Every finding on record at Capistrano Beach Care Center

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were implemented for one of four sampled residents (Resident 1). * Resident 1's PICC line dressing and StatLock were not changed as ordered by the physician. This failure placed Resident 1 at increased risk for developing a central line-associated bloodstream infection related to the PICC line.Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes revised 3/2022 showed the purpose of the procedure is to prevent complications associated with intravenous therapy including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Further review of the P&P also showed to maintain a sterile dressing and to change it if it becomes damp, loosened, or visibly soiled. Medical record review for Resident 1 was initiated on 5/27/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/11/26, showed Resident 1 had the capacity to understand and make medical decisions. Review of Resident 1's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 1's Order Summary Report showed a physician's order dated 5/15/26, for Resident 1 to have his right upper arm PICC dressing and Stat-lock to change every Friday. On 5/27/26 at 1545 hours, an observation was conducted with Resident 1. Resident 1 was observed to have a PICC line inserted in his right upper arm with a dressing dated 5/15/25. On 5/27/26 at 1608 hours, an observation, interview, and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 confirmed he changed the dressing and Stat-Lock on 5/15/25. RN 2 stated the dressing and Stat-Lock should have been changed one week later, on 5/22/26. On 5/27/26 at 1630 hours an observation, interview, and concurrent medical record review for Resident 1 was conducted with the DON. The DON confirmed the above findings. The DON stated the PICC line dressing and Stat-lock should have been changed every Friday, and as needed to prevent infections. Cross Reference to F842

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of four sampled residents (Resident 1) was accurate. * Resident 1's PICC line dressing and Stat Lock were documented as being changed on 5/22/26; however, they were last changed on 5/15/26. This failure contributed to delay in Resident 1's PICC line dressing and Stat-lock to be changed as ordered by the physician.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Further review of the P&P also showed treatments or services performed should be documented in the resident medical record. Medical record review for Resident 1 was initiated on 5/27/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/11/26, showed Resident 1 had the capacity to understand and make medical decisions. Review of Resident 1's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 1's Order Summary Report showed a physician's order dated 5/15/26, for Resident 1 to have his Right Upper Arm PICC dressing and Stat-lock changed every Friday. On 5/27/26 at 1545 hours, an observation was conducted with Resident 1. Resident was observed to have a PICC line inserted into his right upper arm with a dressing over it dated 5/15/25. On 5/27/26 at 1608 hours, an observation, interview, and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 confirmed he changed the dressing and Stat-lock on 5/15/25. RN 2 stated the dressing and Stat-lock should have been changed a week later on 5/22/26. Review of Resident 1's Intravenous MAR showed the PICC line dressing and Stat-lock had been documented as changed on 5/22/26 by RN 1. RN 2 stated the documentation should be done after a task was completed and not before. On 5/27/26 at 1630 hours an observation, interview, and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the above findings. The DON stated the PICC line dressing and Stat-lock should have been changed every Friday and as needed to prevent infections. The DON stated the documentation should have been done after the nurse completed the dressing change. The DON stated if the documentation was done prior to a task being performed, there was a potential for it to be missed. On 5/28/26 at 0730 hours, an interview and concurrent record review was conducted with RN 1. RN 1 stated she had documented that the task was completed but must have forgotten to update the record accordingly. RN 1 stated she should have documented it after she finished the dressing change. Cross Reference to F880

Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of January through November 2025. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. This failure posed the risk for not identifying the residents' infections and controlling the potential transmission of communicable diseases to other residents throughout the facility. * The facility failed to establish specific testing protocols and acceptable ranges for control measures, to reduce Legionella risk. This failure posed the risk for Legionella growth in the facility building water system. Legionella has the potential to cause a serious type of pneumonia called Legionnaires disease in the vulnerable resident population. * LVN 7 failed to ensure the contaminated equipment was disinfected prior to use on Resident 42. This failure posed the risk for the spread of pathogens.Findings: 1. Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the infection preventionist (IP) will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections. Infections that will be included in routine surveillance include those with evidence of transmissibility in a healthcare environment and pathogens associated with serious outbreaks. The nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible. The charge nurse will notify the attending physician and IP of suspected infections. The IP is responsible for gathering and interpreting surveillance data. On 11/17/25 at 1047 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to describe the facility's resident infection surveillance program. The IP stated he was responsible for the surveillance of the residents' infections in the facility. The IP stated the infection surveillance was necessary to identify the residents' infections to guide appropriate interventions and mitigate the spread of infections. The IP stated when a resident exhibited signs and/or symptoms of an infection and was prescribed antimicrobial medications, the licensed nurse who received the antimicrobial order would then initiate the facility's McGeer's criteria form. The IP stated the facility utilized McGeer's criteria to determine if a resident had an infection. The IP stated the information specific to the resident's infections was documented on the facility's monthly Infection Prevention and Control Surveillance log. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from January through October 2025 showed the following resident infection surveillance data for HAIs, CAIs, and residents who did not meet McGeer's criteria (DNMC): - 1/2025: HAI – 14, CAI – 21, and DNMC – 18 - 2/2025: HAI – 11, CAI – 20, and DNMC – 4 - 3/2025: HAI – 10, CAI – 16, and DNMC – 7 - 4/2025: HAI – 9, CAI – 18, and DNMC – 2 - 5/2025: HAI – 12, CAI – 13, and DNMC – 6 - 6/2025: HAI – 4, CAI – 12, and DNMC – 10 - 7/2025: HAI – 12, CAI -26, and DNMC – 5 - 8/2025: HAI – 11, CAI 12, and DNMC – 8 - 9/2025: HAI – 11, CAI – 21, and DNMC – 6 - 10/2025: HAI – 12, CAI – 19, and DNMC -7 Further review of the facility's monthly Infection Prevention and Control Surveillance logs from January through October 2025 showed documentation that all the residents included on the facility's Infection Prevention and Control Surveillance logs were prescribed antimicrobial medications. The IP was asked when a resident at the facility exhibited signs and/or symptoms of infection and was not prescribed antimicrobial medications, if the facility initiated the McGeer's criteria form and included these residents in the facility's infection surveillance program (for the months of January through October 2025). The IP stated the facility did not initiate the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications. The IP was asked how many residents in the facility had infections (met McGeer's criteria) and were not prescribed antimicrobial medications (from January through October 2025). The IP stated he was uncertain as the facility did not initiate the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications. 2. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to the policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: * Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. * Develops and implements a water management program that considers the ASHRAE (American Society of Heating Refrigerating and Air-Conditioning Engineers) industry standards and the CDC (Centers for Disease Control and Prevention) toolkit; and * Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Legionella Water Management Program reviewed 9/2022 showed the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program. The water management program includes the following elements: Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants). The control limits or parameters that are acceptable and that are monitored. A system to monitor control limits and the effectiveness of control measures. A plan for when control limits are not met and/or control measures are not effective, and documentation of the program. On 11/19/25 at 0907 hours, an interview and concurrent facility record review was conducted with the Administrator. Review of the facility's Water Management Program for Legionella Control (undated) failed to show specific testing protocols and acceptable ranges for the control measures. The Administrator verified the facility's Water Management Program for Legionella Control (undated) failed to show specific testing protocols and acceptable ranges for the control measures. 3. Review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 9/2022 showed the [NAME] Classification System is used to distinguish the level of sterilization/disinfection necessary for items used in resident care: Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpan, blood pressure cuffs, crutches and computer. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed. On 11/18/25 at 1600 hours, a medication pass observation was conducted with LVN 7. LVN 7 obtained the sphygmomanometer (medical device used for measuring blood pressure) from the medication cart and fell to the floor. LVN 7 did not disinfect the sphygmomanometer cuff. LVN 7 went inside Resident 42's room and placed the sphygmomanometer on Resident 42's left upper arm to check the resident's blood pressure. On 11/18/25 at 1608 hours, an interview was conducted with LVN 7. LVN 7 verified the sphygmomanometer was on the floor and when she picked it up, she did not clean or disinfect prior to using it on Resident 42. On 11/19/25 at 0956 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated any equipment used for the residents needed to be clean or disinfected prior to use. On 11/19/25 at 1052 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the essential equipment was maintained in proper working condition. * The kitchen walk-in freezer had ice build-up which prevented the door from closing completely. * The walk-in refrigerator fan cover had black debris and brown residue resembling rust. * The floor tiles under the kitchen oven were not intact and clean. These failures had the potential for the equipment to not function the way it was intended.Findings: According to the USDA Food Code 2022, Chapter 4 Equipment, Utensils, and Linens, Section 4-501.11 Good Repair and Proper Adjustment, equipment shall be properly maintained. 1. Review of the facility's P&P titled Procedure for Freezer Storage dated 2023 showed the freezer doors are to close tightly to prevent storage temperature fluctuations. Review of the facility's document titled Sanitation and Food Safety Checklist dated 6/16/25, completed by RD 1 showed there was ice build up on the freezer door and was not able to fully close. Review of the facility's document titled Sanitation and Food Safety Checklist dated 7/28/25, completed by RD 1 showed the walk-in freezer could not maintain the temperature range. Review of the facility's document from a third-party maintenance company dated 7/29/25, showed a service report for the walk-in freezer. The service report showed an itemized bill that listed a thermostatic expansion valve replacement, drier filter replacement, service port replacement and refrigerant. However, review of the facility's document titled Sanitation and Food Safety Checklist dated 8/29/25, completed by RD 2 showed the walk-in freezer had ice build-up and water on the floor outside of the unit. a. On 9/29/25 at 0834 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Manager. An ice build-up was observed on the floor, ceiling, and the top boxes on the shelves of the walk-in freezer. The Dietary Manager acknowledged the findings. b. On 9/29/2 at 0844 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Manager. There was ice build-up around the interior and exterior bottom lining of the walk-in freezer door. The ice build-up prevented the door from properly closing. The Dietary Manager acknowledged the findings. On 9/29/25 at 0956 hours, an interview and concurrent observation was conducted with the Maintenance Director. The Maintenance Director verified the above findings. On 11/18/25 at 1346 hours, an interview was conducted with the Dietary Manager. The Dietary Manager stated the staff members were aware of the ice build-up in the walk-in freezer and have been chipping the ice off every day. On 11/18/25 at 1355 hours, an interview and facility record review was conducted with the Administrator. The Administrator stated they were made aware of the ice build-up in the walk-in freezer. The Administrator hired a third-party maintenance vendor to assess and fix the walk-in freezer on 7/29/25. When the Administrator was asked if he was aware of RD 2's 8/2025 report where RD 2 documented in the Sanitation and Food Safety Checklist about the walk-in freezer had ice build-up and water on the floor outside of the unit, the Administrator stated he never received RD 2's report or heard any issues regarding the ice-build-up. The Administrator stated RD 2 should have communicated these issues to him. 2. On 9/29/25 at 0834 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Manager. The walk-in refrigerator fan cover had black debris and brown residue which resembled rust. The Dietary Manager acknowledged the findings. On 9/29/25 at 0956 hours, an interview and concurrent observation of the walk-in refrigerator was conducted with the Maintenance Director. The Maintenance Director stated he wiped down the fans every six months. The Maintenance Director verified the above findings. 3. According to the USDA Food Code 2022, Chapter 6 Physical Facilities, Section 6-201.11 Floors, Walls, and Ceilings showed floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth any easily cleanable. Review of the facility's P&P titled General Cleaning of Food & Nutrition Services Department dated 2023 showed the floors must be scheduled for routine cleaning and maintained in good condition. On 9/29/25 at 0956 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Maintenance Director. The tiles next to the stove were chipped and were noted peeling off with black residue. There were missing tiles and exposed cement material observed underneath the stove. The Maintenance Director verified the above findings. On 11/18/25 at 1534 hours, an interview was conducted with the Administrator, DON, and RCDM. The Administrator, DON, and RCDM acknowledged and verified all of the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitation in the kitchen was maintained. * The facility failed to ensure the kitchen was free from flies. This failure posed the risk for the pests to contaminate the residents' food.Findings: Review of the facility's Matrix showed 77 residents consumed food prepared in the kitchen. Review of the facility's P&P titled Miscellaneous Areas dated 2023 showed the flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food and Nutrition Services Department. Review of the facility's P&P title Sanitation dated 2023 showed monthly a pest control company will inspect and service the Food and Nutrition Services department. Review of the facility's documents from a pest elimination company dated 6/18, 8/5, and 9/8/25, showed the pests treated/inspected for were for flies. On 9/29/25 at 0827 and 0910 hours, an observation was conducted during the initial kitchen tour. The door to the kitchen was adjacent to the back door of the facility which led to the trash dumpster in the parking lot. Three files were observed in the kitchen near the food preparation area. On 9/30/25 at 0836 and 1105 hours, a follow-up observation was conducted in the kitchen. Two flies were observed in the kitchen near the food preparation area. On 10/1/25 at 1049 hours, another follow-up observation was conducted in the kitchen. One fly was observed in the kitchen near the food preparation area. On 10/1/25 at 1012 hours, an interview was conducted with the Maintenance Director. The Maintenance Director was made aware of the findings and stated a pest elimination company installed an insect control box on the kitchen wall for pest control in early September 2025; however, the Maintenance Director further stated he did not know if the fly pest control had improved.