Every finding on record at Camden Postacute Care, Inc

Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1) following hospitalization when Resident 1 was ready to be discharged from an acute care hospital on 7/13/26 and facility indicated there was no available isolation room. Facility staff did not review Resident 1's current clinical information to determine the appropriate infection control precautions and did not explore alternative room placement options. This failure delayed Resident 1's return to the facility.Findings:Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was a long-term resident with diagnoses that included Bilateral Primary Osteoarthritis of Knee (wear and breakdown of cartilage in both knee joints) and Acute Embolism and Thrombosis of Deep Veins of Lower Extremity (blood clot in the deep vein of the leg).Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) dated 7/1/26 indicated Resident 1 returned to the facility at approximately 7:00 p.m. following hospitalization. Within approximately two hours, Resident 1 developed chills, a fever, warmth in both knees, and redness around the right-knee surgical incision. Staff notified the physician, who ordered Resident 1 to be transferred back to the emergency department.Review of Resident 1's Admissions online referral record dated 7/13/26 indicated the facility entered Decision Pending Review, with the comment, NO ISO (isolation) BED AVAILABLE.During an interview with the Infection Preventionist (IP) on 7/29/26 at 12:30 p.m., the IP stated the facility did not have a private isolation room available. The IP stated she recommended placing Resident 1 in a private isolation room because Admissions staff informed her that Resident 1 was positive for MRSA (Methicillin-resistant Staphylococcus aureus. It is a type of staph bacteria that has developed a resistance to many of the common antibiotics typically used to treat infections) involving the knee. During an interview with the Director of Nursing (DON) on 7/29/26 at 12:50 p.m., the DON stated Resident 1 had not returned because the facility did not have private isolation room available.During an interview with the Admissions Coordinator (AC) on 7/29/26 at 2:10 p.m., the AC stated she received a call on 7/7/26 from the acute care Case Manager (CM) that Resident 1 was ready to return to the facility. The AC told the hospital CM that the facility did not have a private isolation room available.Review of the facility's daily census dated 7/8/26 and 7/13/26 indicated Rooms A and B were two-bed rooms. Each room had one empty bed and one bed occupied by a male resident.During a phone interview with the IP on 8/4/26 at 3:47 p.m., the IP stated she did not have information about the condition of Resident 1's wound. The IP stated she did not know whether the wound was draining or whether drainage could be contained. The IP stated she knew only that Admissions staff reported that Resident 1 had MRSA involving the knee. The IP stated a resident with active MRSA required a private room. The IP further stated Resident 1 returned on 8/1/26, shared a room with another resident, and was placed on Enhanced Barrier Precautions while continuing oral antibiotic (ATB, treatment for bacterial infections) treatment through 8/15/26.During a phone interview with the DON on 8/10/26 at 12:31 p.m., regarding Resident 1's admission referral record dated 7/13/26, the DON stated the interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) required Resident 1 to remain in contact precautions in a private room because the hospital CM reported that Resident 1 had active MRSA and was receiving IV (intravenous, within a vein) antibiotic. The DON stated the facility staff did not review Resident 1's wound condition, current laboratory results, or the hospital's precaution orders before making the private isolation room decision. The DON also stated that when the facility readmitted Resident 1 on 8/1/26, the facility had no laboratory result indicating that Resident 1 no longer had an active MRSA infection. During a phone interview with the DON on 8/10/26 at 2:10 p.m., regarding facility's daily census dated 7/8/26, the DON stated facility staff did not consider moving other male residents into the same room to make a private isolation room available for Resident 1. The DON stated that when the facility readmitted Resident 1 on 8/1/26, his wound was closed and had no drainage, he had completed the IV ATB, and the physician had cleared Resident 1 for discharge. The facility placed Resident 1 in a shared room on Enhanced Barrier Precautions and Resident 1 continued to receive oral ATB.Review of the undated facility's policy titled Infection Control Policy For Multi-Drug Resistant Organism (MDRO) indicated .In LTC, it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protects the resident and others .each resident should be assessed for active signs and symptoms of infection. If symptoms are absent, isolation is not necessary in a LTCF .The decision to start isolation precautions .this decision should be based on the clinical assessment of the resident .placing MDRO residents in private rooms or cohorting becomes a secondary infection control measure and. NOTE: In the event a resident requires isolation precautions or separation from a roommate, where no other compatible roommate is available, a separation between roommates maybe accomplished by keeping the privacy curtain drawn at all times until separation is no longer required when symptoms of active infection have abated .Review of the CDC (Centers for Disease Control and Prevention) Frequently Asked Questions About Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, indicated nursing homes should use Contact Precautions for a resident with an MDRO when the resident has acute diarrhea, a draining wound, or other secretions that staff cannot cover or contain, or during a suspected or confirmed MDRO outbreak. When these conditions are not present, the facility may use Enhanced Barrier Precautions. Residents on Enhanced Barrier Precautions do not require a private room and may share a room with another resident. Review of the facility's readmission to the Facility dated 1/2018, indicated Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility .resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1 One can of grape juice in the dry storage room was dented and was not removed to prevent use; and 2. One pack of open cereal with no date when it was opened and no expiration date; 3. Refrigerator #2 had the following: 12 pieces of tomatoes inside a plastic bag container, three pieces of carrots inside a plastic bag, four pieces of white onions inside a plastic bag, 2 bunches of lettuce inside a plastic bag and one bunch of celery inside a plastic bag were not labeled and no date when it was delivered to the facility; and 4. Freezer #2 in front of the kitchen, there was one pack of cauliflower, and one pack of chopped spinach with no opened date or expiration date. These failures had the potential to result in a foodborne illness outbreak amongst a population of 55 vulnerable residents with complex medical conditions. Findings: 1. During an initial kitchen tour on 5/12/25 at 7:48 a.m., with the Dietary Manager (DM), she confirmed one can of grape juice in the dry storage room in the other building was dented and was not removed to prevent use. According to the United States Food and Drug Administration (FDA, a federal agency) indicated, A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. Review of the facility undated policy and procedure (P&P), titled, Food Storage - Dented Cans, indicated, food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility .All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. 2. During an initial kitchen tour observation and interview on 5/12/25 at 7:44 a.m., with the DM, she confirmed one pack of open cereal had no date when it was opened and no expiration date and the DM stated that it should have been dated when it was opened and with expiration date. 3. During an initial kitchen tour on 5/12/25, at 7:53 a.m., with the DM, refrigerator #2 had 12 pieces of tomatoes inside a plastic bag container, three pieces of carrots inside a plastic bag, four pieces of white onions inside a plastic bag, 2 bunches of lettuce inside the plastic bag and one bunch of celery inside a plastic bag were not labeled and no date when it was delivered to the facility. 4. During an initial kitchen tour on 5/12/25, at 7:55 a.m., with the DM, freezer #2 in front of the kitchen, there was one pack of cauliflower, and one pack of chopped spinach with no date or expiration date. Review of the facility undated P&P, titled, Labeling and Dating of Foods indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Based on interview and record review, the facility failed to ensure their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [ a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) for six of 8 sampled residents (Resident 10, 13,18,19,27, and 37). This failure could lead to the delivery of unnecessary or inappropriate medical services against sampled residents' goals and wishes. Findings: Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 10/24/24. Review of Resident 10's form for physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form prepared on 10/29/24 indicated section D for AD documented No Advance Directive. Further review of Resident 10's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 10 to execute an AD. Review of Resident 13's FS indicated Resident 13 was admitted to facility on 7/8/24. Review of Resident 13's POLST form prepared on 7/8/24 indicated section D for AD documented No Advance Directive. Further review of Resident 13's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 13 to execute an AD. Review of Resident 18's FS indicated Resident 18 was admitted to facility on 1/27/16. Review of Resident 18's POLST form prepared on 11/21/2019 indicated section D for AD documented No Advance Directive. Further review of Resident 18's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 18 to execute an AD. Review of Resident 19's FS indicated Resident 19 was admitted to facility on 11/2/20. Review of Resident 19's POLST form prepared on 10/21/20 indicated section D for AD documented Advance Directive not available. Further review of Resident 19's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 19 to execute an AD. Review of Resident 27's FS indicated Resident 27 was admitted to facility on 9/5/24. Review of Resident 27's POLST form prepared on 9/6/24 indicated section D for AD documented No Advance Directive. Further review of Resident 27's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 27 to execute an AD. Review of Resident 37's FS indicated Resident 37 was admitted to facility on 1/3/25. Review of Resident 37's POLST form prepared on 1/6/25 indicated section D for AD documented Advance Directive not available. Further review of Resident 37's clinical record indicated there was no documented evidence that the facility discussed, offered or assisted Resident 37 to execute an AD. During a concurrent record review and interview with the facility's social service director (SSD) on 5/14/25 at 1:45 p.m., the SSD reviewed POLST form for the above residents. The SSD confirmed there was no AD for the above residents. The SSD stated she did not discuss, offer or assist the residents to execute an AD. The SSD also stated she should have offered and assisted the residents to execute an AD. During a concurrent record review and interview with Registered Nurse (RN) A on 5/15/25 at 8:29 a.m., RN A reviewed POLST form for the above residents. RN A confirmed there was no AD for the above residents. RN A stated the SSD was responsible to follow up the AD for residents. RN A also stated SSD should have offered and provided assistance to execute an AD for residents. Review of facility's policy and procedure (P&P) titled, Advance Directive, release date January 2018, the P&P indicated, If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.

During a concurrent observation and interview on 05/12/25 8:40 a.m., with Resident 5, he was lying in bed with 1/2 both siderails up and stated he was using the 1/2 both rails for his turning and repositioning. During a concurrent interview and record review on 05/14/25 at 10:57a.m., with RN A, she reviewed Resident 5's clinical records documentation and stated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 5's bed. Review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS score was 15, intact cognition. Review of facility's policy and procedure (P&P) titled, Bed Rails, release date July 2017, the P&P indicated, The Interdisciplinary Team (IDT: interdisciplinary team, a group of healthcare professionals from different disciplines work together to provide and coordinate care for residents) will determine whether a resident should be provided with bed rails on his/her bed, based on individual assessment which includes the risk of entrapment. The facility must attempt to use appropriate alternatives prior to installing a side/bed rail. Assess resident for risk of entrapment from bed rail prior to installation. Review the risks and benefits of bed rails with the resident or resident representative. Prior to placing a side rail on the bed, informed consent will be obtained Based on observation, interview, and record review, the facility failed to follow their bed rails (side rails, bed rails, safety rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for six of 15 sampled residents (Resident 39,19,27,33,17, and 5) when: 1. There was no documentation that alternatives for side rails were attempted prior to installing bed rails; 2. There was no informed consent (IC, the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from resident or responsible parties (RP, individual designated to make decisions on behalf of the residents) including risks and benefits explained prior to installing bed rails; and 3. There was no documentation that an assessment for the use of bed rails and risk for entrapment prior to installing bed rails was done. These failures resulted in the residents and RP's not being fully informed of the risks of the use of bed rails and had the potential to place the residents at risk of serious injury. Findings: During an observation on 5/12/25 at 8:10 a.m., noted Resident 39's bed had partial bed rails up on both sides. Review of Resident 39's face sheet (FS, a document that gives resident's information at a quick glance) indicated Resident 39 was admitted to facility on 12/12/22. Review of Resident 39's minimum data set (MDS, resident's clinical and functional assessment tool) assessment dated [DATE] indicated Resident 39's brief interview for mental status (BIMS) score was 15 of 15 (score of 13-15: intact cognition). Review of Resident 39's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for the use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 39's bed. During an observation on 5/12/25 at 8:11 a.m., Resident 19's bed was noted with one partial bed rail up at the foot of the bed on left side. Review of Resident 19's FS indicated Resident 19 was admitted to facility on 11/2/20. Review of Resident 19's MDS assessment dated [DATE] indicated Resident 19's BIMS score was 15 of 15, intact cognition. Review of Resident 19's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 19's bed. During an observation on 5/12/25 at 8:20 a.m., Resident 27's bed was noted with partial bed rails up on both sides. Review of Resident 27's FS indicated Resident 27 was admitted to facility on 9/5/24. Review of Resident 27's MDS assessment dated [DATE] indicated Resident 27's BIMS score was 15 of 15, intact cognition. Review of Resident 27's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 27's bed. During an observation on 5/12/25 at 9:08 a.m., Resident 33's bed was noted with one partial bed rail up at the head of the bed on left side. Review of Resident 33's FS indicated Resident 33 was admitted to facility on 8/14/20. Review of Resident 33's MDS assessment dated [DATE] indicated Resident 33's BIMS score was 4 of 15 (score of 0-7: severe impaired cognition). Review of Resident 33's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 33's bed. During an observation on 5/12/25 at 9:23 a.m., Resident 17's bed was noted with one partial bed rail up at the head of the bed on left side. Review of Resident 17's FS indicated Resident 17 was admitted to facility on 3/28/17. Review of Resident 17's MDS assessment dated [DATE] indicated Resident 17's BIMS score was 5 of 15, severe impaired cognition. Review of Resident 17's clinical documentation indicated there was no documented evidence for bed rail assessment, alternatives attempted, risk versus benefits explained for use of bed rails, IC taken, and risk of entrapment assessment prior to installing bed rails for Resident 17's bed. During an interview with Registered Nurse (RN) A on 5/15/25 at 8:39 a.m., RN A confirmed the above residents had bed rail/s. RN A also confirmed there was no documented evidence for bed rails assessment, attempted alternatives, risk and benefits education, informed consent taken and risk for entrapment assessment completed before using bed rails for the above residents. RN A stated facility should have documented and followed their policy for bed rails for these residents.

