Every finding on record at Centinela Grand Inc

Based on interview and record review, the facility failed to ensure that the resident representative had the opportunity to exercise the resident's rights regarding care decisions for one of three residents reviewed (Resident 1), when the facility removed Resident 1 from hospice services (medical care that focuses on comfort, dignity, and quality of life for patients approaching the end of life) without involving a resident representative.This failure resulted in Resident 1 being removed from hospice services without having a representative present or involved in the decision making process.Findings:On August 27, 2026, Resident 1's medical record was reviewed.The facility admission record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental abilities) and congestive heart failure (CHF-severely depressed heart function). Resident 1 was transferred to the general acute care hospital (GACH) on July 27, 2026, for fever.The GACH Internal Medicine admission History and Physical Note dated July 27, 2026, at 6:34 pm, indicated Past medial History (PMH) of Dementia Alert and Oriented x 0 (cannot answer or identify person, place, time, situation) at baseline, Afib (atrial fibrillation- heart rhythm disorder).CHF (EF-heart pumping ability) 30-35% (range to classify heart failure).who presented from.facility.with concerns for fever.facility stated that Resident 1 (pt) is full code (medical staff must use all life-saving measures if a patient's heart or breathing stops). Facility stated decision makers for pt has no family.Admit to GACH.The GACH document titled, Clinical Ethics Consultation, dated August 7, 2026, indicated, .Narrative.history of dementia.bed-bound.nonverbal, and is reliant on others for all activities of daily living (ADL).A meeting was requested to determine what the best course for this patient should be.lacks decision making capacity.The patient's Skilled Nursing Facility (SNF) has been making medical decisions for her at the facility.Discussion.A multidisciplinary meeting was held.Healthcare Decisions for Unrepresented Patients (residents).Recommendations.The committee unanimously agreed that it would be in (Resident 1) best interest to change code status to Do Not Resuscitate (DNAR)/comfort care, remove (Resident 1) nasogastric (NG- flexible plastic tube that goes through the nose down the throat into the stomach) tube and obtain hospice consult.will have to see if (Resident 1) facility is able to take (Resident 1) back with hospice.The GACH document titled, Social Work Consult Note, dated August 7, 2026, at 5:25 pm, indicated, .Social work contacted.facility for placement.confirmed that they have a bed available.Referral information was sent to facility.Report received from hospice care Medical Doctor (MD) agreeable to admit patient (Resident 1) to hospice for CHF.The facility admitting nurse progress note dated August 10, 2026, at 10:30 pm, indicated, . admitted to facility.via Ambulance from GACH.Received report from GACH Registered Nurse (RN).that (Resident 1) will be discharged with hospice care, discontinued all medications, hospice care to pursue comfort-focused treatment.The physician order dated August 12, 2026, indicated, .may admit to hospice diagnoses (Dx) of CHF, respiratory distress, Physician Orders for Life Sustaining Treatment (POLST) DNR (Do Not Resuscitate).The Interdisciplinary Team (IDT) Review and Recommendations, dated August 12, 2026, indicated .Risk Factors: acute on chronic combined congestive heart failure.Recommendations: Discussed with IDT current conditions of (Resident 1), noted with decline in ADLs, on NPO status.Office of Aging representative & Ombudsman made aware of the hospice order from GACH.IDT agreed on hospice referral. Obtained order for hospice eval. Order noted.POLST DNR .The history and physical dated August 13, 2026, indicated .Resident 1 did not have the capacity to make decisions.reason dementia.Surrogate Decision maker: Skilled Nursing Facility (SNF) Administrator.The nurse progress note dated August 13, 2026, at 3:01 pm, .Resident seen by hospice RN and Nurse Practitioner (NP) on August 13, 2026. Continue with current plan of care.The social service progress note dated August 13, 2026, at 4:27 pm, indicated .Effort made to find family through https://www.fastpeoplesearch.com, Facebook & by email address. Resident has not received any calls or visitors.The nurse progress note dated August 13, 2026, indicated .IDT discussed. Resident 1 current status.paperwork sent to Office of Aging and want to discuss the DNAR recommendations from named GACH bioethics committee on August 19, 2026.will obtain order from hospice to D/C (discontinue) services and will be full code status.admit to facility with orders for.if patient is not eating to start Dextrose 5% (D5 - intravenous fluid solution of sugar) 1/2 Normal Saline (NS) at 100 cc (cc-unit of measurement) per hour for 48 hours.There was no documented evidence that Resident 1 had a representative present for the IDT meeting to discontinue Resident 1's hospice on August 13, 2026.The nursing note dated August 15, 2026, at 1:28 pm, indicated .Per nursing assistant patient is unable to open her mouth nor swallow.MD made aware. IDT made aware, awaiting MD response.The physician order dated August 15, 2026, at 6:52 pm, indicated transfer to acute hospital via 911 (emergency transport) related (r/t) hypotension, poor by mouth (po) intake, unable swallow food safety for further evaluation and treatment.On August 27, 2026, at 2:14 pm, a concurrent interview and record review was conducted with the social worker designee (SW). The Social Worker (SW) stated that the facility's process for locating family or friends of unrepresented residents relies primarily on Facebook and public people-search engines. The facility does not utilize county or state agencies for these searches. If family members cannot be located, the SW contacts the Public Guardian to request the assignment of a conservator or public guardian. The SW stated she made a request to the Public Guardian's Office for the appointment of a public conservator or guardian and Resident 1's application was denied. The SW was unable to provide documented evidence of petitioning the Public Guardian's Office or documented evidence that Resident 1 was denied a conservator or public guardian.The Social Worker (SW) stated that the facility's process for placing a resident on hospice requires contacting the Department of Aging to request a designated representative for the resident to participates in the hospice care decision-making process. Following the request the Department of Aging conducts an on-site clinical assessment of the resident, an IDT meeting is scheduled with the Department of Aging representative and facility staff to review and coordinate the resident's care plan. The SW stated an IDT meeting was held on August 12, 2026, to place Resident 1 on hospice per the GACH bioethics committee.The SW stated an IDT meeting was held on August 13, 2026, to remove resident 1 off of hospice. The SW stated there was no representative for Resident 1 present at the IDT meeting, nor was the Department of Aging Representative present for the IDT meeting, and Resident 1 should have had a representative present.On August 27, 2026, at 4:55 pm, a concurrent interview and record review was conducted with the Administrator (Admin). The Admin stated the facility process for unrepresented residents returning from the GACH on hospice or comfort care requires that the IDT conducts a clinical meeting and contact the Department of Aging to request a representative for the hospice discussion. The Admin stated that an IDT meeting was conducted on August 12, 2026, for Resident 1's hospice placement and there was no representative for Resident 1 from the Department of Aging present and there should have been a representative present. The Admin stated that an IDT meeting was conducted on August 13, 2026, for Resident 1's removal from hospice, and there was no representative for Resident 1 present and there was no representative from the Department of Aging, and there should have been a representative present.A review of the facility policy and procedure titled, Unrepresented Residents, undated indicated .it is this policy of this facility to support a resident's right to have a legally recognized presentative participate in care decisions. When there is no available decision-maker, and the resident lacks capacity to make medical decisions, the resident is considered unrepresented and the following procedure will be followed.Unrepresented residents who have complex healthcare or psychosocial needs will be referred to the county Public Guardian's office.A review of the policy titled, IDT Policy and Procedure, undated, indicated .The IDT shall develop, implement, monitor, and service a comprehensive care plan for each resident that reflects the resident's medical, physical, mental, psychosocial, and cultural needs, incorporates resident and representative preferences and goals, and is updated at required interval or upon significant change of condition .A review of the policy and procedure titled, Resident's Rights, undated, indicated .If a resident lacks the ability to understand theses rights and the nature and consequences of proposed treatment, the resident's representative shall have the rights specified in this section to the extent the right may devolve to another.

Based on observation, interview, and record review, the facility failed to ensure:1. 14 of 17 residents reviewed (Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12, 13, 14, 15, 16, and 17) were supervised by the facility staff, as ordered by their physician, during leave of absence passes (LOA); and2. One resident reviewed (Resident 3) did not have sharp objects on the meal trays, as indicated in the residents' care plan.This failure had the potential for:1. Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 to experience avoidable environment risks, hazards, and accidents; and 2. Placed Resident 3 at risk for self-harm.Findings:On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.1a. On July 30, 2025, Resident 1's medical record was reviewed.Resident 1 was admitted to the facility on [DATE], with diagnoses which included Major depressive disorder (persistent feeling of sadness), paranoid schizophrenia (symptoms of suspicious/mistrust/delusions/hallucination), anxiety (feeling of nervousness) disorder, bipolar disorder (manic and depressive episodes).The history and physical completed by the physician on June 20, 2024, indicated Resident 1 had the capacity to understand and make decisions.The physician orders dated June 20, 2024, indicated .may go on temporary leave of absence with staff for sensory stimulation.The care plan dated July 15, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secure.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on May 4, May 7, May 27 - 30, June 1, and July 17, 2025, Resident 1 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 1 during the LOA.1b. On July 30, 2025, Resident 2's medical record was reviewed.The admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Major depressive disorder (persistent feeling of sadness), psychosis (loss with reality), extrapyramidal movement disorder (movements related to side effects of antipsychotic medications-medications to treat psychological disorders);The history and physical completed by the physician on June 1, 2025, indicated Resident 2 had the capacity to understand and make decisions.The physician order dated May 2, 2025, indicated .may go for temporary leave of absence with staff for sensory stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on May 15, 2025, at 1:00 p.m., Resident 1 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 2 during the LOA.1c. On July 30, 2025, at 12:17 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated during his leave of absence pass on July 20, 2025, he experienced anxiety and right leg pain requiring him to call 911 (emergency services) for assistance. On July 30, 2025, Resident 3's medical record was reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), anxiety disorder (feeling nervousness), depression (persistent feeling of sadness), abuse of non-psychoactive substances (excessive use of illegal drug), neuropathy (nerve problem), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The physician order dated July 10, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation .The care plan dated July 1, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.The nursing progress notes indicated the following:On July 20, 2025, at 10:38 a.m., Resident 3 left the faciity on pass to the store.On July 20, 2025, at 8:00 p.m., nursing staff contacted Resident 3 via phone and Resident 3 stated he called 911 due to anxiety and right leg pain.On July 21, 2025, at 7:31 a.m., the facility called (name of hospital) and was informed by (name of hospital) staff Resident 3 was on a 5150 hold ( 72-hour hold for a person experiencing a mental health crisis).On July 23, 2025, at 5:50 p.m., Resident 3 was re-admitted into the facility.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 20, 2025, at 10:30 a.m., Resident 3 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 3 during the LOA.The Leave of Absence Logbook further indicated on June 24, June 25, June 26, July 3, July 7, July 12-19, and July 24-31, 2025, Resident 3 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 3 during the LOA.1d. On July 30, 2025, Resident 4's medical record was reviewed.The admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness) and psychosis (loss of reality).The history and physical completed by the physician on August 9, 2024, indicated Resident 4 can make needs known but cannot make medical decisions.The physician order dated July 30, 202, indicated .may go on temporary leave of absence for sensory stimulation with staff.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 10 and July 21, 2025, Resident 4 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 4 during the LOA.1e. On July 30, 2025, Resident 6's medical record was reviewed.The admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included psychosis (loss of reality).The history and physical completed by the physician on July 2, 2025, indicated Resident 6 had the capacity to understand and make decisions.The physician order dated July 2, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The progress note nursing dated July 11, 2025, indicated Resident 6 .left via Uber (transportation service) for appt and LOA to stay overnight with a friend.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 3, July 6, and July 11, 2025, Resident 6 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 6 during LOA.There was no documented evidence an assessment was conducted to ensure Resident 6 was safe to go out overnight on LOA independently on July 11, 2025.1f. On July 30, 2025, Resident 7's medical record was reviewed.The admission record indicated Resident 7 was admitted to the facility on [DATE], with the diagnoses which included Dementia (loss of intellectual functioning), depressive disorder (persistent feeling of sadness), and Alzheimer (slowly destroys memory).The history and physical completed by the physician on September 27, 2025, indicated Resident 7 does not have the capacity to understand and make decisions with a BIMS (measurement of cognitive function 0 to 15) score of 05 (higher the score higher the cognitive function).The physician order dated September 6, 2024, indicated .may go on temporary leave of absence with staff for therapeutic sensory stimulation.The care plan dated July 3, 2025, indicated .Focus.elopement.Goal.resident will be kept in safe environment.Intervention.allow resident to wander within the unit; assure that environment is safe and secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on May 10, June 18, June 20, June 21, June 25, and July 2, 2025, Resident 6 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 6 during the LOA.1g. On July 30, 2025, Resident 9's medical record was reviewed.The admission record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), major depressive disorder (persistent feeling of sadness), and auditory hallucinations (perception of something not present),suicidal ideations (thinking, considering, or planning suicide), anxiety disorder (feeling nervousness), cannabis dependency (need of marijuana), alcohol abuse (need of alcohol).The facility was unable to provide a history and physical for Resident 9.The physician order dated June 20, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The care plan dated June 20, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 22 and June 23, 2025, Resident 9 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 9 during the LOA.1h. On July 30, 2025, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included Anxiety disorder (feeling nervousness) and major depressive disorder (persistent feeling of sadness).The history and physical completed by the physician dated May 1, 2025, indicated Resident 10 had the capacity to understand and make decisions.The physician order dated May 8, 2024, indicated .may go on temporary leave of absence for sensory stimulation with staff.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 6, June 17, June 20, and June 25, 2025, Resident 10 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 10 during the LOA.1i. On July 30, 2025, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included Depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness) disorder, delusional (belief of things not true), bipolar (manic and depressive episodes).The history and physical completed by the physician on May 19, 2025, indicated Resident 12 had the capacity to understand and make decisions.The physician order dated May 19, 2025, indicated the following, .may go on temporary leave of absence with staff for therapeutic stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on April 22, April 25, May 2, May 20, May 22, May 25, June 1, June 2, June 7, and July 10, 2025, Resident 12 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 12 during the LOA.1j. On July 30, 2025, Resident 13's medical record was reviewed.The admission record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality) and anxiety (feeling nervousness disorder) depression (persistent feeling of sadness).The history and physical completed by the physician on May 19, 2025, indicated Resident 13 had the capacity to understand and make decisions.The physician order dated June 17, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The care plan dated July 4, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 2 -7, June 18 - 22, June 28 - June 30, July 5, July 7 - 15, July 17 - 20, July 26, and July 28 - 30, 2025, Resident 13 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 13 during the LOA.1k. On July 30, 2025, Resident 14's medical record was reviewed.The admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), anxiety (feeling of nervousness), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on May 30, 2025, indicated Resident 14 had the capacity to understand and make decisions.The physician order dated May 30, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 10, June 13, June 15 -18, June 20, June 28 - 30, July 2, July 4-5, July 9-11, July 13 - 15, July 18, July 25, and July 27 -30, 2025, Resident 14 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 14 during the LOA.1l. On July 30, 2025, Resident 15's medical record was reviewed.The admission record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes) and depressive disorder (persistent feeling of sadness).The history and physical completed by the physician on October 2, 2025, indicated Resident 15 had the capacity to understand and make decisions.The physician order dated October 2, 2024, indicated .may go on temporary leave of absence with staff for therapeutic stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 28, 2025, at 8:20 a.m., Resident 15 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 15 during the LOA.1m. On July 30, 2025, Resident 16's medical record was reviewed.The admission record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), depressive disorder (persistent feeling of sadness), and anxiety (feeling of nervousness).The history and physical completed by the physician on May 1, 2025, Resident 16 had the capacity to understand and make decisions.The physician order dated May 4, 2025, indicated .may go on temporary leave of absence with staff for sensory stimulation.The care plan dated July 10, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on May 13 - 14, May 16 - 20, June 23 - 26, July 3, July 6, and July 8, 2025, Resident 16 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 16 during the LOA.1n. On July 30, 2025, Resident 17's medical record was reviewed.The admission record indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included Anxiety (feeling nervousness) and Bipolar (manic and depressive episodes).The history and physical completed by the physician on June 23, 2025, indicated Resident 17 had the capacity to understand and make medical decisions.The physician order dated June 23, 2025, indicated .may go on temporary leave of absence with staff for sensory stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on March 25-27, April 22-23,and June 6, 2025, Resident 17 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 17 during the LOA.On August 1, 2025, at 12:41p.m., a concurrent interview was conducted with the Director of Staff Development (DSD). The DSD stated there is no daily assigned staff to cover residents' LOA passes. The DSD stated staff is only assigned to LOA passes for physician appointments and activities that are far from the facility. The DSD stated residents who have LOA are self-responsible and do not require staff to accompany them. The DSD stated if a physician order indicates residents should be accompanied on LOA than the resident should be accompanied by staff on LOA. The DSD further stated Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 should have been accompanied while on LOA.On August 1, 2025, at 4:32 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process for determining a residents' LOA is the resident must be alert and oriented to participate in LOA pass. The DON stated Residents 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 physicians order indicated they may go on temporary leave of absence with staff for sensory stimulation. The DON further stated that Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 should have been accompanied by staff on LOA passes.A review of the facility policy and procedure titled, Therapeutic Leave, revised November 2017, indicated .the nurse will obtain and order from the practitioner specifying approval of a therapeutic leave.the facility will document in the medical record the resident's leave of absence.A review of the facility policy and procedure titled, Physician Orders, not dated, indicated .physician orders are those given to the nurse by the physician.all physician orders shall be noted by a licensed nurse and carried out accordingly.2. On July 30, 2025, Resident 3's medical record was reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), anxiety disorder (feeling nervousness), depression (persistent feeling of sadness), abuse of non-psychoactive substances (excessive use of illegal drug), neuropathy (nerve problem), and suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The physician order dated July 1, 2025, indicated .suicidal ideations.Intervention .remove sharp objects.On August 1, 2025, at 12:19 p.m., Resident 3's lunch tray was observed with a fork, spoon, and knife. The lunch tray was placed on the bedside table readily available for Resident 3 to use.On August 1, 2025, at 12:24 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the contents of Resident 3's lunch tray included a fork, spoon, and knife. Resident 3's care plan was reviewed. LVN 1 stated the knife and fork on Resident 3's tray would be considered sharp objects. LVN 1 stated according to Resident 3's care plan he should not have sharp objects.On August 4, 2025, at 11:51 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that when a care plan is developed it should be followed through. The DON stated if the care plan indicated resident should not have sharp objects the resident should not have sharp objects. The DON stated the sharp objects should not have been on Resident 3's meal tray.

