Based on observation and interview, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety for 1 of 1 kitchen observed. Findings include: Observation on 10/28/24 at approximately 8:40 a.m. Staff F (Chef Manager) and Staff G (Assistant Chef Manager) revealed a box containing an open, undated bag of frozen rib patties in the walk-in freezer. Observation in the walk-in refrigerator revealed a box of tomatoes with black spots visible and a bag of cubed moldy pepper jack cheese. Interview on 10/28/24 at approximately 8:45 a.m. with Staff F and Staff G confirmed the above findings. Review on 10/28/24 of the FDA 2022 Food Code, retrieved from https://www.fda.gov/media/164194/download?attachment, revealed: .Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation .FOOD shall be protected from cross contamination by .storing the FOOD in packages, covered containers, or wrappings; .Preventing Contamination from the Premises 3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location (2) Where it is not exposed to splash, dust, or other contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #48 Review on 10/24/23 of Resident #48's electronic medical record revealed that Resident #48 was initially admitted to the facility on [DATE]. Review on 10/24/23 of Resident #48's Level 1 PASARR dated 5/24/22 revealed that the PASARR form, under Section 6 Exemption/Exclusion, Hospital discharge was checked and dated 5/24/22, which indicated that the physician certified that Resident #48 required less than 30 days of nursing facility (NF) services. Under the date read Note: If the NF stay is 30 days or longer, a new PASARR screen and resident review must be performed within 40 calendar days of admission. Interview on 10/26/23 at 8:30 a.m. with Staff A confirmed the above findings. Staff A confirmed that Resident #48 remained in the facility longer than 30 days and there was no additional PASARR performed. Review of the facility's policy titled, Presidential Oaks Policy on Pre-admission Screening and Annual Resident Review, dated 2022/2023, revealed .that every resident with a known or suspected primary or secondary diagnosis of a serious mental illness or developmental delay will be screen by PASSAR .6) Be aware that if a resident's length of stay is suspected to extend past 30 days . Based on interview and record review, it was determined that the facility failed to ensure that residents with a mental disorder received an accuracte Level I Pre-admission Screening and Resident Review (PASARR) for 2 of 4 residents reviewed for PASARR in a final sample of 19 residents (Resident identifiers are #14 and #48). Findings include: Resident #14 Review on 10/25/23 of Resident #14's medical record revealed that Resident #14 was admitted to the facility on [DATE]. Review on 10/25/23 of Resident #14's diagnosis list in the electronic health record revealed that #14 had a diagnosis of Schizophrenia on admission to the facility. Review on 10/25/23 of Resident #14's Level I PASARR form (completed 2/9/22) revealed: Section 2: Screening for Mental Illness (MI), No was checked. Section 3: Screening for Intellectual Disability/Developmental Disability (ID/DD), No was checked. Section 4: Screening for Related Condition (RC), No was checked. Section 5: Undiagnosed Condition No was checked. Section 8: Level I Screening Summary, Not requiring PASARR involvement Not MI, Not ID/DD, and Not RC checked. Interview on 10/26/23 at approximately 9:00 a.m. with Staff A (Social Worker) revealed that the PASARR dated 2/9/22 was not accurate and a new PASARR should have been completed reflecting a diagnosis of Schizophrenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that a resident had a comprehensive person-centered care plan for a Post-Traumatic Stress Disorder (PTSD) diagnosis for 1 of 1 resident reviewed for behavioral-emotional (Resident identifier is #11). Findings include: Review on 10/24/23 of the facility's matrix revealed that Resident #11 triggered for PTSD/Trauma. Review on 10/24/23 of Resident #11's medical records revealed that Resident #11 was admitted to the facility on [DATE]. Further review of Resident 11's medical records revealed that Resident #11 had a diagnosis on admission of PTSD. Review on 10/26/23 of Resident #11's psychiatric consult notes from 1/11/23 to 9/12/23 revealed that on 1/11/23 Resident #11 reported extensive history of sexual trauma and was seeking to re-establish for therapy. Resident #11 reported nightmares, hypervigilance, and guarding/flashbacks throughout the day. On 1/23/23, Resident #11 reported improved symptoms, as mentioned above, and that Resident #11 was working with the social worker to re-establish with his/her community therapist. Resident #11 had no other concerns of PTSD symptoms after 1/23/23. Review on 10/26/23 of Resident #11's medical records revealed no other assessments of Resident #11's PTSD such as past trauma and/or triggers. Further review of Resident #11's medical