Every finding on record at Burlington Convalescent Hospital

Based on observation, interview, and record review, the facility failed to make reasonable efforts to accommodate and timely respond to one of five sampled residents (Resident 1), request for a room change and failed to document Resident 1's request and the facility's actions in the medical record, in accordance with facility policy.This failure resulted in Resident 1 remaining in an environment that increased her anxiety due to disruptive behaviors exhibited by neighboring residents.During a review of Resident 1's admission Record, dated 7/28/2026, indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 5/18/2026, indicated Resident 1 had severely impaired cognition (ability to think, remember and reason) for daily decision making. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating, maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, and was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair to bed transfers. During an observation on 7/28/2026 at 11 AM, in Resident 1's room, Resident 1 was observed laying down in her bed, with head of bed elevated. Resident 1 was unable to provide details about her current living situation, and stated she spoke Spanish. Resident 1 was not interview able at the time of the survey. During a phone interview on 7/28/2026 at 12 PM with Resident 1's Family Member 1 (FM1), FM1 stated he had requested a room change for Resident 1 more than one week earlier because her roommate frequently yelled and another resident across the room also yelled, causing Resident 1 significant anxiety (Persistent feeling of dread or panic that can interfere with daily life). FM1 stated staff was aware of the residents who yell frequently, and he notified Social Services Director (SSD) about a room change request, but was told that no rooms were available, and no other efforts on behalf of the staff were made to accommodate Resident 1's request. During a review of the facility's daily census dated 7/28/2026, the census indicated the facility had two vacant female beds available on 7/28/2026. During an interview on 7/28/2026 at 11:52 AM with Licensed Vocational Nurse 1 (LVN1), LVN1 stated that Resident 2 had a history of depression, and she frequently yelled and cried because she was upset her family does not visit her. The LVN 1 stated when Resident 2 yells, it triggers Resident 1's roommate to start screaming as well. During an interview on 7/28/2026 at 12:06 PM with the SSD, the SSD acknowledged Resident 1 had requested a room change about two weeks ago, confirmed that rooms were available on 7/28/2026, and admitted the request and any follow-up actions had not been documented in the resident's medical record. The SSD stated that Resident 1's requested room change had not been completed because she was waiting for a room to become available with a Spanish-speaking roommate. The SSD acknowledged Resident 1's current roommate primarily spoke Korean, and that a shared language had not been a factor in determining Resident 1's current room assignment. The SSD acknowledged Resident 1 had severely impaired cognition and that she had failed to document the reason for delaying the requested room change, as well as failed to meet Resident 1's request in a timely manner, and had not offered Resident 1 any of the available rooms at the time of the survey. During an interview on 7/28/2026 at 12:44 PM with the Administrator, he verified that he was not aware of the situation with Resident 1, but accommodations for resident requests and staff documentation should be provided by staff as best possible. The Administrator stated if staff have issues doing so, this should be communicated to the DON and or himself. During an interview on 7/28/2026 at 1:14 PM with the Director of Nursing (DON), the DON stated she was unaware of Resident 1's room change request, and stated when a resident requests a room change, the request is communicated to the Administrator and or the DON. The DON stated that an interdisciplinary team (IDT) meeting is held to discuss the request and that the facility strives to accommodate resident's needs and complete room changes as soon as possible, when feasible. Any refusals or requests should be documented in progress notes to ensure staff is well aware of the resident's requests and that requests are followed up by staff. Failure to do so placed residents at risk for unmet needs. During a review of the facility's policy and procedures titled Room Change/Roommate Assignment dated 3/2021, indicated changes in room or roommate assignment are made when the facility deems it necessary or when the resident request the change. Resident preferences are taken into account, residents have the right to share a room with their roommate of choice, and documentation of a room change is recorded in the resident's medical record. Inquiries concerning room changes should be referred to the administrator.

Based on observation, interview, and record review, the facility failed to notify the physician regarding a significant change in condition for one of three sampled residents (Resident 1), who refused to continue dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) treatment and verbalized a desire to die.This failure resulted in delayed physician evaluation, psychiatric intervention, and implementation of medically necessary treatment and safety measures.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and depression (a mood disorder that may cause persistent sadness or loss of interest in activities).During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 3/9/2026, indicated Resident 1 had severely impaired cognition (ability to think, remember and reason, the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, putting on and taking off footwear, rolling left and right, sit to lying, lying to sitting in bed, sit to stand, and chair to bed transfers. Resident 1 required maximal assistance for upper body dressing, oral hygiene, and personal hygiene. Resident 1 required supervision for eating.During a review of Resident 1's nursing progress notes dated 5/20/2026, indicated the dialysis center reported to the facility that on 5/20/2026 Resident 1 refused to finish his dialysis treatment and verbalized statements indicating a desire to die. The progress note indicated that the facility nurse made physician aware of the resident's refusal of dialysis treatment.During a concurrent observation and interview on 5/21/2026 at 11:19 AM, Resident 1 lay down in his room wearing a gown, covered with blankets, had a flat affect, made poor eye contact, and had limited verbal engagement. Resident 1 appeared lethargic, stated he was sleepy and did not care about anything anymore. When I tried to engage with him and ask him questions his response was I don't care.During an interview on 5/21/2026 at 11:48 AM with Licensed Vocational Nurse 1 (LVN1), the LVN1 stated Resident 1 had a history of depression, refused to eat breakfast and lunch, and refused to take his medications in the morning.During an interview on 5/21/2026 at 12:55 PM with the Minimum Data Set (MDS) nurse, the MDS nurse verified Resident 1 had a diagnosis of depression upon admission to the facility. The MDS nurse stated antidepressant medication had been ordered; however, the medication was being held because Resident 1 was unable to provide consent and refused medications. The MDS nurse stated Resident 1 did not have a responsible party who could make health care decision for him; however in such cases the facility's Medical Director and Interdisciplinary Team members could sign off on providing necessary treatment. The MDS nurse verified there was no active Care Plan or new Physician orders in place since Resident 1's return from the hospital on 5/18/2026, to address Resident 1's depression or non-pharmacological interventions to address the resident's psychosocial needs and depressive symptoms.During a phone interview on 5/21/2026 at 1:54 PM with the Attending Physician (AP), the AP stated he was not notified that Resident 1 had refused dialysis or verbalized a desire to die. The AP stated that if he had been notified, he would have ordered a psychiatric consultation, ordered a repeat dialysis treatment, and considered transfer to the hospital for further evaluation and treatment.During an interview on 5/21/2026 at 2:33 PM with the Director of Nursing (DON), the DON stated failure to notify the AP placed Resident 1 at risk for complications related to his dialysis in depression, such as fluid overload and weight loss. The DON stated it is the responsibility of the licensed nurses to update the Care Plan as needed and when residents have a change in condition.During a review of the facility's policy and procedure titled Change in a Resident's Condition or Status dated 2/2021, indicated the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical, emotional, and mental condition. A significant change of condition is a major decline in the residents' health that will not normally resolve itself without intervention by staff or by implementing clinical interventions. A significant change of condition requires interdisciplinary review and revision of the Care Plan.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) to address diagnosis of depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of treatment, and non-pharmacological interventions for mood and behavioral symptoms.This failure had the potential to place the resident at risk for worsening depression, psychosocial decline, nutritional compromise, and lack of appropriate mental health interventions.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and depression.During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 3/9/2026, indicated Resident 1 had severely impaired cognition (ability to think, remember and reason, the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, putting on and taking off footwear, rolling left and right, sit to lying, lying to sitting in bed, sit to stand, and chair to bed transfers. Resident 1 required maximal assistance for upper body dressing, oral hygiene, and personal hygiene. Resident 1 required supervision for eating. The MDS indicated Resident 1 had little interest or pleasure in doing things and was feeling down, depressed, or hopeless.During a concurrent observation and interview on 5/21/2026 at 11:19 AM, Resident 1 lay down in his room wearing a gown, covered with blankets, had a flat affect, made poor eye contact, and had limited verbal engagement. Resident 1 appeared lethargic, stated he was sleepy and did not care about anything anymore. When I tried to engage with him and ask him questions his response was I don't care.During an interview on 5/21/2026 at 11:48 AM with Licensed Vocational Nurse 1 (LVN1), the LVN1 stated Resident 1 had a history of depression, refused to eat breakfast and lunch, and refused to take his medications in the morning.During an interview on 5/21/2026 at 12:55 PM with the Minimum Data Set (MDS) nurse, the MDS nurse verified Resident 1 had a diagnosis of depression upon admission to the facility. The MDS nurse stated antidepressant medication had been ordered; however, the medication was being held because Resident 1 was unable to provide consent and refused medications. The MDS nurse stated Resident 1 did not have a responsible party who could make health care decision for him; however in such cases the facility's Medical Director and Interdisciplinary Team members could sign off on providing necessary treatment. The MDS nurse verified there was no active Care Plan or new Physician orders in place since Resident 1's return from the hospital on 5/18/2026, to address Resident 1's depression or non-pharmacological interventions to address the resident's psychosocial needs and depressive symptoms.During an interview on 5/21/2026 at 2:33 PM with the Director of Nursing (DON), the DON stated it is the responsibility of the licensed nurses to update the Care Plan as needed to provide residents with interventions to manage their health problems.During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/2023, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The IDT team reviews and updates the care plan when there is a significant change in the resident's condition, when the desired outcome is not met, when resident has been readmitted to the facility from a hospital stay and at least quarterly in conjunction with the required MDS assessment.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of three residents (Resident 1) by failing to obtain timely psychiatric evaluation and intervention for Resident 1 exhibiting depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to), and verbalizations indicating a desire to die.This failure placed Resident 1 at risk for worsening mental health status, self-neglect, decline in medical condition, and avoidable harm.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and depression (a mood disorder that may cause persistent sadness or loss of interest in activities).During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 3/9/2026, indicated Resident 1 had severely impaired cognition (ability to think, remember and reason, the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, putting on and taking off footwear, rolling left and right, sit to lying, lying to sitting in bed, sit to stand, and chair to bed transfers. Resident 1 required maximal assistance for upper body dressing, oral hygiene, and personal hygiene. Resident 1 required supervision for eating.During a review of Resident 1's nursing progress notes dated 5/20/2026, indicated the dialysis center reported to the facility that on 5/20/2026 Resident 1 refused to finish his dialysis treatment and verbalized statements indicating a desire to die. The progress note indicated that the facility nurse made physician aware of the resident's refusal of dialysis treatment.During a review of Resident 1's Order Summary, no active orders were found to address Resident 1's depression.During a concurrent observation and interview on 5/21/2026 at 11:19 AM, Resident 1 lay down in his room wearing a gown, covered with blankets, had a flat affect, made poor eye contact, and had limited verbal engagement. Resident 1 appeared lethargic, stated he was sleepy and did not care about anything anymore. When I tried to engage with him and ask him questions his response was I don't care.During an interview on 5/21/2026 at 11:48 AM with Licensed Vocational Nurse 1 (LVN1), the LVN1 stated Resident 1 had a history of depression, refused to eat breakfast and lunch, and refused to take his medications in the morning due to being depressed.During an interview on 5/21/2026 at 12:55 PM with the Minimum Data Set (MDS) nurse, the MDS nurse verified Resident 1 had a diagnosis of depression upon admission to the facility. The MDS nurse stated antidepressant medication had been ordered; however, the medication was being held because Resident 1 was unable to provide consent and refused medications. The MDS nurse stated Resident 1 did not have a responsible party who could make health care decision for him; however, in such cases the facility's Medical Director and Interdisciplinary Team members could sign off on providing necessary treatment. The MDS nurse verified there was no active Care Plan or new Physician orders in place since Resident 1's return from the hospital on 5/18/2026, to address Resident 1's depression or non-pharmacological interventions to address the resident's psychosocial needs and depressive symptoms. The MDS nurse verified Resident 1 had not been monitored sinceDuring a phone interview on 5/21/2026 at 1:54 PM with the Attending Physician (AP), the AP stated he was not notified that Resident 1 had refused dialysis or verbalized a desire to die. The AP stated that if he had been notified, he would have ordered a psychiatric consultation, ordered a repeat dialysis treatment, and considered transfer to the hospital for further evaluation and treatment.During an interview on 5/21/2026 at 2:33 PM with the Director of Nursing (DON), the DON stated failure to notify the AP placed Resident 1 at risk for complications related to his dialysis in depression, such as fluid overload and weight loss. The DON stated it is the responsibility of the licensed nurses to update the Care Plan as needed and when residents have a change in condition.During a review of the facility's policy and procedure titled Depression dated 3/2023, indicated the nurse shall assess and document reports of suicidal ideation, whether mood decline is associated with anorexia, crying, sleeplessness. The physician will evaluate underlying causes of mood disorder, depression, and contributing factors. The physician will identify the need for additional testing or psychiatric consultation. The staff will provide pertinent individualized non-pharmacological interventions for the individual with depression addressing psychological, spiritual, and family issues. The physician will identify and order appropriate non-pharmacological and pharmacological interventions based on preceding assessments. The staff and physician will monitor the resident/patient

Based on observation and interview, the facility failed to ensure kitchen staff labeled all foods stored in the refrigerator and freezer with the correct food name, date of food delivery, date the food container was opened, and best by date. This deficient practice of not correctly labeling all foods stored in the refrigerator and freezer had the potential for residents who consume food from the kitchen to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and hospitalization Findings: During an observation in the kitchen on 5/11/2026 at 7:55 AM, several food items and drinks in the refrigerator and freezer were not labeled as follows:Iceberg lettuceClear drinks (appeared to be water)CilantroFrozen food in red color in dessert cups (unable to identify what it is)White colored drinks (appeared to be milk). During a concurrent observation and interview on 5/11/2026 at 8:12 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), when asked why several food items and drinks in the kitchen refrigerator and freezer were not labeled, DSS stated, I don't know. I gave them (staff) in-service on labeling. I told them (staff) over and over about labeling. But they still did not label all the foods. DSS stated the food labeling is important so staff will know if the food is still good to consume and to prevent infection, and risk of food poisoning. According to DSS, the potential harm that may come to all residents is risk of choking likely lead to death and risk of poison and infection. During an interview on 5/12/2026 at 8:47 AM with the dishwasher (DI), DI stated, it is important to have labels on all foods so we know if food is okay to eat or to throw away because it's bad to eat it. DI also stated that when residents consume unlabeled food, the residents are at risk to have tummy ache.might get diarrhea, vomiting, they might to go the hospital if the illness is very bad. During an interview on 5/12/2026 at 9:52 AM with the dietary cook (DC), DC stated food labels are important because, we don't want to give the residents expired foods because it's bad for their stomach, they will get sick. DC also stated that the potential harm that may come to the residents, they will go to the bathroom a lot, you know to poop. They will have stomach pains. They will vomit. A review of the facility's in-service education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) on Dating and Labeling dated 1/22/2026, 2/25/2026 and 4/16/2026 indicated all kitchen staff were in-serviced when to date and label each food item. A review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Dating and Labeling with a revision date of 4/2025, indicated, all items should be properly covered, dated, and labeled and that food items should have the delivery date, open date, and thaw date labeled on each food item. The P&P also indicated that the staff should be trained on the importance of food labeling.to maintain food safety.

