medications is to assess the resident and try non-pharmacological interventions first. LVN 1 stated if that doesn't work she would check the resident's physician orders and medicate the resident according to pain scale (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain). LVN 1 stated she would then take out the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), sign the CDR, medicate the resident, and then document on the MAR. LVN 1 stated the entries should have been documented on the MAR. During an interview on 01/14/2022 at 08:58 a.m., with the Director of Nursing (DON), the DON stated the process when giving PRN pain medications is to assess the resident for pain location and severity and to try non-pharmacological interventions first. The DON stated if that doesn't work the next step is to check the record for pain management order. The DON stated the license nurse would get the narcotic and sign it out from the narcotic book (CDR) and would then give it to the resident and document on the MAR. The DON stated the entries should be documented on the MAR. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed and updated on 04/18/2021, indicated, A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/18/2021, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications .The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site .d. Signature or initials of person recording administration. b. A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (elevated blood pressure), cardiomegaly (enlarged heart), and heart failure (heart is not pumping as well as it should be). A review of Resident 13's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/12/2021 indicated the resident has the ability to make self-understood and has the ability to understand others. A review of Resident 13's physician's orders indicated an order for tramadol (a controlled strong pain medication) 50 milligrams (mg - unit of measurement) every 12 hours as needed. During an inspection of Medication Cart #2 in Station 1 on 01/12/2022 at 03:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 13's Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) were reviewed. LVN 1 verified one dose of tramadol 50 mg documented on the CDR for 01/02/2022 was not documented on the MAR. LVN 1 stated the process when giving pain medications is to assess the resident and try non-pharmacological interventions first. LVN 1 stated if that doesn't work she would check the resident's physician orders and medicate the resident according to pain scale (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain). LVN 1 stated she would then take out the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), sign the CDR, medicate the resident, and then document on the MAR. LVN 1 stated the entries should have been documented on the MAR. During an interview on 01/14/2022 at 08:58 a.m., with the Director of Nursing (DON), the DON stated the process when giving PRN pain medications is to assess the resident for pain location and severity and to try non-pharmacological interventions first. The DON stated if that doesn't work the next step is to check the record for pain management order. The DON stated the license nurse would get the narcotic and sign it out from the narcotic book (CDR) and would then give it to the resident and document on the MAR. The DON stated the entries should be documented on the MAR. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed and updated on 04/18/2021, indicated, A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/18/2021, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications .The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site .d. Signature or initials of person recording administration.

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by: 1. Failing to label and date half-cut tomatoes and onions found in the facility refrigerator for 39 out of 44 residents who receive and consume food from the facility kitchen. 2. Failing to maintain a bag of potato dices off the floor in the dry storage area. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) Findings: a. During an initial kitchen tour observation, on 1/11/2022 at 8:03 a.m., observed the following unlabeled food items in the refrigerator: - two half-cut tomatoes with no date - a half-cut onion with no date During a concurrent observation and interview, on 1/11/2022 at 8:03 a.m., [NAME] 1 observed and verified the 2 half-cut tomatoes and 1 half-cut onion in the refrigerator were not labeled. [NAME] 1 stated the tomatoes and onion should have been labeled with the date once they were cut and before storing it in the refrigerator. During an interview, on 1/12/2022 at 10:02 a.m., the Registered Dietician (RD) confirmed the half-cut tomatoes and onion should have been labeled with the date once they were cut. The RD stated food items should be labeled and used as fast as possible once they are cut through the surface since there is potential for contamination and further exposure to germs. A review of the facility's policy and procedure titled, Refrigerated Storage, last reviewed and approved on 4/18/2021, indicated, leftover food or unused portions of packaged foods should be covered, labeled and dated to assure they will be used first. b. During an initial kitchen tour observation, on 1/11/2022 at 8:21 a.m., observed a large bag of potato dices on the floor of the dry storage area located in the facility's pantry. During a concurrent observation and interview, on 1/11/2022 at 8:21 a.m., [NAME] 1 observed and verified the bag of potato dices on the floor of the dry storage area. [NAME] 1 stated the bag of potato dices should not be on the floor for infection control. Observed [NAME] 1 pick up the bag of potato dices off the floor and place it on the dry storage rack. During an interview, on 1/12/2022 at 10:02 a.m., the RD stated all dry food storage should be maintained on a shelf and off the floor. The RD confirmed the bag of potato dices should not have been placed on the floor in case of leaks or contaminants on the floor to potentially seep into the potatoes. A review of the facility's policy and procedure titled, Canned and Dry Goods Storage, last reviewed and approved on 4/18/2021, indicated, all food items will be stored off the floor on racks, shelves or other surfaces that can be cleaned thoroughly. The policy further indicated, food and supplies should also be stored six inches off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) doffed (removed) her contaminated gowns and gloves prior to leaving isolation room within the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) to discard a tray in the trash bin located outside of the room. 2. Ensure Certified Nursing Assistant 5 (CNA 5) and Certified Nursing Assistant 6 (CNA 6) wore eye protection within six feet of providing care for Residents 17 and 143. