Every finding on record at Brighton Place San Diego

Based on observations, interviews, and record reviews, the facility failed to provide a homelike environment for three of eight sampled residents (2, 4, 6). This failure had the potential to have negative psychosocial (intersection between an individual's psychological state (thoughts, feelings, and internal mental health) and their surrounding social environment (relationships, cultural norms, and societal factors)) effects on residents living in the affected rooms.Findings:1. A review of the admission Record for Resident 2 indicated, the resident was admitted on [DATE] for diagnoses which included: Respiratory Failure (when your respiratory system cannot adequately supply oxygen to your blood or properly remove carbon dioxide from it) and Congestive Heart Failure (a chronic condition where the heart muscle becomes too weak or stiff to pump blood efficiently). A review of Minimum Data Set (MDS-a clinical assessment tool used in nursing homes; section C-Cognitive [thinking]) Patterns dated 4/4/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, indicating intact cognition (thinking processes). On 5/27/26 at 1:45 P.M. an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER] was observed with eight quarter sized holes covered with spackle (a ready-mixed, putty-like compound used to fill small holes, dents, and cracks in walls), not sanded or painted. The foam guard covering the telephone wire on wall close to floor had two large rips across the foam could be a tripping hazard for residents. On 5/27/26 at 1:50 P.M., a concurrent interview with Resident 2 and observation of room [ROOM NUMBER] was conducted. Resident 2 was observed resting in bed watching TV. Resident 2 was alert, oriented, and agreeable to interview. Resident 2 stated the holes in the wall did not feel homelike to him and he would like them to be fixed. On 5/27/26 at 1:55 P.M., an observation of room [ROOM NUMBER]'s bathroom was conducted. The sink in bathroom was observed to have extensive water damage directly on the wall behind it, with peeling paint, no sealant, and the sink physically separating from the wall. The bathroom baseboard at its entrance had a large three-inch chunk missing from it. 2. A review of the admission Record for Resident 4 indicated, the resident was admitted on [DATE] for diagnoses which included: Hemiplegia (the loss of voluntary muscle control of one entire side of the body (left or right), which affects motor function, limbs, and sometimes the face) and Epilepsy (disorder characterized by recurrent, unprovoked seizures[a sudden, uncontrolled surge of abnormal electrical activity in the brain]). A review of MDS section C-Cognitive Patterns, dated 5/13/26, indicated Resident 4 had a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition (thinking processes). On 5/27/26 at 2:05 P.M., an observation of room [ROOM NUMBER] and connected bathroom was conducted. room [ROOM NUMBER]'s wall beneath the window near Bed C had a 3x2 foot area repaired and with spackle but not sanded or painted. On far wall with a window, another 2x3 foot area with multiple tears in the wall from wheelchair approximately eight inches from the floor with varying degrees of repair with spackle, unsanded, and not painted. room [ROOM NUMBER]'s bathroom had a loud fan that sounded like loose blades moving around in the fan. On 5/27/26 at 2:10 P.M., an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER] was observed to be a six-bedroom unit with three beds on either side of a dividing wall. The dividing wall was observed to have multiple levels of damage and repair to the divider, with some spackle covering areas near the bottom and other open broken areas a few feet up, total damage and repair area about 3 feet up from floor, uneven spackle, no sanding or paint observed. The wall underneath the resident's TVs on the A, B, C side with multiple quarter sized holes filled with spackle, not sanded or painted. The wall by floor baseboard had a 2.5 foot x 3 inch tear in the dry wall with no repair or paint. On 5/27/26 at 2:15 P.M., an observation of room [ROOM NUMBER] and interview with Resident 4 was conducted. Resident 4 was observed in his wheelchair after using the urinal. Resident 4 was alert, oriented, and agreeable to interview. Resident 4 stated he often saw spiders by the window where he put his urinal. Resident 4 stated that his sink was clogged very often, and he had just reported to the maintenance staff that morning that it was still clogged. Resident 4 pointed out shreds of old curtain observed hanging from the curtain pole and stated he had not had a curtain or shade on his window for a while and the resident prior to him had ripped off the window and the facility had never replaced it for him. Resident 4 also stated he could barely fit his wheelchair in the restroom, so he could not use the restroom and why he used urinal outside. Resident 4 stated the clogged sink and not having a curtain to block the sun was not homelike for him, and he had wanted both fixed. 3. A review of the admission Record for Resident 6 indicated, the resident was admitted on [DATE] for diagnoses which included: Cerebral Infarction (when a blood vessel in the brain becomes blocked or severely narrowed) and Encephalopathy (term for any disease, damage, or malfunction of the brain that alters its structure or function). A review of MDS section C-Cognitive Processes dated 4/21/26, indicated Resident 6 had a Brief Interview for Mental Status score of 15 of 15, indicating intact cognition (thinking processes). On 5/27/26 at 2:30 P.M., an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER]'s wall adjacent to the doorway with two 2x2.5-foot rectangles with repaired holes with spackle, but unsanded and unpainted. A 3x4 ft area under the window was observed to be repaired with spackle, but unsanded and unpainted. A 2x2.5-foot area in bathroom area above electrical outlet with spackle, but uneven unsanded, and unpainted. On 5/27/26 at 2:35 P.M., an interview with CNA 1 was conducted. CNA 1 stated the process for reporting damage or problems with equipment was to write it in the maintenance log and then follow up with it the next day. CNA 1 stated that the damaged wall in room [ROOM NUMBER] was not homelike. CNA 1 stated the expectation for residents' rooms was for them to have painted non-damaged walls and working bathrooms, because the residents should feel like they are home. On 5/27/26 at 2:45 P.M., a concurrent observation of room [ROOM NUMBER] and interview with Resident 6 was conducted. Resident 6 was alert, oriented, and agreeable to interview. Resident 6 stated that she had limited eyesight, but she could see the holes and disrepair in her room on the walls. Resident 6 stated the walls were not homelike, and she felt embarrassed to have guests come to visit her and she would like them repaired. On 5/27/26 at 2:55 P.M., an interview with LN 1 was conducted. LN 1 stated that the process for repair was to write the needed repair in the maintenance log, and review maintenance log to make sure it was noted and repaired. LN 1 stated that damaged walls and non-functional sinks were not homelike, and should be repaired in a timely manner, because residents should have a decent place to live to maintain their dignity while in the facility. On 5/27/26 at 3:10 P.M., an interview with CNA 2 was conducted. CNA 2 stated the process for repair was to notify maintenance, write in maintenance log, and then follow up if repairs done. CNA 2 stated that the walls that were in disrepair were not homelike, and repairs should be done timely to make residents feel safe and comfortable. On 5/27/26 at 3:45 P.M., a concurrent interview with the Director of Maintenance (DOM) and observation of room [ROOM NUMBER]'s bathroom sink was conducted. The DOM stated that he was not aware of the water damage to the wall above the sink. The DOM stated that no had reported it to him, so he did not know about it. The DOM stated that he made room rounds on all the rooms monthly but did not find the disrepair of the wall above the sink. The DOM stated that the condition of the sink was not safe and he would have it repaired immediately today. On 5/27/26 at 3:55 P.M., a concurrent interview with the Director of Maintenance (DOM) and observation of room [ROOM NUMBER]'s bathroom sink was conducted. The DOM stated that he was made aware of the sink clogging this morning and that he had someone look at the sink already. The sink was observed to still be clogged with standing water in sink without a stopper. The DOM stated that residents often wash things in the sink that they should not wash, and that clogs the sink. The DOM stated that the sink should be repaired, because clogged sinks can be a safety hazard and are not homelike. On 5/27/26 at 4 P.M., a concurrent interview with the Director of Maintenance (DOM) and observation of room [ROOM NUMBER]'s bathroom fan was conducted. The DOM stated that he was not aware of the noise the fan was making and agreed that it was loud. The DOM stated that no one had reported it to him, so he did not know about it. The DOM stated that he made room rounds on all the rooms monthly but did not find the disrepair of the bathroom fan. The DOM stated that the loud sound the fan was making was not homelike and needed to be repaired. On 5/27/26 at 4:05 P.M., a concurrent interview with the Director of Maintenance (DOM) and observation of room [ROOM NUMBER],130, 131, and 132's walls were conducted. The DOM stated that they were renovating the rooms currently and that the big holes were the priority. The DOM stated he rounded on the rooms monthly but was not aware of the amount of disrepair on each of the walls. The DOM stated when he rounded he focused mainly on checking things that affected the safety of the residents such as beds, water temperature, room temperature, wheelchairs, doors, call lights, resident lifts, exhaust fans and fire system, but didn't really round on room's walls disrepair, only that the large wall penetrations were a priority, but he did not document rounding on rooms for that. The DOM stated the importance of fixing all holes in the wall was for the safety of the residents and to prevent pests from coming into the facility. The DOM stated the importance of efficient room rounding was for the safety of the residents and making the facility homelike. On 5/27/26 at 4:15 P.M., an interview with ADM was conducted. The ADM stated the expectation for repairs was that all repairs should be done in timely manner, and that the residents should have a homelike environment while they are at the facility to maintain their psychosocial well-being. Review of facility policy titled Resident Rooms and Environment dated January 01, 2012, indicated .The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence, and personal neess and preferences.Procedure.I. Facility Staff aim to create personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order.