Based on interview and record review, the facility failed to ensure that two out of two residents (Resident 5 and Resident 45) did not sign Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Resident 5 and Resident 45 had severe cognitive (the mental ability to make decisions of daily living) impairment. This deficient practice violated Resident 5 and Resident 45's rights with the potential to cause conflict with the residents healthcare wishes.Findings: During a review of Resident 5's admission Record, the admission record indicated the facility admitted the resident on 1/10/2018 with diagnoses that included but not limited to cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 4/2/2026, the MDS indicated Resident 5 had severe cognitive ) impairment. The MDS indicated Resident 5 needed supervision/touching assistance for eating, maximum staff assistance with activities of daily living (ADL) including, personal hygiene, upper body dressing and oral hygiene, dependent on staff for toileting hygiene, showering, upper body, sitting to lying and lying to sitting). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had severe cognitive impairment. The MDS indicated Resident 5 needed limited staff assistance with personal hygiene, toilet use dressing, bed mobility and transfer bed/chair/wheelchair and supervision for eating and oral hygiene. During a review of Resident 5's Advanced Directive dated 7/25/20245, the Advanced Directive indicated, Resident not capable to make decisions at this time. Advanced Directive indicated to refer to Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an Advance Directive). During a review of Resident 5's POLST dated 1/16/2018, the POLST indicated Resident 5 signed the POLST on 1/17/2018. The POLST indicated Do attempt Resuscitation (Not to attempt an emergency life-saving procedure used when someone is not breathing or heartbeat stopped, allowing natural death), Comfort Focused Treatment (in case of emergency focus on pain relief and reduce suffering instead of using any drastic life saving measures)primary goal is to prolong life), no long term artificial nutrition including feeding tubes (medical device used to deliver nutrition and medications in liquid form). During a review of Resident 45's admission Record, the admission record indicated the facility admitted the resident on 1/26/2016 and readmitted on [DATE] with diagnoses that included but not limited to hemiplegia and aphasia (a disorder that makes it difficult to speak).During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 45 needed limited staff assistance with eating and moving around in room and in facility corridor, extended assistance for bed mobility, transfer bed/chair/wheelchair, personal hygiene and toileting. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment. The MDS indicated Resident 45 needed maximum staff assistance with personal hygiene, toileting and shower, partial/moderate assistance with ADL of, lower body dressing, oral hygiene, sit to stand and chair/bed transfer, walking 50-150 feet and supervision/touching assistance for eating, upper body assist, sitting to stand, lower body dressing and putting/taking off footwear. During a review of Resident 45's Advanced Directive dated 1/14/2025, the Advanced Directive indicated, Resident not capable to make decisions at this time. Advanced Directive stated to refer to Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST form is not an Advance Directive). During a review of Resident 45's POLST dated 8/17/2017, the POLST indicated Resident 45 signed the POLST on.9/21/2016. POLST indicated, attempt Resuscitation (an emergency life-saving procedure used when someone is not breathing or heartbeat stopped), Full Treatment (in case of emergency provide all medically effective means to prolong life, primary goal is to prolong life), long term artificial nutrition including feeding tubes (medical device used to deliver nutrition and medications in liquid form). During a concurrent interview and record review with Medical Data Sheet Nurse (MDS - nurse responsible to complete a resident assessment tool for all residents in the facility on 05/14/2026 at 10:19 am, Resident 5 and Resident 45's the Advanced Directive and POLST were reviewed). MDS stated and confirmed that both Resident 5 and Resident 45 didn't have capacity to understand the Advanced Directive and POLST upon admission. MDS stated that Resident 45 didn't have any family member that could have been contacted and that Resident 5 has a family member listed as an emergency contact. MDS stated that the POLST for Resident 5 and Resident 45 signed a few years ago and could not remember if the facility contacted the residents' family members. During a concurrent interview and record review with MDS on 05/14/2026 at 11:14 am Resident 5 and Resident 45's Advance Directive and POLST was reviewed, MDS stated, We would follow this POLST in emergencies. We really don't know what is their (resident's) choice or not. Family member can back up what resident's wishes are. It's not appropriate for residents to sign a consent when they don't have capacity [NAME] make decisions., We (facility) should make sure if resident has power of attorney (POA - a legal document that authorizes a trusted person to make decision or act on behalf of someone)) or any other legal document when they are admitted before having them sign anything, or any relative or emergency contact is available to help with signing POLST or other forms if resident is not able to due to cognitive impairment. During an interview on 05/14/2026 at 12:37 pm, Director of Nursing (DON) stated that Resident 5 and Resident 45 didn't have the capacity to make decisions or sign a POLST. DON stated that, Its not a good standard of practice, it effect resident's rights and preferences, we didn't give them right. According to our process, we get POLST signed as soon as resident is admitted , we involve family if resident not cognitive capable of signing. We need to have a family meeting and resident to see their POLST. If resident's family not there then social services should find a legal guardian or conservative. During a review of the facility's policy and procedures (P&P) titled, Advance Directive, reviewed 3/17/2026, P&P indicated, If the resident is incapacitated and unable to receive information about his or her rights to formulate an advance directive, the information may be provided to the resident's legal representative.

Based on observation, interview, and record review, the facility failed to securely store and dispose off personal health identifiable (PHI - any health-related data that can directly or indirectly trace back to a specific individual) information was stored securely and disposed after admission from a general acute care hospital (GACH) visit for one of one (Resident 129). The deficient practice had the potential to result in a breach protected PHI and medical identity theft, targeted financial fraud, and alterations to personal medical records for Resident 129's. Findings: A review of Resident 129's admission record indicated Resident 129 was admitted to the facility on [DATE], with diagnoses that include end stage renal disease (severe phase of kidney (organ that filters bodily waste) disease where your kidneys permanently lose about 85 percent (%- unit of measurement) to 90% of their function, leaving them unable to filter waste and excess fluid from the blood), fracture (crack or break in one of the bones) of left pubis (bone of the hip), hypertension (high blood pressure), cognitive communication deficit (communication impairment affecting memory, attention, or executive function), toxic encephalopathy (brain dysfunction, damage, or malfunction caused by exposure to poisonous or neurotoxic substances), history of falling and dependence on dialysis (medical treatment that filters waste products, toxins, and excess fluid from the blood when the kidneys are no longer functioning properly). A review of Resident 129's history and physical (H&P) dated 5/11/2026 indicated Resident 129 has the capacity to understand and make decisions. During a tour on 5/11/2026 at 11:06 a.m., a bracelet with Resident 129's identifiable health information (name, age, sex, date of birth , date of admission, medical record number, visitation number) from the GACH visit was observed on top of Resident 129's bedside drawer. During an interview on 5/11/2026 at 11:09 a.m., infection prevention nurse (IPN) stated the patient identification bracelet was from Resident 129's recent acute care visit prior to admission to the facility. IPN stated leaving a Residents personal information at bedside could result in a medical data breach (unauthorized actors access, steal, or disclose sensitive PHI and violation of Health Insurance Portability and Accountability Act (HIPAA- a federal law passed in 1996 that sets the national standard to protect sensitive patient medical information and dictates how healthcare organizations must handle, store, and share that data). During an interview on 5/14/2026 at 3:29 p.m., the Director of Nursing (DON) stated patient personal identifiable information must be kept confidential, secured and is used only through authorized access as part of medical records. DON stated unsecured access to personal health information (PHI) can result in nefarious breach (unethical violation of patient privacy or data security). The facility's policy and procedures (P&P) titled Protected Health Information (PHI), Management and Protection of dated 3/17/2026, indicated, it is the responsibility of all personnel who have access to Resident and facility information t ensure that such information is managed and protected to prevent unauthorized release or disclosure. The facility's P&P titled Resident Rights dated 3/17/2026, indicated, the unauthorized release, access, or disclosure of resident information was prohibited and must be in accordance with current laws governing privacy information issues.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one out of one resident (Resident 110). This deficient practice had the potential for Resident 110 to experience low self esteem and not appreciated. Findings: During a review of Resident 110's admission Record, the admission record indicated the facility admitted the resident on 3/25/2026 with diagnoses that included but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 110's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 110 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 110 needed partial/moderate staff assistance with activities of daily living (ADL- including upper body assist and personal hygiene, set up/cleaning assistance for eating and dependent on staff for toileting lower body dressing, hygiene, showering). During an observation on 5/11/2026 at 12:13 pm, Resident 110 was observed lying in bed. An uneven brown splash stain observed on the wall right in front of the resident's bed and within Resident 110's line of sight. Resident 110 not aware the origin of stain and how long stain has been on the wall. During a concurrent observation and interview on 5/12/2026 at 2:05 pm with Infection Prevention Nurse (IPN) in Resident 110's room, the uneven brown splash stain was observed on the wall right in front of the resident's bed. IPN stated, I don't know what this stain is from, it could be anything. Yes, the stain is right in front of the resident. This is resident's home, with her room not being clean resident wouldn't feel like it her home.During a concurrent interview on 5/14/2026 at 12:55 pm with Director of Nursing (DON), DON stated, This stain could be anything, blood, bowel (stool/feces), feeding, coke or anything. It can make resident not feel like at home. This is resident's home so they should feel like a clean home. During a review of the facility's policy and procedures (P&P) titled Homelike Environment revised on 3/17/2026, the P&P indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Those characteristics may include clean, sanitary and orderly environment.

Based on interview and record review, the facility failed to ensure facility staff provided an accurate medical concern description to an optometrist (OPT - a primary healthcare professional who specializes in eye and vision care) when Resident 101's eyeglasses were missing for of one of four residents' (Resident 101) . This deficient practice resulted in Resident 101 complaining that without his eyeglasses, his eyes would get wet, it was very hard to see or do anything, he could not read and loves to read. Findings: During a review of Resident 101's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 101 was admitted to the facility on [DATE] with the following diagnoses: hypercapnia (a condition where there is an abnormally high level of carbon dioxide in the bloodstream), hypercalcemia (a condition where the calcium level in your blood is abnormally high that can lead to weakened bones, kidney stones, and severe heart or neurological complications if left untreated), pressure ulcer of left buttock, stage 2, hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time with heart muscle not able to pump enough blood for the body's needs), reduced mobility (any temporary or permanent physical, sensory, or cognitive condition that limits a person's ability to move, travel, or navigate environments freely), generalized muscle weakness (lack of physical or muscle strength), hyperparathyroidism (a condition where one or more of the parathyroid glands [regulate the body's calcium levels, which are critical for nerve and muscle function, bone health, and blood clotting] become overactive and produce too much parathyroid hormone [PTH - primary function is to strictly regulate and maintain the balance of calcium and phosphorus in your blood, which is essential for healthy bones, nerves, muscles, and heart function], asthma (a lung disease that causes the airways to swell, narrow, and fill with mucus, leading to difficulty breathing, wheezing, coughing, and chest tightness), and metabolic encephalopathy (a general term that describes a brain disease, damage or malfunction; brain function is disturbed). During a review of Resident 101's history and physical (H&P - a physician's complete patient examination) dated 11/22/2205 indicated, Resident 101 did not have the capacity to make medical decisions and could not make needs known. The H&P also indicated Resident 101's overall vision and eye health was normal. During a review of the facility's In-Service Education (a professional development for workers aimed to enhance skills, knowledge, and competence to improve job performance) sign-in sheet dated 2/10/2026 indicated, an in-service education course on Special Needs of Resident: Blindness and Deafness was provided. The in-service course content included common challenges for blindness and visually impaired residents were mobility, personal care, navigating the environment and communication. During a review of Resident 101's optometry exam (comprehensive test that includes visual exams, diagnoses, and treatment plans) dated 2/13/2026 indicated, an OPT conducted a visual exam one Resident 101 and that the OPT recommended reading glasses for Resident 101. During a review of Resident 101's Minimum Data Set (MDS - a resident assessment tool) dated 2/26/2026, indicated, Resident 101 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS indicated, Resident 101 had impaired vision, sees large print but not regular print in newspapers or books, and wore corrective lenses (eyeglasses). The MDS also indicated, Resident 101 needed substantial or maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to urinary and bowel incontinence (lack of voluntary control over urination or bowel movement). During a review of Resident 101's Acknowledgement of Receipt of Eyeglasses dated 4/07/2026, glasses were received and signed for by Social Services Assistant (SSA). During a review of Resident 101's physician progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 5/04/2026, indicated, Resident 101's overall vision and eye health was normal. During a review of SSA's email dated 5/11/2026 at 10:05 AM addressed to OPT, indicated, [Resident 101] lost the glasses and that the resident's prescribed eye glasses were received on 4/07/2026. SSA email further indicated that Resident 101 stated that the eye glasses are too blurry and unable to see with the eye glasses. During a review of SSA's notes dated 5/11/2026 at 3:49 PM, the SSA notes indicated that Resident 101 visited SSA's office and notified SSA that her (Resident 101's) eyeglasses were missing. The SSA note also indicated that on 5/08/2026, the OPT's office was notified of the missing eye glasses via email. During a review of Resident 101's SSA notes dated 5/14/2026 at 9:41 AM, the SSA notes indicated that SSA called the OPT's office to inquire about a scheduling exam appointment for a vision Resident 101 because Resident 101's previous eyeglasses got lost. The SSA notes indicated that Resident 101 visual exam appointment was scheduled between 5/25/2026 and 5/29/2026, and Resident 101 was notified of the appointment date. During a review of Resident 101's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on impaired ambulation (act of walking) initiated on 11/24/2025 and with a target date of 5/27/2026, indicated, Resident 101 has impaired visual functioning related to aging and resident wears glasses. The CP goal indicated Resident 101 will minimize the risk of injury related to visual impairment daily. The CP interventions included optometrist/ophthalmologist consult as needed. During an interview on 5/12/2026 at 1:24 PM with Resident 101, Resident 101 stated, my eyeglasses are bifocal (distance and reading) and transition (lens tinting- changing from clear to dark in the sun) which he has had for 2.5 years. This is my only glasses. I wear it on a regular basis, every day, all day until I go to bed. I cannot see well without them. Resident 101 stated he noticed that the eyeglasses were missing on 5/07/2026. Resident 101 stated he tried to notify SSA on the same da 5/07/2026y, but SSA was not working on that day. Resident 101 stated that on 5/08/2026, he visited SSA in SSA's office and told SSA that his eyeglasses were missing. Resident 101 stated that his eyeglasses were never found after an exhaustive search. Resident 101 stated I can see a little bit without my glasses but it's very hard to see anything and then after a while, my eyes get wet that's why I need my glasses. It's difficult to do anything without it (eyeglasses). I love reading and now I cannot read. Resident 101 stated a pair of reading glasses was made available to her around April 2026 was no good. They are too blurry for me. They are only for reading. I can't read my books with those [glasses]. During a concurrent interview and record review with SSA on 5/13/2026 at 2:47 PM, SSA email dated 5/11/2026 timed at 10:05 a.m. was reviewed. SSA stated Resident 101 told SSA that Resident 101's eyeglasses were lost (missing). SSA stated Resident 101's eyeglasses were in Resident 101's nightstand and which disappeared on Thursday, 5/07/2026. SSA stated that SSA told Resident 101 that SSA will call the OPT office to schedule an visual exam appointment. SSA stated that per SSA's email to OPT dated 5/11/2026 at 10:05 a.m. indicated Resident 101 needed a replacement eyeglasses because [Resident 101] stated they (eyeglasses are too blurry she is unable to see with. SSA re-read SSA's email again and then stated, I think I got it mixed up with the other one. SSA explained that Resident 1 had two glasses: one eyeglasses that was missing and uses that every day and the other eyeglasses [Resident 101] cannot use because it's too blurry for Resident 101. SSA stated that SSA did not accurately communicate with OPT about the reason for replacing eyeglasses, SSA stated that Resident 101, cannot see, could fall and get fractured hands, legs, head, could hurt self while transferring to the bed or going to the restroom, and trouble seeing staff. During a phone interview on 5/14/2026 at 9:26 AM with the OPT office Receptionist (REC), REC stated and confirmed that Resident 101's visual exam appointment will be between 5/2/2026 and 5/29/2026. REC also stated and confirmed that the facility received Resident 101's reading glasses on 4/07/2026 and that Resident 101 was seen by the optometrist on 2/13/2026. During a follow up interview on 5/14/2026 at 10 AM with SSA, SSA Resident 101's quality of life while waiting for the replacement eyeglasses to arrive would be difficult.because [Resident 101] likes to read.eyes become watery.difficult to be around activities, move around the bed, use the phone to play games, [Resident 101] likes playing games on the phone. During an interview on 5/14/2026 at 4:21 PM with the Director of Nursing (DON), the DON stated SSA should have included in SSA's email about Resident 101's eyeglasses were missing, and not blurry. DON stated Resident 101 was unable to see the surroundings well without eyeglasses, which might limit Resident 101's movement around the facility for fear of falling or getting hurt and that the facility are not meeting Resident 101's psychosocial needs. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Visually Impaired Resident, Care of with a revision date of 3/17/2026, indicated, It is the facility's responsibility to assist the resident.in scheduling appointments and ensuring arrangements to obtain needed services.

