Every finding on record at Chico Terrace Care Center

Based on interview and record review, the facility failed to ensure that one of three (Resident 1), who spoke Spanish was explained what medications were being administered to them in a language they understood. This failure had the potential to result in violating the resident's right to be informed of their treatment. Findings:During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (lung inflammation caused by an infection), and end stage renal disease (the kidneys no longer work as they should to meet the needs of one's body). Resident 1's primary language is Spanish. During a review of Resident 1's Care Plan Report located in Resident 1's electronic health record, indicated that on 11/26/25 Resident 1 was identified as having potential communication problem related to language barrier of primary language Spanish. , and the plan was to, Provide interpreter or use language line. During an interview on 12/23/25 at 3:07 pm with the Director of Nursing (DON), the DON confirmed that Resident 1 is Spanish Speaking. The DON's expectation for nursing staff is to explain to residents what medications they are taking in their own language. The DON would expect nursing staff to use Spanish speaking staff or use the facility interpreter service to communicate with Resident 1. During an interview on 12/23/25 at 3:19pm with Licensed Nurse (LN) A, LN A confirmed that Resident 1 is Spanish Speaking and that LN A does not speak Spanish. LN A stated that only sometimes will they use Spanish speaking staff to communicate with Resident 1, and they do not always explain to Resident 1 what medications he is taking. During an interview on 12/23/25 at 3:46 pm with CNA A, CNA A stated that she is Spanish speaking and staff will occasionally use them to help translate for Resident 1 but she has not recently done any translating for Resident 1 regarding their medications. During an interview on 12/23/25 at 3:57 pm with Resident 1, Resident 1 stated that staff do not always get a translator for them, and if they need one it can take up to 30 minutes. Resident 1 states that nursing staff do not always tell him what medications he is taking, and he will just take them even if he does not know what they are. Resident 1 feels that communication with staff about his condition has been poor and they would like the nursing staff to come in and answer their questions and give them an update.

Based on interview and record review, the facility failed to notify the physician of a change of condition for one of three sampled residents (Resident 1), when Resident 1 was having loose stools for eight days before the physician was notified. This failure resulted in the physician being unaware of Resident 1's condition and unable to evaluate the resident for needed changes in the treatment plan. Findings: During a review of the facility policy titled Change of Condition Notification, dated 4/1/15 indicated that the facility will promptly inform the resident, consult with the residents Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: an accident, a significant change in the residents physical, mental, or psychosocial status; and or a significant change in treatment. A change of condition related to attending physician notification is defined as when the attending physician must be notified when any sudden and marked changes in the resident's condition which is manifested by signs and symptoms different than usual.During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (lung inflammation caused by an infection), and end stage renal disease (the kidneys no longer work as they should to meet the needs of one's body).During a concurrent interview and record review on 12/23/25 at 2:02 pm with the Director of Staff Development (DSD), the DSD confirmed from 11/30/25 to 12/8/25 Certified Nursing Assistants (CNAs) documented that Resident 1 was having loose stools every day. The DSD confirmed that CNAs should report loose stools to the nurse and that after three days of loose stools the nurse should contact the doctor. During a concurrent interview and record review on 12/23/25 at 3:07 pm with the Director of Nursing (DON), the DON confirmed that Resident 1 was given a stool soften on 12/4/25, 12/5/25, and 12/6/25 even though it was documented that Resident 1 had been having loose stools since 11/30/25. The DON stated that the expectation for nurses is to review bowel elimination documentation and assess the resident before giving a stool softener. The DON confirmed that after three days of loose stools the doctor should be contacted and that the doctor was not contacted for Resident 1 until 12/8/25 after eight days of loose stools. During an interview on 12/23/25 at 3:19 pm with Licensed Nurse (LN) A, LN A stated that she typically does not go back and review CNA documentation pertaining to bowel elimination LN A relies on the CNAs to tell them if a resident is having loose stools or from other LNs during report. After three days of a Resident having loose stools LN A would notify the doctor. During an interview on 12/23/25 at 3:37 pm with LN B, LN B stated that if a resident was having loose stools for three days, they would contact the doctor. LN B does not always review bowel elimination documentation before giving stool softener medication to residents.During an interview on 12/23/25 at 3:57 pm with Resident 1, Resident 1 stated that nursing staff do not ask him about his bowel movements, and he feels that communication with staff about his condition has been poor.