Based on observations, interviews, and record review the facility failed to report the alleged abuse of one (Resident 1) of seven sampled residents to the California Department of Public Health (CDPH) within two hours of the initial abuse allegation.This failure had the potential for further abuse to Resident 1.Findings:Record review of admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included: Anxiety Disorder (excessive fear or worry that interferes with daily life) and need for assistance with personal care. On 3/6/26 at 2:45 P.M., an observation and interview was conducted with Resident 1. Spanish translation was done by the Admissions Director (AD). Resident 1 was observed resting in bed watching television. Resident 1 was observed to have inch long imitation fingernails. Resident 1 stated that on 3/4/26 in the evening, CNA 1 was giving her a bed bath and she (Resident 1) stated she turned to tell CNA 1 not to scrub her glutes when CNA 1 raised her hand and tried to slap me (Resident 1). Resident 1 stated she put up her hand to protect her face and the imitation nail on her right pinky broke. Resident 1 stated she reported the incident to License Nurse 1 (LN 1) that night (3/4/26) at about 10 P.M. Resident 1 stated she talked with the Social Services Assistant (SSA) on 3/5/26 at 4 P.M. about the incident. Resident 1 stated that the Administrator (ADM) came by to see her on 3/6/26 at about 2:40 P.M. to talk with her about the incident.On 3/6/26 at 3 P.M., an interview with the Social Services Assistant (SSA) was conducted. The SSA stated that on 3/5/26 at 4 P.M., she overheard Resident 1 talking with another staff member about the incident. Resident 1 stated that CNA 1 broke her nail during a bed bath. The SSA stated that Resident 1 alleged that CNA 1 was not following her instruction of how to properly clean her. The SSA stated that Resident 1 alleged she raised her hand and CNA 1 hit her and broke her nail. The SSA stated that the ADM was called on 3/5/26 at 4 P.M. to report the alleged abuse.Record review of Behavior Note by LN 1 dated 3/4/26 at 11:13 P.M., indicated Resident 1 made threatening verbal statement toward CNA during care and stated, You are not doing the right thing and I will report you. Resident noted speaking in raised voice and appearing agitated.Supervisor notified.On 3/6/26 at 5 P.M. an interview with the ADM was conducted. The ADM stated she was told about the incident after the incident happened on 3/4/26 at 11 P.M. by LN 1 and on 3/5/26 at about 4 P.M. by the SSA. The ADM stated she did not report the alleged abuse to CDPH. The ADM stated she sent SOC 341 on 3/6/26 while onsite investigation was taking place.Record review of SOC 341 indicated it was sent on 3/6/26 at 3:59 P.M.On 3/19/26 at 11:45 A.M., an interview with the ADM was conducted. The ADM stated that the expectation for reporting alleged abuse was to report any alleged abuse to CDPH within two hours of the allegation being made. The ADM stated the importance of reporting within two hours of allegation was to protect residents from abuse and to be in compliance with state and federal regulations.Review of facility policy titled Abuse-Reporting & Investigations dated March 2018, indicated .V. Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury: A. The Administrator or designated representative will notify within two (2) hours notify by telephone, CDPH.

Based on observation, interview, and record review, the facility failed to implement the infection control program practices when: 1. The facility did not report COVID (infectious disease) outbreak to the California Department of Public Health Licensing and Certification (CDPH L&C, program which is responsible for regulatory oversight of licensed health care facilities and health care professionals to assess the safety, effectiveness, and quality of health care for all Californians).2. The resident's family member was not educated on infection control and the use of personal protective equipment (PPE, use of gown, gloves and mask to be worn or held by an individual for protection), for one of two residents (1) on contact precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room). This failure had the potential to transmit infections to residents, staff, and visitors.Findings: 1.On 8/19/25, the Department received a report which indicated there was a COVID outbreak in the facility with three residents tested positive. On 9/2/25, an unannounced onsite was conducted to the facility. On 9/2/25 at 2:03 P.M., a joint review of residents' clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated they had 10 residents who were tested positive from 8/18/25 to 8/26/25. The DON stated there was one Certified Nursing Assistant (CNA) who also tested positive. The DON stated the Infection Preventionist (IP) informed him the outbreak was reported to CDPH. The DON stated he did not follow up. The DON stated he should have followed up on to whom the outbreak was reported to be in compliance with the regulation and protect the residents and the community. On 9/2/25 at 2:28 P.M., an interview was conducted with the Administrator (ADM). The ADM stated she should have clarified and verified it was reported to CDPH L&C. The ADM stated, It was reported to the local county. A review of the facility's policy titled Respiratory Virus Prevention and Control Plan, revised 3/31/25, indicated, .OUTBREAK DEFINITIONS, REPORTING, AND DURATION OF OUTBREAK CONTROL MEASURES; COVID-19: Residents: 2 cases of probable or confirmed COVID-19 among residents. 2. Resident 10 was admitted to the facility on [DATE], per the facility's admission Record. On 9/2/25 at 2:07 P.M., an observation of Resident 10 was conducted in his room with the presence of the DON and Licensed Nurse (LN) 1. There was a contact precaution (intended to prevent transmission of infectious agents and microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment) sign by the resident's door. There were three residents in the room. Resident 10 laid in bed with a family member (FM) at bedside. Resident 10's FM was assisting Resident 10 during meals. Resident 10's FM did not wear PPE while assisting Resident 10. At this time, the DON prompted LN 1, LN 1 then asked Resident 10's FM why she was not wearing PPE, Resident 10's FM stated she was allergic to the gown and that she was not going to leave. On 9/2/25 at 3:21 P.M., an interview was conducted with LN 1. LN 1 stated Resident 10's FM was aware of the facility's policy. LN 1 stated it was important for the visitors to comply with putting on and removing the PPE to prevent spread of infection. LN 1 stated Resident 10's FM did not report allergic reactions to the use of PPE until today (9/2/25). On 9/2/25 at 3:25 P.M., a joint review of the facility's infection log and an interview was conducted with the Director of Nursing (DON). The DON stated visitors were to wear PPE when entering the residents on contact precautions to protect themselves and prevent the spread of infection to others. A review of the facility's policy titled Respiratory Virus Prevention and Control Plan, revised 3/31/25, indicated, .Don gowns and gloves after performing hand hygiene upon entry into the room or entry into a bedspace and doff gowns and gloves followed by hand hygiene upon exiting the room or leaving a bedspace.

Based on interview and record review, the facility failed to provide residents and their families with a written Notice of Transfer/Discharge for three of three residents (Resident 1, 2, and 3), when reviewed for discharge. In addition, Resident 1 did not have a nurse's note, indicting when she left the facility for discharge, with whom she left, where she was going, and how she was being transported. These failures had the potential for residents to experience increased anxiety, when last minute discharges were conducted, with no ability to appeal the discharge, and the reader was uninformed of where the resident was transported to and when. Finding:An unannounced visit was made to the facility on 8/13/25, in response to a complaint involving a discharge.1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (progressive memory loss), per the facility's admission Record. On 8/13/25, Resident 1's clinical record was reviewed. According to the facility's Social Service notes, dated 1/12/25 at 5:31 P.M., Resident 1 was going to be discharged to (name of facility), for supervised care in a secured unit (when residents are unable to leave the unit because of cognitive impairment, such as dementia, who require supervision and a safe environment). There was no documented evidence that nursing staff documented when resident left the faciity on 1/13/25, with whom she left, where she was going, or how she was getting there. According to the facility's Discharge Planning Review, dated 1/13/25, Resident 1 was being discharged as a lateral transfer to another facility for continuum of care. The name of the facility she was being transferred to was not documented.There was no documented evidence that a written Notice of Transfer/Discharge was provided to Resident 1 or her family, prior to discharge.2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record.On 8/13/25, Resident 2' clinical record was reviewed. According to the facility's Discharge Planning Review, dated 6/12/25, Resident 2's health had improved and was being discharged to a lower level of care.According to the facility's Discharge Summary note, dated 6/12/25 at 11:06 A.M., Resident 2 was transported to (name of facility) Board and Care by her son, with all belongings and medications.There was no documented evidence that a written Notice of Transfer/Discharge was provided to Resident 2 or her family, prior to discharge.3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (a progressive disease in which affects brain functioning), per the facility's admission Record.On 8/13/25, Resident 3's clinical record was reviewed. According to the facility's Social Service notes, dated 7/11/25 at 3:20 P.M., Resident 3 was discharged to Board and Care (name of facility).According to the facility's Discharge Planning Review, dated 7/11/25, Resident 3 was being discharged for a lower level of care. There was no documented evidence that a written Notice of Transfer/Discharge was provided to Resident 3 or the family, prior to discharge. An interview was conducted with Licensed Nurse 1 (LN 1) on 8/13/25 at 11 A.M. LN 1 stated written Notice of Transfer/Discharges were provided to the residents and their families by the Social Service Director (SSD). LN 1 stated Notices of Transfers/Discharges were important, so the residents knew what was coming and that staff were making preparations for the discharge. LN 1 stated if the Notice was not provided, it could increase anxiety for the resident before discharge, because they did not have time to prepare and ask questions. LN 1 stated without a Notice of Discharge being provided, it also eliminated the resident's right to appeal the discharge, because they were never informed they had that right. An interview and record review was conducted with LN 2 on 8/13/25 at 11:05 A.M. LN 2 stated written Notice of Transfer/Discharge were given to the residents and families within 30 days prior to discharge. LN 2 stated the Notice of Transfer/discharge was important, so residents and families were aware the discharge was pending and they could appeal, provide input, and make choices about where they were being discharged to. LN 2 stated Notice of Transfer/Discharge also decreased anxiety, so planning and preparation for discharge could be provided. LN 2 reviewed Resident 1, 2, and 3's clinical record and could not find any documentation a written Notice of Transfer/Discharge was ever provided. LN 2 stated the SSD was responsible for providing the Notice of Transfer/Discharge to the residents and their families.The SSD was unavailable on 8/13/25 for an interview.An interview and record review was conducted with the Director of Nursing (DON) on 8/13/ 25 at 11:20 A.M. The DON reviewed Resident 1's nurses note and stated there was no discharge documentation related to when the residents left the facility or where she was transported to. The DON stated a nurse's note was required for every discharge of when, where, how and with who. The DON stated this was a nursing standard or practice and was not followed when Resident 1 was discharged . The DON stated since the LN did not document the necessary information, the reader had no idea of what happened to the resident and there was no continuum of care. The DON continued, stating Notice of Transfer/Discharge were required for every discharge to inform the residents and their family of what was coming, to decrease anxiety and fear. The DON stated the Notice of Transfer/Discharge also provided instructions to the residents and family on how to appeal the discharge. The DON stated since the Notice was not provided as required, there was the potential that the residents were not adequately prepared for the discharge, and they were unaware of the appeal process.According to the facility's policy, titled Notice of Transfer/Discharge, dated October 2017, .1. When a transfer or discharge is initiated.the facility will provide the resident, responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior to the transfer or discharge. IV. The facility's notice of Proposed Transfer and Discharge includes an explanation of the right to appeal the transfer.According to the facility's policy, titled Discharge and Transfer of Residents, dated February 2018, .IV. Prior to discharge, Social Services Staff or Nursing will provide the resident/resident representative with the Notice of Proposed Transfer and Discharge document.VIIII. Discharge Documentation: .nursing staff must document the following information in the resident's medical record: A written statement for the reason of discharge; The date, time, and condition of the resident upon discharge; .