Based on interview and record review, the facility failed to supervise and monitor and immediately attend to residents' meal carts to ensure that one of one sample resident (Resident 54) did not access meal carts that had left over foods and drinks. Resident 54 has a history of dysphagia (difficulty swallowing). This deficient practice placed Resident 54 at increased risk for aspiration (accidentally inhaling food or liquids which can lead to infection), hospitalization, and death.Findings: During a review of Resident 54's admission Record, the admission record indicated the facility admitted the resident on 3/2/2026 with diagnoses that included but not limited to severe protein-calorie malnutrition (potentially life-threatening condition caused by an inadequate intake of protein, calories and other macronutrients) and dysphagia.During a review of Resident 54's Minimum Data Set (MDS-a resident assessment tool) dated 4/2/2026, the MDS indicated Resident 54 had moderate cognitive impairment. The MDS indicated Resident 54 needed partial/moderate assistance for activities of daily living (ADL) including, personal hygiene, upper body dressing, oral hygiene, toileting hygiene, showering, upper body, sitting to lying and lying to sitting. During an observation and concurrent interview on 05/11/2026 at 1:32 pm, two meal tray carts (with multiple meal trays in it) were observed in the hallway outside the facility kitchen, the kitchen doors were closed, and no staff was present/seen in the around/near the kitchen hallway and where the meal carts were located. The meal carts had residents' eaten leftover food on the meal trays. Resident 54 who was ambulating (walking) in the hallway outside the kitchen area, picked up cup of 4 ounces of milk (cover with a lid) from one of the meal carts. Resident 54 then walked towards his room. When the writer asked Resident 54 regarding the milk, the resident didn't respond and kept walking towards resident's room. The writer informed Certified Nurse Assistant (CNA) 3 who then stopped Resident 54 and asked Resident 54 about the cup of milk that resident had, Resident 54 gave the cup of milk back to CNA 3.During an interview on 05/11/2026 at 2 pm, with CNA 3, CNA 3 stated that Resident 54's intention was possibly to drink the 4 ounces of milk. CNA 3 stated, it is not safe for residents to have access to the leftover food from the meal cart outside of kitchen. During an interview on 5/13/2026 at 1:07 pm, Interviewed Speech Therapist (ST - a licensed health care professional who diagnose and treat patients with problems like speech difficulties, cognitive and swallowing disorders), ST stated, Resident (Resident 54) is nil per oral (NPO -no eating or drinking by mouth), has diagnosis of dysphagia. If residents had drunk the milk, he would have aspirated. I educated the resident about aspiration precautions. ST stated that Resident 54 has a gastric tube (G tube -flexible tube that is used to provide food/nutrition/hydration and medication in liquid form) which was placed around 1/26. ST stated that Resident 54 was agreeable to NPO status. ST stated that Resident 54, told me he was hungry; I told Registered dietician (RD) to adjust his G-tube feeding. ST stated that RD increased the G-tube feeding to 65 milliliters (ml-unit of measurement) per hour (ml/hour). ST stated that Resident 54 is at risk of silent aspiration (aspiration without typical aspiration symptoms like coughing or any kids of discomfort) and pneumonia (lung infection) because the milk/food would enter into Resident 54's lungs, and the resident would be hospitalized .During an interview on 5/13/2026 at 12:50 pm with RD, RD stated, (Resident 54) is NPO, on G-tube diet. He has a history of dysphagia. If resident with dysphagia drinks milk, he can aspirate. RD stated that the nursing staff bring the dirty food trays/carts and leave them outside the kitchen after residents are done with their meals. RD stated that dietary staff then bring the meal trays/carts inside the kitchen area right after the meal carts are brought to the kitchen by the facility staff and then start cleaning them. Food is not safe in dirty trays for any resident to eat. Residents shouldn't have access to the leftover food in meal trays.During an interview on 5/14/2026 at 12:59 pm with Director of Nursing (DON), DON stated that since Resident 54 can't swallow (dysphagia), the resident is at risk of aspiration and hospitalization due to aspiration pneumonia. DON stated that if residents have access to leftover food in the unsupervised trays, residents can ingest food they are allergic to which can cause allergic reactions in residents. During a review of the facility's policy and procedures (P&P) titled Dysphagia - Clinical Protocol revised on 3/17/2026, the P&P indicated, In conjunction with the resident/ patient and family, the physician must carefully consider the clinical and ethical appropriateness of any recommendation that the resident/patient should not be allowed to eat it all or should be tube fed because of aspiration risk.During a review of the facility's P&P titled Safety and Supervision of Residents revised on 3/17/2026, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Residents safety and supervision and assistance to prevent accidents or facility wide priorities.

Based on observation, interview and record review, the facility failed to remove expired medication prescribed for two out of eight sampled residents (Resident 6 and Resident 64) from the medication cart (is a mobile workstation used in healthcare facilities to store, transport, and dispense medicines, medical equipment, and supplies). This deficient practice had the potential to result in the administration of expired medications to residentsFindings: A review of Resident 6's admission record indicated Resident 6 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood), and Depression (a constant feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a resident screening tool) dated 4/23/2026, indicated Resident 6's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 6 required total care with eating and oral hygiene, and required substantial to maximum assistance for toileting hygiene, shower bathing and upper and personal hygiene, and was non-ambulatory. A review of Resident 6's Physician Order dated 11/28/2026 timed at 3:17 pm, Loratadine (medication used to relieve allergy symptoms such as sneezing, runny nose, itchy or watery eyes, and an itchy throat)10 milligrams (mg-unit dose measurement) give 1 tablet by mouth every 24 hours as needed for allergies. A review of Resident 6's Medication Administration Record (MAR) for 5/2026 indicated Resident 6 did not receive Loratadine A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Depression (a constant feeling of sadness and loss of interest) and Anxiety (a condition characterized by constant, excessive, and uncontrollable worry about everyday things like work, health, or finances). A review of Resident 64's Physician Order dated 8/17/2024 timed at 12:06 pm, indicated Resident 64 to receive Loratadine 10 mg give 1 tablet by mouth every 24 hours as needed for allergies. A review of Resident 64's MDS dated [DATE], indicated Resident 64's cognition was intact. The MDS indicated Resident 64 required minimal assistance with eating and oral hygiene, and required minimal assistance for toileting hygiene, shower bathing and upper and personal hygiene, and was able to walk at least 10 feet in a room. A review of Resident 64's MAR for 5/2026 indicated Resident 6 did not receive Loratadine. During a concurrent observation/inspection and interview with licensed vocational nurse (LVN) 4 on 5/14/2026 at 12:21 pm, the facility medication cart was inspection/observed. A bottle of Loratadine 10 mg tablets with an expiration date of 4/2026 was observed in the top drawer of the medication cart. LVN 4 stated the nurse in charge of the medication cart is responsible to make sure that there are no expired medications in the medication cart. LVN 4 stated that another LVN checks all the medication carts for any outdated or cancelled medications left in all medication carts. LVN 4 stated she will dispose the expired Loratadine left in the cart. LVN 4 stated that if expired medication is left in the cart there is the possibility that the medication can be administered to residents which is considered medication in error. LVN 4 stated that all expired medications should be removed from the medication carts to prevent medication error involving expired medications. During an interview on 5/14/2026 at 12:42 pm, Registered Nurse Supervisor (RNS) 2 stated every Sunday, a licensed nurse checks all the facility's medication carts for any expired medications, especially the Over the Counter (OTC) medications (medications sold without a prescription in stores or pharmacies). RNS 2 stated that the licensed nurse assigned to check for expired medication removes all expired and discontinued/cancelled prescription medications from the medication carts, destroys and logs the expired and discontinued/cancelled medications. RNS 2 stated that licensed nurse assigned to administer medication is responsible in making sure that expired and or cancelled prescriptions medications are removed from the medication carts During an interview on 05/14/2026 at 12:49 pm, LVN 5 stated once a month a pharmacy consultant checks the medication carts for expired medications and makes no expired medications are left in any of the facility's medication carts. During an interview on 05/14/2026 at 12:25 pm Director of Nursing (DON) stated that every nurse that administers medication to residents must make sure that there are no expired medications. DON stated that a licensed nurse comes to the facility once a week to check the carts for any expired medications. DON stated that for additional, for safety, a consultant comes once a month to the facility to check the carts for expired medications. DON stated that, it is the charge nurse assigned to administer medications is responsible in making sure that there are no expired medications in the medication cart. DON stated expired medications left in the medication cart increases the risk of the medications to be administered to a resident and the medication would not be beneficial (the medication may not work as intended when it is expired). A review of the facility's policy and procedures titled, Storage of Medications dated reviewed 3/17/2026, indicated the following:PolicyThe facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and ImplementationDrugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destructed as indicated.

