Every finding on record at Bayshire Torrey Pines Post-Acute

Based on interview and record review the facility failed to implement a toileting schedule according to a resident's care plan intervention for one of three residents reviewed for care planning (Resident 1). This deficient practice had the potential for Resident 1 not to receive appropriate care, treatment, and interventions for fall prevention. Resident 1 was re-admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. An interview on 3/25/26 at 9:42 A.M. with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 had a fall incident, was sent out to the hospital and has not returned to the facility. LN 1 stated fall risk assessments were completed for new residents and after a fall incident. LN 1 further stated the resident's care plan was also updated after a fall to add interventions to prevent further falls. During an interview on 3/25/26 at 9:52 A.M. with Certified Nurse Assistant (CNA) 1, CNA 1 stated he was regularly assigned to Resident 1. CNA 1 stated Resident 1 had episodes of getting up unassisted to go to the bathroom. CNA 1 stated Resident 1 only attempted to get up unassisted to go to the bathroom. A review of the electronic medical record (EMR) for Resident 1 was conducted. The Skilled Nursing - IDT [Interdisciplinary Team- team members with various areas of expertise who work together toward the goals of their residents) Post Accident/Fall, (SN- IDT) dated 3/13/26 indicated Resident 1 fell on 3/12/26 at 7:20 pm. The SN-IDT indicated a Licensed Nurse (LN) got a call from a family member that they saw a resident on the floor. The SN-IDT indicated Resident 1 was next to the bathroom door with his back on the wall. The SN-IDT indicated interventions which included Existing and New Interventions [s] Initiated post fall: bed placed in lowest position with call light and personal items within reach, bed alarm, frequent rounding and toileting schedule to reduce unassisted ambulation to the bathroom. During a review of Resident 1's FALL CARE PLAN initiated on 3/10/26, the care plan (CP) indicated resident was at risk for falls related to generalized weakness. The CP indicated Interventions.Toileting schedule initiated to reduce unassisted ambulation to bathroom. Date initiated: 03/16/26. During a review of Resident 1's BOWEL/BLADDER INCONTINENCE CARE PLAN initiated on 3/13/26, the CP indicated, Interventions.Toileting Program: Establish Voiding/Bowel Patterns. A review of CNA Task in Resident 1's EMR was conducted. The Task indicated Toileting Program: Staff To Assist With Toileting Before and After Meals As Tolerated & PRN [as needed]. The Task indicated check marks for the toileting program on 3/18/26 and 3/19/26 only. During an interview on 3/25/26 at 10:52 A.M. with the Director of Nursing (DON), the DON stated the check marks in Resident 1's EMR under Task indicated toileting was provided to Resident 1 on 3/18/26 and 3/19/26. The DON stated there was no documentation regarding Resident 1's toileting schedule following Resident 1's fall incident on 3/12/26. An interview on 3/25/26 at 2:37 P.M. was conducted with CNA 4. CNA 4 stated she was assigned 2 P.M. until 10 P.M. to Resident 1. CNA 4 stated Resident 1 was not on a toileting schedule but Resident 1 woke up whenever he needed to use the bathroom. During an interview on 3/27/26 at 2:22 P.M. with the DON, the DON stated resident care plan interventions should be followed. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022 was conducted. The P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to initiate a baseline care plan for two of 43 sampled residents (Resident 1 and Resident 3) with actual pressure ulcers. This deficient practice had the potential to delay the necessary person-centered care needed to prevent negative outcomes. Cross reference F686 Findings: 1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1.5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care. A clinical chart review for Resident 1 was conducted, which indicated: - The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25. - Admission ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound. Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days . - Skin & Wound Evaluation: 2/4/25 In-house Stage III Sacrum Present on admission. Measurements area: 0.6cm length 1.2 cm width 0.6 cm. - Medical Doctor (MD) ordered on 2/4/25 indicated, .Treatment- Cleanse stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl [ointment that removes dead tissue] f/b [followed by] DSD [Director of staff Development]. Monitor for s/s [signs and symptoms] of infection, notify MD of any changes. every day shift for wound care . On 2/7/25 at 2:21 P.M., an interview and record review was conducted with the Minimum data set (MDS) nurse. The MDS nurse stated the admission assessment states open area to coccyx with measurements. I believe that ' s a pressure ulcer. The reason why is because they [admission nurses] are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer. The MDS nurse stated that the pressure ulcer care plan as not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing. On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments. A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals . 2. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included a history of malnutrition (lack of proper nutrition). A record review of Resident 3's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/29/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 3 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A clinical chart review for Resident 3 was conducted, which indicated: - The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN, LPN, LVN] on 1/23/25. - Admission ordered on 1/23/25 indicated, no treatment orders to the pressure ulcer on the coccyx. - Medical Doctor (MD) ordered on 1/29/25 indicated, - Treatment- Cleanse chronic stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl f/b calcium alginate and DSD. Monitor for s/s of infection, notify MD of any changes. every day shift for wound care . - Skin & Wound Evaluation 2/4/25: Coccyx Present on admission. Measurements area: 1.2 cm length 1.9 cm width 0.9 cm.stage 3 pressure injury to sacrococcyx [tailbone and the triangular shaped bone to the lower spine] . 2/7/25 at 2:10 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 3 ' s admission skin assessment dated [DATE] indicated, .Coccyx [tailbone] with small skin opening and quarter sized redness but was checked marked as a pressure ulcer. LN 1 stated the pressure ulcer care plan was initiated on 1/26/25 and should have been initiated within 48 hours (three days after admission). LN 1 stated it was important that the pressure ulcer care plan was in place within 48 hours to prevent delayed care and treatment for the pressure ulcer. LN 1 further stated delayed care can contribute to the worsening of pressure ulcers and infections if not cared for timely. On 2/7/25 at 2:38 P.M., an interview and record review was conducted with the Minimum Data Set (MDS) nurse. The MDS nurse stated Resident 3 ' s admission skin assessment dated [DATE] indicated Resident 3 had a pressure ulcer to the coccyx. The MDS nurse stated it was important that the pressure ulcer care plan was completed within 48 hours to provide a baseline description for the monitoring the pressure ulcer ' s status with interventions and/or worsening of the pressure ulcer and infection. On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments. A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .

Based on observation, interview, and record review, the facility failed to accurately assess an actual pressure ulcer on admission, provide appropriate treatment and preventative measures according to standards of practice to prevent further progression of a pressure ulcer for one of 43 sampled residents (Resident 1) at risk for pressure ulcers. This failure resulted in a delay of Resident 1's stage III pressure ulcer to be appropriately staged during an initial admission assessment and proper treatment for continous care necessary to prevent the worsening of the pressure ulcer. Cross reference F655 Findings: 1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1.5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care. A clinical chart review for Resident 1 was conducted, which indicated: - The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25. - Admission Medical Doctor (MD) ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound. Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days . - Skin & Wound Evaluation: 2/4/25 In-house Stage III Sacrum Present on admission. Measurements area: 0.6cm length 1.2 cm width 0.6 cm. - MD ordered on 2/4/25 indicated, .Treatment- Cleanse stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl [ointment that removes dead tissue] f/b [followed by] DSD [Director of staff Development]. Monitor for s/s [signs and symptoms] of infection, notify MD of any changes. every day shift for wound care . On 2/7/25 at 2:21 P.M., an interview and record review was conducted with the Minimum data set (MDS) nurse. The MDS nurse stated the admission assessment states open area to coccyx with measurements. I believe that ' s a pressure ulcer. The reason why is because they [admission nurses] are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer. The MDS nurse stated that the pressure ulcer care plan as not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing. On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments. A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Opened food items had no use by date. 2. Food items with mold in it. 3. Employees' personal belongings were stored inappropriately in a food preparation area. 4. Boxes on top of the ice machine. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses. Findings: 1. On [DATE] at 8:40 A.M., an observation was conducted with the Certified Dietary Manager (CDM) in the walk-in refrigerator. These observations included: - sweet and sour basting sauce with no use by date - grated carrots with no use by date - salsa with no use by date - noodle soup with no use by date - tomato soup with no use by date On [DATE] at 11:09 A.M., an interview was conducted with the CDM. The CDM stated it was important to label and indicate the use by date on the food items to ensure residents were not served with expired foods for safety, and protocols were taken to ensure susceptible residents were free from harm related to food consumption. On [DATE] at 1:45 P.M., an interview was conducted with the Registered Dietician (RD) with the presence of the Administrator (ADM) and the Director of Nursing (DON). The RD stated the expectation was for the dietary staff to conduct quick inspection, label, and indicate the use by date to ensure residents were not served expired foods. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].17 (A) (B) (C) (D), .required food labeling and dating .the day the original container is opened .The date marked shall not exceed a manufacturer's use by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. A review of the facility's policy, titled Food Storage, revised [DATE], indicated, .All products should be .dated upon receipt, when open and when prepared. Use Use-By dates on all food stored in refrigerators . 2. On [DATE] at 8:40 A.M., an observation was conducted with the CDM in the walk-in refrigerator. There were two packs of strawberries with mold in it. The CDM stated, I don't know what to say. On [DATE] at 11:09 A.M., an interview was conducted with the CDM. The CDM stated it was important to inspect the food items in the refrigerator to ensure the residents were served fresh fruits and free from harm related to food consumption. On [DATE] at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated the expectation was for the dietary staff to check the fruits to ensure they were fresh because it was a health risk to the residents. A review of the facility's policy, titled Food Storage, revised [DATE], indicated, .All products should be inspected for safety and quality .Fresh Fruits, 1. Fresh fruit should be checked . 3. On [DATE] at 8:40 A.M., an observation was conducted with the CDM in the food preparation area. There was a cellphone, keys, and speaker by the food tray. Next to these items was a gallon of corn syrup. On the other side, was a tray of bread. On [DATE] at 11:09 A.M., an interview was conducted with the CDM. The CDM stated the employees' personal belongings should be kept in the lockers and should not be in the food preparation area to prevent food contamination. On [DATE] at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated the expectation was for the dietary staff to keep their personal belongings in the designated location to prevent food contamination, which may cause illness to the residents. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].11(B), .Storage of personal items: Lockers or other suitable facilities are to be provided for the storage of employee personal possessions, ,d+[DATE].11 (b) - lockers or suitable facilities are to be located in a designated area where contamination of food, equipment, utensils cannot occur . A review of the facility's policy, titled Personal Hygiene/Safety/Food Handling/Infection Control, revised [DATE], indicated, .5. Designated Area for Employee Personal Belongings .b. Personal belongings .may be stored in the designated area . 4. On [DATE] at 8:40 A.M., an observation and an interview was conducted with the CDM in the food preparation area. There were two boxes of Styrofoam products on top of the ice machine. The CDM stated, The boxes should not be there. On [DATE] at 11:09 A.M., an interview was conducted with the CDM. The CDM stated the boxes were removed on top of the ice machine. The CDM stated, The kitchen should be clutter free as a best practice. On [DATE] at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated, The expectation was the ice machine should be completely clear to keep the ice machine sanitized because there might be a debris that may fall in the ice machine which could create mold because mold builds up very quickly. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].11, Equipment .Food-Contact Surfaces .indicate, .(A) Equipment Food-Contact Surfaces .shall be clean .