Based on interview and record review, the facility failed to develop and implement a person -centered care plan related to discharge, during the stay for two of three residents (Resident 1 and Resident 3), reviewed for discharges.This failure had the potential for staff to be uninformed of the residents' wishes for discharge, resulting in an uncoordinated effort for a planned and organized discharge.Findings:An unannounced visit was made to the facility on 8/13/25, in response to a complaint involving a discharge.1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (progressive memory loss), per the facility's admission Record.On 8/13/25, Resident 1's clinical record was reviewed.According to the facility's Social Service notes, dated 1/12/25 at 5:31 P.M., Resident 1 was going to be discharged to (name of facility), for supervised care in a secured unit (when residents are unable to leave the unit because of cognitive impairment, such as dementia, who require supervision and a safe environment).According to the facility's Discharge Planning Review, dated 1/13/25, Resident 1 was being discharged as a lateral transfer to another facility for continuum of care. The name of the facility she was being transferred to was not documented.There was no documented evidence that a discharge care plan had been developed or implemented.2. Resident 3 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (a progressive disease in which the brain functioning is affected), per the facility's admission Record.On 8/13/25, Resident 3's clinical record was reviewed.According to the facility's Social Service notes, dated 7/11/25 at 3:20 P.M., Resident 3 was discharged to Board and Care (name of facility).According to the facility's Discharge Planning Review, dated 7/11/25, Resident 3 was being discharged for a lower level of care.There was no documented evidence that a discharge care plan had been developed or implemented. An interview was conducted with Licensed Nurse 1 (LN 1) on 8/1/25 at 11 A.M. LN 1 stated discharge care plans should be developed upon admission, so all staff were aware of the residents' discharge wishes. LN 1 stated the discharge care plans were also important, because staff should be working towards a common goal of getting the residents ready for discharge, to decrease anxiety for the them and their families. An interview and record review was conducted with LN 2 on 8/13/25 at 11:05 A.M. LN 2 stated discharge care plans were important, so staff were aware of the residents' goals for discharging. LN 2 stated if a discharge care plan was not created, then there was no collaborated goal and organization of staff honoring the resident's wishes to discharge. LN 2 reviewed Resident 1 and Resident 3's clinical records and stated she could not locate a discharge care plan for either resident, which could have harmed their actual discharge, due to last minute planning.An interview was conducted with the Director of Nursing DON. The DON stated individual discharge care plans should be developed and implemented at the time of admission. The DON stated discharge care plans were important for staff communication, to know what the residents' plans were for an organized, goal-oriented, discharge. The DON stated by Resident 1 and Resident 3, not having a discharge care plan, there was potential the for harm because staff were not working towards the resident's goal of discharging. According to the facility's policy, titled Comprehensive Person-Centered Care Planning, August 2023, The facility will provide person-centered, comprehensive, and interdisciplinary care that reflets best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed for two of three sampled residents (Resident 2 and Resident 3). This failure increased the risk for Resident 2 and Resident 3 to have an unsafe discharge from the facility back to the community. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included stroke, per the Admission Record. On 5/13/25, a review of Resident 2's clinical record was conducted. Resident 2 was discharged from the facility on 3/12/25. The Discharge care plan was not updated for Resident 2. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), per the Admission Record. On 5/13/25, a review of Resident 3's clinical record was conducted. Resident 3 was discharged from the facility on 5/7/25. There was no evidence that a Discharge Care Plan was developed for Resident 3. On 5/13/25 at 12:03 P.M., an interview was conducted with the Social Service Director (SSD) and the Social Services Assistant (SSA). The SSD stated she and her assistant were responsible for developing a discharge care plan for Resident 2 and Resident 3 on admission. The SSD stated Resident 2 was not updated when Resident 2 was discharged on [DATE]. The SSD stated the discharge care plan for Resident 3 was missed. The SSD further stated that the care plan should have been created and updated to ensure the residents were discharged according to the plan. On 5/13/25 at 11:27 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the discharge care plan should have been developed to meet residents' needs. Per the facility's policy and procedure, dated 7/2020, titled Transfer and Discharge, .To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the Facility, I. Policy, Social Services Staff will participate in assisting the resident with transfers and discharges, and preparing the Discharge Summary and post discharge plan of care/discharge instructions .III. Discharge Care Plan, A. Based on resident needs, Social Services Staff will develop a Discharge Care Plan in coordination with the IDT .

Based on interview and record review, the facility failed to provide a copy of medical records within two business days of the request for one of two sampled residents (1). As a result, Resident 1's Responsible Party (RP 1) was not able to review the records in a timely manner. Findings: Per the facility's Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental and physical decline). Per the facility's undated Records Request Checklist, the request for Resident 1's medical records were provided on 3/17/25. The form did not list when the records were initially requested. On 4/1/25 at 1:36 P.M., an interview and record review was conducted with the Medical Records Director (MRD). The MRD stated, the first time she heard of RP 1's medical records request was on Thursday 3/13/25, and she delivered the medical records on Monday 3/17/25. The MRD further stated, no one at the facility notified her of RP 1's medical records request, and she was not aware of the request prior to 3/13/25. On 4/1/25 at 2:15 P.M., an interview and record review was conducted with the Admissions Coordinator (AC). The AC stated, RP 1 sent the AC an email on 3/5/25 (eight business days before the records were provided) which included a request for copies of Resident 1's medical records. The AC further stated, she forwarded the email to the Director of Nursing (DON). On 4/1/25 at 2:25 P.M., an interview was conducted with the DON. The DON stated, the AC forwarded him the email of RP 1's record request and he spoke with RP 1 about her record request on 3/5/25 (eight business days before the records were provided). On 4/1/25 at 2:34 P.M., an interview was conducted with the Administrator. The Administrator stated, it was the facility's policy to provide copies of medical records within two business days of the request. Per the facility's policy, titled Resident Access to PHI, revised 11/1/15, .If the resident and/or their personal representative requests a copy of the resident's medical record, the .Privacy Officer will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request .

Based on observation and interview, the facility failed to ensure that resident bathrooms were maintained in a sanitary manner for four of 16 sampled bathrooms (1 and 2). As a result, there was an increased risk of residents feeling uncomfortable using their bathroom. Findings: 1. Per the facility's Admission Record, Resident 144 was admitted to the facility on [DATE]. On 1/12/25 at 9 A.M., an interview was conducted with Resident 144. Resident 144 stated, Bathroom [ROOM NUMBER] had feces on the walls and at the base of the toilet. Resident 144 further stated, the feces had been there since she admitted to the facility (48 days prior), and the bathroom had never been cleaned in that time. Per the facility's Admission Record, Resident 56 was admitted to the facility on [DATE]. On 1/12/25 at 9:16 A.M., an interview was conducted with Resident 56. Resident 56 stated, Bathroom [ROOM NUMBER] was dirty, and it looked like someone, had an explosion in the bathroom. Resident 56 further stated, there had been feces around the toilet for more than a week. On 1/12/25 at 9:20 A.M., an observation was conducted of Bathroom [ROOM NUMBER]. There was brown material at the base of the toilet, streaks of a brown liquid that had ran down the wall behind the toilet, and the back of the toilet. 2. On 1/12/25 at 9:35 A.M., an observation was conducted of Bathroom [ROOM NUMBER]. There was brown material at the base of the toilet where the bolt secured it to the floor. Per the facility's Admission Record, Resident 60 was admitted to the facility on [DATE]. On 1/12/25 at 9:47 A.M., an interview was conducted with Resident 60. Resident 60 stated, that Bathroom [ROOM NUMBER] should have been cleaner. Resident 60 further stated, that he thought about the cleanliness of the bathroom while he was using it, but he tried not to let it bother him. Per the facility's Admission Record, Resident 55 was admitted to the facility on [DATE]. On 1/12/25 at 10:42 A.M., an interview was conducted with Resident 55. Resident 55 stated that Bathroom [ROOM NUMBER] was not clean enough. On 1/15/25 at 7:49 A.M., a concurrent observation and interview was conducted with the Housekeeping Supervisor (HKS). The referenced brown spots in Bathrooms [ROOM NUMBERS] were still there from the observation on 1/12/25. The HKS stated, that Bathrooms [ROOM NUMBERS] should not have still been soiled, and the brown spots should have been cleaned in the last three days. Per the facility's policy, titled Resident Rooms and Environment, revised 1/1/12, .The Facility provides residents with a safe, clean, comfortable, and homelike environment . Per the facility's policy, titled Housekeeping - Resident Rooms, revised 9/16, .The Housekeeping Department coordinates the daily cleaning of all resident rooms .The restroom is cleaned thoroughly with disinfectants .

Based on interview and record review, the facility failed to ensure that food temperatures were checked before serving to residents for two of 11 sampled days (10th, 11th). This failure placed residents at an increased risk of food-borne illness. Findings: On 1/12/25 at 7:35 A.M., a record review was conducted of the Food Temperature Log, dated January 2025. The log was blank for breakfast and lunch on the 10th and the 11th. On 1/13/25 at 11:45 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, [NAME] 1 was responsible for filling out the missing temperatures on the Food Temperature Log on 1/10/25, and [NAME] 2 was responsible for the missing temperatures on 1/11/25. DS 1 further stated, the Food Temperature Log should have been filled out at the time the temperatures were taken. On 1/13/25 at 12:10 P.M., an interview was conducted with [NAME] 1. [NAME] 1 stated, he did not remember why he did not fill out the Food Temperature Log on 1/10/25, but he may have forgotten to fill it out. Cook 2 was not available for interview. Per the facility's policy, titled Food Temperatures, revised 9/28/23, .Record the readings on .Food Temperature Log at the beginning of the tray line (placing food on plates for meals) .