Based on interview, and record review, the facility failed to ensure mental health services were provided when:1. The physician or psychiatrist was not notified for one resident (Resident 3) of Resident 3's concern regarding his methadone addiction and possibly experiencing a relapse; and 2. The facility did not arrange psychological evaluations for 12 of 12 residents reviewed (Resident's 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15).This failure had the potential for Resident's 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 to have a delay in the necessary care and services to address their behavioral health needs. Findings:1.On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.On July 30, 2025, at 12:17 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he felt the facility was not addressing his problem with methadone (synthetic opioid medication) addiction.On July 30, 2025, Resident 3's medical record was reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), anxiety disorder (feeling nervousness), depression (persistent feeling of sadness), abuse of non-psychoactive substances (excessive use of illegal drug), neuropathy (nerve problem), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The (Name of Facility - methadone clinic) After Visit Summary dated June 18, 2025, indicated .member stated, I am an addict on methadone my last dose was June 10, 2025 I need .services to help me I am withdrawing from not having my medication.member is willing to enter treatment member has been on methadone since 2016 and is having stronger urges to use.member is high risk for relapse due to his current state of withdrawal from methadone.member lacks coping skills to cope with life on life's terms.member reports he is currently in nursing home for physical health issues.The physician order dated July 16, 2025, indicated .consult/appointment with methadone clinic secondary to opioid use disorder.There was no documented evidence indicating Resident 3's concerns about his methadone addiction, withdrawal, and high risk for relapse were addressed with the physician or the psychiatrist until July 16, 2025, when the physician ordered another consult/appointment be made with the methadone clinic.On August 1, 2025, at 4:32 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the Registered Nurse (RN) supervisor is in charge of reading the residents after visit summary and scheduling follow up appointments. The DON stated, after reading Resident 3's after visit summary dated June 18, 2025, the RN supervisor should have contacted the psychiatrist or the physician regarding Resident 3's high risk of relapse. The DON stated there is no documented evidence that the RN supervisor contacted the psychiatrist or the physician regarding Resident 3.A review of the facility policy and procedures titled Specialized Rehabilitative Services, not dated indicated .mental health services and supportive psychotherapy for mental illness.specialized rehabilitative services will be provided under the written order of a physician.the services will be provided or coordinated by qualified personnel.the care plan for individuals receiving specialized rehabilitative services will be monitored by a licensed professional.specialized rehabilitative services are considered a facility service and included within the scope of facility services.2a.On July 30, 2025, Resident 4's medical record was reviewed.The admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness) and psychosis (loss of reality).The history and physical completed by the physician on August 9, 2024, indicated Resident 4 can make needs known but cannot make medical decisions.The physician order dated July 30, 2025, indicated psychology consult & follow up treatment as indicated & prn (as needed).depression.psychosis.The facility could not provide documented evidence Resident 4 received a psychology evaluation as ordered by the physician.2b.On July 30, 2025, Resident 5's medical record was reviewed.The admission record indicated Resident 5 was admitted to the facility on [DATE], with the diagnoses which included bipolar (manic and depressive episodes) and dementia (loss of intellectual functioning);The history and physical completed by the physician on June 4, 2025, indicated Resident 5 had the capacity to understand and make decisions;The physician order dated June 4, 2025, indicated .psychology consult, treatment, follow up.The psychiatric note dated July 3, 2025, indicated .exhibiting aggressive behavior and is observed talking to himself.continue monitoring and follow ups.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 5 received a psychology evaluation as ordered by the physician.2c.On July 30, 2025, Resident 6's medical record was reviewed.The admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included psychosis (loss of reality).The history and physical completed by the physician on July 2, 2025, indicated Resident 6 had the capacity to understand and make decisions.The physician order dated July 2, 2025, indicated .psychology consult, treatment, and follow up.The care plan dated July 2, 2025, indicated .Focus.psychosis m/b auditory hallucinations.Intervention.reality orientation daily and prn.psychiatry/psychology evaluation with treatment and follow ups.The facility could not provide documented evidence Resident 6 received a psychology evaluation as ordered by the physician.2d.On July 30, 2025, Resident 7's medical record was reviewed.The admission record indicated Resident 7 was admitted to the facility on [DATE], with the diagnoses which included Dementia (loss of intellectual functioning), depressive disorder (persistent feeling of sadness), and Alzheimer (slowly destroys memory).The history and physical completed by the physician on September 27, 2025, indicated Resident 7 does not have the capacity to understand and make decisions with a BIMS (measurement of cognitive function 0 to 15) score of 5 (higher the score higher the cognitive function).The physician order dated September 6, 2024, indicated .psychology consult, treatment, and follow up.The facility could not provide documented evidence Resident 7 received a psychology evaluation as ordered by the physician.2e.On July 30, 2025, Resident 8's medical record was reviewed.The admission record indicated Resident 8 was admitted to the facility on [DATE], with the diagnoses which included Bipolar (manic and depressive episodes), depression (persistent feeling of sadness), history of suicidal behavior (thinking, considering, or planning suicide), psychoactive substance abuse (chemical changes to mood, cognition, and behavior);The history and physical completed by the physician on September 12, 2024, indicated Resident 8 has the capacity to understand and make decisions;The physician order dated November 8, 2024, indicated .psychology consult and follow up treatment.The care plan dated June 16, 2025, indicated the following: .Focus.resident diagnosis psychosis.Goal.resident will note decreased psychotic features.Intervention.psychiatry/psychology evaluation with treatment and follow up.Focus.resident uses psychotropic medication.Intervention.behavioral management program.Focus.resident is a long-term stay with no discharge plan.Goal.resident will receive appropriate care to meet needs daily.Intervention.assess and provide residents' psychosocial.needs.-The psychiatry note indicated the following dated May 17, 2025, indicated .continue to implement .Supportive Therapy.The facility could not provide documented evidence Resident 8 received a psychology evaluation as ordered by the physician, behavioral management as indicated in Resident 8's care plan, and Supportive Therapy as indicated in the psychiatrist note.2f.On July 30, 2025, Resident 9's medical record was reviewed.The admission record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), major depressive disorder (persistent feeling of sadness), and auditory hallucinations (perception of something not present),suicidal ideations (thinking, considering, or planning suicide), anxiety disorder (feeling nervousness), cannabis dependency (need of marijuana), alcohol abuse (need of alcohol).The facility was unable to provide a history and physical for Resident 9.The physician order dated June 20, 2025, indicated the following: .psychiatry consult, treatment, follow up.psychology consult, treatment, follow up.The facility could not provide documented evidence Resident 9 received a psychology and/or psychiatrist evaluation as ordered by the physician.2g.On July 30, 2025, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included Anxiety disorder (feeling nervousness) and major depressive disorder (persistent feeling of sadness).The history and physical completed by the physician dated May 1, 2025, indicated Resident 10 had the capacity to understand and make decisions.The physician order dated May 8, 2024, indicated .psychology consult & follow up treatment.The facility could not provide documented evidence Resident 10 received a psychology evaluation as ordered by the physician.2h.On July 30, 2025, Resident 11's medical record was reviewed.The admission record indicated Resident 11 was admitted to the facility on [DATE], with the diagnoses which included Major depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness), and psychosis (loss of reality).The history and physical completed by the physician dated December 13, 2024, indicated Resident 11 had the capacity to understand and make decisions.The physician order dated December 12, 2024, indicated .psychologist consult, treatment, and follow up.The behavior management team note dated January 2025 through July 2025, indicated .medications Ativan (anti-anxiety medication).Zoloft (anti-depressant medication).behaviors.anxiety.depression.plan.refer to psychologist.The psychiatrist note dated June 5, 2025, indicated .inability to relax.continue monitoring and follow-ups.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 11 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 11 received supportive psychotherapy as indicated by the psychiatrist.2i.On July 30, 2025, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included Depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness) disorder, delusional (belief of things not true), and bipolar (manic and depressive episodes);The history and physical completed by the physician on May 19, 2025, indicated Resident 12 had the capacity to understand and make decisions;The physician order dated May 19, 2025, indicated .psychology consult, treatment, and follow up.The care plan dated July 24, 2025, indicated the following: .Focus.resident requires skilled nursing.Intervention.monitor psychosocial.refer to psychologist.Focus.psychosis.Intervention.psychiatry/psychology evaluation.-The behavior management team note dated June 4, 2025, and July 7, 2025, indicated .medications.behavioral problems.plan of action.refer to psychologist.-The psychiatrist note dated June 6, 2025, indicated .inability to sleep accompanied by angry Outbursts.continue monitoring.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 12 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 12 received supportive psychotherapy as indicated by the psychiatrist.2j.On July 30, 2025, Resident 13's medical record was reviewedThe admission record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality) and anxiety (feeling nervousness disorder) depression (persistent feeling of sadness).The history and physical completed by the physician on May 19, 2025, indicated Resident 13 had the capacity to understand and make decisions.The physician order dated June 17, 2025, indicated .psychology consult, treatment and follow up.The care plan date July 4, 2025, indicated the following: .Focus.resident is a long term stay with no discharge plan.Intervention. assess and provide resident psychosocial needs.Focus.care plan for discharge.Intervention.refer to psychologist.The psychiatrist note dated July 4, 2025, indicated .sudden anger outburst.poor impulse control.continue to monitor and follow-up.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 13 received a psychology evaluation as ordered by the physician. The facility could not provide documented evidence Resident 13 received supportive psychotherapy as indicated by the psychiatrist.2k.On July 30, 2025, Resident 14's medical record was reviewedThe admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), anxiety (feeling of nervousness), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on May 30, 2025, indicated Resident 14 had the capacity to understand and make decisions.The physician order dated May 30, 2025, indicated .psychology consult, treatment, follow up.The psychiatrist note dated June 6, 2025, indicated .exhibiting mood swings.physical aggression.continue to monitor.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 14 received a psychology evaluation as ordered by the physician. The facility could not provide documented evidence Resident 14 received supportive psychotherapy as indicated by the psychiatrist. 2l.On July 30, 2025, Resident 15's medical record was reviewed.The admission record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes) and depressive disorder (persistent feeling of sadness).The history and physical completed by the physician on October 2, 2025, indicated Resident 15 had the capacity to understand and make decisions.The physician order dated October 2, 2024, indicated .psychology consult, treatment, follow up.;The psychiatrist note dated April 1, May 5, and June 6, 2025, indicated .mood swings signs of paranoia.continue to monitor.plan.supportive psychotherapy.The behavioral management team note dated January 8, February 5, March 5, April 2, May 7, and June 4, 2025, indicated .medications.behavioral problems.plan of action.refer to psychologist.The facility could not provide documented evidence Resident 15 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 15 received supportive psychotherapy as indicated by the psychiatrist.On August 4, 2025, at 11:44 a.m., a concurrent interview and record review was conducted with the Social Worker (SW). The SW stated she is the one to schedule appointments for psychiatry and psychology evaluations and follow ups. The SW also stated she is in charge of reviewing psychiatry and psychology notes. The SW stated she is on the behavioral management team and is the one to schedule appointments for the recommendations. The SW further stated Resident 8 supportive services were not scheduled and should have been scheduled. The SW stated Resident 11 and Resident 12 psychology evaluation should have been scheduled. The SW stated the facility should have located a psychologist that accepts Medi-Cal to schedule Resident 4 and 17 psychology evaluations.On August 4, 2025, at 11:51 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated she is a part of the behavioral management team. The DON stated depending on the recommendation it can be nursing or social services who scheduled evaluations and follow up appointments. The DON stated the social service department is responsible of scheduling psychology and psychiatry evaluations. The DON stated the facility should have scheduled the psychology evaluations and that the possible outcome to the residents would be a delay in mental health care.A review of the facility policy and procedures titled Specialized Rehabilitative Services, not dated indicated .mental health services and supportive psychotherapy for mental illness.specialized rehabilitative services will be provided under the written order of a physician.the services will be provided or coordinated by qualified personnel.the care plan for individuals receiving specialized rehabilitative services will be monitored by a licensed professional.specialized rehabilitative services are considered a facility service and included within the scope of facility services. A review of the facility policy and procedures titled Social Services, not dated indicated .the facility regardless of size will provide medically related social service to each resident attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.any need for medically related social services will be documented in the medical record.the social worker or social worker designee will pursue the provision of any identified need for medically related social services of the resident.services to meet resident's needs may include.providing or arranging for needed mental and psychosocial counseling services.the resident's plan of care will reflect any ongoing medically related social services needs and how these needs are being addressed.the social worker or social worker designee will monitor the residents progress in improving physical, mental, and psychosocial functioning.