Based on observation, interviews, and record review, the facility did not ensure it followed professional standards of practice when a gastrostomy tube (GT-tube inserted through the belly to bring nutrition and medications directly to the stomach) placement and residual (the amount of liquid drained from a stomach following administration of nutrition) was not checked before medication administration for one resident (20). This failure had the potential for causing complications related to GT health. Findings: Per the facility face sheet, Resident 20 was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (presence of an artificial opening into the stomach). On 12/11/24 at 8:22 A.M., licensed nurse (LN) 1 was observed and interviewed during a medication administration for Resident 20. On 12/11/24 at 8:31 A.M., LN 1 entered Resident 20's room. LN 1 explained the procedure to Resident 20 and detached Resident 20's GT from the nutrition feeding tube. LN 20 attached a syringe to the GT and flushed the GT with water. LN 20 then proceeded to administer medications. On 12/11/24 at 8:45 A.M., LN 1 stated she was done with administering Resident 20's medication. LN 1 stated, I forgot to check the GT placement and residual prior to giving the medications. On 12/12/24 at 2:00 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that all nurses check GT placement and residual prior to administering medications and that it is important in order to help prevent complications such as aspiration pneumonia. A review of the facility policy titled, Administering Medications through an Enteral Tube dated November 2018, .6. Verify placement of feeding tube .

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aid in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of two residents reviewed for urinary catheter care (Resident 95). This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: A review of Resident 95's Admission Record indicated Resident 95 was admitted to the facility on [DATE], with diagnoses which included benign prostatic hyperplasia (BPH, a condition in which the prostate gland is larger than normal and may block the bladder and the urethra) with urinary tract symptoms. A review of Resident 95's history and physical (H&P) dated 11/29/24, indicated he had the capacity to make his own medical decisions. The H&P indicated Resident 95 had chronic urinary retention due to BPH with chronic urinary catheter. A review of Resident 95's minimum data set (MDS - a federally mandated resident assessment tool), dated 12/5/24, Resident 95 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 15/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). The MDS section for bowel and bladder indicated Resident 95 had a urinary catheter upon admission. On 12/9/24 at 3:14 P.M., an observation and an interview with Resident 95 was conducted in his room. Resident 95 laid in bed with a urinary catheter visible next to the bed. Resident 95's catheter bag and privacy bag were on the floor. Resident 95 stated he was, Not comfortable. On 12/9/24 at 3:18 P.M., an observation with Licensed Nurse (LN) 14 was conducted. LN 14 administered medication to Resident 96. After giving Resident 96 his medications, LN 14 jumped over the catheter bag and the privacy bag which were on the floor. On 12/9/24 at 3:22 P.M., an interview was conducted with LN 14. LN 14 stated the catheter bag should have been hung and not laid on the floor to prevent from accidentally pulling the catheter which may cause trauma, and prevent bacteria to enter the catheter bag which may cause an infection to Resident 95. On 12/10/24 at 2:22 P.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the urinary catheter, and the privacy bag should be always off the floor to prevent infection to the residents. On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated there should be no catheter bag on the floor for infection control purposes. The DON stated, That should not happen. A review of the facility's policy titled Catheter Care, Urinary, dated 2001, indicated, .Infection Control .2. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interviews, and record review, the facility failed to indicate the appropriate use of anti-anxiety (medication used for worry and fear) medications and communicated the target behavioral monitoring for the use of anti-anxiety medication among staff members, for one of five residents reviewed for unnecessary psychotropic (mind-altering) medications (Resident 96). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being. Findings: A review of Resident 96's Admission Record indicated Resident 96 was admitted to the facility on [DATE]. A review of Resident 96's physician order dated 11/28/24 indicated the following order: - Clorazepate (an anti-anxiety medication) for psychosis. - Monitor episodes of ( .psychosis .AEB [sic, as evidenced by]: hallucinations, agitation) .for drug use of clorazepate. On 12/10/24 at 4:33 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11, outside Resident 96's room. CNA 11 stated she was familiar with Resident 96. CNA 11 stated Resident 96 had no behaviors, and no behavior monitoring was reported for them (the staff) to observe. On 12/11/24 at 10:02 A.M., an interview was conducted with CNA 12, outside Resident 96's room. CNA 12 stated Resident 96 was a nice resident and there was no behavioral monitoring conducted for Resident 96. CNA 12 stated the nurses will tell us if they (residents) need to have any behavioral monitoring. On 12/11/24 at 12:12 P.M., a concurrent review of Resident 96's clinical record and an interview was conducted with Licensed Nurse (LN) 12. LN 12 stated she admitted Resident 96 to the facility on [DATE]. LN 12 stated Resident 96 had a physician's order of clorazepate and was indicated for psychosis. LN 12 stated Resident 96 had no diagnosis of psychosis. LN 12 stated clorazepate was an anti-anxiety medication. LN 12 stated the indication of the clorazepate is not the right diagnosis, it is important to know the right indication because with this one, it is not the right behavior that we are targeting. LN 12 stated it was important to specify the indication to prevent confusion and unnecessary drug use. LN 12 stated she put the order, Wrong. In addition, LN 12 stated she did not know where to find the documentation for the behavioral monitoring related to the use of clorazepate for Resident 96. On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to clarify the indication of psychotropic medication. The DON stated it was important to know why the residents were taking the medications and what disease process the residents were treated for. A review of the facility's undated policy, titled Psychotropic Medication Use, indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition .2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .c. Anti-anxiety medications .

Based on interview and record review, the facility failed to indicate the appropriate indication for the use of anticoagulant (blood thinner) medication for one of two residents (Resident 22), reviewed for unnecessary medications. This had the potential for unnecessary medication use and had the potential to negatively impact the resident's well-being. Findings: A review of Resident 22's Admission Record indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and atrial fibrillation (A-fib, irregular and rapid heartbeat). A review of Resident 22's physician order dated 11/9/22 indicated the following order: - Apixaban (blood thinner medication) for anticoagulant. On 12/10/24 at 4:33 P.M., a concurrent review of Resident 22's clinical record and an interview with Licensed Nurse (LN) 12 was conducted. LN 12 stated Resident 22 had been in the facility since 11/9/22. LN 12 stated there was a physician's order of apixaban for Resident 22 on 11/9/22 and the indication for its use was for anticoagulant. LN 12 stated the LN who transcribed the order no longer worked in the facility. LN 12 stated there should be a clear indication for the use of apixaban whether it's for A-fib or PVD for Resident 22. LN 12 stated the LNs should have verified with the attending physician what was the apixaban intended for. On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to verify the order from the physician and clarify the indication for the medication and the intended use of it. A review of the facility's policy titled, Medication Orders, revised 10/2018, indicated, .B. Completeness of Orders .1 .Orders must include the drug .It is also recommended that the indication/diagnosis for use be included on each order .

Based on observation, interview and record review, the facility did not ensure a dressing for a peripherally inserted central catheter (PICC- a long, thin, flexible tube inserted into a vein that allows delivery of medications) was changed in a timely manner for one resident (151). This failure had the potential to increase the risk of infection to Resident 151. Findings: Per the facility face sheet, Resident 151 was admitted to the facility on [DATE] with diagnoses that included pelvic osteomylitis (infection of the bone). On 12/9/24 at 3:56 P.M., an observation and interview was conducted with Resident 151 in the resident's room. Resident 151 was sitting in the wheelchair watching TV. An observation of a PICC line on the resident's left upper arm covered with a dressing dated 12/1/24. Resident 151 stated that the dressing had not been changed since the nurse at the hospital did. On 12/12/24 at 2:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 151's PICC line dressing should have been changed on 12/8/24 and that it was her expectation that all dressings be changed according to standards of practice and facility policy. A review of the facility policy titled, Peripheral and Midline IV Dressing Changes dated March 2023, indicated that IV dressings need to be changed .a. at least every 7 days .