Based on observation, interview, and record review, the facility failed to ensure that dietary staff were trained to properly test the strength of kitchen sanitizer for two of two sampled dietary staff (Cook 1, Dietary Aide 2). As a result, there was an increased risk of food-borne illness. Findings: On 1/13/25 at 9 A.M., an interview and observation was conducted with [NAME] 1. [NAME] 1 stated that when testing the quaternary sanitizer (a sanitizing liquid) he needed to take a test strip and hold it in the liquid for 10 seconds before checking the color. [NAME] 1 demonstrated testing the quaternary sanitizer strength in a red bucket by holding a test strip in the liquid for four seconds. [NAME] 1 reiterated that the sanitizer strip had to be held in the liquid for 10 seconds. [NAME] 1 then retested the quaternary sanitizer strength by holding the strip in the liquid for four seconds. On 1/13/25 at 9:02 A.M., an observation was conducted of the container for the test strips used by [NAME] 1 to test the sanitizer. The container read, .Test Paper IMMERSE FOR 10 SECONDS . On 1/13/25 at 9:15 A.M., an interview was conducted with Dietary Aide (DA) 2. DA 2 stated, he did not test the sanitizer in the red buckets and he did not know how to do so. On 1/13/25 at 9:16 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, all kitchen staff should have known how to test the sanitizer in the red buckets. DS 1 then instructed DA 2 on how to test the sanitizer. On 1/13/25 at 9:17 A.M., an observation was conducted. DA 2 demonstrated testing the sanitizer by holding the test strip in the liquid for 13 seconds. On 1/13/25 at 12:32 P.M., an interview was conducted with the Administrator. The Administrator stated, DA 2 had not yet completed his initial competencies (a checklist to ensure new employees knew how to do the tasks of their job). On 1/14/25 a review was conducted of DA 2's employee file. DA 2 was hired on 10/15/24 (90 days before the observed sanitizer testing). The file did not have any evidence of an orientation or training specific to DA 2's role in the kitchen. On 1/14/25 at 1:45 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated, the competencies for dietary staff should have been completed by the DS. Per the facility's policy, titled Pot and Pan Cleaning, revised 6/22/23, .Test quaternary sanitizer for adequacy using appropriate test strips .

Based on observation and interview, the facility failed to ensure: 1. Food was discarded before the expiration date 2. Food containers were labeled after opening 3. Dietary staff had their facial hair covered while in the kitchen for one of one kitchens. These failures placed residents at an increased risk of food-borne illness. Findings: 1. On [DATE] at 7:50 A.M., an observation was conducted of the walk-in refrigerator in the kitchen. There was a container of dill pickle relish with a use by date of [DATE]. On [DATE] at 7:55 A.M., a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 stated, the dill pickle relish was past it's use by date and should have been thrown out. On [DATE] at 9:10 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, the expired relish should have been thrown out. The facility's policy, titled Food Storage and Handling, revised [DATE], did not have guidance on how to handle pickled food, or general guidance on use by dates. 2. On [DATE] at 7:50 A.M., an observation was conducted of the walk-in refrigerator in the kitchen. The following food items were opened and were not labeled with a use by date: - A bag of shredded cheddar and Monterey jack cheese. - A Bag of shredded lettuce. - A reusable container was filled with a substance that appeared to be applesauce. The container was unlabeled. On [DATE] at 7:55 A.M., a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 stated, the applesauce, cheese, and lettuce should have been labeled with their use by dates when they were opened. [NAME] 1 further stated that the bags of cheese and lettuce should have been moved into reusable containers once the bags were opened instead of being tied off, but there were no more containers available to put them in. On [DATE] at 9:10 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, all opened food in the fridge should have been labeled with the date they were opened. Per the facility's policy, titled Food Storage and Handling, revised [DATE], .All items will be correctly labeled and dated . 3. On [DATE] at 7:40 A.M., an observation and interview was conducted with Dietary Aide (DA) 3. DA 3 was observed preparing breakfast meal trays in the kitchen, and his beard was uncovered. DA 3 stated, he was required to cover the hair on the top of his head while in the kitchen, but not the hair on his face. On [DATE] at 9:10 A.M., an interview was conducted with Dietary Supervisor (DS) 1. DS 1 stated, that dietary staff were required to wear a beard net if they had facial hair. Per the facility's policy, titled Dietary Department - Infection Control, revised [DATE], .Cover hair, beard, and mustache with an effective hair restraint .while in any kitchen and food storage area .

Based on observations, interviews, and record review, the facility failed to follow their infection control policies and procedures to prevent the spread of infection and cross contamination when: 1. Resident 72's oxygen supplies were not stored properly. 2. The facility did not have an infection surveillance tracker to properly conduct a contact tracing for residents with respiratory illness. 3. The facility did not properly screen staff and visitors during an active coronavirus (COVID19- a virus that can cause severe respiratory illness) outbreak. This failure had the potential to increase the spread of infection for all residents, staff and visitors in the facility. The facility census was: 95. Findings: 1. A review of Resident 72's Admission Record indicated Resident 72 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral Infarction (type of stroke, when the part of the brain tissues dies and loss of blood flow to the brain). A record review of Resident 72's minimum data set (MDS - a federally mandated resident assessment tool) dated 11/21/24 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 72 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/12/25 at 8:55 A.M., an observation was conducted with Resident 72's roommate, in Resident 72's roommate's room. Resident 72's oxygen tubing and concentrator was seen at Resident 72's roommate's side of the room divided by a curtain. The unlabeled oxygen tubing was on the floor with an oxygen concentrator and humidifier unidentifiable of Resident 72's use. On 1/12/25 at 10:41 A.M., an observation was conducted with Resident 72's roommate, in Resident 72's room. Resident 72's oxygen tubing was in the same position as the previous observation (on the floor and unlabeled) along with the oxygen concentrator and humidifier still at Resident 72's roommate's side of the room. On 1/12/25 at 12:42 P.M., an observation was conducted with Resident 72's roommate, in Resident 72's room. Resident 72's roommate was resting in bed. The oxygen tubing was seen in Resident 72's roommate's side of the room remained unlabeled and was wrapped around the oxygen concentrator. On 1/13/25 at 7:15 A.M., a clinical chart review was conducted on Resident 72's Medical Doctor (MD) orders. Resident 72's MD order's dated 1/5/25 indicated, Oxygen @2 L/min [liters per minute] to keep 02 Sat 92% every shift .). On 1/13/25 at 8:08 A.M., an observation was conducted on Resident 72, in Resident 72's room. Resident 72 was asleep in bed not using oxygen. On 1/13/25 at 9:34 A.M., an interview was conducted with LN 5, outside of Resident 72's room. LN 5 reviewed photos of Resident 72's oxygen tubing and supplies taken on 1/12/25 at 8:56 A.M., 9:53 A.M., 10:40 A.M., and 12:43 P.M. LN 5 stated the oxygen tubing should be stored in a clear plastic bag that is labeled with Resident 72's name, dated and not the floor to keep the tubing clean and prevent cross contamination. LN 5 stated the oxygen concentrator and oxygen supplies should not be placed in Resident 72's roommate's side of the room and should be within Resident 72's side of the room. LN 5 stated that he did see that Resident 72's oxygen concentrator and supplies placed at his roommates side of the room which should not be there to prevent cross-contamination. LN 5 stated it was an infection control issue because the oxygen tubing was on the floor and not labled and we would not know if he [Resident 72] used it or not. LN 5 further clarified this would cause confusion or might cause staff to mistakenly put the oxygen on Resident 72's roommate instead of Resident 72. On 1/13/25 at 11:17 A.M., a joint interview and record review was conducted with the Infection Preventionist (IP). The IP nurse stated Resident 72 had oxygen orders which were PRN [as needed] and confirmed that his roommate did not have any oxygen orders. The IP reviewed photos of Resident 72's oxygen tubing and supplies taken on 1/12/25 at 8:56 A.M., 9:53 A.M., 10:40 A.M., and 12:43 P.M. The IP nurse stated Resident 72's oxygen tubing should be stored in a bag away from the floor with a name, date, and labeled along with the concentrator and oxygen supplies to remain in Resident 72's side of the room to avoid confusion, safety concerns, and prevent cross contamination with a wrong resident. On 1/15/25 at 8:09 A.M., an interview was conducted with the Director of Nursing (DON). The DON reviewed photos of Resident 72's oxygen tubing and supplies taken on 1/12/25 at 8:56 A.M., 9:53 A.M., 10:40 A.M., and 12:43 P.M. The DON stated Resident 72's oxygen tubing should be labeled, dated and off the ground stored in a plastic bag. The DON stated it was important that the oxygen concentrator and oxygen supplies be stored appropriately in Resident 72's side of the room to avoid confusion. The DON stated if Resident 72's roommate was confused they [Resident 72's roommate] might use it and cause an improper use of oxygen and also for infection control practices that could be a risk for cross-contamination. A review of the facility's policy and procedure titled INFECTION CONTROL-POLICIES & PROCEDURES dated January 1, 2012, indicated, .Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public . The Policy and procedure did not indicate infection control measures specific to oxygen supplies and storage methods. 50175 2. A tour of the facility was conducted on 1/12/25 at 7:56 A.M. One room was observed to have transmission-based precautions (isolation to prevent the spread of infection). An interview and record review was conducted on 1/14/25 at 10:53 A.M. with the Infection Preventionist (IP). Per the IP, there was no infection surveillance located for the year 2024 and for January 2025. The IP stated it was important to have an infection surveillance tracker to know who had an infection within the facility and to help prevent the spread of infection. A follow-up interview was conducted with the IP on 1/15/25 at 9:20 A.M. The IP stated Resident 63 tested positive for COVID 19 on 1/6/25. The IP stated Resident 244 was the second resident to test positive for COVID-19 on 1/13/25. The IP stated having more than one resident test positive for COVID 19 meant there was an outbreak. An interview was conducted with the Director of Nursing (DON) on 1/15/25 at 9:39 A.M. The DON stated it was important to have an up-to-date infection surveillance tracker to help control the spread of infection. A follow-up interview was conducted with the IP on 1/15/25 at 10:56 A.M. The IP stated there was no contact tracing done after the first COVID 19 case on 1/6/25. A review of the facility's Covid-19 Mitigation Plan, revised 8/2/23, indicated .An outbreak is defined as: [greater than or equal to] 1 facility-acquired COVID-19 case in a resident .The facility will perform contact tracing to identify any HCP (healthcare personnel) who have had a high-risk exposure or resident who has had a high-risk close contact with the individual with [COVID-19] . A review of the facility's policy titled Infection Control Surveillance, revised 3/1/14, indicated .The Infection Preventionist conducts ongoing surveillance for HAIs (Healthcare-associated Infections) .that have substantial impact on potential resident outcome, and that require transmission-based precautions and other preventative interventions . A review of the facility's policy titled Management of COVID 19, revised 10/11/22, indicated .Perform contact tracing for both suspected and confirmed cases and document results on the Contact Tracing Log . 3. An interview and record review was conducted with Certified Nurse Assistant (CNA) 32 on 1/15/25 at 7:30 A.M. A binder at the nursing station was reviewed and found to have a screening form for staff to complete and indicate whether or not they have symptoms of COVID-19. According to the screening sheets in the binder, CNA 32 stated the staff started screening for COVID-19 symptoms on 1/14/25. An interview was conducted with the Infection Preventionist (IP) on 1/15/25 at 9:20 A.M. The IP stated Resident 63 tested positive for COVID 19 on 1/6/25. The IP stated Resident 244 was the second resident to test positive for COVID-19 on 1/13/25. The IP stated having more than one resident test positive for Covid 19 meant there was an outbreak. The IP stated screening for staff started on 1/14/25, and should have started on 1/12/25 when Resident 244 was sent to the hospital with symptoms of COVID 19. The IP stated it was important to do screening for staff and residents to control the spread of infection. A joint interview and record review with the Administrator (ADM), Receptionist, and Activities Director (AD) was conducted at the reception desk on 1/15/25 at 10:35 A.M. A visitor log titled Daily Screening Log of Visitors, Vendors, and Medical Providers (non-facility employees), located at the Reception Desk, ranging from 12/23/24 through 1/15/25 was reviewed. The visitor log included a screening tool where the visitor would indicate their name, who they were visiting, and if they had any symptoms of COVID 19 such as cough, chills, and difficulty breathing. Multiple entries indicated the visitor's name but did not indicate whether or not the visitor exhibited symptoms of COVID-19. Some entries were not dated. The ADM, receptionist, and AD stated some of the screenings were incomplete. The Receptionist stated it was important to do a complete screening to stop the spread of infection within the facility. The ADM stated the outbreak of COVID-19 started on 1/13/25, and the screening of visitors were inconsistent. A review of the facility's COVID-19 Mitigation Plan, revised 8/2/23, indicated .Any visitor entering the facility .must adhere to the following: Visitors will sign in electronically or on the visitors' log and be asked to leave information to facilitate contact tracing, full name, date, contact information, who they are visiting .All visitors must be educated to screen themselves prior to entry . A review of the facility's policy titled Management of COVID-19, revised 10/11/22, indicated .Visitors will self-screen upon visiting .Any person who refuses screening will not be allowed into the Facility .Any person, who meets any of the temperature or symptom criteria will not be permitted to enter the Facility .For those permitted entry, the visitor must pass all self-screening criteria .

