Every finding on record at Amaya Springs Health Care Center

Based on observation, interview and record review the facility failed to ensure appropriate corrective action of an abuse allegation when the alleged victim's (Resident 1) room was in close proximity from the alleged perpetrator (offender) (Resident 2). This failure had the potential to affect Resident1's safety and well-being with the potential to have another altercation with Resident 2.Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD, a mental and behavioral disorder that can develop because of exposure to a traumatic event) and anxiety disorder (a mental health disorder characterized by worry or fear that interferes with daily functioning) according to the facility's admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and anxiety disorder according to the facility's admission Record. An observation and interview on 8/11/26 at 9:17 A.M. was conducted with Resident 1. Resident 1 was in room [ROOM NUMBER], sitting on a wheelchair in between bed A and bed B. The floor near bed A was wet, one shoe was on top of bed B's overbed table, bedside table with multiple personal belongings and several random things on the floor at bed B's side of the room. Resident 1 stated he was cleaning up his room and was getting the mice out (pointed towards a wall by bed A). Resident 1 stated he was organizing things in his room and when something fell on the floor, his roommate (Resident 2) in bed A got upset and hit him on the left cheek. Resident 1 stated he yelled at the roommate then staff came to take the roommate away. Resident 1 stated the roommate was transferred to another room but still saw him walking in the halls when he went out of his room. During a review of care plans in the electronic medical record (EMR) for Resident 1, a care plan dated 7/29/26 indicated, Potential for emotional distress r/t [related to] alleged resident to resident altercation. The care plan further indicated, Interventions.Separate residents. An observation and interview on 8/11/26 at 9:33 A.M. was conducted with Resident 2. Resident 2's name was posted in room [ROOM NUMBER]A directly across the hall from Resident 1. Resident 2 was observed sitting on a chair in the lobby reading an activity program. Resident 2 stated he had been at the facility for two or three days and had always been in room [ROOM NUMBER]. An interview on 8/11/26 at 9:55 A.M. was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated she was assigned to both Resident 1 and Resident 2. CNA 1 stated Resident 1 had episodes of agitation, anger and talked a lot about things she did not understand. CNA 1 stated she would have to step out of the room until Resident 1 calmed down. CNA 1 stated Resident 2 was in room [ROOM NUMBER]A with Resident 1, but the residents had an argument and was moved to room [ROOM NUMBER]A, across room [ROOM NUMBER]. CNA 1 stated Resident 2 was confused and walked around in the halls, so she had to ensure that both residents were separated. During an interview on 8/11/26, at 10:17 A.M. with Licensed Nurse (LN)1, LN 1 stated Resident 1 had episodes of confusion and hallucinations (seeing, hearing, smelling tasting or feeling something that is not actually there). LN 1 stated Resident 1 and Resident 2's separation was not far enough from each other to prevent another altercation. LN 1 stated she would ask the charge nurse if one of the residents could transfer to another room farther away. During an interview on 8/11/26, at 10:27 A.M. with CNA 2, CNA 2 stated CNA 1 was on break, and she was covering CNA 1's section. CNA 2 stated she did not receive report regarding Resident 1 and Resident 2. CNA 2 stated she was not aware of the altercation between Resident 1 and Resident 2. CNA 2 stated it was important for her to know about the altercation to prevent residents from fighting again. During an interview on 8/11/26, at 10:34 A.M. with the charge nurse (CN), CN stated staff should know about resident altercations to prevent re-occurrence. An interview on 8/11/26 at 11:23 A.M. was conducted with the Director of Nursing (DON). The DON stated to prevent another altercation between Resident 1 and Resident 2, they should be separated. The DON acknowledged that Resident 1 and Resident 2's rooms were right across from each other and would need 24-hour staff supervision, especially after hours. The DON stated facility will offer Resident 2 another room farther away from Resident 1's room. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, revised on 5/30/24 was conducted. The P&P indicated, Prevention.d. The facility identifies, corrects, and intervenes in situations in which abuse, neglect.and/or mistreatment is more likely to occur.The administrator or designated representative will provide for a safe environment for the resident as indicated by the situation.If the suspected perpetrator is another resident, separate the resident so they do not interact with each other until the circumstances of the reported incident can be clarified.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) related to a resident's nail care for one of two residents (Resident 2), reviewed for care plan. As a result, the lack of a resident centered care plan with specific interventions had the potential to result in delayed care, miscommunication among caregivers, and a decreased physical well-being of the residents. Cross Reference: F 677 Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis (a degenerative joint disease) and needed assistance for personal care, per the facility's admission Record. A review of Resident 2's clinical record was conducted.According to the initial MDS dated [DATE], Resident 2 had a BIMS (ability to recall) score of 15/15 which indicated Resident 2's cognition was intact. The functional status indicated Resident 2 was dependent on a staff member for personal hygiene. On 6/22/26 at 10:40 A.M., an observation and an interview were conducted of Resident 2 as he laid in bed. Resident 2's feet were exposed, and toenails appeared long, and curved. Resident 2 stated he needed someone to cut his left toenails because they were long and uncomfortable. On 6/22/26 at 11:45 A.M., a joint observation of Resident 2's left toenails, an interview and record review was conducted Licensed Nurse (LN) 2. LN 2 stated Resident 2's toenails were long. LN 2 stated there was no documentation related to Resident 2's long toenails. LN 2 stated the documents did not indicate Resident 2's long toenails were assessed, identified and noted during Resident 2's admission, and during the LN's weekly summary notes (a document that summarizes key information regarding the health condition of a person in relation to nursing care). LN 2 stated if identified, LNs should have developed a care plan related to Resident 2's long toenails and should have been referred to the podiatrist (a doctor who specializes in caring for your feet and ankles) timely and followed thoroughly. On 6/22/26 at 1:28 P.M., a joint observation of Resident 2's toenails and an interview with the Administrator (ADM) and the Director of Staff Development (DSD) was conducted. The ADM and the DSD stated Resident 2's toenails were long. The DSD the expectation was for the LNS to conduct head-to-toe assessments for the resident upon admission and the LNs should have noted and documented in the resident's clinical record and the LNs should have developed a care plan related to Resident 2's long nails and should have been referred to the podiatrist timely. A review of the facility's policy and procedure, titled, Person-Centered Care Planning, revised 4/24/25, indicated, .2. Baseline Care Plan, a. The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs.and assistance for activities of daily living.

Based on observation, interview, and record review, the facility failed to provide routine nail care to one of two residents (Resident 2), reviewed for Activities of Daily Living (ADL, activities related to personal care/ hygiene) for dependent residents. As a result, Resident 2's toenails were long and curved and Resident 2 was at risk for skin injury and infection. Cross Reference: F 655 Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis (a degenerative joint disease) and needed assistance for personal care, per the facility's admission Record. A review of Resident 2's clinical record was conducted.According to the initial MDS dated [DATE], Resident 2 had a BIMS (ability to recall) score of 15/15 which indicated Resident 2's cognition was intact. The functional status indicated Resident 2 was dependent on a staff member for personal hygiene. On 6/22/26 at 10:40 A.M., an observation and an interview were conducted of Resident 2 as he laid in bed. Resident 2's feet were exposed, and toenails appeared long, and curved. Resident 2 stated he needed someone to cut his left toenails because they were long and uncomfortable. On 6/22/26 at 11:36 A.M., a joint interview and record review of Resident 2's shower sheet was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 2 needed assistance with ADLs. On 6/22/26 at 11:45 A.M., a joint observation of Resident 2's left toenails, an interview and record review was conducted Licensed Nurse (LN) 2. LN 2 stated Resident 2's toenails were long. LN 2 stated the process upon a resident's admission to the facility; the admitting LN was to conduct skin check on the resident and the treatment nurse would do the follow up skin check the following day. LN 2 stated she did not see any documentation regarding Resident 2's left toenails which were long and curved. LN 2 stated there was no documentation in Resident 2's minimum data set (MDS, a clinical assessment tool), the LN admission progress notes, and in the treatment nurse notes that talked about Resident 2's long toenails. LN 2 stated the documents did not indicate Resident 2's long toenails were assessed, identified and noted during Resident 2's admission, and during the LN's weekly summary notes (a document that summarizes key information regarding the health condition of a person in relation to nursing care). LN 2 stated Resident 2's long toenails should have been assessed and referred to the podiatrist (a doctor who specializes in caring for your feet and ankles) timely and followed thoroughly. On 6/22/26 at 1:28 P.M., a joint observation of Resident 2's toenails and an interview with the Administrator (ADM) and the Director of Staff Development (DSD) was conducted. The ADM and the DSD stated Resident 2's toenails were long. The DSD the expectation was for the LNs to conduct head-to-toe assessments for the resident upon admission and the LNs should have noted and documented in the resident's clinical record for any skin and nail issues. The DSD stated the staff could have notified the Nurse Practitioner (NP, is a nurse who has advanced clinical education and training. NPs share many of the same duties as doctors) and the NPs could have cut Resident 2's toenails when the NPs came to visit him. A review of the facility's policy and procedure, titled, Grooming Care of the Fingernails and Toenails, revised 10/21/21, indicated, Nail care is given to clean the nail bed and keep the nails trimmed.