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. 1. One of 14 kitchen employees did not perform hand hygiene during food preparation.2. The sanitizing test strips were not available to test the sanitizing solution and sanitizing solution log was incomplete.3. The residents' nutritional supplements were not stored appropriately.4. The hair restraints were not utilized by kitchen staff.5. The food stored in the nourishment refrigerator was not stored at the proper temperature.6. The employee's personal items were not stored appropriately.7. The expired food was not discarded and food was not dated.8. The food in the nourishment refrigerator was not dated.9. The food was not covered in the walk-in freezer.10. One of fourteen kitchen employees was observed eating in the kitchen.11. The food in the dry storage area was not stored appropriately.12. The ice packs intended for residents' personal use were stored with the food in the nourishment refrigerator. 13. The food preparation equipment and utensils were not clean or in good working condition.14. The non-food contact surfaces were not in good working condition.15. The food preparation equipment was not air-dried. These failures posed the risk for food borne illnesses in a highly susceptible resident population of 77 facility residents who received food prepared in the kitchen.Findings: Review of the facility matrix showed 77 of 77 residents who resided in the facility consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Hand Washing Procedure dated 2023 showed hand washing is important to prevent the spread of infection. Employees must wash their hands:- before starting work in the kitchen;- after handling soiled dishes and utensils;- before and after doing housekeeping procedures;- before and after handling foods with hands (cutting peeling, mixing, etc.);- after going to the toilet, after sneezing, after using a handkerchief or tissue or after touching your hair or face;- before and after eating or smoking;- after leaving a resident's room; and- touching trash can or lid. On 9/30/25 at 1210 hours, an observation was conducted in the kitchen. [NAME] 1 was observed wearing gloves while he opened the refrigerator, touched multiple counter surfaces, and then [NAME] 1 began to cut the raw onions, lettuce, and tomato. [NAME] 1 was not observed performing hand hygiene or changing his gloves. The Dietary Manager was made aware and informed [NAME] 1 to perform hand hygiene and put on new gloves. 2. Review of the facility's P&P titled Quaternary Ammonium Log Policy dated 2023 showed the following:- Test the concentration of the sanitation solution per the instructions on the test strips; and- Test the sanitation solution at least every shift and record the readings twice a day. On 9/29/25 at 0908 hours, an observation and interview was conducted in the kitchen with Dietary Aide 1. Dietary Aide 1 was asked to provide the ammonia quaternary test strips to test the sanitizing solution in the red bucket. Dietary Aide1 stated the test strips provided were unusable because the strips inside the container were wet. On 9/29/25 at 0910 hours, the Dietary Manager stated they did not have extra test strips for the ammonia sanitizing solution. On 9/29/25 at 1010 hours, an interview and facility document review was conducted with the Dietary Manager in the kitchen. The Dietary Manager verified the Quaternary Ammonium Log had missing entries for 9/28 and 9/29/25. 3. Review of the facility's P&P titled Procedure for Refrigerated Storage dated 2023 showed the supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. On 9/29/25 at 0845 hours, an observation and concurrent interview was conducted with the Dietary Manager in the walk-in refrigerator of the kitchen. An opened box containing the individual health shakes had a received and use by date written on the box. The health shake box had manufacturer's instructions to store frozen or thaw at or below 40 degrees Fahrenheit, and to use the thawed products within 14 days. The box was observed without a date label on when the health shakes were removed from the freezer. The Dietary Manager verified the box did not have a date when the health shakes were pulled out from the freezer. When asked about the thawing process of the health shakes, the Dietary Manager stated he did not know for how long the health shakes could be stored in the refrigerator once transferred out from the freezer. The Dietary Manager further stated he did not have a system in place to monitor the dates of the health shakes once they thawed. 4. Review of the facility's P&P titled Dress Code dated 2023 showed the appearance is very important in maintaining a high standard of food service. Proper dress code included hair nets for hair and if applicable, beards and any facial hair must wear a beard restraint.a. On 9/30/25 at 1148 hours, an observation was conducted the kitchen during the tray line preparation. Dietary Aide 6 was observed with uncovered hair while she worked in the food preparation area.b. On 9/30/25 at 1152 hours, an observation was conducted in the kitchen during tray line preparation. Dietary Aides 4 and 5 were observed with uncovered facial hair while they prepared the food. On 9/30/25 at 1153 hours, an interview and observation was conducted with the Dietary Manager. The Dietary Manager verified the kitchen staff members were not wearing hair restraints and told them to wear hair restraints. 5. Review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping dated 2023 showed the staff shall review and record the temperature of all refrigerators and freezers to ensure they are the correct temperature for food storage and handling. Refrigerator temperature standards are less or equal to 41 degrees Fahrenheit, the goal is to keep the temperature at 34 degrees to 39 degrees Fahrenheit. On 9/30/25 at 0902 hours, an observation of the nourishment refrigerator in the nursing unit used to store resident's food, interview, and concurrent facility record review was conducted with LVN 6. When asked how the staff members monitored the internal temperature of the nourishment refrigerator, LVN 6 provided a binder containing the refrigerator temperature log dated 09/2025. Review of the refrigerator temperature log showed the temperature range should be between 36 degrees Fahrenheit and 46 degrees Fahrenheit. The following dates showed the temperature entries above 41 degrees Fahrenheit: - dated 9/4/25, the temperature was 45 degrees Fahrenheit; -dated 9/17 to 9/20/25, the temperature was 43 degrees Fahrenheit; and- dated 9/22/25, the temperature was 46 degrees Fahrenheit.When asked what the holding temperature was for the food, LVN 6 stated it was a precaution. On 9/30/25 at 0920 hours, an interview and concurrent record review was conducted with the Dietary Manager. The Dietary Manager stated the temperature range on the nourishment refrigerator log was not safe for food storage. 6. Review of the facility's P&P titled Dress Code dated 2023 showed no cell phones in the kitchen area. Review of the facility's P&P titled Employee Personal Items dated 2023 showed personal items brought in by the staff will not be kept in the kitchen, the items will be kept in a cabinet by the janitor's closet. On 09/29/25 at 0912 and 0918 hours, an observation was conducted in the kitchen. There were two cell phones observed on top of the food preparation surfaces. On 10/1/25 at 0848 hours, an interview was conducted with the RCDM. The RCDM stated the cell phones were not allowed in the kitchen and expected the staff members to place their personal belongings in the break room, their own car, or the Dietary Manager's office. 7. Review of the facility's P&P titled Dry Goods Storage Guidelines dated 2023 showed the storage length is to be followed unless you have a manufacturer's recommendation. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the food will not be kept longer than the expiration date on the product. On 9/29/25 at 0858 hours, an observation was conducted of the dry storage area in the kitchen. An unopened box of moderately thickened orange juice had the best if used by date of 8/20/25. On 9/29/25 at 1455 hours, an observation and concurrent interview was conducted of the dry storage area in the kitchen with the RCDM. The RCDM confirmed the unopened box of orange juice had expired. 8. Review of the facility's P&P titled Foods Brought by Family/Visitors dated 3/2022 showed the resident's food container is labeled with the resident's name and use by date. On 9/30/25 at 0910 hours, an observation of the nourishment refrigerator and freezer in the nursing unit used to store resident's food and concurrent interview was conducted with LVN 1. The refrigerator contained the following:- two boxes of assorted fruit ice pops with no date;- a box of frozen country fried chicken and gravy meal with no date;- an ice cream tub, which showed signs of freezer burn, a condition of discoloration or other damage caused to frozen food by evaporation with no date;- a can of soda with no name or date; and- a can of fruit juice cocktail with no name or date. LVN 1 verified the above findings and stated food should be stored for 72 hours and discarded after the timeframe. 9. Review of the facility's P&P titled Procedure for Freezer Storage dated 2023 showed to store the frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. On 9/29/25 at 0843 hours, an observation in the walk-in freezer of the kitchen and concurrent interview was conducted with the Dietary Manager. An opened box containing an open plastic bag of carrots was observed. The carrots showed signs of freezer burn. The Dietary Manager verified the food in the freezer should be properly sealed. The Dietary Manager was observed removing the carrots from the walk-in freezer. 10. Review of the facility's P&P titled Employee Meals dated 2023 showed the staff must eat in the designated meal areas and eating in the kitchen was not allowed. According to the USDA Food Code 2022, Annex 3. Public Health Reasons/Administrative Guidelines, Section 2-401.11 Eating, Drinking, or Using Tobacco Products showed proper hygienic practices must be followed by food employees in performing the assigned duties to ensure the safety of the food.and minimize the possibility of transmitting disease through food. Eating by employees in the food preparation areas is prohibited because of the potential that the hands, food, and food contact surfaces may become contaminated. On 9/30/25 at 0919 hours, an observation of Dietary Aide 3 and concurrent interview was conducted with the Dietary Manager. Dietary Aide 3 was observed eating in the food preparation area of the kitchen. The Dietary Manager was made aware and stated the kitchen staff members were not allowed to eat in the kitchen area and the staff members were expected to eat in the break room or outside of the kitchen. 11. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed food and supplies will be stored properly and in a safe manner. Dry bulk foods should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. If using the plastic bags, food grade bags must be used; if lining bins, use food grade bags. Routine cleaning procedures should be developed and followed. On 9/29/25 at 0847 hours, an observation was conducted in the dry storage area of the kitchen. The following was observed:- one large bin lined with black plastic liners of pearl barley;- one large bin lined with black plastic liners of food thickener;- one large bin lined with black plastic liners of oatmeal;- one small bin of peas that was not fully sealed; and- one small bin of breadcrumbs with an unclean lid and not fully sealed. The Dietary Manager verified the above observations. When asked if the black plastic liners were food grade bags, the Dietary Manager stated he would find verification if the liners used were food grade safe. On 9/29/25 at 1455 hours, an interview was conducted with the RCDM. The RCDM stated the black plastic liners were not food grade safe. 12. According to the USDA Food Code 2022, Chapter 3 Food, Section 3-305.11 Food Storage showed food shall be protected from contamination by storing food in an area where it is not exposed to splash, [NAME] or other contamination. On 9/30/25 at 0930 hours, an observation of the nourishment refrigerator in the nursing unit used to store residents' food and concurrent interview was conducted with LVN 1. Three personal care ice packs were stored in the freezer compartment adjacent to the residents food items. The ice packs had a caution label of for external use only.do not swallow contents. If contents accidentally swallowed drink large amounts of water (not milk) and contact Poison Control Center or physician. The ingredients listed on the ice packs were urea blend and water. LVN 1 stated it was not acceptable for the personal care ice packs to be stored with the resident's food. LVN 1 removed the ice packs from the freezer. 13. Review of the facility's P&P titled Sanitation dated 2023 showed the following: - all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas; and- plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. On 9/29/25 at 0936 hours, during an initial tour of the kitchen with the Dietary Manager, the following was observed, verified, and removed by the Dietary Manager:- three large pans with anti-stick covering with excessive wear;- one dirty large pan with greasy residue;- more than five bowls with loss of glaze; and- two chipped and partially melted rubber spatulas. 14. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. On 9/29/25 at 0914 hours, during the initial tour in the kitchen with the Dietary Manager, the following was observed and verified by the Dietary Manager:- one large mixer holder had peeling paint and brown residue which resembled rust;- two wood base knife racks with metal lining had a brown residue which resembled rust; and- one can opener blade was worn and had black residue. 15. Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed all items are air-dried, which means no water droplets are present. On 9/29/25 at 0925 hours, an observation and concurrent interview was conducted with the Dietary Manager. A blender was observed stored wet with the lid on. The Dietary Manager verified the inside of the blender was not air-dried.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six final sampled residents (Residents 46) reviewed for the unnecessary medications were free from the unnecessary medications. * The facility failed to ensure Resident 46's was monitored for the side effects of paroxetine HCl (antidepressant medication). In addition, the facility failed to show documentation of the behavior monitoring for depression. These failures had the potential for the resident to not receive the necessary care due to the delay in the detection of adverse effects and determination of the effectiveness of the psychotropic medication.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the psychotropic medication management includes adequate monitoring for efficacy and adverse consequences; residents receiving psychotropic medications are monitored for adverse consequences. Medical record review for Resident 46 was initiated on 11/17/25. Resident 46 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 46's H&P examination dated 8/25/25, showed the resident had the capacity to understand and make decisions. Review of Resident 46's Order Summary Report showed a physician's order dated 11/6/25, for paroxetine HCl oral tablet 10 mg, give one tablet by mouth one time a day for major depression disorder manifested by verbalization of sadness. Review of Resident 46's Monitoring Record and MAR for November 2025 failed to show documented evidence if Resident 46 was monitored for the side effects of the paroxetine HCl medication use after Resident 46 started taking the medication on 11/7/25. In addition, the document failed to show if Resident 46's behavior was monitored for the verbalization of sadness. On 11/17/25 at 1508 hours, an interview and concurrent medical record review for Resident 46 was conducted with the DON. The DON acknowledged there were no documentation to show the monitoring of the side effects for the paroxetine medication use and no monitoring of the episodes of the depression, to ensure the facility was able to monitor the effectiveness of the medication and for the adverse side effects. The DON verified and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one final sampled resident (Resident 16) and one nonsampled resident (Resident 48) who participated in the Resident Council meeting. * The facility failed to ensure Residents 16 and 48 was informed on how to file a grievance. This failure had the potential to cause the residents feeling hopeless and may negatively affect their emotional well-being.Findings: Review of the facility's P&P titled Investigating Grievances/Complaints dated 11/2010 showed the facility investigate all grievances and complaints filed with the facility. The investigation report form must be filed with the Administrator or designee and begin investigating grievances and complaints. Copies of all reports will be available to the resident or person acting on behalf of the resident. On 9/30/25 at 1029 hours, a Resident Council Meeting was conducted with the residents in the facility. When asked to whom they would report if they had concerns, the residents responded they would raise their concerns to the administration, they would take time to respond but were able to resolved their concerns. When asked if the residents were aware on how to file a grievance, Resident 16 and 48 replied no and added they did not know how to file a grievance. 