records revealed no follow up with a community therapist, as mentioned on above psychiatric consult notes. Review on 10/26/23 of Resident #11's current care plan revealed no care plan for Resident #11's PTSD diagnosis such as what was mentioned by psychiatrist on 1/11/23, or triggers and interventions to mitigate re-traumatization. Interview on 10/26/23 at approximately 1:00 p.m. with Staff D (Social Worker) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that a residents pressure ulcer was evaluated weekly for 1 of 2 residents reviewed for pressure ulcers (Resident identifier is #40). Findings include: Review on 10/24/23 of the facility matrix revealed that Resident #40 had a facility acquired unstageable pressure ulcer. Review on 10/24/23 of Resident #40's active physician orders revealed a wound treatment order for the left heel pressure injury with a start date of 9/26/23. Review on 10/24/23 of Resident #40's current care plan revealed that Resident #40 has an eschar wound on left heel. Review on 10/26/23 of Resident #40's wound specialist notes revealed that on 5/24/23 Resident #40 has a left heel deep tissue injury with persistent non-blanchable deep red, maroon or purple discoloration. Wound measurement was 3 centimeters (cm) length by 5 cm width with no measurable depth. On 6/7/23 Resident #40's left heel progressed to an unstageable pressure injury with obscured full-thickness skin and tissue loss. Wound measurement was 4 cm length by 5 cm width and wound bed has 100 percent eschar. Further review of the wound specialist notes revealed that there was no documentation of Resident #40's weekly wound evaluation after 8/16/23. Review on 10/26/23 of Resident #40's medical records revealed no weekly evaluation with description, progress, and measurements of Resident #40's left heel unstageable pressure injury after 8/16/23. Review on 10/26/23 of the facility's policy titled, Skin Care Protocol, revision date of 6/8/11, revealed . Wound Care Nurse will assess and document weekly. Weekly wound rounds will include: Measuring and staging weekly and assessing wound healing and treatment modalities . Interview on 10/26/23 at approximately 11:42 a.m. with Staff E (Licensed Practical Nurse) confirmed the above findings. Staff E also confirmed that there were no weekly pressure ulcer evaluations (wound description and wound measurements) for Resident #40's left heel unstageable pressure ulcer after 8/16/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident remained free of accident hazards in regards to assessments of bedrail use for 1 of 3 residents reviewed for accidents (Resident identifier is #13). Findings include: Observation on 10/24/23 at 10:01 a.m. with Resident #13 revealed that Resident #13 had a dark red and dark purple discoloration on the left cheek. Further observation also revealed that Resident #13's hospital bed had the half rails (bed rails/side rails) up and in use on both sides of the bed. Interview on 10/24/23 at 10:01 a.m. with Resident #13 confirmed the above observation. Resident #13 stated that he/she hit his/her left cheek on the bed rail/side rail after using the bed pan in bed. Review on 10/24/23 of Resident #13's medical records revealed that Resident #13 was admitted to the facility on [DATE]. Further review of Resident #13's medical record revealed an incomplete bed rail assessment dated [DATE]. Further review of Resident #13's medical record also revealed no documentation of a completed bed rail assessment. Review on 10/25/23 of Resident #13's Brief Interview for Mental Status (BIMS) score, dated 9/26/23, revealed a score of 15 which indicated an intact cognition. Observation and interview on 10/26/23 at approximately 10:00 a.m. with Staff F (Licensed Practical Nurse) and Resident #13 confirmed that Resident #13 had a dark red and dark purple discoloration on his/her left cheek and that Resident #13 stated it was from hitting the bed rail/side rail. Further observation and interview with Staff F revealed that Resident #13's half rails on both sides of the bed were in use. Staff F stated that Resident #13 utilized it for repositioning in bed. Review on 10/26/23 of Resident #13's current care plan revealed that Resident #13 uses the half rails to maximize independence with turning and repositioning in bed. Interview on 10/26/23 at approximately 10:30 a.m. with Staff B (Director of Nursing) revealed that a bed rail assessment was to be done quarterly. Staff B was unable to provide documentation of Resident #13's completed bed rail assessments. Staff B stated that the facility utilized the electronic medical record system assessment called Bed Rail Assessment for residents utilizing the bed rails/side rails. Review on 10/26/23 of the facility's policy titled, Siderail use/Reduction, dated 11/8/05, revealed .Each resident will be assessed for siderail use on admission, readmission, change in status, and at least quarterly using the Siderail Assessment Form .