Based on observation, interview, and record review, for two of two sampled residents (Resident 4 and Resident 54) the facility failed to:1. Ensure staff provide Resident 4 with a clean urinal (a portable, reusable or disposable container into which a resident can urinate without getting out of bed) This deficient practice placed Resident 4 at increased risk for infections due to contamination (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident).2. Ensure Resident 54 did not have access to meal carts with left over foods and drinks already consumed by residents. This deficient practice placed Resident 54 at increased risk to suffer from food borne illness/ infections due to contaminated (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident) food and drinks Findings: 1. During a review of Resident 4's admission Record, the admission record indicated the facility admitted the resident on 3/25/2026 with diagnoses that included but not limited to dementia (a progressive state of decline in mental abilities) and cerebral infarction (loss of blood flow to a part of the brain) and hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s - are organs that filter blood, remove waste and excess water to produce urine, and regulate the body's chemical, fluid, and hormone balance) have failed).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 4 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 4 needed partial/moderate staff assistance with activities of daily living (ADL-, toileting, upper body assist, sitting to lying, lying to sitting, personal hygiene, lower body dressing, putting/taking off footwear, sitting to standing and tub/shower transfer, set up/cleaning assistance for eating and maximum assistance for showering.) During an observation on 5/11/2026 at 12:22 pm, Resident 4 was observed in a wheelchair in Resident 4's room. Resident 4's urinal which was placed at the side rail of the bedside had the date 4/10/26. During another observation on 5/12/2026 at 1:56 pm, Resident 4 was observed in a wheelchair in resident's room. Resident 4's urinal which was placed at the bedside had the date 4/10/26. During an interview on 5/12/2026 at 1:56 pm with Certified Nursing Assistant (CNA) 2, CNA 2 stated, I change the urinal when it looks dirty, it has yellow some color in it or a ring in it , well it kind of looks dirty.During an interview on 5/12/2026 at 2:05 pm with Infection Prevention Nurse (IPN), IPN stated, Urinal for all residents should be changed once a week or as needed. Urinal not changed for every week can cause bacteria to grow, residents can get UTI (urinary tract infection - UTI- an infection in the bladder/urinary tract) and it can get progress if not cured, can get sepsis.During an interview on 5/14/2026 at 12:52 pm with Director of Nursing (DON), DON stated that if a urinal is not changed for a month or longer, the resident can get Infection in bladder (the organ that stores urine) or any kind of infection. It can potentially progress to sepsis or hospitalization. Urinals should be changed weekly or earlier if needed to.During a review of the facility's policy and procedures (P&P) titled Infection Prevention and Control Program revised on 3/17/2026, the P&P indicated, An infection prevention and control program is established and maintained to provide a safe., sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During a review of Resident 54's admission Record, the admission record indicated the facility admitted the resident on 3/2/2026 with diagnoses that included but not limited to severe protein-calorie malnutrition (potentially life-threatening condition caused by an inadequate intake of protein, calories and other macronutrients) and dysphagia (difficulty swallowing).During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 had moderate cognitive impairment. The MDS indicated Resident 54 needed partial/moderate assistance for ADL including, personal hygiene, upper body dressing, oral hygiene, toileting hygiene, showering, upper body, sitting to lying and lying to sitting. During an observation and concurrent interview on 5/11/2026 at 1:32 pm, two meal tray carts (with multiple meal trays in it) were observed in the hallway outside the facility kitchen, the kitchen doors were closed and no staff was present/seen in the hallway. The meal carts had residents' eaten leftover food on the meal trays. Resident 54 who was ambulating (walking) in the hallway outside the kitchen area, picked up cup of 4 ounces of milk (cover with a lid) from the meal carts. Resident 54 then walked towards his room. When the writer asked Resident 54 regarding the milk, the resident didn't respond and kept walking towards resident's room. The writer informed Certified Nurse Assistant (CNA) 3 who then stopped Resident 54 and asked Resident 54 about the cup of milk that resident had. Resident 54 gave the cup of milk back to CNA 3.During an interview on 5/11/2026 at 2 pm, with CNA 3, CNA 3 stated that Resident 54's intention was possibly to drink the 4 ounces of milk. CNA 3 stated, it is not safe for residents to have access to the leftover food from the meal cart outside of kitchen. During an interview on 5/13/2026 at 2:35 pm, Interviewed Infection Prevention nurse (IP). IP stated, it's not safe for residents to have access to the leftover food from the resident's meal trays. IP stated, It is an infection issue. We don't know who that tray belongs to, so no resident should be touching another resident's food or belongings. There could be transmission of potential infection.During an interview on 5/14/2026 at 12:59 pm, Director of Nursing (DON). DON stated, Dirty trays don't have clean food. Its leftover food from other residents. There is potential for resident to get infection by eating food from unsupervised dirty trays. It's not safe.During a review of the facility's policy and procedures (P&P) titled Infection Prevention and Control Program revised on 3/17/2026, the P&P indicated, An infection prevention and control program is established and maintained to provide a safe., sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations and interview, the facility failed to maintain an insect free building according to its facility's policy and procedures (P&P) titled Pest Control with review date 3/17/2026, for one of one sampled resident room (Resident 14). This deficient practice had the potential to significantly compromise the resident's safety, health leading to infection and possibly hospitalization.Findings: A review of Resident 14's admission Record indicated the facility admitted Resident 14 on 4/7/2026 with diagnoses including hypertension (HTN-high blood pressure) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2026, indicated Resident 14 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 14 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 5/14/2026, at 10:24 A.M., with Certified Nursing Assistant (CNA) 1, in Resident 14's room, nightstand, three alive cockroaches were seen in the top drawer of the nightstand, one alive cockroaches on the right hind corner of the nightstand and two alive on the left front corner of the nightstand. CNA 1 stated that she saw the two alive cockroaches on the left front corner of the nightstand drawer. CNA 1 stated that alive cockroaches in the residents' rooms may cause infection, get into the open orifices of the residents such as the nose, ears, any opening on the resident and cause infection. During an interview, on 5/14/2026, at 10:45 A.M., with the Maintenance Supervisor (MS), the MS stated that last week, he saw two alive cockroaches in two different residents' room. MS stated he called the pest control company that the facility is contracted with, the technician came and placed small traps in the two resident rooms including three additional residents' room but did not treat the entire facility for cockroaches. MS stated the facility should not have cockroaches in the residents' rooms as they may affect the resident's health causing infection and may end up on the resident's food and inside the ears. During a concurrent interview and record review, on 5/14/2026, at 11:16 A.M., with the Director of Nursing (DON), the facility's pest control report dated 4/27/2026 was reviewed. The report indicated that the pest control company provided treatment in only five rooms in the facility and not the entire facility. The DON stated if treatment is done in some rooms, cockroaches may move from one room to the next and the whole facility needs to receive treatment for it to be effective. The DON stated that cockroaches are pests which can transmit infection, bite the residents, enter residents open areas which may lead to affecting the resident's psychosocial health may adversely be affected. A review of the facility's P&P, titled, Pest Control with review date 3/17/2026, indicated,Policy StatementOur facility shall maintain an effective pest control program.Policy Interpretation and Implementation1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.2. Pest control services are provided by Orkin.3. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas.4. Garbage and trash are not permitted to accumulate and are removed from the facility daily.5. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review the facility failed to maintain record that is complete and accurate for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1.Provide assistance with activities of daily living (ADLs) on 11/11/22. 2.Document nursing services that were provided to Resident 1 on 11/11/22 from 7 p.m. to 12:30 a.m. These deficient practices resulted in incomplete and inaccurate medical record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/11/22 with diagnoses including respiratory failure (impaired gas exchange between the lungs (breathing organ) and the blood) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's admission Assessment indicated the facility admitted Resident 1 on 11/11/22 at 7 p.m. The Assessment indicated Resident 1 was confused. Resident 1 was dependent with eating/nutrition, personal hygiene and grooming. Resident 1 was incontinent of bowel and bladder. During a concurrent interview and record review on 6/12/25 at 12:01 p.m., Resident 1's admission Assessment was reviewed the registered nurse supervisor (RNS 1). RNS 1 stated the facility admitted Resident 1 on 11/11/22 at 7 p.m. RNS 1 stated the nurses should make rounds at least every two to three hours, check on how Resident 1 was doing and make sure Resident 1 was okay . RNS 1 stated she was unable to find documentation that the nurses made their rounds. RNS 1 stated it is important to document what .we did for the patient (Resident 1). RNS 1 stated the documentation communicates how Resident 1 was doing during the shift. During a concurrent interview and record review, on 6/12/25 at 1:26 p.m., Resident 1's Documentation Survey Report (record of ADLs and assistance provided to residents) for 11/22 was reviewed with the director of staff development (DSD). DSD stated she was unable to find documentation that the certified nursing assistant (CNA) provided care to Resident 1. DSD stated even if Resident 1 was a new admit on 11/11/22, the CNA should do frequent rounds to find out how Resident 1 was doing. DSD stated the CNA should document what was done for the patient that included if Resident 1 had voided or was turned. During a review of the facility Policy titled Activities of Daily Living (ADLs), Supporting , reviewed on 12/18/24 indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The same Policy indicated appropriate care, and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care) b. Mobility (transfer and ambulation, including walking) c. elimination (toileting) d. dining (meals and snacks) e. communication (speech, language and any functional communication systems). During a review of the facility Policy titled Charting and Documentation reviewed on 12/18/24 indicated all services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The same Policy indicated the following information is to be documented in the resident medical record: a. objective observations b. medications administered c. treatments or services performed d. changes in the residents' condition e. events, incidents or accidents involving the resident and f. progress toward or changes in the care plan goals and objectives The same Policy indicated the documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on interview and record review, the facility failed to revise/update fall care plan to include updated interventions after the fall on 12/28/2024 to prevent a repeat fall for one of two residents (Resident 165) who was a high risk for fall. As a result, on 2/3/25, Resident 165 fell again and suffered severe pain of 7 (seven) out of 10 (7/10 - a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the buttocks and to the left and right thighs. On 2/5/2025, the facility transferred Resident 165 to General Acute Care Hospital (GACH) 1 via non-emergency medical transportation where Resident 165 was diagnosed with a left hip fracture (broken bone). On 2/16/25, GACH 1 performed an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 165. Findings: During a record review, Resident 165's Admission Record indicated the facility admitted the resident on 10/2/2019 with diagnoses including dementia (a progressive state of decline in mental abilities), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and a history of falling. During a record review, Resident 165's at risk for falls care plan, initiated on 10/17/2019 and reviewed on 1/7/2025, indicated the resident was at risk for falls due to the resident's diagnosis of dementia, being unaware of safety and poor judgment. The care plan indicated the goal included to reduce the resident's risk of falls and injury. The care plan interventions indicated staff to: - Visibly observe resident frequently. - Encourage the resident to attend and participate in activity programs; and - Provide safety instruction to resident regarding ambulation, transfers, and ADLs when appropriate. Bilateral 1/3 side rails (a barrier on the side of the bed that prevents one from falling out of bed) up and grab bars (bars are safety devices designed to enable a person to maintain balance, lessen fatigue while standing), walker. The care plan indicated all interventions were initiated on 10/18/2019. During a record review, Resident 165's care plan titled, Resident is at risk for spontaneous/ pathological (a break in the bone caused by a disease and not an injury)/ stress fracture (a small crack in the bone caused by placing too much stress on the bone), initiated on 2/22/2022 and reviewed on 1/7/2025, indicated the resident was at risk for fracture due to related to dx of osteoarthritis. The care plan goal included to reduce the risk of fracture and injury to Resident 1. The care plan interventions indicated to: - Perform x-ray as indicated - Provide a safe and hazard free environment - Assist with all transfers and ambulation as needed - Facility POP (Protect Our Patients from Pathological Fracture) program -Fall risk interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) conference. The care plan interventions were not updated since 2/22/2022. During a record review, Resident 165's History and Physical (H&P), dated 11/13/2024, indicated Resident 165 did not have the capacity to understand and make decisions. During a record review, Resident 165's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 12/28/2024, indicated Resident 165 was observed sitting on the floor on the left side by the housekeeping staff and the charge nurse (Licensed Vocational Nurse - LVN) in the smoking patio. The COC indicated the resident reported to Registered Nurse (RN) 1 that he was walking towards the resident's chair to sit down when he [Resident 165] fell . The COC indicated that per Resident 165, the resident landed on the butt and back and did not have pain or discomfort. The COC further indicated Resident 165 was noted with same shuffling gate pattern. During a record review, Resident 165's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 1/2/2025, indicated the resident's cognition (ability to think, understand, and reason) was moderately impaired. The MDS indicated Resident 165 required supervision or touch assistance (helper provides verbal cues and /or touching/steadying as the resident completes the activity) with oral hygiene, upper body dressing and toileting hygiene. The MDS also indicated Resident 165 uses a walker for mobility and required supervision or touching with walking 10 feet, 50 feet and 150 feet. The MDS further indicated Resident 165 had one prior fall since the last MDS assessment (assessments are completed every 3 months. [Date not indicated.]) During a record review, Resident 165's Fall Risk assessment dated [DATE] (one month prior to the 2/3/2025 fall), indicated Resident 165 scored 22 (high risk for falls). During a record review, Resident 165's COC form, dated 2/3/2025 (37 days after the 12/28/24 fall), indicated Resident 165 was observed sitting on the smoking patio floor. Resident 165 complained of pain to the buttocks and both thighs. The COC also indicated the resident reported a 7/10 pain level with movement and the physician ordered a stat (immediate) x-ray of both hips. During a record review, Resident 165's Radiology Results Report (from the facility), dated 2/4/2025, indicated Resident 165 had x-ray of both hips. The x-ray report indicated Resident 165 had an intertrochanteric left femoral fracture (left thigh bone break). During a record review, Resident 165's COC form, dated 2/4/2025, indicated the x-ray results indicated Resident 165 had left thigh fracture. The COC further indicated a physician ordered to transfer the resident to GACH. During record review, Resident 165's Physician Order, dated 2/4/2025, indicated the facility to transfer Resident 165 to GACH 1 for evaluation of acute intertrochanteric left femoral fracture sustained after a fall. During a record review Resident 165's Progress Note, dated 2/5/2025, indicated the resident was transferred to GACH 1 via non-emergency medical transportation. During a record review, Resident 1's GACH 1's Emergency Department (ED) Medical Doctor (MD) Note, dated 2/5/2025, indicated Resident 165 presented to the ED after falling while trying to smoke. The ED MD note also indicated Resident 165 complained of left arm and hip pain and received Morphine (an opioid pain medication) 2 milligrams (mg - unit of measurement) intravenously (IV -inside a vein) for pain control (pain level not indicated). The ED MD note further indicated Resident 165's x-ray showed a comminuted (where the bone breaks in two or three places) left hip fracture. During a record review, Resident 165's Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgical Consultation Report, dated 2/5/25, indicated the resident came to the GACH complaining of pain involving the left hip, which developed following a ground level fall landing on the left hip. The Orthopedic Surgical Consultation Report also indicated there was tenderness and swelling around the left hip and that Resident 165 experienced pain when attempting range of motion (ROM - the extent to which a joint in the body can move) to the left hip. The Orthopedic Surgical Consultation Report further indicated the x-ray of the left him revealed a comminuted unstable left hip fracture. During a record review, Resident 165's GACH 1 Operative Report, dated 2/16/2025, indicated Resident 165 had an ORIF surgery on 2/16/2025 to treat the resident's left femoral fracture. During a concurrent interview and record review 2/20/2025 at 10:18 AM with Registered Nurse Supervisor (RN) 1, Resident 165's electronic health records were reviewed. While reviewing Resident 165's COC form dated 2/3/2025, RN 1 stated that Resident 165 was found sitting on the ground on the smoking patio. RN 1 stated whenever a resident is found on the floor, the resident is considered to have fallen. RN 1 stated Resident 165 complained of pain when found on the patio floor and was administered Tylenol (pain medication). RN 1 stated Resident 165 had slight pain relief. RN 1 further stated that on 12/28/2024, Resident 165 previously fell when RN 1 was on duty and that the resident did not have any injuries. During a concurrent review of Resident 1's care plans, RN 1 stated RN 1 did not update Resident 165's fall care plan after the fall on 12/28/2024. Also, RN 1 stated that RN 1 did not create a new care plan that addressed the resident falling. RN 1 stated the fall care plan should have been updated to prevent the resident from falling again. RN 1 further stated an updated care plan should address the resident's needs and may have prevented the resident from falling and breaking his bone. During a concurrent interview and record review with the Director of Nursing (DON) on 2/21/2025 at 10:40 AM, Resident 165's care plans and COCs were reviewed. The DON stated Resident 165 had two recent falls. The DON stated after Resident 165 last fell on [DATE], the resident was transferred to a GACH and was diagnosed with a left hip fracture. Upon reviewing Resident 165's care plans, the DON stated Resident 165's care plan interventions to prevent falling were not updated after the resident fell on [DATE]. The DON stated Resident 165's risk for fall care plan interventions were not updated after 10/18/2019. The DON further stated the care plan addresses the resident's identified problems and contains interventions to prevent or minimize the risk to residents. The DON further indicated staff update the care plan when new issues arise or and the care should have been updated after the 12/28/24 fall to prevent or minimize the risk of Resident 165 falling again. During a record review, the facility's policy, and procedures (P&P) titled, Safety and Supervision of Residents, revised 7/2017, indicated, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P also indicated, monitoring the effectiveness of interventions shall include evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. During a record review, the facility's P&P titled, Falls - Clinical Protocol, revised 3/2018, indicated, while many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. For an individual who has fallen, the staff will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. The P&P also indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. The P&P further indicated, based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. During a record review, the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 3/2023, indicated, a comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs, incorporate the resident's personal and cultural preferences in developing the goals of care. The P&P further indicated, assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observation, interview, and record review, the facility failed to ensure residents received meals with flavor, attractive, appetizing, nutritive value, proper temperature, safe, and adequate portions. This deficient practice had the potential for the residents to experience poor/reduced meal intake, weight loss, and a decline in their health status. Findings: a. During a record review, the Resident Council Meeting minutes 11/13/2024 at 2 PM, a resident complained that the, [NAME] is not cook enough and can't digest it. During Resident Council Meeting on 2/19/2025 at 10:50 AM, four residents (Residents 40, 45, 62, and 65) were present. Resident 62 stated the facility give so little food and we eat cold soup. Resident 40 stated, the sandwich has cheese, and no meat. Resident 65 stated the sandwich has two breads and a cheese, no meat, nothing more. I didn't like the food. The food is not enough. Resident 45 stated that, the food food was cold when it's supposed to be hot. During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. During record review, the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Food Preparation and Service revised in 2022, indicated, Potentially harzadous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, . When food is left in the danger zone (temperatures between 41-135 degrees F) for more than four hours rapid growth of pathogenic microorganisms (organisms that can cause disease) can cause foodborne illness (a disease or infection caused by consuming contaminated food). The P&P did not address palatability (quality of food being tasty) of the food served to residents. 45455 b. During record review, Resident 58's Admission Record indicated Resident 58 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure), encephalopathy (a change in your brain function due to injury or disease), rhabdomyolysis ( a breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream.), and acute kidney failure (a condition in which kidneys suddenly stop working, causing a buildup of waste and fluid in the body). During record review, Resident 58's Minimum Data Set (MDS - a resident assessment tool) dated 01/3/2025, indicated the Resident 58's cognition (The mental ability to make decision of daily living) was intact, Resident 53's required setup for eating, upper body dressing and taking off foot wear, supervision for oral hygiene, toileting hygiene and lower body dressing, Resident 58 required partial/moderate assistance with shower/bathing and personal hygiene. During record review, Resident 58's History and Physical (H&P) dated 1/6/2025, indicated Resident 58 did not have the capacity to understand and make decisions. During a facility tour and concurrent interview on 2/18/2025 at 11:50 AM, Resident 58 stated, lunch and dinner meals taste awful. Resident 58 stated he does not eat the food most of the time because the food looks like dog food and had lost a significant amount of weight since admission to the facility. During record review, Resident 58's electronic health record (EHR) indicated Resident 58 had lost 8 pounds (lbs-unit of measurement) in 2 months. During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. 45037 c. During an observation and concurrent interview on 2/20/2025 at 12:49 PM, the facility served a test tray to State Agency (SA). The test tray consisted of rice mixed with red kidney beans, roast beef, carrots, and a brownie, and not appealing. Dietary Supervisor (DS) used a thermometer to tested the temperature of the roast beef. The roast beef temperature registered at 127 degrees Fahrenheit (F - a scale for measuring temperature). SA tasted the food from the test tray but barely ate any of the test tray food. SA tested the food and stated that the roast beef was hard to chew and did not have any flavor, the carrots were not palatable or tender, the red beans and rice was mushy and salty, the temperature was okay, but the portions were small. During record review, the facility policy and procedures titled Food and Nutrition Services revised 10/2017, indicated, 7. the food appears palatable and attractive, and it is served at a safe and appetizing lempe.rature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to ensure that: 1. Kitchen staff are trained and competent in food cooling down method 2. Cooked left over chicken and ground beef are not stored in the refrigerator 3. Kitchen staff recorded and retained documented evidence of the cooling down food/meat following the cooling down method. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour and observation of the kitchen on 02/18/2025 at 7:29 am, with Tray line staff, the kitchen refrigerator had a container of cooked chicken and ground beef. During a concurrent interview, the Tray line staff he stated the cooks are not supposed to store cooked food in the refrigerator at any time. During an interview with Dietary Cook, Dietary [NAME] stated that she cooked the ground beef on 2-17-25. Dietary [NAME] stated she does not know the cooling down method for food/meats. Dietary [NAME] stated, if cooked food is not stored properly the residents could get very sick or have a stomachache. During an interview with on 02/18/25 at 11 am, Dietary Supervisor stated kitchen staff is not supposed to store cooked chicken and ground beef in the refrigerator. Dietary Supervisor stated the dietary department does not have a cooling down process for food/meats because the cooks are not supposed to keep cooked food in the refrigerator. Dietary Supervisor stated the cooks prepares and cooks fresh food for every meal. Dietary Supervisor stated, if food is not stored properly the residents could get salmonella (bacteria that causes diarrhea, fever and stomach pains) and sickness to the residents. During record review, the facility policy and procedures titled Safe Cooling Method dated12/18/2024, indicated, Policy: All cooked food not prepared for immediate use will be cooled properly to keep bacteria form developing. A. 6-hour or two stage method. 2. A cooling log will be maintained to ensure standards are met.