Based on observation, interview, and record review, the facility failed to ensure two of 32 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were not occupied by more than four residents This failure could potentially cause overcrowding and compromise the quality of care for the residents occupying the six-bed rooms. Findings: A tour of the facility was conducted on 1/12/25 at 7:41 A.M. At 8:12 A.M., room [ROOM NUMBER] was observed to occupy six residents. room [ROOM NUMBER] was also observed to occupy six residents. An interview and record review was conducted with the Administrator (ADM) on 1/13/25 at 3:08 P.M. The Client Accommodations Analysis was received indicating rooms [ROOM NUMBERS] each had a capacity for six residents. The Analysis indicated Bedroom [ROOM NUMBER] and 132 had a bedroom waiver. The ADM stated the facility did not have any room waivers. The ADM stated the last room waiver was from 2012. A follow-up interview was conducted with the ADM on 1/15/25 at 9:02 A.M. The ADM stated it was important to have a waiver to follow regulations.

Based on interviews, and record reviews, the facility failed to send a copy of the notice to transfer/discharge form to the Ombudsman office for two of six reviewed residents (Resident 6 and 72) that required immediate transfer to an acute care hospital for urgent needs. These failures resulted in a lack of resident discharge notification to the State Long Term Care (LTC) Ombudsman to advocate and assist the residents (Resident 6 and 72) with appeal rights as needed. Findings: 1. A review of Resident 6's Admission Record indicated Resident 6 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). On 1/12/25 at 3:46 P.M., a record review was conducted. Resident 6 had a change of condition (COC) progress note dated 12/11/24 that indicated Resident 6 was transferred to acute care related to an abnormal heart rate (HR) of 35 with notification given to the Medical Doctor (MD) and son. On 1/14/25 at 9:06 A.M., an interview was conducted with the Social Services Director (SSD). The SSD stated that she was responsible to notify the LTC Ombudsman when they were discharged home or transferred to another LTC facility. The SSD stated for acute hospital transfers the nurses do it. On 1/14/25 at 9:08 A.M., an interview was conducted with the Medical Records Director (MRD). The MRD stated at her previous facility as an MRD she used to send out a copy of transfer/discharge notice to the LTC Ombudsman (OMB). The MRD stated that she questioned the current facility if sending out a copy of transfer/discharge notice to the LTC OMB was part of her workload and stated nobody got back to me in regards to doing that but I'm willing to do that here. The MRD stated it's important to send that information to the ombudsman so that they are aware of residents being transferred to the hospital and to follow up to advocate and to appeal when needed. On 1/14/25 at 9:13 A.M., a telephone interview was conducted with the OMB. The OMB stated she had never received a copy of transfer/discharge notice for residents transferred to acute care hospitals. On 1/15/25 at 7:40 A.M., a joint interview and record review was conducted with LN 2, at the nursing station. LN 2 stated that Resident 6 was sent out to the emergency room (ER) per the COC (e-interact) document on 12/11/24. LN 2 stated that the MD and son were notified but was unable to find documentation or records that indicated that the LTC Ombudsman was notified. LN 2 stated she was not aware that they needed to contact the OMB and stated that licensed nurses (LN)s usually only notified the MD, family members, and/or their responsible parties (RP). On 1/15/25 at 8:39 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that it was his expectations to follow the regulations for transfer/discharge notifications and that the LTC OMB should be notified for hospitalization transfers. The DON stated it was important for the OMB to be notified because they were the patient advocates and in case they want to get more information to appeal, it is their [residents] right. A review of the facility's policy and procedure titled NOTICE OF TRANSFER AND DISCHARGE revised October 2017, indicated When a transfer or discharge is initiated by the facility, the facility will provide the resident, responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior to the transfer or discharge .C. The resident's urgent medical needs that cannot be met in the facility and requires immediate transfer; and D. The health of individuals in the facility would otherwise be endangered; In these cases, the notice will be given as soon as practicable prior to discharge . 2. A review of Resident 72's Admission Record indicated Resident 72 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral Infarction (type of stroke, when the part of the brain tissues dies and loss of blood flow to a part of the brain). On 1/14/25 at 8:59 A.M., a joint interview and record review was conducted with Licenced Nurse (LN) 4, in the nursing station. LN 4 stated that Resident 72 was transferred to an acute hospital on 12/26/24 for low hemoglobin (HGB- is a protein in red blood cells that carries oxygen throughout the body. When hemoglobin levels are low, the body's tissues don't get enough oxygen and can't function properly) labs. LN 4 stated that according to the document titled SBAR (Situation, Background, Appearance, Review) Communication Form that the Nurse Practitioner (NP) and family members were notified along with Hospice (End of life medical care). LN 4 stated that he was unable to find documentation that the Long Term Care (LTC) Ombudsman (OMB) was notified. LN 4 stated as part of the clinical role with transfers that the LNs were responsible for contacting the Medical Doctor (MD) or NP and then call the family per face sheet. LN 4 stated he was not aware that the LTC OMB needed to be notified and sent a copy of transfer/discharge for hospital transfers. On 1/14/25 at 9:06 A.M., an interview was conducted with the Social Services Director (SSD). The SSD stated that she was responsible to notify the LTC OMB when they are discharged home or transferred to another LTC facility. The SSD stated, for acute hospital transfers the nurses do it. On 1/14/25 at 9:08 A.M., an interview was conducted with the Medical Records Director (MRD). The MRD stated at her previous facility as an MRD she used to send out a copy of transfer/discharge notice to the LTC Ombudsman (OMB). The MRD stated that she questioned the current facility if sending out a copy of transfer/discharge notice to the LTC OMB was part of her workload and stated nobody got back to me in regards to doing that but I'm willing to do that here. The MRD stated it's important to send that information to the ombudsman so that they are aware of residents being transferred to the hospital and to follow up to advocate and to appeal when needed. On 1/14/25 at 9:13 A.M., a telephone interview was conducted with the Ombudsman (OMB). The Ombudsman stated she had never received a copy of transfer/discharge notice for residents transferred to acute care hospitals. On 1/15/25 at 8:19 A.M., an interview was conducted with the Director of Nursing (DON), in the DON's office. The DON stated it was his expectations that we send the notice of transfer/discharge form to the Ombudsman from here on out. The DON stated it should be part of the Medical Records Director (MRD) to be responsible to send that information to the Ombudsman according to regulations. The DON stated it was important that the Ombudsman is informed and alerted because they are the patient advocate for the residents for their right to appeal and to be informed of the residents whereabouts. A review of the facility's policy and procedure titled NOTICE OF TRANSFER AND DISCHARGE revised October 2017, indicated When a transfer or discharge is initiated by the facility, the facility will provide the resident, responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior to the transfer or discharge .C. The resident's urgent medical needs that cannot be met in the facility and requires immediate transfer; and D. The health of individuals in the facility would otherwise be endangered; In these cases, the notice will be given as soon as practicable prior to discharge .