Based on record review and interview, it was determined that the facility failed to ensure that as needed (APRN) psychotropic drugs were limited to 14 days for 1 resident in a final sample of 19 residents (Resident identifier is # 28). Findings include: Review on 10/26/23 of Resident #28's current physician orders revealed an order for Lorazepam 0.5mg [milligrams] by mouth every 4 hours PRN for anxiety/insomnia-moderate and Lorazepam 0.5mg 2 tabs [tablets] by mouth every 4 hours PRN anxiety /insomnia-severe that was initiated on 9/24/23. Review on 10/26/23 of Resident #28's October Medication Administration Record (MAR) revealed that no doses of as needed Lorazepam had been given in the month of October. Review on 10/26/23 of Hospice Communication/Continuation Note revealed the following recommendation: 1. Lorazepam 0.5mg 1 tab PO [by mouth] every 4 hours PRN anxiety/insomnia-moderate 2. Lorazepam 0.5mg 2 tabs PO every 4 hours PRN anxiety/insomnia Interview on 10/26/2023 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that there was no 14 day stop date or evaluation for continued use for the PRN Lorazepam since its origination date of 9/24/23. Staff B further confirmed that there should have been either an evaluation of the need to continue the order or a stop date 14 days after the start date of 9/24/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that alleged violation involving abuse or neglect, including injuries of unknown origin, are reported to the State Survey Agency (SSA) for 1 out of 4 accidents reviewed. (Resident identifier is #106.) Findings include: Review on 11/21/22 of the facility's policy titled, Resident Abuse Policy, dated 9/8/22, revealed .Any allegation of abuse (of any form) will be reported to the State Survey Agency within 2 hours of the allegation .injuries of unknown origin: source of the injury was not observed and could not be explained by the resident; AND the injury is suspicious because: the extent or seriousness of the injury, or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) . Review on 11/22/22 of Resident #106's hospital note dated 6/8/22 revealed the following: -Resident #106 was complaining of acute chest pain that was located under left breast describing it as a pressure sensation. -Resident #106 reported to facility nursing staff of intermittent lung pain. Resident #106 was hypoxic with oxygen saturation fluctuating between 85% to 90%. Was sent to hospital for further evaluation and found to have multiple rib fractures on his/her left side. -Resident #106 had some slight tenderness of the left lateral chest with palpation and an area of ecchymosis on the left lateral chest wall. -Resident #106 had Computed Tomography (CT) scan on 6/8/22 which showed acute non displaced fractures involving the anterior aspects of the left 6th through 8th ribs. -Resident #106 has a diagnoses of dementia and an activated Durable Power of Attorney (DPOA). -Resident #106 mentioned that he/she had a fall however was unable to provide more details. Resident #106's DPOA mentioned that the only fall that was reported to her/him was on 5/31/22. Review on 11/22/222 of Resident #106's medical records revealed that Resident #106 was admitted to the facility on [DATE]. Review also revealed that Resident #106's care plan indicated Resident #106 was a fall risk and that the fall risk care plan was initiated on 6/1/22. Further review of Resident #106's medical records revealed a primary diagnoses of dementia. Review on 11/22/22 of Resident #106's progress notes revealed the following: -On 5/31/22, Resident #106 was found on the floor on his/her back and was bleeding from his/her head. Resident #106 was sent to the hospital for further evaluation and had his/her scalp laceration treated with staples