Based on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when:1. An injectable medication (heparin, anticoagulant) comingled with oral medications.2. Discontinued medications of residents were not disposed of accordingly.3. A resident's medication was left at bedside (Resident 38). These failures had the potential for medications to be incorrectly administered, decrease medication potency (medication strength) that could compromise the therapeutic effectiveness of stored medications and prevent misappropriation of the medications. Findings: 1.A medication cart storage observation was conducted on [DATE] at 9:06 A.M. with Licensed Nurse (LN) 11. LN 11 opened the first drawer of the medication cart # 2 which contained over the counter (OTC) oral medications. A box of heparin injectable medications comingled with the oral OTC medications. LN 11 stated the injectable medications should not be included in the oral medications for safety and infection control. An interview with the Director of Nursing (DON) on [DATE] at 5:12 P.M., the DON stated the injectable medications should not be co-mingling with the oral medications for safety and infection control. A review of the facility's policy titled Medication Storage in the Facility, dated 4/2008, indicated, Medications and biologicals are stored safely.and properly.C. Orally administered medications are kept separate. 2. A medication storage room observation was conducted on [DATE] at 4:21 P.M. with LN 12. There was combination of patch, injectable pens, oral inhalation medications and medicated shampoo that belonged to eight residents. LN 12 stated two of the eight residents expired on [DATE] and [DATE] (one of the two expired residents was discharged to comfort care on [DATE] and later died on [DATE]), three of the eight residents had medications that were discontinued by the attending physician, and another three of the eight residents were discharged from the facility. LN 12 stated the discontinued medications of the residents should have been disposed of according to the facility's policy to prevent misappropriation of the medicines. LN 12 stated the medications should have been marked as discontinued. An interview with the DON on [DATE] at 5:12 P.M., the DON stated discontinued medications should have been disposed of properly to prevent misappropriation of medications. A review of the facility's policy titled Disposal of Medications and Medication-Related Supplies, dated 12/2018, indicated, When medications are.discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/ her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. 3.Resident 38 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (breathing problem) and polyneuropathy (malfunction of many peripheral nerves throughout the body), per the facility's admission record. On [DATE] at 4:25 P.M., an observation was conducted with Resident 38 in her room. Resident 38 sat in her wheelchair by the bedside table. Resident 38 was alert and verbally responsive. Resident 38 had two pills in the medicine container, which she identified as gabapentin (treat for nerve pain), Senokot (stool softener), an inhaler (for breathing), and an eye drop were left at the bedside. A review of Resident 38's Medication Administration Record (MAR) indicated the gabapentin, Senokot, eye drop, and the inhaler were scheduled to be administered at 5 P.M. On [DATE] at 4:40 P.M., an interview was conducted with Licensed Nurse (LN)1. LN 1 stated medications should have not been left at the bedside. On [DATE] at 4:45 P.M., an interview was conducted with LN 2. LN 2 stated she left the gabapentin, Senokot, inhaler and the eye drops on Resident 38 bedside table. LN 2 stated she was in the room to administer the medications but left and forgot to come back. LN 2 stated she should not have left the medications unattended in Resident 38's bedside table for resident's safety. On [DATE] at 5 P.M., an interview was conducted with the Director of Nursing (DON). The Director of Nursing stated that medications should never be left unattended at the bedside for the safety of the residents. A review of the facility's policy titled Medication Storage in the Facility, dated 4/2008, indicated, Medications and biologicals are stored safely.and properly.

Based on interview and record review, the facility failed to provide documentation to verify performance evaluation had been completed for two certified nursing assistants (CNAs).These failures had the potential to affect clients' well-being, should the staff be unable to perform duties effectively, efficiently, and competently.Findings: On 1/29/26 at 11 A.M., a concurrent review of the personnel files and interview was conducted with the Director of Staff Development (DSD). CNA 1 was hired on 10/29/18. The DSD could not find performance evaluations in CNA 1's personnel file. On 1/29/26 at 11:15 A.M., a concurrent review of personnel files and interview was conducted with the DSD. CNA 2 was hired on 9/17/24. The DSD could not find performance evaluation in CNA 2's personnel file.On 1/29/26 at 4:50 P.M., an interview was conducted with the Director of Nursing (DON). The Director of Nursing stated that staff should undergo performance evaluations annually to ensure they have the necessary skills to provide quality care and maintain compliance.On 1/29/26 at 4:55 P.M., an interview was conducted with the Administrator (ADM). The ADM acknowledged that performance evaluations were not completed for CNA 1 and CNA 2. The ADM stated performance evaluation should have been completed yearly. A review of the facility's provided documentation titled, Performance Evaluations, dated 1/24, indicated .performance evaluations maybe conducted annually, on or around their anniversary date .

Based on observation, interview, and record review, the facility failed to ensure a resident's behavior was managed effectively, for one of one sampled resident (Resident 39). As a result, Resident 39's yelling and screaming was constant and disruptive to other residents.Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses which included brain disorders (progressive loss of structure and function of the brain as a consequence of progressive degeneration and/or death of nerve cells), per the facility's admission record. A review of Resident 39's Brief Interview for Mental Status (BIMS, cognitive assessment), dated 11/19/25, indicated a score of 9, which meant Resident 39 had a moderate cognitive impairment. A review of the psychiatric assessment dated [DATE], indicated diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), adjustment disorder (the reaction to a stressful change or event) and anxiety disorder (persistent and excessive worry that interferes with daily activities). On 1/26/26 at 9 A.M., an initial screening was conducted in the facility's hallway. A yelling was heard coming from Resident's 39's room. On 1/26/26 at 3:50 P.M., an observation and an interview was conducted with Resident 39 in her room. Resident 39 was lying in her bed, spoke Spanish. Resident 39 yelled out loudly in Spanish. On 1/28/26 at 8:30 A.M., an observation was conducted of Resident 39 in her room. Resident 39 yelled out loudly in Spanish, constantly screaming Ya and hey. There were times Resident 39 yelled comprehensible words and there were times Resident 39 yelled out incomprehensible words. On 1/28/26 at 12:39 P.M., an observation was conducted of Resident 39 in her room. Resident 39 yelled out loudly in Spanish. Staff went into Resident 39's room and after exiting, Resident 39 started yelling out again. On 1/28/26 at 2:47 P.M., an observation was conducted in Resident 39's room. Resident 39 continued to yell out loudly even when the staff was in the room. On 1/26/26 at 9 A.M., an interview was conducted with Resident 39's roommate. Resident 39's roommate stated Resident 39 was Noisy all the time and it bothered her. Resident 39's roommate stated she was unable to get enough sleep because of Resident 39's constant yelling. On 1/28/26 at 8:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 39 was alert but confused at times. CNA 3 stated Resident 39 yelled out intermittently throughout the day. CNA 3 stated Resident yelled out his brother's name and wanted to go home. CNA 3 stated he was unable to redirect Resident 39's behavior at times. On 1/28/26 at 3:06 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 39 was confused and disoriented. CNA 4 stated Resident 39 yelled out all day. CNA 4 stated Resident 39's roommate had voiced her complaints related to Resident 39's constant yelling. On 1/29/26 at 10:13 A.M., an interview was conducted with CNA 5. CNA 5 stated Resident 39 was alert but confused, yelled all the time when she was awake. CNA 5 stated Resident 39 yelled for a brief change even after care had been provided. CNA 5 stated Resident 39's roommate voiced her concerns about not being able to sleep due to Resident 39's constant yelling. On 1/28/26 at 3:24 P.M., an interview was conducted with Licensed Nurse (LN) 4. LN 4 stated Resident 39 frequently yelled during the afternoon and early evening. LN 4 stated she felt sorry for Resident 39's roommate. On 1/28/26 at 3:29 P.M., an interview was conducted with the Director of Social Services (DSS). The DSS stated Resident 39 was alert and confused. The DSS stated Resident 39 yelled while staff were in the room. The DSS stated Resident 39 could communicate her needs and requested things repetitively. The DSS stated It might be an attention seeking behavior. On 1/28/26 at 5:22 P.M., an interview was conducted with LN 12. LN 12 stated Resident 39 was agitated and yelled throughout the morning and afternoon shifts. LN 12 stated the staff could not consistently redirect Resident 39's behavior. LN 12 stated Resident 39 received medications but were ineffective. LN 12 stated she was not aware of Resident 39's roommate's concerns about Resident 39's yelling. On 1/29/26 at 10:23 A.M. an interview was conducted with LN 11. LN 11 stated Resident 39 was confused and yelled frequently. LN 11 stated Resident 39 screamed that she would like to go home. LN 11 stated Resident 39 received medications but was ineffective. On 1/29/26 at 5 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 39 had an increased disruptive behavioral symptom. The staff were no longer able to redirect Resident 39 and the medication for her behavior was ineffective. The DON stated a psychiatric referral was made for Resident 39. A review of the facility's undated policy titled Behavior Management, indicated, .The facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties (e.g. crying, yelling, hitting, etc.).will receive appropriate treatment to address the problem or attain the highest practical mental and psychosocial well-being.

Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed when a Licensed Nurse (LN)13 did not wear a gown for Resident 6 with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), while passing medication (med/s) during med pass observation. This failure had the potential for cross contamination and spread of infection.Findings: A review of Resident 6's admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included urinary tract infections and with a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings/ meds to be administered directly to the stomach common for people with swallowing problems). On 1/28/26 at 8:26 A.M., an observation and an interview were conducted of LN 13 prepared medications for Resident 6. There was an EBP sign attached to Resident 6's door. LN 13 assembled Resident 6's medications in a medication tray. LN 13 went in to Resident 6's room and checked Resident 6's g-tube placement and gave the medications to Resident 6 via the g-tube. LN 13 stated, I have to correct myself, I forgot to put a gown on. On 1/28/26 at 8:37 A.M., an interview of LN 13 was conducted. LN 13 stated she should have worn a gown while passing medications to Resident 6 via the g-tube for infection control. On 1/29/26 at 5:10 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to follow the procedures on EBP for protection of the staff and the residents to prevent spread of infection. A review of the facility's policy titled, Enhanced Barrier Precautions revised 10/15/24, indicated, .Process.2. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities.g. Device care or use.feeding tube.