Based on observation, interview, and record review, the facility failed to provide nail care to one of two residents (Resident 96), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 96 was at risk for skin injury and infection. Findings: Resident 96 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness and needed assistance for personal care, per the facility's Admission Record. On 12/9/24 at 4:03 P.M., an observation and interview were conducted for Resident 96 as she laid in bed. Resident 96's arms and hands were exposed, and fingernails appeared long, split and with brown materials underneath the nails. Resident 96 stated, No one asked if I want my nails cut short, I want it trimmed but no one asked me. They (facility staff) see it. On 12/10/24, Resident 96's clinical record was reviewed. A review of Resident 96's History and Physical (H&P) dated 11/30/24, indicated Resident 96 had fluctuating capacity to make her own medical decisions. A review of Resident 96's minimum data set (MDS - a federally mandated resident assessment tool), dated 12/3/24, Resident 96 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 11/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). The functional status indicated Resident 96 required one to two-person (staff member) assistance for hygiene and grooming. A review of Resident 96's care plan (directs the plan of care for the residents that included the goal and interventions), dated 11/28/24, indicated one of the goals for Resident 96's ADLs included provide grooming and hygiene daily . On 12/10/24 at 4:24 P.M., a follow up observation and an interview were conducted for Resident 96 as she laid in bed. Resident 96 pointed her right thumb fingernail, stated the facility staff did not trim her fingernails, and there was a split between her fingernails. Resident 96 stated she was not comfortable about the split in her fingernail. Resident 96 stated There is something underneath it and they have to trim so that it will not split. On 12/10/24 at 4:33 P.M., a joint observation of Resident 96's fingernails and an interview with Certified Nursing Assistant (CNA) 11 were conducted. CNA 11 stated the CNAs spent the most time with the residents when providing care, and should have checked Resident 96's fingernails. CNA 11 stated Resident 96's fingernails were long and needed to be trimmed. CNA 11 stated Resident 96 might scratch herself with long fingernails. On 12/10/24 at 4:50 P.M., a joint observation of Resident 96's fingernails and an interview with Licensed Nurse (LN) 11 were conducted. LN 11 stated LNs did the assessment to newly admitted residents and one of their responsibilities was to check the residents' fingernails. LN 11 stated Resident 96's fingernails were long, curling and with brown materials underneath the fingernails. LN 11 stated Resident 96's fingernails needed to be trimmed. LN 11 stated the brown materials underneath Resident 96's fingernails could have been a food debris. LN 11 stated it was important to trim the residents' fingernails because they might scratch themselves and if something was in the fingernails, it might cause an infection to the residents. On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectations was for the facility staff to ensure the residents' fingernails were cleaned and trimmed as part of the hygiene provided to the residents. A review of the facility's undated policy titled, Activities of Daily Living (ADL), Supporting, indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal .hygiene .

Based on interview and record review, the facility failed to implement policies and procedures when the facility failed to conduct a comprehensive investigation of allegations of inappropriate comments that involved one resident (Resident 1). This failure had the potential for allegations of inappropriate behavior to not be fully investigated. Findings: According to the Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included visual loss and need for assistance with personal care. According to the Minimum Data Set (MDS, an assessment tool), Resident 1 was cognitively intact with a BIMS (Brief Interview of Mental Status, a cognition tool) score of 12. On 10/22/24 at 10:59 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated on 9/16/24 Certified Nursing Assistant (CNA) 1 reported while assisting Resident 1 with a shower, Resident 1 made inappropriate comments to her. The DSD stated the comments were of a sexual nature. On 10/22/24 at 2:04 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON acknowledged CNA 1 had accused Resident 1 of making inappropriate sexual comments to her. The DON stated she did not document the investigation per facility policy. The DON further stated .no, it wasn ' t done . The DON stated it was important to follow the facility ' s abuse policy .so that no harm comes to them [residents and staff] .so they stay safe in the facility . On 11/8/24 at 2:22 P.M., an interview was conducted with the Administrator (ADM). The ADM stated his expectation was for the facility to follow their abuse policy. The ADM stated, .the tricky thing for this is we didn ' t classify it as abuse .we didn ' t have the stuff [documentation] in the chart . A review of the facility ' s policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revised September 2022 indicated, All reports of .are thoroughly investigated by facility management .The individual conducting the investigation as a minimum .reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly .

Based on observation, interview, and record review, the facility failed to ensure food safety was maintained in the kitchen according to facility policy when multiple food items were not dated or were dated in the future; and no received on or use by date was noted. These deficient practices had the potential to cause foodborne illness. Findings: An observation of the facility's kitchen was conducted on [DATE] at 8:30 A.M. Seven containers had no received or expire dates: parsley flakes, black pepper, granulated garlic, oregano, paprika, thyme leaves, and basil. Multiple items were marked with received dates which were in the future ([DATE]): a one-pound package of ground beef, a one-pound package of ground pork, boxes of Rice Krispy Treats, quick oats, boxed pancake mix, boxed cake mix, cans of tomato soup, cans of cranberry sauce, cans of corned beef hash and a box of quinoa. There were multiple items with dates but not identified as whether the date was received by, or use-by dates: pecan pieces, sugar, pancake syrup, coffee creamer, brown sugar, salt, pound cake, and frozen mixed berries. Several items had no dates: bags of shredded cabbage and bags of shredded carrots, whole cabbage (stored in boxes) and cantaloupes (stored in boxes.) An interview was conducted with the Dietary Services Manager (DSM) on [DATE] at 8:40 A.M. The DSM stated, There are many things mislabeled, staff should be more careful, we don't want to serve expired food to residents. An interview was conducted with the facility administrator (Admn) on [DATE] at 9:43 A.M. The Admn stated, Non-labeled food can be expired and that can cause food borne illness. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:43 A.M. The DON stated, Food that is expired can cause illness. An interview was conducted the the Registered Dietitian (RD) on [DATE] at 10:46 A.M. The RD stated, It is important to label and date items so that we know what we are serving to residents and that it is safe. The facility was unable to provide a policy regarding labeling and dating of foods.

Based on observation, interview, and record review, the facility failed to ensure residents received foods in measured amounts when standardized recipes were not followed for residents receiving pureed diets. This failure had the potential for residents to have decreased nutrition and possible weight loss. Findings: An observation of the pureed food production for lunch was conducted on 1/10/24 at 10:30 A.M. The Culinary Director (CD) cut seven portions of the ravioli bake casserole and placed them in the blender. The CD did not measure or weigh the portions. In addition, seven portions of cauliflower were pureed with no measurement or weighing of the portions. The CD poured chicken stock into the blender without measuring the amount. There was no recipe/recipe book available for the CD to use. An interview was conducted with the CD on 1/10/24 at 10:45 A.M. The CD stated, I did not use a recipe, I know them. There is a recipe binder here in the department. It is important to follow the recipes to keep nutritional value. An interview was conducted with the Dietary Services Manager (DSM) on 1/10/24 at 10:50 A.M. The DSM stated, It is important to use the recipes so that the correct texture is obtained; if it is too runny or too thick, residents might not eat it. An interview was conducted with the Director of Nursing (DON) on 1/ 11/24 at 9:43 A.M. The DON stated, Following the recipe is important for nutritional value and for consistency. An interview was conducted with the Registered Dietitian (RD) on 1/11/24 at 11:46 A.M. The RD stated, Following recipes for puree food is very important because the recipe has specific amounts of servings and liquid to preserve the nutrition, and we don't want to dilute or add to the diet. A review of the facility policy titled, Standardized Recipes, dated 4/2017, indicated, Policy statement: Standardized recipes shall be developed and used in the preparation of foods.

Based on observation, interview and record review, the facility failed to utilize urine collection containers (UCC) in a safe, clean manner for two of two residents reviewed for Environment of Care. This failure had the potential to cause urinary tract infections (UTIs). Findings: 1. Resident 156 was admitted to the facility on [DATE] with diagnosis to include a fractured bone in the spine and UTI, per the Admission Record. On 1/8/24, at 9:30 A.M., Resident 156 was observed in bed. A plastic device with long tubing was observed set on towels on the floor. The coiled tubing went from the device on the floor up under the blankets and between Resident 156's legs. A liquid which appeared to be urine was in the tubing, and in the UCC. Resident 156 stated she did not know what the tubing or device were for. On 1/11/24, a record review was conducted. On 12/29/23, Resident 156 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Per a nursing Admission Evaluation, dated 12/23/23, Resident 156 was on an antibiotic (a medication to treat infections) for a current UTI. 2. Resident 107 was admitted to the facility on [DATE] with diagnosis to include paralysis to one side of the body, per the Admission Record. On 1/11/24 at 9:10 A.M., an observation of Resident 107 was conducted in her room. Resident 107 was in bed, sitting up. Resident 107 had a UCC sitting on the floor, on towels. The UCC tubing was coiled on the towel. Resident 107 stated her family brought the device for her to use at night, so she would not have to get up and walk to the bathroom. Resident 107 stated the UCC would remove urine from her body through the tube. Per Resident 107, the device was always left on the floor. On 1/11/24, a record review was conducted. On 12/23/23, Resident 107 had a BIMS score of 13, indicating intact cognition. On 1/11/24 at 9:30 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the UCC for both residents was brought in by family members. LN 1 stated the UCC needed to be kept below bladder level to work properly, so it was placed on towels on the floor. LN 1 stated leaving the UCC and tubing on the floor could cause UTI's. LN 1 stated a low table or container should be used rather than placing the UCC on the floor but this had not been done. On 1/11/24 at 9:40 A.M., an interview was conducted with Infection Preventionist 1 (IP 1). IP 1 stated, The device shouldn't be on the floor, it could put the resident at risk for infections. UTIs could easily be a result of poor practice. IP 1 stated since the UCC was not commonly used in the facility, staff had to be trained on its proper use to prevent infections. IP 1 stated the training had not been provided for the UCC. On 1/11/24 at 10:09 A.M., an interview was conducted with the Director of Nursing (DON). Per the DON, the UCC cannot sit on the floor. The DON stated the towel was intended as a way to keep the UCC off of the floor, but may not be best practice for infection prevention. Per a facility policy, revised September 2014 and titled Catheter Care, Urinary, .Infection Control .2B. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interview and record review, the facility failed to develop and transmit Discharge Minimum Data Set (MDS, a comprehensive assessment and care screening tool) assessments for two of two residents reviewed for Resident Assessment (Residents 5, 8). This failure resulted in Resident 5 and 8's discharge status not being communicated to the Centers for Medicare and Medicaid (CMS) as required, and had the potential to result in delayed quality measurements from the data. Findings: On 1/11/24, a record review was conducted. Per the MDS 3.0 Resident Assessments list: Resident 5 was due for a Discharge MDS assessment on 9/19/23. Resident 5's MDS status was indicated as, In progress. Resident 8 was due for a Discharge MDS assessment on 8/28/23. Resident 8's MDS status was indicated as, In progress. On 1/11/24 at 2:35 P.M., a concurrent interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated it was important to complete a Discharge MDS when a resident left the facility. The MDSC reviewed Resident 5 and Resident 8's MDS summaries and stated, I missed these. I take ownership of it, it was a mistake. On 1/11/24 at 3:19 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was important for the MDS to be completed and transmitted in order for CMS to track the resident, and to see that payment was correct and not fraudulent. Per a facility policy, dated 2001, titled, Resident Assessment, .Required Assessments-are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes .1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a required assessments conducted for all residents in the facility: .(7) Discharge Assessment .