Based on observation, interview and record review, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours to the State Survey Agency (SSA) and to the Long-Term care (LTC) Ombudsman for one of three sampled residents (Resident 1). The facility was made aware of Resident 1 ' s right arm fracture on May 23, 2025. This failure had the potential for state agencies and the LTC Ombudsman not to be able to advocate for the residents in protecting their rights to be free from abuse and neglect. Findings: On June 9, 2025, at 10:35 a.m., during a concurrent observation and interview, Resident 1 was observed with right arm in a blue sling with right hand contracted. Resident 1 was attempted to be interviewed but only responded with a mumble. A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was transferred to the hospital on May 23, 2025, for a fracture on the right arm. A review of Resident 1 ' s nursing notes dated May 23, 2025, indicated, .Relayed x-ray result to Right forearm w/ (with) conclusion: Osteopenia w/ flexion contracture, displaced fracture of Olecranon w/ margins appearing chronic .ordered to Transfer to (name of hospital) for further evaluation and treatment . A review of Resident 1 ' s progress notes, did not indicate documentation of how the patient sustained the right arm fracture. On June 9, 2025, at 12:34 p.m., during a concurrent interview and record review with the Assistant Director of Nursing (ADON), the ADON verified Resident 1 was transferred to the hospital for a higher level of care on May 23, 2025, and the Ombudsman was notified only of the transfer via fax transmittal on May 23, 2025. The ADON verified there was no documented evidence the facility notified the Ombudsman and SSA of Resident 1 ' s fracture of unknown origin. The ADON further stated there was no documented evidence the facility performed an investigation of Resident 1 ' s fracture of unknown origin. The ADON stated the Ombudsman and SSA should have been notified of Resident 1 ' s fracture of unknown origin and the facility should have investigated of Resident 1 ' s fracture of unknown origin. On June 9, 2025, at 1:34 p.m., during a concurrent interview and record review with the Social Worker (SW), the SW verified that the transfer notice for a higher level of care for Resident 1 was dated May 23, 2025, and only a copy of the transfer notice was sent to the Ombudsman on May 23, 2025. The SW verified there was no documented evidence the facility reported Resident 1 ' s fracture of unknown origin to the Ombudsman and CDPH. The SW further stated the Ombudsman and CDPH should have been notified of Resident 1 ' s fracture of unknow origin. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, not dated, indicated .Identification of Abuse, Neglect .The facility will consider factors indicating possible abuse, neglect of residents .the following possible indicators .physical injury of resident unknown source .an investigation is immediately warranted .once the resident is cared for and initial reporting has occurred an investigation should be conducted .anyone in the facility can report suspected abuse .When abuse, neglect is suspected the licensed should respond to resident .notify Director of Nursing .initiate an investigation immediately .notify physician .contact the State Agency and the local Ombudsman office to report the alleged abuse .

Based on observation, interview, and record review, the facility failed to investigate what could have caused one of three sampled residents ' (Resident 1) right arm fracture. The facility did not witness the source of the fracture, and the resident could not explain the source of the right arm fracture. This failure had the potential to delay provision of corrective action to ensure Resident 1 is free from potential abuse, neglect, and mistreatment. Findings: On June 9, 2025, at 10:35 a.m., during a concurrent observation and interview, Resident 1 was observed with right arm in a blue sling with right hand contracted. Resident 1 was attempted to be interviewed but only responded with a mumble. A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was transferred to the general acute care hospital (GACH) on May 23, 2025, for a fracture of right arm. A review of Resident 1 ' s nursing notes dated May 23, 2025, indicated, .Relayed x-ray result to Right forearm w/ (with) conclusion: Osteopenia w/ flexion contracture, displaced fracture of Olecranon w/ margins appearing chronic .ordered to Transfer to (name of hospital) for further evaluation and treatment . A review of Resident 1 ' s progress notes, did not indicate documentation of how the patient sustained the right arm fracture. A review of Resident 1 ' s medical record indicated no documented evidence the facility investigated Resident 1 ' s injury of unknown origin on the right arm. On June 9, 2025, at 12:34 p.m., during a concurrent interview and record review with the Assistant Director of Nursing (ADON), the ADON verified Resident 1 was transferred to the GACH for a higher level of care on May 23, 2025. The ADON verified there was no documented evidence the facility performed an investigation of Resident 1 ' s fracture of the right arm, which was of unknown origin. The ADON stated the facility should have investigated Resident 1 ' s fracture of the right arm. On June 9, 2025, at 1:34 p.m., during a concurrent interview and record review with the Social Worker (SW), the SW verified that the transfer notice for a higher level of care for Resident 1 was dated May 23, 2025. The SW verified there was no documented evidence the facility investigated Resident 1 ' s fracture of unknown origin. The SW further stated the facility should have been investigated Resident 1 ' s fracture of unknown origin. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, undated, indicated .Identification of Abuse, Neglect .The facility will consider factors indicating possible abuse, neglect of residents .the following possible indicators .physical injury of resident unknown source .an investigation is immediately warranted .once the resident is cared for and initial reporting has occurred an investigation should be conducted .anyone in the facility can report suspected abuse .When abuse, neglect is suspected the licensed should respond to resident .notify Director of Nursing .initiate an investigation immediately .notify physician .contact the State Agency and the local Ombudsman office to report the alleged abuse .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #24) of 1 sampled resident reviewed for vision/hearing was provided their hearing aid when they were received in the facility. Findings included: An undated facility policy titled, Hearing and Vision Services, indicated, 3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources, for the provision of the vision and hearing services the resident needs. An Admission Record revealed the facility admitted Resident #24 on 02/21/200605/13/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #24 had minimal difficulty with hearing and a hearing aid or other hearing appliance was not used. Resident #24's Order Summary Report which contained active orders as of 12/11/2024, revealed an order dated 05/13/2024, for an audiology consultation and follow-up treatment annually and as needed. Resident #24's audiogram (a graph that visually represented the results of a hearing test) dated 06/11/2024, revealed the resident had hearing loss significant enough to qualify for hearing aids and the provider would start the process of obtaining the resident's hearing aids. Resident #24's consultation report dated 08/20/2024, indicated the resident was seen for diminished hearing, stuffy ears, nasal congestion, throat congestion/clearing. The consultation report revealed, the resident needed hearing aids and had not received them. A Hearing Aid Delivery Report dated 10/08/2024, revealed Resident #24's hearing aid was delivered to the facility and the Social Services Designee (SSD) signed the form to acknowledge receipt of the resident's hearing aids. During a concurrent observation and interview on 12/09/2024 at 9:45 AM, Resident #24 was in a wheelchair, and the resident did not have hearing aids in their ear. Resident #24 stated they did not get their hearing aids. A sign posted at the bedside of the resident directed staff to please charge the resident's hearing aids overnight. During a concurrent observation and interview on 12/09/2024 at 1:35 PM, the surveyor noted Resident #24 was without their hearing aids. Resident #24 stated they still did not have their hearing aids and that maybe she (the SSD) forgot. During an observation on 12/10/2024 at 11:08 AM and 1:23 PM, Resident #24 was not wearing hearing aids. On 12/11/2024 at 1:41 PM, Certified Nursing Assistant (CNA) #2 stated Resident #24 was hard of hearing, but did not wear hearing aids. On 12/11/2024 at 1:44 PM, CNA #3 stated Resident #24 had hearing impairment and did not have hearing aids. On 12/11/2024 at 1:28 PM, Licensed Vocational Nurse (LVN) #1 stated Resident #24 did not wear hearing aids. When asked about the posting at the bedside of the resident related to charging the resident's hearing aids, LVN #1 stated the hearing aids may be at the nursing station and asked for more time to investigate. On 12/11/2024 at 1:34 PM, LVN #1 brought a pair of new hearing aids labeled with Resident #24's name and room number to the surveyor. LVN #1 stated he found the resident's hearing aids, but did not know how long they had been in the facility. On 12/11/2024 at 2:11 PM, the SSD stated they oversaw residents' hearing services. The SSD acknowledged signing for Resident #24's hearing aids on 10/08/2024. Per the SSD, she failed to alert the nursing department the resident's hearing aids had arrived and that was an error on her part. On 12/11/2024 at 2:32 PM, the Director of Nurses (DON) stated the SSD did not communicate receipt of Resident #24's hearing aids to the facility to ensure the Medical Director and the resident's responsible party were notified, and to ensure that nursing staff were educated on assisting the resident with their hearing aids and caring for the hearing aids. The DON stated the expectation was for the SSD to make the interdisciplinary team (IDT) aware of ancillary services, such as hearing aids, to ensure the residents wore them to improve their quality of life.

Based on observation, interview, and record review, the facility failed to ensure: 1. Residents with physician's orders for WanderGuards (a device used to protect residents from unsafe wandering and elopement) were checked by the licensed staff to ensure residents were wearing the device at all times for two of four residents reviewed (Resident 2 and 4) ; and 2. The WanderGuards were tested and monitored for the proper functioning for four of four residents reviewed (Residents 1, 2, 3, and 4). This failed practice increase the potential for residents identified as an elopement risk to leave the facility without staff knowledge which placed residents' safety at risk. Findings: 1 a. On February 8, 2022, at 1:24 p.m., a concurrent observation and interview was conducted with the Assistant Director of Nursing (ADON) for Resident 4. Resident 4 was observed awake sitting in his wheelchair in the hallway. Resident 4 was not interviewable and was observed not wearing a WanderGuard bracelet. The ADON stated Resident 4 should have been wearing a WanderGuard bracelet all the time. He stated he was not aware Resident 4 did not have the WanderGuard bracelet on. On February 8, 2022, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included schizoprenia (a mental illness). Resident 4's History and Physical (H&P) dated September 29, 2021, indicated Resident 4 did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated September 29, 2019, indicated Resident 4 was at risk for wandering and elopement. The physician's summary orders for the month of February 2022, indicated Resident 4 had an order to APPLY WANDERGUARD DUE TO RISK OF WANDERING/ELOPEMENT . dated November 15, 2019. The care plan dated October 3, 2020, indicated Resident 4 was at risk for elopement secondary to his diagnoses, needs WanderGuard alarm, and Use wanderguard alarm as per protocol . The nurse's notes from September 21, 2021 to January 29, 2022, did not indicate Resident 4 was checked by licensed staff on each shift to verify if Resident 4 was wearing his WanderGuard bracelet. b. On February 8, 2022, at 1:32 p.m., a concurrent observation and interview was conducted with the ADON for Resident 2. Resident 2 was observed sitting on the bench outside the facility's smoking patio. Resident 2 was alert and able to verbalize her needs. Resident was observed not wearing a WanderGuard bracelet. Resident 2 stated she never had a bracelet. The ADON stated Resident 2 should have been wearing a WanderGuard bracelet all the time. He stated he was not aware Resident 2 did not have the WanderGuard bracelet on. On February 8, 2022, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)]. Resident 2's H&P dated January 10, 2022, indicated she did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated January 10, 2022, indicated Resident 2 was at risk for wandering and may use WanderGuard as ordered. The physician's order dated January 10, 2022, indicated .May use wanderguard . The care plan dated January 10, 2022, indicated Resident 2 was at risk for elopement secondary to [CONDITION(S)], and may use the WanderGuard. The nurse's notes from January 10, 2022 to February 7, 2022, did not indicate Resident 2 was checked by the licensed staff on each shift to verify if Resident 2 was wearing her WanderGuard bracelet. On February 8, 2022, at 1:44 p.m., the ADON was interviewed. The ADON stated the licensed nurses on every shift were responsible for checking the residents with physician's orders for WanderGuards. 2. On February 8, 2022, at 1:44 p.m., a concurrent interview and record review was conducted with the ADON for Residents 1, 2, 3, and 4. a. Resident 1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory). Resident 1's History and Physical (H&P) dated August 23, 2021, indicated Resident 1 did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated August 23, 2021, indicated Resident 1 was at risk for elopement and wandering due to Alzheimer's disease. The physician's order dated August 23, 2021, indicated WanderGuard use due to risk for elopement secondary to diagnosis of Alzheimer's disease. The care plan dated August 23, 2021, indicated Resident 1 was at risk for elopement and use of WanderGuard as ordered by the physician. There was no documented evidence in Resident 1's record to indicate the WanderGuard was monitored and tested since August 23, 2021. b. Resident 2 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] (a mental illness). Resident 2's H&P dated January 10, 2022, indicated Resident 2, did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated January 10, 2022, indicated Resident 2 was at risk for wandering and may use WanderGuard as ordered. The physician's order dated January 10, 2022, indicated the use of WanderGuard. The care plan dated January 10, 2022, indicated Resident 2 was at risk for elopement secondary to [CONDITION(S)], and the use of WanderGuard. There was no documented evidence in Resident 2's record to indicate the WanderGuard was monitored and tested since January 10, 2022. c. Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). Resident 3's H&P dated January 25, 2021, indicated Resident 3 did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated January 25, 2021, indicated Resident 3 was at risk for wandering. The physician's order dated January 25, 2021, indicated to apply WanderGuard due to risk of wandering and elopement. The care plan dated January 25, 2021, indicated Resident 3 was at risk for elopement and the use of WanderGuard. There was no documented evidence in Resident 3's record to indicate the WanderGuard was monitored and tested since January 25, 2021. d. Resident 4 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)]. Resident 4 's H&P dated September 29, 2021, indicated Resident 4 did not have the capacity to understand and make decisions. The document titled, INITIAL WANDERING ASSESSMENT, dated September 29, 2019, indicated Resident 4 was at risk for wandering. The assessment updated on November 15, 2019, indicated to apply WanderGuard. The physician's order dated November 15, 2019, indicated to apply WanderGuard due to risk of wandering and elopement. The care plan revised on October 3, 2020, indicated Resident 4 was at risk for elopement and the use of WanderGuard. There was no documented evidence in Resident 4's record to indicate the Wanderguard was monitored and tested since November 15, 2021. On February 8, 2022, at 1:44 p.m., the ADON stated Residents 1, 2, 3, and 4 's WanderGuards were not monitored by licensed staff since the order dates of the physicians. He stated the licensed staff should have tested the WanderGuards by bringing the residents close to the nearest exit door with sensors. He stated if the exit door did not alarm, the licensed staff should check the WanderGuard's battery to see if the battery needs to be replaced. The ADON was not able to provide documented evidence the WanderGuards ordered for Residents 1, 2, 3, and 4, were monitored and tested by the facility. The facility's policy and procedure titled, WanderGuard - Equipment Monitoring, dated 2021, was reviewed. The policy indicated, .The facility will strive to prevent unsafe wandering with frequent monitoring of the equipment that alerts staff to potential elopement by residents .The Nursing staff will use a list of residents using the WanderGuard as per physician's orders to inspect each WanderGuard/Bracelet as working properly. Malfunctioning equipment will be replaced immediately with properly functioning equipment .