1. Medical record review for Resident 16 was initiated on 9/30/25. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's MDS assessment dated [DATE], showed Resident 16's BIMS score of 11 (cognitively intact). 2. Medical record review for Resident 48 was initiated on 9/30/25. Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's H&P examination dated 8/7/25, showed Resident 48 had the capacity to make decisions. Further review of Resident 16 and 48's medical records for failed to show documented evidence if the information on how to file a grievance was provided to the residents. On 9/30/25 at 1120 hours, an interview and concurrent facility document review for Residents 16 and 48 was conducted with the admission Office Manager. The admission Office Manager verified and acknowledged the grievance information was not documented on the admission packet and provided to Residents 16 and 48. On 9/30/25 at 1146 hours, an interview and concurrent facility document review for Residents 16 and 48 was conducted with the SSD. The SSD verified and acknowledged there was no documentation to show the information on how to file a grievance was explained to the Residents 16 and 48. On 10/1/25 at 0903 hours, an interview for Resident 16 and 48 was conducted with the Activity Director. The Activity Director verified and acknowledged there was no documentation if the residents were informed on how to file a grievance and no documentation on providing education regarding the filing of grievance. On 11/19/25 at 1145 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the resident to attain or maintain the highest practicable well-being for one of two final sampled residents (Resident 4). * The facility failed to ensure the 72 hours monitoring following a change of condition for Resident 4 was completed. This failure posed the risk of the residents not receiving the appropriate care and potential for the delay in providing the necessary care to the residents.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 2/2021 showed the following:- our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical or mental condition and status;- prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information provided by the Interact SBAR Communication form; and- the nurse will record in the resident's medical record the information relative to changes in the resident's medical or mental condition or status. Medical record review for Resident 4 was initiated on 11/17/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 7/28/25, showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4's BIMS score was 99, indicating unable to complete the interview. Review of Resident 4's Change in Condition Evaluation dated 8/16/25 at 2347 hours, showed Resident 4 had low PO intake, consumed approximately 25% of meals, and only sips of water. Further review of Resident 4's medical records failed to show documented evidence if Resident 4's nutritional status was monitored on 8/17 to 8/19/25, after the change in condition on 8/16/25, for having a low PO intake. On 11/18/25 at 1408 hours, an interview and concurrent medical record review was conducted with RN 1. Resident 4's Change in Condition Evaluation dated 8/16/25, and progress notes on dates 8/17 to 8/19/25, was reviewed with RN 1. RN 1 verified the above findings. In addition, RN 1 stated after the completion of the change in condition evaluation, the 72 hours documentation of the monitoring every shift would be completed by the licensed nurses to show the provided care and resident's well-being. On 11/19/25 at 1135 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Furthermore, the DON stated after the completion of the resident's change in condition evaluation, the licensed nurses would monitor the resident's condition and document in the progress notes every shift for 72 hours.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident remained free from accident hazards for one of 23 final sampled resident (Resident 2). * The facility failed to ensure Resident 2 was supervised in Shower room [ROOM NUMBER]. In addition, Shower room [ROOM NUMBER] had no call system available to call the staff for assistance if needed. These failures had the potential to place the resident at risk for accidents and serious injury.Findings: Review of the facility's P&P titled Bath, Shower/Tub revised 2/2018 showed to never leave the resident unattended in the tub or shower and to use the emergency call signal for assistance, if needed. Review of the facility's P&P titled Call System, Residents dated 9/2022 showed the residents are provided with a means to call the staff for assistance from his/her bed and from toileting/bathing facilities through a communication system that directly call a staff member or a centralized workstation. On 11/17/25 at 1122 hours, an observation was conducted of Resident 2. Resident 2 was observed in Shower room [ROOM NUMBER] with the door open. Resident 2 was observed shaving his face using a razor in front of the bathroom mirror by himself. Shower room [ROOM NUMBER] was observed without a call system. On 11/17/25 at 1124 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified Resident 2 was shaving by himself in Shower room [ROOM NUMBER] and there was no call system/call light in-placed in the shower room. Medical record review for Resident 2 was initiated on 11/17/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 needed supervision or touching assistance from the staff for personal hygiene tasks. Review of Resident 2's Care Plan Report showed the following focused problems:- initiated on 8/22/25, for Resident 2's risk for unavoidable falls related to his history of falls and limited mobility. The interventions included to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, and the resident needs prompt response to all requests for assistance.- initiated on 9/6/25, for Resident 2's ADL maintenance which included personal hygiene assisted by one staff member. The interventions included to have a call light within reach and answer promptly; and to assist Resident 2 to wash face, brush teeth, comb hair, shave, apply lotion, etc. On 11/17/25 at 1140 hours, an interview was conducted with the DON. The DON stated all the residents should not be left alone, unsupervised in the shower room, even if they were independent because there was a risk for falls/injury. On 11/18/25 at 1534 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings.

Based on observation, interview, facility document and P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for one of four final sampled residents (Resident 72) ) reviewed for nutrition status. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weighed 174 pounds (lbs) on 4/8/25. In addition, the facility failed to monitor Resident 72's weight and implemented interventions to address Resident 72's severe weight loss. * The facility failed to conduct a nutritional assessment in a timely manner when Resident 72 weighed 160 lbs on 8/4/25. In addition, the facility failed to closely monitor Resident 72's weight. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weight 155 lbs on 10/3/25. In addition, the facility failed to monitor Resident 72's weekly weights as ordered by the physician. These failures contributed to Resident 72's severe weight loss of 45 lbs/22.50% since admission on [DATE], which could lead to increased medical complications including increased mortality.Findings: Review of the National Library of Medicine professional reference titled An approach to the management of unintentional weight loss in elderly people dated 3/15/25, showed in part, unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ Review of the facility's P&P titled Nutritional Assessment revised October 2017 showed the following:- The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition; and- The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components under the Dietitian section: (1) an estimate of calorie, protein and fluid needs; and (2) whether the resident's current intake is adequate to meet his or her nutritional needs. Review of the facility's P&P titled Weight Assessment and Intervention revised 3/2022 showed the threshold for significant unplanned and undesirable weight loss will be based on the following criteria:a. one month - 5% weigh loss is significant, greater than 5% is severe;b. three months - 7.5% weight loss is significant, greater than 7.5% is severe; and c. six months - 10% weight loss is significant, greater than 10% is severe. The P&P section for Evaluation showed undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation included the resident's target weight range (including rationale if different from ideal body weight), and resident's calorie, protein and other nutrient needs compared with the resident's current intake. The section for Interventions showed the interventions for undesirable weight loss are based on careful consideration which included the resident choice and preferences, nutrition and hydration need of the resident, functional factors that may inhibit independent eating, chewing and swallowing abnormalities and the need for diet modifications and medications that may interfere with appetite , chewing, swallowing, or digestion. Medical record review for Resident 72 was initiated on 10/1/25. Resident 72 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 72's diagnoses included type two diabetes mellitus, dysphagia, and NSTEMI. Review of Resident 72's H&P examination dated 1/31/25, showed Resident 72 had no capacity to make medical decisions. The H&P further showed Resident 72 weighed 200 lbs. Review of Resident 72's Care Plan Report showed the following focused problems:- initiated on 1/31/25, addressing the resident's high risk for malnutrition related to variable PO intake, weakness and deconditioning. The interventions included to consult a dietician per order; and- initiated on 4/17/25 and revised on 7/31/25, addressing the resident's high nutritional risk and/or fluid deficit related to poor/variable meal intake, recent weight loss and at risk for further weight loss. The interventions included for the RD to assess nutritional and hydration needs PRN. Review of Resident 72's Weights and Vitals Summary showed the following weights:- dated 1/31/25 = 200 lbs;- dated 2/7/25 = 198 lbs;- dated 3/11/25 = 184 lbs; and- dated 4/8/25 = 174 lbs (a sever weight loss of 10 lbs/5.4% in one month; -26 lbs since admission)- dated 7/2/25 = 169 lbs;- dated 8/28/25 = 165 lbs; and- dated 10/3/25 = 155 lbs (a severe weight loss of 10 lbs/6.1% in one month, severe weight loss of 14 lbs/8.3% in three months and severe weight loss of 19 lbs/10.9% in six months) a. Review of Resident 72's Change in Condition Evaluation form dated 4/8/25, showed Resident 72 had a weight loss. The section for Summarize your observations, evaluation and recommendations showed Resident 72 had a weight loss of 10 lbs in a month, the weight loss was inevitable due to variable PO (oral) intake, presence of multiple comorbidities such as cerebral infarction (stroke), diabetes, and dysphagia. The form further showed the MD was informed and gave orders including to follow up with the RD consultation. Review of the facility's documents titled IDT Weight Management assessment dated [DATE], showed Resident 72 weight 174 lbs. The section for the IDT Recommendations did not indicate any new interventions. The assessment form further showed the RD spoke with the resident who was seemingly more alert, the RD encouraged PO intakes of meals and snacks. Review of Resident 72's Weight Management Update dated 4/21 and 4/28/25, showed Resident 72's current weight was 174 lbs on 4/8/25, no new. The section for IDT Recommendations did not indicate any new interventions. The form further showed extra portions ordered, assist with meals, Glucerna BID (two times a day) and Pro-Stat 30 ml. The update on 4/28/25, further showed the MD ordered to continue with the RD recommendations. Review of Resident 72's Order Summary Report dated 3/31/25, showed a physician's order for the following:- dated 2/4/25, for Glucerna (nutritional drink) two times a day for supplement;- dated 3/21/25, for Pro-Stat Sugar Free (protein supplement) 30 ml two times a day for wound management; and-dated 3/31/25, for CCHO NAS Pureed texture, nectar consistency diet. Review of Resident 72's Order Summary Report dated 4/30/25, showed the same physician's order for Glucerna and Pro-Stat; and a diet change dated 4/17/25, for CCHO NAS Mechanical texture, thin consistency diet. Further review of Resident 72's medical record failed to show if Resident 72's weight was reassessed or monitored and there were no additional type of interventions. Furthermore, the medical record failed to show the RD consultation/assessment of Resident 72's nutritional status as ordered when the MD was notified of Resident 72's weight loss on 4/8 and 4/28/25. On 11/17/25 at 0918 hours, an interview and concurrent medical record review for Resident 72 was conducted with the DON. When asked to explain the process when a resident experienced a significant weight change, the DON stated if a resident experienced an unplanned weight change, the nurse was responsible to conduct a change of condition evaluation, notify the physician and referral to the RD. The DON verified Resident 72's severe weight loss of 10 lbs (5.4%) on 4/8/25, compared to 3/11/25. The DON stated the IDT met on 4/14, 4/21, and 4/28/25; however, the DON was unable to verify if the RD conducted a nutritional assessment with calorie, protein, and fluid needs in comparison with Resident 72's intake. The DON also verified Resident 72 was not weighed weekly to monitor his weight. In addition, the DON verified the IDT did not make any recommendations to address Resident 72's severe weight loss. b. Review of Resident 72's Quarterly MDS assessment dated [DATE], showed Resident 72 weighed 160 lbs. The section for Weight Loss - Loss of 5% or more in the last month or loss of 10% or more in the last six months was coded 2 (yes, not on physician- prescribed weight-loss regimen). Review of Resident 72's Change in Condition Evaluation dated 8/5/25, showed Resident 72 had a weight loss 9 lbs in a month. The section for Summarize your observations, evaluation and recommendations showed Resident 72 had a weight loss 9 lbs in a month, the weight loss is inevitable due to variable PO intake, presence of multiple comorbidities such as cerebral infarction, diabetes, and dysphagia, consumed 25-50% of his meals each day, the resident was on vancomycin (antibiotics) for C-Diff. The form further showed the MD was informed with orders including to follow up RD consultation. Review of the facility's document titled IDT Weight Management Update dated 8/11/25 showed the above weights and weight loss/changes in the past six months. The section for IDT Recommendations-Others showed to add CCHO and discontinue the NAS part of the diet and add Glucerna (nutritional supplement) 8 oz (ounces) with meals. The IDT members included the RD, DON and Dietary Manager. However, the IDT weight management did not include a nutritional assessment completed by the RD. Review of Resident 72's Order Summary Report dated 8/29/25, showed the following physician's order:- dated 5/14/25, for Pro-Stat Sugar Free (protein supplement) 30ml three times a day for wound management; and - dated 8/16/25, to provide Regular Mechanical Soft texture, thin consistency diet and Boost (nutritional supplement) two times a day for supplement. Review of Resident 72's IDT Weight Management Update dated 8/29/25, showed Resident 72 weighed 165 lbs on 8/28/25, a 5 lb. weight gain in three weeks. The RD completed a nutritional assessment showing the estimated calorie and protein needs; however, Resident 72's intake was not compared to the calculated estimated needs. The RD nor IDT made any recommendations or implemented any new interventions. On 11/17/25 at 0930 hours, an interview and concurrent medical record review for Resident 72 was conducted with the DON. The DON verified Resident 72 weighed 160 lbs, a severe loss of 9 lbs (5.3%) in one month, significant weight loss of 13 lbs (7.5%) in three months and severe weight loss of 38 lbs (19.2%) in six months on 8/4/25. The DON verified the IDT met to discuss Resident 72's severe weight loss on 8/11 and 8/29/25. The DON verified the RD did not assess Resident 72 until 8/29/25, and acknowledged the assessment was not done in a timely manner. The DON verified Resident 72 did not have an order for weekly weights and the DON stated it should have been ordered to monitor Resident 72's weight closely. c. Review of Resident 72's Change in Condition Evaluation dated 10/3/25, showed Resident 72 had a weight loss. The section for Summarize your observations, evaluation and recommendations showed Resident 72 had a weight loss of 6 lbs in a month, the weight loss was inevitable due to variable po intake, presence of multiple comorbidities such as cerebral infarction, diabetes, and dysphagia, consumed 25-50% of his meals each day. The evaluation further showed the MD was informed with orders including follow up RD consultation. Review of Resident 72's Weight Variance dated 10/9/25, showed Resident 72's most recent weight was 155 lbs. The IDT Attendees included only the RD and the Team Recommendations showed weekly weight for four weeks.Review of Resident 72's Order Summary Report dated 10/31/25, showed the following physician's order:- dated 8/16/25, for Boost two times a day;- dated 9/17/25, for High Calories Pudding two times a day for supplement;- dated 10/10/25, to monitor weight every week for four weeks; and- dated 10/19/25, for LiquaCel Liquid Protein Supplement three times a day for wound management. Review of Resident 72's Quarterly MDS assessment dated [DATE], showed Resident 72 weighed 155 lbs. The section for Weight Loss - Loss of 5% or more in the last month or loss of 10% or more in the last six months was coded 2 (yes, not on physician- prescribed weight-loss regimen). On 11/17/25 at 0938 hours, an interview and concurrent medical record review for Resident 72 was conducted with the DON. The DON verified on 10/3/25, Resident 72 weighed 155 lbs, 10 lbs/6.1% severe weight loss since 8/28/25, 14 lbs/8.3% severe weight loss since 7/2/25 and 19 lbs/10.9% severe weight loss since 4/8/25. The DON verified the weight variance on 10/9/25, was completed by the RD and the RD documented Resident 72 weighed 155 lbs. The DON was not able to verify if the RD had completed a nutritional assessment to assess Resident 72's severe weight loss. The DON verified there was a physician's order to weigh Resident 72 every week for four weeks. However, review of Resident 72's medical record failed to show documented evidence Resident 72 was weighed weekly as ordered by the physician. The DON verified and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 14) reviewed for oxygen therapy. * The facility failed to ensure Resident 13 received oxygen therapy as ordered by the physician's order. * The facility failed to ensure the oxygen tubing for Resident 14 was labeled with the date. These failures had the potential for the residents not to receive the appropriate respiratory care and may negatively impact the residents' medical conditions.Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed under the preparation section, to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. 1. On 9/29/25 at 0853 hours, during the initial tour of the facility, an observation was conducted in Resident 13's room. Resident 13 was observed lying in bed receiving oxygen therapy via nasal cannula at three liters per minute. The nasal cannula was observed on Resident 13's chest. On 9/29/25 at 0907 hours, an observation and concurrent interview was conducted with the MDS Coordinator in Resident 13's room. The MDS coordinator verified Resident 13 oxygen concentrator was turned on, however; the oxygen nasal cannula was not on the Resident 13 nose. Medical record review for Resident 13 was initiated on 9/29/25. Resident 13 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 1/20/25, for the continuous oxygen to be administered at two liters per minute up to four liters per minute via nasal cannula to maintain an oxygen saturation above 90%. Review of Resident 13's MDS assessment dated [DATE], the section for Functional Limitation in Range of Motion showed Resident 13 had impairment on both side of the upper extremity (shoulder, elbow, wrist and hands). On 11/17/25 at 1450 hours, a follow-up observation was conducted with Resident 13. Resident 13 was observed with the oxygen concentrator turned on at a rate of five liters per minute. On 11/17/25 at 1456 hours, an observation and concurrent interview was conducted with LVN 3 in Resident 13's room. LVN 3 verified Resident 13's oxygen concentrator was on at a rate of at five liters per minute. On 11/17/25 at 1459 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 13 had a physician's order for oxygen administration at a rate of two liters per minute up to four liter per minute via nasal cannula continuously to maintain an oxygen saturation above 90% . LVN 3 stated she did not know who changed the oxygen rate to five liters per minute. On 11/19/25 at 1052 hours, an interview was conducted with DON and Administrator. The DON and Administrator verified and acknowledged above findings. 2. On 9/29/25 at 1224 hours, an observation was conducted for Resident 14. Resident 14 was observed in the dining room using the oxygen via nasal cannula. However, Resident 14's oxygen tubing was observed with no date label. Medical record review for Resident 14 was initiated on 9/29/25. Resident 14 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of Resident 14's Order Summary Report showed the following physician's order:- dated 7/11/24, to administer continuous oxygen at two liters per minute to three liters per minute via nasal cannula; and- dated 6/10/25, to change the oxygen humidifier and nasal cannula/tubing every week on Sundays and PRN (label with date). On 9/29/25 at 1230 hours, an observation and concurrent interview was conducted with the IP. The IP verified Resident 14's oxygen tubing was undated. The IP further stated the oxygen tubing were changed every Sunday, and all oxygen tubing should be labeled with the date when it was changed.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for three of three final sampled residents (Resident 2, 20, and 69) reviewed for the unnecessary medications. * The facility failed to ensure the insulin (medication to lower the blood sugar) injection administration sites were rotated for Residents 2 and 20. * The facility failed to ensure the Zosyn (antibiotic) IV medication was administered to Resident 69. These failures had the potential for the residents to not receive the necessary medications and could negatively affect the residents' well- being. Findings: Review of the facility's P&P titled Insulin Administration revised on 9/2014 showed the following: - to provide guidelines for the safe administration of insulin to residents with diabetes; - select an injection site. Insulin may be injected into the subcutaneous tissue of the upper arm and anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two inches around the navel; - injection sites should be rotated, preferably within the same general area (abdomen, thigh or upper arm); and - document the injection site for presence or absence of any bruising, pain, redness, swelling, or unusual marks on or near the injection site. 1. Medical record review for Resident 20 was initiated on 11/17/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 7/17/25, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's Order Summary Report showed a physician's order dated 7/15/25, for Humalog insulin (a rapid acting insulin used to control blood glucose) injection solution 100 unit per ml, inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus. Review of Resident 20's Location of Administration Report for September 2025 showed the Humalog insulin was administered subcutaneously on Resident 20's left lower quadrant (LLQ) of the abdomen on the following date and times: - 9/24/25 at 1630 and 2100 hours; - 9/25/25 at 0630, 1630, and 2100 hours; and - 9/27/25 at 1130, 1630 and 2100 hours. On 11/17/25 at 0945 hours, an interview and concurrent medical record review was conducted with LVN 4. Resident 20's Location of Administration Report for September 2025 was reviewed with LVN 4, which showed the insulin injection sites were not rotated on 9/24, 9/25, and 9/27/25. LVN 4 verified the above findings. LVN 4 stated the insulin injection sites must be rotated because it would cause swelling, pain, bruising, and poor absorption of the medication. On 11/19/25 at 1135 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 2 was initiated on 9/17/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 8/20/25, showed Resident 2 had the capacity to make decisions. Review of Resident 2's Order Summary Report showed a physician's order dated 8/18/25, to administer Sem [NAME] Subcutaneous Solution 100 unit/ml (Insulin Glargine) 8 unit subcutaneously at bedtime for Diabetes Mellitus; and Humalog Injection Solution 100 unit/ml (Insulin Lispro) subcutaneously as per sliding scale before meals and at bedtime for Diabetes Mellitus. Review of Resident 2's Location of Administration Report for October 2025 showed the Humalog Insulin was administered on the following sites: a. left lower quadrant of the abdomen on the following date and times: - 10/1/25 at 1615 and 2043 hours, - 10/2/25 at 1642 and 2323 hours; - 10/3/25 at 0647 hours; and - 10/7/25 at 1924 and 2224 hours; b. left deltoid on the following date and times: - 10/9/25 at 1705 hours and 2050 hours; and - 10/23/25 at 1616 and 2151 hours. c. left upper quadrant of the abdomen on 10/21/25 at 1145 and 1722 hours. On 11/19/25 at 1110 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 2. LVN 2 verified Resident 2 had an insulin injection and the insulin injection sites should be rotated to avoid the scarring of the skin that will affect the absorption of the insulin medication. LVN 2 verified and acknowledged Resident 2's insulin injection sites were not rotated. On 11/19/25 at 1114 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 2. RN 2 stated she was responsible for the implementation of the care of the residents including the monitoring of the residents medication. RN 2 stated the insulin administration sites should be rotated to prevent any complications such as skin scarring that will affect the absorption of the insulin medication. RN 2 verified and acknowledged Resident 2's insulin administration injection sites were not rotated. On 11/19/25 at 1355 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON was informed and verified the findings. 3. Review of facility's P&P titled Documentation of Medication Administration revised 4/2007 showed the facility shall maintain a medication administration record to document all the medications administered; a nurse shall document all medication administered to each resident on the resident's medication administration record (MAR). Medical record review for Resident 69 was initiated 11/17/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's MDS assessment dated [DATE], showed the resident's BIMS score was 12 (cognitively intact). Review of Resident 69's Order Summary Report showed a physician's order dated 9/10/25, to administer Zosyn (antibiotics) 3-0.375 gm/50 ml intravenously every eight hours for right foot osteomyelitis for 35 days. Review of Resident 69's MAR for September 2025 failed to show the documentation of Zosyn medication administration on 9/18/25 at 1400 hours and 9/28/25 at 2200 hours. On 11/17/25 at 1007 hours, an interview and concurrent medical record review for Resident 69 was conducted with the DON. The DON verified there were no documentation on Resident 69's MAR to show the Zosyn medication was administered to the resident on 9/18 and 9/28/25. The DON further stated the administration of any medication should be documented in the MAR. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (nonsampled resident, Resident 40) observed for medication administration was free from the significant medication errors. * LVN 5 did not check the resident's pulse rate prior to the administration of the metoprolol (a medication to lower blood pressure) to Resident 40. This failure had the potential to negatively impact the resident's health and well-being.Findings: Review of the facility's P&P titled Administering Oral Medications revised 10/2010 showed to verify that there is a physician's medication order for this procedure and perform any pre-administration assessments. On 10/1/25 at 0828 hours, a medication administration observation for Resident 40 was conducted with LVN 5. LVN 5 was observed checking Resident 40's blood pressure prior to the medication administration, then prepared Resident 40's medications including the metoprolol 12.5 mg one tablet. The metoprolol medication bubble pack had a direction to hold the medication if the SBP (systolic blood pressure) was less than 110 mmHg or pulse rate was less than 60 beats per minute. LVN 5 checked the resident's blood pressure but did not check Resident 40's pulse rate. On 10/1/25 at 0846 hours, LVN 5 stated she was ready and proceeded to Resident 40 to administer her medications. LVN 5 had started to administer one of the medications and was asked if she would give all of the prepared medications to Resident 40. LVN 5 stated yes. LVN 5 was asked to stop administering the metoprolol medication to Resident 40. LVN 5 was informed and acknowledged she did not check Resident 40's pulse rate. LVN 5 verified there was an order to check Resident 40's pulse rate and hold the metoprolol medication if the pulse rate was less than 60 beats per minute. Medical record review for Resident 40 was initiated on 9/29/25. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's Order Summary Report showed a physician's order dated 4/16/24, to administer metoprolol tartrate give 12.5 mg one tablet by mouth two times a day for hypertension and hold if the SBP was below 110 mmHg or pulse rate was below 60 beats per minute. On 11//18/25 at 1442 hours, an interview was conducted with DON. The DON was made aware and acknowledged the above findings. The DON stated if there was a physician's order to check the blood pressure and pulse rate and hold the medication if the SBP was below 110 mmHg or pulse rate was below 60 beats per minute, the licensed nurses need to assess both the blood pressure and the pulse rate of the resident. On 11/19/25 at 1052 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was made aware and acknowledged above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the medications/supplies in the medication room and medication cart were store properly. * The facility failed to ensure the expired Covid-19 Binax Now (a test to detect Covid-19) were removed from Medication Room A. In addition, the facility failed to ensure the oral medications were stored separately from the externally used medications. * The facility failed to ensure the expired bottles of the 0.9% normal saline solutions were removed from Medication Cart A. These failures had the potential for medication errors and the use of the expired medications/supplies which could negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Medication Storage in the Facility (undated) showed the outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists, and orally administered medication are kept separate from externally used medication, such as suppositories, liquid, and lotions. 1. On 10/1/25 at 0956 hours, an inspection of Medication Room A and concurrent interview was conducted with RN 2. During the inspection the following were observed in Medication Room A:- 20 individual packages of Covid-19 Binax Now, with expiration date of 9/23/23; and- enema (a laxative solution given per rectum) was observed in the same cabinet with the orally administered Geri-Lanta (antacids) and calcium tablets (supplement). RN 2 verified the above findings and stated any expired supply needs to be discarded according to the facility protocol. RN 2 further stated the external and internal medications needed to be separated and not stored in the same cabinet. 2. On 10/1/25 at 1123 hours, a medication cart inspection for Medication Cart A and concurrent interview was conducted with RN 2. During the inspection, two sterile bottles of 0.9% normal saline 100 ml were observed inside Medication Cart A. One bottle was expired on 2/13/21, and the other bottle was expired on 4/1/22. RN 2 verified the findings and stated any expired supply needs to be discarded according to the facility protocol. On 11/18/25 at 1442 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the R N supervisors need to check the medication room in a daily basis for any expired medication or supply. The DON further stated the medication cart should be checked by the licensed nurses for any expired medication and any expired medications should have been discarded. On 11/19/25 at 1052 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was made aware and acknowledged above findings.