Based on observation, interview and record review, the facility failed to treat a resident with dignity when a Certified Nursing Assistant (CNA 1) stood while assisting with breakfast (Resident 108). This failure had the potential to cause Resident 108 a loss of self-esteem and/or self-worth. Findings: Resident 108 was admitted to the facility on [DATE] with diagnoses to include generalized muscle weakness and dysphagia (difficulty swallowing), per the Admission Record. On 12/29/23, Resident 108 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On the same date, Resident 108 was assessed to require partial to moderate assistance with eating. On 1/9/24 at 8:30 A.M., an observation was conducted in the dining room. Six residents were seated, five were feeding themselves. Resident 108 was seated at a table, with his hands in his lap. CNA 1 was standing on Resident 108's right side, feeding him the plated food. On 1/9/24 at 8:35 A.M., an interview was conducted with CNA 1. CNA 1 stated she should have been seated while feeding Resident 108, as well as all residents who require feeding assistance. CNA 1 stated being seated would make it easier to see how the resident was chewing and swallowing, and would give the resident dignity while dining. On 1/9/24 at 8:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the CNA should have been seated in order to provide dignity to the resident. Per a facility policy, revised July 2017 and titled Assistance with Meals, .Residents Requiring Full Assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals .

Based on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medication was followed for one of two sampled residents. This failure had the potential to affect Client 1 ' s quality of life, health and well- being. Findings: Resident 1 was admitted to the facility on [DATE], per the facility ' s Face Sheet. On 11/15/23 a record review was conducted. Resident 1 had diagnoses which included subarachnoid bleed (bleeding in the space that surrounds the brain), per the physician ' s admission history and physical visit, dated 10/6/23. Per the MDS, dated [DATE], Resident 1 had a BIMS of 11 (BIM score of 8-12 indicated a resident was moderately cognitively impaired). On 11/15/23 at 3:07 P.M., an interview and record review were conducted with Licensed Nurse (LN) 2. The LN 2 stated Client 1 had an order of blood pressure medicine since she was admitted to the facility on [DATE]. The blood pressure medication was ordered one time a day and scheduled at 9 A.M. There was no written parameter order until 10/13/23. The LN 2 stated the standard of practice for blood pressure medication was to check the blood pressure of the resident before giving the medication and follow the physician ' s parameter order. If no written parameter, follow the facility standard of practice which to hold the medicine if the systolic blood pressure is below 110 millimeter of mercury (mmHg) and if pulse was less than 60 beats per minute. On 11/15/23 at 3:27 P.M., an interview was conducted with LN 4. The LN 4 stated that he always checked the blood pressure of residents before administering the blood pressure medicine. The LN 4 stated the normal practice was to hold the blood pressure medicine if the systolic pressure was below 110 mmHg and if pulse below 60 and notify attending physician. LN 4 further stated, if there were no parameters written, verify with the attending MD. On 11/15/23 a record review of Client 1 ' s Medication Administration Record (MAR) and Vitals Summary log was conducted. Per the MAR, dated 10/11/23, the blood pressure medicine was administered to Client 1 at 9 A.M. There was no documentation of Client 1 ' s blood pressure (BP) reading in the MAR. Per the Vitals Summary Log, dated 10/11/23 at 7:04 A.M., the BP reading was 104/61 and at 19:31 P.M., Client 1 ' s BP reading was 90/60. Per the MAR, on 10 /12/23, the blood pressure medicine was administered at 9 A.M. There was no documentation of BP reading in the MAR. Per the Vitals Summary Log, dated 10/12/23 at 9:48 A.M., Client 1 ' s BP reading was 103/58 mmHg. Per the Physician ' s order dated 10/12/23 indicated Irbesartan Oral Tablet 150 MG (Irbesartan) Give 150 mg by mouth one time a day for HTN Hold for SBP less than 110. On 11/15/23 at 3:45 P.M., a joint record review and interview with the Director of Nursing (DON) was conducted. The DON stated, staff should have held the medicine when the blood pressure reading was low even with no parameter was written. The standard of practice of the facility was to hold medicine when BP reading is below 110 mmHg and pulse below 60 beats per minute. On 12/19/23 at 4:37 P.M., an interview with LN 3 was conducted. The LN 3 stated BP reading should be checked before giving the blood pressure medicine. Hold medicine when BP reading is below 110 mmHg and pulse less than 60 beats per minute. The LN 3 stated that they have a policy & procedure on the administration of the blood pressure medicine and parameter when to hold the medicine. On 12/19/23 at 4:45 P.M., an interview with LN 4 was conducted. The LN 4 stated the standard of practice was to check resident BP before administered the medicine. If systolic blood pressure is below 110 mmHg and pulse was less than 60 beats per minute was to hold the medicine and notify the attending physician. Policy and procedure were not provided upon request.

Based on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medication was followed for one of two sampled residents. This failure had the potential to affect Client 1 ' s quality of life, health and well- being. Findings: Resident 1 was admitted to the facility on [DATE], per the facility ' s Face Sheet. On 11/15/23 a record review was conducted. Resident 1 had diagnoses which included subarachnoid bleed (bleeding in the space that surrounds the brain), per the physician ' s admission history and physical visit, dated 10/6/23. Per the MDS, dated [DATE], Resident 1 had a BIMS of 11 (BIM score of 8-12 indicated a resident was moderately cognitively impaired). On 11/15/23 at 3:07 P.M., an interview and record review were conducted with Licensed Nurse (LN) 2. The LN 2 stated Client 1 had an order of blood pressure medicine since she was admitted to the facility on [DATE]. The blood pressure medication was ordered one time a day and scheduled at 9 A.M. There was no written parameter order until 10/13/23. The LN 2 stated the standard of practice for blood pressure medication was to check the blood pressure of the resident before giving the medication and follow the physician ' s parameter order. If no written parameter, follow the facility standard of practice which to hold the medicine if the systolic blood pressure is below 110 millimeter of mercury (mmHg) and if pulse was less than 60 beats per minute. On 11/15/23 at 3:27 P.M., an interview was conducted with LN 4. The LN 4 stated that he always checked the blood pressure of residents before administering the blood pressure medicine. The LN 4 stated the normal practice was to hold the blood pressure medicine if the systolic pressure was below 110 mmHg and if pulse below 60 and notify attending physician. LN 4 further stated, if there were no parameters written, verify with the attending MD. On 11/15/23 a record review of Client 1 ' s Medication Administration Record (MAR) and Vitals Summary log was conducted. Per the MAR, dated 10/11/23, the blood pressure medicine was administered to Client 1 at 9 A.M. There was no documentation of Client 1 ' s blood pressure (BP) reading in the MAR. Per the Vitals Summary Log, dated 10/11/23 at 7:04 A.M., the BP reading was 104/61 and at 19:31 P.M., Client 1 ' s BP reading was 90/60. Per the MAR, on 10 /12/23, the blood pressure medicine was administered at 9 A.M. There was no documentation of BP reading in the MAR. Per the Vitals Summary Log, dated 10/12/23 at 9:48 A.M., Client 1 ' s BP reading was 103/58 mmHg. Per the Physician ' s order dated 10/12/23 indicated Irbesartan Oral Tablet 150 MG (Irbesartan) Give 150 mg by mouth one time a day for HTN Hold for SBP less than 110. On 11/15/23 at 3:45 P.M., a joint record review and interview with the Director of Nursing (DON) was conducted. The DON stated, staff should have held the medicine when the blood pressure reading was low even with no parameter was written. The standard of practice of the facility was to hold medicine when BP reading is below 110 mmHg and pulse below 60 beats per minute. On 12/19/23 at 4:37 P.M., an interview with LN 3 was conducted. The LN 3 stated BP reading should be checked before giving the blood pressure medicine. Hold medicine when BP reading is below 110 mmHg and pulse less than 60 beats per minute. The LN 3 stated that they have a policy & procedure on the administration of the blood pressure medicine and parameter when to hold the medicine. On 12/19/23 at 4:45 P.M., an interview with LN 4 was conducted. The LN 4 stated the standard of practice was to check resident BP before administered the medicine. If systolic blood pressure is below 110 mmHg and pulse was less than 60 beats per minute was to hold the medicine and notify the attending physician. Policy and procedure were not provided upon request.