Based on interview and record review, the facility failed to withhold (not give) a stool softener medication as directed by the physicians' orders for one of three sampled residents (Resident 1). This failure resulted in Resident 1 continuing to receive the medication despite experiencing diarrhea. Findings:During a review of Resident 1's medical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (lung inflammation caused by an infection), and end stage renal disease (the kidneys no longer work as they should to meet the needs of one's body).During a review of Resident 1's physician order, dated 11/17/25, indicated a new order for Bisacodyl (a laxative) oral tablet to be given once every day. Additional directions indicated hold for loose stools. During a review of Resident 1's electronic medication administration record (MAR) for 12/2025, indicated that from 12/1/25 to 12/3/25 Bisacodyl was held due to loose stools. From 12/3/25 to 12/6/25 bisacodyl was given. On 12/7/25 Bisacodyl was refused by Resident 1. It was not until 12/8/25 once the physician was notified that the order for Bisacodyl was changed to every day as needed for Resident 1.During a concurrent interview and record review on 12/23/25 at 2:02 pm with the Director of Staff Development (DSD), the DSD confirmed from 11/30/25 through 12/8/25 Certified Nursing Assistants (CNAs) documented that Resident 1 was having loose stools every day. The DSD confirmed that CNAs should report loose stools to the nurse and that after three days of loose stools the nurse should contact the doctor. During a concurrent interview and record review on 12/23/25 at 3:07 pm with the Director of Nursing (DON), the DON confirmed that Resident 1 was given a stool soften on 12/4/25, 12/5/25, and 12/6/25 even though it was documented that Resident 1 had been having loose stools since 11/30/25. The DON stated that the expectation for nurses is to review bowel elimination documentation and assess the resident before giving a stool softener. The DON confirmed that after three days of loose stools the doctor should be contacted and that the doctor was not contacted for Resident 1 until 12/8/25 after eight days of loose stools. During a concurrent interview and record review on 12/23/25 at 2:30 pm with the Infection Control Preventionist (IP), the IP stated that if a resident is having loose stools, then medications that cause loose stools should not be given to the resident and after three days of loose stools the doctor should be contacted. The IP confirmed that Resident 1 was having loose stools from 11/30/25 through 12/8/25 and on 12/8/25 the doctor was finally contacted, and infectious testing was done. During a review of the facility policy titled Medication - Administration, dated 6/26/25 indicated all medications shall be administered by licensed nursing staff according to the physician orders.