Based on observation, interview, and record review, the facility failed to adhere with their infection prevention and control program to ensure proper hand hygiene and personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves ) were implemented during delivery of care to residents in the facility when: 1. Facility staff did not follow the Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, is a germ that is resistant to many antibiotics] in nursing homes) wearing personal protective equipment (PPE, is equipment used to prevent or minimize exposure to hazards such as gown and gloves) during wound dressing change to Resident 12 and during Foley catheter (F/C: a thin felxible tube inserted in to bladder [a body organ that stores urine] to drain urine) care to Resident 109; 2. Licensed Vocational Nurse (LVN) E did not perform hand hygiene in every glove changed during wound treatment observation; 3. Resident 25's unlabeled nebulizer (a medical device that delivers medication in the form of fine mist) container mouthpiece with tubing mask (plastic mask and tubing used as a connected to nebulizer) that was attached to the machine was exposed and touching the bedside table, the unlabeled yankauer suction tube (oral suctioning tool) tip catheter with tubing attached to the suction canister was stored inside the bedside drawer in an open plastic package; and 4. Facility staff did not perform hand hygiene prior to providing feeding assistance to Resident 23 during lunch time on 5/12/25. These failures had the potential to result in cross-contamination and the spread of infection between 55 residents in the facility. Findings: 1. During an initial tour observation on 5/12/25, at 7:57 and 7:59 a.m., a sign for EBP was posted on Resident 12's and 109's room door. Resident 109 was confined in bed and Resident 12 had a F/C anchored below the bladder level to the bed frame. During a review of Resident 12's admission record indicated his initial admission date was 11/4/24 and readmission date was 12/20/25. Resident 12 had diagnoses including sepsis with unspecified organism (a life-threatening condition where the body's response to infection causes damage to its own tissues and organs, and the specific causative organism is not identified), and infection and inflammatory reaction (body's response to an illness) due to indwelling urethral catheter and Methicillin-resistant Staphylococcus aureus (MRSA, is a type of staph infection that is resistant to certain antibiotics, making it harder to treat). During a review of Resident 109's admission record indicated he was admitted to the facility on [DATE] and Resident 109 had diagnoses including multiple sclerosis (a chronic neurological disorder) and with multiple pressure ulcer (bed sore, caused by prolonged pressure combined with shear) wounds. During an observation on 5/15/25, at 10:50 a.m., in Resident 109's room, Certified Nursing Assistant (CNA) F assisted Licensed Vocational Nurse (LVN) E to perform wound dressing change to Resident 109's multiple wounds. Both CNA F and LVN E were observed only wearing surgical disposable facemask and gloves, both CNA F and LVN E did not wear disposable gown. During an interview on 5/15/25, at 2:10 p.m., with the Director of Staff Development (DSD), the DSD stated when providing wound care, foley care and activities of daily living (ADL, the tasks of everyday life include eating, dressing, getting into or out of a bed or chair, taking a bath or shower) care to the residents with EBP, staff must wear PPE including gown and gloves, a facemask (optional) to perform care. During an interview on 5/16/25, at 9:55 a.m., with CNA F, CNA F stated she did not wear gown during Resident 109's wound dressing change and ADL care. CNA F further stated she did not wear gown when emptying Resident 12's urine bag or ADL care. During an interview on 5/16/25, at 10:02 a.m., with LVN E, LVN E stated she did not wear gown during wound dressing change to Resident 109. LVN E further stated she also forgot wearing gown during foley care to Resident 12. LVN E confirmed she should have worn PPE during wound care and foley care to both Resident 12 and 109, because they were on EBP, and a PPE cart was placed nearby their room in the hallway. During a follow-up interview on 5/16/25, at 10 a.m., with CNA G, CNA G stated she did not wear PPE during ADL care to a resident who was on EBP because it was not required except during handling a foley catheter with urine bag. During a follow-up interview on 5/16/25, at 11:05 a.m., with the Director of Nursing (DON), the DON confirmed staff should wear PPE during wound care, foley care and ADL care to the residents who were on EBP. The DON further stated staff had received in-services regarding PPE in the past and facility staff should follow instructions to implement appropriate PPE. During a review of the centers for disease control and prevention (CDC) titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, it indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html 2. During a wound treatment observation on 5/16/25 at 11:07 with LVN E, after washing her hands and putting pair of gloves she started to prepare the treatment supplies infront of the treatment cart outside Resident 5's room then locked the treatment cart using the same pair of gloves, she picked up and threw a medication cup with wound barrier into the garbage can that was attached to the treatment cart. LVN E dropped it on the floor then she opened the treatment cart using the same pair of gloves, put wound cream inside the medication cup, locked the treatment cart, touched the key, touched Resident 5's privacy curtain, bedside table with treatment supplies on top without changing gloves or performing hand hygiene. LVN E took out the used pair of gloves from the start of the treatment preparation and changed it to a new pair of gloves without performing hand hygiene. During a wound observation on 5/16/25 at 11:12 a.m., LVN E started to do the wound dressing treatment to Resident 5's different wound sites without performing hand hygiene in every change of gloves. During an interview on 5/16/25 at 11:50 a.m., with LVN E, she acknowledged the above observation and stated that she should perform hand hygiene in every change of gloves for each wound site to prevent contamination that could cause the spread of infections. Review of facility's P&P dated 2018, titled, Handwashing Hand Hygiene, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. During an initial observation tour of the facility on 5/12/25 at 8:46 a.m., Resident 25's unlabeled nebulizer container mouthpiece with tubing mask that was attached to the machine was exposed and touching the bedside table and the unlabeled yankauer suction tube tip catheter with tubing was attached to the suction canister was stored inside the bedside drawer in an open plastic package together with open wet wipes, lotion, mouth wash, paper, cardboard and an open tissue box . During a concurrent observation and interview with LVN O on 5/12/25 at 8:48 a.m., she confirmed the above observation and stated the nebulizer container mouthpiece should be stored inside the plastic bag after cleaning, label it with a date, resident's name and discard every seven days. She stated that the suction tip catheter with tubing should be stored inside the plastic bag, labeled with resident's name and store it on top of the bedside table to prevent contamination from personal items. She further stated that these are infection control issues. Review of the facility's policy and procedure (P&P) dated 1/2018, titled Departmental (Respiratory Therapy)- Prevention of Infection indicated, infection control considerations related to Medication nebulizers after completion of therapy: remove the nebulizer container, rinse the container, with fresh tap water, dry on a clean paper towel or gauze sponge, reconnect to the administration set - up when air dried, take care not to contaminate internal nebulizer tubes , wipe the mouth piece with damp paper towel or gauze sponge , store the circuit in plastic bag, marked with date and resident's name, between uses and discard the administration set-up every seven days infection control considerations related to suction machines indicated after completion of suctioning : discard single-use suction catheters immediately in appropriate waste receptacle if using reusable tubing: rinse tubing with sterile water, hang tubing to air dry in a clean, designated area or store in a clean plastic bag labeled with resident's name, ensure tubing is not in contact with the contaminated surfaces , suction tubing must be replaced at least seven days or sooner if visibly soiled and thoroughly clean and disinfect the . 4. During lunch meal observation in the dining room on 5/12/25 at 12:18 p.m., noted Certified Nursing Assistant / Activity Assistant M (CNA / AA M) was feeding Resident 30. CNA / AA M got up from the chair, went to another table to Resident 23, opened lunch plate cover, and started feeding Resident 23. CNA/AA M did not perform hand hygiene between task. During an interview with CNA / AA M on 5/12/25 at 12:24 p.m., CNA / AA M confirmed that she did not perform hand hygiene before feeding Resident 23 and after feeding Resident 30. CNA / AA M stated she should wash her hands before feeding Resident 23. During an interview with the Director of Nursing (DON) on 5/16/25 at 10:28 a.m., the DON stated nursing staff should perform hand hygiene in between when feeding two residents. Review of facility's P&P titled, Handwashing Hand Hygiene, release date: 2018, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. a. Before and after assisting a resident with meals

3. Review of Resident 23's admission record indicated she was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease (is a progressive movement disorder of the nervous system). During a review of Resident 23's MDS, dated [DATE], the MDS indicated her eating (the ability to use utensils to bring food and /or liquid to the mouth and swallow food and /or liquid once the meal is placed before the resident) was dependent. Review of Resident 23's nutrition assessment, dated 1/9/25, indicated, Resident 23 was on no added salt, puree texture, regular liquid consistency; one on one feeding assistance. During a dining observation on 5/12/25, at 12:11 p.m., in the dining room, Resident 23 was observed sitting alone by a table facing her lunch tray. There was no staff observed providing assistance to Resident 23 while other residents had started eating their meals and were being provided assistance. During a concurrent observation and interview on 5/12/25, at 12:15 p.m., with CNA H, in the dining room, CNA H stated Resident 23 was waiting for her daughter to come and feed her. While CNA H was explaining why Resident 23 was left behind waiting for feeding assistance, LVN I suddenly walked into the dining room and placed a spoon onto Resident 23's hand and asked to scoop food from the plate. During another meal observation on 05/14/25, at 12:01 p.m., Resident 23 was observed sitting by the dining table next to a resident that was being fed by LVN E. Resident 23 was observed with no feeding assistance provided while the other residents were assisted. Resident 23 waited about two minutes before Activity Assistant (AA) J provided assistance to the resident. During a concurrent interview with AA J, AA J stated Resident 23 would need assistance with feeding during mealtime. During an interview on 5/15/25, at 9:20 a.m., with the Social Service Director (SSD), the SSD stated all the residents should be fed at the same time during mealtime in the social dining room. During an interview on 5/16/25, at 11 a.m., with the DON, the DON confirmed that residents should be served meal at the same time in the dining room, and staff should not delay providing feeding assistance to Resident 23. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated 4/2018, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. Nursing staff and /or feeding assistants will feed those patients needing full assistance upon delivery of food trays. Based on observation, interview, and record review, the facility failed to treat four of 15 sampled residents (Resident 1, Resident 18, Resident 23 and Resident 28) with dignity and respect when: 1. Housekeeping (HK) N and the dietary staff were speaking in their own language other than English in the presence of Resident 1; 2. Resident 18 and 28 urinary catheter drainage bags (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) were left uncovered; and 3. Staff did not assist Resident 23 during lunch while other residents in the same dining room were already eating with staff assistance. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/25/25, indicated Resident 1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition). During a concurrent observation and interview on 5/12/25 at 11:07 a.m., with Resident 1, she stated staff spoke in foreign language while providing care and working in the facility. Resident 1 further stated that Certified Nursing Assistants (CNA's) and HK staff were speaking with their own language other than English while providing care or when HK staff was working inside the room and in the hallway. During an initial tour of the facility on 5/12/25 at 11:07 a.m., HK N was talking to the dietary staff in the hallway in a foreign language other than English. During an interview on 5/16/25 at 9:47 a.m., with HK N, she confirmed that she was working in the facility on 5/12/25 as a janitor and she was communicating with the dietary staff in the hallway infront of Resident 1's room. HK N further stated that she should speak English while working in the facility especially when residents were present. During concurrent interview and record review on 5/15/25 at 11:38 a.m., with Registered Nurse (RN) A, she reviewed Resident 1's clinical records and stated Resident 1 was admitted to the facility on [DATE] with diagnosis including right eye blindness, left eye low vision, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (feeling of worry and fear). 2a. During the facility tour observation on 5/12/25 at 8:27 a.m., Resident 28 was observed with an uncovered urinary catheter drainage bag hanging from his bed. During a concurrent observation and interview on 5/12/25 at 8:28 a.m., with Resident 28, he stated that facility staff did not put cover on his urinary catheter draining bag that was hanging from his bed. During a concurrent observation and interview on 5/12/25 at 8:59 a.m., with Licensed Vocational Nurse (LVN) O, she acknowledged the above observation and stated it should have been covered with privacy blue bag. During a concurrent interview and record review on 5/16/25 at 9:20 a.m., with RN A, she reviewed Resident 28's clinical records and stated that Resident 28 was admitted to the facility on [DATE] with the diagnosis including neuro muscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and has supra pubic (a type of urinary catheter inserted into the bladder through a small incision in the lower abdomen, above the pubic bone) that attached to the urinary catheter drainage bag. She further stated that one of the care plan interventions for supra pubic catheter was to provide privacy bag for the catheter urinary bag. During an interview on 5/16/25 at 10 a.m., with the Director of Nursing (DON), the DON stated all residents with urinary catheters should have privacy bags covering the urinary catheter drainage bag. 2b. During an initial room observation on 5/12/25 at 7:54 a.m., Resident 18's indwelling catheter (a thin, flexible tube inserted into bladder [a body organ that stores urine] to drain urine out) urine collection drainage bag was anchored to his bed frame not covered with privacy bag. Review of Resident 18's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 18 was admitted to facility on 1/27/16 with diagnoses including neuromuscular dysfunction of bladder (problem with muscles controlling bladder function can lead to variety of problems including difficulty emptying the bladder). Review of Resident 18's physician order dated 10/15/24 indicated, Suprapubic Catheter Review of Resident 18's care plan for bladder elimination (voiding urine) indicated, Provide privacy bag for the catheter urinary bag. During an interview with CNA L on 5/12/25 at 8:03 a.m., CNA L confirmed Resident 18's urine collection drainage bag was not covered with privacy bag. During an interview with LVN I on 5/15/25 at 3:10 p.m., LVN I stated nursing staff should have covered Resident 18's urine collection drainage bag with privacy bag for privacy, dignity and infection control. During an interview with the facility's Director of Staff Development (DSD) on 5/15/25 at 3:18 p.m., the DSD stated nursing staff should have covered Resident 18's urine collection drainage bag with a privacy bag for privacy, dignity and infection control. A review of the facility's, policy and procedure (P&P) dated 1/28, titled Quality of life - Dignity the P&P indicated, each resident shall be cared for a manner that promotes and enhances quality of life, dignity, respect and individuality Residents shall be always treated with dignity and respect . Staff shall promote dignity and assist residents as needed by : Helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to perform interdisciplinary team (IDT, staff from different departments who coordinate the residents care) assessment and obtain a physician order for self-administration of medication for two of eight sampled residents (Resident 27 and 37) when: 1. Resident 27 had over the counter (OTC, can be purchased without a prescription from medical doctor) bottle of isopropyl alcohol (used for cleaning wounds and as disinfectant) on the bedside tray table unattended; and 2. Resident 37 had a bottle of OTC hydrogen peroxide (used for cleaning wounds and as disinfectant), and a bottle folic acid (vitamin supplement) medication on the bedside table unattended. This failure had the potential for unsafe and improper administration of OTC and medication supplement for Residents 27 and 37. Findings: 1. During an observation and interview with Resident 27 on 5/12/25 at 8:20 a.m., there was a bottle of isopropyl alcohol on Resident 27's tray table that was unattended and was next to the resident. Resident 27 stated he had used the isopropyl alcohol to clean his skin everyday. Resident 27 also stated the facility did not provide the isopropyl alcohol and he had bought it himself from the store when he went outside the facility. Resident 27 further stated the facility nursing staff were aware of that he was using the isopropyl alcohol to clean his skin everyday. Review of Resident 27's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 27 was admitted to facility on 9/5/2024. Resident 27's FS also indicated diagnosis included non-pressure chronic ulcer of left foot (persistent open sore that's not caused by prolonged pressure or friction). Review of Resident 27's Minimum Data Set (MDS, clinical, and functional assessment tool) dated 3/11/25 indicated Resident 27's Brief Interview for Mental Status (BIMS) score was 15 of 15 (score of 0 to 7: severe cognitive impairment, 8 to 12: moderate cognitive impairment, and 13 to 15: intact cognition). Review of Resident 27's clinical documentation indicated there was no documented evidence of the IDT's assessment for self-administration of medication. Review of Resident 27's physician orders indicated there was no order for OTC isopropyl alcohol for self-administration. During an interview with Licensed Vocational Nurse (LVN) I on 5/12/25 at 8:26 a.m., LVN I confirmed a bottle of isopropyl alcohol OTC medication was left on Resident 27's tray table unattended. LVN I stated the medication should not be left in the room unattended for Resident 27 to self-use. 2. During an observation and interview with Resident 37 on 5/12/25 at 12:35 p.m., a bottle of 1/4 full liquid of hydrogen peroxide, and a bottle of folic acid 1 milligram (mg, a unit of mass equal to a thousandth of a gram) tablets were on the tray table next to Resident 37's bed unattended. During a concurrent interview with Resident 37, he stated he was using stated the hydrogen peroxide to clean his teeth once a week and taking folic acid one tablet every day from the medication bottle. Resident 37 also stated his son brought the hydrogen peroxide and the folic acid to the facility months ago. Resident 37 further stated the facility nursing staff were aware of self-administration of both medications. Review of Resident 37's FS indicated Resident 37 was admitted to facility on 1/3/25 with the diagnoses including anemia (a condition with blood doesn't have enough healthy red blood cells). Review of Resident 37's MDS dated [DATE] indicated Resident 37's BIMS score was 15 of 15. Review of Resident 37's clinical documentation indicated IDT's assessment for self-medication administration dated 4/7/25 indicated resident request for self-medication administration of medication was documented No. Review of Resident 37's physician orders indicated there were no orders for hydrogen peroxide and folic acid for self-administration. During an interview with LVN I on 5/12/25 at 12:46 p.m., LVN I confirmed a bottle of OTC hydrogen peroxide and folic acid medications were left on Resident 37's tray table unattended. LVN I stated both medications should not be left in the room unattended for self-administration for Resident 37. During an interview with Registered Nurse (RN) A on 5/15/25 at 1:59 p.m., RN A confirmed there were no IDT assessment and physician orders for self-medication administration for Resident 27 and 37. RN A stated medications should not be at bedside unattended for both residents. Review of the facility's policy and procedure (P&P) titled, Medications storage in the facility, effective date: April 2008, the P&P indicated, For residents who self-administer medications, the following conditions are met for bedside storage to occur: 1. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is deemed inappropriate . Review of facility's P&P titled, Preparation and General Guidelines, effective date: April 2008, the P&P indicated, Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility's interdisciplinary team. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a routine basis

Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment was provided for two of 14 sampled residents (Resident 1 and Resident 25) when: 1. The privacy curtain in Resident 25's room was left sticky, had brownish dry food particles, and dirty; and 2. In Resident 1's room, the floor was sticky when walked on and Resident 1 complained that her room was not cleaned by the housekeeper daily. These failures increased the potential for Resident 1 and Resident 25 not attaining their highest practicable well-being. Findings: 1. During an initial tour of the facility on 5/12/25 at 9:01 a.m., Resident 25's privacy curtain in his room was left sticky, and had brownish dry substances. During a concurrent observation and interview on 5/12/25 at 9:02 a.m., with Licensed Vocational Nurse (LVN) O, she confirmed the above observation and stated that those brownish dry substance was food particles, sticky and dirty. She further stated that it should have been changed by the housekeeper or janitor. 2. During concurrent interview and record review on 5/15/25 at 11:38 a.m., with Registered Nurse (RN) A, she reviewed Resident 1's clinical records and stated Resident 1 was admitted to the facility on [DATE] with diagnoses including right eye blindness, left eye low vision, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (feeling of worry and fear). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/25/25, indicated she had a BIMS (Brief Interview for Mental Status) of 15 meaning her cognition was intact and Resident 1 could walk independently using her roller walker with set up help only. During a concurrent observation and interview on 5/12/25 at 11:07 a.m. with Resident 1 in her room, the floor was sticky when walked on. Resident 1 stated housekeeping just came today to clean her room because the state surveyor was in the facility and did not mop the floor with a wet mop. Resident 1 further stated Housekeeper did not do a good job and she was not okay if the floor was still dirty and sticky. During an interview on 5/14/25 at 1:05 p.m., with the Housekeeping Supervisor (HKS), he stated that housekeeping and janitor were responsible for daily cleaning and deep cleaning of the resident's room once a month. The HKS further stated that changing of residents' privacy curtain was scheduled once a month during deep cleaning and as needed. During a concurrent interview and record review on 5/14/25 at 1:07 p.m., with the HKS, he stated that he could not provide any documentation that the residents' room were cleaned daily, and deep cleaning was done once a month because he was just doing the visual checking of each room. He further stated that he will create a Daily Room Clean sign off sheet, deep Clean Room Check list and daily clean room check list starting today 5/14/25. A policy and procedure was requested but was not provided by the facility.

Based on interview and record review the facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal. The transfer/discharge was improper and violated Resident 20's resident rights. Findings: During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), unsteadiness on feet, history of falling, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose), hearing loss , left ear, Psychotic disturbance, mood disturbance and anxiety (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.). Resident 20's RP was his granddaughter as indicated in the Resident 20's face sheet. Minimum Data Set (MDS, an assessment tool) dated 2/14/25 indicated Resident 20's cognition was severely impaired, minimal difficulty of hearing impaired vision, usually understood other and usually understands. Resident 20's physician order, dated 4/24/25, indicated may discharge to board and care on Monday 4/28/25 with home health (a type of medical care provided in a resident's home to function independently) follow up, RN (registered nurse: a healthcare provider who works with medical doctor and others to give the best possible care), Physical therapist (PT: a healthcare discipline that uses movement and physical thechniques to treat illnesses), Occupational Therapist (OT: a healthcare discipline that helps individuals with participate in everyday activities). There was no documentation indicating Resident 20's the RP had been notified of resident's rights to appeal. Resident 20 had resided in the facility for more than 30 days. During an interview on 5/15/25 at 9:06 a.m., with RP, she stated that the Social Services Director (SSD) called her on 4/24/25 to inform her that Resident 20 needs to be transferred/discharge due to an alleged abuse at the facility and will keep her in the loop of Resident 20's transfer/discharge in the coming days. The RP stated that she tried to reach out to the SSD because she did not give consent for Resident 20's discharge but did not receive any call back. The RP further stated she received a call back from the SSD on 4/28/25 the day Resident 20 was transferred/discharged in the board and care facility and that was the time the SSD told the RP the address and phone number of the receiving board care where Resident 20 was being transferred. The RP further stated that she was not given anything in writing prior to Resident 20's discharge on [DATE] and was not informed of her rights to appeal. During an interview with the SSD, on 5/15/25, at 3:31 p.m., the SSD stated that she was not the one who initially initiated the discharge plan for Resident 20 and she did not notify Resident 20's RP in writing prior to transfer/discharge on [DATE]. The SSD stated she did not provide Resident 20's RP any advice that she could appeal. The SSD stated she called the RP on 4/24/25 to inform her that Resident 20 needs to be transferred/discharged due to an alleged abuse at the facility and will keep the RP in the loop in the coming days. During a concurrent interview and record review on 5/16/25 at 1:08 p.m., with Certified Nursing Assistant/Activity Assistant (CNA/AA) M, she acknowledged that she was the one who initiated the transfer and discharge of Resident 20 and completed the notice of transfer/discharge date d 4/24/25 using her previous title as Social Service (SS). CNA/ AA M stated that there was no MD (medical doctor)and IDT discussion and documentation that Resident 20 was danger (danger or harm) to others that needs to be transferred or discharged . She further stated that it was her own opinion that the Resident 20 was a danger to other residents. During an interview on 5/16/25 at 1:50 p.m., with the ADMN, he stated CNA/ AA M was working as SSD on 5/2024 when he started working in the facility as ADMN. The ADMN further stated CNA/AA M status was changed on 2/2025 as CNA/ AA M until now. The ADMN stated CNA/ AA M should not have initiated and completed Resident 20's notice of transfer/discharge date d 4/24/25. The ADMN further stated that Resident 20's transfer and discharge was not safe because the SSD should be the one responsible for the transfer/discharge process in coordination with the IDT. During an interview on 5/16/25, at 2 p.m., with the administrator (ADMN), he stated that the SSD was responsible for initiating the process of residents transfer and discharge, and giving 30 day written notice of transfer or discharge. Review of the facility's policy and procedure (P&P) dated 1/2018, titled Transfer or Discharge Notice indicated facility shall provide a resident and /or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge Process 1. A resident, and/or his or her representative, will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility . 3. The residents and or representative will be notified in writing of the following information I. The reason for the transfer or discharge j. the effective date of the transfer or discharge k. The location to which the resident is being transferred or discharged l. A statement of the resident's rights to appeal the transfer or discharge . information about how to obtain, complete and submit an appeal form; and how to get assistance completing the appeal process.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for residents with mental disorder and residents with intellectual disability) Level 1 and Level II screening was completed for two of 15 sampled residents (Resident 9 and 13). This failure had the potential for mentally ill sampled residents not to receive benefit from specialized health care and services. Findings: Review of Resident 9's admission record indicated he was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (is a mental health problem where you experience psychosis as well as mood symptoms) and major depressive disorder (is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time). Review of Resident 9's notice of PASRR Level I screening results dated 9/3/24, indicated, A serious mental illness (SMI, is characterized as any mental health condition that impairs seriously or severely from one to several significant life activities) level II mental health evaluation was required. During a further review of Resident 9's notice of attempted evaluation dated 9/3/24, indicated, Unable to complete level II evaluation for serious mental illness (SMI). Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening. The case is now closed. To open, the facility must resubmit a new level I screening. During an interview on 5/13/25, at 10:40 a.m., with Registered Nurse (RN) A who was the minimum data set (MDS, an assessment tool) nurse, RN A verified and confirmed there was no PASRR level II referral and evaluation done for Resident 9 because they forgot to follow up the notice of attempted evaluation letter to resubmit a new level I screening for Resident 9. Review of Resident 13's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 13 was admitted to facility on 7/8/24 and readmitted on [DATE]. Review of Resident 13's FS indicated Resident 13's diagnoses included delusional disorders (a serious mental illness that involves persistent false beliefs, that are not based in reality) dated 7/12/24 and schizophrenia (a serious mental illness [SMI] that interferes with affects resident's ability to think clearly, manage emotions, make decisions and relate to others) dated 8/26/24. Review of Resident 13's discharge summary notes from an acute hospital (AH, a short-term acute care provides intense medical treatment with severe illnesses, injuries, or conditions that require rapid interventions) dated 7/8/24 indicated no SMI. Review of Resident 13's discharge summary notes from the AH dated 8/26/24 indicated diagnosis of schizophrenia. Review of Resident 13's Minimum Data Set (MDS, resident's clinical and functional assessment tool) assessment, dated 7/12/24, under section I for active diagnoses indicated, psychotic disorder. Review of Resident 13's MDS dated [DATE], under section I for active diagnoses indicated, schizophrenia and psychotic disorder. Review of Resident 13's PASRR Level 1 screening assessment dated [DATE] indicated no SMI. Further review of Resident 13's clinical record indicated there was no documented evidence of Level 1 PASRR screening after 7/12/24 or 8/26/24 when there was a diagnoses of SMI. During an interview with the facility's admission and Marketing Manager (AMM) on 5/14/25 at 8:32 a.m., the AMM confirmed there was no Level 1 screening completed after 7/5/24 for Resident 1. The AMM stated the admission staff was responsible for PASRR Level 1 screening. The AMM also stated the facility should have a Level 1 screening when Resident 13 was diagnosed with SMI. During an interview with RN A on 5/14/25 at 1:06 p.m., RN A confirmed Resident 13's SMI diagnoses dated 7/12/2024 and 8/26/2024 and confirmed there was no documented evidence of Level 1 screening being done. RN A stated the facility should have completed a new Level 1 PASRR for Resident 13. RN A also stated there was a potential for Resident 13 to miss receiving specialized mental health services by not completing the Level 1 PASRR screening. During telephone interview with the Medical Doctor (MD) on 5/15/25 at 1:45 p.m., the MD stated that the AH potentially did not capture Resident 13's diagnoses of schizophrenia during July 2024 stay. The MD also stated the diagnosis typically do not develop at late stages of life. The MD further stated that the resident had the diagnosis for long time. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review, dated 1/2018, the P&P indicated, It is the policy of this facility to comply with federal and state regulations regarding the Preadmission Screening and Resident Review (PASRR) process. PASRR ensures that individuals with serious mental illness (SMI), intellectual disabilities (ID: resident has difficulties with cognitive abilities of learning, reasoning, problem solving, practical and social skills), or related conditions are appropriately placed in a skilled nursing facility (SNF) and receive necessary services. If the Level I screening indicates a potential SMI . the resident must be referred for a Level II PASRR evaluation conducted by the designated state agency or contracted entity. The Admissions Coordinator must submit all required documentation to the state PASRR agency and follow up to ensure timely completion of the Level II evaluation.