Based on interview and record review, the facility failed to provide regular showers to two of two sampled residents (1, 2). As a result, Resident 1 and Resident 2 were placed at an increased risk of skin infections. Findings: 1. Per the facility's Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include paraplegia (difficulty moving the lower half of the body) and muscle weakness. Per the facility's Shower Schedule, each resident had showers scheduled on two days of the week based on what room they were in. Per the facility's Body Check Sheets, there was documentation of the facility providing 7 of the 11 scheduled showers to Resident 1. There was no documentation of the facility offering a shower to Resident 1 on 8/3, 8/10, 8/14, or 9/1. On 10/27/23 at 11:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, she was not able to find documentation to explain the missing shower notes for Resident 2. The DON further stated, the staff should have documented whether a shower was given or refused on each scheduled shower day. 2. Per the facility's Admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (difficulty moving one side of the body), need for assistance with personal care, and weakness. Per the facility's Shower Schedule, each resident had showers scheduled on two days of the week based on what room they were in. Per the facility's Body Check Sheets, there was documentation of the facility providing 4 of the 12 scheduled showers to Resident 2. There was no documentation of the facility offering a shower to Resident 2 on 7/28, 8/4, 8/8, 8/11, 8/18, 8/22, 8/29, or 9/1. On 10/27/23 at 11:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, she was not able to find documentation to explain the missing shower notes for Resident 2. The DON further stated, the staff should have documented whether a shower was given or refused on each scheduled shower day. Per the facility's policy, titled Bath, Shower/Tub, revised February 2018, .Documentation . The date and time the shower/tub bath was performed . If the resident refused the shower/tub bath .