Based on observation, interview, and facility document review, the facility failed to employ a staff with the skills and abilities to effectively implement the departmental processes in accordance with standards of practice in the food services department. * The facility failed to ensure the Dietary Manager was competent in managing the day-to-day functions of the food services department. This failure had the potential to jeopardize the health and well-being of the 77 residents who received food prepared in the kitchen.Findings: Review of the facility's Matrix showed 77 residents consumed food prepared in the kitchen. Review of the facility's document titled Dietary Manager dated 6/25/24, the section for Position Summary showed the purpose of your job position is to organize, plan and supervise the dietary department functions in accordance with current applicable federal, state, and local standards that govern the facility and as directed by the Administrator and Dietitian. During the annual recertification survey from 9/29 to 10/1/25, 11/17, and 11/18/25, multiple issues were found in the kitchen including: the proper hand hygiene was not performed during meal preparation, sanitizing test strips were not available to test the sanitizing solution and the sanitizing log was not complete, resident nutritional supplements were not stored appropriately, hair restraints were not donned by the kitchen staff, food stored in the resident nourishment refrigerator was not dated or stored at the proper temperature, employee personal items were not stored appropriately, expired food was not discarded, food stored in the walk-in freezer was not covered, a kitchen employee was observed eating in the kitchen, food in the dry storage area was not stored appropriately, food preparation equipment and utensils were not clean or in good working condition, non-food contact surfaces were not in good working condition, food preparation equipment was not air dried, the appropriate food texture was not served, the menu was not followed, a meal entree substitute was not equivalent in nutrient value to the main entree served, one kitchen employee was not competent in their job duties, kitchen equipment was not in good working order, and flies were observed in the kitchen. On 10/01/2025 at 0911 hours, an interview was conducted with the Administrator. When asked how the Administrator ensured his department managers were competent in their job duties, the Administrator stated all the managers should be experts in their area of supervision. The Administrator stated he relied on the Registered Dietitian for feedback on the Dietary Manager's job performance. Cross references to F812 examples #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15; F805; F803; F806; F802; F908, and F925.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 14 kitchen staff members (Cook 2) had the appropriate skill set necessary to safely perform the manual dishwashing. * The facility failed to ensure [NAME] 2 was competent to describe or demonstrate the manual dishwashing process. This failure had the potential for the residents' dishes to not be washed correctly which could lead to sanitation concerns.Findings: Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed the following:- The first compartment is for washing. Fill the first compartment with detergent per manufacturer's instructions and hot water (110 to 120 degrees Fahrenheit);- The second compartment is for rinsing. Fill the second compartment with clean, clear hot water (110 to 120 degrees Fahrenheit); and- The third compartment is for sanitizing. Fill the third compartment with Sani Tech solution (a cleaning solution) from the dispenser. Test the concentration with the appropriate test strip, which is dipped in the sanitizer solution for ten seconds before reading. The test strip must read 200 to 400 ppm. Immerse all washed items for sixty seconds. Review of the facility's document titled Inservice Lesson Plan and Attendance Record for Sanitation Procedures for Dietary Kitchen Staff in-service dated 6/11/25, showed [NAME] 2 was in attendance of the in-service. The handout showed the in-service training purpose was to ensure all dietary staff understand and follow proper sanitizing procedures to maintain food safety and meet California Health and Safety Code requirement. On 9/30/25 at 0844 hours, an observation and concurrent interview was conducted with [NAME] 2 and Dietary Manager. [NAME] 2 was asked to describe the manual dishwashing process. [NAME] 2 stated the first compartment was used to wash items, the second compartment was used to rinse items, and the third compartment was used to sanitize items. When asked what the minimum temperature for the hot water used during the manual dishwashing, [NAME] 2 was unable to answer. When asked for how long the items needed to be sanitized for, [NAME] 2 stated the items could stay in the compartment for a long time. [NAME] 2 was asked to demonstrate how to test the sanitizing solution. [NAME] 2 used a test strip and dipped the strip in the sanitizer solution for one second, instead of 10 seconds. The RCDM verified and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 77 residents (Resident 23). * The facility failed to ensure Resident 23 was provided with the high caloric pudding and whole milk on her lunch tray. This failure had the potential to not meet the resident's nutritional needs.Findings: Review of the facility's Matrix showed 77 residents consumed food prepared in the kitchen. On 9/29/25 at 1238 hours, during the dining observation, Resident 23's lunch meal ticket showed Resident 23 was on a controlled carbohydrate diet with pureed texture. The meal ticket indicated for Resident 23 to have a high caloric pudding and 8 fluid ounces of nectar - mildly thick whole milk. However, Resident 23's lunch tray did not contain the high caloric pudding and whole milk. An observation, interview and concurrent meal ticket review was conducted with the MDS Coordinator in the dining room. The MDS Coordinator verified Resident 23 was not provided with the high caloric pudding and whole milk in her lunch tray. On 11/18/25 at 1534 hours, an interview was conducted with the Administrator, DON, and RCDM. The Administrator, DON, and RCDM was made aware and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the food served was in accordance with the prescribed diet texture to one of 23 final sampled residents (Resident 12). * The facility failed to provide Resident 12's diet was according to the physician's order. This failure posed a risk for the resident to not tolerate the food texture and choke.Findings: Medical record review of Resident 12 was initiated on 9/29/25. Resident 12 was admitted to the facility on [DATE], with diagnoses which included COPD and dysphagia. Review of Resident 12's Order Summary Report showed a physician's order dated 9/15/25, for Regular Diet, Soft and Bite-Sized Level 6 texture, vegetarian, no salad entree and may give grilled cheese, allow regular bread and toast. Review of the facility's document titled 2023/2025 Diet Manual, the IDDSI (International Dysphagia Diet Standardization Initiative) Level 6: Soft & Bite-Sized Diet showed to avoid all raw vegetables. On 9/29/25 at 1225 hours, during the dining observation, Res 12 was observed with a small, tossed salad with croutons, fresh chopped cantaloupe melon, cooked green beans, a grilled cheese sandwich and chocolate pudding for her lunch meal. On 10/1/25 at 1510 hours, an interview and concurrent record review was conducted with the RCDM. The RCDM acknowledged raw vegetables were not allowed on a Soft and Bite-Sized texture diet. The RCDM stated Resident 12 had an order to allow fresh fruits and vegetables. When asked about the physician's order, the RCDM was not able to find a physician's order for Resident 12 to have fresh fruits and vegetables.

Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives for three of 23 final sampled residents (Residents 20, 46, and 63). * The facility failed to provide documented evidence if the written information and assistance on how to formulate an advanced directive were provided Residents 20, 46, and 63 when the residents did not have an advance directive. This failure had the potential for the residents to not receive the treatment and services based on the residents' wishes. Findings: Review of the facility's P&P titled Advance Directives revised on 9/2022 showed the following: - the residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance Directives are honored in accordance with state law and facility policy; - prior to or upon admission of a resident, the SSD or designee inquires of the resident, his or her family members and/or his or her legal representatives about the existence of any written advance directives; - the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; - if the resident or representative indicates he or she had not established an advance directive, the facility staff will offer assistance in establishing an advance directive; and - nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical record review for Resident 20 was initiated on 11/17/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Advance Healthcare Directive (AHCD) Acknowledgement Form dated 7/15/25, indicated I do not have an AHCD. Review of Resident 20's POLST form dated 7/17/25, the section for Information and Signatures indicated Resident 20 had no advance directive. Review of Resident 20's H&P examination dated 7/17/25, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's MDS assessment dated [DATE], showed Resident 20's BIMS score was 10 (moderate cognitive impairment). On 11/19/25 at 1045 hours, a medical record review and concurrent interview was conducted with the SSD. Resident 20's POLST and AHCD form was reviewed and the SSD. The SSD verified there was no documented evidence the facility had provided the information on how to formulate an advance directive to Resident 20 when Resident 20 did not have an advance directive. The SSD stated she must complete a new social service review assessment after any resident was readmitted to the facility and document if the information was provided to the resident or responsible party on how to formulate an AHCD. On 11/19/25 at 1135 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 46 was initiated on 9/30/25 Resident 46 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 46's POLST dated 8/23/25, the section for Information and Signatures showed Resident 46 had no advanced directive. Review of Resident 46's H&P examination dated 8/25/25, showed Resident 46 had the capacity to understand and make decisions. Review of Resident 46 's MDS assessment dated [DATE], showed Resident 46 had BIMS score of 11 (moderate cognitive impairment). Further review of Resident 46's medical record failed to show the documented evidence if the facility had provided the information and assistance on formulating the advance directive to Resident 46 and/or the resident's representative. 3. Medical record review for Resident 63 was initiated on 9/30/25. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 63's POLST dated 2/25/24, the section for Information and Signatures showed Resident 63 had no advanced directive. Review of Resident 63's H&P examination dated 2/26/25, showed Resident 63 had the capacity to understand and make decisions. Review of Resident 63's MDS assessment dated [DATE], showed Resident 63 had a BIMS score of 13 (cognitively intact). Further review of Resident 63's medical record failed to show the documented evidence if the facility had provided the information and assistance on formulating the advanced directive to Resident 63. On 10/1/25 at 0925 hours, an interview and concurrent medical record review for Residents 46 and 63 was conducted with the SSD. The SSD stated the admission nurse will fill out the advance directive acknowledge form, then the SSD would follow up if the resident had an advance directive. If the resident had an advanced directive, the SSD would ask for a copy, and if the residents did not have an advanced directive, the SSD would provide the information on how to formulate an advanced directive. The SSD further stated the information provided would be documented in the Advanced Healthcare Directive Acknowledgement form. The SSD verified there were no documentation in Resident 46 and 63's medical record to show if the facility had provided the information or discussed with the residents on how to formulate an advance directive. On 11/19/25 at 1155 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 46 and 63.