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene upon doffing contaminated gloves used to remove a dressing from a wound site and prior to donning (putting on) new gloves during Resident 39's wound care. 4. Check and monitor vital signs every four hours for one of one sampled resident (Resident 39) in the red zone. 5. Ensure transmission-based precaution (measures used to help stop the spread of germs from one person to another) signs and donning (putting on)/doffing (taking off) signs were posted outside of one of one sampled resident's room (Resident 26) in the yellow zone (cohort of the facility consisting of following residents under quarantine: newly admitted or readmitted , resident who leave the facility for more than 24 hours, symptomatic, close contact to known COVID-19 case, indeterminate test results, unvaccinated or partially vaccinated residents who frequently leave the facility for medical appointments). These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. The deficient practice involving Resident 39 had the potential to result in failure to identify clinical deterioration in residents confirmed with COVID-19 timely and allow for early intervention opportunities that includes transferring resident to a higher level of care. Findings: a. During an observation, on 1/11/2022 at 1:05 p.m., observed Certified Nursing Assistant 4 (CNA 4) wearing isolation gown and gloves leaving Resident 39's room in the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection])and discarding disposable meal tray in trash bin located outside of the room. During an interview, on 1/11/2022 at 1:06 p.m., CNA 4 confirmed she was still wearing her gown and gloves when stepping out of the isolation room to throw away Resident 39's meal tray in trash bin located outside of the room. CNA 4 stated she should be doffing (removing) her contaminated gowns and gloves in the bin designated for personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) located inside the room near the exit before she leaves the isolation room per policy for infection control. During an interview, on 1/13/2021 at 11:31 a.m., the Infection Preventionist (IP) stated staff should be doffing gown and gloves and discarding them in the trash bin located inside the room prior to exiting an isolation room. The IP stated the purpose of doffing contaminated gowns and gloves inside is for infection control and making sure whatever is in the room stays in there. A review of the facility's policy and procedure titled, Personal Protective equipment - Gowns, Aprons, Lab Coats, last reviewed and approved on 4/18/2021, indicated, when gowns are used, they must be used only once and discarded into appropriate receptacles located in the room in which the procedure was performed. The policy further indicated, soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. b. During a concurrent observation and interview, on 1/12/2022 at 12:43 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Certified Nursing Assistant 5 (CNA 5) with goggles resting on the top of her head. Observed CNA 5 within six feet of Resident 17 in her room and assisting with meal tray. LVN 2 observed and verified CNA 5 was not wearing face shield or goggles properly to cover the eyes. LVN 2 stated staff are required to wear eye protection while providing care and within six feet of residents in the green zone (cohort reserved for residents who do not have COVID-19). LVN 2 further stated CNA should have worn eye protection for infection control. During an interview, on 1/12/2022 at 12:43 p.m., CNA 5 verified her goggles were on the top of her head and that she was not wearing her goggles properly to cover her eyes. CNA 5 stated she should be wearing a mask and goggles while within six feet of residents. CNA 5 stated wearing her goggles is important for infection control and for her protection. During a concurrent observation and interview, on 1/14/2022 at 7:48 a.m., in the presence of the Infection Preventionist (IP), observed Certified Nursing Assistant 6 (CNA 6) without a goggle or face shield while assisting Resident 143 with feeding. The IP observed and confirmed that CNA 6 was not wearing eye protection while feeding Resident 143. The IP further stated CNA 6 should have been wearing one since he was providing care within six feet of the resident. During an interview, on 1/14/2022 at 7:50 a.m., CNA 6 verified he was not wearing goggles while feeding Resident 143. CNA 6 stated he should be wearing his goggle and mask when providing care for residents in the green zone. CNA 6 stated the purpose of wearing eye protection is to protect himself and the residents from infection. During an interview, on 1/14/2022 at 7:50 a.m., the IP stated all staff should be wearing eye protection while providing care within six feet of residents in the green zone. The IP further stated face shields or goggles should not be resting on the top of the head but should completely cover the eyes. The IP stated the purpose of face shields and goggles is to protect the eyes and for infection control. A review of the facility's policy and procedure titled, COVID-19 Mitigation Plan, last reviewed and updated on 1/7/2022, indicated, eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within six feet of residents, or while in resident rooms in all cohorts. c. During a concurrent observation and interview, on 1/13/2022 at 10:18 a.m., observed Licensed Vocational Nurse 2 (LVN 2) perform wound care for Resident 39. Observed LVN 2 remove the old dressing from Resident 39's right upper posterior thigh wound and doff (remove) her contaminated gloves. However, LVN 2 did not perform hand hygiene before donning (putting on) new gloves. Observed LVN 2 proceed to cleanse wound with normal saline (NS, solution used to clean wounds during wound treatment) and apply hydrogel (dressing applied to wound to facilitate healing) to wound. Observed LVN 2 doff gloves again and don new gloves without performing hand hygiene. LVN 2 