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one out of 15 sampled residents (Resident 5). This deficient practice had the potential to result in not meeting the residents' needs. Findings: During a concurrent interview and record review on 5/15/25 at 11:10 a.m., with Registered Nurse (RN) A, RN A reviewed Resident 5's clinical records and stated that Resident 5 was admitted to the facility on [DATE] with diagnosis including paraplegia (paralysis of the legs and lower body.), Chronic kidney disease (CKD, the gradual loss of kidney function), contracture (hardening of muscles and other tissues causing rigidity to the joints of muscle) left lower leg, contracture of muscles multiple sites, pressure ulcer left and right buttock stage 4 (most severe form of bedsore, also called a pressure sore, pressure ulcer, or decubitus ulcer and is a deep wound reaching the muscles, ligaments, or bones. They often cause extreme pain, infection, invasive surgeries, or even death.), pressure ulcer of sacral region and abnormal posture. During a concurrent interview and record review on 5/11/18 at 11:18 with RN A, RN A reviewed Resident 5's pressure ulcer care plan initiated date was 6/24/ 24 with focus problem, pressure ulcer left and right buttock stage 4, pressure ulcer of sacral region stage four, right lateral lower leg, vascular and left posterior thigh MASD (Moisture-Associated Skin Damage) were combined with the same goals and interventions. RN A stated that each pressure ulcers site should have been care planned individually with own goals and interventions to provide Resident 5 a person-centered care. RN A further stated that interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) skin meeting dated 5/1/25 indicated different measurements for each individual pressure ulcers site, change of treatments and status of the pressure ulcers site and confirmed that the pressure ulcer care plan was not individualized and person-centered care specifically for Resident 5. Facility did not provide the policy and procedure.

Based on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans for two of 15 sampled residents (Resident 12 and Resident 40) when: 1. A care plan to address Resident 12's dementia (memory loss) was not updated and revised; and 2. A care plan to address Resident 40's end stage of renal disease (ESRD, a severe and irreversible condition where the kidneys have lost most of their function and are no longer able to adequately filter waste products from the blood) on hemodialysis (HD, is a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) was not updated and revised after increasing HD from three times per week to four times per week. These failures had the potential to result in not meeting the residents' needs. Findings: Review of Resident 12's admission record indicated he was initially admitted to the facility on [DATE] and had diagnoses including dementia with other behavioral and disturbance (loss of memory, language, problem-solving and changes in behavior and mood). Review of Resident 12's Minimum Data Set (MDS, an assessment tool), dated 4/20/25, indicated that his Brief Interview for Mental Status (BIMS) score was of 7 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition), severely impaired cognition. Review of Resident 12's care plan addressing his impaired cognitive function and dementia with initial date of 11/13/24 indicated, Ask yes/no questions in order to determine the resident's needs. Cue, resident and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. During observations on 5/13/25, at 8:38 a.m. and 5/15/25, at 10:30 a.m., Resident 12 was lying in bed most of the time. He was confused and verbally responsive to express his needs. During an interview on 5/14/25, at 11:13 a.m. and 5/16/25, at 8:45 a.m., with the Social Service Director (SSD), the SSD stated Resident 12 spoke different language other than English and used to self-propel in his wheelchair in the facility with more vocal, after hospitalization Resident 12 became spending more time in bed than before. The SSD further stated Resident 12 had a personal cellphone at bedside and it was very important for him to speak with his family members over the phone to support his psychosocial well-being and the cellphone need to be fully charge on daily basis in order for resident to receive calls from his family members. During an interview and record review on 5/16/25, at 12:05 p.m., with the Director of Nursing (DON), Resident 12's dementia care plan, dated 11/13/24 was reviewed. The dementia care plan did not include keeping Resident 12's personal cellphone fully charge at bedside and to assist him to receive calls from his family members. The DON confirmed Resident 12's dementia care plan should have been updated and revised in accordance with Resident 12's culture background and to have an individualized person-centered care plan. 2. Review of Resident 40's admission record indicated she was admitted to the facility on [DATE] and had diagnoses including ESRD and dependence on renal dialysis. During an interview on 5/12/25, at 8:40 a.m., with Resident 40, Resident 40 stated she was receiving HD four times per week through a catheter on her right upper chest, which was covered with clean, dry dressing. Review of Resident 40's ESRD HD care plan dated 5/16/23, indicated Resident 40 had HD three times per week through her right upper chest with a Perma catheter (is a type of central venous catheter used for long-term hemodialysis access). During an interview and concurrent record review on 5/16/25, at 1:45 p.m., the DON reviewed Resident 40's ESRD HD care plan, dated 5/16/23. The DON confirmed the care plan needs to be updated and revise for the HD schedule, from three times per week increasing to four times per week. The DON stated each resident's care plan needs to be reviewed and updated every three months. During a review of the facility's policy and procedure (P&P) titled, Care Plan Conference, dated 12/2016, the P&P indicated, Fundamental information at interval of every 90 days thereafter; with any subsequent completed assessments; and, when there is a change in resident status or condition. Care plans are reviewed to meet the needs and requests of the resident/ resident's family .

Based on observation, interview and record review, the facility failed to ensure the safety of one of four residents (Residents 29) who smoke without oversight staff supervision. This failure had the potential to put Resident 29 at risk of harm. Findings: During a concurrent observation and interview on 5/16/25 at 10:413 a.m., Residents 29 was in the patio smoking and was not wearing a smoking apron. There was no facility staff in the patio providing supervision for Resident 29. without facility staff's supervision. Resident 29 stated facility staff was not supervising him when he was smoking except when staff provides his cigarette and light his cigarette. During a concurrent observation and interview on 5/16/25 at 10:14 a.m., with Activity Assistant (AA) J, she confirmed the above observation and stated that Resident 29 needs supervision from the facility staff while smoking for safety. During a concurrent interview and record review with Registered Nurse (RN) A, she reviewed Resident 29's clinical records and stated Resident 29 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including of muscle weakness, hemiplegia (paralysis that affects just one side) hemiparesis (weakness on half of the body) and hemiparesis (weakness on half of the body) following cerebral infarction (stroke, lack of blood flow to the brain, causes brain tissue to die) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose). Resident 29's Smoking-Safety Screen initially dated 5/11/24 and smoking assessment dated [DATE], indicated interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) decision indicated Resident 29 can smoke with oversight supervision, safe to smoke with oversight supervision due to Resident 29's current physical function and diagnoses of gout, hemiplegia and hemiparesis following stroke. During an interview on 5/16/25 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that facility staff should supervise residents who smokes during smoking schedules. The facility did not provide a policy and procedure.

Based on interview and record review, the facility failed to ensure there was sufficient direct care nursing staff to provide nursing and related care and services to meet resident's needs safely for 24 hours a day during the weekend. This failure had the potential to compromise care, health, and well-being of the 55 residents residing in the facility. Findings: Review of facility's census and direct care service hours per patient day (DHPPD) form dated 5/10/25 (Saturday) indicated actual CNA (certified nursing assistant) DHPPD was 2.13, and actual total DHPPD (including CNA and license nurses) was 3.15. Review of DHPPD form dated 5/11/25 (Sunday) indicated an actual CNA DHPPD of 1.99, and actual total DHPPD of 2.99. During concurrent record review of DHPPD forms and interview with the facility's Director of Staff Development (DSD) on 5/15/25 at 10:52 a.m., the DSD reviewed the DHPPD forms above on both days. The DSD confirmed the above DHPPD for CNA and the total for both days. The DSD stated the facility did not meet sufficient DHPPD on both days on the weekend. The DSD also stated the facility should have 2.4 CNA DHPPD, and 3.5 total DHPPD for both days to provide sufficient nursing staffing to meet all resident's care needs. During an interview with Registered Nurse (RN) A on 5/15/25, at 2:20 p.m., RN A stated facility should have provided sufficient direct care nursing staff during the weekend and provided 2.4 CNA DHPPD and 3.5 total DHPPD. Review of facility's policy and procedure (P&P) titled, Direct Healthcare Service Hours Per Patient Day, release date [DATE], the P&P indicated, the facility will employ and schedule sufficient licensed nurses and CNAs to meet or exceed the minimum required 3.5 DHPPD and 2.4 CNA DHPPD on every calendar day.

Review of Resident 156's admission record indicated he was admitted to the facility on [DATE] and had diagnoses including gastro esophageal reflux disease (GERD, which is a common condition in where stomach acid flows back up into the esophagus, causing a burning sensation in the chest , often called heart burn) and other chronic pain. Review of Resident 156's MRR dated 4/30/25, indicated the CP identified a medication form concern for gabapentin (medication used to control seizures [is abnormal electrical activity in your brain], to treat nerve pain)100 milligrams (mg, unit of measurement) with recommendations as pharmacy is sending capsules form, update your MAR (Medication administration record) and frequency issue for pantoprazole (medication used to treat damage from GERD) 20 mg, with recommendations as clarify frequency and update your order. However, the MRR did not have an evidence that it was reviewed by the nurse nor a signature that indicated it was reviewed. Review of Resident 156 physician's orders dated 5/13/25, indicated, Pantoprazole sodium oral tablet delayed release 20 mg (pantoprazole sodium) give 1 tablet by mouth before meals for GERD. Gabapentin Capsule 10 mg, give 1 capsule by mouth every 24 hours as needed for neuropathic pain. During an interview on 5/13/25, at 2:20 p.m., with Registered Nurse (RN) A, RN A stated Resident 156's drug regimen review with recommendations was missed and was not followed-up. During an interview on 5/16/25, at 11:05 a.m., with the DON, the DON confirmed that Resident 156's MRR with recommendations should have acted upon when the facility received the CP's recommendations for potential clinically significant medication issues identified on 4/30/25. Review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated 6/202, the P&P indicated, The findings are phoned, faxed, or e-mailed to the director of nursing or designee and documented and stored with the other consultant pharmacist recommendations within 72 hours. Recommendations are acted upon and documented by the facility staff and or the prescriber. Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP, a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported the lack of blood work related to use of anticoagulant (AC, used to treat prevent or delays blood clots forming in blood vessels) medication to the facility during the monthly medication regimen review (MRR, a thorough evaluation of resident's medications) for one of three sampled resident (Resident 10); and the facility failed to follow up MRR recommendations for one of two sampled resident (Resident 156). These failures resulted in Resident 10 not receiving a baseline and periodical blood work, and Resident 156's medication orders not clarified. Findings: Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 10/24/24 with diagnoses including atrial fibrillation (A Fib, an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary embolism (blood clot in lung vessels). Review of Resident 10's physician order dated 10/24/24 indicated rivaroxaban (used to treat reduce and prevent blood clots) 20 milligrams (mg: a unit of mass equal to a thousandth of a gram) in the evening for A Fib. Further review of Resident 10's physician orders indicated there was no laboratory (lab) work ordered to monitor kidney function and blood levels since Resident 10 was admitted to facility. Review of the facility provided MRR reports for Resident 10 indicated there was no MRR related to the use of an AC medication and lack of lab work orders. Review of Resident 10's care plan for AC drug therapy dated 11/11/24 indicated intervention, Monitor lab reports, and notify physician promptly of results. During an interview with Licensed Vocational Nurse I (LVN I) on 5/16/25 at 8:56 a.m., LVN I confirmed Resident 10 receives AC medication every evening. LVN I also confirmed there were no lab work ordered for Resident 10 since admission to the facility. LVN I stated there should be a lab work order for Resident 10 due to an AC medication use. LVN I stated she will request to the MD (medical doctor) a lab work order for Resident 10. During an interview with the Director of Nursing (DON) on 5/16/25 at 9:56 a.m., the DON confirmed there was no MRR recommendation for Resident 10 to have lab work with the use of AC medication. The DON also confirmed there were no blood work orders since Resident 10 was admitted to facility. The DON stated Resident 10 should have a baseline and periodical lab orders to monitor kidney and blood levels when receiving an AC medication. During a telephone interview with the facility's CP on 5/16/25 at 9:56 a.m., the CP confirmed there was no MRR recommendation for Resident 10 to have lab work with the use of AC medication. The CP stated routine blood work was not recommended for the use of rivaroxaban. The CP also stated baseline and periodical blood work was needed to monitor kidney and blood levels when resident receives this medication. The CP further stated she should have identified the lack of blood work orders and recommended blood work orders during monthly MRR review for Resident 10. Review of facility's policy and procedure (P&P) tilted, Anticoagulation-Clinical Protocol, release date: January 2018, the P&P indicated, The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking . Review of facility's P&P titled, Consultant Pharmacist Reports, effective date: June 2021, the P&P indicated, Resident-specific irregularities and /or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing and/or prescriber as appropriate. Recommendations are acted upon and documented by the facility staff and or the prescriber.