Based on observations, staff interviews, and facility document reviews, the facility failed to ensure the management and oversight of food and nutrition service operations was maintained with a qualified full-time dietitian or nutrition professional who met the requirements as specified in established state (California Code, Health and Safety Code - HSC S 1265.4) standards and federal standards, which include an onsite, qualified, full-time dietetic services supervisor (DSS) or food service manager (FSM); and a Dietitian employed full or part-time. The lack of oversight of dietetic and food services by a full-time DSS or FSM, resulted in the kitchen staff not having adequate oversight, tools, and training to develop the skills to carry out the Food and Nutrition Services in a competent, safe, and sanitary manner, particularly when the dietitian was part-time. In addition, because the facility did not employ a Dietitian from December 22, 2022 - January 23, 2023, regular frequently scheduled consultations between the Dietitian and the DSS or FSM, did not occur. The lack of competent, full-time, dietetic services management oversight of the food and nutrition services staff placed 38 residents who received food from the licensed kitchen at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutrition needs of the residents, which both have the potential to result in death. An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on February 28, 2023, at 5:31 P.M., in the presence of the Administrator (ADM) for not having a full-time qualified professional, onsite for day-to-day oversight in the Food and Nutrition Services Department which left kitchen staff unable to carry out necessary functions to safely feed the Skilled Nursing facility residents. The facility submitted a removal plan of action, which included: 1) a signed contract between the facility and a consulting company for employment of a full-time Registered Dietitian (RD) to serve as Manager of Food and Nutrition Services (also referred to as a dietary services supervisor- DSS) until a Certified Dietary Manager (CDM) was employed and trained at the facility; 2) The RD manager initiated one-to-one (1:1) education with each kitchen staff member including Cooks and Diet Aides who provide meals to residents in the licensed skilled nursing unit, which included staff return demonstration to RD; 3) The Director of Staff Development (DSD)/Nurse Consultant initiated 1:1 education for Certified Nursing Assistants and licensed nursing staff to ensure resident are served meals with meal tray tickets that match the physician ordered diet using a facility physician ordered diet list. Education will be validated with verbal return demonstration. 4) The therapeutic menu spreadsheet was signed and approved by the RD Manager on 3/1/23, and the signed therapeutic menus were provided to the Cooks and Diet Aides who prepare and serve meals to residents in the facility's licensed unit. And the signed therapeutic menu spreadsheet was posted on a clip board near the trayline station in the licensed satellite kitchen. The RD will monitor meal service 3 times weekly alternating mealtimes to ensure dietary staff are following the menu spreadsheet. On the spot reeducation will be given to staff if any issues are identified. 5) All resident meal diet tickets were updated to match the physician ordered diets as of 2/28/23 at 8 pm. This was validated on 3/1/23 by the facility's corporate culinary consultant. The RD manager will enter and update all diet orders going forward until a full-time CDM is hired and trained to ensure accuracy and they match the physician's order. 6) In the event the full-time RD Manager is unavailable to provide oversight of the facility's dietetic services, another RD consultant group signed an agreement to provide coverage at the facility until a CDM is hired. When evidence of an onsite full-time DSS/RD Manager was employed by the facility, and the facility's kitchen and clinical staff were in-serviced on how to perform essential food and nutrition services tasks such as safe food preparation, storage, and service; and safe meal tray delivery accuracy, an acceptable removal plan of action provided by the ADM was approved on March 2, 2023, at 1:07 P.M., and the immediate jeopardy was removed. Findings: A. The facility did not have an onsite, full-time, qualified DSS, FSM or RD to provide oversight of Food and Nutrition Services operations in the Skilled Nursing Facility (SNF) satellite kitchen. During multiple observations of the main and SNF satellite kitchens, staff interviews, and document reviews from 2/27/23 at 8:24 A.M. and 2/28/23 at 5:00 P.M., the facility did not have a qualified, full-time, nutrition professional onsite to provide management and oversight for the dietetic, food, and nutrition service systems for the SNF residents. During the initial tour of the main kitchen on 2/27/23 at 8:26 A.M., an observation and concurrent interview was conducted with Cook (CK) 1 and Diet Aide (DA) 1. The main kitchen was cluttered and with multiple empty cardboard boxes, empty food containers, chemical bottles scattered on the floor, along with wrappers, trash, and other debris on the floor along the walkway from the kitchen entrance to the food equipment area. CK 1 was in the middle of plating breakfast meals service. CK 1 was asked if the manager in charge was available and he stated Yes, he's in the office. CK 1 also stated, He's new, but I was told he is the new kitchen manager. I haven't seen the old manager in a while. On 2/27/23 8:33 A.M., an interview was conducted with the Executive Chef (EC) in the main kitchen office. The EC stated he was recently hired and, started working at the facility a week ago. The EC stated he did not know where many things in the kitchen were. EC stated he was hired to manage the facility's the entire kitchen department, which included both the main and satellite kitchens. The EC was asked if he was a Certified Dietary Manager (CDM) and he stated No, but I have my ServSafe Certificate. The EC further stated he had not seen or met with the former kitchen manager or the facility's Registered Dietitian (RD). On 2/27/23 at 12:35 P.M., an interview was conducted with the ADM about the kitchen manager for the SNF unit and the facility's RD. The ADM stated the kitchen manager was out sick with covid and she did not know when he would return. The ADM stated the kitchen manager was a CDM, and a new consultant RD was hired sometime in January 2023, who would be at the facility this afternoon. The ADM stated the facility ended the last RD Consultant contract in December 2022. The ADM stated the last time the kitchen manager/certified dietary manager (CDM) was onsite at the facility was a couple of weeks ago, but she had to double check the exact date. On 2/27/23 at 1:01 PM, an interview was conducted with the consultant RD. The RD stated she was hired to work part-time for the SNF residents, and the ADM told her the facility would be hiring a new person to replace the kitchen manager. The consultant RD stated she worked at the facility 16 hours a week starting late January 2023. The consultant RD stated she had not seen or worked with the kitchen manager. On 2/27/23 at 1:36 PM, a review of the EC's personnel file indicated no documentation of a CDM credential or other evidence of education or training to meet the requirements of a DSS/FSS to oversee and manage the daily operations of the SNF satellite kitchen, per state and federal regulations. On 2/27/23 at 03:36 PM, an interview of the PM Cook (CK) 2 was conducted. CK 2 stated she was the head evening cook on Sundays and Mondays. CK 2 stated the kitchen manager left the facility three weeks ago, and it's been a while since she saw him. On 2/27/23 at 4:15 PM, an interview was conducted with the consultant RD. The consultant RD stated she primarily performed clinical nutrition services like monitoring residents on tube feedings and other tasks, but she had not completed any kitchen sanitation audits or staff in-services. During an observation and interview on 2/28/23 at 7:43 AM with CK 3 in the main kitchen, CK 3 stated neither manager, the old kitchen manager, or the new kitchen manager (EC) was there. On 2/28/23 at 8:03AM, a joint observation and interview was conducted with DA 1 and DA 3 in the SNF satellite kitchen. DA 1 stated she was told the EC was the new manager and in charge of both kitchens, but he was not at work yet, today. DA 1 also stated she was also told when the EC was not there, the Lead Diet Aide (LDA) was in charge. DA 1 further stated when neither the EC or LDA is here, the MSD (minimum dataset) Nurse will help out if we need assistance or guidance in the kitchen. On 2/28/23 at 11:59 AM, an interview was conducted with the ADM. The ADM stated the manager/supervisor over the assisted living restaurant is the same person as the executive chef (EC) from the facility's executive chef job description. The ADM stated the facility recently hired a person who started a week ago in the EC position. During an interview with the ADM on 2/28/23 at 3:05 PM, the ADM stated the facility had an FSM who asked to work evenings and weekends as of January 16, 2023. The ADM stated the FSM called out sick on February 17th, 2023 but she could not confirm when or if he worked in the facility in January or February 2023. The ADM restated the FSM was the manager of both the SNF satellite kitchen and main kitchen for the assisted living section. The ADM further stated she did not know if he would return to work and the facility did not have an RD from December 2022 - January 2023, until a consultant RD was hired part-time. The ADM stated the consultant RD did not have a set schedule. Review of the RD consultant services from October-December 2022 indicated there were no kitchen sanitation audits for food safety conducted. According to the state of California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to the 2022 Federal FDA Food Code, the person in charge (PIC) of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness. Section 2-102.11 states how a person in charge may demonstrate required knowledge of food safety is through certification .by passing an examination that is part of an accredited program. Review of the undated document titled SNF Dietary Manager Job Description, indicated .Minimum Qualifications .must have successful completion of a course approved by the Dietary Manager's Association (or possess a minimum of individual state regulation requirements for Dietary Services Director position); Certified Dietary Manager (CDM) .Essential functions and responsibilities included but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance; ensure that quality food service and nutritional care is always provided for each resident; .6. Participates in long term care survey process, always maintains a presence while surveyors are onsite and directs timely collection of information required by the survey team . Review of the facility undated document titled Registered Clinical Dietitian indicated, .Essential Duties and Responsibilities .completes clinical duties which include comprehensive and accurate, timely nutritional documentation as indicated. This includes annual assessments, quarterly progress notes as well as residents deemed as high risk .conducts sanitation audits of dietary dept. in conjunction with Dietary Service Director to ensure dept. is maintained in safe, clean, sanitary manner .Routinely audits food service areas and practices for compliance with current regulations and policies (includes sanitation reviews, meal service, nutritional documentation) . Review of the undated document titled Registered Clinical Dietitian Job Description indicated, Overall function: Responsible for nutritional care of the residents in accordance with current federal, state, and local regulations; Essential duties and responsibilities included but not limited to: completes comprehensive and accurate, timely nutrition documentation including annual assessment and quarterly notes for residents at high risk; provides nutrition education to dietary dept. as well as other departments; routinely audits food service areas and practices for compliance with current policies (includes sanitation reviews, meal service) . Review of the Consulting Agreement between the Consultant Registered Dietitian and the skilled nursing facility signed on 1/2/23 by the ADM, showed the Consultant RD was to perform consultative duties within the realm of her profession. The services performed may include, but not limited to, the following: 1) review nutritional documentation on all new resident admissions, residents with significant weight loss/gains, or require tube feeding nutritional support; 2) review all yearly or quarterly basis for changes in nutritional status; 3) evaluate sanitation and safety practices in food service department; 4) survey readiness; 5) provide in-service education and training as needed for dietary staff; 6) review and approve all regular and therapeutic diet menus for facility's residents. The contract showed the number of hours is as needed per the administrator and shall be determined by the needs of the facility. B. The facility did not have a qualified, full-time DSS, FSM, or RD to oversee or monitor safe sanitizer solution levels for the SNF satellite kitchen dish machine. On 2/27/23 at 10:06 AM, a concurrent observation and interview was conducted with DA 1 in the satellite kitchen. DA 1 failed to correctly demonstrate the process to test the chlorine chemical sanitizer solution level of the low temperature dish machine with the manufacturer's test strips. DA 1 tried three different sets of test strips, and each test strip color was white and did not change colors. The white color on the test strip container indicated zero (0) ppm (parts per million) of chlorine chemical in the solution. DA 1 stated the strips do not work. DA 1 stated she may be using the wrong test