confirmed that she did not perform hand hygiene upon doffing her gloves and prior to donning new gloves during Resident 39's wound treatment. LVN 2 stated she washes her hands prior to and after providing wound care but she does not perform hand hygiene in between changing gloves during wound care. LVN 2 stated she should wash hands with soap and water or with alcohol-based hand sanitizer (ABHS) in between changing gloves to prevent possible spread of infection. During an interview, on 1/13/2022 at 11:34 a.m., the IP stated the licensed nurse should have doffed her contaminated gloves and performed hand hygiene using at least ABHS before putting on new gloves. The IP stated the purpose of performing hand hygiene in between doffing contaminated gloves and donning new gloves is for infection control to prevent further spread of infection. A review of the facility's policy and procedure titled, Wound Care, last reviewed and approved on 4/18/2021, indicated the following: Steps in the Procedure 1.Use disposable cloth to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on the exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly. 6. Put on gloves. A review of the facility's policy and procedure titled, Handwashing, last reviewed and approved on 4/18/2021, indicated, if gloves are worn for a procedure, hands are to be washed before putting gloves on and after removal and deposit of gloves in appropriate container. d. During a concurrent interview and record review, on 1/13/2022 at 12:18 p.m., Licensed Vocational Nurse 1(LVN 1), stated vital signs are monitored once every shift for COVID-19 positive residents in the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]). LVN 1 reviewed Resident 39's MAR from January 2022 and confirmed that vital signs were checked only once per shift since 1/10/2022 when the resident tested positive and was placed in the red zone. During a concurrent interview and record review, on 1/13/2022 at 3:56 p.m., the Infection Preventionist (IP), stated vital signs are monitored every four hours for COVID-19 positive residents in the red zone. The IP reviewed Resident 39's Medication Administration Record (MAR) from January 2022 and confirmed that the vital signs for Resident 39 was done once per shift. The IP stated Resident 39 tested positive for COVID-19 on 1/10/2022 and staff should have monitored her vital signs every four hours. The IP further stated it is important to increase vital sign monitoring to every four hours for residents in the red zone since they are more susceptible to issues and to identify any changes in the resident's condition promptly due their diagnosis of COVID-19. The IP stated the facility is following guidelines from Centers for Disease Control and Prevention (CDC) relating to managing residents with suspected or confirmed COVID-19. A review of the Interim Infection Prevention and Control Recommendations to Prevent Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, virus that can lead to COVID-19 and cause respiratory illness) Spread in Nursing Homes, updated 9/10/2021, indicated to increase monitoring of residents q4 (every four hours) with suspected or confirmed SARs-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation (measure of oxygen level in the blood) via pulse oximetry (noninvasive test used to measure the oxygen saturation), and respiratory exam, to identify and quickly manage serious infection. e. A review of Resident 26's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] with a readmission date of 06/08/2020 with diagnose that included heart failure (the heart is unable to provide adequate blood flow to other organs), chronic kidney disease, and personal history of COVID-19 (Coronavirus disease-2019, a highly contagious viral infection that can trigger respiratory tract infection). A review of Resident Minimum Data Set (MDS - an assessment and care screening tool) dated 11/09/2021 indicated the resident has the ability to make self-understood and has the ability to understand others. During a concurrent observation and interview on 01/11/2022 at 11:20 a.m., with the Infection Preventionist (IP), observed no transmission-based precaution (measures used to help stop the spread of germs from one person to another) signs and donning (putting on) and doffing (taking off) signs in front of Resident 26's room who is in the yellow zone (cohort of the facility consisting of following residents under quarantine: newly admitted or readmitted , resident who leave the facility for more than 24 hours, symptomatic, close contact to known COVID-19 case, indeterminate test results, unvaccinated or partially vaccinated residents who frequently leave the facility for medical appointments). The IP stated the purpose of the signage is for everyone to know the resident is being monitored for exposure or possible symptoms. The IP stated Resident 26 was a close contact to a positive case who was her roommate. During an interview on 01/14/2022 at 9:06 a.m., with the Director of Nursing (DON), the DON stated the purpose of having isolation and donning and doffing signs are for visible reminders for proper infection control measures. The DON stated donning and doffing signs are used as a guide for proper donning and doffing. A review of the facility's COVID-19 Mitigation Plan revised 01/07/2022, indicated the following: Yellow Cohort (Mixed quarantining and symptomatic cohort) All exposed residents can remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate transmission-based precautions should be placed outside of these residents' rooms. Transmission Based Precautions and Personal Protective Equipment (PPE) Post appropriate transmission-based precaution signage outside of each resident room. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas. A review of the facility's policy and procedure titled, Isolation-Initiating Transmission-Based Precautions, last reviewed and updated on 04/18/2021, indicated, When transmission-based precautions are implemented, the Infection Control Coordinator (or designee) or shall post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. A review of the facility's policy and procedure titled, Isolation-Notices of Transmission-Based Precautions, last reviewed and updated on 04/18/2021, indicated, When transmission-based precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of transmission-based precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy.