Based on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were identified during medication pass for two residents (Resident 16 and 41). These failures had the potential to result in ineffective drug therapy and possible adverse effects for the resident. Findings: 1. During a review of Resident 16 physician's orders dated 2/21/25, it indicated, Glipizide (is used to treat high blood sugar levels) tablet 5 milligrams (mg, unit of measurement), give 0.5 tablet by mouth in the afternoon related to type two diabetes mellitus (a chronic condition that happens with persistent high blood sugar levels), 0.5 tablet =2.5 mg. give 30 minutes prior to meals. During a medication administration observation on 5/12/25, at 4:04 p.m., Registered Nurse (RN) B prepared half tablet of glipizide in a medicine cup after verifying the medication orders then administered to Resident 16 with a cup of water. 2. During a review of Resident 41's minimum data set (MDS, an assessment tool) dated 3/14/25, it indicated his Brief interview for Mental Status (BIMS, is a quick assessment used to gauge a person's cognitive functioning) score of 13 (score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During a review of Resident 41 physician's orders dated 4/26/25, it indicated, Hydrocortisone (is used to treat a variety of inflammatory, autoimmune, and hormonal conditions) oral tablet 10 mg, give 1 tablet by mouth in the morning for low cortisol, give with food. During a medication administration observation on 5/12/25, at 4:35 p.m., Licensed Vocational Nurse (LVN) C checked Resident 41's vital signs first and then prepared two scheduled medications including one tablet of hydrocortisone 5 mg, and administered the medications to Resident 41 without food. During an interview on 5/12/25, at 4:43 p.m., with LVN C, she stated she thought Resident 41 already had snacks around 3 p.m. in the afternoon, so Resident 41 does not need to take food with hydrocortisone because Resident 41's stomach was not empty. During a concurrent interview with Resident 41 in his room, Resident 41 stated that he did not take any snacks in the afternoon between 2 p.m. to 3 p.m. During a telephone interview on 5/14/25, at 10:05 a.m., with the Consultant Pharmacist (CP), the CP confirmed glipizide would need to be given 30 minutes before meals and hydrocortisone would need to take with food to prevent gastrointestinal irritation. During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 10/2017, the P&P indicated, Medications are administered in accordance with written orders of the attending physician. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label . if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored accordance with currently accepted professional standards for two of 15 sampled Residents( 5 and 25) when: 1. A bottle of oral liquid lorazepam (a controlled medication used to relieve anxiety [persistent worry and fear about everyday situations]) without legible expiration date was stored in the medication room for Resident 25 to be used; and 2. An unlabeled normal saline solution (NSS, 0.9% sodium chloride in water ) in a bottle was found at Resident 5's bedside table unattended. These deficient practices could lead to unsafe and ineffective medication use for the residents. Findings: 1. During an observation on 5/12/25, at 7:30 a.m. to 7:50 a.m., in the medication storage room with Licensed Vocational Nurse (LVN) I, Resident 25's lorazepam medication did not have a legible expiration date. Review of Resident 25's controlled drug record indicated the last time the lorazepam medication was administered to Resident 25 was on 9/30/24. A further review of Resident 25's initial telephone order dated 9/19/24 indicated, Lorazepam oral concentrate 2 mg/ml (Lorazepam). Give 0.5 ml by mouth every 4 hours as needed for anxiety for 14 days. During an interview on 5/12/25, at 10:10 a.m. and 10:20 a.m., with Registered Nurse (RN) A, RN A stated the expiration date on lorazepam bottle was not clear and readable. RN A further stated that expiration date should be clear, able to be read, and it should have clarified with the pharmacy upon opening to be used on 9/30/24 for Resident 25. During a follow-up interview on 5/16/25, at 10:50 a.m., with the Director of Nursing (DON), the DON stated license staff should have clarified and requested a new bottle of oral liquid lorazepam with clear expiration date for Resident 25. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering And Receiving From Pharmacy -Medication Labels, dated 4/2008, the P&P indicated, Each prescription medication label includes . expiration date of medication. 2. During an initial tour of the facility on 5/12/25 at 8:54 a.m., on top of Resident 5's bedside table there was one bottle of NSS unlabelled and unattended. During concurrent observation and interview on 5/12/25 at 8:55 a.m., with Resident 5, he stated that facility staff left the bottle of NSS for them to use for his foley catheter (F/C, a thin, flexible tube inserted into bladder [body organ, that stores urine] to drain urine) flushing (a process of cleaning of obstructions) and wound (open area) treatment. During concurrent observation and interview on 5/12/25 at 8:56 a.m., with Licensed Vocational Nurse (LVN) O, she confirmed the above observation and stated that the bottle of NSS should have been labeled and stored in the treatment cart. LVN O further stated that it should not be kept at the bedside table unattended. During a concurrent interview and record review on 5/14/25 at 10:57 a.m., with RN A, she reviewed Resident 5's clinical records and stated that the Minimum Data Set (MDS, an assessment tool) dated 3/21/25 indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition). Review of facility's P&P titled, Medication storage in the facility, effective date: April 2008, the P&P indicated, All nurses and aids are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and give to unauthorized medications to the charge nurse .

Based on interview and record review, the facility Administrator (ADMN) failed to provide consistent administrative oversight to ensure that the Social Services Department and interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) implemented the facility's policy and procedure (P&P) for safe transfer and discharge for one of three residents (Resident 20) when Resident 20 was discharged to a board and care facility (smaller more intimate living option for residents who need assistance with daily activities but not nursing care 24/7). This failure had resulted in Resident 20's having eloped (run away secretly) from the board and care facility. Findings: During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), unsteadiness on feet, history of falling, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hearing loss , left ear, psychotic disturbance, mood disturbance and anxiety (feeling of worry and fear). Resident 20's responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) was his granddaughter as indicated in the Resident 20's face sheet. Minimum Data Set (MDS, an assessment tool) dated 2/14/25 indicated Resident 20's cognition was severely impaired, minimal difficulty of hearing-impaired vision, usually understood by others and usually understands. During a concurrent interview and record review on 5/15/25 at 2:21 p.m., with RN A, she reviewed Resident 20's clinical records and stated Resident 20's physician order, dated 4/24/25, indicated may discharge to board and care on Monday 4/28/25 with home health (medical care and services provided in a patient's residence rather than in a hospital or other healthcare facility) follow up, RN, (registered nurse: a healthcare provider who works with medical doctor and others to give the best possible care), Physical therapist (PT: a healthcare discipline that uses movement and physical techniques to treat illnesses), Occupational Therapist (OT: a healthcare discipline that helps individuals with participate in everyday activities). RN A stated the facility IDT did not meet with Resident 20's RP to evaluate the resident needs prior to discharge. RN A could not provide IDT documentation that IDT had a discharge meeting prior to Resident 20's transfer and discharge to a board and care facility on 4/28/25. During an interview on 5/15/25 at 9:06 a.m., with the RP, she stated that the Social Services Director (SSD) called her on 4/24/25 to inform that Resident 20 needs to be discharge due to an alleged abuse at the facility and that the SSD will keep her in the loop of Resident 20's discharge in the coming days. The RP stated that she tried to reach out to the SSD because she did not give consent for Resident 20's discharge but did not receive any call back until the day Resident 20's discharge to the board and care on 4/28/25. The SSD told the RP on 4/28/25 the day Resident 20 was discharged , the new address and phone number of the board and care facility where Resident 20 will be transferred. The RP further stated that she was not notified about Resident 20's discharge orders, medication instructions and RP did not pick-up Resident 20's personal belongings from the facility. During a concurrent interview and record review on 5/15/25 at 12:03 p.m., with the RP, she stated she came to the facility to get the medical records of Resident 20 especially the POLST (physician orders for life-sustaining treatment, legally valid form allow residents to specify what medical treatments they want or don't want during a medical emergency) as instructed by the board and care facility administrator because the facility did not send the POLST to the board and care. The RP further stated that the facility did not send the POLST to the board and care facility staff on 4/28/25 when they picked up Resident 20 in the facility. The RP stated that she was not notified when the board and care staff came to assess Resident 20, was not given a chance to go and check the board and care prior to Resident 20's discharge on [DATE]. The RP further stated that she received a call from the board and care facility that Resident 20 had eloped three times since his transfer to the board and care facility. During a concurrent interview and record review on 5/15/25, at 3:16 p.m., with the SSD, she reviewed Resident 20's psychosocial notes dated 4/24/25, the notes indicated the SSD was informed that Resident 20 will need to move to a board and care facility due to an alleged abuse at the facility and the previous SSD who was the current Activity Assistant (AA) M /certified nursing assistant (CNA) informed the administrator and the SSD of a home that will accept the resident with 24 hours care and was aware of Resident 20's situation. During a concurrent interview and record review on 5/15/25, at 3:28 p.m., with the SSD, she reviewed Resident 20's psychosocial note dated 4/29/25 at 13:55, indicated SSD was notified that Resident 20 eloped from the new home and went across the street, board and care homeowner changed Resident 20's house with a gated fence. During an interview with the SSD, on 5/15/25, at 3:31 p.m., the SSD stated that she was not the one who initially initiated the discharge plan for Resident 20. She further stated that she started working in the facility full time as SSD on 1/20/25. During a concurrent interview and record review on 5/16/25 at 1:08 p.m., with CNA/AA M, she acknowledged that she was the one who initiated the transfer and discharge of Resident 20 and completed the notice of transfer/discharge date d 4/24/25 using her previous title as Social Service (SS). CNA/ AA M stated that there was no MD (medical doctor)and IDT discussion and documentation that Resident 20 was danger (danger or harm) to others that needs to be transferred or discharged . She further stated that it was her own opinion that the Resident 20 was a danger to other residents. During an interview on 5/16/25 at 1:50 p.m., with the ADMN, he stated CNA/ AA M was working as SSD on 5/2024 when he started working in the facility as ADMN. The ADMN further stated CNA/AA M status was changed on 2/2025 as CNA/ AA M until now. The ADMN stated CNA/ AA M should not have initiated and completed Resident 20's notice of transfer/discharge date d 4/24/25. The ADMN further stated that Resident 20's transfer and discharge was not safe because the SSD should be the one who was responsible for the transfer/discharge process in coordination with the IDT. Review of the Social Service Supervisor job description revised 10/19/2018 indicated, SS reports to Administrator, performs highly responsible professional work in the administration and supervision of social services programs including the interpretation and assessment of policies and the supervision of professional and office support personnel within the social services division; supervises a unit providing services in one or more of the following program areas; adult- protective services, mental health case management, developmental- disabilities case management, family- based services, and social services; performs related work as assigned .Responsibilities /Accountabilities:3. Holds individual conferences with staff and interprets agency/state policies , rules and regulations. 4. Reviews case records to ensure that agency and state policies, rules and regulations are adhered to ensure that agency and state policies, rules and regulations are adhered to, and proper social work practices are observed 5. Monitors and evaluates the provision of client services in the program area. Review of the facility's policy, Transfer or Discharge Notice, release date January 2018, indicated, the facility shall provide a resident or the RP with a 30 day written notice of an impending transfer or discharge. The resident or RP will be notified in writing the reason for the transfer or discharge. the effect date, the location to which the resident will be transferred/discharged . The policy and procedure further indicated the resident or the RP will be notified on how to appeal the discharge

Based on observation and interview, the facility failed to ensure a resident's room accommodated no more than four residents when room [ROOM NUMBER] had six beds, and six residents and room [ROOM NUMBER] had five beds and five residents. Having more than four residents per room had the potential of compromising the quality of life and quality of care the residents received. Findings: During an observation on 5/13/25 at 11:50 a.m., there were six beds and six residents in room [ROOM NUMBER] and five beds and five residents were in room [ROOM NUMBER]. Both these rooms had an adequate space for residents to move around and for the care to be given. Each resident had a bed, a privacy curtain, a nightstand, and a closet. The beds did not block any closets, bathrooms, or exits. There was no safety hazard or privacy concerns noted. During interviews with randomly selected residents, there were no quality of care issues identified concerning the size of the room and number of occupants in room [ROOM NUMBER] and 2. During an interview with Certified Nursing Assistant (CNA) K on 5/15/25 at 11:06 a.m., CNA K confirmed room [ROOM NUMBER] and room [ROOM NUMBER] had more than four residents. CNA K stated there were no concerns when providing care for residents in room [ROOM NUMBER] and room [ROOM NUMBER] with more than four residents in both rooms. During an interview with Licensed Vocational Nurse (LVN) I on 5/15/25 at 12:08 p.m., LVN I confirmed there were more than four residents in room [ROOM NUMBER] and 2. LVN I stated there were no care, privacy and safety concerns of residents in room [ROOM NUMBER] and 2. Recommend continuance of the room waiver.