Based on observation, staff interview and clinical record review, the facility failed to ensure three of 18 sampled residents (Residents 9, 15, and 12) maintained acceptable parameters of nutritional status. The facility failed to implement individualized interventions to stabilize and/or improve the resident's weight. The facility failed to reevaluate the residents unplanned weight loss and the need for meal assistance. This resulted in severe weight loss. Findings: Immediate Jeopardy was identified on 7/19/12 at 1130 hours, regarding the facility's failure to assess and prevent pressure ulcers, failure to maintain acceptable parameters of nutritional status; and failure to provide the appropriate care and treatment of [REDACTED]. The Administrator and DON were made aware of the Immediate Jeopardy on 7/19/12 at 1140 hours. An acceptable written plan of action was provided on 7/19/12 at 1818 hours, by the Administrator. The Immediate Jeopardy was abated on 7/23/11 at 1035 hours, prior to the exit date of survey. The corrections the facility took were: 1. Resident 9 and Resident 15 were reassessed by the physician for weight loss, an RD consultation was initiated, food preference documentation was updated, an OT evaluation for adaptive equipment was preformed and a new plan of care was developed. 2. All residents were reassessed for food preferences. 3. All residents were screened for the need of adaptive equipment and feeding assistance. 4. All residents with weight losses were referred to the weight committee for weekly review and weights. 5. P&Ps for the RNA program and weight management were reviewed and all RNA staff were in-serviced regarding the P&P. 6. Dietary staff was in-serviced regarding food preferences. 7. All CNAs were in-serviced on adaptive equipment and feeding techniques. 8. All licensed nurses were in-serviced on supervision during meals, monitoring weight changes and notify the physician regarding weight loss. 9. The IDT was in-serviced regarding risks and benefits of resident choices and communication. 1. Clinical record review for Resident 9 was initiated on 7/17/12. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's hospital history and physical dated 3/14/12, shows Resident 9 was admitted to the facility following her GT (a tube surgically inserted through the abdominal wall into the stomach) being dislodged. The physician documented the resident stated the only reason she has the GT is because the food at the facility is inedible. Review of Resident 9's Nutritional Screening and Data Collection Form dated 8/10/11, shows she is not on a planned weight loss or gain program. She is five feet seven inches tall and weighs 163 pounds. Review of Resident 9's Dietary Quarterly Progress Notes dated 11/21/11, shows her current weight as 172 pounds (weight gain of 16 pounds). Her diet is a mechanical soft, no added salt, fortified diet, with a 50-75% intake and is also receiving Fibersource HN (enteral feeding formula) at 95 ml per hour for 19 hours (providing 2166 calories). Review of Resident 9's Dietary Quarterly Progress Notes dated 2/20/12, shows her current weight as 187 pounds (weight gain of 24 pounds). Her diet is a regular, no added salt, fortified diet, with a 50-75% intake and is also receiving [MEDICATION NAME] 1.5 (enteral feeding formula) at 65 ml per hour for 12 hours (providing 1170 calories). Review of Resident 9's Dysphagia Medical Workup dated 3/16/12, shows Resident 9 previously was on enteral feedings due to failure to thrive and poor appetite. The Speech Therapist documented on 3/30/12, for the RD to follow Resident 9's medical condition for weight and nutritional management. Review of Resident 9's Dietary Progress Notes dated 3/30/12, shows significant weight gain (18 pounds-10.5%) in three months. Now eating regular, no added salt diet, tube feeding discontinued, with the current diet meeting her nutritional needs with oral intake alone. On 7/7/12, Resident 9's weight was 177 pounds (five pound weight loss) and four ounces of health shake were added at lunch and dinner. On 7/16/12, Resident 9's weight was 173 pounds (four pound weight loss in one week). A psychiatric consult was ordered secondary to not eating. The health shakes were held and ice cream was added to her lunch and dinner meals. Review of Resident 9's IDT Weight Management and Care Plan form shows: a. On 8/23/11, Resident 9 had an expected weight gain. b. On 7/5/12, Resident 9 had an unavoidable weight loss of five pounds in 30 days and the recommendation was for weekly weights. c. On 7/10/12, Resident 9 lost four pounds due to poor intake and attention seeking behaviors. MedPass 120 ml four times a day and ice cream were added twice a day. d. On 7/17/12, Resident 9 only eats snacks and supplements. The recommendation was to add snacks twice a day. e. On 7/19/12, Resident 9 lost four pounds due to poor intake and changes her likes and dislike preferences often. The reinsertion of a GT was discussed. [MEDICATION NAME] 400 mg twice a day was ordered as an appetite stimulant. Review of Resident 9's CNA-ADL Tracking Form for June, 2012, shows the following for her meal intake for breakfast (good 75-100%, fair 50-74%, poor 25-49% and refused 0-24%): two days = good, eight days = fair, and 20 days = poor. (28 out of 30 days, Resident 9 ate less than 75% of her breakfast). Her meal intake for lunch showed: three days = fair, and 26 days = poor. (29 out of 30 days, Resident 9 ate less than 75% of her lunch). Her meal intake for dinner showed: one day = good, and 28 days = fair. (28 out of 30 days, Resident 9 ate less than 75% of her dinner). Her afternoon snack showed she was offered a snack only on 6/21/12, and 29 days she was not offered a snack. Review of Resident 9's CNA-ADL Tracking Form for July 1-17, 2012, shows the following for her meal intake for breakfast: two days = fair, and 15 days = poor. (17 out of 17 days, Resident 9 ate less than 75% of her breakfast). Her meal intake for lunch showed: one day = fair, and 16 days = poor. (17 out of 17 days, Resident 9 ate less than 75% of her lunch). Her meal intake for dinner showed: nine days = good, and six days = fair. (six out of 15 days, Resident 9 ate less than 75% of her dinner). She was not offered an afternoon snack. On 7/17/12, a physician's orders [REDACTED]. During an interview on 7/18/12 at 0800 hours, the DON stated Resident 9 lost 5.3% of her weight in 90 days. She stated a reinsertion of a GT was not discussed with Resident 9. The DON stated they are waiting for her weight to be stabilized first to see if a GT is needed. On 7/18/12 at 1230 hours, Resident 9 was observed sitting in the dining room. Her lunch tray was served and she asked LVN 3 to get her a different plate of food, without gravy on it. An observation of Resident 9's lunch tray showed gravy was served on her food. On Resident 9's tray was her dietary card. The dietary card shows she dislikes gravy, and to serve salad and ice cream with her meal. No salad or ice cream was observed on her tray. In addition, Resident 9 had cucumbers on her tray. She stated she does not like cucumbers. During an interview on 7/18/12 at 1230 hours, the DSD stated he checked Resident 9's tray for the correct diet, not the food on the tray. On 7/18/12, a physician's orders [REDACTED]. During an interview on 7/19/12 at 0755 hours, Resident 9 was observed lying in bed, with her breakfast tray in front of her. She placed a spoon into her cream of wheat, lifted the spoon and turned the spoon sideways. The cream of wheat was running off the spoon. She stated, "how can I eat this? It should be thick." In addition, Resident 9 stated she is allergic to milk products. She stated, for the past two weeks, she has received a health shake on her trays and has sent it back unopened. Resident 9 stated, "doesn't the the staff see I have returned the shake back unopened?" She stated, "what am I supposed to live on?" She stated she does not like fish, cucumbers, spicy foods, and peas. During an interview on 7/19/12 at 0815 hours, Resident 9 stated she is starving for good food. She stated the staff told her if she does not like the food, have her family bring her food from home. Resident 9 stated "I do not think that is fair." She stated she is allergic to milk, has asked for specific food, but the facility is limited to what they have, she is only offered grilled cheese and peanut butter and jelly sandwiches. Resident 9 was asked about her food preferences. Review of Resident 9's Nutrition Screening/Food Preference Record dated 7/19/12, shows she dislikes milk and to place gravy on the side. On 7/19/12 at 0910 hours, an interview and clinical record review was conducted with the RD. The RD stated Resident 9 is five feet seven inches tall and weighed 156 pounds on 7/18/11 (admission). She stated Resident 9 was receiving enteral feedings in addition to her oral diet and weighed 190 pounds on 3/6/12 (34 pound weight gain in eight months). The RD stated Resident 9 was not on a weight gain program. When the RD was asked the reason Resident 9 gained 34 pounds since admission, she stated Resident 9 was admitted to the facility with a [DIAGNOSES REDACTED]. She stated she did not think Resident 9 was stable enough to decrease the enteral feedings faster. (Resident 9's GT was removed on 3/14/12). The RD reviewed Resident 9's weight record: On 1/5/12 = 178 pounds On 2/7/12 = 187 pounds (+9) On 3/6/12 = 190 pounds (+3) On 4/5/12 = 187 pounds (- 3) On 5/6/12 = 183 pounds (- 4) On 6/5/12 = 182 pounds (- 1) On 7/4/12 = 177 pounds (- 5) On 7/8/12 = 173 pounds (-4) On 7/18/12 = 169 pounds (-4) The RD stated on 7/10/12, Resident 9 was noticed to have a poor dietary intake. She stated Resident 9 is not on a planned weight loss program and is possibly losing weight due to her behavior of changing her mind frequently on her likes and dislikes of food preferences. When the RD was asked if Resident 9 was ever on a calorie count, she stated "no, I just did not do one." During an interview on 7/19/12 at 0940 hours, when the DSS was asked about the food sent on Resident 9's lunch tray yesterday, he stated the dietary aide must have misread the dietary card. On 7/20/12, Resident 9's weight was 169 pounds (four pounds in one week, eight pounds in two weeks, 18 pounds in three months. [MEDICATION NAME] (appetite stimulant) and Ensure (a nutritional supplement) one can three times a day with meals were started. Her diet was changed to a regular lactose-free diet (Resident does not want milk products.). The dietary note showed Resident 9 prefers her weight to be in the 180's. Review of Resident 9's physician's orders [REDACTED]. 2. On 7/19/12, clinical record review for Resident 15 was initiated. Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDSs dated 2/16/12, and 5/17/12, showed Resident 15 has short and long-term memory problems, and daily behavioral issues of yelling and screaming. He requires extensive assistance of one staff member with eating. Review of Resident 15's weight record showed the following weights: On 2/8/12 = 178 pounds and 6 feet (72 inches) on admission. On 3/6/12 = 170 pounds (- 8) On 4/1/12 = 168 pounds (- 2) On 5/6/12 = 164 pounds (- 4) On 6/5/12 = 162 pounds (- 2) On 7/4/12 = 158 pounds (- 4) On 7/15/12 = 157 pounds (-1) This was a total loss of 21 pounds, or 11.8 % in 5 months. Review of Resident 15's Nutritional Screening and Data Collection Form dated 2/12/12, shows he is totally dependent on staff for eating. His estimated calorie intake need is 2190-2670, with a protein intake of 73-89 gm. The estimated percentage of meal intake to meet his nutritional needs is 99%. On 2/17/12, the RD documented Resident 15's loss of six pounds was anticipated with his terminal [DIAGNOSES REDACTED]. On 2/24/12, Resident 15 continued to lose weight (three pounds in one week, nine pounds in two weeks and recommended to increase MedPass (a protein nutritional supplement) 2.0 to 120 ml four times a day. There were no further RD notes until the quarterly review dated 5/21/12. The RD documented Resident 15 lost four pounds in one month (2.4%), and 14 pounds in three months (7.9%). Significant weight loss for three months noted due to possible decreased intake and meeting approximately 48% of his estimated nutritional needs and on hospice care. If continued weight loss, may consider adding a high protein shake as a supplement. No documentation was available in Resident 15's clinical record to show he was receiving hospice care. Review of Resident 15's IDT Weight Management and Care Plan dated 2/14/12, shows his desirable body weight is 162-196 pounds, to continue weekly weights and to provide a fortified mechanical soft diet with MedPass four times a day. On 2/21/12, Resident 15 lost three pounds and a dietary preference consult was recommended. On 2/28/12, he lost an additional two pounds and the recommendation was to continue the same plan of care. On 3/6/12, Resident 15 gained three pounds and the recommendation was to continue the same plan of care. On 3/12/12, his weight was stable and to discontinue the weekly weights. There was no documentation to address interventions to ensure the resident consumed an adequate meal intake related to the need for assistance during meal times. On 7/5/12, the IDT Weight Management and Care Plan notes show Resident 15 lost four pounds in one month. He is currently receiving a fortified diet with large portions for breakfast, MedPass 2.0 120 ml four times a day, high calorie snacks three times a day and health shakes three times a day. In addition, [MEDICATION NAME] (appetite stimulant) was started on 3/2/12, for 30 days, and now he is having gradual weight loss since the [MEDICATION NAME] was discontinued. The IDT Committee recommended to restart [MEDICATION NAME] 400 mg twice a day for 30 days, weekly weights and to add ice cream to his lunch and dinner trays. A note dated 7/10/12, shows Resident 15's weight is stable and he is consuming 100% of his evening snacks. On 