Based on interview and record review, the facility failed to notify the resident's responsible party for 24 out of 44 residents (Residents 3, 5, 6, 11, 12, 13, 14, 16, 17, 18, 21, 24, 26, 27, 28, 29, 35, 36, 37, 38, 39, 40, 42, 142) by 5 p.m. the next calendar day following a confirmed COVID positive case within the facility. This deficient practice resulted in a delay in informing the residents' responsible parties regarding the status of the outbreak (a sudden rise in the incidence of disease) within the facility. Findings: During a phone interview, on 1/12/2022 at 1:45 p.m., Family Member 1 (FM 1) stated he was not aware of the facility's Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) outbreak (a sudden rise in the incidence of disease). FM 1 confirmed he did not receive any email, text, or phone call regarding a positive case among residents or staff within the facility. During an interview, on 1/12/2022 at 2:02 p.m., the Social Service Director (SSD) stated the responsible party of all residents are notified of positive cases that occur within the facility immediately and no later than 5 p.m. the same day. The SSD stated Resident 39 had tested positive on 1/10/2022 and confirmed that there was no notification sent to any of the resident's family members regarding the positive case. The SSD stated he is responsible for notifying and updating the resident's RP regarding the facility's outbreak status by email or text. However, SSD stated he was not present at the facility on 1/10/2022 and 1/11/2022 and verified there was no one to cover for him while he was out sick. The SSD stated the importance of notifying family members and responsible parties timely regarding COVID-19 cases within the facility to keep them informed and up to date. The SSD further stated the information may be helpful for family members who are planning to visit as it may change their outlook on doing so during an outbreak. During a concurrent interview and record review, on 1/14/2022 at 4:21 p.m., the Director of Nursing (DON) stated the SSD sends a group text to the resident's responsible party regarding any confirmed cases among staff or residents within the facility by 5 p.m. the next day. The DON stated COVID-19 updates are also provided through group texting by the SSD. The DON reviewed the group text sent to the responsible parties regarding the positive case and verified the group text was sent on 1/12/2022 at 4:46 p.m. The DON stated that since Resident 39 tested positive on 1/10/2022, the family members or responsible parties should have been notified no later than 1/11/2022 at 5 p.m. The DON confirmed the group text was sent late. The DON stated she told the Infection Preventionist (IP) to coordinate with the SSD to send a group text to the responsible parties since the SSD was not present and agreed there should be someone to back up the SSD in case he is not available. The DON stated responsible parties of residents should be notified of the positive cases within the facility so they are aware of the resident's status and to follow guidelines regarding informing family representatives along with actions taken by the facility. During an interview, on 1/14/2022 at 4:38 p.m., the Infection Preventionist (IP) confirmed that he had not relayed the information regarding the positive case on 1/10/2022 to the SSD and that the SSD was unaware. A review of the facility's policy and procedure titled, Notification of Responsible Agent/Residents regarding COVID-19 Outbreak, dated 6/1/2021, indicated the following: 1. The facility will ensure that notification is provided to the resident, their responsible agent and/or family by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. a. The notification will not include any personally identifiable information. b. The notification will include information/mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered, such as visitations et cetera. c. Cumulative updates will be provided for residents, responsible agents/families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.