Based on interview and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), was free from sexual abuse. This failure occurred when the facility assistant maintenance worker (AMW) was observed by facility staff engaging in sexual activity with the resident in the maintenance shed/workshop on the facility property. Findings: On May 17, 2022, at 10:25 a.m., an unannounced visit was conducted at the facility for an investigation regarding resident abuse. On May 17, 2022, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's face sheet indicated, .Marital Status: Never married . Review of Resident 1's Minimal Data Set (MDS-an assessment tool used to provide continuity of care) section C Cognitive Patterns, indicated Resident 1's Brief Interview for Mental Status (BIMS) was a score of 10. [Score of 8-12 suggests moderately impaired function]. Review of Resident 1's Behavior Management Team, note dated May 4, 2022, indicated, .She can make simple needs known and carry on a simple conversation . Review of Resident 1's Licensed Personnel Progress Notes, dated May 14, 2022, at 1:30 p.m., indicated, .Resident with episode of experienced intimacy; she is alert, oriented x2 (times two-person and place), with periods of confusion . Review of the written Certified Nursing Assistant (CNA) 1 statement, dated May 14, 2022, indicated, .Residen (sic) approachd (sic) me end (sic) insisted to go in the back (workshop/shed) so I went their (sic) the door of the shed was close but not lock so I open the door and I saw (AMW) end (sic) Resident 1 both pants down and he is behind of (Resident 1) they was (sic) having sex. And as soon as I saw them they stoped (sic) end (sic) tried to grab my hand end (sic) he said Don't say anything . Review of the facility typed interview with the AMW, dated May 14, 2022, at 6:30 p.m., indicated, .(AMW) claimed (Resident 1) came to him in the shed and asked for cigarettes. He claims that he closed the door of the shed with him and (Resident 1) inside. (AWM) also confirmed that he had sexual intercourse with (Resident 1) in the shed . Review of the written Registered Nurse (RN) 1 statement dated May 14, 2022, at 1:30 p.m., indicated, .CNA reported to undersigned re: (regarding) what she saw/witnessed @ (at) the back shed/workshop: Per CNA the staff maintenance & (and) resident (Resident 1) inside the shed, both pants down, staff behind the resident (having sex). She turned her back right away & staff followed her & tried to grab her hand & said Don't say anything .Brought the resident to her room, assessed & interviewed her. Resident is alert, oriented x 2 with periods of confusion .Asked resident if someone touched her inappropriately had contact without her consent, she said No, I'm okay. I'm fine. Per resident no one hurt her, no one touched her. Resident kept saying I'm okay, I'm fine . Review of the written statement from the Director of Nursing (DON) dated May 16, 2022, at 1:32 p.m., indicated, .Met with (Resident 1) .followed up how her weekend was and she said, I'm happy, I'm fine, .Nothing really happened, I'm here .I know what's going on . On May 17, 2022, at 10:50 a.m., Resident 1 was observed lying on her bed, dressed. During a concurrent interview Resident 1 stated the AMW asked her if she wanted a cigarette. She stated he met her at the shed and told her to remove her top to get the cigarette. Resident 1 stated she refused and left. Resident 1 denied she had sexual intercourse with the AMW and stated she only had sex with her husband. Resident 1 stated the AMW did not touch her and Nothing happened. Resident 1 was questioned again regarding the incident on Saturday, Resident 1 stated He asked me to take off my top but I refused and left. On May 17, 2022, at 11:18 a.m., an interview was conducted with housekeeper (HSK) 1. HSK 1 stated Resident 1 was like a little girl able to make her needs known but not capable of making the decision regarding sexual intercourse. She stated she saw CNA 1 and CNA 2 coming in from the shed. HSK 1 stated CNA 1 was obviously upset and CNA 2 was yelling at the AMW Get out of here! She stated Resident 1 did not appear in distress and was acting like nothing happened. On May 17, 2022, at 12 p.m., an interview was conducted with CNA 2. CNA 2 stated CNA 1 came to her saying there was an emergency. She stated the AMW was following CNA 1 around saying Don't say anything. CNA 2 stated CNA 1 told her about the incident and they notified RN 1. CNA 2 stated Resident 1 would do just about anything to get a cigarette, and that Resident 1 would look for her husband but she was not married. On May 17, 2022, at 1:30 p.m., an interview was conducted with the DON. The DON stated Resident 1 had a BIMS score of 10, moderately impaired, but was able to express her needs. She stated Resident 1 denied the incident, even though CNA 1 directly observed the incident. The DON stated Resident 1's physician was notified and he ordered Resident 1 to go to the emergency room for evaluation but Resident 1 refused. She stated the facility needed to respect the resident's wishes for sexual intercourse but staff should not engage in sexual activities with the residents. The DON stated Resident 1 did not appear in distress, and a psychologist consult was ordered. On May 17, 2022, at 2:05 p.m., an interview was conducted with the Administrator (Adm). The Adm stated he received a call from the facility on May 14, 2022, about 1:30 p.m., that Resident 1 was found having sexual intercourse with the AMW in the shed. He stated the AMW was immediately sent home and was terminated. The Adm stated he and the Director of Staff Development (DSD) spoke with Resident 1 regarding the incident. He stated Resident 1 denied having intercourse with the AMW. The Adm stated after talking with Resident 1, she stated the AMW was a nice guy who offered her cigarettes and nothing happened without her consent. The Adm stated Resident 1 had a BIMS of 10 and was moderately impaired in her decision making. On May 17, 2022, at 2:30 p.m., an interview was conducted with the DSD. The DSD stated she came to the facility after the Adm had called her. She stated Resident 1 denied having sexual intercourse with the AMW and stated Nothing happened, just asked for a cigarette, nothing happened. The DSD stated after questioning Resident 1 she became upset and said it was ok because he was a good friend. On May 18, 2022, at 10:10 a.m., a telephone interview was conducted with CNA 1. CNA 1 stated a resident told her to go outside and check the shed. She stated she went outside and saw the shed door was closed but not locked. CNA 1 stated that when she opened the door she saw Resident 1 with her pants down, bent over the table, and the AMW was behind her with his pants down, having sex. CNA 1 stated they stopped when she walked in. She stated she ran away and the AMW pulled up his pants and ran after her. CNA 1 stated the AMW grabbed her arm and said, Don't say anything. CNA 1 stated she was scared because the AMW kept grabbing her arm and telling her not to talk. She stated CNA 2 yelled at the AMW and told him to leave her alone. CNA 1 stated she was not sure what happened with Resident 1 after the incident, she stated she did not provide care for Resident 1. On May 18, 2022, at 10:25 a.m., a telephone interview was conducted with RN 1. RN 1 stated CNA 1 came to her about 1-1:30 p.m., and told her Resident 1 was having sexual intercourse with the AMW in the shed outside. She stated CNA 1 told her the AMW told her not to say anything. RN 1 stated she called the Adm and DON and went to assess Resident 1. RN 1 stated Resident 1 denied anything happened. RN 1 stated she questioned Resident 1 if someone touched her or hurt her and Resident 1 stated No, I'm ok, I'm fine, RN 1 stated she notified the physician who recommended transfer to the emergency room for evaluation, but Resident 1 refused to go. RN 1 stated Resident 1 continued to deny having sexual intercourse with the AMW saying He's my good friend, he gave me a cigarette, no, nothing happened. RN 1 stated Resident 1 never admitted to having sexual intercourse with the AMW. RN 1 stated she spoke with Resident 1 the following day (May 15) and Resident 1 continued to state she was ok and that it was ok, he was my good friend and my husband before. RN 1 stated Resident 1 may not have capacity to consent to sexual intercourse based on her belief the AWM was her husband previously. Review of the facility policy titled Abuse, Neglect and Exploitation undated, indicated, .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff .Sexual Abuse is non-consensual sexual contact of any type with a resident .Investigation of Alleged Abuse .When suspicion of abuse .occur, an investigation is immediately warranted .If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person .gather how he/she believes the resident would react to the incident .

Based on interview and record review, the facility failed to ensure identification and reporting of reasonable suspicion of crime to the local law enforcement and the State Survey Agency was conducted within the mandated timeframe stipulated by federal regulations, when Certified Nursing Assistant (CNA) 1 observed the facility assistant maintenance worker (AMW) having sexual intercourse with Resident 1. This failure increased the potential to result in delayed protection of the residents, delayed independent investigation by the local law enforcement and the state agencies of the criminal activities, and delayed implementation of enforcement and corrective actions. Findings: On May 17, 2022, at 10:25 a.m., an unannounced visit was conducted at the facility for an investigation regarding resident abuse. On May 17, 2022, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's face sheet indicated, .Marital Status: Never married . Review of Resident 1's Minimal Data Set (MDS-an assessment tool used to provide continuity of care) section C Cognitive Patterns, indicated Resident 1's Brief Interview for Mental Status (BIMS) was a score of 10. [Score of 8-12 suggests moderately impaired function]. Review of Resident 1's Behavior Management Team, note dated May 4, 2022, indicated, .She can make simple needs known and carry on a simple conversation . Review of Resident 1's Licensed Personnel Progress Notes, dated May 14, 2022, at 1:30 p.m., indicated, .Resident with episode of experienced intimacy; she is alert, oriented x2 (times two-person and place), with periods of confusion . Review of the written Certified Nursing Assistant (CNA) 1 statement, dated May 14, 2022, indicated, .Residen (sic) approachd (sic) me end (sic) insisted to go in the back (workshop/shed) so I went their (sic) the door of the shed was close but not lock so I open the door and I saw (AMW) end (sic) Resident 1 both pants down and he is behind of (Resident 1) they was (sic) having sex. And as soon as I saw them they stoped (sic) end (sic) tried to grab my hand end (sic) he said Don't say anything . Review of the facility typed interview with the AMW, dated May 14, 2022, at 6:30 p.m., indicated, .(AMW) claimed (Resident 1) came to him in the shed and asked for cigarettes. He claims that he closed the door of the shed with him and (Resident 1) inside. (AWM) also confirmed that he had sexual intercourse with (Resident 1) in the shed . Review of the written Registered Nurse (RN) 1 statement dated May 14, 2022, at 1:30 p.m., indicated, .CNA reported to undersigned re: (regarding) what she saw/witnessed @ (at) the back shed/workshop: Per CNA the staff maintenance & (and) resident (Resident 1) inside the shed, both pants down, staff behind the resident (having sex). She turned her back right away & staff followed her & tried to grab her hand & said Don't say anything .Brought the resident to her room, assessed & interviewed her. Resident is alert, oriented x 2 with periods of confusion .Asked resident if someone touched her inappropriately had contact without her consent, she said No, I'm okay. I'm fine. Per resident no one hurt her, no one touched her. Resident kept saying I'm okay, I'm fine . Review of the written statement from the Director of Nursing (DON) dated May 16, 2022, at 1:32 p.m., indicated, .Met with (Resident 1) .followed up how her weekend was and she said, I'm happy, I'm fine, .Nothing really happened, I'm here .I know what's going on . On May 17, 2022, at 10:50 a.m., Resident 1 was observed lying on her bed, dressed. During a concurrent interview Resident 1 stated the AMW asked her if she wanted a cigarette. She stated he met her at the shed and told her to remove her top to get the cigarette. Resident 1 stated she refused and left. Resident 1 denied she had sexual intercourse with the AMW and stated she only had sex with her husband. Resident 1 stated the AMW did not touch her and Nothing happened. Resident 1 was questioned again regarding the incident on Saturday, Resident 1 stated He asked me to take off my top but I refused and left. On May 17, 2022, at 11:18 a.m., an interview was conducted with housekeeper (HSK) 1. HSK 1 stated Resident 1 was like a little girl able to make her needs known, but not capable of making the decision regarding sexual intercourse. She stated she saw CNA 1 and CNA 2 coming in from the shed. HSK 1 stated CNA 1 was obviously upset and CNA 2 was yelling at the AMW Get out of here! She stated Resident 1 did not appear in distress and was acting like nothing happened. On May 17, 2022, at 12 p.m., an interview was conducted with CNA 2. CNA 2 stated CNA 1 came to her saying there was an emergency. She stated the AMW was following CNA 1 around saying Don't say anything. CNA 2 stated CNA 1 told her about the incident and they notified RN 1. CNA 2 stated Resident 1 would do just about anything to get a cigarette, and that Resident 1 would look for her husband but she was not married. On May 17, 2022, at 1:30 p.m., an interview was conducted with the DON. The DON stated Resident 1 had a BIMS score of 10, moderately impaired, but was able to express her needs. She stated Resident 1 denied the incident, even though CNA 1 directly observed the incident. The DON stated Resident 1's physician was notified and he ordered Resident 1 to go to the emergency room for evaluation but Resident 1 refused. She stated the facility needed to respect the resident's wishes for sexual intercourse but staff should not engage in sexual activities with the residents. The DON stated Resident 1 did not appear in distress, and a psychologist consult was ordered. The DON stated the facility did not contact local law enforcement after the incident. On May 17, 2022, at 2:05 p.m., an interview was conducted with the Administrator (Adm). The Adm stated he received a call from the facility on May 14, 2022, about 1:30 p.m., that Resident 1 was found having sexual intercourse with the AMW in the shed. He stated the AMW was immediately sent home and was terminated. The Adm stated he and the Director of Staff Development (DSD) spoke with Resident 1 regarding the incident. He stated Resident 1 denied having intercourse with the AMW. The Adm stated after talking with Resident 1, she stated the AMW was a nice guy who offered her cigarettes and nothing happened without her consent. The Adm stated Resident 1 had a BIMS of 10 and was moderately impaired in her decision making. The Adm stated the facility did not contact the local police after the incident. On May 17, 2022, at 2:30 p.m., an interview was conducted with the DSD. The DSD stated she came to the facility after the Adm called her. She stated Resident 1 denied having sexual intercourse with the AMW and stated Nothing happened, just asked him for a cigarette, nothing happened. The DSD stated after questioning Resident 1 she became upset and said it was ok because he was a good friend. On May 18, 2022, at 10:10 a.m., a telephone interview was conducted with CNA 1. CNA 1 stated a resident told her to go outside and check the shed. She stated she went outside and saw the shed door was closed but not locked. CNA 1 stated she opened the shed door. CNA 1 stated she saw Resident 1 with her pants down, bent over the table, and the AMW was behind her with his pants down, having sex. CNA 1 stated they stopped when she walked in. She stated she ran away and the AMW pulled up his pants and ran after her. CNA 1 stated the AMW grabbed her arm and said, Don't say anything. CNA 1 stated she was scared because the AMW kept grabbing her arm and telling her not to talk. She stated CNA 2 yelled at the AMW and told him to leave her alone. CNA 1 stated she was not sure what happened with Resident 1 after the incident, she stated she did not provide care for Resident 1. CNA 1 stated the incident was not reported to the police, but should have been. On May 18, 2022, at 10:25 a.m., a telephone interview was conducted with RN 1. RN 1 stated CNA 1 came to her about 1-1:30 p.m., and told her Resident 1 was having sexual intercourse with the AMW in the shed outside. She stated CNA 1 told her the AMW told her not to say anything. RN 1 stated she called the Adm and DON and went to assess Resident 1. RN 1 stated Resident 1 denied anything happened. RN 1 stated she questioned Resident 1 if someone touched her or hurt her and Resident 1 stated No, I'm ok, I'm fine RN 1 stated she notified the physician who recommended transfer to the emergency room for evaluation, but Resident 1 refused to go. RN 1 stated Resident 1 continued to deny having sexual intercourse with the AMW saying He's my good friend, he gave me a cigarette, no, nothing happened. RN 1 stated Resident 1 never admitted to having sexual intercourse with the AMW. RN 1 stated the local law enforcement were not called. RN 1 stated she spoke with Resident 1 the following day (May 15) and Resident 1 continued to state she was ok and that it was ok, he was my good friend and my husband before. RN 1 stated Resident 1 may not have capacity to consent to sexual intercourse based on her belief the AWM was her husband previously. On May 19, 2022, at 4:20 p.m., a telephone call was received from the DON. The DON stated local law enforcement was notified May 17, 2022, at 3:15 p.m., (5 days after the incident occurred) regarding the incident with Resident 1 and CNA 1's concerns for her personnel safety. Review of the facility policy titled Abuse, Neglect and Exploitation undated, indicated, .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff .Sexual Abuse is non-consensual sexual contact of any type with a resident .Investigation of Alleged Abuse .When suspicion of abuse .occur, an investigation is immediately warranted .If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person .gather how he/she believes the resident would react to the incident .If a crime, or suspicion of a crime has occurred, notify the local law enforcement .