7/17/12, Resident 15 lost an additional pound and a recommendation was for the RNA feeding program at lunch and dinner. Review of Resident 15's CNA-ADL Tracking Form for June, 2012, shows the following for his meal intake for breakfast (good 75-100%, fair 50-74%, poor 25-49% and refused 0-24%): five days = good, eight days = fair, eight days = poor, and eight days = refused. (24 out of 30 days, Resident 15 ate less than 75% of his breakfast). His meal intake for lunch showed: two days = good, 10 days = fair, 13 days = poor, and three days = refused. (26 out of 30 days, Resident 15 ate less than 75% of his lunch). His meal intake for dinner showed: four days = good, 15 days = fair, eight days = poor, and two days = refused. (26 out of 30 days, Resident 15 ate less than 75% of his dinner). His afternoon snack showed he received a snack 15 days, he refused his snack on three days and the was no documentation of his snack intake for 10 days. Review of Resident 15's CNA-ADL Tracking Form for July 1-19, 2012, shows the following for his meal intake for breakfast: seven days = good, seven days = fair, and four days = poor. (11 out of 19 days, Resident 15 ate less than 75% of his breakfast). His meal intake for lunch showed: six days = good, and nine days = poor. His meal intake for dinner showed: nine days = poor, and nine days = refused. His evening snack showed two days he received a snack. Review of the facility's RNA program show the RNA feeding program orders can be written three times a day and should be seven days per week. The RNA will stay with all the residents throughout the entire meal. On 7/18/12, a physician's orders [REDACTED]. During an observation on 7/18/12 at 1755 hours, Resident 15 was not sitting at the RNA table. He was sitting at another table with three residents, with the DSD feeding another resident. Resident 15's dinner tray was placed on the table in front of him. He was observed yelling "help me, help me, help me." No staff members were assisting Resident 15 with his dinner tray, until after he was asking for help. 3. Review of the facility's P&P titled Nutrition (Impaired)/Unplanned weight Loss, shows significant weight loss is identified as having a loss of 5% in one month; greater than 5% is severe. Weight loss of 7.5% in 90 days is identified as significant, greater than 7.5% is severe. Weight loss of 10% in 180 days is considered significant, greater than 10% is severe. On 7/18/12, clinical record review for Resident 12 was initiated. Resident 12 was admitted to the facility on [DATE], for rehabilitation. Review of the MDS dated [DATE], shows Resident 12's cognition is moderately impaired. He requires limited assistance of one staff member with eating. On 7/18/12 at 1200, and 1730 hours, Resident 12 was observed seated at the dining room table, while staffing members were assisting other residents. He ate only very small bites of food. He drank only several sips of fluid at all the meals. Staff appeared to verbally encourage the resident, but he still did not eat. On 7/19/12 at 0815 hours, Resident 12 was sitting on his bed, eating his breakfast. CNA 3 was observed serving his tray, cut his omelet, and left his room. The resident was staring at his plate, and finally held his spoon, feeding himself. There was no staff with the resident. On 7/19/12 at 0830 hours, an interview was conducted with CNA 3. She stated Resident 12 needs help for eating. Review of Resident 12's weight record showed the following weights: On 4/26/12 = 195 pounds and 6 feet high on admission. 5/6/12 = 192 pounds 6/5/12 = 174 pounds 7/8/12 = 171 pounds 7/14/12 = 174 pounds * This represents was a total weight loss of 21 pounds, or 10.7% in 70 days. On 7/18/12 at 0900 hours, an interview was conducted with the RD. The RD stated she was not sure why Resident 12 was losing weight, the IDT even recommended to re-start [MEDICATION NAME], to add high calorie snacks and increase high protein to his diet, but he still doesn't have any weight gain. The RD stated, regarding food preferences, he likes pretty much everything. The RD stated she does not know why Resident 12 is not in the RNA feeding program. On 7/18/12 at 0930 hours, an interview was conducted with RNA 1. The RNA confirmed Resident 12 is not in the RNA feeding program. The RNA stated the resident only eats well when the family member is here, encourages and feeds him in the dining room. The RNA stated Resident 12 is eating an average of 40% per meal.

Based on observation, interview, clinical record review and review of the facility's P&P, the facility failed to develop and implement specific interventions to address the skin risk factors to prevent the development of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure) for two of 18 sampled residents (Residents 2 and 3). *The facility failed to monitor the skin around a resident's indwelling urinary catheter resulting in Resident 3 developing a "urethral cut" (traumatic injury of the urethra, the tube that leads from the urinary bladder) of his penis glans (bulbous structure at the distal end of the human penis) and shaft (main part, providing most of the penis' length; it contains the urethra). On 7/20/12, the "urethral cut" was reassessed and a Stage II (a partial thickness skin loss or blister presenting as a shallow open ulcer with a pink wound bed) pressure ulcer secondary to the use of urinary indwelling catheter was identified to his penis shaft and glans. In addition, the facility failed to ensure Resident 3's bilateral heels were offloaded (pressure is kept off the area). This poses the potential for development of new pressure ulcers or deterioration of the pressure ulcers. *Resident 2 was admitted to the facility without pressure ulcers and was identified as being at high risk for developing pressure ulcers. The facility failed to implement preventive measures to address her risks of developing pressure ulcers. While in the facility, Resident 2 developed a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to her right ankle, an UTD (unable to determine depth, unstageable tissue damage - full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough of eschar (dead tissue) in the wound bed) which deteriorated to a Stage IV pressure ulcer, and an UTD pressure ulcer of her left heel. In addition, she developed a Stage II pressure ulcer to her buttocks, which resolved once treatment was initiated. Findings: Immediate Jeopardy was identified on 7/19/12 at 1130 hours, regarding the facility's failure to assess and prevent pressure ulcers, failure to maintain acceptable parameters of nutritional status; and failure to provide the appropriate care and treatment of [REDACTED]. The Administrator and DON were made aware of the Immediate Jeopardy on 7/19/12 at 1140 hours. An acceptable written plan of action was provided on 7/19/12 at 1818 hours, by the Administrator. The Immediate Jeopardy was abated on 7/23/11 at 1035 hours, prior to the exit date of survey. The corrections the facility took were: 1. Resident 3 and Resident 2 were reassessed by a wound care consultant and the medical director to identify their current condition, and new plans of care were developed. 2. All residents received a full body check. 3. All residents with indwelling urinary catheters were evaluated for appropriate placement, positioning, and signs and symptoms of loss of skin integrity. 4. All care plans were updated according to any identified change of skin condition. 5. All CNAs were in-serviced on identifying and reporting of skin abnormalities, proper hygiene techniques, how to implement interventions to address prevention and maintenance of skin integrity, and care and positioning of a resident with an indwelling urinary catheter. 6. All licensed nurses were in-serviced on how to perform an accurate skin assessment and physician notification, developing and implementing the plan of care to address skin integrity, proper skin assessment and monitoring for residents with indwelling urinary catheters, and following the facility's P&P regarding skin management. 7. The Shower Day Skin Inspection Check form was developed. The Resident Census and Conditions of Resident Report (CMS form 672 ) signed and dated by the DON on 7/16/12, showed eight residents with pressure ulcers, three of which developed pressure ulcers in the facility. As part of the plan of correction for the Immediate Jeopardy, skin assessments were done on all residents. Review of the facility's Skin Committee Minutes dated 7/21/12, showed the facility identified 25 wounds in the facility and 10 were shown to be facility acquired. 1. According to the National Pressure Ulcer Advisory Panel, offloading is the most effective preventive method for pressure relief. On 7/17/12, clinical record review was initiated for Resident 2. Resident 2 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. Review of the admission MDS (a standardized assessment tool) dated 1/16/12, shows Resident 2 has short and long term memory impairment with moderate cognitive impairment. The assessment shows Resident 2 requires extensive assistance, requiring one person's physical assistance with bed mobility, transfers, and personal hygiene, she is totally dependent on staff for locomotion on and off the unit using a wheelchair, has functional limitations in range of motion in both lower extremities and is at risk of developing pressure ulcers. The assessment shows no pressure ulcers were identified on admission. The MDS dated [DATE], shows three unstageable pressure ulcers. The MDS dated [DATE], shows two Stage IV and one unstageable pressure ulcer. Review of the Pressure Ulcer Risk Assessment shows an entry dated 1/13/12, showing a total score of 13 (eight or above is a HIGH RISK for pressure ulcers). Review of the care plan shows a care plan problem dated 1/3/12, to address pressure ulcers/ skin integrity manifested by impaired mobility, diabetes, and refusal of care and treatment. The section to show the goal is blank and no interventions are checked on the form. Further review of the clinical record shows a short term care plan problem dated 2/7/12, to address an intact blood blister to the left heel and the outer right heel. The interventions show to treat as ordered; keep clean and dry; follow turning and repositioning program; handle the affected area carefully; explain to the resident the risk factors for development of new skin problems; provide good skin care; monitor for signs and symptoms of infection; and to use pillows to relieve pressure to both heels as tolerated. A short term care plan problem dated 3/2/12, to address the left heel blister shows on 3/2/12, the blister popped and is shown to be an UTD pressure ulcer. A short term care plan dated 3/2/12, to address the right heel unstageable pressure ulcer shows on 5/23/12, the pressure ulcer was assessed to be a Stage IV pressure ulcer. The intervention shows the use of a LAL mattress (low air loss mattress- a pressure relieving mattress) which was discontinued on 5/3/12, and on 7/17/12, the use of heel protectors was implemented. A short term care plan problem dated 2/13/12, to address a Stage I (non-blanchable redness to intact skin) pressure ulcer to the right buttocks, which deteriorated to a Stage II pressure ulcer on 2/21/12, shows the use of an APP mattress (Alternating pressure pad system used to prevent Stage I pressure ulcers). A short term care plan problem dated 3/13/12, to address a DTI (deep tissue injury - depth unknown) to the right lateral malleolus, which deteriorated to a Stage IV pressure ulcer on 5/1/12, shows to float with pillows as tolerated. On 7/17/12 at 0745 hours, Resident 2 was observed laying in bed. Both heels with dressings in place were observed laying directly on the mattress. A pillow was observed to be placed between Resident 2's knees. On 7/18/12 at 0835 hours, wound treatment was observed with LVN 7. LVN 7 stated the right buttocks Stage II pressure ulcer is healed and maintenance treatment is now ordered. Intact skin to the right buttocks was observed. LVN 7 removed the dressing on the left foot, revealing a pressure ulcer measuring 3.3 cm by 5 cm with 100% black eschar (dead tissue) to the back of the heel, and intact brownish discolored skin on the bottom of the heel. LVN 7 removed the dressing to the right foot revealing a Stage IV pressure ulcer measuring 1.5 cm by 2 cm by 0.3 cm to the right heel with 60% slough (a layer or mass of dead tissue separated from the wound bed) and 40% eschar, which was observed pulled away from the white edges of the wound. A pressure ulcer was observed measuring 0.5 cm by 0.3 cm with pink tissue on the right lateral malleolus (outer ankle bone). LVN 7 stated the pressure ulcer on the right lateral malleolus is healing. On 7/19/12 at 0805 hours, Resident 2 was observed laying in bed on her left side with dressings to both feet, laying directly on the mattress. Both heel protectors were observed off and laying at the end of the bed. On 7/18/12 at 0810 hours, an interview and clinical record review was conducted with LVN 3. LVN 3 verified Resident 2 was assess to be at high risk to developed ulcers in the facility and stated Resident 2 should have been on a turning schedule, and off loading of her heels should have been implemented. LVN 3 stated the care plan problem should have included those interventions. On 7/18/12 at 0920 hours, an interview and clinical record review was conducted with the DON. The DON was unable to show documentation preventive interventions were implemented when Resident 2 was identified to be at high risk to develop pressure ulcers. The DON stated, initially, Resident 2 was not on a turning schedule. The DON stated the care plan problem dated 1/3/12, to address skin integrity was not correct and she would need to do a complete review of the record and get back to the surveyor. On 7/19/12 at 0725 hours, an interview and documentation review was conducted with the DON. The DON stated she had completed