and went back to the facility. -On 6/8/22, Resident #106 was complaining of left lung pain and tingling in left arm. Resident #106 had low oxygen saturation (85%-91% room air). Resident #106 was sent to hospital for evaluation. -On 6/10/22, Resident #106 returned to facility with diagnoses of 6th to 8th rib fractures. -There was no documentation of any falls or accidents between 6/1/22 to 6/8/22. -There was no documentation of any pain to left chest or left ribs before 6/8/22. -Resident #106 complained of left lung pain 9 days after the last documented fall of 5/31/22. Interview on 11/22/22 at approximately 1:00 p.m. with Staff C (Licensed Practical Nurse (LPN)) and Staff D (LPN) revealed that Resident #106 was complaining of left side pain and that they were not aware nor witnessed any incident(s) which would have caused trauma to Resident #106's left ribs. Interview on 11/22/22 at approximately 2:00 p.m. with Staff A (Administrator) revealed that he/she was unaware of any report submitted to the SSA related to Resident #106's injury of unknown origin (left rib fractures).

Based on interview and record review, it was determined that the facility failed to have evidence that alleged violations involving abuse or neglect, including injuries of unknown origin, were investigated related to an injury of unknown origin for 1 of 4 residents reviewed for accidents in a final sample of 22 residents (Resident identifier is #106). Findings include: Review on 11/21/22 of the facility's policy titled, Resident Abuse Policy, dated 9/8/22, revealed .the facility will investigate all allegations and prevent further potential abuse while investigation is ongoing .injuries of unknown origin: source of the injury was not observed and could not be explained by the resident; AND the injury is suspicious because: the extent or seriousness of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) .Investigating - The Administrator or Director of Nursing an investigation of alleged abuse . Review on 11/22/22 of Resident #106's hospital note dated 6/8/22 revealed the following: -Resident #106 had Computed Tomography (CT) scan on 6/8/22 which showed acute non displaced fractures involving the anterior aspects of the left 6th through 8th ribs. Review on 11/22/22 of Resident #106's progress notes revealed the following: -On 5/31/22, Resident #106 was found on the floor on his/her back and was bleeding from his/her head. Resident #106 was sent to the hospital for further evaluation and had his/her scalp laceration, treated with staples, then went back to the facility. -On 6/8/22, Resident #106 was complaining of left lung pain and tingling in left arm. Resident #106 had low oxygen saturation (85%-91% room air). Resident #106 was sent to hospital for evaluation. -On 6/10/22, Resident #106 returned to facility with diagnoses of 6th to 8th rib fractures. -There was no documentation of any falls or accidents between 6/1/22 to 6/8/22. -There was no documentation of any pain to left chest or left ribs before 6/8/22. -Resident #106 complained of left lung pain 9 days after the last documented fall of 5/31/22. Interview on 11/22/22 at approximately 1:00 p.m. with Staff C (Licensed Practical Nurse (LPN)) and Staff D (LPN) revealed that Resident #106 was complaining of left side pain and that they were not aware nor witnessed any incident(s) that would have caused trauma to Resident #106's left ribs. Staff C and Staff D also stated that they were unaware that the event mentioned above was investigated. Interview on 11/22/22 at approximately 2:00 p.m. with Staff A (Administrator) revealed that Staff A was unable to provide any documentation of any investigation for the above mentioned event related to Resident #106 left rib fracture (injury of unknown origin).