Based on observation, interview and record review, the following multi-resident rooms were less than 80 square feet per resident. Findings: Room Beds Square Feet/Room Square Feet/Resident 2 2 146 73 3 2 148 74 4, 5, 6 3 225 75 7 3 222 74 8 2 156 78 9 2 144 72 10, 11, 12, 13 2 146 73 14 2 148 74 15, 16, 17, 18 2 140 70 19 3 228 76 20 3 225 75 21 3 228 76 room [ROOM NUMBER] 6 432 72 room [ROOM NUMBER] 5 323.4 64.68 During an observation, interview with staff and resident on 5/13/25 at 11:50 a.m., on 5/14/2025 at 2:10 p.m., on 5/15/2025 at 11:06 a.m., and 12:08 p.m., there were no care or privacy issues identified with the lack of space regarding the size of resident rooms. During an interview with the facility's administrator (ADMN) on 5/15/25 at 12:15 p.m., the ADMN confirmed the rooms indicated above had less than 80 square feet space per resident. The residents were observed in their rooms throughout the survey. The nursing care and services were not impacted by the shortage of space for residents' rooms. The closet and storage spaces were sufficient to accommodate the needs of the residents. Review of the facility's room variance reports recommend the waiver remain in place.

Based on observation, interview and record review, the facility failed to provide necessary care and services to one of one residents (Resident 7) when the facility: a) to provide intervention/s to keep Resident 7's skin clean and dry, b) to have a skin care plan related to the right breast and abdominal fold redness, c) to conduct IDT (interdisciplinary team- composed of different disciplines like nursing, etc.) skin meeting, and d) to notify the doctor and responsible party (RP) when staff identified and reported Resident 7's skin redness and rashes. These failures resulted in Resident 7's having pain and discomfort, potential for skin infection and expressed feelings of frustration and embarrassment. During the initial tour on 3/2/2020 at 9:16 a.m., Resident 7 was observed lying on her bed and upon entering her room, there was a bad smell noted, and Resident 7 noted the surveyor's facial expression. Subsequently Resident 7 voluntarily opened her shirt and showed her right breast and the whole abdominal folds which were both noted to be red, raw, and with scattered open areas. The surveyor took a picture of Resident 7's right breast and abdominal folds with Resident 7's verbal consent. Resident 7 stated, the smell is awful and expressed feeling terrible and ashamed, and frustrated the wound was getting worse and painful and nobody was treating it. While still inside Resident 7's room, another surveyor entered the room at 9:20 a.m. When the surveyor commented, smells bad in here, Resident 7 stated, that's me and I'm sorry that is smells bad. Again, Resident 7 lifted the skin folds in her abdomen and right breast and showed the surveyor her skin and indicated it was very painful and apologized for the bad smell. Resident 7 stated, she did not refuse a shower and agreed right away when staff offered to give her a shower. During a follow-up observation and concurrent interview on 3/2/2020 at 10:36 a.m., when licensed vocational nurse A (LVN A), a treatment nurse assessed Resident 7, she confirmed the observation regarding Resident 7's wounds under her right breast and abdominal folds were red, raw, and with open areas that smelled bad. LVN A stated, yes, it smells bad. LVN A stated, the resident needed a treatment order from the doctor. LVN A also stated she was responsible for treatments of non-pressure (i.e skin tear, abrasions, moisture related [MEDICAL CONDITION], etc.) and pressure-related skin problems, and completion of Weekly Skin Evaluations. Review of Resident 7's Nurse's Progress notes and Skin/Wound notes dated November 2019 to March 2020 with LVN A, there were no documentation the MD and RP were notified; no MD order for wound treatment was taken and done; no change of condition (COC) for new skin problem; no care plan; no skin initial assessments/evaluation, and no IDT skin meeting were initiated. LVN A did not find documentation other than treatment and progress notes of redness on left groin dated 6/28/19. Review of Resident 7's treatment administration record (TAR) from November 2019 to March 2020, did not indicate any treatment done to Resident 7's under right breast and abdominal folds. During an interview and concurrent record review on 3/3/2020 at 3:09 p.m. with Registered Nurse B (RN B), and assistant director of nursing (ADON), RN B stated LVN A informed her that Resident 7's wounds were really bad, the certified nursing assistants (CNAs) should have reported to the nurse when they found the skin problem. RN B also stated, Resident 7 needed treatment for [REDACTED]. RN B reviewed Resident 7's progress notes dated 3/2/2020 which indicated, the MD and RP were notified on 3/2/2020 at 9:17 p.m. with treatments ordered for redness on right under breast, abdominal folds and groins (only after the surveyor called staff's attention that morning). A new treatment order dated 3/2/2020 for [MEDICATION NAME] (antifungal) powder apply topically (applied to skin or body surfaces) to abdominal fold, rt. groin and under breast every day shift for moisture-associated skin damage (MASD, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown) was ordered. During an interview on 3/3/2020 at 4:41 p.m., with certified nursing assistant C (CNA C), evening shift CNA, he stated having informed many times (but could not recall the dates) the evening charge nurse and treatment nurse when he and another female CNA first noted Resident 7's skin problems on right under breast and abdominal folds. During a follow-up observation and interview on 3/4/2020 at 7:52 a.m., Resident 7's right breast redness was observed less while under abdominal folds open areas and redness were also less and her pain had decreased and mainly on the right abdomen. Resident 7 stated, the pain had decreased and staff were treating the wound so it was improving. During an interview on 3/5/2020 at 9:40 a.m. with the director of nursing (DON), he stated Resident 7's MD and RP should have been informed of the new skin problems and if Resident 7 refused a shower on 2/25 and 2/28/2020, staff could have cleaned and treated the affected areas to prevent infection and deterioration. The DON concurred the skin problem did not happen overnight and so treatment should have been initiated and documentation of skin problems should have been done when identified. During an interview and concurrent record review on 3/5/2020 at 2:07 p.m., the ADON and medical record staff reviewed Resident 7's medical record from 6/29/19 to 3/2/2020 and did not find any skin assessments/re-evaluation, a situation, background, assessment, recommendation (SBAR, an assessment/reporting tool), weekly IDT skin meeting done regarding Resident 7's identified skin problems under right breast and abdominal folds. Both staff stated, any charge nurse can initiate the skin sheet and SBAR when any new skin problem was identified. The only SBAR done was on 6/29/19 regarding redness on left groin and on 8/16/19 redness of left breast. No other SBAR done. A review of the facility's policy and procedure, Pressure Ulcers/Skin Breakdown-Clinical Skin/Wound Management, dated January 2018, indicated the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings and application of topical agents if indicated for type of skin alteration. A review of the facility's policy and procedure, Changes in Resident Condition, dated April 2005, indicated the attending physician and legal representative or designated family member are notified when there is a significant change in the resident's physical, mental and psychosocial status using the SBAR. Changes in the resident status that affect the problem(s), goals or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Documentation in the Interdisciplinary Progress Notes include the date, time and Who was notified, information communicated and response and/or orders received. A review of the facility's policy and procedure, Comprehensive Care Plan, dated January 2018, indicated, each resident's comprehensive care plan has been designed to incorporate identified problem areas, reflect treatment goals and objectives, care plans are revised as changes in the resident's condition dictates.