her clinical record review and documented her findings. Review of the documentation presented by the DON showed Resident 2 was identified as a high risk for skin breakdown and had a significant weight loss of 13 pounds, a 9% weight loss, within the first month of admission. The documentation shows Resident 2 was sleepy and required a decrease in [MEDICATION NAME] (antipsychotic medication). When asked if preventive measures were in place to address Resident 2's change in condition and increased risk, the DON stated, once the blisters on Resident 2's heels and the Stage I pressure sore to her coccyx were identified, measures were put into place; however, she stated she was unable to show documentation a preventive plan was in place. (cross reference F-309) 2a. According to the Ostomy Wound Management dated December, 2010, medical devices may be an overlooked cause of pressure ulcer in the long term care setting. Severe erosive urethral injury can occur with an indwelling urinary catheter over a short time period. Unlike many other pressure ulcers, no topical therapy will heal the defect caused by tissue erosion. Clinical record review for Resident 3 was initiated on 7/17/12. Resident 3 was admitted on [DATE]. Review of the MDS dated [DATE], shows Resident 3 has moderate cognitive impairment, he is totally dependent on staff for toileting, and he needs extensive assistance, and requires two person's assistance for bed mobility. Resident 3 has an indwelling catheter, and is incontinent of bowel. Review of the Pressure Sore Risk assessment dated [DATE], shows a score of 17 (a total score of 8 or above represents a HIGH RISK for developing pressure ulcers. Review of a physician's orders [REDACTED]. On 7/19/12 at 0945 hours, wound care was observed being provided to Resident 3 by LVN 5. There was an indwelling urinary catheter present with a leg strap securing the catheter tubing to his upper left leg. The shaft of the penis was observed with an erosion measuring 4 cm, causing an indentation along the shaft of the penis. The indwelling urinary catheter was observed inside the indentation of the shaft of the penis. Moderate brown discharge was observed on the outside of the catheter tubing. Review of the Licensed Fall/Skin/Tear/Discoloration Investigation Report dated 6/27/12 at 1120 hours, shows the early morning CNA found blood in Resident 3's diaper. Resident 3 was assessed and a urethral cut was noted. The resident had an indwelling urinary catheter. The CNA stated she found the resident like that. In-service was given to staff on how to handle an indwelling urinary catheter carefully. On 7/19/12 at 1000 hours, an interview and clinical record review was conducted with LVN 5. LVN 5 stated her role as the Wound Nurse includes monitoring and measuring wounds. LVN 5 reviewed the Wound Documentation Sheet dated 6/27/12, showing a "urethral cut," scant blood noted, painful, and medicated. The form did not have any documentation related to the wound size/extent. LVN 5 stated she only "looked at the wound" and never measure it. Review of the Nurse's Notes dated 5/30/12 at 0300 hours, showed the licensed nurse documented the indwelling urinary catheter was intact. No documentation was available to show Resident 3 had a skin condition involving his penis. Review of a physician's orders [REDACTED]. Urethral cut site: monitor every shift for signs and symptoms of complications. Review of the care plan shows a care plan problem dated 6/27/12, to address alteration in skin integrity due to the urethral cut secondary to tugging at the indwelling urinary catheter tubing. The approaches included to use pressure relieving devices, in-service staff on proper indwelling urinary catheter care. On 7/19/12 at 0950 hours, an interview was conducted with CNA 1. CNA 1 stated she provides care for Resident 3 often. She stated she does not know how the tear happened, but she never saw the resident pulling on the catheter. Review of the Wound Care Clinician Report dated 7/20/12, shows the penis shaft and glans with a Stage II, secondary to the resident's indwelling urinary catheter. On 7/20/12 at 1000 hours, Resident 3 was observed with LVN 5. The resident grimaced every time the LVN handled the penis to inspect the current condition of the wound and obtain the wound measurements. Review of the Pressure/Vascular/Diabetic Ulcer Weekly Flow Sheet dated 7/20/12, shows a Stage II pressure ulcer to the shaft and glans of the penis measuring 4.3 cm x 0.4 cm x 0.1 cm in an "L" shape. On 7/19/12 at 1150 hours, an interview with the DON was conducted. The DON stated "it was a cut from the indwelling urinary catheter, caused by excessive force from the tubing." b. Review of the facility's P&P titled Pressure Ulcer Risk Assessment revised date 3/2005, shows, when in bed, every attempt should be made to "float heels" (keep heels off of the bed) by placing a pillow from the knee to the ankle, or with other devices as recommended by the therapist and prescribed by the physician. Review of a physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the care plan shows a care plan problem dated 5/31/12, to address the DTI pressure ulcer to the left heel. The approaches include to use a pressure-relief device: float with pillows as tolerated. Review of the care plan shows a care plan problem dated 5/30/12, to address the DTI pressure ulcer to the right inner lateral foot. The approaches include to use a pressure-relief device: float with pillows as tolerated. Initial tour round observations were conducted with the MDS Coordinator on 7/16/12 beginning at 1300 hours. At 1330 hours, Resident 3 was visited. The MDS Coordinator stated Resident 3 has pressure ulcers to his heels. Resident 3 was awake, and was observed to be positioned on his back with the head of the bed elevated. Resident 3 had cotton fabric heel protectors on (designed to pad the heels); however, his heels were resting directly on the mattress. On 7/17/12 at 0900, 1130 and at 1400 hours, Resident 3 was observed in bed lying on his back. His right and left heels were lying on the mattress without support to prevent pressure. On 7/18/12 at 0900, and 1300 hours, and again on 7/19/12 at 0750 and 0900 hours, Resident 3 was observed lying in his bed, positioned on his back. Both of the resident's heels were resting on the mattress and were not offloaded. On 7/19/12 at 0945 hours, an interview was conducted with LVN 5. The LVN stated Resident 3 is at risk for developing a pressure ulcers. LVN 5 was asked if the resident's heels should be offloaded. LVN 5 confirmed there was no support in bed or in the room to elevate the resident's heels, and stated they should be elevated. Review of the MAR for July, 2012, from the 16th through the 19th, shows the licensed nurses initialed every shift Resident 3's heels were floated.

Based on observation, interview and clinical record review, the facility failed to ensure necessary treatment and services was provided to promote healing for one of nine sampled residents (Resident 19). Resident 19 developed a Stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue)) and a DTI (deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left buttock. The low air loss mattress did not have the appropriate setting to promote healing. This put the resident at risk for delayed healing. Findings: During the initial tour of the facility with LVN 1 on 9/6/12 at 0810 hours, Resident 19 was observed in bed, asleep. LVN 1 stated the resident has a pressure ulcer and is on a low air loss mattress. On 9/6/12 at 0935 hours, Resident 19 was observed in bed, asleep. The low air loss mattress setting was observed to be on the sixth line, with a cycle time of 10. Clinical record review was initiated for Resident 19 on 9/6/12. The MDS dated [DATE], showed the resident is dependent on staff for bed mobility and transfers. The care plan problem to address a Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area, usually over a bony prominence) to the left buttock dated 8/26/12, showed to provide a low air loss mattress. Review of the Pressure Sore Flowsheet dated 9/2/12, showed the resident has a Stage II pressure ulcer to the left buttock measuring 2.1 cm x 3.4 cm. Further review of the clinical record failed to show documentation on the setting of the low air loss mattress. During a skin treatment observation with LVN 5 on 9/6/12 at 1030 hours, a Stage II pressure ulcer and a DTI to the left buttock was observed. LVN 5 was asked who monitors the setting of the bed. She stated the nurses monitor the setting. She was asked what the setting is supposed to be. She stated she has to check the clinical record. On 9/6/12 at 1455 hours, LVN 5 stated the DON figured out the appropriate setting and LVN 5 went to the resident's room. It was observed the mattress setting was on the third line, with a cycle time of 10. She stated this is the appropriate setting. She was informed the setting previously was on the sixth line. She stated the setting is on the care plan. She was informed the setting is not documented on the care plan earlier. She acknowledged it was added today. During an interview with the DON on 9/6/12 at 1340 hours, she stated, when the mattress is delivered to the facility, the vendor determines the appropriate setting and in-services the nurse who accepts the delivery. The nurse will communicate it to the incoming nurse and during the stand-up meeting. She was informed there was no mattress setting in the clinical record. She acknowledged they added it today. On 9/7/12 at 0910 hours, the DON demonstrated how to determine the mattress setting, using the hand check procedure. She was asked how to read the bed setting. She stated one line represents 10 and the appropriate setting was 20 to 45 (on the third line). She was informed it was observed the bed setting was on the sixth line. She stated that was 60, and not the right setting, the bed was firmer.

Based on observation, interview and clinical record review, the facility failed to ensure interventions to prevent further weight loss were implemented for one of nine sampled residents (Resident 19). Resident 19 had a significant weight loss of 10 pounds (8% in a month) in July, 2012, and continued to lose weight. Findings: Clinical record review was initiated for Resident 19. The MDS dated [DATE], showed the resident has memory problems and requires extensive assistance with meals. The recapped physician's orders [REDACTED]. The care plan problem to address weight loss of 5% or more in the last 30 days dated 7/15/11, showed the following approaches: provide diet as ordered, encourage nutritional supplements and offer food alternatives when appropriate. Review of the Weight Record showed the following: 7/4/12 - 125 pounds 8/4/12 - 115 pounds 8/12/12 - 114 pounds 8/19/12 - 111 pounds 8/26/12 - 110 pounds The Dietary Note dated 8/28/12, showed a continued weight loss trend due to poor meal intake. It also showed the resident is dependent on staff for meals and the resident is already on a fortified diet with multiple supplements and snacks. The Interdisciplinary Team Conference Record dated 9/5/12, showed the physician and the family were aware of the weight loss. There was no documented evidence the interdisciplinary team discussed and attempted other interventions to prevent weight loss. On 9/6/12 at 0935 and 1000 hours, Resident 19 was observed in bed, asleep. On 9/6/12 at 1020 hours, CNA 2 went to Resident 19's room. She was asked if the resident requires assistance with meals. She stated the resident is a feeder. There was no cookie observed in the room. On 9/6/12 at 1030 to 1100 hours, LVN 1 and LVN 3 were observed in the room providing skin treatments. On 9/6/12 at 1235 hours, CNA 3 was observed going to Resident 19's room, carrying a lunch tray. He set-up the tray, cut the chicken, and gave Resident 19 three spoonfuls of chicken and noodles. CNA 3 left the room and went to the tray cart. CNA 3 was observed going in and out of the residents' rooms several times. He took a tray from the tray cart, went in a resident's room and stayed in the room. On 9/6/12 at 1255 hours, LVN 1 was asked if Resident 19 got her tray. LVN 1 went to the resident's room. She went out and got CNA 3. CNA 3 went to Resident 19's room. He was asked if he was feeding two residents at a time. He stated he was helping pass the trays. He was asked what the resident was having. He stated chicken, noodles, spinach tomato soup, pudding, milk, a vanilla shake and juice. There was no ice cream on the tray. He then started feeding the resident. On 9/6/12 at 1425 hours, a cookie labeled with Resident 19's name was on a container at the nurses' station. CNA 5 was asked if she was going to give Resident 19 her cookie. She stated the cookie was too dry,and Resident 19 did not like it. She further stated Resident 19 will eat a pudding. She was asked if she told the nurse. She stated they will just get a pudding. CNA 5 stated she gave the cranberry juice and that was enough. On 9/7/12 at 0755 hours, CNA 4 was observed in Resident 19's room, repositioning the resident. The breakfast tray was observed on the bedside table. The breakfast tray contained egg, toast, cream of wheat, a health shake, milk, prune juice and coffee. LVN 1 was asked if the breakfast tray contained a regular size serving. She replied, yes. During an interview with RN 2 on 9/7/12 at 0930 hours, she confirmed the current diet order for Resident 19 is to provide a fortified, no added salt diet with large portions for breakfast, cranberry juice between meals, ice cream for lunch and dinner, and cookies at 1000 hours and 1400 hours. On 9/7/12 at 1020 and 1040 hours, a cookie labeled with Resident 19's name was observed in a container at the nurse station. Further review of the CNA ADL Tracking Form for the month of September, 2012, 7-3 shift, showed no snack was offered on 9/3/12 and 9/4/12, and the section to document snacks for 9/1/12, 9/5/12, 9/6/12 and 9/7/12 were left blank.