Based on interview and record review, the facility failed to provide influenza vaccines (prevents the seasonal flu, a contagious respiratory illness) and pneumococcal (an immunization protecting against streptococcus pneumoniae bacteria, which causes severe infections) for two of five residents (Resident 6 and 39), reviewed for vaccinations. As a result, Residents 6 and 39 were at risks of acquiring flu and pneumonia.Findings: 1.Resident 6 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) per the admission Record. Resident 6's history and physical dated 11/1/25 indicated Resident 6's family member (FM) was the responsible party (RP) to sign consents for Resident 6. On 1/28/26 at 3:09 P.M., Resident 6's clinical record was reviewed for immunizations. There was no documented evidence the facility offered influenza vaccination to Resident 6 or the RP consented or declined to influenza vaccination for Resident 6 for 2025 - 2026 Influenza season. On 1/28/26 at 3:10 P.M., a joint review of Resident 6's immunization record and an interview was conducted with the Infection Preventionist Nurse (IPN). The IPN stated there was no influenza vaccination offered to Resident 6. The IPN stated it was important to offer influenza vaccines to Resident 6 for protection and prevention of Resident 6 from acquiring influenza. On 1/29/26 at 5:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the licensed nurses to administer the vaccinations to the residents especially when they consented as part of the primary care prevention of illness to the residents. According to the facility's policy, titled Influenza Prevention and Control, revised 9/10/20, .Policy: The facility will follow infection prevention and control policies and procedures to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza.Procedure: ii. Vaccinating Residents against Influenza .B. Residents are offered an influenza immunization every year during flu season. 2. Resident 39 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening blood infection), per the admission Record. Resident 39's FM was the RP. On 1/28/26 at 3:09 P.M., Resident 39's clinical record was reviewed for immunizations. According to the immunization consent form dated 11/12/25, Resident 39's RP consented the facility to provide pneumococcal vaccination to Resident 39. There was no documented evidence the facility offered and administered pneumococcal vaccination to Resident 39. On 1/28/26 at 3:10 P.M., a joint review of Resident 39's immunization record and an interview was conducted with the IPN. The IPN stated there was no pneumococcal vaccination offered to Resident 39. The IPN stated it was important to offer pneumococcal vaccines to Resident 39 for protection and prevention of Resident 39 from acquiring pneumonia. On 1/29/26 at 5:08 P.M., an interview was conducted with the DON. The DON stated the expectation was for the licensed nurses to administer the vaccinations to the residents especially when they consented as part of the primary care prevention of illness to the residents. According to the facility's policy, titled Pneumococcal Disease Prevention, revised 2/18/21, .Policy: The facility will offer pneumococcal immunization to each resident.

Based on interview and record review, the facility failed to ensure a resident's medical record were clear and complete when licensed nurses (LN) did not consistently sign the Medication Administration Record (MAR) when the tube feeding (TF) formula was administered, and a TF order did not have a rate (the speed of the TF delivered to the stomach) order for 1 of 3 sampled residents (Resident 4). As a result, Resident 4's medical record was incomplete, which compromised the ability to track and verify the amount of TF formula administered. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses that included gastrostomy ( a surgical procedure to create an opening in the abdomen and into the stomach to allow for the insertion of a feeding tube) status. A review of Resident 4's medical record was conducted on 4/15/25. Per the hospital discharge record dated 2/26/25, under Order Instructions for preparing TF formula, give one pouch for the formula to be warmed in a warm water bath, poured into a TF bag, and diluted with 120 milliliters (ml) of sterile water. Once this was done. Hang the bag and set the TF rate at 60 ml per hour continuously. Resident 4 should receive three pouches of TF formula per day. Per the Facility Physician's Order Summary Report dated 2/27/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not written in the Order Summary. Per the Medication Administration Record, dated 2/27/25 through 3/4/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not recorded, and only one licensed nurse signed the MAR each day. On 4/15/25 at 3 P.M., an interview and joint record review was conducted with LN 2. LN 2 stated the licensed nurses had to administer the TF formula once every eight hours. LN 2 stated that he administered the TF formula to Resident 4 without signing the MAR. LN 2 stated he should have signed the MAR every time the TF was administered to Resident 4, so there would be a record of the number of pouches given per day, and there would be a record of the work he had done. LN 2 also stated that the MAR and the order summary should have a complete order that included the TF rate. LN 2 stated he could not be sure what Resident 4's TF rate was when the TF was administered to Resident 4. On 4/15/25 at 4:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the TF order in the MAR, and the order summary should include the TF rate. In addition, the DON stated that the LNs should have signed the MAR every time they started (began/provided) a new pouch, to ensure that the resident was provided three pouches per day. Per the facility's policy and procedure, dated 1/1/12, titled Enteral Feeding, .Calculate [the] amount of formula to be given per shift .document administration of enteral feeding .

Based on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic respiratory condition that causes inflammation and breathing difficulty) per the facility admission record. Resident 2 was admitted to the facility on 12.31/24 per the facility admission record. During an observation of the facility building and grounds on 1/28/25 at 2:25 PM a long black pole with a blue feather toy and a silver bell was seen propped up against the wall in the hallway of the facility outside administrative offices. A cat scratching post and a pet food water dish were observed on the back patio nearby a small shelter resembling a cat house was also visible. During an observation on 1/28/25 at 2:30 PM in the activity room, the facility activities director (AD) was seen interacting with residents watching television and painting one resident ' s fingernails. During an observation and interview on 1/28/25 at 2:45 PM the facility case manager/infection preventionist (CM IP) was seen carrying a gray colored cat down the hallway inside the facility. The cat appeared agitated with claws extended and was yowling. The CM/IP initially stated the cat belonged to a neighbor and had entered the facility but then admitted the cat belonged to the facility. The CM/IP acknowledged the cat was in and out of the facility and was a potential infection control risk if left unsupervised. During an interview and review of the cat ' s file and facility animal policy, on 1/28/25 at 3:28 PM, the AD stated she was responsible for the supervision of the cat. The AD stated that the facility used a cat spray on the floor in front of the doors of residents who did not want the cat in their room. The AD stated the cat was not registered. The AD stated the cat ' s file did not include documentation of flea and tick treatment or a formal bathing and grooming schedule for the cat. The AD acknowledged the facility policy on animals required the cat to be registered and have documentation of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse ' s station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat ' s care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1 ' s window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat ' s file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility ' s Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets . Based on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic respiratory condition that causes inflammation and breathing difficulty) per the facility admission record. Resident 2 was admitted to the facility on 12.31/24 per the facility admission record. During an observation of the facility building and grounds on 1/28/25 at 2:25 PM a long black pole with a blue feather toy and a silver bell was seen propped up against the wall in the hallway of the facility outside administrative offices. A cat scratching post and a pet food water dish were observed on the back patio nearby a small shelter resembling a cat house was also visible. During an observation on 1/28/25 at 2:30 PM in the activity room, the facility activities director (AD) was seen interacting with residents watching television and painting one resident's fingernails. During an observation and interview on 1/28/25 at 2:45 PM the facility case manager/infection preventionist (CM IP) was seen carrying a gray colored cat down the hallway inside the facility. The cat appeared agitated with claws extended and was yowling. The CM/IP initially stated the cat belonged to a neighbor and had entered the facility but then admitted the cat belonged to the facility. The CM/IP acknowledged the cat was in and out of the facility and was a potential infection control risk if left unsupervised. During an interview and review of the cat's file and facility animal policy, on 1/28/25 at 3:28 PM, the AD stated she was responsible for the supervision of the cat. The AD stated that the facility used a cat spray on the floor in front of the doors of residents who did not want the cat in their room. The AD stated the cat was not registered. The AD stated the cat's file did not include documentation of flea and tick treatment or a formal bathing and grooming schedule for the cat. The AD acknowledged the facility policy on animals required the cat to be registered and have documentation of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse's station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat's care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1's window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat's file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility's Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets .

Based on observation, interview, and record review the facility failed to obtain a physician order to provide services in accordance with standards of care when admission orders for one resident, (Resident 1), did not include blood glucose monitoring (a process of regularly measuring the amount of sugar in the blood) before each meal and before bed. This failure had the potential for Resident 1 ' s blood glucose level to be undetected and untreated. Findings: On 10/17/24 the State Agency (SA) received a complaint that indicated Resident 1 ' s blood glucose was checked once per day and reached 477 (elevated above 70-99, a recommended range). Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type two (a disease in which blood sugar is higher than normal and can cause permanent damage to the body). On 10/21/24 at 12:10 P.M. an unannounced visit was conducted at the facility. Resident 1 was discharged from the facility on 9/30/24. On 10/21/24 at 12:30 P.M. an interview was conducted with Licensed Nurse (LN) 2 who stated, We do blood glucose checks before meals. If there ' s no order for that, I ' d call the doctor. On 10/21/24 at 4:10 P.M. an interview and concurrent record review were conducted with the Director of Nursing (DON). Resident 1 ' s physician orders indicated she was receiving two types of insulin upon admission. The admission orders indicated blood glucose monitoring was to be performed once per day at 5 P.M. A joint review of Resident 1 ' s blood glucose monitoring indicated documentation started on 9/13/24 at 8:24 A.M. and continued once per day until 9/25/24 when monitoring happened three times, four times on 9/26/24, two times on 9/27/24, four times on 9/28/24, five times on 9/29/24, and three times on 9/30/24 which was the date of Resident 1 ' s discharge. A joint review of a change of condition document dated 9/25/24 indicated, Patient ' s husband requested to have her blood sugar checked as he stated she was acting differently.Blood sugar check result 477. MD (Medical Doctor) notified. 9/25/24 2030 (8:30 P.M.) awaiting reply. The DON stated when they come from the hospital we continue the orders. The physician ordered monitoring once per day. We did not question the frequency of monitoring that was ordered. The order for blood glucose checks increased to four times a day on 9/26/24 after her husband brought up a concern. The DON stated the facility practice regarding blood glucose monitoring of a resident on insulin was usually before each meal and sometimes also at bedtime. A joint review of the facility policy titled Diabetic Care indicated, A Licensed Nurse will monitor the resident ' s blood glucose per the Attending Physician ' s order and will administer medication as indicated. The policy was requested but not received from the facility. On 10/22/24 at 12:15 P.M. a telephone interview was conducted with the DON who stated, The resident did not receive any extra insulin for the blood glucose of 477. An internet search for standard of care for blood glucose monitoring was performed. A review of National Institute of Health, National Library of Medicine StatPearls titled Blood Glucose Monitoring dated April 23, 2023 indicated, Blood glucose testing is recommended before meals and bedtime for clients who can eat retrieved 10/22/24 from https://www.ncbi.nlm.nih.gov/books/NBK555976.