Part One (IJ and IJ abated) Based on observation, interview and record review, the facility failed to ensure the dishwasher machine follow the manufacturer requirement to maintain the proper temperature and sanitizer concentration level; the facility failed to ensure dietary staff know how to check dishwasher machine temperature correctly; the facility failed to ensure dietary staff know what to do when the dishwasher temperature did not meet manufacturer's requirement. These failures placed all residents at risk to acquire food related gastrointestinal (GI; stomach and intestine, digest system) illness outbreak when dishes were not sanitized properly. On 3/5/19 at 8:57 a.m., the survey team called an Immediate Jeopardy (IJ; immediate danger or harm to residents or potential to harm residents if not correct immediately) with the administrator (Admin) and vice president of operations (VPO) related to the dishwasher machine when the dishwasher did not maintain the proper temperature and sanitizer concentration per manufacturer's requirement. Dietary staff did not know how to check dishwasher machine temperature correctly and dietary staff did not know what to do when the dishwasher temperature did not meet the manufacturer's requirement. On 3/5/19 at 5:10 p.m., the survey team abated the Immediate Jeopardy with the Admin and VPO related to the dishwasher, after the team received evidence of an acceptable plan of correction (P[NAME]). Findings: During an observation on 3/4/19 at 2:29 p.m., there was only one dishwasher in the kitchen. The dietary supervisor (DS) stated the facility used this low temperature dishwasher machine to sanitize all dishes for residents. During an observation and interview on 3/4/19 at 2:30 p.m., dietary aide H (DA H) washed dishes with the dishwasher. He checked the dishwasher wash temperature and stated the temperature was 100 Fahrenheit (F, temperature measure unit). The actual temperature reading from the thermometer on the dish machine was 80 F. DA H stated he could not see the temperature reading on the thermometer clearly and just guessed the reading as 100F. He said he needed to check and make sure the dishwasher wash and rinse temperatures reached to 100F. DA H did not know what to do when the dishwasher temperature was 80 F. During an observation and interview on 3/4/19 at 2:39 p.m., DA I washed dishes with the dishwasher. She checked the wash and rinse temperatures and stated the temperature was 80 F. DA B stated she needed to check and make sure the dishwasher's wash and rinse temperature to reach to 100 F. DA I did not know what to do when dish machine temperature was 80 F. During an observation and interview with the DS on 3/4/19 at 2:51 p.m., she washed the dishes with dishwasher, she stated she could not see the temperature reading from the thermometer on the dishwasher due to her vision problem. The dishwasher's wash and rinse temperature were 80 F. The DS stated the wash and rinse temperature should be 120 F per manufacturer requirement. She stated the maintenance department was responsible to provide the hot water to the dishwasher. The DS stated the dishwasher's temperature could not reach to 120 F during the day time because everyone was using hot water in the facility. The DS stated when the dishwasher temperature did not reach to 120 F, there was no need to call the manufacturer and she just notified the maintenance department to fix the hot water issues. During an interview with the DS on 3/4/19 at 3 p.m., she stated the dietary staff checked and record the dishwasher temperature three times a day. DS stated she checked the dishwasher temperature and sanitizer concentration log daily and did not identify any issues. During an observation and interview with cook [NAME] (Cook E) on 3/5/19 at 7:50 a.m., she washed dishes with dishwasher. She checked dishwasher wash and rinse temperature and sanitizer concentration. Cook [NAME] stated the dishwasher temperature was 80 F and the sanitizer concentration was 10 parts per million (PPM: concentration measurement unit). Cook [NAME] stated when the dishwasher temperature did not reach to 120 F, she just needed to run the dishwasher a few times. Cook [NAME] ran the dishwasher two time and the temperatures were 100 F and 110F. Cook [NAME] stated the dishwasher temperature normally couldn't reach to 120 F in the day time because everyone was using hot water in the facility. Cook [NAME] stated the dishwasher temperature had been like this for a while. Cook [NAME] stated the dishwasher sanitizer concentration should be between 50 ppm and 100 ppm per manufacturer requirement. During an interview with the dishwasher manufacturer field technician (DMFT) on 3/5/19 at 12:50 p.m., he stated the the dishwasher rinse temperature should be maintained for at least 120F and sanitizer concentration should be 50-100 ppm. The DMFT stated the facility heater booster in the kitchen was not working and unable to provide the hot water to dishwasher. Review the facility's undated policy, Dish Washing, indicated .The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations .If you cannot achieve this temperature, alert the dietary supervisor or cook who will alert the maintenance personnel and stop washing dishes. Due to the facility's failure to: 1. Dishwasher did not maintain the proper temperature and sanitizer concentration per manufacturer's requirement; 2. Dietary staff did not know how to check dishwasher machine temperature correctly. 3. Dietary staff did not know what to do when the dishwasher temperature did not meet manufacturer's requirement. On 3/5/19 at 8:57 a.m., the survey team called an Immediate Jeopardy and informed the Admin and VPO to provide the survey team with immediate measures that would be taken to ensure the safety of the residents to prevent the GI outbreak. On 3/5/19 at 5:10 p.m., the survey team reviewed the evidence of P[NAME] provided by the facility. According to the P[NAME]: 1. Facility used paper plates and portable utensils for residents until the dishwasher temperature and sanitizer concentration met the manufacturer's requirement. 2. Facility called the dishwasher manufacturer immediately to fix the dishwasher. Manufacturer replaced a new dishwasher heater booster. Dishwasher temperature and sanitizer concentration met the manufacturer requirement. 3. Facility would monitor dishwasher temperature and sanitizer concentration every one hour for 72 hours and notified manufacturer if not met the requirement. 4. Facility checked all residents for any symptoms and signs of vomiting, nausea, diarrhea, and any GI issues. No residents had issues. Facility notified all residents' responsible parties and physicians. The facility would continue to monitor all residents for 72 hours; care plans for residents regarding the risk of GI symptoms were in place; 5. Facility gave in-service to all dietary staff regarding how to check the dishwasher temperature and sanitizer concentration correctly; 6. Facility gave in-service to all dietary staff regarding what to do when the dishwasher temperature did not meet the manufacturer requirement. The survey team accepted the P[NAME] and informed the Admin and VPO on 3/5/19 at 5:10 p.m., that the Immediate Jeopardy was abated. Part Two (Other kitchen issues) Based on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not wash hands after she touched the water bottle in the washing sink and proceeded to clean kitchen stove and counter; 2. Dietary staff did not cover their hair completely with a hairnet; 3. The can opener had black and orange substances; 4. The ice machine had black substance on the wall and frame of the ice bin (the bin inside the ice machine where the ice is collected) and black & gray substances at exterior of ice machine; 5. The refrigerators and freezer had black and orange substance; 6. The freezer stored a damaged carton of ice cream; ice cream spilled in freezer; the opened ice cream carton did not cover with food wrap completely; 7. Cook G wore the same pair of gloves to prepare the hot food, touched meal carts, plates, lids, resident diet cards, kitchen stove surfaces and counters during tray line (Food preparation system, used in the facility, in which trays move along an assembly line.) 8. Dietary staff did not know how to check quaternary sanitizer (sanitizer used to clean kitchen surface and counter, used to manually sanitizer dishes) 9. Dietary staff did not know how to manually sanitize dishes; 10. Dietary staff did not know how to calibrate the thermometer; 11. DS and RD did not identify dishwasher temperature and sanitizer log issues when dishwasher temperature and sanitizer concentration level did not meet manufacturer's requirement since (MONTH) (YEAR); These failures had the potential to cause foodborne illness for residents. Findings: 1. During an initial kitchen tour observation on 3/3/19 at 8:05 a.m., cook E's (Cook E) gloved hand touched a water bottle in the washing sink. She continued to clean the kitchen stove and counter with the same pair of gloves. Cook [NAME] stated she should have removed the gloves and washed her hands after she touched the water bottle in the sink. Review the facility's policy, Handwashing Hand Hygiene dated Jan (YEAR), indicated .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 2a. During an observation and interview on 3/3/19 at 8:05 a.m., Cook E's hair on the sides and back were not completely covered with a hairnet. Cook [NAME] stated she should covered her hair completely with a hairnet. 2b. During an observation and interview on 3/3/19 at 8:11 a.m., DA F's hair on the sides and back were not covered completely with a hairnet. DA F stated she should cover her hair completely with a hairnet. 2c. During an observation and interview on 3/4/19 at 7:30 a.m., Cook G's hair on the sides and back were not covered completely with a hairnet. Cook G stated she should cover her hair completely with a hairnet. 2d. During an observation and interview on 3/4/19 at 10:50 a.m., the dietary supervisor's (DS) hair on the back was not covered completely with a hairnet. DS stated she should cover her hair completely with a hairnet. She stated it was hard to cover all the hair with a hairnet. 2e. During an observation and interview on 3/4/19 at 11:48 a.m., DA H's hair on the back was not covered completely with a hairnet. DA H stated he should cover his hair completely with a hairnet. 2f. During an observation and interview on 3/4/19 at 2:25 p.m., DA I's hair on the back was not covered completely with a hairnet. DA I stated she should cover her hair completely with a hairnet. Review of the facility's revised policy's Dress Code dated (YEAR), indicated dietary staff should cover the hair completely with a hair net or hat. 3. During an initial kitchen tour with Cook [NAME] on 3/3/19 at 8:17 a.m., Cook [NAME] stated there was only one can opener in the kitchen. The can opener had noted with black and orange substances at the top, base, blade and blade surrounding areas. Cook [NAME] stated the can opener should have been cleaned after each use. Review of the facility's policy, Can Opener and Base dated 3/13, indicated .Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation .The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. 4. During an initial kitchen tour with Cook [NAME] on 3/3/19 at 8:17 a.m., Cook [NAME] stated there was only one ice machine in the kitchen for the facility. Ice machine had noted with black substance on the ice bin walls and frames; black and gray substances noted on ice machine lid and exterior walls. Cook [NAME] stated the staff should clean the ice machine inside and outside. Review of the facility's policy's Ice Machine Cleaning Procedures dated (YEAR), indicated .The ice machine (bin and internal components), need to be cleaned monthly .Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions .Be sure special attention is paid to cleaning the door molding and the lid of the machine. 5. During an initial kitchen tour with Cook [NAME] on 3/3/19 at 8:38 a.m., black substance had noted on gaskets (rubber area inside the refrigerator and freezer to seal the door), walls, bases of the two refrigerators and freezer; orange substances had noted on the racks inside the refrigerators and freezer. During an interview with Cook [NAME] on 3/3/19 at 8:45 a.m., she stated there were only two dietary staff work in the kitchen, they did not have time to clean the refrigerators and freezer. 6. During an initial kitchen tour with Cook [NAME] on 3/3/19 at 8:38 a.m., one opened carton of ice cream was not fully covered with food wrap, the food wrap dated with open date of 2/28/19. The bottom of the ice cream carton was damaged, the yellow ice cream spilled inside the freezer. During an interview with Cook [NAME] on 3/3/19 at 8:45 a.m., she stated the opened carton of ice cream should be fully covered with a food wrap. She stated the ice cream carton was damaged with ice cream leaking in the freezer. Cook [NAME] stated the facility still used the ice cream for residents because the DS did not give instruction to discard the ice cream yet. Review of the facility's policy, Storeroom, Refridgerator/Freezer, dated (YEAR), indicated .The general cleanliness and care of the storeroom, supplies, and refrigerator & freezer are important to insure safe wholesome food . Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods .All will be cleaned weekly. 7. During a tray line observation on 3/4/19 at 12 p.m., Cook G wore the same pair of gloves to prepare all the hot food for residents, her gloved hands touched meal carts, plates, lids, resident diet cards, kitchen stove surfaces and counters. She did not change to a new pair of gloves or wash her hands. During an interview with the DS on 3/4/19 at 12:30 p.m., she stated Cook G should have performed hand hygiene after the gloved hands touched all these surfaces during tray line. 8. During an observation on 3/4/19 at 10:44 a.m., DA F tested quaternary sanitizer with a test strip. She dipped the test strip into the sanitizer less than one second and took the trip out right away. DA F stated she would wait for two to three minutes and then check the test strip against the color chart for the sanitizer concentration level. During an observation on 3/4/19 at 11:58 a.m., DA H removed one test strip with his wet finger to test quaternary sanitizer. He dipped the test strip into the sanitizer solution for three times for total three seconds, then he compared the test strip with color chart in one second. DA H stated he should have followed the manufacturer guide to check the sanitizer concentration correctly. Review the quaternary test strip instruction indicated .use dry fingers to remove strip from vial. Remove one strip and dip strip for one second into solution to be tested . Allow 5 to 10 seconds to develop, then compare to color chart below. During an interview with the DS on 3/4/19 at 12:30 p.m., she stated dietary staff should follow the manufacturer guide for the correct quaternary sanitizer concentration check. 9. During an interview with DA H on 3/4/19 at 2:30 p.m., he stated the facility only had two compartments of wash and rinse sinks for manual sanitizing dishes. He stated he used rinse sink as sanitizer sink to sanitize dishes. DA H stated he did not know how to sanitize dishes manually and how long the dishes need to be sanitized. During an interview with DA I on 3/4/19 at 2:39 p.m., she stated the facility only had two compartments for wash and rinse. Therefore there was no need to sanitize the dishes when manually sanitize dishes. DA I stated she washed and rinsed the dishes, and then dried the dishes. Review the facility's undated policy, 2-Compartment Sink Dishwashing Procedure, indicated dishes needed to immerse into the sanitizer for 30 second for sanitizing. 10. During an observation on 3/4/19 at 11:56 a.m., DA F did thermometer calibration (process of adjusting the thermometer to an accurate reading). She put the thermometer into an ice water glass. The ice tubes flowing on the top of the water. The tip of the thermometer touched the side of the glass. DA F put the thermometer in the ice water for 15 seconds and then calibrated the thermometer. DA F was unable to answer how long the thermometer need to be submerged into the ice water before calibration. Review of the facility's undated policy, Thermometer Calibration, indicated .Food thermometers are to be calibrated to ensure accurate temperature reading .Fill a large glass with crushed ice and clean tap water until the glass is full. Stir the mixture well .Put the thermometer or probe stem into the ice water so that the sensing area is completely submerged. Do not let the stem touch the bottom or sides of the glass. Wait 30 seconds. (Note: the thermometer stem or probe must remain in the ice mater the full 30 seconds and during calibration.) 11. Review of the facility's DISH MACHINE TEMPERATURE LOG from (MONTH) (YEAR) to (MONTH) 2019 indicated the wash temperatures must be at least 120F, use manufacturer guidelines on machine for range of wash and rinse temperatures, and sanitizer chlorine should be 50 to 100 PPM. There were multiple records did not meet the manufacturer requirement level as following: a. (MONTH) (YEAR): 77 of 90 records of wash temperatures were less than 120F; nine of 90 rinse temperature were less than 120F, 84 of 90 sanitizer level were out of normal range; b. (MONTH) (YEAR): Dietary staff did not check and record dishwasher temperature and sanitizer level for three times; 90 of 90 wash temperature were less than 120F; two of 90 rinse temperature were less than 120F; c. (MONTH) (YEAR): 86 of 90 wash temperature were less than 120F; d. (MONTH) (YEAR): one of 93 wash temperature was less than 120F; 10 of 93 sanitizer level were out of normal range; e. (MONTH) 2019: Dietary staff did not check and record dishwasher temperature and sanitizer level for three times. f. (MONTH) 2019: Eight of 84 wash temperatures were less than 120F; 17 of 84 rinse temperatures were less than 120F; 18 of 84 sanitizer level were out of normal range. During an interview with the DS on 3/4/19 at 3 p.m., she stated the dietary staff checked and recorded the dishwasher temperature three times a day. The DS stated she checked the dishwasher temperature and sanitizer concentration log daily and did not identify any issues. During an interview with the registered dietitian (RD) on 3/5/19 at 1:46 p.m., she stated did not identify dishwasher issues from dishwasher temperature and sanitizer concentration logs.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcer (skin integrity caused by unrelieved pressure which results in damage to the underlying tissues) for one of three sampled residents (Resident 40) when treatment was not provided for three months on Resident 40's coccyx (tail bone) redness, and a high risk for pressure ulcer care plan was not developed upon admission. These failures resulted in Resident 40's sustaining a unstageable (a full thickness tissue loss in which the base of the ulcer is covered by slough (a yellow color, tan, and gray color in the wound bed) pressure ulcer in the coccyx. Findings: Review of Residents 40's face sheet indicated he was admitted on [DATE] with the [DIAGNOSES REDACTED]. His Minimum Data Set (MDS, an assessment too) dated 8/5/18, indicated he was high risk for pressure ulcer, could make decision, and required assistance for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. There was no care plan for high risk pressure ulcer. Review of Resident 40's Nursing Admission assessment dated [DATE], indicated the resident had redness on his coccyx. Review of Resident 40's Treatment Administration Record, there was no indication the redness on his coccyx had treatment for [REDACTED]. Review of Resident 40's Wound assessment dated [DATE], indicated the resident acquired a unstageable pressure ulcer on his coccyx with a slough on 8/27/18. Review of Resident 40's Braden Scale (a tool to assess the patients' risk of developing a pressure ulcer) dated 8/27/18, indicated he had a score of 14 (a score of 13-14 represents a moderate risk for pressure ulcer). During a wound observation, interview, and record review with licensed vocational nurse (LVN D) on 3/6/19 at 8:14 a.m., she stated Resident 40 had a redness on his coccyx, had an 80 percent slough with 20 percent granulation. LVN D stated Resident 40's redness on his coccyx was upon admission and she confirmed there was no treatment on 5/2018, 6/2018, and 7/2018. She acknowledged the licensed nurses should have treated the redness on his coccyx to prevent development of a pressure ulcer. LVN D stated she was unable to find the care plan for high risk pressure ulcer to prevent pressure. During an interview and record review with the director of nursing (DON) on 3/7/19 at 9:35 a.m., she confirmed Resident 40's unstageable pressure ulcer on his coccyx was acquired in the facility and he was high risk for pressure ulcer. The DON confirmed there was no treatment on the month of 5/2018, 6/2018, 7/2018 and the licensed nurse should have treated the redness on his coccyx to prevent pressure ulcer. The DON stated the licensed nurse should have develop a care plan for high risk pressure ulcer upon admission to prevent pressure ulcer. The DON acknowledged the unstageable pressure ulcer in coccyx could have prevented and avoided if the treatment was initiated upon admission and the high risk for pressure ulcer care plan was develop. Review of the facility's 1/2018, Pressure Ulcer/Skin Breakdown-Clinical Breakdown, indicated the nursing staff will examine the skin of the new admission for alteration in skin or ulceration. Review of the facility's 1/2018, Pressure Ulcer/Injury Risk Assessment, indicated to develop resident -centered care plan and interventions based on the risk factors identified in the assessments.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for one out of 14 sampled residents (Resident 11). This failure resulted in Resident 11's fall with an injury of acute nasal bone fracture. Findings: Review of Resident 11's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Review of Resident 11's fall risk assessment tool, dated 3/3/19 indicated Resident 11 had a fall risk score of 18, 5/30/18 score of 16, 2/27/18 score of 23 and 11/13/17 score of 20 (a score of 10 or above represents high risk for falls and environmental risk factors needed to be consider). Review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 12/14/18, indicated his brief interview for mental status (BIMS) score was 6, indicated his cognition was severely impaired and he required extensive assistance (staff provide weight bearing support) for moving on and off the unit using the wheelchair. Review of Resident 11's Situation Background Assessment recommendation (SBAR) Communication Form (communication tool), dated 5/30/18, indicated he had a witnessed fall at 8:20 a.m., when staff was pushing resident's wheelchair without footrests on both feet to the smoking area; when it came across a rock that caused Resident 11 to fall out from his wheelchair with his right leg first on the ground and no footrests intervention. Review of Resident 11's nursing progress note dated 3/3/19, indicated Activity Assistant (AC) was pushing resident 11's wheelchair without footrests to go to the patio to smoke at 11:00 a.m., and Resident 11 lost his balance and tripped off the ground due to the footwear that he was wearing and sustained skin tear at the bridge of his nose and left shin peeled off skin measuring seven centimeters (cm, unit of measurement) by 2 cm. Review of Resident 11's radiology results report, dated 3/4/19, indicated an X-ray result revealed acute nasal bone fracture. During an interview with the AC on 3/3/19 at 11:19 a.m., the AC confirmed on 3/3/19 at 11:00 a.m., he was the one who pushed Resident 11's wheelchair without the footrests on both feet in the patio going to the smoking area when Resident 11's right slipper caught on the uneven floor pavement and Resident 11 fell face down from his wheelchair. The AC further stated that he has no training in pushing resident's wheelchair in the facility and Resident 11 had no footrests for his feet every time he was in his wheelchair. During a concurrent interview and rehabilitation notes review dated 3/31/17 and 1/29/19 with the Director of Rehabilitation (DOR/PT, a type of rehabilitation therapy) on 3/5/19 at 1:00 p.m., she confirmed that rehabilitation staff forgot to document that Resident 11 should have footrests for his feet for safety. The DOR further stated rehab definitely recommended footrests when Resident 11 was in his wheelchair and wheeled by the staff members for safety. During a concurrent interview and record review with the Occupational Therapist (OT, a type of rehabilitation therapy) on 3/5/19 at 1:32 p.m., he stated rehab recommended footrests for Resident 11 when he was wheeled by staff members and to wear socks or regular sneakers. The OT further stated footrests would support proper positioning in the wheelchair as Resident 11 had a posture problem. The OT confirmed he did not document on the rehabilitation screening form dated 1/29/19 when he did the screening for Resident 11. During a concurrent observation in Resident 11's closet and interview with the DOR on 3/5/19 at 2:15 p.m., she confirmed that Resident 11's footrests were inside the closet and was recommended by the rehab staff to have them on when Resident 11 was in his wheelchair and wheeled by staff members for safety. The DOR further stated footrests needed to be in Resident 11's wheelchair and not inside the closet. During multiple observations on 3/3/19 at 11:32 a.m., Resident 11 was sitting in his wheelchair in the patio smoking without footrests and wearing brown slippers, on 3/3/19 at 1:20 p.m., was sitting in his wheelchair in the patio smoking without footrests and wearing brown slippers, on 3/5/19 at 8:25 a.m., Resident 11 was sitting in his wheelchair in front of his room without footrests and barefooted and on 3/6/19 at 10:15 a.m., Resident 11 was sitting in his wheelchair in front of his room without footrests and bare footed. This was confirmed by Certified Nursing Assistant K (CNA K) on 3/6/19 at 10:15 a.m. During a concurrent observation of Resident 11's face and interview with the licensed vocational nurse D on 3/7/19 at 11:46 a.m., LVN D was measuring Resident 11's right eye discoloration measuring four centimeters (cm, unit of measurement) by 5.5 cm, left eye 3.5 cm by 6 cm and the nose is 5.5 cm by 2 cm. During a concurrent interview and record review with the director of nursing (DON) on 3/7/19 at 8:41 a.m., she confirmed Resident 11's falls on 5/30/18 and 3/3/19 had the same cause of incidents. The DON stated that there was no care plan and monitoring of refusal of foot rest for Resident 11. The DON further stated the fall on 3/3/19 would have been prevented if there were footrests on the wheelchair. The AC was trained by the rehabilitation staff or nursing for Resident 11's safe wheelchair mobility, right footwear was used not slippers and referral to therapy for his safe wheelchair mobility. Review of the facility's policy, Falls and Fall Risk Managing dated 11/17, indicated the staff, with the input of the attending physician, will identify appropriate interventions to reduce or minimize serious consequences of falling. The staff will monitor resident's response to interventions intended to reduce falling or the risk of falling.