Based on observation and record review, the facility failed to provide a refrigerator to store food brought in for the residents. This deficient practice had the potential to cause food borne illness due to the residents not having a refrigerator to store their food. Findings: During record review, the Facility Listing Report dated 2/18/2025, indicated the resident census was 111. During an observation and interview on 2/20/25 02:41 pm with the Registered Dietician, the Registered Dietician stated that the facility does not have a refrigerator for the residents to store food brought in from outside the facility. Registered Dietician stated she recommends that the residents and the residents family members to not bring in food that needs refrigeration. Registered Dietician stated it is the residents right to have food bought in by their families. During record review, the facility policy and procedures titled Food From Outside Sources indicated, Policy: Food brought to the facility by visitors and family is permitted.

Based on observation, interview, and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that a resident would not be allowed to keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications for one of 12 sampled residents (Resident 58). This deficient practice had the potential for other residents to gain access/ingest the medication and or result in adverse reaction to the medication. Findings: During record review, Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure), encephalopathy (a change in your brain function due to injury or disease), rhabdomyolysis ( a breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream.), and acute kidney failure (a condition in which kidneys suddenly stop working, causing a buildup of waste and fluid in the body). During record review, Resident 58's Minimum Data Set (MDS - a resident assessment tool) dated 1/3/2025 indicated Resident 58's cognition (The mental ability to make decision of daily living) was intact, Resident 53's required setup for eating, upper body dressing and taking off foot wear, supervision for oral hygiene, toileting hygiene and lower body dressing, Resident 58 required partial/moderate assistance with shower/bathing and personal hygiene. During record review, Resident 58's history and physical (H&P) dated 1/6/2025 indicated Resident 58 did not have the capacity to understand and make decisions. During a facility tour on 2/18/2025 at 10:08 AM, Resident 58 was observed to have to round pills on top of a box of tissue that was on his dresser. During a concurrent interview, Resident 58 stated the pills were tums (a medication used to treat heartburn, indigestion and an upset stomach caused by too much stomach acid), Resident 58 stated he takes the tums after meals, and he was going to take the tums after his noon time meals. During an interview on 2/28/2025, at 10:25 AM, licensed vocational nurse (LVN) stated the medication at Resident 58's bedside was Simethicone (medication used to treat abdominal symptoms of gas, fullness, pressure, and bloating). LVN 2 stated Resident 58 did not have a physician's order for self-administration of medication, LVN 2 was unable to state the risks of leaving medications at Resident 58's bedside. During an interview on 2/21/2025 at 12:17 PM Director of Nursing (DON) stated Residents are only allowed for have Meds at bedside if they have been assessed to be cognitive and physically demonstrated they can safely able to do so and have a physician approval, DON stated medication at bedside should be in a locked container, DON further stated medications should not be left at bedside, because an confused wandering Resident may consume the medications which could lead to an adverse reactions, unnecessary hospitalization and possible poor outcomes, During record review, the facility's policy and procedures titled Self-Administration of Medication dated 03/2023 indicated, .the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the Resident), assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other Residents .

Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change in a Residents Condition or status revised 3/2023 for one of four sampled residents (Resident 39). This deficient practice had the potential to result in the delay of care for Resident 39. Findings: During record review, Resident 39's Admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 on 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review Resident 39's Weight Summary indicated the following weights: 10/29/2024 : 105.0 pounds (lbs -unit of measure) 10/15/2024: 104.0 lbs 10/8/2024: 104.0 lbs 10/4/2024: 104.0 lbs 9/9/2024: 114.0 lbs During record review, the Nutrition/Dietary note dated 10/4/2024, at 4:19 P.M., indicated Resident 39 lost 10 lbs weight loss related to wounds, recent hospitalization , fluid shifts, advanced age, variable by mouth intake, mechanically altered diet . unavoidable. During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 39 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 2/20/2025, at 12:45 P.M., with Minimum Data Set/ Registered Nurse Supervisor (MDS/RNS), Resident 39's electronic chart was reviewed. MDS/RNS stated Resident 39 had lost a total of 10 lbs between 9/9/2024 and 10/4/2024. MDS/RNS stated facility should have done a COC of the weight loss, however, there is no documented evidence that a COC was done. Weight loss is a change in condition that needs to be monitored, physician needs to be notified as well as family member or representative so that the resident should not lose more weight, get weak and have an overall decline in ADL. During an interview on 2/21/2025, at 7:27 A.M., the Director of Nursing (DON) stated, a COC is a deviation from the resident's baseline and should be done as soon as the deviation is noted. DON stated the COC for weight loss is done to alert everyone, licensed nurses, certified nursing assistants, all the departments including the doctor and family that there was a change in the resident's condition that needs to be monitored and if the COC is not done, the doctor may not know what is happening to the resident and the right interventions will not be applied. During record review, the facility's P&P, titled, Change in a Residents Condition or status revised 3/2023, indicated, Policy statement: Our facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the residents medical/mental condition and/or status. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), who had dementia (loss of memory, thinking and reasoning), impaired vision, and was at risk for elopement (a resident who leaves the facility when doing so may present an imminent threat to the resident's health and safety because the resident is too impaired to make a decision to leave), was provided with a safe environment and supervision to prevent the resident from eloping as per the resident's comprehensive assessment, plan of care, and facility's policy. As a result, on 8/26/2021, Resident 2 to eloped (left the facility, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) from the facility, sustained multiple injuries and required transfer to the General Acute Care Hospital (GACH), where he was diagnosed with a cephalohematoma (accumulation of blood under the scalp), a fracture (break in a bone) of the inferior (below) right pelvic bone (connects the trunk and legs of the body) and severe compression fracture (break in the back bones) of L4 (4th lumbar bone of the spine). Findings: A review of Resident 2's Admission Record (Face sheet) indicated the facility admitted Resident 2 on 10/17/2019, and was readmitted on [DATE], with diagnoses including dementia (loss of memory, thinking and reasoning), [CONDITION(S)] (an irregular heartbeat), heart failure (the heart muscle does not pump blood), hypertension (a condition when the force of the blood against the artery wall is too high), unspecified [CONDITION(S)] (a group of eye conditions that cause [CONDITION(S)]), and muscle weakness. A review of Resident 2's Care Plan dated 7/8/2021, indicated Resident 2 had impaired vision function related to [CONDITION(S)]. The goal was to minimize the risk of injury related to visual impairment daily by providing a safe environment and free of hazards for Resident 2. The care plan did not indicate how to provide a safe environment free of hazards. A review of Resident 2's Care Plan dated 7/8/2021, indicated Resident 2 was at risk for spontaneous fractures related to osteopenia (a condition that occurs when the body does not make new bone as quickly, as it reabsorbs old bone), chronic compression fracture (loss of bone mass, occurs when the bony block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height). The goal was to reduce the risk of injury daily by providing a safe, hazard free environment, assist with all transfers and ambulation as needed, and a fall risk assessment for Resident 2. A review of the Elopement Risk Evaluation form dated 7/9/2021 indicated Resident 2 had intermittent confusion, did not have any vision or communication problem and had not expressed the desire to go home. The Elopement Risk Evaluation indicated Resident 2 was assessed as no risk of elopement / wandering. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/15/2021, indicated Resident 2 needed one-person physical limited assistance with bed mobility, and one-person physical extensive assistance with transfers, dressing, walking, and toilet use. Resident 2 used a walker and wheelchair for mobility. According to a review of the Licensed Nurse Weekly Summary Report dated 8/2/2021, Resident 2 was monitored for discoloration (a change in color) of both lower legs and swelling. No other documentation was noted. A review of Resident 2's Change of Condition (COC) Assessment Form dated 8/26/2021, indicated the resident was in his room, seen in wheelchair talking to a peer on 8/26/2021 at 8 AM and that Resident 2 did not speak nor understand English. At 9:45 AM, the facility staff were not able to locate Resident 2 during rounds. The COC indicated the facility staff located and brought back Resident 2 to the facility on [DATE] at 10:30 AM and Resident 2 was noted with multiple skin abrasions and dried blood to the right side of Resident 2's forehead. The right foreside abrasion measured 4.5 cm (centimeters, unit of measurement) in length by (x) 4.5 cm in width, the left small finger abrasion measured 0.5 cm x 0.5 cm and left fourth finger abrasion measured 0.2 cm x 0.2 cm. The COC indicated Resident 2 stated that while he was out on the street, he tried to propel self in wheelchair with both feet off the ground, but he fell face down when he leaned forward. Resident 2 denied pain. A review of the Change of Condition Assessment Form dated 8/28/2021, indicated Resident 2 had a right shin excoriation and another excoriation was noted on Resident 2's left lateral knee. A review of Resident 2's Physician's Order dated 8/31/2021 at 4:20 PM, indicated transfer Resident 2 to a General Acute Care Hospital (GACH) due to right front leg wound infection. According to a review of Resident 2's Discharge Summary Report dated 8/31/2021 at 9:40 PM, Resident 2 required transfer to the GACH, including a right front leg wound infection. A review of Resident 2's GACH History and Physical dated 9/2/2021, indicated Computed Tomography (a series of images taken from different angles around the body) abdomen and pelvis indicated fracture of the inferior right pubic ramus (pelvic fracture) age is uncertain, but acute and severe compression fracture of the L4 vertebral body involving the superior and inferior end plates. CT of the head indicated a small cephalohematoma (an accumulation of blood under the scalp) to the right frontal scalp. A review of Resident 2's GACH Physician Daily Progress Note dated 9/3/2021, indicated Resident 2 had neurology (medical specialty concerned with the diagnosis and treatment of disorders of the nervous system which includes the brain) consult. Resident 2 had a fracture of the inferior right pubic ramus and severe compression fracture of L4. Orthopedic (medical specialty concerned with diagnosis and treatment of disorders of bones) recommendations for Resident 2 included, no surgical indication, non-weight bearing for now, and administer Tylenol (medication for pain) and [MEDICATION(S)] (medication for pain) as needed for pain. During an interview, on 9/3/2021 at 2:50 PM, the Treatment Nurse stated, I know he (Resident 2) always says he would like to go home. During an interview, on 9/3/2021 at 3 PM, the Director of Nurses (DON) stated she did not know how Resident 2 left the facility. The DON stated, We are always monitoring all the residents, we looked everywhere, we eventually found him on the street and brought him back to the facility. The DON stated, Someone is supposed to always monitor the front door, but I am not sure what happened on this day. During an interview, on 10/12/2021 at 11:30 AM, the Facility Receptionist stated she monitors the front entrance of the facility to make sure the residents stay inside the facility. The Receptionist stated she would call someone to monitor the facility's front entrance if she needed to step away but did not remember what happened the day Resident 2 left the facility. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/13/2021 at 2 PM., LVN 1 stated someone (did not identify the person), informed LVN 1, that Resident 2 was missing. LVN 1 further stated he located Resident 2 a couple blocks away from the facility. LVN 1 stated, No one was monitoring the main entrance at the time Resident 2 left the facility. A review of the facility's document titled, Job Description for Receptionist/Office Assistant, dated 10/1/2011, indicated the facility observes safety and security procedures; reports potentially unsafe conditions and ensures residents or responsible parties sign residents in and out appropriate sheet when leaving or returning to the community. A review of the facility's policy and procedures (P&P) titled, Monitoring Exit Door Alarm, dated 3/4/2019, indicated the facility has installed alarms on all main exit doors (front/back station). The P&P further indicated the facility will ensure safety of residents who attempt to elope from facility premises, maintenance staff to check all exit door twice a week on Mondays and Fridays to ensure function of door alarms, and any malfunction identified will be reported to administration immediately. According to a review of the facility's undated policy and procedures titled, Care of Wandering Residents, undated, residents who wander shall have their picture taken and placed in the medical record. A plan of care shall address the wandering. Wanderers are to be checked on a regular basis. Nursing and care duties include, explaining procedures and their purpose to the resident, continuously reorienting resident to room and belongings, encouraging resident to participate in group activities, and monitoring the resident's location with visual checks as needed. A review of the facility's undated policy and procedures titled, Care of Wandering Residents, indicated the facility would protect the wandering resident from injury, residents who wander shall have their picture taken and places in the medical record. Wanderers are to be checked on a regular basis. Nursing staff to monitor the resident's location with visual checks as needed, continuously reorienting the resident to their room and belongings.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with history of falls, and history of healed fracture (broken bone), was observed by staff frequently and provided a floor mat by the bed, per Resident 1's care plans on falls/injury and fracture. As a result, on 8/9/2021, at 1:02 PM, Resident 1 had a fall to the floor, requiring transfer to General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a displaced and angulated oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect of a medullary rod within the right femur (broken thigh bone). Resident 1 underwent an open reduction and internal fixation (ORIF, a surgical procedure to fix severely broken bones) of the right distal femur (bottom part of the thigh bone). Findings: A review of the Admission Record (Face Sheet) indicated Resident 1 was [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including, history of falling, [CONDITION(S)] (degeneration of joint cartilage), and [CONDITION(S)] (a condition of increased pressure within the eye, causing gradual loss of sight). A review of the Physical Therapy evaluation and plan of treatment form dated, 2/24/2020 indicated Resident 1 was a fall risk and required supervision during transfers and reached maximized functional potential that included supervision during bed mobility and transfers. There were no other updates from physical therapy. A review of Resident 1's Fall Risk Assessment, dated 5/31/2021, indicated Resident 1 had intermittent confusion, poor safety awareness, and unable to stand without assistance due to unsteady gait making her at risk for falls. According to a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 6/2/2021, Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making was moderately impaired. The MDS indicated Resident 1 required limited assistance with one person assist with transfers, and was not stable, only able to stabilize with staff assistance when walking. A review of Resident 1's care plan revised 6/4/2021, indicated Resident 1 was at risk for falls/injury related to difficulty walking, history of falls, right femur fracture due to fall, and impaired cognition. The goal indicated Resident 1 was to have a reduced risk of falls and injury. The care plan interventions indicated to observe resident frequently, keep frequently used personal items within easy reach, provide safety instructions to resident regarding ambulation, transfer, and activities of daily living when appropriate, low bed, and a floor mat. A review of Resident 1's care plan revised 6/4/2021, indicated Resident 1 was at risk for spontaneous pathological stress fracture (occur in normal weakened bone) related to a history of right femur fracture (a broken thigh bone), status post ORIF due to a previous fall. The goal indicated the facility will minimize the risk of fracture and reduce the risk of injury daily. The care plan interventions indicated to assist Resident 1 with all transfers and ambulation as needed. A review of the Change of Condition Assessment form dated, 8/9/2021, indicated at 1:02 PM, Registered Nurse 1 (RN 1) was called by a certified nursing assistant to go to Resident 1's room. RN 1 noted Resident 1 was sitting on the floor in front of her wheelchair beside her bed. Resident 1 complained of right leg pain. The Director of Nurses came in to assess Resident 1. The DON stated Resident 1 reported she always transfers from the wheelchair to the bed by herself and now she ended up on the floor in a sitting position. Resident 1 was assisted back to bed and noted with facial grimacing. At 1:08 PM, the Physician was notified, and new orders indicated Resident 1 received an X-ray to the right leg. A review of Resident 1's Radiology Report dated 8/9/2021 indicated a displaced and angulated (two ends of the bone have shifted out of alignment), oblique fracture (a break that is curved or at an angle to the bone) near the distal aspect (a part of the body that is farther away from the center the body than another part) of the medullary rod within the femur (a broken thighbone). According to a review of the change of condition assessment form dated 8/9/2021, Resident 1 complained of pain when moving the right leg and the right leg was noted to be swollen and warm to touch. The Medical Doctor was notified with new orders for Tylenol 1000 mg by mouth every four as needed for moderate pain, ice compression, immobilize the right leg with pillows, and transfer Resident 1 to a General Acute Care Hospital. A review of the GACH Discharge Summary dated 8/10/2021, indicated Resident 1 was found to have another longitudinal prosthetic fracture (associated with an orthopedic implant) which the resident was required to have an additional surgical procedure. A review of the GACH History and Physical (H&P) dated 8/11/2021, indicated Resident 1 had an unwitnessed fall, was found to have painful swelling in the right thigh and brought to the emergency room . Resident 1 had a fracture of the right distal femur (broken thigh bone). Resident 1 was admitted and referred for orthopedic evaluation and surgery. A review of the GACH Operative Report dated 8/13/2021, indicated Resident 1 who had a previous right proximal femur fixed with long intramedullary rod fixation done, was found to have an new oblique fracture of right distal femur associated with previous rod fixation. Resident 1 recently underwent an open reduction and internal fixation (ORIF) of the right distal femur. Resident 1 received intravenous antibiotic, under general anesthesia (combination of medications for sleep like state, prior to surgery), a Stryker 9-hole plate (device or instrument with circular holes with locking plates and screws) was placed which was stabilized with clamps and cable fixation. Resident 1 received two units of packed red blood transfusion. During an interview with the Director of Nurses (DON) on 8/17/2021 at 2 PM, the DON stated Resident 1 went to her room after lunch and had been going from the wheelchair to the bed by herself. The DON stated Resident 1 must have lost her balance and fell on the floor. The DON stated Resident 1 did not have a floor mat because she had never fallen before and was not a high risk for falls. However, the resident had fallen before and was a fall risk. During an interview with Certified Nurse Assistant 1 (CNA 1) on 8/17/2021 at 2:30 PM, CNA 1 stated Resident 1 went to her room after lunch. CNA1 stated Resident 1 had been going back to bed by herself and did not have any issues before. CNA1 stated she was called by another nurse stating that Resident 1 was found on the floor, and she immediately called the supervisor. CNA 1 stated no floor mat was in place at the time of the fall. On 9/7/2021 at 3 PM during an interview, the Director of Rehabilitation (DOR), stated according to the physical therapy evaluation and the plan of treatment form, Resident 1 needed supervision when transferring from wheelchair to bed and bed to wheelchair. During an interview on 10/27/2021 at 2:30 PM, Resident 1 stated the day that she fell , she went back to the room by herself and noticed a shoe under the bedside table, so she got up and tried to get the shoe, but she lost her balance and fell . During a telephone interview on 11/4/2021 at 10 AM with the DON and Assistant DON, they stated frequent monitoring was done by supervisor, charge nurses, social worker, and CNA's and that there was no scheduled time, but it was done throughout the day. Each staff makes rounds at different times throughout the day. A review of the facility's policy and procedure titled, Promoting Safety and Reducing falls, undated, indicated because of aging, underlying processes: and psychological, social, and economic stresses, the elderly population is at an increased risk of accident and injury. Injuries from accidents are the fifth leading cause of death in individuals over age 65. By focusing on fall preventions, caregivers can enhance the quality of life for residents and maintain their highest practical level of functioning. Caregivers can best assist in falls or accident prevention by being alert to residents who have a history of falls and make conscious effort to eyeball them more frequently (observe the resident). Prevention of falls is the responsibility of everyone in the facility. A review of the facility's policy and procedure titled, The Resident Care Plan, undated, indicated it was the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident was aware of the written plan of care including its location, the current problems of the resident, and the goals or objectives of the plan. It was the responsibility of the Licensed Nurse to ensure the plan of care was initiated and evaluated.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse and prevent abuse (willful infliction of injury) for one of three sampled residents (Resident 3), when Resident 1, who was diagnosed with [CONDITION(S)] (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), identified with paranoia (thought process that causes an irrational suspicion or mistrust of others), and aggressive behavior leading to anger, and attempts to harm others, assaulted (a sudden, violent attack) Resident 3 on 11/1/2020. Resident 1 asked Resident 3 for a cigarette lighter. When Resident 3 stated he did not have a lighter, Resident 1 punched Resident 3 in the right eye. As a result, Resident 3 sustained right eye swelling, bleeding and discoloration. Resident 3 was taken to the general acute hospital (GACH 1) by paramedics where Resident 3 was found to have a dislocated lens (helps focus light and images) of the right eye, with complaints of pain and blurry vision. Findings: Cross Reference F 689 A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H and P) dated 10/28/2020, indicated Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The H and P indicated Resident 1 had the capacity to understand and make decisions. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] and follow up treatments. A review of Resident 1's Care Plan dated 10/28/2020, indicated Resident 1 was at risk from effects of [MEDICATION(S)] (antipsychotic medication used to treat certain mental/mood disorders) and [MEDICATION(S)] (antipsychotic medication used to treat symptoms of [CONDITION(S)] and seizure). The goal indicated Resident 1s risk for the use of medications would be monitored by the licensed nurse and the physician would be notified promptly. The care plan intervention indicated to monitor for potential risk / effects and alert physician when indicated. According to a review of the Nurse's Drug Guide, 2021, [MEDICATION(S)] side effects included agitation, anxiety, headache, and aggressive behavior. The Nurse's Drug Guide, 2021, indicated [MEDICATION(S)] side effects included unusual excitement, restlessness, and [CONDITION(S)] (mental illness marked by periods of great excitement and overactivity, many people suffering from [CONDITION(S)] do not think anything is wrong). A review of the Care Plan dated 10/30/2020, indicated Resident 1 had a problem of screaming and demanding for a cigarette from staff. The goal included to minimize injury to self and others. The care plan interventions included to monitor for signs of impending violence, monitor resident location through visual checks every hour to two hours, redirect as needed and to notify the psychologist and psychiatrist for follow up as needed. A review of the Change of Condition form (COC), dated 11/1/2020 at 7:49 a.m., indicated a resident informed RNS 2 that Resident 1 and Resident 3 were fighting in the smoking patio. The COC indicated RNS 2 went to the smoking patio immediately and found Resident 1 and Resident 3 standing two to three feet apart. Resident 1 had blood stains on his right hand. Resident 3 had blood on the right side of his face, his right eye was swollen, purple in color and bleeding. The COC indicated Resident 1 stated he hit Resident 3 because Resident 3 did not have a cigarette lighter. RNS 2 called the police and the paramedics. At 9:19 a.m., the police arrived, and took Resident 1 to the police station. The COC indicated the police would find proper placement for Resident 1. Resident 3 was taken to General Acute Care Hospital (GACH) 1. A review of the GACH 1 Emergency (ER) Record, dated 11/1/2020 at 9:27 a.m., indicated Resident 3 had a swollen right eye with ecchymosis (discoloration of the skin resulting from bleeding underneath) and complained of right eye pain and vision changes. The ER Record indicated Resident 3 stated he had normal vision in the right eye before the assault, but now reported he was able to see light only and no movement. A review of the ophthalmologist consultation (medical doctor who specializes in eye and vision care) dated 11/2/2020, indicated Resident 3 had right lens dislocation, traumatic mydriasis (widening of the pupil [opening located in the center of the eye] and iridoplegia [paralysis of the muscle located in the colored part of the eye]), [MEDICATION(S)] hemorrhage (leakage of blood into the gel-like fluid of the eye that can interfere with vision), [CONDITION(S)] (drooping) of the right eye and hematoma (collection of blood caused by a break in a blood vessel) of the upper and lower lids, zygomatic arch (cheek bone), lateral (side) face and subconjunctival hematoma (tiny blood vessels that break just underneath the clear surface of the eye). The ophthalmologist recommended if the [MEDICATION(S)] hemorrhage does not clear, Resident 3 may be a candidate for surgery. According to a review of the Admission Record, Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation in Resident 3's room, on 11/4/2020, at 12:20 p.m. Resident 3 was observed to have a swollen right eye that was half open and red in color. The skin around the right eye was purple in color. During a concurrent interview, licensed vocational nurse (LVN 1) interpreting, Resident 3 stated Resident 1 asked him for a cigarette lighter on 11/1/2020, and when he said he did not have a lighter, Resident 1 punched him in the right eye. Resident 3 stated after he was punched, he had pain and blurry vision. During a telephone interview, on 11/5/2020, at 11:50 a.m., RNS 2 stated on 11/1/2020, she was at the nurse's station when a resident informed her that Resident 1 and Resident 3 were fighting in the smoking patio. RNS 2 went to the smoking patio immediately and found Resident 3 had blood on his face and his right eye was swollen, purple in color and bleeding. Resident 3 was taken to his room and ice pack was applied to the right eye. RNS 2 stated she asked Resident 1 why he hit Resident 3. Resident 1 replied that he asked Resident 3 for a cigarette lighter and when Resident 3 replied he did not have a lighter, Resident 1 punched him in the right eye. On 11/5/2020, at 2:53 p.m., during a telephone interview, RNS 1 stated on 10/30/2020, at 5 p.m., Resident 1 demanded to have a cigarette and RNS 1 gave Resident 1 a cigarette. RNS 1 stated Resident 1 asked for another cigarette, at about 8 p.m. that same day, and RNS 1 stated there were no more cigarettes to give Resident 1. RNS 1 stated Resident 1 became angry, threatening and started yelling at her. During a telephone interview and concurrent record review on 11/9/2020, at 1:21 p.m., Resident 1's medical record was reviewed with RNS 3. RNS 3 stated on 10/30/2020 at 10 p.m., a voicemail was left for Resident 1's psychiatrist regarding Resident 1's aggressive behavior. RNS 3 was unable to find documentation that the psychiatrist returned the call. RNS 3 stated the psychiatrist should have been notified of the aggressive behavior. During a telephone interview on 11/10/2020 at 3:35 p.m., Resident 3's primary physician (MD) stated Resident 3 continued to complain of poor vision in the right eye. The MD stated he did not know if Resident 3's vision would improve. During a telephone interview on 11/13/2020, at 11:20 a.m., Resident 1's psychiatrist physician assistant (PA) stated, there should have been a follow up call by the facility. The PA stated when Resident 1 was verbally and physically aggressive on 10/30/2020 (per Resident 1's care plan), an order would have been given to send Resident 1 to the GACH ER for psychiatric evaluation. The PA stated Resident 1 could go willingly or Resident 1 could be sent out by 5150 (allows an individual with a mental illness to be involuntarily held for 72 hours psychiatric hospitalization ). Resident 1 remained in the facility placing other residents at risk. A review of the facility's undated policy titled, Change of Condition, indicated all changes of condition in a resident shall be handled promptly. The physician shall be called promptly. The policy indicated if for some reason the physician cannot be reached, alternative physician shall be contacted. If the alternate cannot be reached, the medical director is to be contacted. All contacts or attempts to contact the physician shall be documented and include the correct time of the activity. A review of the facility's undated policy titled, Abuse and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents with possible needs and potential behavioral symptoms and manifestations that may lead to conflict, and anger or neglect shall be identified through comprehensive assessments, initially upon resident's admission and continually thereafter, as deemed appropriate and necessary. The policy indicated residents identified with such behavioral symptoms and manifestations shall be assessed by members of the Interdisciplinary Team and referred to appropriate healthcare professionals as deemed necessary to ensure adequate care planning and interventions needed to treat, modify and address such problems. Those residents identified to have behavioral symptoms with a potential for conflict and anger shall be monitored in accordance with plans of care developed to address such problems.