Based on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed regarding his discharge. Findings: Per the facility's Admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 that Resident 8 was provided with a Notice of Proposed Transfer and Discharge form prior to his transfer. On 9/12/24 at 3:26 P.M., an interview was conducted with Licensed Nurse (LN) 6. LN 6 stated, Resident 8 went to the hospital due to a change in his condition and was awake at the time of discharge. LN 6 further stated, he did not provide any paperwork to Resident 8 at the time of discharge, and he was not familiar with the Notice of Proposed Transfer and Discharge form. On 9/12/24 at 4:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when a resident was sent to an acute care hospital the Social Worker (SW) was responsible for providing the Notice of Proposed Transfer and Discharge form to the resident. On 9/13/24 at 8:28 A.M., an interview was conducted with the SW. The SW stated, the licensed nurses were responsible for providing the Notice of Proposed Transfer and Discharge form to residents when they were transferred to an acute care hospital. Per the facility's policy, titled Discharge and Transfer of Residents, revised February 2018, .The resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable .

Based on interview and record review, the facility failed to provide a written notice of the facility's bed hold policy at the time of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed of his bed hold rights. Findings: Per the facility's Admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 or 9/5/24 that Resident 8 was provided with a written notice of the facility's bed hold policy. Per the facility's Bed Hold Agreement, signed by Resident 8 on 1/17/24 (at the time of admission), the portion of the form titled, Notification of Bed Hold Option Upon Transfer/Therapeutic Leave was not completed. The form was blank for the sections on which acute care hospital Resident 8 transferred to, what day and time he left, who notified him of the bed hold option, when he was notified, and the location for staff to sign that they completed the form. On 9/12/24 at 3:26 P.M., an interview was conducted with Licensed Nurse (LN) 6. LN 6 stated, Resident 8 went to the hospital due to a change in his condition and was awake at the time of discharge. LN 6 further stated, he transferred Resident 8 to the hospital and did not provide a written notice of bed hold. On 9/12/24 at 3:38 P.M., an interview was conducted with the Admissions Coordinator (AC). The AC stated, when a resident was sent to a hospital, the licensed nurses were responsible for offering the bed hold at the time of discharge if the resident was awake, otherwise she would notify the resident's responsible part by phone the following day. The AC stated that when she called to offer the bed hold, she did not provide a written notice of bed hold to the resident or resident representative. On 9/12/24 at 4:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when a resident was sent to an acute care hospital the facility did not provide a written notice of the facility's bed hold policy. Per the facility's policy, titled Bed Hold, revised July 2017, .The Facility notifies the resident and/or representative, in writing, of the bed hold, option any time the resident is transferred to an acute care hospital .

Based on interview and record review, the facility failed to notify the physician of a resident's low blood sugar readings, and did not monitor fluid intake and output for two of 12 sampled residents (1, 29). As a result, Resident 1 did not receive treatment for low blood sugar, and the facility could not determine if Resident 29 had proper fluid intake and adequate output, which may have lead to the late detection of fluid abnormalities in the body. Findings: 1. Per the facility's Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (disease of abnormal blood sugar). A record review was conducted. Per the facility's Orders, there was an order on 11/29/23 to check Resident 1's blood sugar before giving insulin (a medication to lower blood sugar), and to notify the physician if it was less than 70 milligrams (mg)/deciliter (dl). Per the facility's Weights and Vitals Summary, on 8/9/24 at 4:46 P.M., Resident 1's blood sugar reading was 13 mg/dl, and on 8/17/24 at 12:13 P.M., Resident 1's blood sugar reading was 59 mg/dl. On 9/12/24 a review was conducted of Resident 1's medical record. There was no documentation on 8/9/24 or 8/17/24 to show that staff notified Resident 1's physician of the blood sugar readings less than 70 mg/dl, any attempts to raise Resident 1's blood sugar, or any rechecks of Resident 1's blood sugar. Licensed Nurse (LN) 1 was not available for interview. On 9/12/24 at 3:43 P.M., an interview was conducted with LN 2. LN 2 stated, she should have offered Resident 1 a snack, rechecked the blood sugar, notified the physician, and documented what she did. On 9/12/24 at 3:53 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, for Resident 1's low blood sugar readings on 8/9/24 and 8/17/24, the nurses should have given Resident 1 a sugary snack, rechecked the blood sugar, notified the physician, and documented what they did. Per the facility's policy, titled Blood Glucose Monitoring, revised 4/27/23, .Notify the healthcare provider of a Blood Sugar Level lower than 70 . 36471 2. Per the facility's Admission Record, Resident 30 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (kidney problem). A review of Resident 30's medical record was conducted. Per the Order Summary, dated 5/15/24, Resident 30's fluid intake and output were to be monitored. Per the same document, dated 7/26/24, Resident 30 was to restrict fluid intake to one liter daily. There was no evidence that Resident 30's fluid intake and output were being monitored and assessed. On 9/13/24 at 8:09 A.M., an interview and record review was conducted with LN 6. LN 6 stated he could not show evidence that the fluid restriction was consistently followed or if the assessments were done. On 9/13/24 at 9:19 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated fluid intake and output should have been monitored and evaluated after seven days. Per the facility's policy and procedure, dated 4/15/21, titled Intake and Output Recording, .Fluid Restriction after seven days of the initial order will be reevaluated .Intake and output will be monitored and recorded per the physician's order.

Based on observation, interview, and record review, the facility failed to ensure that opened dressings in the refrigerator were labeled with an open date and that the freezer's foods were stored per the facility's policy and procedure. These failures placed residents at risk of acquiring foodborne illness and may have caused the texture of the food in the freezer to become less palatable. Findings: On 9/10/24 at 7:42 A.M., an initial tour of the kitchen was conducted with the Dietary Manager (DM). It was observed in the reach-in refrigerator that two large jars of dressings were opened, and there was no date. In addition, inside the reach-in freezer, there was a large sealable bag full of air, containing chicken thighs that had icicles built up on the meat. There was also an opened clear bag of diced chicken which was manually tied to close the item. On 9/10/24 at 8:07 A.M., an interview was conducted with the DM. The DM stated that opened items should be labeled and dated. Items in the freezer should have been stored appropriately. Per the facility's policy and procedure, dated 6/4/24, titled Dietary Services: Food Storage and Handling, .Refreezing of defrosted food is not recommended .Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers .label and date all food items .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: (1) The nebulizer (a small machine that turns liquid medicine into a mist that gets inhaled into the lungs), mask, and cup (contains liquid medicine for the nebulizer) were not cleaned and bagged after each use, per the facility's policy, and (2) The water waste management program was not implemented. These deficient practices placed residents at risk for infections. Findings: 1. Resident 29 was readmitted to the facility on [DATE] with diagnoses which included Respiratory Failure (breathing problem), per the Admission Record. On 9/11/24 at 10:09 A.M., Resident 29's nebulizer machine was observed on top of the dresser with a long clear tubing attached to the machine. The clear tubing was hung on the privacy curtain and down tuck inside the drawer. Inside the drawer were opaque-colored nebulizer cup and masks attached to the tubing. On 9/11/24 at 10:12 A.M., Resident 29 stated the licensed nurse (LN) administered his nebulizer treatment this morning. On 9/11/24 at 2:18 P.M., a joint observation and interview was conducted with LN 5. LN 5 stated he administered the nebulizer treatment to Resident 29 at 9 A.M. and 1 P.M. LN 5 further stated he did not clean the nebulizer mask and cup after administering the medication to Resident 29, but he should have. On 9/13/24 at 9:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the nebulizer mask and cup should be rinsed with water, dried, and placed in the bag after use. Per the facility's policy and procedure, dated 10/15/20, titled Nebulizer (small volume), .Drain any condensate from the nebulizer, rinse nebulizer cup with sterile normal saline or water and empty. Dry the nebulizer cup by placing the nebulizer in the Resident's equipment bag and leaving the compressor on for approximately ten minutes . 2. On 9/13/24 at 8:45 A.M., an interview and record review of the waste management program was conducted with the Maintenance Director (MAIN). The MAIN stated he was testing the water monthly and quarterly but ran out of the testing kit two months ago. In addition, the MAIN could not provide documented evidence of monitoring and tracking the water system. Per the facility's policy and procedure, dated 5/25/23, titled Water Management, .Quarterly measurement of the water quality throughout the system to ensure changes that may lead to Legionella growth are not occurring .Monthly monitoring of chlorine levels .

Based on interview and record review, the facility failed to ensure the Infection Control Preventionist (ICP) completed the specialized infection and prevention training. This failure could result in the ICP not being knowledgeable or qualified to perform the duties to prevent the spread of infection. Findings: On 9/13/24 at 9:37 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IPN). The IPN stated she was helping with the infection control prevention program, and the designated IPN quit, leaving her to do the job. IPN further stated she did not have the chance to do the required specialized training. On 9/13/24 at 11:38 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the designated ICP should have had the required training. Per the facility's policy and procedure, dated 2/19/21, titled Infection Preventionist, .[The Infection Preventionist] Have education, training, expertise or certification in specialized infection control and prevention practices .