Based on interview and record review, the facility failed to ensure the fall care plans were updated after fall incidents for one of three sampled residents (Resident 1). This resulted in Resident 1's unwitnessed three falls with injuries occurring on [DATE] (separated right shoulder) , [DATE] (bump on the head), and [DATE] with loss of consciousness. Findings: A review of Resident 1's medical record indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated the resident required staff assistance for mobility and that his balance during transitions and walking was not steady, only able to stabilize with staff assistance. A review of the medical record, IDT POST-EVENT NOTE for [DATE] at 8:10 p.m., indicated, The nurse doing rounds saw the resident on the floor on the prone position. Resident was moaning and groaning. Assisted him back to wheelchair and ask what happened. Resident stated was reaching out for his TV lost balance and fell . A review of the medical record, THERAPY POST-FALL SCREEN for [DATE] completed by the IDT, indicated the root cause of the fall was determined to be related to behavioral symptoms and non-compliant with safety precautions. A recommendation was made for a physical therapy eval(uation). A review of the medical record, IDT POST-EVENT NOTE for [DATE] at 11:00 a.m., indicated Resident seen laying on the floor by his bedside incurring a head lump/bump . measuring 3.5 cm (length) x 3 cm (width) . When asked what happened, resident said that he bend over to reach this false teeth that fell on the floor in between his bed and his side table which caused him to fall and hit his frontal side of his head on the wall. A review of the medical record, THERAPY POST-FALL SCREEN for [DATE], completed by the IDT, indicated the root cause of the fall was determined to be related to behavioral symptoms and poor safety awareness. A recommendation was made for frequent monitoring and chair alarm-pressure. A review of the medical record, IDT POST-EVENT NOTE for [DATE] at 8:45 a.m., indicated, CNA (1) went inside the room and found resident's wheelchair which was flipped to the side and found his head up to his shoulder was inside the trash bin. Per CNA, she removed the head out of the trash bin by herself and called for help. Staff came and found resident unresponsive, no pulse, no breathing . CPR initiated . called 911. A review of the medical record indicated a THERAPY POST-FALL SCREEN had not been completed for [DATE]. A review of the medical record COMPREHENSIVE PLAN OF CARE update dated [DATE], indicated refused bed and tab alarm to alert staff. Update dated [DATE] indicated be sure call light is within resident's reach. Update dated [DATE] indicated adaptive devices as recommended by therapy or MD . Monitor/document to ensure appropriate use of safety/assistive devices. A review of the facility policy, FALLS-RISK ASSESSMENT, IDENTIFICATION & REDUCTION dated [DATE], indicated Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on their individual risk factors . The IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or related incident. A review of the facility policy, COMPREHENSIVE PLAN OF CARE dated [DATE], indicated the comprehensive plan of care must include interventions to attempt to manage risk behaviors . re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment. In an interview on [DATE] at 3:00 p.m., the director of nurses (DON) stated the care plan should have been updated after the falls. When asked what interventions were implemented for Resident 1 addressing falls related to reaching for objects, the DON stated, We put an alarm. He really doesn't want anything done . We provided him a reacher. The DON said the interventions were documented in the short-term care plan. When asked if they should be documented in the long-term care plan, the DON stated, It should be in the long-term care plan. When asked how Resident 1 is supervised, the DON stated, We monitor him. We don't have a specific time that we monitor. Not in place that we document every hour. Mostly it's the huddle we do every morning. In an interview on [DATE] at 8:46 a.m., certified nursing assistant 1 (CNA 1) stated on [DATE] at 8:45 a.m., I walked near his bed and saw his wheelchair flat on its side. Then I saw his body . I saw his face in the trash can . it was to his shoulder. It had a liner .the plastic bag. I removed the wheelchair and removed the trash can and removed the liner. In an interview on [DATE] at 9:30 a.m., licensed vocational nurse 1 (LVN 1) stated, He is told not to transfer himself but he does it anyway. In an interview on [DATE] at 9:41 a.m., registered nurse 1 (RN 1) stated, We remind him of the call light. We tell him not to transfer alone. He says he can do it. In an interview on [DATE] at 10:00 a.m., restorative nurse assistant 1 (RNA 1) stated, We know he is a fall risk. In an interview on [DATE] at 1:10 p.m., RNA 1 was asked if Resident 1 used his call bell. RNA 1 stated, Most of the time he does not use that one. When asked about the grabber, RNA 1 stated, I never saw him with the grabber . I did not know about that one. RNA 1 identified the grabber and the reacher as the same object. In an interview on [DATE] at 1:20 p.m., CNA 1 stated the grabber was not on the bedside table when she found Resident 1 on the floor on [DATE].

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (1) had two staff members needed to safely transfer (lift and move away from one surface to another) the resident from the bed to a chair as indicated on the care plan. On 12/10/10 at 11:45 a.m. certified nurse assistant A (CNA A) transferred Resident 1 from her bed to a wheelchair without the use of a second person. On 12/10/10 at 2:30 p.m., Resident 1 was noted to have a bruise on her left lower leg. Subsequently the evening of 12/10/10 Resident 1 was diagnosed by X-ray to have a displaced fracture (the ends of the broken bone are out of alignment) of the left tibia (a bone of the lower leg). Resident 1 was transferred to a local hospital where she underwent surgery to the fractured tibia. Findings: Resident 1 was admitted with [DIAGNOSES REDACTED]. The 11/29/10 Minimum Data Set (MDS) assessment indicated Resident 1 had poor memory function and needed help to make decisions. The MDS assessment indicated Resident 1 was dependent on staff for mobility, bathing, dressing, and eating. The MDS indicated Resident 1 required two people to transfer, and did not walk. Resident 1's record was reviewed on 12/17/10. The 11/10 care plan for activities of daily living (daily self-care task) indicated to transfer Resident 1 using two staff. The 11/10 care plan for osteoporosis indicated a goal to be free from fracture and swelling of joints, and be free of pain daily. Interventions included to handle gently during care, maintain proper body alignment during positioning; and observe caution when turning and repositioning A nurse's note of 12/10/10 at 2:30 p.m. indicated CNA B reported to a licensed nurse a red purplish discoloration measuring 3 centimeters (cm) by 3 cm on Resident 1's left lower leg (a centimeter is roughly equivalent to one-half inch). A nurse's note of 9:20 p.m. of the same day indicated Resident 1 was calling out, "Daddy, Daddy", and she was given a sedative. A nurse's note of 12 a.m. on 12/11/10 indicated the purplish discoloration measured 9 cm by 7 cm and there was swelling present, and Resident 1 said "ouch, ouch" when the area was touched. A nurse's note of 12/11/10 at 1:30 a.m. indicated Resident 1 was transferred to an acute care hospital by ambulance. A 12/11/10 history and physical from a local hospital indicated Resident 1 was diagnosed with [REDACTED]. A 12/13/10 Pre-op history and physical note written by orthopedic physician (bone specialist) A (MD A) at an acute hospital indicated Resident 1 had a spiral type of displaced tibia fracture. The note indicated this type of fracture was primarily caused by a twisting force. The note indicated Resident 1's leg may have been twisted. The note indicated a common cause of this type of fracture was a fall. A 12/15/10 discharge summary from the acute care hospital indicated Resident 1 on 12/12/10 underwent a surgical procedure to pin her left tibia back together. During an observation on 12/17/10 at 9:35 a.m., Resident 1 was in bed with her head elevated on pillows. Resident 1 was awake and spoke but did not give appropriate verbal responses. Resident 1's left leg was elevated on two pillows. The leg was swollen and wrapped in a bandage. During an interview on 12/17/10 at 12:45 p.m. CNA A stated she was caring for Resident 1 on the day shift on 12/10/10. She stated at 11:45 a.m. she lifted Resident 1 from the bed to the wheelchair by herself. She stated Resident 1 only needed the help of one person to transfer. During further interview on 12/21/10 at 10 a.m. CNA A demonstrated how she put a gait belt (a thick belt with Velcro fastener to wrap around the resident's waist to grasp during transfer) around Resident 1's waist and then lifted and turned, in a simultaneous motion, Resident 1 about forty-five degrees to the left, to place her in the wheelchair. CNA A stated she did not get help transferring Resident 1 on 12/10/10 at 11:45 a.m. During an interview on 12/21/10 at 10:10 a.m. CNA B stated she cared for Resident 1 on the evening shift starting at 2 p.m. She stated at 2:30 p.m. she went to the activity room, and brought Resident 1 back to her room. She stated she summoned CNA C to help her transfer Resident 1 to a shower chair. CNA B stated after undressing Resident 1 she noticed a discoloration on Resident 1's left lower leg and notified a licensed nurse. During an interview on 12/21/10, occupational therapist A (OT A) stated a resident who could not bear weight, such as Resident 1, must be transferred carefully. Preferably two persons should be utilized. OT A demonstrated and verbalized how if a non-weight bearing resident's leg was extended and in contact with the floor, a twisting motion could occur when the resident was moved from a bed to a wheelchair placed alongside the bed. He stated injury to the leg could result from the twisting motion combined with weight placed on the leg and foot. During an interview on 12/21/10 at 12 noon, the director of nurses (DON) stated CNA A should not have transferred Resident 1 unaided. On 12/21/10 a review of the undated facility policy and procedure, "Turning, Repositioning and Transfer of Patient with Osteoporosis" indicated osteoporosis weakens bones, making them more susceptible to fractures. The policy indicated staff would use proper techniques for transferring the resident. The policy indicated patients must be handled gently and carefully, observing caution when turning, repositioning and transferring.