Based on observation, interview and record review, the facility failed to ensure one out of 95 residents (Resident 75) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant severe weight loss of 14 lbs (pounds, a unit of measurement), 6.7 percent (%) from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the Interdisciplinary Team (IDT) which may include, Physician (MD), Registered Nurse (RN), Dietary Manager/Dietitian (Registered Dietitian, RD), Social Services, Activity Director/Coordinator .weight variance meeting; nor were interventions implemented to prevent further significant severe weight loss, and 2. There was no documented order for a Physician prescribed weight loss regimen. These failures contributed to on-going unaddressed significant severe weight loss in one, three, and six-month time frames which posed a threat for further medical complications. Findings: A record review for Resident 75 was conducted beginning March 15, 2022. Resident 75 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] lenses cannot correct the vision). Resident 75 was self-responsible. The most recent Minimum Data Set (MDS, a resident assessment tool), dated February 4, 2022, showed Resident 75 had a BIMS (brief interview of mental status) score of six which indicated she had moderate cognitive impairment. A review of the facility document titled, history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Section K (Swallowing/Nutritional Status) of the annual MDS assessment, dated November 5, 2021, indicated Resident 75's height was 68 inches () and weight was 194 lbs. Review of a quarterly MDS assessment, dated February 4, 2022, indicated Resident 75's height was 68 and weight was 185 lbs. Both MDS assessments indicated Resident 75 had an unplanned significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months. The MDS assessments further indicated Resident 75 was not on a physician-prescribed weight loss regimen. A review of the facility document titled, Monthly Weight Record, for the year of 2021 and 2022, indicated the following weights for Resident 75: 8/23/21: 210 lbs 9/14/21: 210 lbs 10/14/21: 208 lbs 11/11/21: 194 lbs (a significant severe weight loss of 14 lbs, 6.7% from 10/14/21) 12/10/21: 193 lbs (a significant severe weight loss of 17 lbs, 8% from 9/14/21 to 12/10/21) 1/18/22: 190 lbs (a significant severe weight loss of 18 lbs, 8.6% from 10/14/21 to 1/18/22) 2/8/22: 185 lbs (a significant severe weight loss of 25 lbs, 11.9% from 8/23/21 to 2/8/22) 3/2/22: 176 lbs (a significant severe weight loss of 34 lbs 16.2% from 9/14/21 to 3/2/22) A review of the monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes indicated Resident 75 did not have a recent change in condition, Resident 75's appetite was fair, and to continue skilled nursing care. The significant severe weight loss of 14 lbs, 6.7 % from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On March 16, 2022, at 12:29 p.m., Resident 75's lunch meal observation and a concurrent interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated Resident 75's meal intake average was about 50% but depended on her mood. CNA 3 showed the finished lunch meal tray and stated Resident 75 ate about 50-75% of her meal. CNA 3 further stated Resident 75 sometimes asked for snacks and specific food, which the CNA 3 would give Resident 75. 1. On March 16, 2022, at 3:34 p.m., an interview and a concurrent review of Resident 75's monthly weight record was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed the documented weights from August 23, 2021 to March 2, 2022 on Resident 75's monthly weight record. LVN 1 stated she would be concerned the 14 lbs weight loss from October 14, 2021 to November 11, 2021, and the 9 lbs weight loss from February 8, 2022 to March 2, 2022. LVN 1 acknowledged Resident 75 had a 34 lbs weight loss in a six-month time frame from September 14, 2021 to March 2, 2022. LVN 1 further stated gradual weight loss was fine since Resident 75 was over her Ideal body weight range (IBWR). When asked if the 34 lbs weight loss from September 14, 2021 to March 2, 2022, was significant, LVN 1 stated she was not sure if the weight loss was significant. LVN 1 stated all significant weight changes were discussed in the weekly IDT weight variance meeting. When asked for documentation of the IDT weight variance meeting addressing the significant severe weight losses from August 23, 2021 to March 2, 2022, the LVN was unable to confirm documentation in Resident 75's medical record. On March 17, 2022, at 8:14 a.m. an interview was conducted with RN 3. RN 3 confirmed all significant weight changes should be discussed in the IDT weight variance meeting. On March 17, 2022, at 10:00 a.m., an interview and concurrent record review for Resident 75 was conducted with the Dietary Supervisor (DS). The DS stated Resident 75's mental status was about the same as the previous admission. Resident 75 had verbalized she wanted to lose weight on her previous admission. The DS stated Resident 75 did not verbalize she wanted to lose weight or set any weight goal during the present admission because she was not able to answer those questions. The DS stated on the readmission on August 22, 2021, the RD set the goal for Resident 75 to have safe weight loss; one to two lbs per month if medically feasible due to the resident's weight status without any significant weight change. The RD set the target weight goal range (TWGR) of 195 to 200 lbs. The document titled Nutrition Screening and Assessment-OBRA, completed by the DS on November 4, 2021 showed, Resident 75's weight was 194 lbs in November 2021, a 14 lbs, 6.73% significant severe weight loss from October 2021 to November 2021. Resident 75's weight was 208 lbs in October 2021, a 16 lbs, 7.62% significant severe weight loss from August 2021 to November 2021. Resident 75's appetite (meal intake) was 50-74%. The section titled Comments showed, Resident 75's intake was down. The section titled Weight Note showed, resident had a weight loss of 14# (6.73%) x 30 days. Readmit weight on August 22, 2021 was 210#. She continued to be on a planned weight loss of 1-2# per month until TWGR is reached. She is currently at her TWGR. I did explain to resident we want the weight loss to be safe .Will refer to RD due to annual assessment & weight note, at her TWGR. The DS confirmed the 14 lbs, 6.73% weight loss in 30 days was a significant severe weight loss. When asked if the 14 lbs, 6.73% weight loss in 30 days was safe, the DS stated the weight loss was not safe if it was a significant weight loss. The annual nutrition review indicated the DS referred the assessment to the RD. A review of the document titled, Nutrition Screening and Assessment-OBRA, completed by the RD on November 8, 2021, under the Section titled Evaluation showed, Intake meets estimated nutrition needs at this time, Continue POC (plan of care). Under the Section titled Goal showed, TWGR 195-200 lbs, Without significant weight change, as medically feasible and Safe weight loss POC to attain TWGR as medically feasible. The DS confirmed the RD did not change the TWGR and that Resident 75 was below the TWGR. The DS confirmed the goal for Resident 75 was to not experience significant weight change and for safe weight loss to attain TWGR. A review of the document titled, Dietary Note: Weight, Quarterly completed by the DS on February 8, 2022, and electronically signed by the RD on February 10, 2022 showed, Resident 75's TWGR had been reduced to 180-184 lbs, weight was 185 lbs, 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The section titled, % Meal Intake showed 50-74% for breakfast, lunch and dinner. The section titled, Refer to RD showed, Yes, weight loss, below TWGR, D/C the planned weight loss on 2/8/22. The section titled, Meeting care plan goal, if no reason? showed, yes. The section titled, RDN Recommendations: showed, to continue POC, Res (Resident 75) is obese, has a weight loss POC (plan of care) and meeting weight goal. Monitor. A review of facility document titled, Nurse Assistant Notes: A.M. Shift and Night Shift, from October 1, 2021 to February 28, 2022, indicated there were 453 meals (Breakfast, Lunch, and dinner) served between October 1, 2021, and February 28, 2022. Resident 75 refused eight% of her meals and consumed 50% or less 41.5% of the time. The DS confirmed she tried to communicate with Resident 75 about her weight loss with the goal of one to two lbs per month but Resident 75 was not able to interview about the weight. The DS stated she suggested to discontinue the weight loss plan at that time and referred to the RD. The DS stated the RD wanted to continue the same plan of care and lowered Resident 75's target weight goal to 180-184 lbs. The DS stated she did not remember if she talked to the RD about the change of Resident 75's target weight goal, but she changed the care plan per the RD's assessment plan. The DS confirmed Resident 75 was not involved in the decision to reduce her TWGR but should have been. The DS confirmed Resident 75's significant severe weight loss of 14 lbs, 6.73% weight loss in 30 days and the significant severe weight loss of 16 lbs, 7.62% in 90 days, and 22 lbs, 11.9% weight loss in 180 days were not discussed in the IDT weight variance meeting. She stated the nurses or herself (the DS) determined which residents should be followed in the IDT weight variance meeting. She confirmed that she did not know why Resident 75 was not included in the weight variance for monitoring the significant weight loss since November 2021. A concurrent review of Resident 75's weight record dated March 2, 2022, was conducted with the DS. Resident 75 had another weight loss of nine lbs in a month, and weight loss of 34 lbs, 16.2% in six months. The DS stated the weight loss should have been discussed in the IDT weight variance meeting and she did not know why it was not discussed until March 16, 2022. The DS stated she did not attend the IDT weight variance meeting on March 16, 2022, but she signed it because the nurse went over what they discussed in the meeting. During an interview on March 17, 2022, at 11:55 a.m., RN 4 stated she entered the February 2022, and March 2022 weights on Resident 75's monthly weight record. On February 22, 2022, Resident 75's weight was 185 lbs with a weight loss of five lbs in a month. RN 4 stated she did not calculate the weight change percentage. RN 4 stated dietary was responsible to calculate the weight percentages and put in a form. RN 4 explained the process of significant weight loss if identified. She stated she would check resident's meal intake, and if the residents had any [CONDITION(S)] or medical conditions. RN 4 stated she would notify the MD and the RD. She stated for Resident 75, the February 2022, and March 2022 weights were still within Resident 75's IBWR but she still notified the MD because the weight loss was a significant change. RN 4 stated she did not document on the nursing progress notes that she notified the MD. RN 4 stated she documented NNO which meant no new order from the MD next to the weight change on the comment column in Resident 75's monthly weight record. When asked what the appropriate time frame to address a significant weight change was or if significant weight loss was considered safe, the RN 4 did not answer. During a follow up interview on March 17, 2022, at 2:11 p.m., the DS explained the process of identifying significant weight changes. The DS stated the Restorative Nurse Assistant (RNA) weighed the residents on the first of each month and took four to five days to complete. The residents' weights were entered in the computer and a form with the weight changes was generated. The DS stated she would go over the weights with the nurse, usually with the Assistant Director of Nursing (ADON). The DS stated if a resident was on a planned weight loss regimen, the facility would monitor the weight monthly. The DS stated if the resident was on a weight loss plan but had a significant weight loss, the facility would monitor weights weekly. The DS would communicate with the RD and initiate the weight loss assessment form which was emailed to the RD. She stated the RD would email the completed assessment back to the DS. During an interview and a concurrent record review with the Director of Nursing (DON) on March 17, 2022, 3:02 p.m., when asked if Resident 75's significant weight loss from November 2021 to March 2022 was discussed in the IDT weight variance meeting, the DON did not answer. The DON stated the facility should address the significant weight loss after the weights were entered in the medical record. The process would be to notify the MD and the RD. She stated then she would carry out any order from the MD. She reviewed Resident 75's record and stated there was no MD order for Resident 75's weight loss plan. The DON stated the facility should have addressed the significant weight loss on February 8, 2022, even though Resident 75 was on weight loss plan. She stated Resident 75 should be included in the IDT weight variance meeting and monitored Resident 75's weights closely. The DON acknowledged the goal from the RD was to have safe weight loss of one to two lbs per month, but she did not answer when asked if 14 lbs weight loss in a month on November 11, 2021, was consider safe. The DON stated that she would monitor weights weekly for a resident who had a significant weight loss even though he or she was on a weight loss program. A concurrent review of the facility document titled, Dietary Care Plan for Nutrition Status, for Resident 75, initiated on August 22, 2021, and updated on November 4, 2021, was conducted with the DON. The DON confirmed the plan of care did not reflect a weight loss plan until Resident 75's TWGR was reduced to 180-184 lbs on February 10, 2022. A phone interview was conducted with the RD on March 18, 2022, at 10:08 a.m. The RD confirmed significant severe weight loss parameters of 5% in a month, 7.5% in three months and 10% in six months. The RD stated she was aware of the consequences of significant severe weight loss. When asked if Resident 75's significant severe weight loss between November 2021 to March 2022 was safe the RD stated obesity was more important to deal with than significant severe weight loss. When asked if she involved Resident 75 in the weight loss plan, the RD stated she could not remember if she spoke to Resident 75. When asked if a resident on a weight loss plan should have a Physician's order, the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. A concurrent review of Resident 75's annual nutrition assessment completed on November 8, 2021, was conducted with the RD during the phone interview. The RD was asked if the significant severe weight loss of 14 lbs, 6.73% in one month was safe weight loss. The RD did not answer the question but stated the November 2021 weight was an outliner weight. The RD further stated, we cannot control how many pounds people lose and how they eat. A concurrent review of Resident 75's quarterly nutrition assessment completed on February 10, 2022, was conducted with the RD during the phone interview. Resident 75's weight in February 2022 was 185 lbs, a significant severe weight loss of 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The DS had a comment to hold the weight loss plan due to the weight loss and she referred to the RD. The RD disagreed and adjusted and reduced the TWGR to 180-184 lbs. When asked why the TWGR was decreased after Resident 75 had experienced a significant severe weight loss in the past 180 days, the RD stated she adjusted the weight goal as Resident 75 lost the weight. She added she would stop the weight loss plan now and the facility would start to follow Resident 75 more closely. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked what Resident 75's nutrition plan was since admission, the MD stated he did not remember. When asked if he remembered Resident 75 was on a weight loss regimen, he stated the RD would be the one to make those recommendations. When asked if he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD was asked if Resident 75's significant severe weight loss of 25 lbs, 11.9% in five months in February 2022 and the significant severe weight loss of 34 lbs, 16.2% in six months in March 2022 was safe, the MD stated he could not answer that question without reviewing Resident 75's medical record. A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations or interventions for Resident 75's significant weight losses which occurred between November 11, 2021 and March 2, 2022. A review of facility document titled, Dietary Care Plan for Nutritional Status, initiated on August 22, 2021, and updated on November 4, 2021, it indicated the plan of planned weight loss did not start until February 10, 2022, with one to two lbs weight loss per month to the goal of 180-184 lbs. The other goal was for Resident 75 to consume meals at least 75% of meals and minimize the risk for significant weight loss of five lbs per month. The care plan indicated the approach plan for the facility to encourage Resident 75 to consume 75-100% of her meal, the facility should monitor weight and report + or - five lbs or more per month to the MD, and to notify the MD for any significant weight loss. A review of the facility policy and procedure titled, Weight Monitoring, revised 2022, indicated, .the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range .the facility will utilize a system approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary .nutrition assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns .the care plan should address the following .a. identified causes of impaired nutritional status .c. Identify resident-specific interventions; d. Time frame and parameters for monitoring; e. Updated as needed such as when the resident's condition changes .interventions are determines to be ineffective or a new causes of nutrition-related problems are identified; f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate .Interventions will be identified, implemented, monitored, and modified, consistent with the resident's assessed needs .to maintain acceptable parameters of nutritional status .Residents with weight loss - monitor weight weekly .A significant change in weight is defined as: a. 5% change in weight in 1 month .b. 7.5% change in weight in 3 months .c. 10% change in weight in 6 months .Documentation: .the physician should be informed of a significant change in weight and may order nutritional interventions; b. The physician should be encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .g. The interdisciplinary plan of care communicates care instructions to staff . 2. On March 17, 2022, at 9:30 a.m., an interview and concurrent record review with the MDS Coordinator (MC) was conducted regarding Section K of Resident 75's annual assessment dated [DATE], and the quarterly assessment dated [DATE]. Section K for both the annual and quarterly assessments indicated Resident 75 experienced a significant unplanned weight loss of 5% or more in the last 30 days, or a significant unplanned weight loss of 10% or more in the last 180 days. The MC confirmed the significant unplanned weight loss in the quarterly and annual assessments for Resident 75 was not a physician-prescribed weight loss regimen. The MC stated physician-prescribed means a physician's order. The MC further stated he was aware Resident 75 was on a weight loss program with a weight loss goal of one to two lbs per month. The MC stated Resident 75 weight losses for the annual and quarterly assessments were more than one to two lbs per month and therefore not considered a physician-prescribed weight loss. The MC stated the MD should be aware of a planned weight loss regimen. The MD was responsible for any new orders or a change of the planned weight loss regimen. The MC confirmed Resident 75 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and a concurrent record review with the DON on March 17, 2022, at 3:02 p.m., the DON confirmed there was not a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During a phone interview with the RD on March 18, 2022, at 10:08 a.m., the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. On March 18, 2022, at 10:50 a.m., an interview was conducted with the RN 2. When asked who was responsible to get a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN 2 was unable to confirm the MD order for a weight loss regime for Resident 75. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked if he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations for a planned weight loss regimen.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. A full sheet deep metal pan of egg salad prepared on March 15, 2022, was found in the reach-in refrigerator without food temperature monitoring for the cool down process; 2. Three various sized cooking pans, readily available for use, had dry and heavy black residue buildup on the cooking surface; 3. Several various sized plastic containers and metal pans were stacked and stored wet; and 4. The kitchen staff did not utilize the correct manufacturer's directions to sanitize the dishes for the manual dishware washing using the 3-compartment sink. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen. The facility census was 95. Findings: 1. On March 14, 2022, at 3:02 p.m., a full sheet deep metal pan of egg salad prepared on March 14, 2022, was observed in the reach-in refrigerator. Its temperature was taken and was 59.9 Fahrenheit (F). A concurrent interview and record review of the cooling log was conducted with Cook 1. Cook 1 stated the egg salad was done at 2:30 p.m., and put in the refrigerator. Cook 1 reviewed the cooling log and stated he did not do the cool down process or monitor the temperature for the egg salad. He stated he did the cool down process for the boiled eggs starting from 12:00 p.m. to 2:00 p.m. Cook 1 stated he started to pour the cooled down eggs into the processor then added celery, mayonnaise, and relish to mix into the egg salad. He stated he did not do the cooling process and did not take the temperature to monitor the cooling down process. Cook 1 stated he was not sure about the cooling process for the egg salad. On March 14, 2022, at 3:10 p.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated Cook 1 needed to start the cooling process once the egg salad was done. On March 18, 2022, at 9:45 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated Cook 1 should have followed the cooling process and record the temperature in the cooling log. A review of the undated departmental policy and procedure titled, COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS (PHF) also called Time/Temperature Control for Safety (TCS), read, .Potentially hazardous foods shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted foods .Use cool down log . 2. During the follow up kitchen observation on March 15, 2022, at 9:38 a.m., three various sized cooking pans hanging on the pots and pans rack, ready to use, were observed to have dry heavy black residue buildup on the cooking surface. During a concurrent interview with the DS, she verified the three cooking pans had heavy black buildup and were not cleanable. The DS stated the black buildup might chip and could contaminate the food. The DS stated they needed new cooking pans. On March 18, 2022, at 9:47 a.m., an interview was conducted with the RD. The RD stated, To follow the facility's policy and take care of the issues. A review of the undated departmental policy and procedure titled, SANITATION, indicated, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 3. During the kitchen initial tour on March 14, 2022, at 9:50 a.m., and 10:25 a.m., there were two 2-quart (a unit of liquid capacity), three eight-quart and three four-quart plastic containers, and five one-quarter (1/4) sheet and one half (1/2) sheet metal pans were found stacked wet and stored in the clean storage areas. During a concurrent interview with the DS, she stated those containers and metal pans needed to be completely air-dry before being stored away. On March 18, 2022, at 9:48 a.m., an interview was conducted with the RD. The RD stated, To follow the facility's procedure. A review of the undated departmental policy and procedure titled, DISH WASHING was conducted. It indicated, .Dishes are to be air dried in racks and before stacking and storing . 4. During the kitchen initial tour on March 14, 2022, at 10 a.m., Dietary Aide (DA) 1 verbalized the process of manual dishware washing by using the three-compartment sink. DA 1 stated the sanitizing step was to immerse the washed dishes in the sanitizing solution for 45 seconds and stated she followed the instructions posted on the wall. A review of the instructions posted on the wall indicated the immersion time for all washed items was 45 seconds. A review of the instructions printed on the tub of the sanitizer solution indicated, Sanitization of food processing equipment, utensils, and other food contact articles .sanitizing by immersing articles .(200-400 ppm [parts per million - unit of measurement] active quaternary [a chemical sanitizer to sanitize the dishes]) for at least 60 seconds . A concurrent interview was conducted with the DS. The DS stated she was not aware that the posted immersion time was incorrect. She stated she needed to contact the manufacturer to confirm the immersion time information. During a follow up interview with the DS on March 15, 2022, at 9:15 a.m., she reviewed a new poster for instructions for the three-compartment sink dishwashing from the manufacturer and confirmed the immersion time should be at least 60 seconds. On March 18, 2022, at 9:50 a.m., an interview was conducted with the RD. The RD stated kitchen staff should follow the manufacturer's guideline when operating the three-compartment sink.