Based on record review and interview it was determined that the facility failed to have a Registered Nurse (RN) in the facility for 8 consecutive hours 7 days a week for 2 of 28 days reviewed. Findings Include: Review on 11/21/22 at 11:33 a.m. of the facility's nursing schedule from October 23, 2022 to November 19, 2022 revealed that on 10/29/22 and 10/30/22 there was no Registered Nurse coverage in the facility. Interview on 11/22/22 at 10:30 a.m. with Staff F (Human Resource Manager/Scheduler) confirmed the above findings.

Based on observation, interview, and record review it was determined that the facility failed to label 3 insulin pens with an open date, failed to remove 1 insulin pen after it's discard date, and failed to remove inhaler medication after it had been discontinued on 2 of 2 med carts observed (Resident identifiers are #2, 3, 44, 159). Findings include: Second Floor East Medication Cart Observation on 11/21/22 at 8:28 a.m. revealed the following: -Resident #2's Lantus (insulin glargine injection) pen with no open date or use by date; -Resident #44's Lantus SoloStar pen with no open date or use by date; -Resident #44 Humalog KwikPen Lispro insulin that was dated opened 10/11/22 (41 days prior). Further observation revealed that the above 3 insulin pens had all been opened and used. Review on 11/21/22 at 8:28 a.m. of Resident #2's Lantus pen revealed manufacturer's instructions to use within 28 days after initial use. Review on 11/21/22 at 8:28 a.m. of Resident #44's Lantus SoloStar pen and Humalog KwikPen revealed that there were stickers covering the manufacturer's instructions which were unreadable. Interview on 11/21/22 at 8:28 a.m. with Staff G (Licensed Practical Nurse (LPN)) confirmed the above. Interview on 11/21/22 at 3:53 p.m. with Staff G confirmed that Lantus pens should be discarded after 28 days of opening. Third Floor Skilled Nursing Medication Cart Observation on 11/21/22 at 8:40 a.m. revealed the following; -Resident #159 Humalog insulin pen with no open date or use by date; -Resident #3 Advair Diskus (Fluticasone Propionate and Salmeterol inhalation powder) with no open date or use by date. Further observation revealed that the above insulin pen and diskus were opened and used. Review on 11/21/22 at 8:40 a.m. of Resident #3's Advair Diskus box revealed manufacturer's instructions to discard 1 month after opening the foil pouch. Interview on 11/21/22 at 8:40 a.m. with Staff H (LPN) confirmed the above. Staff H stated that Resident #3 did not have a physician's order currently for Advair and was unsure why it was in the med cart. Review on 11/22/22 of Resident #3's physician's orders revealed that the Advair had been discontinued on 7/6/22. Interview on 11/21/22 with Staff I (Assistant Director of Nursing) confirmed that the above medications had not been dated when opened and Resident #44's humalog was dated 10/11/22 and was beyond the 28 days after opening. Review on 11/21/22 of the facility's policy titled Storage of Medications dated August 2020 revealed, .Medications . are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Expiration Dating (Beyond-use dating) . C. Certain medications or package types, such as . multiple dose injectable vials . once opened, require and expiration date shorter than the manufacturer's expiration date to insure medication purity and potency . c. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose vial 3. An item for which the manufacturer has specified a usable life after opening. D when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1). The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration . E. The nurse will check the expiration date of each medication before administering it Review on 11/21/22 of the manufacturer's instructions for use of Humalog KwikPen, provided by the facility, revealed .Storing your Pen . In-use Pen . Throw away the Humalog Pen you are using after 28 days, even if it still has insulin left in it . Review on 11/21/22 of the manufacturer's instructions for use of Lantus Solostar prefilled Pen, provided by the facility, revealed, Storage instructions . Once you take your SoloStar out of cool storage . you can use it for up to 28 days . Do not use it after this time .