Based on interview and record review the facility failed to fully prepare three of four sampled residents, (1, 2, 4) for discharge in accordance with the facility discharge policy. Findings: A review of the facility policy entitled Discharge and Transfer of Residents revised February 2018 indicated, .When a resident is admitted to the Facility, Facility Staff will initiate a discharge plan. The resident/ resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. When the resident is near a planned discharge, the Interdisciplinary Team (IDT) will complete a Discharge Summary/ Post Discharge Plan of Care. Nursing Staff will complete a Discharge Summary/ Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident ' s stay and final summary of the resident ' s status . 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included bilateral lower extremity lymphedema (a condition in which fluid that comes from the liquid part of the blood builds up in tissues causing swelling) with cellulitis (an infection of the skin) and maggot infestation and homelessness. Resident 1 was discharged from the facility on 4/6/24. Resident 1 was not provided with a Notice of Proposed Discharge. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue that releases chemicals into the blood that can cause kidney damage), difficulty in walking, and need for assistance with personal care. Resident 2 was discharged from the facility on 4/1/24. Resident 2 received a Notice of Proposed Discharge on 4/1/24, the same date as her discharge. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (difficulty communicating because of injury to the brain), toxic encephalopathy (brain dysfunction caused by exposure to a toxin), acute systolic heart failure (failure of the bottom left chamber of the heart), obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep), acquired absence of right leg below knee (removal of the leg below the knee), unsteadiness on feet, and need for assistance with personal care. Resident 4 was discharged from the facility on 4/23/24. Resident 4 received a Notice of Proposed Discharge one day prior to discharge. Direct care staff for Residents 1, 2 and 4 were not available for interview during the on-site investigation. On 5/6/23 at 1:25 P.M., an interview and concurrent record review were conducted with the Director of Nursing (DON) and Social Worker (SW). The SW stated her role in the discharge process was to assist with resources, find placements, create referrals for Home Health/ ILF/ ALF. The SW stated, I find out where they live during the first interview with the resident. I ask if they have income. I ask where they want to go, and invite them to CP/ IDT meetings, talk with them about their plans. The DON stated Resident 1 ' s discharge care plan was template interventions (a software generated selection that is not specialized to a patient), not resident centered and specific, and there were no interventions for adjustment to living in a shelter or car with new medical needs. The SW stated the facility did not provide Resident 1 with a Notice of Proposed Discharge. A concurrent record review of a nursing discharge note dated 4/6/24 at 11 A.M. indicated, Discharge: friend ' s business (address). A record review of the IDT Discharge Planning Review note dated 4/5/24 signed by the SW indicated the review was done one day prior to Resident 1 ' s discharge. On 5/6/23 at 2:30 P.M., an interview and concurrent record review were conducted with the DON and SW regarding Resident 2. The DON stated Resident 2 ' s discharge care plan did not have specific interventions regarding her goals. A concurrent review of the Notice of Proposed Transfer and discharge date d 4/1/24 was conducted. The SW stated Resident 2 had been in the facility for several months but was not given the notice 30 days prior to discharge. The SW stated, There was no notice given in advance, she got it the same day she discharged . A review of the IDT Discharge Planning Review note dated 3/31/24 signed by the SW indicated the review was done one day prior to Resident 2 ' s discharge. No nursing discharge note was produced during or after the onsite investigation. On 5/6/24 at 3:20 P.M., an interview and concurrent record review were conducted with the DON and SW regarding Resident 4. The DON stated Resident 4 did not have a discharge care plan. The SW stated the first discharge planning note was on 4/19/24, one month after Resident 4 was admitted . The SW stated, Patient was aware of discharge to shelter, he has no home. No one at a shelter can be relied on to provide needed assistance. I didn ' t document his last covered day. We could have still skilled him (changed billing status within the facility), I don ' t know what happened. Everyone at IDT knew he needed assistance. He wanted to try ALF/ ILF. I don ' t know why we discharged this resident. The SW stated no 30-day notice of discharge was given though Resident 4 was at the facility for more than 30 days. The DON stated, We do not have a discharge note. The DON and SW acknowledged the facility did not implement all steps of the facility discharge process as indicated in the facility policy.

Based on observation, interview and record review the facility failed to provide supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle. Findings: Resident 1 ' s Admission Record indicated admission to the facility on [DATE], and included diagnoses of paranoid schizophrenia (a pattern of thoughts, feelings and behaviors that include suspicion of others), generalized muscle weakness, essential hypertension (high blood pressure often requiring medication that can have side effects increasing risk for falls) and cognitive communication deficit (difficulty with thinking and communication). A review of the Minimum Data Set (MDS) section GG dated 11/11/23 indicated Resident 1 required supervision or touching assistance (assistance from one person) for toileting hygiene, lower body dressing, chair and bed to chair transfer, walking 10 feet or more. The MDS indicated Resident 1 required set up or clean up assistance with toilet transfer. A review of facility Change of Condition (COC) note dated 1/26/23 indicated Resident 1 had an unwitnessed fall on her right knee on the physical therapy patio. A review of the facility COC note dated 2/28/23 indicated Resident 1 had a witnessed fall on the floor with her walker directly in front of her. A review of the facility COC note dated 3/14/23 indicated Resident 1 had an unwitnessed fall and was found on the left side of her bed with her head between her bed and the side dresser, Patient said she hit her head and has level seven out of ten pain in her right leg. A review of the facility COC noted dated 5/3/25 indicated Resident 1 had an unwitnessed fall and was found kneeling by her bedside. A review of the facility COC note dated 2/2/24 indicated Resident 1 had an unwitnessed fall and was found on the floor in front of toilet with her underwear on but pants around calves and stated I fell . ' An observation of Resident 1 ambulating in the hallway with a walker was conducted on 2/15/24 at 1:10 P.M. During the observation, Resident 1 did not have assistance or supervision from a staff member. Resident 1 was noted to walk with a limp on her left side. In an interview with the Director of Nursing (DON) conducted on 2/15/24 at 1:30 P.M., the DON stated at the time of the most recent fall (Resident 1) had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment). The DON stated, (Resident 1) was heard by a nurse asking for help in the bathroom. The nurse went in and saw the resident on the floor. A concurrent review of the Change of Condition (COC) note by Licensed Nurse (LN) 1 indicated, On 2/2/24 at approximately 9:20 P.M. the call light was on. Someone mumbled ' help me. ' Upon entry resident found on floor with pants down and underwear on. Resident stated, ' I fell . ' In an interview with LN 2 conducted on 2/15/24 at 1:50 P.M., LN 2 stated, She needs set up and clean up assistance for toilet transfer and ability to get on and off commode. You can ' t see her room from the nurse ' s station. In a joint interview with LN 3 and the DON conducted on 2/15/24 at 2:15 P.M., LN 3 stated Resident 1 was not on a bowel and bladder program (a schedule for elimination of the bladder and bowel). The DON stated, Bowel and bladder training means a staff member goes to help the Resident use the restroom every two hours, after meals and before sleep at night. An interview with LN 3 was conducted on 3/13/24 at 1:10 P.M. LN 3 stated the most recent interventions in Resident 1 ' s fall care plan dated 5/5/23 included anticipate and meet resident needs. A toileting program is a way to anticipate a resident need. A review of the Physical Therapy evaluation dated 5/5/22 indicated Resident 1 could walk 10 feet with maximum assistance (assistance of 75% or more from one person), move from sitting to standing with maximum assistance, transfer to a toilet with maximum assistance, and that both of her legs were impaired. A review of Resident 1 ' s fall risk assessment dated [DATE], prior to the fall on 2/2/24, indicated her score was 12 which was noted as high risk r/t (related to) taking more narcotic (prescribed controlled substance for pain relief which may increase risk of falls)/ psychotropic (prescribed medication for some psychiatric diagnoses which may increase risk of falls) meds (medications). A review of the facility policy titled Fall Management Program revised March 13, 2021 indicated The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards. A review of the facility policy titled Ambulation of a Resident revised January 1, 2012 indicated, Unless contraindicated, all assisted ambulation will utilize gait belts for resident and staff safety. Offer verbal encouragement and physical support.

Based on observation, interview and record review, the facility failed to provide resident safety for 1 resident (Resident 1) when Resident 1 eloped (leaving the facility unsafely or unescorted) from the facility ' s exit door which was equipped with an audible alarm. As a result, Resident 1 had a successful elopement and there was the potential risk for the elopement of other residents. Findings: On 11/22/23 the Department of Public Health received a facility report of an elopement for Resident 1 on 11/22/23 at 4:30 A.M. During a review of Resident 1 ' s facility record on 11/22/23 at 7:05 A.M., the record indicated .around 4;30[sic] am resident up on wheelchair and verbally responsive, no c/o[sic] and any discomfort.at[sic] 5Am[sic] went to resident room and unable to find resident on her room checked the whole building. But resident nowhere to found and call 911 and informed resident is missing and gave description of resident . During a review of Resident 1 ' s facility record on 11/23/23 at 7:41 A.M., the record indicated, .Spoke to Sheriff .Deputy will give the facility a call if they find the resident. If ever they don ' t call. That means she is not found yet . On 11/22/23 at 1: 38 P.M., an observation of the facility was conducted. The facility building had two entrances/exits. The facility entrance/exit had one main entrance with steps from outside and one entrance/exit with a ramp from outside. These two entrances/exits were connected to the two hallways in the building where resident rooms were located. On 11/22/23 at 2: 45 P.M., a phone interview was conducted with CNA 1 with the DON 1 present. CNA 1 stated Resident 1 was last seen on 9/2/23 around 4:30 A.M. near the hallway in a wheelchair. CNA 1 stated around 5:20 A.M. to 5:30 A.M., LN 2 was looking for Resident 1. CNA 1 stated he was making rounds on the other side of the building on the other hallway. CNA 1 stated he was inside another resident's room attending to the morning care and could not hear when the entrance/exit audible alarm sounded. On 11/22/23 at 3:30 P.M., an observation and interview was conducted with CNA 2. The entrance/exit with ramp from outside made an audible alarm when opened. CNA 2 stated the purpose of the audible alarm was to alert staff when residents were going out the building. On 11/22/23 at 3: 39 P.M. an observation and interview was conducted with LN 1. LN 1 demonstrated how the audible alarm could be heard as long as the entrance/exit door was held open. LN 1 stated the audible alarm was to alert staff and prevent elopement of residents. On 11/22/23 at 3: 40 P.M. a phone interview with LN 2 was conducted with the DON 1 present. LN 2 stated Resident 1 was out of bed on 11/22/23 early around 4:30 AM. to 5:30 A.M. LN 2 stated Resident 1 was looking for coffee but informed her the kitchen was still closed. LN 2 stated this was during LN 2 ' s med pass (administration of medications to residents). LN 2 stated when it was time to give medication to Resident 1, Resident 1 was nowhere to be found. LN 2 stated we looked for Resident 1 in every room and around the building. LN 2 stated around 4:30 to 5 A.M. he was on the other side of the building. LN 2 stated the entrance/exit doors were closed which meant no one from outside could open them. LN 2 stated people from inside the building could push open the entrance/exit door per fire safety compliance. LN 2 stated the entrance/exit door audible alarm was on at the time of Resident 1 ' s elopement. LN 2 stated Resident 1 must have eloped from the entrance/exit with ramp outside because he was passing medications on the other side of the building and Resident 1 was in a wheelchair. LN 2 stated the CNAs working that time were providing care in other resident rooms. LN 2 stated the purpose of the audible alarm was to alert staff that someone was going out the entrance/exit door. LN 2 stated the employees were not able to hear the audible alarm when inside other resident ' s rooms and Resident 1 eloped as a result of staff not hearing the audible alarm.