Based on observation, interview, and record review the facility failed to complete a comprehensive elopement assessment for one of six sampled residents (Resident 198). As a result, Resident 198 eloped from the facility. Findings A review of Resident 198's Admission Record dated 12/27/24, indicated that Resident 198 had a diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During an observation on 1/12/25 at 10:50 A.M. Resident 198 was observed ambulating without assistance or assistive devices in the main hallway of the building. Resident 198 was accompanied by a facility staff member. During an observation on 1/13/25 at 8:50 A.M. The location of Resident 198's elopement was identified and found to provide access to Highway on and off ramps. During an interview on 1/13/25 at 8:50 A.M. with the Administrator (ADM). The ADM stated on 1/2/25, Resident 198 came out of the door, set off the alarm, went past two residents, climbed over the fence, and went toward the church. The staff followed and Resident 198 was found at the church and returned to the facility. We are working on having her transferred to another facility . that should happen today. During an interview on 1/13/25 at 9 A.M. with Resident 198. Resident 198 stated the nurse was making me upset, and I wanted to get away. I was going to the bus stop, but I saw people running after me and I didn't want to get anyone in trouble. The bus came by, and I just waved it off, I wasn't going to get on it. A record a review was conducted on 1/15/25 with the following: - The Psychiatric Consultation Note dated 12/20/2024, the note states She (Resident 198) is forgetful and has attempts to wander off by herself. - The Psychiatric Consultation Follow up Note dated 12/24/2024, the note stated .needs redirection as she (Resident 198) wanders off . - The Hospitalist Progress note dated 12/27/2024, the note stated .given the patients (Resident 198) elopement risk . During an interview on 1/15/25 at 9:49 A.M. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated we can tell by their behavior, pacing, irritable, or they may verbalize that they don't want to be here. LVN 2 further stated we assess the triggers, get social services involved, redirect to why they are here, and get families involved. LVN 2 stated If a resident does elope, we notify all staff, family, and the Police Department. We do send out staff to look for the resident. LVN 2 further stated, we have a binder for elopement and wander risk residents, but it has not been updated since June. Depending on their cognition level, a resident could get hit by a car, or they could get dehydrated. During an interview on 01/15/25 at 10:10 A.M. with the Director of Nursing (DON), the DON stated we do an assessment on admission, if there is a diagnosis of dementia we reach out to RP (Responsible Party) to get authorization for a wander guard [a safety bracelet that alarms when triggered], contact the doctor and get the order. The DON further stated staff is notified in the morning meeting about wander risk residents and as identified during the shift. If they get off the premises, we report it public health, Ombudsman, law enforecement. The DON concluded If a resident does successfully elope there is the possibility of injury or missing medications.

Based on observations, interviews, and record reviews, the facility failed to accurately code the Minimum Data Set (MDS-a federally mandated resident assessment tool) according to the Resident Assessment Instrument (RAI-instructions for MDS) manual and the facility's MDS policies and procedures for three of 29 sampled residents (Resident 72, 29, and 23) when: 1. Resident 72's fall incident was not accurately coded. 2. Resident 29's fall incident was not accurately coded. 3. Resident 23's pneumonia diagnosis was coded as active without supporting documentation. As a result, the facility sent Residents (Resident 72, 29, and 23) MDS's to the federal database with inaccurate health status. Findings: 1. A review of Resident 72's Admission Record indicated Resident 72 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral Infarction (type of stroke, when the part of the brain tissues dies and loss of blood flow to the brain). A record review of Resident 72's MDS dated [DATE] 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 72 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/13/25 at 7:32 A.M., a record review was conducted on Resident 72's clinical chart. Resident 72's progress note dated 10/27/24, indicated an unwitnessed fall happened while attempting to self-toilet. On 1/13/25 at 10:03 A.M., a joint record review and interview was conducted with the MDS Nurse (MDSN), in the MDS office. The MDSN stated the progress note on 10/27/24 at 1915 (8:15 P.M.) indicated, resident fell assisted back to bed due to attempting to self-toilet. The MDSN stated Resident 72 did not have an injury of indication of head injury from the fall. The MDSN reviewed the quarterly MDS dated [DATE] quarterly assessment and stated she did not capture the fall on section J1800 and did not accurately capture the number of falls for no injury on section J1900 of the MDS. The MDSN stated since the fall happened on 10/27/24 it would not be captured on the previous MDS dated [DATE] but should have been accurately coded on the MDS dated [DATE] because of the fall incident timeline. The MDSN stated it was important to capture an accurate assessment because the MDS is transmitted to the federal database and it was important that it reflected Resident 72's current health status which also triggers the quality measures (QM) of the facility. The MDSN stated that the MDS drives the whole assessment for care coordination and also the plan of care for the resident and what interventions we need to monitor. I have to modify the MDS and re-transmit. On 1/15/25 at 8:04 A.M., and interview was conducted with the Director of Nursing (DON), in the DON's office. The DON stated it was important for the MDSN to accurately code Resident 72's fall incident to capture Resident 72's current health status. The DON stated the MDS drives the plan for the residents and the information sent by MDS is transmitted to the federal database. The DON's expectations was for the MDS to be accurately coded. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2024, (Page J-34-35) Section J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent .Code 1, yes: if the resident has fallen since the last assessment Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent .A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury . 50175 2. Resident 29 was admitted on [DATE] with diagnoses including degenerative disease of the nervous system (a condition that cause nerve cells to die causing mental and physical decline) per the Admission Record. A review of Resident 29's record was conducted on 1/13/25. A progress note dated 5/28/24 at 11:27 P.M. indicated Resident 29 was found on the floor laying on the right side. A progress note dated 5/28/24 at 11:36 P.M. indicated the fall was not witnessed and the fall occurred in Resident 29's room. A joint interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 1/14/25 at 11:00 A.M. The MDSN stated the MDS assessment, dated 8/1/24, was the assessment completed after Resident 29's fall. The MDSN stated the MDS assessment for 8/1/24 did not reflect that Resident 29 had a fall prior to 8/1/24. The MDSN stated the MDS assessment should be accurate so everyone knew what happened to the patient. An interview with the Director of Nursing (DON) was conducted on 1/15/25 at 9:52 A.M. The DON stated the MDSN should have updated the MDS assessment to reflect Resident 29's fall because the MDS assessment helped guide patient care. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2024, (Page J-34-35) Section J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent .Code 1, yes: if the resident has fallen since the last assessment Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent .A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury . 39448 3. Per the facility's Admission Record, Resident 23 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD - a lung disease). Per the agency's MDS' dated 2/22/24, 5/22/24, 8/21/24, and 11/19/24, under Section I - Active Diagnoses, Resident 23's Primary Medical Condition was Pneumonia (a lung infection). On 1/14/25 at 2:23 P.M., a concurrent interview and record review was conducted with the MDSN. The MDSN stated, Resident 23 was diagnosed with pneumonia on 12/18/23. The MDSN further stated, Resident 23's pneumonia resolved, and it should not have been documented on the MDS on 2/22/24, 5/22/24, 8/21/24, or 11/19/24. Per the facility's policy, titled RAI (Resident Assessment Instrument) Process, revised 10/4/16, .Purpose .To provide resident-assessments that accurately depict and identify resident-specific issues . Per the facility's policy, titled Diagnosis List, revised 4/8/16, .Ensure that accurate .coding is assigned .When a diagnosis is resolved, the Diagnosis List form will indicate the date the diagnosis was resolved .

Based on interview and record review, the facility failed to ensure the Preadmission Screening Resident Review (PASRR, a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes) was accurate for one of six sampled residents (Resident 69). This failure had the potential for Resident 69's mental health needs to be unmet. Findings: Resident 69 was admitted to the facility on [DATE] with diagnoses including psychosis (a mental illness involving hallucinations and delusions) and depression (a mental illness involving long periods of being sad or hopeless) per the Admission Record. A review of Resident 69's medical record was conducted on 1/12/25. Resident 69 was discharged from a hospital prior to his admission to the facility with medications including aripiprazole (an antipsychotic medication) to start on 12/15/24. A review of Resident 69's physician's orders for January 2025 indicated a current order for aripiprazole. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 1/14/25 at 1:05 P.M. The MDSN stated Resident 69 has a diagnosis of psychosis and was taking a psychotropic medication (an antipsychotic). The MDSN stated the PASRR screening dated 12/5/24 indicated that Resident 69 did not have a serious mental illness like psychosis and did not indicate Resident 69 was on psychotropic medications. The MDSN stated the PASRR was not accurate. The MDSN stated there were no other PASRRs completed during Resident 69's admission. The MDSN stated the PASRR should have been corrected so Resident 69 would get the care he needs. An interview with the Director of Nursing (DON) was conducted on 1/15/25 at 10:06 A.M. The DON stated the PASRR should have reflected that Resident 69 was on a psychotropic medication and that Resident 69 had psychosis. The DON stated the PASRR should have been reviewed and corrected so Resident 69 would get the appropriate mental health care. A review of the facility's policy titled Admission Screening Resident Review (PASRR), revised 9/1/23, indicated, .will be responsible to assess and ensure updates to the PASRR are completed per MDS (Minimum Data Set, an assessment tool) guidelines .