Based on observation, interview, and record review, the facility failed to maintain the ice machine in safe operating condition when the ice machine was not cleaned, and the manufacturer's manual was not followed. This failure had potential to cause food-borne illness in a highly susceptible population of 90 out of 95 residents who received food from the kitchen. Findings: A review of facility document titled, Physician Orders List, dated March 14, 2022, indicated 90 residents were on diets and received food from the kitchen. During an observation of the ice machine on March 14, 2022, at 11:25 a.m., there were significant amounts of black and gelatinous residue found behind the bottom of the harvester (a part of ice machine looks like a panel where a sheet of ice cubes slides into the storage bin during the harvest cycle) and could be easily removed with a white paper towel. In addition, there were white deposits found located on the top at the side of the ice storage bin. During an interview on March 14, 2022, at 11:25 a.m. and the follow up interview on March 14, 2022, at 3:41 p.m., with the Maintenance Supervisor (MS), he stated the maintenance department was responsible to do deep cleaning for the ice machine monthly and there was a technician from an outside company to clean the ice machine every two months. The MS stated the last deep cleaning for the ice machine was on February 27, 2022. He stated the technician from the outside company was responsible to clean the harvester part and he was not supposed to clean that area. The MS stated he did not take components of ice machine apart except the hose to clean. He stated he was not licensed and just tried his best to clean the ice machine. He stated he was responsible to run the cleaning and sanitizing cycles of the ice machine and cleaning the ice storage bin during the deep cleaning monthly. The MS stated he used the cleaning solution to pour into the machine and run the cleaning cycle for 20-45 minutes, then ran the sanitizing cycle for 20-45 minutes with sanitizing solution, and next to rinse with warm water for few cycles. For the ice storage bin, the MS stated he would use four drops of bleach mixed with 12 ounces of water to clean the interior area of the bin with a clean cloth, and then he would use plain water to rinse and let it dry before making ice. The MS acknowledged that he did not follow the proper steps to clean and sanitize the ice machine. He stated he never received training from anyone, but learned by mistakes and what the surveyors taught him during the prior annual surveys. He added he learned from the employees who worked for the industrial supply store by asking questions about the ice machine. The MS stated he did not follow the manufacturer's manual because he did not have one. He stated he followed the steps of cleaning and sanitizing instructions inside the ice machine cover. During an interview with the technician from the outside company (TOC) on March 14, 2022, at 4:33 p.m., he stated he provided cleaning service for the ice machine every two months, and he replaced the filter for the ice machine during each of his visits. He stated he would clean the machinery part for the ice machine. He stated he would use the cleaner solution to run the cleaning cycle for 45 minutes and then using plain water to run two cycles as rinsing. Then the ice machine started making ice and needed to discard first two batches of ice and the ice could be used when making the third batch. He stated he followed the manufacturer's manual. During the follow up interview on March 15, 2022, at 8:31 a.m., the MS provided the manufacturer's manual from the TOC, and stated the manual was not for the right model. He stated he did not know the model number of the ice machine and could not obtain the right manufacturer's manual. A review of the cleaning and sanitizing instructions inside of the ice machine titled, Scale Removal and Sanitizing Instructions, undated, indicated there were 22 steps to clean and sanitize the ice machine. The ice machine needed to use cleaning solution for the cleaning cycle and sanitizing solution for the sanitizing cycle. In addition, components of the ice machine needed to be taken apart to clean and sanitize with cleaning and sanitizing solutions respectively. A review of an undated departmental policy and procedure titled, Ice Machine Cleaning Procedures, read, .the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly .information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and /or in the directional panel on the inside of the ice machine .

Based on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for three of four residents reviewed for smoking (Residents 24, 3, 18 and 25), when: 1. Resident 24 was observed smoking inside the facility; 2. Resident 3 had his cigarettes and lighter in his possession, offered a cigarette to another resident, and smoked a cigarette himself without staff supervision; 3. Resident 18 stated he usually had his lighter in his possession; and 4. Resident 25 had a cigarette in his possession while inside the facility. These failures had the potential to result in accidents or injuries to the residents. Findings: 1. On March 14, 2022, at 1:20 p.m., Resident 24 was observed in the North hallway, by her room. Resident 24 had, in her possession, a cigarette and a lighter. Resident 24 lit up the cigarette and started smoking inside the facility. Resident 24 continued smoking inside the facility, walked passed several residents' rooms and the nursing station, towards the outside patio. On March 14, 2022, at 1:25 p.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 24 was not allowed to have the cigarette and lighter in her possession, and was not allowed to smoke inside the facility. On March 14, 2022, at 2:40 p.m., an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated residents were not allowed to smoke inside the facility. RN 2 also stated she did not know how Resident 24 got possession of the cigarette and the lighter. RN 2 stated Resident 24 could not smoke safely and she should not have possession of smoking materials, as this was a safety risk for her and the other residents in the facility. RN 2 stated residents were only allowed to smoke in the designated smoking area (the outdoor patio), and only with supervision. On March 16, 2022, at 11:10 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated no residents were allowed to smoke inside the facility. The DON also stated Resident 24 was not supervised and the incident should not have happened. Resident 24's record was reviewed. Resident 24 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder (mood disorder), [CONDITION(S)] disorder (hallucinations, delusions, disorganized behavior), unspecified [CONDITION(S)] (disturbance in thoughts and perception), and nicotine dependence. The care plan titled, Resident Care Plan for Smoking, initiated on June 7, 2021, indicated, .Concerns & Problems .Resident is at risk for self-injury related to smoking .Potential for accidental [CONDITION(S)] from cigarette smoking .Resident Goals .Will have no injuries to self and others .Will be able to verbalize understanding of risks and complications associated with smoking .Approach Plan .Explain to resident the facility's policy and procedures regarding smoking .Explain to resident that smoking inside the facility is prohibited . The Resident Smoking Assessment Form, dated June 7, 2021, indicated, .Resident is considered a safe smoker and may smoke at this time supervised . 2. On March 14, 2022, at 9:55 a.m., a smoking observation was conducted. Several residents were observed waiting for facility staff to come outside and begin supervised smoking. Resident 3 was observed in a wheelchair by the East Wing patio, legs raised, with a blanket over his legs. On his chest was a small black bag containing one pack of cigarettes and a light blue disposable lighter. One resident was observed to approach him and talk to him. Resident 3 proceeded to hand him one cigarette and light the cigarette with the disposable lighter. Both residents had a conversation for a few minutes. Resident 3 then instructed the other resident to move away from him. Resident 3 was observed to get one cigarette from the pack in his bag and light the cigarette with the disposable lighter. Resident 3 was interviewed. Resident 3 stated the facility had nine different times for smoking. Resident 3 stated he was allowed to keep his lighter and cigarettes, Me anyway, because I know what I'm doing. Resident 3 stated he had no issues regarding smoking except the facility staff did not get out on time for the smoke breaks. Resident 3 was observed flicking the ashes from his cigarette to the left side of his wheelchair. When he was finished smoking, he disposed of the cigarette butt on the concrete to the left side of his wheelchair. There were two cigarette butts on the concrete, indicating Resident 3 finished two cigarettes prior to the staff coming out to supervise smoking. At 10:05 a.m., two facility staff were observed to exit the Central Dining Room door towards the outside patio and started setting up for the smoke break. The staff started distributing smoking aprons and cigarettes to the residents at 10:07 a.m. At 10:40 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she supervised the smoke breaks until 10 a.m., the Activities department supervised until 1:45 p.m., and the Certified Nursing Assistants supervised in the afternoon until the 10 p.m., smoke breaks. CNA 2 stated Resident 3 was not supposed to have his cigarettes or lighter with him because he had an issue before where he also gave another resident cigarettes. CNA 2 stated the agreement with him was 1-2 cigarettes per smoke break and We're the ones who are supposed to give it to him. CNA 2 stated Resident 3 should not have had his cigarettes and lighter with him and should not have offered the other resident a cigarette and lit it. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] (impaired muscle coordination), contractures (shortening of the muscles) of the right upper arm and both lower legs. The History and Physical, dated February 16, 2022, indicated Resident 3 had the capacity to understand and make decisions. The Resident Smoking Assessment Form, dated December 2, 2021, indicated Resident 3 was an .unsafe smoker and must be supervised at all times when smoking . The Resident Smoking Assessment Form, dated March 3, 2022, was not completed to indicate if Resident 3 was a safe smoker and may smoke supervised. The Resident Care Plan for Smoking, revised March 5, 2021, indicated, Concerns and Problems .Resident is at risk for self-injury related to smoking .Potential for accidental [CONDITION(S)] from cigarette smoking .Resident Goals .Will have no injury to self and others daily . The care plan did not indicate interventions to prevent the resident from keeping his smoking materials including his cigarettes and lighter, or offering cigarettes to other residents. At 3:00 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 confirmed Resident 3 was not safe to smoke unsupervised. RN 2 stated Resident 3 should not have had his cigarettes and lighter with him and should not have offered the other resident any cigarettes. On March 18, 2022, at 9:35 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated residents were assessed upon admission and quarterly if they were safe to smoke. If they were, then they are allowed to smoke supervised. The DON stated the smoking materials including cigarettes and lighters were stored in the lockbox at the nurses' station. During smoke breaks, the smoking monitors (staff who supervised smoking) would take the lockbox out to the smoking area, distribute the cigarettes, and light the cigarettes for the residents. The DON stated Resident 3 should not have had his smoking materials with him and should not have offered the other resident a cigarette. The DON confirmed Resident 3's care plan was not updated. The DON stated if Resident 3 did not follow the facility's smoking guidelines, then his smoking care plan should have been updated and modified. 3. On March 14, 2022, at 3:52 p.m., Resident 18 was interviewed. Resident 18 stated, They just took my lighter today. Resident 18 stated he usually had his lighter with him. Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] ([CONDITION(S)] - a lung condition causing breathing difficulties). The History and Physical, dated August 7, 2021, indicated Resident 18 had the capacity to understand and make decisions. The Resident Smoking Assessment Form, dated August 7, 2021, indicated Resident 18 was .considered a safe smoker and may smoke at this time supervised . The Resident Smoking Assessment Forms, dated September 21, 2021 and December 21, 2021, were not completed to indicate if Resident 18 was a safe smoker and may smoke supervised. There was no documented evidence Resident 18 had a care plan for smoking. At 4:00 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 stated Resident 18 should not have had his lighter with him. RN 2 confirmed Resident 18 did not have a care plan for smoking. RN 2 stated Resident 18 should have had a care plan for smoking. On March 18, 2022, at 9:35 am., the DON was interviewed. The DON stated Resident 18 should not have had his lighter with him and a care plan should have been developed for smoking. 4. On March 14, 2022, at 3:39 p.m., an observation was conducted with Resident 25. Resident 25 was observed wheeling himself in the main dining room going towards the back patio. Resident 25 was observed holding one unlit cigarette in his left hand. Resident 25 stated, I need a lighter. Resident 25 then proceeded to the back patio smoking area while there was no staff present nearby. On March 14, 2022, at 3:43 p.m., a concurrent observation and interview was conducted with the Activities Director (AD). The AD was observed to go out in the back patio to assist another resident. The AD passed by Resident 25 and talked to him for a bit. Resident 25 was still observed holding the unlit cigarette in his left hand. After speaking with Resident 25, the AD went back to the dining room. On March 14, 2022, at 3:44 p.m., an interview was conducted with the AD. The AD stated residents in the facility were not allowed to keep their lighters and cigarettes in their own possession for safety reasons. The AD further stated the activity personnel kept the residents' cigarettes and lighters for safety. The AD was asked if she noticed Resident 25 holding the unlit cigarette. The AD stated she did not notice Resident 25 holding an unlit cigarette. The AD went back out to talk to Resident 25. The AD stated Resident 25 had an unlit cigarette in his possession and he stated he had his cigarette stashed in his room and did not want to give the cigarette to her. On March 18, 2022, Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] disorder (type of behavioral disorder) and weakness. The History and Physical, dated December 18, 2021, indicated Resident 25 had fluctuating capacity to understand and make decisions. The Resident Care Plan, dated December 18, 2021, indicated .Concerns & Problems .Resident is at risk for self-injury related to smoking .Potential for accidental [CONDITION(S)] from cigarette smoking .Resident Goals .Will have no injuries to self and others daily .Approach plan .Explain to the resident the facility's policy and procedures regarding smoking .Explain to resident that smoking inside the facility is prohibited . The Resident Smoking Assessment Form, dated December 18, 2021, indicated .Resident is an unsafe smoker and must be supervised at all times when smoking . On March 18, 2022, at 11:33 a.m., Resident 25's Smoking Assessment Form, dated December 18, 2021, was reviewed with RN 2. RN 2 stated, Resident 25 was evaluated as an unsafe smoker and he should not be allowed to keep his own cigarette or lighter in his possession. RN 2 further stated residents in the facility were not allowed to keep cigarettes and lighters in their possession. The facility policy and procedure titled, Resident Smoking, revised 2019, was reviewed. The policy indicated, .Smoking is prohibited in all areas except the designated smoking area .Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff .

Based on observation, interview, and record review, the facility failed to ensure discontinued and expired medications were not stored in the medication and treatment carts, readily available for use. This failure increased the risk for the licensed nurses to administer discontinued and expired medications to the residents which could result in medication and treatment errors. Findings: 1. On March 16, 2022, at 11:36 a.m., an inspection of the medication cart in the medication room was conducted with RN 2. A medication cart was observed stored inside the medication room. In a concurrent interview, RN 2 stated the medication cart was not used since February 2022. RN 2 stated all medications inside the medication cart were readily available for use. The following medications were stored in the medication cart: -one open bottle of Vitamin C (vitamin/supplement) liquid with an expiration date of November 2021; -one open bottle of ProStat (protein supplement) with an expiration date of June 2021; -one open bottle of Geritussin (cough medicine) with an expiration date of September 2021; -one open bottle of Normal Saline 250 ml (milliliter - unit of measurement) with an expiration date of February 2022; -one open box of needles with an expiration date of November 2021; -one open bottle of Loratadine (an antihistamine medicine that helps with the symptoms of allergies) 10 mg (milligram a unit of measurement) tablet with an expiration date of August 2021; -one open bottle of [MEDICATION(S)] Sodium (stool softener) 100 mg tablet with an expiration date of November 2021; -one open bottle of Geri-dryl (allergy relief) 25 mg tablet with an expiration date of November 2021; -one open bottle of [MEDICATION(S)] ([MEDICATION(S)]) 5 mg tablet with an expiration date of January 2022; -one open bottle of [MEDICATION(S)] Sodium 100 mg gel capsule with an expiration date of January 2021; -one open bottle of [MEDICATION(S)] Sulfate (iron supplement) 325 mg tablet with an expiration date of January 2022; -one open bottle of Vitamin E (vitamin/supplement) 400 IU (international unit) soft gel with an expiration date of June 2021; and -one open bottle of Acetaminophen (pain medicine) 500 mg tab with an expiration date of January 2022. In a concurrent interview with RN 2, RN 2 stated the discontinued and expired medications stored in the medication cart should have been discarded properly and should not have been stored readily available for use. RN 2 further stated, These medications are not effective anymore. On March 16, 2022, at 2:32 p.m., the Director of Nursing (DON) was interviewed. The DON stated the discontinued and expired medications from the medication cart should have been removed and should have been disposed of properly. The DON further stated the discontinued medications should not have been stored in the medication cart because this had the potential for the licensed nurses to administer the medications and may result in medication error. 2. On March 16, 2022, at 10:23 a.m., an inspection of the treatment cart was conducted with the Treatment Nurse (TN). The following were found, readily available for use: - [MEDICATION(S)] ([MEDICATION(S)]- an antifungal) powder labeled for Resident 22, with a fill date of February 10, 2022. The label further indicated APPLY TOPICALLY TO PERINEAL REDNESS 2 TIMES A DAY FOR 30 DAYS . The TN stated Resident 22 had the treatment before and did not have a current order for it. The TN stated she did not discard the bottle because the resident would ask for it. - One container of [MEDICATION(S)] moisturizing cream labeled for Resident 72, with a fill date of January 5, 2022. The TN stated Resident 72 was already cleared so he did not need it anymore. - Eleven 4x4 gauze dressings with expiration dates of July 2020. The TN stated these were supplies from hospice. The TN stated she cleaned the treatment cart but missed these items and she should have removed them. The TN stated medications without a doctor's order and expired treatment supplies should not be in the treatment cart, readily available for use. On March 18, 2022, at 9:20 a.m., the Director of Nursing (DON) was interviewed. The DON stated unused and expired treatment medications and supplies should not have been in the treatment cart, readily available for use. The facility's policy and procedure titled, DISCONTINUED MEDICATIONS, revised 2022, was reviewed. The policy indicated, .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with the facility policy . The facility's policy and procedure titled, Destruction of Unused Drugs, revised 2022, indicated .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with our established procedures .

Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when one Cook (Cook 1) did not monitor and did not know the process for ambient (current air temperature) cool down of Time/Temperature Control for Safety (TCS) foods (cross refer to F812, finding number 1). This failure had the potential to cause food borne illness in a potentially compromised population of 90 out of 95 residents who received food from the kitchen. Findings: During the review of facility document titled, Physician Orders List, dated March 14, 2022, it indicated there were 90 residents who had physician diet orders and received food from the facility kitchen. During the follow-up observation of the reach-in refrigerator in the kitchen on March 14, 2022, at 3:02 p.m., a batch of egg salad in a full sheet and deep metal pan was found with a temperature of 59.9 degrees Fahrenheit (F). During a concurrent interview with Cook 1, he stated he prepared it around 2:30 p.m., and stated he did not monitor the temperature before storing it away in the refrigerator. He stated used the cooling log for the boiled eggs. During a concurrent review of the cooling log, it showed he started the cool down of the boiled eggs at 140 degrees F at 12:00 p.m. Cook 1 stated he put the boiled eggs in the ice bath, took the temperature at 1:30 p.m., and it measured 70 degrees F. At 2:00 p.m. it was 34 degrees F. Cook 1 stated he then put the cooled down eggs in the processor and mixed them with celery, mayonnaise, and relish. Cook 1 stated he put the mixture of egg salad in the refrigerator around 2:30 p.m., without measuring the temperature. Cook 1 stated he did not use the cooling log to track the cooling down process of the egg salad. He stated he was not sure of the process for cooling down the egg salad. He stated he got the cooling down in-service last week from the Dietary Supervisor (DS). During a concurrent interview with the DS, she acknowledged Cook 1 did not monitor the temperature for the cooling down process of the egg salad. The DS stated Cook 1 needed to do cooling down after he mixed the ingredients of the egg salad by using the cooling log to track the temperature. A concurrent review of departmental document titled, Title of In-service: Cooling and Reheating PHF (potential hazardous foods), completed on August 27, 2021, was reviewed. It did not show the in-service included ambient food cooling down procedure. During the follow up interview with the DS on March 17,2022, at 10:15 a.m., she stated Cook 1 should know the process of ambient food cooling down, and that the kitchen made egg salad usually twice a week. During an interview with the facility Registered Dietitian on March 18, 2022, at 9:46 a.m., she stated Cook 1 needed to follow the cooling process and filled in the cooling log. During a review of Cook 1's personnel file (date of hire: August 24, 2018), included a facility document titled, Dietary Aide Competency: Annual Competency, completed on January 10, 2022, it indicated that Cook 1 was competent with food handling and evaluated by the DS. A review of undated departmental policy and procedure titled, Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), indicated PHF must be cooled within four hours to 41 degrees F or less when prepared from ambient temperature ingredients and using the cool down log to track the ambient temperature foods. According to the FDA Federal Food Code, 2017, Safe cooling required removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety food has been consistently identified as one the leading contributing factors to foodborne illness.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on March 15, 2022, when 11 residents with a CCHO (Consistent Carbohydrate to treat medical condition of diabetes) mechanical soft (food was broken down for easy chewing) diet and 21 residents with a CCHO regular (no modification made to food) diet received a whole piece of chocolate cake with whipped topping instead of a half piece. This failure had the potential to result in increased blood sugar levels of 32 residents with a CCHO diet. Findings: On March 15, 2022, at 1:15 p.m., the dietary staff was observed to serve the whole, size of two inches by two inches by half inch (2x 2x 1/2) chocolate cakes to residents receiving regular CCHO and mechanical soft CCHO diets. A concurrent review of the undated departmental menu spreadsheet titled, Spring Cycle menus, week 2 Tuesday 3/15/22 ., indicated residents with a CCHO regular diet and a CCHO mechanical soft diet should have received a half piece of 2x 2x 1/2 chocolate cake with whipped topping. A review of the physician order for all residents' diet titled, Physician orders list, dated March 14, 2022, indicated there were 21 residents receiving a regular CCHO and 11 residents receiving a CCHO mechanical soft diet. On March 15, 2022, at 1:50 p.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated the residents with a CCHO diet should have been served half of the regular 2x 2x 1/2 chocolate cake instead of the whole piece. A review of the facility's policy titled, Food Preparation Guidelines, dated 2022, indicated, .The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes .

Based on interview and record review, the facility failed to develop and implement a policy and procedure for Foods Brought by Family/Visitors, that included provisions on facility providing education and information about safe food handling (such as safe cooling/reheating process, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.) practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who were involved in preparing, handling, serving, or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of residents who could consume food and receive food from family or visitors. The facility census was 95. Findings: On March 12, 2022, at 3:35 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated family and visitors could bring food for the residents. She stated the food from outside, or leftovers would be kept in the designated resident's refrigerator for 72 hours. RN 2 was not able to verbalize the process of safe food handling and stated she did not receive any in-service regarding safe food handling for food brought in from outside of the facility. On March 15, 2022, at 9:45 a.m., an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated family and visitors could bring food for the residents and the leftovers could be kept in the designated resident's refrigerator. She stated she did not know how long the leftovers could be kept in the refrigerator. CNA 2 stated she had an in-service regarding food brought in from outside sources. CNA 2 was not able to verbalize the process of safe food handling. On March 15, 2022, at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated family and visitors could bring food from outside for the residents and the leftovers could be kept in the designated resident's refrigerator for three days. LVN 1 stated she had an in-service for food brought in from outside sources a long time ago, but she was not able to verbalize the process of safe food handling. On March 15, 2022, at 10:08 a.m., an interview was conducted with CNA 2. CNA 2 stated family and visitors could bring food for residents and the leftovers would be kept in the designated resident's refrigerator for one day. CNA 2 stated she had an in-service for food brought in from the outside but could not remember if the process of safe food handling was provided. On March 15, 2022, at 10:15 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated he was involved in the process of admitting new residents to the facility. The ADON stated the facility usually did not tell the new residents' families that they could bring food for them. The ADON stated the facility allowed family and visitors to bring food from the outside for the resident if necessary. He stated the leftovers could be kept in the designated resident's refrigerator for three days or 72 hours. On March 15, 2022, at 10:35 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility allowed the family and visitors to bring in food and home-cooked food for the residents. She stated the food could be kept in the resident's refrigerator for no more than a day because the facility tried to encourage the residents to consume in the same day. The DON reviewed the policy and procedure and stated she was not aware the food leftovers could be kept in the refrigerator for 2 days. She also acknowledged that the staff had inconsistent information regarding the time frame to keep the food and leftovers in the resident's refrigerator. A concurrent review with the DON regarding the facility's policy and procedure titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, undated, indicated, .3. Prepared food brought in for the resident must be consumed within one (1) hour of receiving it .Unused food will be disposed of immediately thereafter .5. Prepared food .If opened .disposed of in 2 days after opening . The DON acknowledged number three and number five of the policy and procedure contradicted each other, and she was not able to clarify both statements The DON acknowledged and agreed the policy and procedure did not include the provision for the facility to provide education or material for family or visitors regarding safe food handling practices.

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 57), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 14, 2022, at 9:48 a.m., Resident 57 was observed in bed with oxygen (O2) via nasal cannula (N/C - a tube used to deliver oxygen through the nose). Resident 57's oxygen administration was observed at one liter per minute (LPM). In a concurrent interview, Resident 57 stated she used O2 as needed, when she was short of breath (SOB), and the level should be at three LPM. Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's order dated January 14, 2022, indicated, .administer O2 inhalation at 2-3 LPM via NC as needed for SOB . On March 14, 2022, at 1:17 p.m., Resident 57 was observed in bed, with O2 on, at one LPM. A concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 went to Resident 57's room and checked the oxygen level. LVN 1 stated the oxygen level was at one LPM. LVN 1 stated the oxygen level should be between two and three LPM, as per physician's order. LVN 1 further stated the physician's order was not followed. The facility policy and procedure titled, Oxygen Administration, revised 2022, was reviewed. The policy indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

Based on interview and record review, the facility failed to provide written information on how to formulate an Advance Directive (AD-a written instruction related to the provision of health care when the resident can no longer make decisions), for two of 25 residents reviewed (Resident 54 and 25). This failure had the potential for Residents 54 and 25 to receive unnecessary care/treatment and services. Findings: 1. On March 15, 2022, Resident 54's record was reviewed. Resident 54 was admitted to the facility on [DATE]. The History and Physical dated January 10, 2022, indicated Resident 54 had fluctuating capacity to understand and make decisions. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility document titled, ACKNOWLEDGEMENT OF RECEIPT Advance Directive/Medical Treatment Decisions, dated January 10, 2022, indicated Resident 54 was self-responsible. The document did not indicate Resident 54 was provided written information on how to formulate an AD. On March 16, 2022, at 11:05 a.m., the Social Service Director (SSD) was interviewed. The SSD stated, Upon admission, the residents were asked to provide a copy of the AD, if available. The SSD stated the residents were asked if they wanted to formulate an AD and the facility would offer to assist if the resident did not have an AD. The SSD stated Resident 54 did not have an AD. The SSD stated, she did not ask Resident 54 if he wanted to formulate an AD and did not offer to assist Residen 54 in formulating an AD. Findings: 2. On March 15, 2022, Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE]. Resident 25's face sheet indicated Resident 25's family member was responsible for making medical decisions for the resident. The History and Physical dated December 18, 2021, indicated Resident 25 had fluctuating capacity to understand and make decisions. There was no documented evidence information on the formulation of an AD was offered to the resident and/or responsible party upon admission. On March 16, 2022, at 9:25 a.m., a concurrent interview and record review was conducted with the SSD. The SSD stated Resident 25 did not have an AD. The SSD stated information about the formulation of an advance directive was not offered to Resident 25 and to his responsible party. The SSD further stated this information should have been offered to Resident 25, or to his responsible party upon his admission to the facility on [DATE]. The facility's policy and procedure titled, Advanced Directives, revised 2022, indicated, .Prior to or upon admission of a resident upon admission to our facility, the Social Service Director or designeee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, and his/her family members, about the existence of any written advance directives .