Based on observation, interview and record review, the facility failed to maintain sufficient food supplies, to ensure the planned menus would be followed as developed by the RD (Registered Dietitian), to meet the nutritional needs of 46 residents. In addition, the facility failed to maintain the facility's planned par level of disaster food supplies, to meet the nutritional needs of the residents and staff, in the event of a disaster or emergency resulting in the loss of gas or electricity. As a result, the lack of sufficient food supplies posed an immediate threat to the health and safety of the facility residents. There was no guarantee that the facility staff would have the means to meet the resident's nutritional needs in day to day meal planning. The lack of sufficient emergency food supplies could also result in not meeting the nutritional needs of the residents during a diaster. The facility failed to have a system in place to ensure adequate food supplies, to implement the facility's planned menus in order to meet the nutritional needs of the residents. The lack of guidance and monitoring of the facility staff to direct, prepare recipes and the quantities of food to serve to the residents, impeded the staff's ability to ensure that the planned amount of calories, proteins, vitamins and minerals, were provided to the residents on a daily basis for approximately 10 days. The lack of planning and food supplies had the potential to impact the nutritional status of the residents. In addition, there was inadequate guidance of dietary staff to ensure that therapeutic diets as ordered were provided, in terms of modified textures. Dietary staff were not provided sufficient guidance, and were not following recipes and planned menus. On 6/26/14 at 4:27 P.M. an Immediate Jeopardy was called by the Department. Findings: On 6/26/14 at 8:53 A.M., the Department received an anonymous complaint that the facility had insufficient food to feed the residents. On 6/26/14 at 10:15 A.M., an on-site investigation was conducted. Joint observations and interviews were conducted with facility Staff 1. Joint observations of the facility's food storage included all areas of the kitchen in which foods were stored: refrigerated, freezer, dry food storage and disaster/emergency food supplies. Three refrigerators in the kitchen area were jointly observed. Refrigerator 1: empty except for 1 pan with a plastic bag inside that contained a grey colored substance. Staff 1 identified the grey substance as 5 pounds of hamburger for dinner. Staff 1 stated that, "Refrigerator 1 was normally stocked with fresh produce, such as vegetables and fresh fruit." Staff 1 continued to state that, "Staff were going to (warehouse store) today for more meat." Refrigerator 2 was empty except for five gallons of milk on the bottom shelf. Staff 1 stated refrigerator 2 was used to stock dairy products, such as, yogurts, cottage cheese, sour cream and milk shakes. Refrigerator 3 was completely empty. Staff 1 stated, refrigerator 3 normally stored eggs and assorted cheeses. The joint observation of six cabinets with three shelves and a interview continued with Staff 1 Staff 1 stated , the cabinets were used to store canned goods and dry food products. The cabinet's contents were as followed: Cabinet 1- One 8-pound can (#10 can) mix fruit, two #10 cans of Mexican sauce, two #10 cans of tomatoes, three #10 cans refried beans, four #10 cans of mash potatoes, and one #10 can pears. All on one shelf, the other two shelves were empty. Cabinet 2 - One commercial box of cream of wheat, one commercial box of cream of rice, one box of coca, one box of tea. All on one shelf, the other two shelves were empty. Cabinet 3- Continued paper products, paper plates, napkins. Cabinet 4- One #10 can cranberry sauce, and additional paper goods. There was no other food items. Cabinet 5- Three 40 ounce bags of dry cereal. There was no other food items. Cabinet 6 - Contained paper cups, plates on one shelf. There were no other food items. Staff 1 stated, the cabinet usually contained canned goods, coffee, a variety of hot and cold cereals, and different types of pasta. Three freezers were jointly observed with Staff 1. Freezer 1 Contained one, 3-gallon container of ice cream. Freezer 2 Contained 6 objects wrapped in foil. Staff 1 stated that freezer 2 usually contained frozen vegetables. Freezer 3 was empty. Staff 1 stated that freezer 3 usually contained frozen meat. Staff 1was asked how and who ordered the food. Staff 1 stated , the routine for ordering food was two times a week. Staff 1 continued to state, "The dietary supervisor quit June 6 and we were told to order food only once a week." Staff 1 stated, " Today the kitchen staff were told not to order food supplies. Instead we need to make a list of the food and give it to the Administrator in Training (AIT). He would then have a facility staff go to (warehouse store)." Staff 1 continue to state, "Sometimes the facility staff person would go to (grocery store)." On 6/26/14 at 10:30, A.M. a joint observation and interview with Staff 1 of the emergency food supplies was conducted. The shelves were empty in areas for canned goods and puree food. Staff 1 stated that, the emergency supply had been rotated out to daily food supply to accommodate the menu and provide meals for the residents. Staff 1 continued to state that, the Administrator in Training (AIT) had been told about the shortage of the food supply yesterday (6/25/14) and he said he would call in an order. On 6/26/14 at 11:05 A.M., a telephone interview was conducted with the facility's food vendor. The food vendor stated that, he had not received a food order from the facility for today. He continued to state his deliveries for (city name) today had been completed and the facility was not on the list for deliveries. On 6/26/14 at 11:10 A.M., an interview was conducted with the AIT. The AIT stated he was not aware of a food shortage. He stated the kitchen staff would give him a list of what food would be needed and he would order from the vendor. On 6/26/14 at 11:20 A.M., an interview was conducted with Staff 2. Staff 2 stated that the refrigerators had been empty " but not as bad as today." Staff 2 stated that Staff 1 used to order after the dietary supervisor left but now the AIT was doing the ordering. On 6/26/14 at 12:26 P.M., facility staff 3 (FS 3) said that he assisted facility staff with a grocery run to (warehouse store) and brought the food from (warehouse store) to the dietary office. FS 3 said the AIT had provided him, and facility staff 4 (FS 4) with the grocery list for the food purchases at (warehouse store) that day. According to the Costco receipt, dated 6/26/14 at 11:26 A.M., the following was purchased; waffles, buns, veggies, fruit cocktail, Splenda, sweet ' N Low, ground beef and sausage. On 6/26/14 at 12:25 P.M.,a lunch observation was conducted in the dining room. According to the planned posted menu that was located on a wall in the dining room the following should have been served: Chopped Lettuce/Tomato, Enchilada Casserole, Salsa Mexicana, Sour Cream/Salsa, Mexican Corn, Refried Beans, and Fresh Fruit in Season. Instead of the planned menu, the following food items had been observed for lunch: barbeque chicken, mashed potatoes, mixed canned vegetables, and pudding. An alternate; grilled cheese sandwich instead of the meal served with ice cream as an alternate for pudding. The planned alternate for 6/26/14 should have been cheeseburger, per the posted menu. On 6/26/14 at 12:27 P.M. an interview was conducted with Staff 1. Staff 1 stated that the facility had not served the planned menu for lunch because the food items needed were not available in the facility. On 6/26/14 at 12:30 P.M., the Administrator (Admin) said the dietary services supervisor (DSS) abruptly left on June 9th or 10th. The Admin said that she had asked the facility's consultant Registered Dietitian (RD) to work full-time until the DSS position could be filled, and the RD said no. The Admin said to my knowledge the dietary services supervisor was working her full-time hours. It was sometimes difficult to track because she said she would need to work on weekends or very early hours. The Admin said she was aware that the dietary department was without a qualified full-time foodservice director. The Admin said that she was aware that there were food shortages occurring "to some extent." The Admin said, "What I do know is they would ask me to make short runs (grocery runs)." The Admin acknowledged that the request to make grocery runs was an unusual occurrence. During the same interview, the Admin said that she was unaware that the planned menus were not being provided to residents. The AIT said, "I'm not sure if the planned menus were served or not. I didn't check" The Admin and AIT acknowledged that the leadership staff provided insufficient oversight over the nutritional services during a time in which they were aware that sudden "grocery runs" were necessary, and while knowing the facility was without a qualified full time food service director. The Admin said that she had asked the RD to increase her hours to monitor the status of the foodservice operation. The Admin said, "I believe by 4-8 hours two times a week, and it used to be only one time a week, on Sundays." The Admin said that the RD had not reported any significant concerns. Upon record review, Consultant Dietitian Report, dated 6/15/14 the following was noted, "Concerns: The food stock for this coming week is below the stock standard limit. (pls (please)) see attached List to Order food and supplies - to be given to manager/Admin by head cook, discussed with cook the food substitutions due to insufficient food supplies (L) (low) par level), Disaster Supply - Insufficient - need to refill & Order to standard supply or Par Level." On 6/26/14 at 1:20 P.M., an interview was conducted with Staff 2. Staff 2 stated that, there had been