Based on observations, interviews, and record reviews, the facility failed to implement or develop a person centered care plan for two of 29 sampled residents (Resident 84, 9, 198) when: 1. Resident 84's nutritional care plan did not address nutritional preferences and dislikes. 2. Resident 9's care plan did not include a Hospice care plan. 3. Resident 198's care plan did not indicate a person-centered approach to prevent future wandering/elopement while at the facility. As a result, Resident 84's and Resident 9's plan of care was not personalized that promotes or maintains their highest practicable physical, mental, and psychosocial well-being. Cross-Reference F803 Findings: 1. A review of Resident 84's Admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included a history of Chronic Kidney Disease Stage four (CKD stage 4- kidneys are moderately or severely damaged and are not properly filtering waste from your blood). A record review of Resident 84's minimum data set (MDS - a federally mandated resident assessment tool) dated 10/28/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 84 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/12/25 at 10:19 A.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 stated that he was a kidney patient and at the border of not having to need dialysis. Resident 84 stated that the facility was consistently serving meals that were not good for him because he was a kidney patient. Resident 84 further stated they [the facility staff] feed me trash I cannot eat such as fruits like oranges that are high in potassium (a mineral that is essential to body functions but an excess of potassium can build up with kidney disease due to the kidney's unable to remove the mineral from the body that could have harmful health effects). On 1/12/25 at 1:22 P.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 had a meal tray on his bedside table that included green peas, mashed potatoes, a bitten slice of chicken and oranges on the side. Resident 84 stated he did not like green peas, potatoes and could not eat the oranges because it is not good for my kidneys and it's on my dislikes list. Resident 84's meal tray card indicated, Dislikes .Oranges .Potatoes . On 1/14/25 at 7:46 A.M., an observation, interview and record review was conducted with Dietary Supervisor (DS) 1 and DS 2, in the conference room. DS 1 stated that they did not have an in-house Registered Dietician (RD) but have a consultant filling in for now. DS 1 stated she knew Resident 84 preferred a renal diet versus a no added salt (NAS), carbohydrate controlled (CCHO) diet. DS 1 stated she completed Resident 84's dietary evaluation titled Dietary Profile on 10/24/24 and stated that the evaluation indicated Resident 84's dislikes included, orange juice/oranges, tomatoes, fresh potatoes, spinach, peas, beef, and pork. DS 1 stated for a renal diet, Resident 84 should not be served orange juice, fresh oranges, tomatoes, fresh potatoes and spinach. DS 1 stated that it was Resident 84's preference to not be served peas, beef and pork. DS 1 and DS 2 was shown a picture of Resident 84's meal tray with the meal tray card. DS 1 and DS 2 stated that the picture looked like it was the menu that was served on Sunday 1/12/25. DS 1 stated that the kitchen and nursing staff should have looked at Resident 84's meal tray card to see Resident 84's preference list and not serve Resident 84 what was on the dislikes and prepared a menu that substituted his dislikes that was nutritionally equivalent. DS 1 and DS 2 stated not following Resident 84's preference would make him unhappy. DS 1 stated the only way the kitchen and nursing staff would know about Resident 84's preference would be to look at the meal tray card because the preferences was not listed in Resident 84's orders or care plan. On 1/14/25 at 8:31 A.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 was lying in bed with a meal tray on his bedside table. Resident 84 stated I received pork and toast for breakfast and pork is on my dislikes list. They [facility staff] should already know while pointing to his meal tray. Resident 84 further stated, if the facility continued to not honor his meal preferences he could loose weight in an unhealthy way. On 1/14/25 at 8:37 A.M., an observation, interview and record review was conducted with LN 2, in the nursing station. LN 2 stated that it was the LN's responsibility to check the trays and check their dietary sheets to make sure that the ordered diet was being served before any residents ate the food that was being served for safety. LN 2 stated that the dietary sheets are Medical Doctor (MD) orders and does not show any preferences, but the actual meal tray card does. LN 2 stated for renal/kidney orders oranges are usually not acceptable because it spikes renal [sic], spikes the blood sugar and it's rich in potassium and are not good for the kidneys. LN 2 was shown a picture of Resident 84's breakfast meal tray taken on 1/12/25. LN 2 stated that Resident 84's preferences according to his meal tray card should be honored. LN 2 stated that Resident 84 should not have been served with orange and peas because it was what Resident 84 disliked. LN 2 stated the menu should have been substituted with foods that were nutritionally adequete and honored Resident 84's preference. LN 2 stated that the MD orders would not include a resident's preference, but it should be included in a person-centered care plan because this would help guide the nursing staff on how to care for Resident 84. LN 2 stated Resident 84 has CKD stage four and has a care plan with the diagnosis that does not include his food preferences. LN 2 stated that Resident 84's nutritional care plan was not person-centered and should include Resident 84's food preference since looking at the meal tray card was missed and could validate the plan of care of how to take care of Resident 84 to prevent a decline in Resident 84's nutritional health status. On 1/15/25 at 8:52 A.M., an interview and record review was conducted with the Director of Nursing (DON), in the DON's office. The DON stated that Resident 84's nutritional care plan was not person-centered and should be person centered to reflect his preferences. The DON stated it was important for Resident 84's care plan to be person centered because this guides the care, we (facility staff) should be providing for Resident 84 to promote his physical, mental and psychosocial well-being. A review of the facility's policy and procedure titled COMPREHENSIVE PERSON-CENTERED CARE PLANNING dated November 2018, indicated .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .the comprehensive care plan will also be reviewed and revised at the following times: i. onset of new problems; ii. change of condition; iii. in preparation for discharge; iv. To address changes in behavior and care . 47956 2. A review of Resident 9's admission record indicated Resident 9 was admitted on [DATE] with a diagnosis of Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and admitted to Hospice on 1/4/25 with a diagnosis of End-Stage Heart Failure (the most severe form of heart failure, when the heart is too weak to pump blood effectively). During an observation on 1/12/25 at 9:25 A.M., Resident 9 was observed in bed, responsive to voice with low single word answers. During an interview on 1/14/25 at 10:19 A.M., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated a Care plan is a patient centered record where other staff can learn about the patient. Care plans come from the doctor. You can generate a new plan of care, but it is based on a doctor's order. LVN 2 stated All changes in resident status or goals of care need to have a care plan. During an interview and record review on 1/15/25 at 10:55 A.M., with the Director of Nursing (DON), in the DON's office. The DON stated Yes, [Resident 9] was admitted to hospice on 1/4/25. Following a review of Resident 9's care plans, the DON stated, There is no care plan for [Resident 9] to be on hospice. The DON further stated [Resident 9] would not have a comprehensive resident centered care plan since hospice is missing. A review of the facility's policy and procedure titled COMPREHENSIVE PERSON-CENTERED CARE PLANNING dated November 2018, indicated .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .the comprehensive care plan will also be reviewed and revised at the following times: i. onset of new problems; ii. change of condition; iii. in preparation for discharge; iv. To address changes in behavior and care . 3. A review of Resident 198's admission record indicated Resident 198 was admitted on [DATE] with a diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During an observation on 1/12/25 at 10:50 A.M., Resident 198 was observed ambulating through facility and outside to the smoking area without the use of assistive devices. During an interview on 1/13/25 at 8:50 A.M., with the Administrator (ADM). The ADM stated on 1/2/25, Resident 198 came out of the door, set off the alarm, went past two residents, climbed over the fence, and went toward the church. The staff followed and Resident 198 was caught at the church and returned to the facility. During an interview and record review on 1/15/25 at 10:50 A.M., with the Director of Nursing (DON), in the DON's office. The DON stated Care Plans are individualized treatment programs for each resident. They are based on diagnoses, function, mental ability and they involve all areas of the facility. The DON stated [Resident 198] had a wandering care plan but it was not individualized enough based on the records from the hospital. Record reviews were conducted on 1/15/25 that indicated: - An Elopement Risk binder, Resident 198 is not listed. The binder is listed as last updated 6-19-24. - Psychiatric Consultation Note dated 12/20/2024, the note states She (Resident 198) is forgetful and has attempts to wander off by herself. - Hospitalist Progress note dated 12/24/2024, the note states .given the patients (Resident 198) elopement risk . - Psychiatric Consultation Follow up Note dated 12/24/2024, the note states .needs redirection as she (Resident 198) wanders off . A review of the facility's policy and procedure titled COMPREHENSIVE PERSON-CENTERED CARE PLANNING dated November 2018, indicated .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .the comprehensive care plan will also be reviewed and revised at the following times: i. onset of new problems; ii. change of condition; iii. in preparation for discharge; iv. To address changes in behavior and care .

Based on observation, interview, and record review, the facility failed to ensure interventions for skin breakdown and/or pressure injury (bed sores) for one of five sampled residents (47) was maintained. Resident 47 had a low air loss mattress (LAL mattress: An air mattress to prevent pressure injury) for prevention of skin breakdown that were not set to the residents' current weight. This failure had the potential for Resident 47 to develop a pressure injury. Findings: 1. Resident 47 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease making it difficult to breathe) per the Admission Record. An observation was conducted on 1/12/25 at 9:17 A.M. Resident 47 was observed laying in bed with a LAL mattress set to static mode (no alternating pressure) and set for a resident weighing 400 pounds. A review of Resident 47's record was conducted on 1/14/25. Resident 47 had an active physician's order for Bariatric low air loss mattress, set to resident weight ., ordered 3/11/24. Resident 47 weighed 233.4 pounds on 12/5/24. An interview was conducted with Certified Nurse Assistant (CNA) 31 on 1/14/25 at 9:14 A.M. CNA 31 was shown photos of Resident 47's LAL mattress pump that was taken on 1/12/25. CNA 31 stated the LAL mattress pump for Resident 47 was on the wrong setting. CNA 31 stated if the LAL mattress pump was not on the correct setting, it may cause the resident to develop a pressure injury because the mattress would be too firm. An interview with Licensed Nurse (LN) 2 was conducted on 1/14/25 at 9:52 A.M. LN 2 was shown photos of Resident 47's LAL mattress pump that was taken on 1/12/25. LN 2 stated the pump was in the incorrect setting. LN 2 stated it was important for the LAL mattress pump to be on the correct setting to prevent pressure injury. An interview was conducted with the Director of Nursing (DON) on 1/15/25 at 9:56 A.M. The DON was shown photos of Resident 47's LAL mattress pump that was taken on 1/12/25. The DON stated if the resident was on a firm mattress consistently, then the resident would not get the full benefit of being on a LAL mattress which would be to prevent pressure injury. A review of the manual for [LAL Mattress Brand] indicated .General Operation .5. According to the weight and height of the patient, adjust the pressure setting .