Based on interview and record review, the facility failed to identify and evaluate accident risks and provide supervision to prevent accidents and injuries for one of three sampled residents (Resident 1). Resident 1, who was diagnosed with [CONDITION(S)] (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), and identified with paranoia (thought process that causes an irrational suspicion or mistrust of others) with aggressive behavior leading to anger and attempts to harm others, the facility failed to: 1.Provide one to one (1:1) monitoring for Resident 1, per the care plan interventions. 2.Develop and revise care plan interventions to address Resident 1's risk for injury and aggressive behavior. These deficient practices resulted in the mental anguish of Resident 2 when Resident 1 had an altercation with Resident 2 on 10/30/2020 at 1:05 p.m., and Resident 1 was verbally and physically aggressive with the registered nurse supervisor (RNS 1) on 10/30/2020 at 5:30 p.m., and again at 8 pm. Findings: Cross Reference F 600 A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H and P) dated 10/28/2020, indicated Resident 1 had diagnoses including chronic [CONDITION(S)] (severe mental disorder that causes abnormal thinking and perceptions) and chronic alcoholism. The H and P indicated Resident 1 had the capacity to understand and make decisions. A review of the Physician's Orders, dated 10/28/2020, indicated Resident 1 received a psychiatry consult (medical doctor who specializes in mental health) and follow up treatments A review of Resident 1's Care Plan dated 10/28/2020, indicated Resident 1 was at risk from effects of [MEDICATION(S)] (antipsychotic medication used to treat certain mental/mood disorders) and [MEDICATION(S)] (antipsychotic medication used to treat symptoms of [CONDITION(S)] and seizure). The goal indicated Resident 1s risk for the use of medications would be monitored by the licensed nurse and the physician would be notified promptly. The care plan intervention indicated to monitor for potential risk / effects and alert physician when indicated. The care plan did not indicate what effects to monitor Resident 1 for. According to a review of the Interdisciplinary Team (IDT) notes, dated 10/28/2020, Resident 1 had incident of striking out and kicking another resident while at another facility. The IDT note indicated Resident 1 was transferred to a psychiatric hospital, placed on a psych hold for management / stabilization of behaviors and medication adjustment. The IDT note indicated Resident 1 remained at risk for behavioral outbursts and conflict with peers. A review of the Progress Record dated 10/29/2020, indicated Resident 1 attempted to leave the facility without notifying the facility staff. Progress Record indicated public guardian made aware. A review of Resident 1's Care Plan, dated 10/30/2020, indicated Resident 1 had a risk for leaving the facility related to constant aimless pacing due to mental illness. The care plan interventions indicated to monitor Resident 1 at frequent intervals, redirect Resident 1 to alternative activities and if indicated to provide 1:1 monitoring on an interim basis to redirect behavior. A review of Resident 1's Monitoring Notes titled, Fire Watch, dated 10/30/2020 indicated Resident 1 had an altercation with Resident 2 in the smoking patio at 1:05 p.m. According to a review of the Change of Condition form, dated 10/30/2020, at 5:30 p.m., Resident 1 was screaming at Registered Nurse Supervisor (RNS) 1 demanding a cigarette. Resident 1 continued to scream until RNS 1 gave him a cigarette. At 8 p.m., Resident 1, while holding a water pitcher, asked RNS 1 for another cigarette. RNS 1 informed Resident 1 that there were no more cigarettes. Resident 1 suddenly poured the contents of the water pitcher on RNS 1 and screamed an expletive with both his fist closed and arms stretched on his side. The COC form indicated Resident 1 remained agitated and RNS 1 called the police. At 9:20 p.m., the police arrived and found Resident 1 inside a closet wearing underpants only. The police interviewed Resident 1 and Resident 1 returned to his room. The COC indicated at 10 p.m., a message regarding the incident was left for Resident 1's psychiatrist office. During a telephone interview on 11/5/2020, at 2:53 p.m., RNS 1 stated on 10/30/2020, at 5 p.m., Resident 1 demanded to have a cigarette and RNS 1 gave Resident 1 a cigarette. At about 8 p.m., RNS 1 stated Resident 1 asked for another cigarette and RNS 1 stated there were no more cigarettes to give Resident 1. RNS 1 stated Resident 1 threatened her and started yelling at her. RNS 1 stated Resident 1 threw the contents of the pitcher at her. RNS 1 stated her clothes, hair, the chairs in the nurse's station, computer and the floor were wet. RNS 1 stated Resident 1 would not calm down and RNS 1 had to call the police because she needed help. RNS 1 stated she was so emotionally hurt that she could not continue her shift. During a telephone interview and concurrent record review on 11/9/2020, at 1:21 p.m., RNS 3 stated on 10/30/2020 at 10 p.m., a voicemail was left for Resident 1's psychiatrist regarding Resident 1's aggressive behavior. RNS 3 was unable to find documentation that the psychiatrist returned the call. RNS 3 stated the psychiatrist should have been notified of the aggressive behavior. On 11/10/2020, at 2:30 p.m., during a telephone interview, the director of nursing (DON) stated it would have been ideal if Resident 1 had a 1:1 sitter and stated it was difficult to find extra staff during the weekend. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] (disorder in which nerve cell activity in the brain is disturbed causing seizures) and hypertension (increased blood pressure). A review of Resident 2's H and P, dated 1/18/20, indicated Resident 2 had the capacity to understand and make decisions. On 11/19/2020, at 8:37 a.m., during a telephone interview, Resident 2 stated he had an argument with Resident 1 on 10/30/2020. Resident 2 stated he was in the smoking patio and listening to the radio when Resident 1 came and tried to change the radio station. Resident 2 stated he did not want Resident 1 to change the station and had an argument. Resident 2 stated he was ready to fight Resident 1 physically. During a telephone conference interview with the DON, Administrator and assistant administrator on 11/24/2020, at 2:25 p.m., the Administrator stated Resident 1 became angry when Resident 2 was listening to the radio and Resident 1 changed the station. The commotion started and the radio was confiscated. A review of the facility's undated policy titled, Change of Condition, indicated all changes of condition in a resident shall be handled promptly. The physician shall be called promptly. The policy indicated if for some reason the physician cannot be reached, alternative physician shall be contacted. If the alternate cannot be reached, the medical director is to be contacted. All contacts or attempts to contact the physician shall be documented and include the correct time of the activity. A review of the facility's undated policy titled, Monitoring Residents, indicated those residents identified to have behavioral symptoms potential for conflict and anger shall be monitored in accordance with the care plans to address such problems.