numerous occasions in the month (June) in which the cooks had to prepare what food was on hand as the food needed to serve the planned menu was not available. Staff 1 was asked what was served when the menu indicated " Fresh Fruit In Season " and Staff 1 said all we have are bananas every day. Bananas are the only fresh fruit we have. We have been serving canned fruit. On 6/26/14 at 2:14 P.M., inventory of the facility's planned Emergency and Disaster Menu was jointly conducted with Cook 1. Cook 1 verified that the following items from the "3 days disaster food supplies" inventory list was missing: 2 cans of low sodium canned mixed veggies (for renal diet), 2 cases of canned pureed chicken, 1 case of canned pureed carrots, 2 # 10 (size) cans of ravioli, 4 tubs of peanut butter, 4 (#10) cans of chili beans, 4 (#10) cans of prepared macaroni & cheese, 1 case and 2 (#10) cans of beef stew, 2 cans (#10) of mixed veggies, 4 (#10) cans of 3 bean salad, 1 case of diced carrots, 1 (#10) can of sliced beets, 1 case of diced carrots, 1 case of green beans, 1 case of fruit cocktail, all of the juices were missing which were 5 cases of apple juice, 1 case of grape juice, and 48 CTS (counts) (5 ? oz.) of cranberry juice, and 2 cases of graham crackers. Cook 1 verified that the items were missing as they had to pull from the disaster food to meet the day to day foodservice operations for the residents. On 6/26/14 at 3:00 P.M., the Admin and the AIT said they were unaware that the facility had not maintained the planned par level of disaster food supply. On 6/26/14 at 4:27 P.M. an Immediate Jeopardy was called by the Department in the presence of the Admin, due to facility failure to maintain sufficient food supplies on hand for day to day operations. In addition, the facility failed to maintain sufficient disaster food supplies on hand to meet the needs of the residents in the event of an external disaster that required sheltering in place, in which food delivery may be impeded. Futhermore, there was lack of an organized dietary department as evidenced by, the lack of a qualified full-time food service director, and the lack of a system to ensure dietary staff prepared meals in accordance with the planned menus for regular and therapeutic diets, to ensure the nutritional needs of the residents would be met. According to the planned dinner menu that was posted in the kitchen, the planned posted menu for residents for 6/26/14 was Spaghetti with meatballs, parmesan cheese, fruit garnish, zucchini tarragon, whole wheat roll/margarine, lemon bars. On 6/26/14 at 5:08 P.M., Cook 1 said the following was prepared for dinner for the residents, "Hamburger, a handful of grapes, #12 portion (1/3 cup) of fruit cocktail, 5 ounces of juice and 5 ounces of milk." At the time of the interview, Cook 1 verified that the residents had already been served dinner. Cook 1 was asked why the planned menu was not served, and Cook 1 said, "Didn't have menu items to serve the planned menu." Cook 1 stated that what was prepared for dinner was what was on hand, so hamburgers was prepared. Cook 1 was asked what guidance was available to prepare the modified textured diets, and asked for clarification. Cook 1 was asked if there were recipes to follow for the hamburgers in regard to those residents who may have a diet order for ground meat, mechanical soft, or puree, and Cook 1 stated, "Oh, there are probably recipes here." When Cook 1 was asked what portion sizes to serve., Cook 1 said, "We don't have a spread sheet, I just gave what we had." On 6/27/14 at 7:33 A.M., the RD said that she found the spread sheets that was guidance to dietary staff on how to serve the planned menu, and she said, "They were stuck in the office (DSS office)." A review of the spread sheet indicated that a #8 scooop (1/2 cup) of "fresh fruit in season" should have been served, instead of the #12 scoop (1/3 cup) that was used to serve the fruit cocktail (that came from a can) on 6/26/14. The consultant RD had identified the insufficient day to day operation food supply, and the insufficient disaster food supply in her written consultation reports that the Administrator had the obligation to review, 11 days earlier to the immediate jeopardy situation that was identified by the Department on 6/26/14. Per the Consulting Agreement between the contracted RD and the facility, "9. Provide written records to the Administrator, DON (Director of Nursing) and Director of Dietetics for job performed ..." On 7/3/14 at 11:00 A.M, the RD reported to the Department that she wanted to make corrections to her statement she made to the Deparment on 6/26/14, and 6/27/14. She said that the Administrator was crying and begging her to lie to the Department on 6/26/14, and 6/27/14, and the RD said, "So I stupidly did not tell the truth." During the same interview as above the RD said the following. 1. The Admin never asked her to work full-time when the DSS had no longer worked at the facility since 6/9/14/. The Admin had not asked the RD to increase her hours to provide oversight over the foodservice operation when the Admin knew there was no DSS. The RD said, "In fact, (name of Admin) gets upset if I increased my hours, she likes me to stay to 4 hours a week." 2. The RD said the Admin had known that the DSS was not working full-time at the facility as the Admin had instructed the DSS to "split her time" between the Admin's two skilled nursing facility's that she administered because one had not had a DSS. The RD said the DSS told the RD that she was splitting her time between the two facility's since 2/28/14. 3. The Admin asked me to change my 6/15/14 Consultant Dietitian Report to take out the part of shortage of food and diaster supplies because the Admin said, "I will be in trouble if you submit your report..." 4. The RD said the following was the reason for the shortage of food, "The regular order for food supplies was completed by the DSS on 6/5/14 before she resigned but that order was cancelled by the AIT with the approval of the Admin. Imagine there was a shortage of food supplies for 10 days, so the cooks had no choice but to start using the disaster (food) supplies." 5. The RD said, "Then on 6/15/14, I was very angry and asked the Cook to submit all the written food supplies that the kitchen needed to (name of AIT)...The following day 6/16/14, delivery came." The RD verified the food order was for only 4 days. 6. The RD said, "On 6/19/14, Thursday - the cook reported to me that (name of food vendor) the food vendor company called to check if the order still stands (routine order that the facility would normally place but had not called the vendor to do so as of yet, so the vendor called the facility), and the AIT told the vendor no, and that's how all the food in the freezer and disaster (food)supplies were exhausted." On 7/3/14 at 4:26 P.M., the former DSS that had worked at (name of facility) via a telephone interview, said, "I was full-time to the facility until the Admin told me that I had to split my time to her other facility which began on 2/28/14." The facility's policy and procedure entitled "Food Ordering" (last revised June 01, 2014) indicated: "Purpose; To ensure that the Facility maintains an adequate supply of food to meet the nutritional needs of the residents. Policy: The Dietary Manager, under the supervision of the Administrator, is responsible for ordering food and non-food supplies necessary to adequately maintain dietary services to meet local, state and federal requirements and the nutritional needs of the residents. The facility will maintain an adequate supply of food and non-food items. The Dietary Manager will only order supplies through designated, contracted vendors of the facility ..., Procedure; ...II. The Dietary Manager will utilize the guidelines for ordering food and non-food supplies as established by the menu purchase guide ...,IV. Under normal operating conditions the following minimum inventory should be available at the facility for both regular and therapeutic diets: A. Staples: 7 days, B. Perishables: 2 days ...." The facility's policy and procedure entitled Menu Planning (undated) indicated, "Policy: The nutritional needs of residents will be met in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (which are adjusted for age, gender, activity level and disability), through nourishing, well-balanced diets, unless contraindicated by medical needs. Procedure: 1. Menu planning is completed by the facility's dietetics professional at least two weeks in advance of need and menus are kept on file in the facility for a minimum of 90 days ..., All current menus will be posted in the kitchen area during the appropriate time period. Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances ..., 3. Regular and therapeutic diets are written by the facility's dietetics professional in accordance with the facility's diet manual." According to the facility's job description for "Cook", "Responsibilities: 5. Follows instrucitons of the DSS in the preparation of meals..." The Cook had not had a spread sheet readily availalbe to follow instructions to ensure portions were served in accordance to the planned menu, to ensure the nutritional needs of residents were met. The faciltiy's Emergency And Disaster Procedures (undated) indicated, "Policy; To provide a planned menu with simplified nutritious meals to be used duirng an emgerncy or disaster. Procedure; In case of emergency, a 3-day menu will be used..., A. Food items designated in the emergency menu must be available at all times..." On 6/27/14 at 10:10 A.M., during an interview with a newly hired dietary services supervisor, the DSS said, "This is my first day here and I will be full-time." On 6/27/14 at 10:30 A.M., the immediate jeopardy was abated in the presence of the Admin after verification that the facility received sufficient food supply, re-stocked the planned disaster food supply, and had a full-time DSS in place.