strips, but she didn't know where any other test strips were in the kitchen. DA 1 was asked when the last time the sanitizer in the dish machine was checked and she said yesterday, I believe. DA 1 further stated she was not trained on how to test the dish machine sanitizer level correctly. On 2/27/23 at 10:30 A.M., a joint observation and interview was conducted with DA 1 and EC in the satellite kitchen. EC brought a small ring of test strips down to the satellite for DA 1 to test the chemical sanitizer of the dishwasher. DA 1 tore of an inch of the orange strip from the ring and dipped it into the dish machine solution. The test strip did not turn a different color, so both DA 1 and EC stated, the chemicals must not be working or it's the wrong test strip. DA 1 stated there are usually other types of test strips in the satellite kitchen but she did not know where any of those strips were. EC stated he could not confirm when the dish machine sanitizer level was checked or if it was at a safe level since he started working at the facility a week ago. According to the 2022 Federal FDA Food Code, section -2-103.11, the person in charge (PIC) is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of chemical concentration and temperature for chemical sanitizing. In addition, a warewashing machine and its auxiliary components are to be operated in accordance with the machine's data plate and other manufacturer's instructions. A test kit or other device that accurately measures the concentration of sanitizing solution is to be provided. The Food Code Annex indicate, the PIC is to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. In addition, the Food Code Annex explains epidemiological outbreak data repeatedly identify contaminated equipment as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness. According to the 2022 Federal FDA Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic. According to the 2022 Federal FDA Food Code, section 4-501.11 Good Repair and Proper Adjustment, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize . A chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. According to the 2022 Federal FDA Food Code, section 4-501.15, titled Warewashing Machines, Manufacturers' Operating Instructions, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly . Review of the undated document titled SNF Dietary Manager Job Description, indicated .Essential functions and responsibilities include but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance .3. Completes management duties including schedules .conducts routine in-services for department personnel in conjunction with the registered dietitian; Routinely audits dietary areas and practices for compliance with current regulations and policies (i.e. meal service, sanitation .food temperatures .); reports all hazardous conditions/equipment to the Administrator immediately . Review of facility policy dated October 2008, titled Sanitization, indicated The food service area shall be maintained in a clean and sanitary manner .8. Dishwashing machines must be operated using the following specifications: .Low-temperature dishwasher chemical sanitization .final rinse with 50 parts per million (ppm) hypochlorite chlorine for at least 10 seconds . C. The facility did not have a qualified, full-time DSS, FSM, or RD onsite to provide oversight of safe food storage in the facility kitchens that served residents in the SNF; including oversight and monitoring staff competency of thermometer calibration for temperature monitoring. During the facility's initial tour on 2/27/23 at 8:34 A.M. of the main kitchen, an observation of the cook's food production area, the walk-in refrigerator and walk-in freezer was conducted. In the cook's food prep area, there was a large clear plastic storage container uncovered, unlabeled, and undated filled with white powder on top of the counter above the food prep sink. The walk-in refrigerator had multiple uncovered, unlabeled, and/or undated potentially hazardous and Time/Temperature Control for Food Safety (TCS) foods (i.e. meat, dairy, etc.) stored unsafely including: a medium sized plastic storage container with black olives half full without a lid, a medium sized plastic container 3/4 full of pickles in juice uncovered dated 1-12-23 without a lid, a medium sized metal pan with chopped pulled barbecue chicken unlabeled and undated with plastic wrap, a large sheet pan of a brown soup or liquid dish with plastic wrap on the top shelf unlabeled and updated, five limes with black gray spots resembling mold in a case of brownish green colored limes, and a metal pan with green leaf lettuce in it covered with plastic wrap with no label or date. The walk-in freezer had four large 1/3 gallon ice cream tubs- strawberry, vanilla, chocolate and mint chocolate chip flavors on the shelf uncovered with bent lids falling off the sides. The ice cream was semi-soft, partially melted and not rock solid. During an observation of the dry storage in the main kitchen on 2/27/23 at 9:39 AM, a large open 10-pound bag of sugar wrapped in plastic and a large opened bag of Panko, were both undated. On 2/27/23 at 9:42 A.M., an interview was conducted in the main kitchen with the EC. The EC acknowledged the undated and unlabeled food items in the in the cook's prep area, the walk-in refrigerator, walk-in freezer, and dry storage and stated, all foods should be labeled and dated with at least an opened date. During an observation in the SNF satellite kitchen of the reach-in refrigerator and freezer and interview on 2/27/23 at 9:50 AM with DA 1, the following foods were found undated and unlabeled: a medium sized plastic container of chopped melon chunks, a plastic container of chopped pineapple, and a plastic container of cream-colored pudding. A dirty rag with brown stains was on a tray with ten glasses of 8 oz. glasses of juice and milk. DA 1 stated she forgot to remove the rag from the tray after wiping the inside of the refrigerator. The reach-in refrigerator's internal thermometer temperature was 50 degrees Fahrenheit (F). The Surveyor took the temperature of a glass of milk, and it was 44.8 degrees F. The DA 1 stated sometimes the refrigerator gets warmer than 40 degrees. There was also an unlabeled and undated large pastry desert in the reach-in freezer. During the observation of the reach-in refrigerator in the SNF satellite kitchen on 2/27/23 at 10:00 AM and interview with DA 1, the Surveyor asked DA 1 if the thermometer she used to take food temperatures in the SNF kitchen had been calibrated. DA 1 stated she did not know the last time it was calibrated. During an interview and record review on 2/28/23 at 10:30 A.M. in the main kitchen, the January 2023 and February 2023 walk-in refrigerator and freezer temperature logs were reviewed. The temperature logs were missing AM and PM temperatures by kitchen staff, during the week of February 22nd -26th. The EC acknowledged the missing temperatures and staff initials. According to the 2022 Federal Food Code, section 2-103.11, an important duty of the Person in Charge (PIC) is to make sure that any required temperatures are achieved or maintained when foods are cooked, cooled, thawed, or held in a food establishment. By making it a duty of the Person in Charge to ensure that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure: 1) that animal foods are being cooked to the required minimum temperatures to prevent the survival of pathogens that may be present (2-103.11(G)); 2) that cooked foods are being cooled rapidly to ensure that the growth of bacterial pathogens and toxin production is prevented (2-103.11(H)); and 3) that temperatures for time/temperature control for safety (TCS) foods (i.e. meat, dairy, foods) are routinely monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented (2-103.11(J) and 4) that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production (new 2-103.11(I)). According to the 2022 Federal Food Code, section 3-302.12 Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. According to the 2022 Federal Food Code, section 2-103.11, the person in charge (PIC) shall ensure that employees are using properly calibrated thermometers to routinely monitor cooking temperatures. In addition, food temperature measuring devices that are scaled in Fahrenheit shall be accurate within a range of degrees in the intended range of use. According to the Food Code Annex, thermometers provide a means for assessing active managerial control of time temperature control for food safety (TCS) food temperatures. Food thermometers must be calibrated at a frequency to ensure accuracy. If a food temperature measuring device is not maintained in good repair, the accuracy of the reading is questionable. Consequently, a temperature problem may not be detected. According to the 2022 Federal Food Code, section 4-302.12, titled Food Temperature Measuring Devices; the presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded. Review of facility policy dated October 2017, titled Food Receiving and Storage, indicated .7. Dry foods stored in bins will be .labeled and dated (use by date) .8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .10. Refrigerated foods must be stored below 41 degrees F .12. The freezer must keep frozen foods solid . On 2/27/23 at 11:54 AM, a review of the trayline food temperature logs from the SNF satellite kitchen was conducted. The temperature log binder had logs from January 2022- December 2022, but the logs for January 2023 were missing. There were 3 temperature log dates completed for February 2023, the 7th, 25th, and 27th. DA 1 confirmed those were the only trayline food temperature logs in the SNF satellite kitchen. On 2/27/23 at 12:06 PM, an observation and interview with DA 1 was conducted of the lunch meal service in the SNF satellite kitchen. DA 1 pushed a food warmer with the lunch meal in separate sheet pans down to the satellite kitchen from the main kitchen. DA 1 entered the satellite kitchen, put on gloves, and started to assemble the pans on the trayline station. DA 1 did not wash her hands before she put on gloves. DA 1 then took temperatures of the trayline food. The trayline temperatures were rice pilaf- 149 degrees F, pork chops -138 degrees F, Chicken breast - 145 degrees F, DA 1 stated the chicken temperature should be 165 F. The surveyor took temperatures of both the puree brussel sprouts, which was 129 F and regular brussel sprouts -133F. DA 1 took the regular brussel sprouts temperature, which was 132.6 F, and the mashed potatoes was 143 F. DA 1 stated the food could be warmer, but it was okay to serve it because the temperatures were higher than 120 degrees F. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 3-501.16, titled Time/Temperature Control for Safety Food, Hot and Cold Holding, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) .135oF or above .or .may be held at a temperature of .130oF or above; or (2) At .41 F or less. During an observation and interview on 2/28/23 at 8:43 AM in the main kitchen with the EC and CK 3, the large plastic bin with white thickener powder was still above the food prep sink unlabeled, undated, and uncovered without a lid. The EC stated he did not know where the lid was, but the large bin should be labeled, dated, and covered with a lid. Review of the facility policy dated April 2019, titled Food Preparation and Service, indicated .1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness .potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk .4. Food and nutrition services staff .wash their hands before serving food to residents . Review of the facility's log documents titled SNF Satellite Kitchen, dated 2/20/23-2/26, 1/9/23, and [DATE]-[DATE], showed the task: Calibrate thermometers was blank with no kitchen staff initials. The other remaining logs for dates in February 2023, January 2023 and December 2022 were missing and not provided. Review of the facility policy dated April 2019, titled Food Preparation and Service, indicated .5. Food thermometers used to check food temperatures are clean, sanitized, and calibrated frequently . Review of the facility undated document titled Registered Clinical Dietitian indicated, .Essential Duties and Responsibilities .completes clinical duties which include comprehensive and accurate, timely nutritional documentation as indicated. This includes annual assessments, quarterly progress notes as well as residents deemed as high risk .conducts sanitation audits of dietary dept. in conjunction with Dietary Service Director to ensure dept. is maintained in safe, clean, sanitary manner .Routinely audits food service areas and practices for compliance with current regulations and policies (includes sanitation reviews, meal service, nutritional documentation) . Review of the Dietary Aide Job Description dated 3/8/20, showed the primary function of the position was to assist with serving, plating, and sometimes prepping food items based on the nutrition needs of their patients; performs tasks to ensure timely preparation and delivery of nutritious attractive meals and supplements to all residents according to physician's orders and in compliance with federal, state, and company requirements; duties and responsibilities: plating and serving meals, snacks, and beverages following procedures; utilizes Grove menus, extension sheets for therapeutic diets and meal tickets with trays; serving meals, ensuring food safety and hygiene at all times; able to follow therapeutic diet and how to serve it properly and safely; clean and disinfect satellite kitchen; follow dietary functions as directed/instructed and in accordance with established dietary policies and procedures. D. The facility did not have a qualified, full-time DSS, FSM, or RD onsite to oversee the meal production and preparation using standardized recipes (i.e. recipes with defined amounts, portions, and yields to ensure nutritional adequacy) and therapeutic menus approved by a Registered Dietitian