Based on observation, interview, and record review, the facility failed to ensure its resident receives adequate supervision and assistance devices to prevent falls and minimize injuries for one of three sample residents (Resident 1), including: 1. Failure to ensure Resident 1, who was assessed as requiring two-person physical assist with bed mobility and personal hygiene, was provided with the necessary assistance. 2. Failure to implement the facility's policy on Resident Care Plan which indicated the care plan acts as a communication instrument between nursing staff and contains important information pertaining to the care. Resident 1's care plan the need of two-staff physical assistance with bed mobility and personal hygiene as indicated in comprehensive assessment. 3. Failure to implement the facility's policy on Accidents/Incident Prevention, by allowing avoidable accidents due to lack of provision of adequate care plans with procedures to prevent accidents. 4. Failure to implement the facility's policy on Positioning and Moving Residents, by not ensuring staff members are to use maximum precautions when moving residents including obtaining assistance from other staff as needed. 5. Failure to implement the facility's policy on Accident Reduction: Useful Interventions, by not utilizing useful interventions including two-person assisted transfer as indicated. As a result, on 3/26/18, at 12:40 p.m. Resident 1 fell out of bed when Certified Nursing Assistant 1 (CNA 1), without another staff, turned Resident 1 in bed during the provision of incontinent care, causing Resident 1 a fracture (break) of the right femur (thigh bone). Resident 1 required hospitalization . Findings: On 4/10/18 at 8:15 a.m., an unannounced visit was made to the facility to investigate a facility reported incident regarding quality of care. A review of the Admission Record dated 1/16/18, indicated Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 1/26/18, indicated Resident 1 was unable to verbally communicate and was totally dependent of staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident 1 required two or more person physical assist with bed mobility, transfer, and toilet use. A review of the Rehabilitation Screening form dated 8/11/15, 11/3/15, and 10/26/17, indicated Resident 1 required two or more person physical assist with bed mobility and transfers. A review of the Care Plan revised on 11/1/17, developed for Resident 1's self-care deficits related to cognitive deficits, communication deficits, poor safety awareness, and joint limitations, did not include in the interventions two-person physical assistance with bed mobility and personal hygiene as assessed in the MDS. A review of the Change of Condition form dated 3/26/18 at 5:30 a.m., indicated Resident 1 rolled over from the bed to the floor. CNA 1 reported Resident 1 rolled over and fell when turning her. When checked, resident was seen at bedside with right leg under her body. Resident was in pain. The attending physician was notified and ordered x-rays. A review of the Radiology Report, dated 3/26/18, indicated Resident 1 had an acute impacted distal femoral (area of the leg just above the knee joint) shaft fracture. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1). A review of the GACH 1 Interdisciplinary Note, dated 3/30/18 indicated, Resident 1 was treated with conservative care (no surgery) with a knee immobilizer splint. On 4/10/18, at 9:05 a.m., Resident 1's room was observed with the Assistant Director of Nursing (ADON). Resident 1 had an electric bed with bilateral side rails that did not extend past the head. Posted at the head of the bed, on the wall, was a, POP sign with a picture of a basket of popcorn, and indicated: two-person assist, handle gently, and follow the plan of care. The ADON stated the sign was present when Resident 1 had fallen. On 4/10/18, at 9:10 a.m., during an interview, the ADON stated CNA 1 should not have turned Resident 1 alone. Resident 1 was not able to follow commands and was obese. On 4/10/18, at 9:15 a.m., during an interview, CNA 1 stated he started was providing perineal (area around the anus and genitals) care without another staff assistance. Resident 1 began to move her left leg when she was on her right side. Before CNA 1 could catch her, Resident fell out of the bed onto the floor. CNA 1 confirmed the presence of the, POP sign but could not explain why he did not ask another CNA's assistance. CNA 1 stated, I did the best I could by myself. On 4/10/18, at 9:31 a.m., the director of staff development (DSD) was interviewed. The DSD stated CNA 1 should not have turned Resident 1 without assistance. On 4/10/18, at 10:00 a.m., the self-care deficit care plan was reviewed with the ADON. The ADON stated the charge nurses communicate the resident's care needs, however, a CNA reviewing the care plan might not know what dependent means. The ADON indicated the support required during care should be included in the care plan interventions. A review of the undated policy on Procedure: The Resident Care Plan, indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professionals involved in the care of the resident shall contribute to the resident's written care plan. The nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. A review of the undated policy on Positioning and Moving Residents, indicated all staff members are to use maximum precautions when moving or lifting residents, these include but not limited to: Obtain assistance from other professionals as needed; Use hydraulic left or mechanical lift as necessary, and always with two persons assisting. A review of the undated facility's policy titled, Accidents/Incident Prevention, with last revision date 3/5/18, indicated the facility strive to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents, and provision of adequate care plans with procedures to prevent accidents. Another undated facility's policy titled, Accident Reduction: Useful Interventions, indicated useful interventions will be utilized to reduce accidents and injuries. Useful interventions should help reduce accidents and injuries includes two-person assisted transfer as indicated.

Based on observation, interview, and record review, the facility failed to ensure the residents' food (119 of 12 residents were prepared free from chemical and biological (related or caused by a living organism) contamination (making something impure or suitable by contact with something unclean or bad), and in a sanitary condition by failing to ensure that: (1) The only sink in the kitchen where water was obtained for food preparation and drinking was not attached to a dish washing detergent dispenser. After detergent was dispensed from the faucet, and then turned off, there was residual detergent left in the water line. The residual detergent therefore mixes with the water in the faucet that is being used for drinking, washing fruits and vegetables, cooking and other uses in the kitchen. This had the potential to affect 119 of 121 residents. (2) The kitchen staff was not preparing food in the same sink in which pots and pans were being washed. This had the potential to affect 119 of 121 residents. (3) The sanitizing bucket had quaternary ammonia concentration of 150 parts per million (ppm), instead of 400 ppm. This level of sanitizer was more than twice the recommended level of 150 ppm, the recommended level for quaternary ammonia. These deficient practices had the potential to result in physical harm to 119 of 121 residents in the facility due to chemical and bacterial contamination of food and water. (4) The food holding temperature for cold food was below 40 degrees Fahrenheit, and the hot food above 140 degrees Fahrenheit. This had the potential to affect 119 of 121 residents. A situation of Immediate Jeopardy (IJ) was declared by the survey team on June 10, 2015 at 12:33 p.m. The facility administrator and director of nursing were informed of these serious findings. The facility submitted an acceptable immediate plan of action on June 10, 2015 at 4:51 p.m., to address the immediate jeopardy concerns. The plans included the removal of soap dispenser hose from the faucet in the kitchen sink; run sufficient water through the piping to ensure no soap residue was left in the faucet; provide bottled water to residents, install a new three compartment sink; change the procedure for pots and pans washing. The situation of immediate jeopardy was lifted on June 12, 2015 at 4:35 p.m., and the facility administrator, director of nurses, and director of staff development were notified. Findings: a. During kitchen observation on June 10, 2015 at 11:00 a.m., Dietary staff G (DS G) was observed adding water to pitchers containing cranberry and orange juice concentrate. There were a total of four pitchers. The pitchers had been placed in one of the two compartment of a sink in the kitchen. There were two large signs on the wall above the sink. The sign on the left side read meat and the one of the right hand side read fruit and vegetables only. DS-G then proceeded to the tray assembly area with only two pitchers of cranberry juice ready to pour into individual glasses for resident consumption. There was no other sink in the kitchen except for the hand washing sink. At 11:02 a.m., another employee, Dietary staff H (DS-H) was observed to add water to two pitchers containing ice cubes. DS-H was later observed on June 10, 2015 at 11:05 a.m., pouring out the ice and water mixture into individual cups for resident consumption. These cups of iced water, approximatey 12, were later observed placed on residents' trays for meal distributions. Closer inspection of the sink in which DS-G and DS-H dispensed water into pitchers revealed pink colored tubing attached to the faucet. Attached to this tubing underneath the sink was a container with a pink colored liquid labeled pots and pan detergent. The sink had stacks of dirty pots and pans. One of the cooks (Cook A) and one of the dietary supervisors (DSS 2) were asked on June 10, 2015, at 11:06 a.m., to demonstrate how the soap dispenser was used. Cook A pulled out a button attached to the faucet and a sudsy liquid flowed out of the faucet. Cook A was asked to turn off the detergent and fill a container with water. After the detergent dispenser was turned off, there was continuous flow of suds and bubbles mixed with water for several seconds being dispensed when only water from the faucet was turned on. DSS 2, who was not an employee of the facility but had been called in to help the facility in the absence of the facility's full time food service director, was also asked to repeat the same process. DSS 2 stated that he had observed the set-up of the sink with a soap dispenser that morning and was concerned about possible contamination when he mixed the juice that morning. He further stated on June 10, 2015 at 11:07 a.m., the faucet needs to run for several seconds to clear the line with detergent before water from the faucet should be used. The corporate dietitian was interviewed on June 10, 2015 at 1:15 p.m., about concerns related to cross-contamination of the water with soap from the detergent dispenser. She did not provide any response to questions raised about the lack of identification of the contamination risk. No information was provided on why the food preparation sink was being used for pot washing. Review of the Material Safety Data Sheet (MSDS, a technical document which provides detailed and comprehensive information on a controlled product related to: health effects of exposure to the product; hazard evaluation related to the product's handling, storage or use measure to protect workers at risk of exposure emergency procedure (www.uregina.ca)) for the detergent titled Pink Suds/Pots and Pan, indicated Manual Warewashing Detergent. The MSDS also recommends under the subheading handling and Storage, Do not ingest. Do not get in eyes, on skin or on clothing . b. Observation on June 9, 2015 at 8:30 a.m., June 10, 2015 at 11:00 a.m., and 5:45 p.m., showed kitchen staff stacking up dirty pots and pans in the sink labeled for meat and vegetables only. This practice increased the risk of both biological and chemical contamination. On June 10, 2015 at 8:45 a.m., the concern about the use of the kitchen sink for both food preparation and dish washing was raised with Cook A. Cook A stated that prior to meal preparation, she ensured that the sink was cleaned and sanitized with the quat (quaternary ammonium) sanitizer. Cook A showed both products used to surveyor. Subsequent observations did not observe that the kitchen staff cleaning the sink before food preparation took place. On June 10, 2015 at 12:00 p.m., Cook B was observed draining the spaghetti in the sink. Two dietary aides, Dietary Aide G and Dietary Aide H, were observed filled up water pitchers in the sink, with dirty pots and pans in the sink. Dietary Aide G and Dietary Aide H, were not observed to wash and sanitize the sink prior to use. Dietary Staff G was observed on June 10, 2015 at 11 a.m., to have placed the four piychers of juice inside the sink. The bottom of the pitchers was contaminated with any substance that was inside the sink. There was concern also about the use of this sink for meat on one side and fruits and vegetables on the other side. There was no barrier separating the meats from the vegetables. (Raw meat and poultry can carry harmful bacteria and microorganisms such as salmonella, listeria, campylobacter etc. These bacteria could splash on to raw fruits and vegetables and cause illness because would not be destroyed because they would not be heat-treated. The soil from fruits and vegetables could carry harmful bacteria such as E. coli and contaminate meat. Some bacteria may be destroyed by the cooking process while others which produce toxins are not affected by heat and could still be hazardous to the health of the residents.) In addition, during meal service on June 10, 2015 at 11:35 a.m., Cook B was observed preparing garlic toast next to a red bucket of sanitizing solution. On June 10, 2015 at 2:00 p.m., another red bucket was observed containing sanitizing solution on the drain board of the meat/vegetables sink. The sanitizing solution was next to the cook spaghetti being drained by cook B. An accidental bump of these buckets could result in a splash which could contaminate garlic toast being prepared. Section 7-201.11 of the 2013 Food Code states poisonous or toxic materials shall be stored so that they cannot contaminate food, equipment, utensils, linens and single-service. A test of one the sanitizing buckets on June 10, 2015 at 8:30 a.m., showed a concentration of 400 parts per million (ppm). This level of sanitizer was more than twice the recommended level of 150 ppm, the recommended level for quaternary ammonia. The consultant RD in an interview on June 10, 2015 at 4:00 p.m. acknowledged the absence of the splash guard. The consultant RD stated it was not identified as a risk when environmental and sanitation issues were being reviewed in the kitchen. She stated that she had not observed the sanitizing buckets on the counters. c. On June 9, 2015 at 12:10 p.m., during a lunch tray line observation, a pan of baked chicken (breast, wing, and leg pieces) was observed on the steam table. In the presence of surveyor, and dietary supervisor, Cook A obtained the temperature of baked chicken in three different chicken pieces. The temperature readings were 125.0 degrees Fahrenheit, 130.0 degrees Fahrenheit, and 135.0 degrees Fahrenheit at the steam table. During an observation, there were three flame burners underneath the steam table, the center flame burner was observed not on. The baked chicken in the pan was position above the flame burner that was not on. On June 9, 2015 at 12:15 p.m., during an interview with dietary service supervisor (DSS), he stated that he was not aware that the flame burner was not turn on. He stated that he would immediately remove the chicken pieces from the steam table that were not at the appropriate hot holding temperature of 140 degrees Fahrenheit and above. A review of the residents' dinner Weekly Menu Guide for June 9, 2015 indicated the residents will have pepper pot soup, tuna salad sandwich, pea and cheese salad, brownie and beverages. On June 9, 2015 at 5:00 p.m., during a dinner tray line observation, the surveyor, in the presence of the dietary supervisor and Cook A, observed the following: 1. There were peas and cheese salad on the steam table. The temperature was measured and the reading was from 53 to 65 degrees Fahrenheit. A review of the recipe for pea and cheese salad indicated the ingredients to be combine and toss lightly were hard cooked eggs, mayonnaise, green peas, chopped celery, and diced cheese. 2. There were puree peas and cheese salad, the temperature was measured and the reading was at 70 degrees Fahrenheit at the steam table. 3. There were ready-to-eat wheat bread and white bread tuna salad sandwiches observed on pan placed on top of the steam table. The temperature was measured and the reading was from 43 to 62 degrees Fahrenheit. A review of the recipe for tuna salad sandwich revealed the ingredients were tuna, hard cooked eggs, mayonnaise, chopped celery and diced cucumber. 4. There were puree tuna observed on a pan at the steam table. The temperature was measured and the reading was 55 degrees Fahrenheit. On June 9, 2015 at 5:20 p.m., during an interview with the DSS supervisor, he stated that the cook should have not placed the tuna salad sandwiches and peas and cheese salad on the steam table. DSS could not explain why the dietary staff placed the tuna salad sandwiches, peas and cheese salad on top of the steam table with the flame on low heat. He stated that he will immediately dispose of the tuna sandwiches, the peas and cheese salad, and provide an alternate menu substitute for the residents. According to the facility policy and procedure titled, Holding Food Temperatures, not dated indicated the facility will ensure that food holding temperatures for cold foods will be maintained at 40 degrees Fahrenheit or less and hot foods will be maintained at 140 degrees Fahrenheit or above.