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents' (Resident 84) planned meal tray card (guidance to staff on what to serve for a meal to a resident) and menu was nutritionally substituted according to preferences to promote nutritional adequacy to current health status. This failure had the potential to result in a poor nutritional intake and weight loss. Cross-reference F656 Findings: 1. A review of Resident 84's Admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included a history of Chronic Kidney Disease Stage four (CKD stage 4- kidneys are moderately or severely damaged and are not properly filtering waste from your blood). A record review of Resident 84's minimum data set (MDS - a federally mandated resident assessment tool) dated 10/28/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 84 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 1/12/25 at 10:19 A.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 stated that he was a kidney patient and at the border of not having to need dialysis. Resident 84 stated that the facility was consistently serving meals that were not good for him because he was a kidney patient. Resident 84 further stated they [the facility staff] feed me trash I cannot eat such as fruits like oranges that are high in potassium (a mineral that is essential to body functions but an excess of potassium can build up with kidney disease due to the kidney's unable to remove the mineral from the body that could have harmful health effects). On 1/12/25 at 1:22 P.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 had a meal tray on his bedside table that included green peas, mashed potatoes, a bitten slice of chicken and oranges on the side. Resident 84 stated he did not like green peas, potatoes and could not eat the oranges because it is not good for my kidneys and it's on my dislikes list. Resident 84's meal tray card indicated, Dislikes .Oranges .Potatoes . On 1/14/25 at 7:46 A.M., an observation, interview and record review was conducted with Dietary Supervisor (DS) 1 and DS 2, in the conference room. DS 1 stated that they did not have an in-house Registered Dietician (RD) but have a consultant filling in for now. DS 1 stated she knew Resident 84 preferred a renal diet versus a no added salt (NAS), carbohydrate controlled (CCHO) diet. DS 1 stated she completed Resident 84's dietary evaluation titled Dietary Profile on 10/24/24 and stated that the evaluation indicated Resident 84's dislikes included, orange juice/oranges, tomatoes, fresh potatoes, spinach, peas, beef, and pork. DS 1 stated for a renal diet, Resident 84 should not be served orange juice, fresh oranges, tomatoes, fresh potatoes and spinach. DS 1 stated that it was Resident 84's preference to not be served peas, beef and pork. DS 1 and DS 2 was shown a picture of Resident 84's meal tray with the meal tray card. DS 1 and DS 2 stated that the picture looked like it was the menu that was served on Sunday 1/12/25. DS 1 stated that the kitchen and nursing staff should have looked at Resident 84's meal tray card to see Resident 84's preference list and not serve Resident 84 what was on the dislikes and prepared a menu that substituted his dislikes that was nutritionally equivalent. DS 1 and DS 2 stated not following Resident 84's preference would make him unhappy. On 1/14/25 at 8:31 A.M., an observation and interview was conducted with Resident 84, in Resident 84's room. Resident 84 was lying in bed with a meal tray on his bedside table. Resident 84 stated I received pork and toast for breakfast and pork is on my dislikes list. They [facility staff] should already know while pointing to his meal tray. Resident 84 further stated, if the facility continued to not honor his meal preferences he could loose weight in an unhealthy way. On 1/14/25 at 8:37 A.M., an observation, interview and record review was conducted with Licensed Nurse (LN) 2, in the nursing station. LN 2 stated that it was the LN's responsibility to check the trays and check their dietary sheets to make sure that the ordered diet was being served before any residents ate the food that was being served for safety. LN 2 stated that the dietary sheets are Medical Doctor (MD) orders and does not show any preferences, but the actual meal tray card does. LN 2 stated for renal/kidney orders oranges are usually not acceptable because it spikes renal [sic], spikes the blood sugar and it's rich in potassium and are not good for the kidneys. LN 2 was shown a picture of Resident 84's breakfast meal tray taken on 1/12/25. LN 2 stated that Resident 84's preferences according to his meal tray card should be honored. LN 2 stated that Resident 84 should not have been served with orange and peas because it was what Resident 84 disliked. LN 2 stated the menu should have been substituted with foods that were nutritionally adequate and honored Resident 84's preference. On 1/15/25 at 8:42 A.M., an interview and record review was conducted with the Director of Nursing (DON), in the DON's office. The DON stated his expectations was for the dietary staff to honor Resident 84's meal preferences. The DON stated that Resident 84's menu should have been substituted and followed according to nutritional equivalencies for Resident 84's dislikes with the peas, oranges and pork. The DON further stated if we don't offer nutritional alternatives for Resident 84 that complications such as weight loss can happen. A review of the facility's policy and procedure titled DIETARY PROFILE and RESIDENT PREFERENCE INTERVIEW revised 4/21/22, indicated .The Dietary Department will provide residents meals consistent with their preferences and Physician's order as indicated on the tray card. A. If a preferred item is not available, a suitable substitute should be provided .

Based on observation, interview and document review, the facility failed to follow chemical sanitation guidelines (hypochlorite/chlorine sanitizer agent), during their dishwashing process. As a result, the dishes and utensils were not properly sanitized and created the potential to cause illness in 82 facility residents and 10 residents receiving tube feedings with oral gratification. Per the Centers for Disease Control (CDC), nursing home residents are more vulnerable to developing severe/potentially life-threatening illnesses, from ingestion of hazardous microorganisms (bacteria, viruses, parasites), due to factors that include chronic disease and advanced age. The CDC identified "contaminated equipment" and lack of proper sanitation practices, as a major contributing factor to the spread of hazardous microorganisms. The facility did not follow guidelines for sanitizer agent levels in the facility ' s dishwashing practices, as established in the U.S. Food and Drug Administration's (FDA), Food Code. In addition, the facility failed to ensure that food preparation areas and refrigerator food storage bins were free of blowing dust and debris. Three circulating fans located directly above the food preparation areas were covered with dust and brown particles. A electrical wire located in the food storage refrigerator was covered in dust and black substance. Findings: 1. On 4/27/11 at 6:07 A.M., during an inspection of the kitchen, dietary aid 1 (DA) 1 was observed using a chemical strip to test the dishwasher sanitizing agent level. The strip indicated a reading of less that 10 ppm (parts per million). DA 1 repeated the test and noted a consistent less than 10 ppm reading. A joint inspection of the dishwasher was performed with DA 1, which revealed that the sanitizer agent container had approximately 1 inch of liquid in the bottom. DA 1 then conferred with the cook (cook) 1 to locate a replacement for the sanitizing agent. DA 1 stated that the facility did not have a replacement on site. On 4/27/11 at 6:17 A.M., a joint review of the facility's "Dishmachine Temperature and Sanitizing Agent Log" was conducted with DA 1. The previous night ' s, 4/26/11, sanitizer level was documented as," 50 ppm " (parts per million). In addition, there was an entry of " 50 ppm " for the future time of " dinner 4/27/11, " that had not yet occurred. Cook 1 and the assistant dietary services supervisor (ADSS) were unable to verify that the prior night 's dishes had been sanitized. A joint decision was made to manually sanitize all the breakfast dishes prior to food service. On 4/27/11 at 6:40 A.M., the dietary services supervisor (DSS) arrived with a replacement container of sanitizing agent. DA 1 proceeded to replace the empty sanitizing agent container, with continued difficulty in dispensing the sanitizing agent into the dishwasher. On 4/27/11 at 7:00 A.M., the ADSS obtained a reading of the dishwasher sanitizing agent level, which was jointly observed to read, "<10 ppm" (less than 10 parts per million), and revealed that the sanitizing agent level continued below the minimum standard of 50 ppm, per manufacturers recommendations. On 4/27/11 at 7:30 A.M., a service representative (SR) for the dishwasher performed a systems check of the machine and its respective connections. The SR addressed DA 1 and ADSS and stated that the sanitizing agent would not properly dispense due to the presence of " air in the line " (connection hose). The SR further stated that air was forced into the hose when the sanitizing agent level was close to empty, which prevented the agent from being dispensed in sufficient quantity to sanitize. The SR continued to state that the sanitizing agent had to be near empty for some time to have that much air in the line. On 4/27/11 at 11:15 A.M., an interview was conducted with dietary aid 2. (DA) 2 acknowledged he had worked until 8:00 P.M. the previous night, 4/26/11. When asked if he performed a test of the dishwasher sanitizing agent on 4/26/11, DA 2 responded, " No, I did not " . DA 2 was asked about the entries noted on the "Dishmachine Temperature and Sanitizing Agent Log" for 4/26/11 "Dinner" and 4/27/11 "Dinner". When asked, " Where did the numbers on the Log come from? ", (DA 2) replied, " I made up the numbers " . On 4/28/11 at 11:10 A.M., a review of the facility's policy and procedure entitled, "Food Services Policy" indicated, " Subject: Low Temperature Dishwashing machine Procedure Policy: To ensure that the washing of dishes is done in a sanitary manner. Procedure 1. Check detergent , sanitizer and rise additive containers. Replace any which are empty." During a kitchen observation on 4/27/11 at 6:07 A.M., it was noted that no sanitizing agent was delivered to the dishwasher. The service representative noted that air had entered the hose connection line between the dishwasher and the sanitizing agent container, and that the dishes could not have been sanitized for some time. However, the facility ' s "Dishmachine Temperature and Sanitizing Agent Log", indicated that the minimum sanitizing level of 50 ppm, had been recorded for the night of 4/26/11. Dietary staff could not confirm that the dishes that were to be used for breakfast on 4/27/11, had been properly sanitized. On 4/27/11 at 12:35 P.M., an Immediate Jeopardy was called and the facility administrator, dietary services supervisor and assistant dietary services supervisor were informed. The Immediate Jeopardy was abated at 3:30 P.M. on 4/27/11, with a plan of correction in place, and the facility administrator, dietary services supervisor and assistant dietary services supervisor were informed. The facility ' s plan of correction was as follows: " It is the intent of the facility to store, prepare, and disinfect and serve food under sanitary conditions. - All plates, silverware, bowls were immediately soaked in hot water with bleach prior to serving breakfast. - The empty sanitizing agent container was replaced - In service training provided by SR representative regarding the procedure of replacing and changing the sanitizing agent bottles and calibrating the equipment - In service was given by the dietary supervisor to the dietary staff regarding the policy and procedure in sanitizing dishes and utensils. - Specific 1:1 in-service and counseling was given by the dietary manager to DA 2 regarding the policy and procedure in sanitizing dishes and utensils and proper documentation - Dietary manager or designee will monitor water temperature and PPM testing by DA 2 for 3 consecutive tests to ensure in-service and counseling was effective. - Policy revised so that 2 kitchen personnel will verify water temperature and PPM test strip after each meal. - Policy revised so that dietary supervisor will monitor the accuracy of the log and assure 2 staff verify temperature and PPM after each meal - Water temperature log and PPM will be reported to QA each month for trends. " 2. On 4/28/11 at 9:08 A.M., observations of a food prep area and in the walk in refrigerator were made during a kitchen inspection. Two high-mounted wall fans were observed to be visibly dusty and blowing in the direction of a clean food preparation table. One high-mounted wall fan was observed to be visibly dusty and blowing in the direction of the clean dish rack and the dishwasher. Observations made in the walk in freezer revealed a sagging wire and [MEDICATION NAME] tubing that were visibly coated with a rust colored substance, and a wet-appearing black substance, as well as being visibly dusty. The dietary supervisor and maintenance director acknowledged the equipment were not maintained a clean condition.