Based on interview and record review, the facility failed to obtain orders to administer [MEDICATION NAME] (a blood thinner to help prevent the formation of blood clots), to 1 sampled Resident (A) for 9 days following hospitalization for the treatment of [REDACTED]. Nursing failed to develop a plan of care to address ongoing assessment of the resident's affected limb. Nursing further failed to assess the resident after the resident complained of pain in her leg to certified nursing assistants (CNAs) and an occupational therapist (OT). Nursing also failed to notify the resident's physician of the change in her condition. These deficient practices resulted in Resident A developing a second blood clot in her leg, causing ischemia (restricted blood flow) to the leg leading to irreversible death of the tissue. Resident A declined amputation of her leg and ultimately died in the hospital 6 days later, having suffered extreme pain from the ischemic limb. Findings: Resident A was originally admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment (a comprehensive assessment of the resident's functional capabilities), completed for Resident A on [DATE], Resident A scored 15 on her mental status assessment, indicating the resident was independent in her decision making. Per the same assessment, the resident's goal was to be discharged to her assisted living facility. Resident A was transferred to the hospital on [DATE], after she experienced fatigue and shortness of breath while ambulating with staff at the facility, according to the [MEDICAL CONDITION]/Critical Care Medicine Admission Note. Examination of the patient in the Emergency Department revealed, a cold and mottled (marked with spots or blotches) left leg. After a CT angiogram, (a technique used to look at blood vessels throughout the body), Resident A was diagnosed with [REDACTED]. Resident A was admitted to the hospital for treatment of [REDACTED]. According to the Internal Medicine Progress Note, dated [DATE], Resident A underwent a procedure to dissolve and remove the blood clot and treatment with [MEDICATION NAME], followed by [MEDICATION NAME] (medications to prevent the formation of further clots). The physician's plan for the resident was to return to the SNF for further rehab. (therapy) and to continue with the [MEDICATION NAME]. Resident A was transferred back to the facility on [DATE] with orders from the hospital. The orders included medications and treatments the physician wanted the resident to continue to receive at the facility. Included on the transfer medication orders was an order for [REDACTED]. Licensed Nurse 1 (LN 1) completed the Nursing Readmisson Data Collection when Resident A returned to the facility. According to the documentation, Resident A was alert to person, time and the situation. LN 1 documented in the Narrative Summary, Resident A had a [DIAGNOSES REDACTED]. LN 1 documented, Verified all orders with (name of the resident's physician). Faxed med list to pharmacy. There was an unsigned handwritten note under the order for the [MEDICATION NAME] which read, MD to dose [MEDICATION NAME] per RX (according to the pharmacy, the physician was to prescribe the [MEDICATION NAME] dose). There was no documentation to show LN 1 told the resident's physician (MD 1) the pharmacy would not manage Resident A's [MEDICATION NAME] orders and MD 1 would be responsible for ordering the [MEDICATION NAME]. MD 1's orders included an order for [REDACTED]. Nursing did not develop a care plan on admission to address ongoing assessment of the resident's left leg, related to the [DIAGNOSES REDACTED]. Nursing did not develop a care plan for monitoring for the administration or side effects of [MEDICATION NAME]. MD 1 made a follow-up visit to the resident on [DATE]. According to MD 1's documentation on the Continuing Care Nursing Home History and Physical, the resident was readmitted to the facility for rehabilitation. MD 1 documented under Assessment and Plan: 1. Femoral artery [MEDICAL CONDITION], left. Now status [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Nursing initialed the Treatment Administration Record for Resident A to show they were monitoring the bruising on the resident's left lower leg; however, nursing did not document any further assessment of Resident 1's left leg until [DATE]. At that time, LN 2 documented on the Daily Skilled Note, LLE arterial occlusions with no complications noted. LN 2 checked the box on the note to indicate Resident A's left pedal pulses were palpable (a pulse on the top of the resident's left foot could be felt, indicating arterial blood was flowing to the resident's foot). On [DATE] at 12:09 P.M., LN 3 completed a Daily Skilled Note but failed to document an assessment of Resident A's pedal pulses or her left lower leg. On [DATE], according to the occupational therapist's Daily Treatment Encounter notes, Resident A complained of, Pain in knee and foot. Pt. (resident) participated in manual massage for pain management in order for pt. to ambulate and participate in therapy. There was no documentation to show nursing assessed Resident A for the complaint of pain in her leg while she was in therapy. The next Daily Skilled Note was initiated, but not completed, on [DATE] at 2:41 P.M. The section for assessing pedal pulses and pain were both left blank. The next nursing documentation was dated [DATE] at 10:34 A.M., at which time, nursing completed a Change Of Condition assessment related to, Left lower leg ,[DATE] pain (a pain scale with 0 being no pain and 10 being the worst possible pain), cold to touch, scattered discoloration left leg. Per the same documentation, MD 1 saw the resident who was then transferred to the Emergency Department for evaluation. According to the hospital's Emergency Record, dated [DATE], Resident A had a cool, pulseless, mottled left lower extremity with delayed capillary refill (indicating impaired blood flow to the toes). Resident A complained of significant left leg pain and received IV [MEDICATION NAME] sulfate (narcotic pain medication administered directly into a vein), for pain relief. According to the hospital's Admission History and Physical notes, Resident A told the physician she had been experiencing left lower leg pain for 1 -2 days and had been unable to sleep the previous night due to pain. The hospital physician noted there was no record of the resident receiving anticoagulation since [DATE] when she was discharged to the facility. Resident A was admitted to the ICU (intensive care unit) for treatment. Unsuccessful attempts were made to reestablish blood flow to the affected limb. According to documentation on the Palliative Care Progress Note, (care that is aimed at relieving the symptoms of severe illness), dated [DATE], Resident A's chief complaint at that time was, Severe left lower extremity pain requiring, escalating doses of oral [MEDICATION NAME] which have not been effective. Resident A also received [MEDICATION NAME] (narcotic pain medication), which slightly helped the pain, but did not fully alleviate (resolve) it. Resident A told the physician, She would rather be sleeping all the time and in no pain/suffering rather than continuing to be awake and alert having such severe pain. Per the same note, Resident A declined amputation of the limb, choosing to focus on comfort. Resident A remained in the hospital until [DATE] when she died at 7:02 A.M. The cause of death listed on the Death Summary, dated [DATE], was left lower extremity limb ischemia. MD 1 was interviewed on [DATE] at 3:45 P.M. and again on [DATE] at 1:20 P.M. MD 1 stated when Resident A was readmitted to the facility on [DATE], he thought pharmacy was ordering the lab tests and Resident A's [MEDICATION NAME] dosing, based on the test results. MD 1 said when he visited the resident the morning after she was admitted , the [MEDICATION NAME] order was not in the computer-based system but it was not unusual for the orders to be entered later in the day. MD 1 stated he expected nursing to call him if the pharmacy was not doing the [MEDICATION NAME] dosing. CNA 1 was interviewed on [DATE] at 1:41 P.M. CNA 1 said he was working on [DATE] when the resident complained of, leg pain specifically. CNA 1 said he put the resident back to bed, elevated her leg on a pillow and reported the resident's complaint to LN 4. CNA 1 said LN 4's response was, I already gave her medication. There was no documentation on the MAR indicated [REDACTED]. There was no documentation in the nursing notes to show LN 4 assessed the resident for the cause of her pain. CNA 2 was interviewed on [DATE] at 1:41 P.M. CNA 2 stated Resident A twice complained to him of pain and asked to see the nurse on [DATE]. CNA 2 said he told LN 4 who said, I already gave her everything, she has to wait. The Occupational Therapist (OT 1) was interviewed on [DATE] at 12:35 P.M. OT 1 said Resident A was very motivated with her therapy because she wanted to go home. OT 1 said during therapy on [DATE], Resident A complained of a tingling pain in her left foot. The OT said she removed the resident's socks and rubbed the resident's big toe and ankle, which seemed to relieve her pain. OT 1 said during therapy in the morning, she did not notice any change in temperature of the resident's leg. According to OT 1, later in the day at about 3 P.M., she answered Resident A's call light and found the resident, vigorously rubbing her left leg. Per OT 1, Resident A complained of, excruciating pain at ,[DATE] and when the OT felt the resident's foot it, Felt like I was touching an ice cube (indicating possible severe restriction of arterial blood flow). OT 1 said she also noticed a bruise on the resident's inner ankle. According to OT 1, the resident said she wanted to talk to her physician (MD 1), but he was gone for the day. OT 1 said she reported her observations to the licensed nurse LN 4 who, Brushed it off and said the resident had poor circulation. OT 1 said, She didn't seem to be too bothered about it. OT 1 said she did not report her concerns to anyone else and went home. According to documentation on the MAR, LN 4 administered 650 milligrams of Tylenol to Resident 1 for, c/o (complaint of) achy pain generalized pain on [DATE] at 6:55 P.M., approximately four hours after OT 1 said she reported to her Resident A was complaining of excruciating pain in her leg. LN 4 failed to document any assessment of the resident's left leg after the OT's report to her earlier in the evening. At 3:15 A.M. on [DATE], LN 5 documented on Resident A's MAR, she gave the resident 650 milligrams of Tylenol for, c/o left leg achy ,[DATE] pain. LN 5 failed to document an assessment of the resident's leg to determine the cause of the resident's pain. OT 1 was interviewed on [DATE] at 12:35 P.M. OT 1 said she went to Resident A's room at 8 A.M. on [DATE]. The OT said at that time, Resident A's leg was mottled and, Her leg didn't look good. OT 1 said she then reported her concerns to LN 6 who went in to see the resident. OT 1 said since the incident she had been told she should have completed a Stop and Watch Early Warning Tool on [DATE], (a form available to staff to report any identified change to nursing, which would prompt nursing to assess the change in the resident's condition), but at the time, she did not know about the form, so she failed to complete one. LN 6 was interviewed on [DATE] at 3 P.M., and again on [DATE] at 1:15 P.M. LN 6 said on [DATE], she went in to see Resident A in the morning. According to LN 6, Resident A was very upset and, Mad at me because she had been waiting to see the doctor and she had complained of leg pain to the nurse the previous day. LN 6 said she assessed Resident A's leg which was cold to the touch and added she could not detect a pedal pulse. At that time, LN 6 said she reported her assessment findings to her supervisor, LN 3. LN 6 also said she would have expected nursing to have developed a care plan for Resident A on admission to address potential problems that could arise from the development of a second blood clot in the resident's leg. LN 6 said interventions on the plan should include, palpating for a pedal pulse, assessing for pain and temperature of the limb, administering [MEDICATION NAME] as prescribed to prevent further clots, and notifying the physician of any changes. LN 6 said nursing should have been assessing the resident every shift. LN 3 was interviewed on [DATE] at 1:25 P.M. LN 3 said she was the supervisor on duty on [DATE] when LN 6 reported her concerns about Resident A's leg. LN 3 said she assessed Resident A's leg and noted it was cold with no detectable pulse in her foot. LN 3 said Resident A was very upset, had pain rated at 8 out of 10 and wanted to see her physician. LN 3 said she notified the resident's physician who gave orders for the resident to be transferred to the hospital. LN 3 said the night shift nursing staff were responsible for double checking the orders of new residents admitted that day. LN 3 said it would appear the night shift staff did not verify Resident A's [MEDICATION NAME] was ordered nor did they develop a care plan to address the resident's arterial blood clot. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at 1:45 P.M. According to the ADON, the nurses used a Clinical Admission Checklist to assist them in completing all the requirements for new admissions. Prompts on the checklist included for nursing to verify physician's orders [REDACTED]. The DON stated the night shift staff were supposed to verify all the areas were completed for each new resident. The following morning, the IDT (an interdisciplinary team with representation from various departments providing care to the residents)) would review the checklist at the morning meeting. The ADON said the admitting nurse, the night shift nurse and the IDT all failed to follow up on the resident's [MEDICATION NAME] orders from the hospital and failed to ensure a care plan was developed for the potential for further blood clots in Resident A's leg. The ADON said nursing should have been completing a Daily Skilled Note for Resident A every shift for three days and then daily afterwards, which would have included pedal pulse and pain assessments. Only one of the three Daily Skilled Notes initiated for Resident A, from her admission on [DATE] to her discharge on [DATE], was completed and in the resident's record. LN 1, LN 2, LN 4 and LN 5 no longer worked at the facility and were unavailable for interview. According to the facility's policy entitled, Admission Data Collection and Orders last revised on ,[DATE], 2. The charge nurse who admits the resident is responsible for completing the Nursing Admission Data Collection, verifying orders are present on admission . and 6a) Orders should be reviewed with the physician and verified. The facility's policy entitled Change of Condition for Skilled Nursing, last revised ,[DATE] was reviewed. According to the policy, All associates shall communicate about a resident's status change to appropriate licensed personnel upon observation the associates will complete the Stop and Watch documentation and notify the charge nurse. Upon receiving a Stop and Watch documentation, the licensed nurse will: perform a comprehensive evaluation or assessment . and, .Call the appropriate Health Care Provider . According to the same policy, a resident change of condition may include, Complaint of new or unrelieved pain. Resident A was readmitted to the facility for rehabilitation on [DATE] after hospitalization and treatment for [REDACTED]. The resident had a [DIAGNOSES REDACTED]. The hospital physician discharged the resident with orders for [MEDICATION NAME] to prevent further clots. The facility failed to implement the plan of care and obtain orders from the resident's physician for the [MEDICATION NAME] and the resident went 9 days without the anticoagulation medicine. Nursing also failed to develop a care plan to monitor for potential blood clots in the resident's leg, and failed to assess and notify the physician when the resident complained of excruciating pain in her leg.