Based on observation, interview, review of facility documents and record review, the facility failed to ensure that 49 residents, including five of 24 sampled residents (2, 3, 4, 7, 24) on mechanically altered diets, received therapeutic diets as ordered by their physicians. The facility staff failed to provide the correct diet based on the texture, size of food, consistency of liquids. This deficient practice placed the residents at risk of choking and aspiration pneumonia. In addition, facility staff failed to provide 95 non-sampled residents the proper diets as ordered by their physicians when they failed to honor food preferences, serve correct portion sizes, texture and prepare food with correct calories and protein based on the diets and ordered by the physicians. These deficient practices placed the residents at risk for weight loss/gain and malnutrition. A situation of Immediate Jeopardy (IJ) was declared by the survey team on June 9, 2015 at 5:30 p.m. The facility administrator and director of nursing were informed of these serious findings. The facility submitted an immediate plan of action on June 10, 2015 at 6:00 p.m., to address the immediate jeopardy concerns. The Immediate Jeopardy was lifted on June 12, 2015, at 4:35 p.m., following a review and validation of the facility's submitted plan of correction that included relieving the dietary service supervisor and replacing with registered dietician (RD) to supervise the operations of the kitchen, including the tray line and food distribution to residents, the RD will provide in-service to all licensed nurses, certified nursing assistant, and kitchen staff to ensure resident received diet as ordered by the physician, all licensed nurses will check the meal trays according to the physician diet orders, all residents will be re-assessed to ensure they are on the proper diet, and to ensure all cooks and dietary staff knows the correct portion measurement. The facility administrator, director of nurses, and director of staff development were notified. Findings: According to the facility policy and procedure manual dated 2008 and reviewed on June 11, 2015, titled Mechanical Soft (Dental Soft) Diet, a Mechanical soft or dental diet is used for individuals who have difficulty chewing regular textured foods. The second document titled Mechanical (Dental Soft) Diet, dated 2014, reviewed on June 11, 2015 states . The foods are modified in texture by chopping, dicing and grinding. It is recommended that most foods be served moist to facilitate chewing and swallowing. On June 9, 2015, at 7:45 a.m., during an observation of the breakfast meal tray distribution to residents, the surveyor, in the presence of the director of staff developer, and registered nurse (RN 10) the following was observed reviewing tray cards against what was served to the residents (The meal card is a mechanism (cards or paper placed on trays) used in dietary services to communicate to trayline and dining room staff physician orders [REDACTED]. Choking Risk 1. The meal card on the tray for Resident 7 indicated a puree diet prescribed by the physician. The resident's meal tray had a box of Cheerio cereal. According to the menu and therapeutic spreadsheet for that meal, residents on pureed diets should have received cream of rice. Review of the meal tray card for Resident 7 did not indicate a dislike for cream of rice or preference for cheerios. The dry cereal could cause choking. 2. The meal card on the tray for non-sampled Resident 6 indicated a nectar thick liquid diet prescribed by the physician. The resident's meal tray had eight ounces of mocha mix that was not thickened to nectar consistency. Diet not served as ordered by physician or according to meal card (preference) 3. The meal card on the tray for Resident 2 indicated yogurt for all meals. The resident's meal tray did not have yogurt. 4. The meal card on the tray for non-sampled Resident 2 indicated dry cereal for breakfast. The resident's meal tray did not have dry cereal. 5. The meal card on the tray for non-sampled Resident 3 indicated two tortillas given at all meals. The resident's meal tray did not have two tortillas. 6. The meal card on the tray for non-sampled Resident 4 indicated flour tortillas given for breakfast. The resident's meal tray had two French toasts instead of flour tortillas. The resident was eventually given corn tortillas, not the flour tortillas as preferred. 7. The meal card on the tray for non-sampled Resident 7 indicated hard boiled eggs given on Monday, Wednesday, and Friday. The resident's meal tray had two hard boiled eggs, Tuesday, June 9, 2015. On June 9, 2015, starting at 12:45 p.m., during a kitchen observation of the lunch meal tray to be distributed to residents, the surveyor, in the presence of RN 1, RN 2, and DSD, the following was observed: Choking Risk 1. The meal card on the tray for non-sampled Resident 6 indicated a mechanical soft diet prescribed by the physician. The resident's meal tray had a whole portion of a chicken leg and wing piece that was not mechanically soft. 2. The meal card on the tray for non-sampled Resident 9 indicated a mechanical soft (finely chopped) diet prescribed by the physician. The resident's meal tray had a whole portion of a chicken breast and wing piece that was not mechanically soft (finely chopped). 3. The meal card on the tray for non-sampled Resident 13 indicated a nectar thick liquid diet prescribed by the physician. The resident's meal tray had four ounces of cranberry juice and four ounces of milk that was not thickened to nectar thicken consistency. An incorrect liquid consistency could result in choking.) 4. The meal card on the tray for Resident 4 a nectar thick liquid diet prescribed by the physician. The resident's meal tray had four ounces of milk that was not thickened to nectar consistency. 5. The meal card on the tray for non-sampled Resident 2 indicated a regular vegetarian diet prescribed by the physician for all meals and salad for lunch and dinner. The meal card also indicated [MEDICATION NAME] and a sippy cup. The resident's meal tray had two pieces of whole chicken. The resident did not receive [MEDICATION NAME] or a sippy cup. The sippy cup is a type of cup used to control the rate of flow of liquids to prevent choking. Diets not served as ordered by physician or according to meal card (preference) 6. The meal card on the tray for non-sampled Resident 8 indicated a regular diet prescribed by the physician. The resident's meal tray had puree chicken, puree corn, and puree spinach. 7. The meal card on the tray for non-sampled Resident 14 indicated large portions for meals. The physician's orders [REDACTED]. The diet order did not indicate large portions. The resident's meal tray had three whole pieces of chicken that was not mechanically soft, chopped. 8. The meal card on the tray for non-sampled Resident 7 indicated a regular diet prescribed by the physician. The resident's meal tray had puree chicken, puree corn, and puree spinach. 9. The meal card on the tray for Resident 24 indicated two ounces of extra meat portion for lunch and dinner. The physician diet order indicated a mechanical soft diet with two ounces of meat with lunch. The resident's meal tray had six ounces of puree meat. 10. The meal card on the tray for non-sampled Resident 12 indicated double portions prescribed by the physician. The resident's meal tray had regular portions of chicken, two pieces, corn, and spinach. It was not clear how much food should have been served for the double portion but according to the therapeutic spreadsheet, residents on large portion, (less food than double portion) should have received 4-1/2 ounces of the herb roasted chicken. 11. The meal card on the tray for Resident 2 indicated cranberry juice all meals. The resident's meal tray did not have cranberry juice. 12. The meal card on the tray for non-sampled Resident 16 indicated fruit plate with cottage cheese for lunch and dinner. The resident's meal tray did not have a fruit plate with cottage cheese. On June 9, 2015, at 1:00 p.m., during an interview with the Dietary Supervisor (DSS 1), he stated he could not explain why the dietary staff did not serve residents' meal as indicated in their meal card. He also stated that the staff were just not reading the meal cards. On June 9, 2015 at 3:00 p.m., dietary staff 1 (the dietary staff who was observed reading the meal card to cook 1 at lunch tray line observation) was interviewed and asked to read resident ' s meal card. Dietary Staff 1 did not know how to read the resident's meal card that was written in English. On June 9, 2015, starting at 6:00 p.m., during a kitchen observation of the dinner meal tray distribution to residents, the surveyor, in the presence of RN 1, RN 3 and DSD, the following were observed: Choking Risk 1. The meal card on the tray for non-sampled Resident 17 indicated eight ounces of water for all meals and a nectar thick liquid diet prescribed by the physician. The meal tray did not have eight ounces of water. The resident's meal tray had four ounces of milk and four ounces of apple juice that were not thickened to nectar consistency. 2. The meal card on the tray for non-sampled Resident 24 indicated thin liquid diet prescribed by the physician for all meals. The resident's meal tray had four ounces of thickened orange juice. Diets not served as ordered by physician or according to meal card (preference) 3. The meal card on the tray for non-sampled Resident 18 indicated eight ounces of water for all meals. The resident's meal tray did not have 8 ounces of water. 4. The meal card on the tray for non-sampled Resident 19 indicated apple juice for all meals. The resident's meal tray did not have four ounces of apple juice. The resident received four ounces cranberry juice. 5. The meal card on the tray for non-sampled Resident 20 indicated two margarines for all meals. The resident's meal tray did not have two margarines. 6. The meal card on the tray for non-sampled Resident 21 indicated the resident preferred soup for lunch and dinner. The resident's meal tray did not have soup. 7. The meal card on the tray for non-sampled Resident 22 indicated mashed potatoes for lunch and dinner. The resident's meal tray did not have mashed potatoes. 8. The meal card on the tray for non-sampled Resident 2 indicated a regular vegetarian diet prescribed by the physician for all meals, and salad for lunch and dinner. The resident's meal tray did not have salad. 9. The meal card on the tray for Resident 3 indicated mocha mix for all meals. The meal card also indicated not to give milk. The resident's meal tray had four ounces of milk, instead of mocha mix. 10. The meal card on the tray for non-sampled Resident 25 indicated mocha mix for all meals. The resident's meal tray had four ounces of milk. 11. The meal card on the tray for non-sampled Resident 26 indicated low fat milk and apple juice for lunch and dinner. The resident's meal tray did not have low fat milk and apple juice. 12. The meal card on the tray for non-sampled Resident 27 indicated mocha mix for all meals. The resident's meal tray did not have mocha mix. On June 9, 2015, at 7:00 p.m., during an observation of the dinner meal in the dining room, a facility staff (AC 1) was observed setting up the tray for Resident 17. On Resident 17's tray, there was a bowl of soup, a bowl of peas and cheese salad, a plate with grilled cheese sandwich cut into two (triangular) pieces. According to her meal tray card, she was on a Mechanical soft diet. Due to concerns about choking risk, due to the grilled cheese not being cut into smaller pieces, AC 1 was asked if Resident 17 was a dependent dinner (needed to be fed) or was she a self -feeder. AC 1 stated she would help her eat and that she also provides supervision. At 7:03 pm Resident 17 was observed to eat the soup on her own and then proceeded to reach for the grilled cheese sandwich. AC 1 had not cut the sandwich into smaller pieces or provide instructions to Resident 17 on how to safely eat the sandwich. At 7:05 pm Resident 17 took a bite of the sandwich and started to chew. AC 1 was called and asked by the surveyor to remove the plate of the uncut sandwich. In an interview on June 9, 2015 at 7:10 pm, with the Activity director (AD) who was present during the observation, she stated AC 1 was an activity staff and not a certified nursing assistant (CNA). (Certified nursing assistants, speech therapists, and licensed nursing staff are the only facility staff that are allowed by law to feed residents.) She further stated that AC 1 does not normally feed or assist residents in the dining room and she was not sure why she did so at this meal. During the observation, AD was not observed to ask AC 1 not to feed or assist the resident. According to the facility diet manual reviewed on June 10, 2015, under the heading Mechanical Soft (Dental Soft,) dated 2008, breads that are dry, tough or crusty, should be avoided. Under the description of the Mechanical (Dental Soft) diet, in a second facility diet manual dated 2014, the size of food classified as chopped should be approximately ¼ to ½ (inches). Chop fine, Diced or minced 1/8 to 1/4 pieces. Review of employee record for AC 1 on June 11, 2015 showed she was not a CNA and neither had she received any specialized training on feeding residents. Random observation throughout the facility showed other residents on mechanical soft diets that had received the grilled cheese sandwich without being cut into smaller pieces that would have ensured safe swallow. As a result of the immediate jeopardy called, DSS 1 decided not to serve the tuna salad that was on the menu and originally prepared for service. Instead, grilled cheese was substituted for the tuna salad due to concerns about serving temperatures. The temperature of the tuna salad was 55 degrees Fahrenheit instead of 40 degrees Fahrenheit or below. (Cross refer F456) The grilled cheese served did not have the same amount of protein as the tuna salad that should have been served. According to the menu pattern for dinner for the week of 06/07/15 through 06/13/15, the protein content at dinner is 3 ounces (or 21 grams of protein). Observation on June 9, 2015 at 6:15 pm showed Cook A preparing grilled cheese with only one slice of cheese. Review of the nutrition information on the packaging showed the serving size was 2 slices of cheese and 5 grams of protein. The grilled cheese provided to the residents contained 2.5 grams of protein. The grilled cheese sandwich provided significantly less protein 2.5 versus 21 grams than was planned by the RD. There were 95 residents on other diets that was not mechanically altered. The dietary services supervisor DSS 1 stated in the concurrent interview that he was not aware that the cheese did not provide adequate protein. In an interview on June 9, 2015 at 5:45 pm with Cook A, who was serving egg salad, she indicated that some kind of sandwich is prepared every meal for residents as a substitution including grilled cheese. If the facility provided the grilled cheese sandwich with inadequate protein and calories, long term it could result in weight loss for residents who may consistently request this menu item. The inadequate protein was not in line with what had been ordered by the physician for residents on a regular diet. On June 11, 2015, starting at 12:35 p.m., during a kitchen observation of the lunch meal tray to be distributed to residents, the surveyor, in the presence of RN 10, RN 2, RN 3, and DSD, the following were observed: 1. The meal card on the tray for non-sampled Resident 22 indicated no Mexican food. The resident's meal tray had two tacos, Spanish rice, Spanish green beans, and sour cream with salsa. 2. The meal card on the tray for non-sampled Resident 24 indicated large portion for meals. The resident's meal tray had regular portions with two tacos, Spanish rice, and Spanish green beans. According to the therapeutic spreadsheet, the large portion diet, receives one a half times the main entrée of the regular diet. On June 11, 2015, at 1:00p.m., during an interview with dietary supervisor 3, she stated she could not explain why the cook 2 had served Spanish food items to the non-sampled Resident 22 when it was indicated not to give Mexican food on the resident's meal card. She also stated she could not explain why the tray line person communicated to cook 2 to served Mexican food to non-sampled Resident 22. In an interview conducted on June 11, 2015 at 1:00 pm with the registered dietitian (RD) and temporary dietary services supervisor (DSS 3), the RD acknowledged the description and guidance of the diet manual. She also showed that the kitchen staff had followed the menu on June 11 and that it did not indicate the items needed to be cut into smaller pieces for residents on mechanical soft diets. The menu had provided instructions and preparation methods and recipes that were contrary to the diet manual. The RD failed to identify the discrepancy and provide guidance to the kitchen staff on the proper preparation method to avoid choking. (cross refer F371)