Based on observation, interview, and record review, the facility failed to ensure for two of three residents reviewed for skin condition (Residents 19 and 5) received the proper care and treatment when: 1a. For Resident 19, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 19 not receiving the complete course of antibiotic treatment which may delay the healing process of the multiple infected pressure ulcers; 1b. The facility failed to develop and initiate a baseline care plan to address Resident 19's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] This failure had the potential to put Resident 19 at risk for the delay of treatment and intervention to promote the wound healing of the multiple infected PU; and 2. For Resident 5, treatments on the right great toe and right outer foot were performed without a doctor's order. In addition, multiple skin problems on the resident's right hand were not identified and treated. This failure resulted in Resident 5 not receiving the proper treatment to address his skin conditions. Findings: 1a. On March 14, 2022, at 10:37 a.m., Resident 19 was observed lying in bed on a low air loss mattress (special mattress used for wound management). On March 14, 2022, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The acute hospital's discharge order document titled, Take Home Medication List, dated March 10, 2022, indicated to give Resident 19 [MEDICATION(S)] (brand name for [MEDICATION(S)]) 100 mg (milligrams - unit of measurement) PO (by mouth) BID (twice a day) to start on March 10, 2022, at 9 p.m., for seven days for infected multiple PU. The facility's admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Comprehensive Resident Assessment, dated March 10, 2022, indicated Resident 19 was admitted with infected PU on right upper buttock, sacrum (bottom of the spine), left ischium (lower and back part of the hip bone), and left lateral foot redness. On March 17, 2022, at 9:50 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 19 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The ADON stated Resident 19 had a discharge order from the hospital to give [MEDICATION(S)] 100 mg PO BID to start on March 10, 2022, at 9 pm. The ADON stated Resident 19 did not receive the [MEDICATION(S)] as ordered by the physician since she was admitted to the facility on [DATE]. On March 17, 2022, at 10:30 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was the licensed nurse who admitted Resident 19 to the facility on [DATE]. RN 1 stated she carried out the discharge orders from the hospital and she missed transcribing the order for [MEDICATION(S)]. RN 1 stated the [MEDICATION(S)] was ordered as a part of the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 further stated if the treatment was not completed or carried out as ordered, it may contribute to the delay of the healing process of the infected wounds. 1b. On March 14, 2022, at 3:40 p.m., Resident 19's record was reviewed. Resident 19 was admitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Comprehensive Resident Assessment, dated March 10, 2022, indicated Resident 19 was admitted with multiple infected PU on right upper buttock, sacrum, left ischium, and left lateral foot redness. There was no documented evidence a baseline care plan was initiated upon admission to address Resident 19's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On March 14, 2022, at 3:40 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2. RN 2 stated upon admission of Resident 19 on March 10, 2022, the facility should have initiated a baseline care plan to address Resident 19's multiple infected pressure ulcers. RN 2 stated the baseline care plan should include interventions and treatment to help prevent the development of further complications of the wounds and/or monitoring of the resident's response to the wound treatment. RN 2 stated the baseline care plan should have been initiated within 48 hours of Resident 19's admission. The facility's policy and procedure titled, Baseline Care Plan, revised 2022, was reviewed. The policy indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care .The baseline care plan will be developed within 48 hours of a resident's admission . 2. On March 14, 2022, at 11:34 a.m., a concurrent observation and interview was conducted with Resident 5. Resident 5 was awake, wearing vinyl gloves on both hands, and cleaning around his bed. In a concurrent interview, Resident 5 stated he had wounds on his right foot. Resident 5 proceeded to remove his sandals and socks, and pointed out the dressing to the inner side of his right great toe and the outer side of his right foot. The dressing on the right outer foot was dated March 13, 2022. Resident 5 stated he had surgery on the right great toe a few weeks ago and the dressing to the right great toe was changed on March 13, 2022. Resident 5 stated the dressing on the outer side of his right foot was placed there by the nurse about 2 days ago because he had scratched it and the skin became open. Resident 5 was observed to remove the glove on his right hand. The skin was observed to be reddish, scaly and dry, with several reddish scabs on the upper surface of the hand. The joints appeared swollen and the fingernails were yellowish and thick. Resident 5 stated he had a sensitivity to alcohol-based products and used the gloves to protect his hands from harsh cleaning products. Resident 5 stated he applied Vitamin A and D ointment on his hands himself and asked for the ointment from the staff at the nurses' station or from the CNAs (Certified Nursing Assistants). Resident 5 stated he had this skin condition on his right hand for 104 days here in this facility as well as in the previous facility where he came from. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .(R [right]) great toe surgical wound .Cleanse with NS (normal saline), pat dry, apply Vaseline and cover with band aid q (every) daily and PRN (as needed) x 7 days then re-evaluate. (3/2/22 - 3/08/22). There was no documented evidence treatment orders were obtained for Resident 5's scratch on the right outer foot or the skin conditions on the right hand. There was no doctor's order for Vitamin A and D ointment to be applied on Resident 5's right hand. The Nursing Weekly Summary Review for the period of March 1 to 7, 2022 indicated a right great toe surgical wound following a skin tag (a skin growth in which a short, narrow stalk sticks out) removal. The Nursing Weekly Summary Review for the period of March 7 to 14, 2022 indicated skin clear. There was no documented evidence the scratch on Resident 5's right outer foot or the skin conditions on his right hand were identified. The Treatment Administration Record for March 2022, indicated the treatment to Resident 5's right great toe was provided from March 2 to 13, 2022 (continued beyond the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On March 15, 2022, a concurrent interview and record review was conducted with the Treatment Nurse (TN). The TN confirmed Resident 5 had a surgical wound on the right great toe and the treatment was continued beyond March 8, 2022. The TN stated the wound should have been re-evaluated on March 8, 2022, and a new order obtained to continue the treatment. The TN stated Resident 5's scratch should have been identified as a change in condition; the doctor notified; a treatment order obtained for the scratch; and a care plan formulated, before providing treatment to the resident. The TN stated she had not assessed Resident 5's right hand, nor identified the multiple skin conditions on it, since Resident 5 always wore vinyl gloves. The TN stated the skin conditions on Resident 5's right hand should have been identified; the doctor notified; treatment orders obtained to address the skin conditions on Resident 5's right hand; and a care plan formulated. On March 18, 2022 at 9:24 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 5's surgical wound on the right great toe should have been re-evaluated on March 8, 2022, and if resolved, the treatment discontinued. If it was not resolved, a new order should have been obtained from the doctor. If the order was renewed, then the care plan should have also been updated. The DON stated there should have been a change of condition done regarding Resident 5's scratch on the right outer foot, the doctor notified, a treatment order obtained before administering the treatment, and a care plan developed. The DON stated the facility's process was to perform skin assessments of the residents weekly by the licensed nurses. Resident 5's multiple skin conditions on the right hand should have been identified. The doctor should have been notified, treatment orders obtained, and a care plan developed. The facility's policy and procedure titled, Skin Assessment, revised 2019, indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions .A full body, head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition .Document observations .Document type of wound .Describe wound .Document other information as indicated or appropriate . The facility's policy and procedure titled, Change in a Resident's Condition or Status, revised 2022, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical .condition and/or status .notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical .condition or status .inform the resident of any changes in his/her medical care or nursing treatments .record in the resident's medical record information relative to changes in the resident's medical .condition or status .

Based on interview and record review, the facility failed to ensure pressure injuries/wounds were thoroughly assessed and preventive measures were implemented for one of three sampled residents (Resident A). These failures increased the potential for Resident A to develop new pressure wounds, for existing wounds to not be fully re-evaluated and treated, and may have contributed to the overall decline in Resident A's overall health. Findings: On (MONTH) 19, 2019, the complainant was interviewed by telephone and stated Resident A was admitted to HOSP 1 (name of hospital) on (MONTH) 7, 2019, with multiple pressure wounds [MEDICAL CONDITION] (life threatening infection of blood). Resident A's record from HOSP 1 was reviewed and indicated Resident A was admitted to the Medical Intensive Care Unit (MONTH) 7, 2019, with [DIAGNOSES REDACTED]. The Physical Exam, dated (MONTH) 7, 2019, at 6:22 p.m., indicated Resident A was intubated (on artificial breathing machine) and, .Eyes: .purulent discharge (containing pus a sign of infection) .Lungs: .coarse breath sounds with rhonchi (abnormal lung sounds) .Penile wound present with purulent discharge .Skin: Sacral, right ankle, and bilateral heel pressure wounds . The Wound Consultation, at HOSP 1, dated (MONTH) 9, 2019, at 2 p.m., indicated Resident A had pressure wounds as follows: -penis .mucosal injury (mucosal-mucous membranes that line body cavities include urinary tract) .0.7 x 0.6 cm (centimeter- a unit of measure in which 2.54 cm equals 1.0 inch ) .100% yellow, nonviable tissue (yellow dead tissue) .Drainage .scant, serosanguinous (serous, bloody) ., -sacrum .9.5 x 10.0 x 0.2 cm .red, excoriated and denuded tissue (excoriated-injury to surface of body caused by trauma such as scratches, abrasion, burn, denuded-erosion of skin) .drainage .scant, serosanguinous ., -right lateral ankle .1.9 x 1.7 x UTD (unable to determine) .100% yellow-brown soft nonviable tissue .Drainage scant, serosanguinous . -right heel .DTI (deep tissue injury) .4.0 x 4.5 cm .white, fluid-filled blister with deep red-purple margins . -left heel .DTI .5.0 x 3.0 cm .red .with 2.0 x 1.0 cm area of intact red-purple tissue .Drainage small, serosanguinous . On (MONTH) 26, 2019, at 10:40 a.m., an unannounced visit was made to the facility for the investigation of one complaint. Resident A's Skilled Nursing Facility (SNF) record, dated (MONTH) 25, (YEAR) through (MONTH) 7, 2019, was reviewed and indicated Resident A was readmitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. The History and Physical, dated (MONTH) 25, 2019, indicated Resident A had the capacity to make decisions. The Admission Assessment, dated (MONTH) 25, (YEAR), at 8:20 p.m., indicated Resident A had an indwelling Foley catheter (tube inserted into the bladder used to drain urine into a collection bag) and MASD (moisture associated skin disease) of the sacrococcyx (tailbone). The physician's orders [REDACTED]. The Orders indicated Resident A's sacrum and penile wounds were treated by .cleanse with NS (normal saline) pat dry, apply zinc oxide (topical medication) .Q (every) shift & PRN (as needed) . There was no documented indication of physician's orders [REDACTED]. The Care Plan, dated (MONTH) 25, (YEAR), indicated, At risk for pressure ulcers/skin breakdown .Monitor skin integrity q shift . Notify MD for any alteration in skin integrity/skin breakdown .Apply other devices as indicated .Notify MD for any change of condition . The Care Plan further indicated Nursing Assistant staff (unlicensed staff) were assigned to evaluate Resident A's skin for discolorations, blisters, or new changes. The Care Plan, dated (MONTH) 26, (YEAR), indicated Resident A had a new 2 x 3 cm penile wound, and, .Goals Will be resolved and with no complications (infection) x 14 days .Monitor .affected area every shift for color changes, swelling, warm, pain, or other signs of infection .notify MD if Tx (treatment) is ineffective . The Care Plan, dated (MONTH) 5, 2019, indicated Resident A had a new left heel open blister 2.0 x 3.0 cm, and .Heel Protectors as tolerated .Provide pressure relief mattress as tolerated The Licensed Nurses Progress Notes for (MONTH) 25, (YEAR) through (MONTH) 7, 2019 were reviewed, and the Notes had no documented indication pressure reducing devices typically used to prevent pressure wounds, including specialty mattress or heel protectors, were implemented for Resident A. There was no documented indication licensed nursing staff evaluated Resident A's existing pressure wounds on the sacrum, penis, and left heel for changes or deterioration from (MONTH) 25, (YEAR) through (MONTH) 7, 2019. There was further no documented indication of Resident A's right heel wound noted on admission to HOSP 1. The Wound Care Nursing Weekly Notes were reviewed and indicated Resident A had: -On (MONTH) 16, 2019 a new, small irregular in size open area penile wound, -On (MONTH) 24, 2019, penile wound .re-assessed .not totally resolved . and -On (MONTH) 31, 2019, .Still with open skin irregular in size . There was no documented indication the primary wound care nurse measured the open penile wound after it was first noted or requested alternative treatment orders when the penile wound did not heal. The Nurse's Assistant Notes for (MONTH) 25, (YEAR) through (MONTH) 7, 2019, were reviewed. The Notes had no documented indication pressure reducing devices were implemented for Resident A during (MONTH) and (MONTH) (YEAR), on any shift, during (MONTH) 2019, for 78 of 84 shifts, and during (MONTH) 1 through 7, 2019, for 12 of 18 shifts. On (MONTH) 26, 2019, at 1 p.m., the Director of Nursing (DON) was interviewed and stated the CNAs did a body check on residents each shift and the Licensed Vocational Nurse evaluated the residents while giving the resident's medications each shift. The DON stated the Licensed Nurses did not document this evaluation unless the resident had a change of condition, and the Licensed Nurses would not document their evaluations of the resident for up to one month at a time. On (MONTH) 4, 2019, Registered Nurse (RN) 1 was interviewed by telephone. RN 1 stated the facility assigned the CNA staff to do a body check every shift because the CNAs did the resident's daily cares. RN 1 stated if any new skin changes were noted, the CNA was supposed to notify the Licensed Nurse. RN 1 stated treatment nurses did Foley catheter care every shift and all staff were responsible for checking the Foley catheter site for changes in appearance. RN 1 stated Licensed Nurses were supposed to start 72 hour monitoring, monitor any new skin or Foley Catheter site changes daily, and document the changes in the Licensed Nurse's Progress Notes. On (MONTH) 5, 2019, at 3:35 p.m., CNA 2 was interviewed by telephone, and stated Resident A did not have a special mattress to prevent pressure wounds during his stay at the facility from (MONTH) 25, (YEAR) through (MONTH) 7, 2019. On (MONTH) 8, 2019, at 10 a.m., CNA 3 was interviewed by telephone and stated Resident A did not have an air mattress (pressure reducing mattress used to prevent wounds) on his bed from (MONTH) 25, (YEAR), through (MONTH) 7, 2019, and CNA 3 was not sure why. CNA 3 stated Resident A had a sore on his sacrum off and on, developed sores on his heels, and he usually had a brace on. CNA 3 further stated any specialty mattress or brace needed a physician's orders [REDACTED]. On (MONTH) 12, 2019, at 11:10 a.m., the Primary Wound Treatment Nurse (WN) was interviewed by telephone and stated the facility's preventive measures for residents at risk for pressure wounds included pressure relief mattress, zinc skin protectant ointment, re-positioning, and heel protectors. The WN stated if a wound was moisture related, it usually improved with zinc ointment after 14-28 days, and if a wound was getting worse, deeper, or the skin was breaking down, the WN would notify the Wound Care Doctor and Primary doctor for new treatment orders. The WN stated the wound treatment nurse was supposed to measure the wound, describe the appearance and how the wound responded to treatment, and the Foley catheter site was supposed to be checked daily for skin wounds. The WN stated the facility no longer obtained a physician's orders [REDACTED]. The WN stated Resident A had scratchy skin on his sacrum and skin breakage from the Foley Catheter. The WN verified she did not measure the size of the wound on Resident A's sacrum, it was pink, superficial, and not bleeding. The WN verified she did not measure Resident A's open penile wound when it was assessed. On (MONTH) 26, 2019, at 10:22 a.m., the DON was further interviewed by telephone. The DON stated for residents at risk for pressure wounds the facility used preventive measures that included a low air mattress, heel protectors, re-positioning, and monitored the resident for skin changes. The DON stated a physician's orders [REDACTED]. The DON stated the treatment nurse was supposed to monitor the Foley catheter site for wounds and the WN was supposed to assess and measure medical device (Foley catheter) related pressure wounds weekly. The National Pressure Ulcer Advisory Panel Statement titled, Mucosal Pressure Ulcers dated (MONTH) 2008, indicated, Mucous membrane is the moist lining of body cavities that communicate with the exterior .These tissues line the .urinary tract .Mucosal tissues are especially vulnerable to pressure from medical devices, such as .urinary catheters . The facility policy and procedure titled, Prevention of Pressure Ulcers, undated, indicated, .facility should have a system/procedure to assure assessments are timely (done at the right time), and appropriate and changes in condition are recognized, evaluated, reported to the .physician .and addressed .The care process should include efforts to stabilize, reduce or remove underlying risk factors, to monitor the impact of interventions, and to modify the interventions as appropriate .Protect bony prominences .Risk factor-Bed-fast .Use a special mattress .keep heels off of bed .with pillows .or .other devices as prescribed by the physician .implement preventive measures .Assess the resident's skin .for factors that increase the risk of developing pressure ulcers .implement preventive measures as indicated .Documentation .Any change in the resident's condition . condition of the skin .the size and location of any red or tender areas . The facility policy and procedure titled, Catheter Care, Urinary undated was reviewed and indicated, .Observe the resident for complications associated with urinary catheters .Documentation .Any problems noted at the catheter-urethral junction (insertion site) .such as drainage, redness, bleeding, irritation, crusting, or pain .