Based on observation, interview and document review, the facility failed to ensure that the administrator managed the facility in a manner that enhanced and supported the physical, mental and psychological well-being of the residents, as evidenced by a failure to maintain sufficient food supplies at the facility to implement planned menus for daily operations, failure to maintain sufficient disaster food supplies on hand. Thus, the facility was incapable of implementing the facility's disaster menu in the event of loss of gas or electricity. The facility further failed to ensure that there was a qualified full-time dietary services supervisor (DSS) or full-time RD (Registered Dietician), when a DSS was not employed full-time, for the adequate oversight of the foodservice operation. As a result, residents were placed at immediate risk for the potential of not having their nutritional needs met on a day to day basis, or in the event of a disaster. (Cross-Reference F363, F361, F517). Findings: On 6/26/14 at 8:53 A.M., the Department received an anonymous complaint that the facility had insufficient food to feed the residents. On 6/26/14 at 10:15 A.M., joint observations and interview with Staff 1 were conducted, of the facility's food storage that included the refrigerated, freezer, dry food storage and disaster food supplies. Three refrigerators in the kitchen area were jointly observed. Refrigerator 1 was empty except for one pan with a plastic bag inside that contained a grey color substance. Staff 1, identified the substance as five (5) pounds of hamburger for dinner. Staff 1 stated that; refrigerator 1 was normally stocked with fresh produce such as, vegetables,and fresh fruit. Staff 1 continued to state that, "Staff were going to Costco today for more meat." Refrigerator 2 was empty except for five gallons of milk on the bottom shelf. Staff 1 stated refrigerator 2 was used to stock dairy products, such as, yogurts, cottage cheese, sour cream and milk shakes. Refrigerator 3 was completely empty. Staff 1 stated, refrigerator 3 normally stored eggs and assorted cheeses. The joint observation of six cabinets with three shelves and a interview continued with Staff 1 Staff 1 stated , the cabinets were used to store canned goods and dry food products. The cabinet's contents were as followed: Cabinet 1- One 8-pound can (#10 can) mix fruit, two #10 cans of Mexican sauce, two #10 cans of tomatoes, three #10 cans refried beans, four #10 cans of mash potatoes, and one #10 can pears. All on one shelf, the other two shelves were empty. Cabinet 2 - One commercial box of cream of wheat, one commercial box of cream of rice, one box of cocoa, one box of tea. All on one shelf, the other two shelves were empty. Cabinet 3- Continued paper products, paper plates, napkins. Cabinet 4- One #10 can cranberry sauce, and additional paper goods. There was no other food items. Cabinet 5- Three 40 ounce bags of dry cereal. There was no other food items. Cabinet 6 - Contained paper cups, plates on one shelf. There were no other food items. Staff 1 stated, the cabinet usually contained canned goods, coffee, a variety of hot and cold cereals, and different types of pasta. Three freezers were jointly observed with Staff 1. Freezer 1 Contained one, 3-gallon container of ice cream. Freezer 2 Contained 6 objects wrapped in foil. Staff 1 stated that freezer 2 usually contained frozen vegetables. Freezer 3 was empty. Staff 1 stated that freezer 3 usually contained frozen meat. Staff 1was asked how the food was ordered and who ordered the food. Staff 1 stated, the routine for ordering food was two times a week. Staff 1 continued, "The dietary supervisor quit June 6 and we were told to order food only once a week." Staff 1 stated, "Today the kitchen staff were told not to order food supplies. Instead we need to make a list of the food and give it to the Administrator in Training (AIT). He would then have a facility staff go to (warehouse store)." Staff 1 continue to state, "Sometimes the facility staff person would go to (grocery store)." On 6/26/14 at 10:30, A.M. a joint observation and interview with Staff 1 of the emergency food supplies was conducted. The shelves were empty in areas for canned goods and pureed foods. Staff 1 stated that, the emergency supply had been rotated out to the daily food supply to accommodate the menu and provide meals for the residents. Staff 1 continued to state that, the Administrator in Training (AIT) had been told about the shortage of the food supply yesterday (6/25/14) and he said he would call in an order. On 6/26/14 at 11:05 A.M., a telephone interview was conducted with the facility's food vendor. The food vendor stated that, he had not received a food order from the facility for today. He continued to state his deliveries for (city name) for today had been completed and the facility was not on the list for deliveries. On 6/26/14 at 11:10 A.M., an interview was conducted with the AIT. The AIT stated he was not aware of a food shortage. He stated the kitchen staff would give him a list of what food would be needed and he would order from the vendor. On 6/26/14 at 11:20 A.M., an interview was conducted with Staff 2. Staff 2 stated that the refrigerators had been empty, "but not as bad as today." Staff 2 stated that Staff 1 used to order after the dietary supervisor left but now the AIT was doing the ordering. On 6/26/14 at 12:26 P.M., facility staff 3 (FS 3) said that he assisted facility staff with a grocery run to (warehouse store) and brought the food from (warehouse store) to the dietary office. FS 3 said the AIT had provided him, and FS 4 with the grocery list for the food purchases at (warehouse store) that day. According to the (warehouse store) receipt, dated 6/26/14 at 11:26 A.M., the following was purchased: waffles, buns, veggies, fruit cocktail, Splenda, sweet ' N Low, ground beef and sausage. On 6/26/14 at 12:30 P.M., the Administrator (Admin) stated that the dietary services supervisor (DSS) abruptly left on June 9th or 10th. The Admin said that she had asked the facility's consultant Registered Dietitian (RD) to work full-time until the DSS position could be filled, and the RD said "no." The Admin said "to my knowledge the dietary services supervisor was working her full-time hours up until she left. It was sometimes difficult to track because she said she would need to work on weekends or very early hours." The Admin said she was aware that the dietary department was without a qualified full-time foodservice director. The Admin said that she was aware that there were food shortages occurring "to some extent." The Admin said, "What I do know is they would ask me to make short runs (grocery runs)." The Admin acknowledged that the request to make grocery runs was an unusual occurrence. During the same interview, the Admin said that she was unaware that the planned menus were not being provided to residents. The AIT said, "I'm not sure if the planned menus were served or not. I didn't check." The Admin and AIT acknowledged that the leadership staff provided insufficient oversight over the nutritional services during a time in which they were aware that sudden "grocery runs" were necessary, and while knowing the facility was without a qualified full time food service director. The Admin said that she had asked the RD to increase her hours to monitor the status of the foodservice operation. The Admin said, "I believe by 4-8 hours two times a week, and it used to be only one time a week, on Sundays." The Admin said that the RD had not reported any significant concerns. On 6/26/14 at 2:14 P.M., inventory of the facility's planned "Emergency and Disaster Menu" was jointly conducted with Cook 1. Cook 1 verified that the following items from the "3 days disaster food supplies" inventory list was missing: 2 cans of low sodium canned mixed veggies (for renal diet), 2 cases of canned pureed chicken, 1 case of canned pureed carrots, 2 # 10 (size) cans of ravioli, 4 tubs of peanut butter, 4 (#10) cans of chili beans, 4 (#10) cans of prepared macaroni & cheese, 1 case and 2 (#10) cans of beef stew, 2 cans (#10) of mixed veggies, 4 (#10) cans of 3 bean salad, 1 case of diced carrots, 1 (#10) can of sliced beets, 1 case of diced carrots, 1 case of green beans, 1 case of fruit cocktail, all of the juices were missing which were 5 cases of apple juice, 1 case of grape juice, and 48 CTS (5 ? oz.) of cranberry juice, and 2 cases of graham crackers. Cook 1 verified that the items were missing as they had to pull from the disaster food to meet the day to day foodservice operations for the residents. On 6/26/14 at 3:00 P.M., the Admin and the AIT said they were unaware that the facility had not maintained the planned par level of disaster food supply. According to the 6/15/14 Consultant Dietitian Report the following was noted: "Concerns: The food stock for this coming week is below the stock standard limit. (pls (please)) see attached List to Order food and supplies - to be given to manager/Admin by head cook, discussed with cook the food substitutions due to insufficient food supplies (L (low) par level), Disaster Supply - Insufficient - need to refill & Order to standard supply or Par Level." The consultant RD had identified the insufficient day to day operation food supply, and the insufficient disaster food supply in her written consultation reports that the Administrator had the obligation to review, 11 days earlier to the immediate jeopardy situation that was identified by the Department on 6/26/14 (cross reference F363). Per the Consulting Agreement between the contracted RD and the facility, "9. Provide written records to the Administrator, DON (Director of Nursing) and Director of Dietetics for job performed ..." On 7/3/14 at 11:00 A.M, the RD reported to the Department that she wanted to make corrections to her statement she made to the Deparment on 6/26/14, and 6/27/14. She said that the Administrator was crying and begging her to lie to the Department on 6/26/14, and 6/27/14, and the RD said, "So I stupidly did not tell the truth." During the same interview as above the RD said the following as outlined: 1. The Admin never asked her to work full-time when the DSS had no longer worked at the facility since 6/9/14/. The Admin had not asked the RD to increase her hours to provide oversight over the foodservice operation when the Admin knew there was no DSS. The RD said, "In fact, (name of Admin) gets upset if I increased my hours, she likes me to stay to 4 hours a week." 2. The Admin asked me to change my 6/15/14 Consultant Dietitian Report, to take out the part of shortage of food and diaster supplies because the Admin said, "I will be in trouble if you submit your report..." 3. The RD said the following was the reason for the shortage of food, "The regular order for food supplies was completed by the DSS on 6/5/14 before she resigned but that order was cancelled by the AIT with the approval of the Admin. Imagine there was a shortage of food supplies for 10 days, so the cooks had no choice but to start using the disaster (food) supplies." 4. The RD said, "Then on 6/15/14, I was very angry and asked the Cook to submit all the written food supplies that the kitchen needed to (name of AIT)...The following day 6/16/14, delivery came." 5. The RD said, "On 6/19/14, Thursday - the cook reported to me that (name of food vendor) the food vendor company called of order still stands (routine order) and the AIT said "no," and that's how all the food in the freezer and disaster (food)supplies were exhausted." The facility's policy and procedure entitled Food Ordering (last revised June 01, 2014) was reviewed and indicated: "Purpose; To ensure that the Facility maintains an adequate supply of food to meet the nutritional needs of the residents. Policy; The Dietary Manager, under the supervision of the Administrator, is responsible for ordering food and non-food supplies necessary to adequately maintain dietary services to meet local, state and federal requirements and the nutritional needs of the residents. The facility will maintain an adequate supply of food and non-food items. The Dietary Manager will only order supplies through designated, contracted vendors of the facility ..., Procedure; ...II. The Dietary Manager will utilize the guidelines for ordering food and non-food supplies as established by the menu purchase guide ...,IV. Under normal operating conditions the following minimum inventory should be available at the facility for both regular and therapeutic diets: A. Staples: 7 days, B. Perishables: 2 days ...." The facility's policy and procedure entitled Menu Planning (undated) indicated, "Policy: The nutritional needs of residents will be met in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (which are adjusted for age, gender, activity level and disability), through nourishing, well-balanced diets, unless contraindicated by medical needs. Procedure: 1. Menu planning is completed by the facility's dietetics professional at least two weeks in advance of need and menus are kept on file in the facility for a minimum of 90 days ..., All current menus will be posted in the kitchen area during the appropriate time period. Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances ..., 3. Regular and therapeutic diets are written by the facility ' s dietetics professional in accordance with the facility's diet manual." The faciltiy's Emergency And Disaster Procedures (undated) indicated, "Policy; To provide a planned menu with simplieifed nutritious meals to be used duirng an emgerncy or disaster. Procedure; In case of emergency, a 3-day menu will be used..., A. Food items designated in the emergency menu must be available at all times..." According to the facility's job description for Administrator (undated), "Job Title: Administrator, Reports To: Regional Vice President; Principal Responsibilities: Serves as liasion between governing body and Center personnel, Ensures Center compliance with all Federal, State and company regulations and policies, Ensures that all practices and policies are carried out in the highest ethical manner, Ensures that all Standard of Care and service provided is of the higheset quality, Ensures recruitment and retention of quality, professional, service-oriented personnel..."