Based on interview and record review the facility failed to:Ensure uncertified Nurse's Aides (NA, in training not certified) did not provide direct resident care (hands on care) while unsupervised by a Certified Nursing Assistant (CNA, certified by state) or Licensed Nurse (LN).Ensure uncertified Nurse's Aide did not go beyond the time frame of four months between hiring, graduation, and certification. This had the potential to put all residents at risk of injury and not to meet their care needs. Refer to F839.Findings:A review of Facility 2's document titled FACILITY: NURSE ASSISTANT TRAINING PROGRAM NOTICE dated 5/8/25, indicated they had an approved Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification) from California Department of Public Health (CDPH).A record review of Facility 2's policy titled, Hiring and Employment Verification revised 12/26/202,) indicated The facility is committed to hiring qualified, ethical, and legally authorized individuals to maintain the safety and quality of care for residents. Hiring and employment verification processes will follow all applicable federal and state regulations, including compliance with California's Department of Public Health (CDPH) requirements for skilled nursing facilities. Under Purpose it stated, To ensure the employees of the facility meet the standards for safe and lawful employment within California. This applied to prospective and current employees of the facility, including clinical, non-clinical, temporary and contracted staff.A record review of Nursing Assistant Job Description, undated indicated states Nurse's Assistants provide each assigned resident with routine daily care and services in accordance with nursing care activities in which nursing assistants have received clinical instruction and demonstrate competency. NA job description states NAs cannot perform direct resident care until theory and clinical skills are accomplished.1. A record review of Facility 2's CNA/NA active employee list, daily assignments for October, November, December 2025, and the California Board Nurse's Aide Registry on 1/08/2025 at 1:35 pm indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/5/2025. On 10/18/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/9/2025 -11/11/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/13/2025-11/16/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/1/2025 - 12/4/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified as a nursing assistant on 12/20/2025. On 11/12/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am. On 12/1/2025- 12/3/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am On 12/6/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am.NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. On 10/13/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/17/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On10/19/2025 NA 3 was assigned 1:1 care (direct observation), unpaired with a CNA from 6:30 am to 2:30 pm. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025). On10/13/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 11/11/2025 -11/12/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 1/15/2025 -11/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/23/2025 NA 4 was assigned to accompany residents to appointments from 6:30 am to 2:30 pm. NA 5 was hired on 9/5/2025, graduated 10/27/2025, and became certified on 11/19/2025. On 11/10/2025 - 11/12/2025 NA 5 was assigned to work independently providing direct resident care, unpaired with a CNA from 2:30 pm to 10:30 pm.NA 6 was hired 9/5/2025, graduated 10/17/2025, and remained uncertified until terminated. On 10/18/2025 NA 6 was assigned to work independently providing direct resident care, unpaired with CNA from 2:30 pm to 10:30 pm.2. A review of CNA and NA employee list dated 9/1/2025 to 12/8/2025 indicated: NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025).NA 7 was hired on 2/5/2025 and was certified on 9/26/2025.NA 8 was hired on 3/12/2025 and was certified on 10/27/2025.NA 9 was hired on 4/2/2025, graduated from NATP on 5/29/25 and certified on 10/6/2025.During an interview with CNA 1 on 12/5/2025 at 2:28 pm, CNA 1 was hired on 5/29/25 and stated they have recently become a CNA and have worked at Facility 2 for six months on evening shift. CNA 1 stated they were trained through Facility 2's NATP. During an interview with Licensed Vocational Nurse (LVN 1) on 12/5/2025 at 2:35 pm, LVN 1 stated after being signed off NAs perform direct resident care and CNAs are standby's (guides) for the NA. LVN 1 stated the NATP was within Facility 2. During a telephone interview with NA 2 on 12/8/2025 at 8:40 am, NA 2 stated they have recently graduated from NATP at Facility 2 and are waiting to retake the state CNA test. NA 2 stated they have been working at Facility 2 for 2 months on night shift. NA 2 stated once the clinical skills were checked off by the Nurse's Aide Training Program Instructor (NATP-I) or the Director of Staff Development (DSD) they were able to provide direct resident care to assigned residents. NA 2 stated they can do everything a CNA can do, including changing, peri care, and ambulating residents. NA 2 stated they know they are not supposed to provide direct resident care independently but there are times when they have. NA 2 stated they are somewhat watched by CNAs mostly when they are uncomfortable providing certain direct resident care tasks independently.During a concurrent interview with NATP-I (Facility 2) and DSD (Facility 2) on 12/23/2025 at 2:00 pm, NATP-I stated the NATP provides 60 hours of theory off-campus and 100 hours of clinical training at Facility 2. NATP-I stated students apply for the NATP and are interviewed prior to their training for hiring at Facility 1, Facility 2, and Facility 3. NATP-I stated 15 NA students are chosen for NATP per training course and once interviewed Facility 1, Facility 2, and Facility 3 hire five NA students for each site. NATP-I stated NAs are not supposed to do provide direct resident care without the supervision of a CNA or licensed nurse until they are state certified. NATP-I stated the graduated NAs are hired as NAs in training until they receive their certification. Upon reviewing statements from NA 2 on 12/8/2025 regarding being somewhat watched and providing care independently on the night shift, DSD stated the NAs have recently been moved to am and pm shifts for closer observation. DSD stated they recently updated their employee assignments to include who the NAs are paired with. DSD and NATP-I stated they were unaware that NA graduates are not permitted to go to Facility 1 and Facility 3 as uncertified NAs. DSD and NATP-I were aware that Facility 1 and Facility 3 did not have NATPs. NATP-I stated NAs hired at Facility 2 do not receive additional competency testing because they have already trained them as NA students and are confident in their abilities. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, the NATP, Facility 2 and Facility 3. VPO stated Facility1 was the only approved NATP site. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 2 and 3 were not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO was unaware that Facility 2 had multiple NAs working beyond the four months without being certified by the state. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview and record review the Governing Body failed to provide oversight for the Administrator to ensure nurse's aides were state certified and had the competencies required prior to providing care to residents independently and were certified within four months of graduating from a Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification). This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.Findings:A review of the Governing Body Agenda and Minutes dated 10/24/2025 indicated that policy development, establishment, and implementation were handled by Administrative Services. A record review of Facility 1's Operational Manual Administrative Policies (undated) indicated the Governing Body (GB) was responsible and accountable for Quality Assurance and has engaged Administrative Services to develop policies and procedures for the management and operations of the facility.A record review of Facility 2's policy titled, Hiring and Employment Verification (revised 12/26/2024) on 1/8/2025 at 3:43 pm stated, The facility is committed to hiring qualified, ethical, and legally authorized individuals to maintain the safety and quality of care for residents. Hiring and employment verification processes will follow all applicable federal and state regulations, including compliance with California's Department of Public Health (CDPH) requirements for skilled nursing facilities. Under Purpose it stated, To ensure the employees of the facility meet the standards for safe and lawful employment within California. This applied to prospective and current employees of the facility, including clinical, non-clinical, temporary and contracted staff.1. A record review of Facility 2's CNA/NA active employee list, daily assignments for October, November, December 2025, and the California Board Nurse's Aide Registry on 1/08/2025 at 1:35 pm indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/5/2025. On 10/18/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/9/2025 -11/11/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with CNA from 6:30 am to 2:30 pm. On 11/13/2025-11/16/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/1/2025 - 12/4/2025 NA 1 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified as a nursing assistant on 12/20/2025. On 11/12/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am. On 12/1/2025- 12/3/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am On 12/6/2025 NA 2 was assigned to work independently providing direct resident care, unpaired with a CNA from 10:30 pm to 6:30 am.NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. On 10/13/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/17/2025 NA 3 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On10/19/2025 NA 3 was assigned 1:1 care (direct observation), unpaired with a CNA from 6:30 am to 2:30 pm. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025). On10/13/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 10/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 11/11/2025 -11/12/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 1/15/2025 -11/16/2025 NA 4 was assigned to work independently providing direct resident care, unpaired with a CNA from 6:30 am to 2:30 pm. On 12/23/2025 NA 4 was assigned to accompany residents to appointments from 6:30 am to 2:30 pm. NA 5 was hired on 9/5/2025, graduated 10/27/2025, and became certified on 11/19/2025. On 11/10/2025 - 11/12/2025 NA 5 was assigned to work independently providing direct resident care, unpaired with a CNA from 2:30 pm to 10:30 pm.NA 6 was hired 9/5/2025, graduated 10/17/2025, and remained uncertified until terminated. On 10/18/2025 NA 6 was assigned to work independently providing direct resident care, unpaired with CNA from 2:30 pm to 10:30 pm. 2. A review of CNA and NA employee list dated 9/1/2025 to 12/8/2025 indicated: NA 3 was hired on 2/24/2025 and became certified as a CNA 12/15/2025. NA 4 graduated from NATP on 6/23/2025, was hired on 6/23/25, and remains uncertified to date (1/15/2025).NA 7 was hired on 2/5/2025 and was certified on 9/26/2025.NA 8 was hired on 3/12/2025 and was certified on 10/27/2025.NA 9 was hired on 4/2/2025, graduated from NATP on 5/29/25 and certified on 10/6/2025.During a concurrent interview with NATP-I (Facility 2) and DSD (Facility 2) on 12/23/2025 at 2:00 pm, NATP-I stated the NATP provides 60 hours of theory off-campus and 100 hours of clinical training at Facility 2. NATP-I stated students apply for the NATP and are interviewed prior to their training for hiring at Facility 1, Facility 2, and Facility 3. NATP-I stated 15 NA students are chosen for NATP per training course and once interviewed Facility 1, Facility 2, and Facility 3 hire five NA students for each site. NATP-I stated NAs are not supposed to do provide direct resident care without the supervision of a CNA or licensed nurse until they are state certified. NATP-I stated the graduated NAs are hired as NAs in training until they receive their certification. Upon reviewing statements from NA 2 on 12/8/2025 regarding being somewhat watched and providing care independently on the night shift, DSD stated the NAs have recently been moved to am and pm shifts for closer observation. DSD stated they recently updated their employee assignments to include who the NAs are paired with. DSD and NATP-I stated they were unaware that NA graduates are not permitted to go to Facility 1 and Facility 3 as uncertified NAs. DSD and NATP-I were aware that Facility 1 and Facility 3 did not have NATPs. NATP-I stated NAs hired at Facility 2 do not receive additional competency testing because they have already trained them as NA students and are confident in their abilities. During an interview with the Governing Body, with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, the NATP, Facility 2 and Facility 3. VPO stated Facility1 was the only approved NATP site. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 2 and 3 were not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO was unaware that Facility 2 had multiple NAs working beyond the four months without being certified by the state. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview, and record review, the facility failed to provide medical records for one out of four Residents (Resident 1) in a timely manner.This had the potential to interfere with Resident 1's care decision making and cause distress to his well-being.During a review of the facility's policy titled Resident Access to Protected Health Information (PHI), revised November 1, 2015, indicated If the resident and/or their personal representative requests a copy of the resident's medical record.[the facility] will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request.During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including Essential Hypertension, Type 2 Diabetes Mellitus, and Mild Protein-Calorie Malnutrition. Resident 1's quarterly Minimum Data Set (MDS, a resident assessment tool), dated 8/11/25, documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment.During a telephone interview on 11/13/25 at 5:42 PM with Family A, Family A stated that multiple requests for medical records had been made since October 2025. Family A stated, We submitted an Advance Health Care Directive (AHCD - a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) and Durable Power of Attorney (POA - a legal document that allows someone else to make financial or health care decisions) to the facility. Despite this, the records were not released until 11/07/25.During an interview on 11/13/25 at 12:57 PM, Resident 1 stated that Family B was authorized to make medical decisions on his behalf, saying, I signed paperwork for him to be in control.During a concurrent interview and record review on 11/14/25 at 1:15 PM, the Administrator stated that the delay in releasing the records was due to the facility's belief that Resident 1 lacked capacity and that the AHCD was therefore invalid. The Administrator confirmed the first documented request was received on 11/03/25, and the records were released on 11/07/25-exceeding the two-working-day timeframe outlined in the facility's policy.During a concurrent interview and record review on 11/18/25 at 9:44 AM, the Director of Nursing (DON) confirmed that Family A was recognized as the decision-maker and acknowledged that the records were not released within the required timeframe.

Based on interview and record review, the facility failed to prevent abuse to one resident (RES1), when a Licensed Nurse at the facility (LVN1) was verbally abusive while providing care to RES1. This failure had the potential to cause harm to all residents residing in the facility that had contact with LVN1. Findings: During a review of a facility policy titled, Abuse Prevention, Screening and Training Program, last revised 7/1/18, and in effect, indicated that the facility did not condone any form of abuse and would provide an environment free of abuse to all residents. Verbal abuse was defined as any oral, written, or gestured communication that is belittling or derogatory and directed at any resident regardless of age, ability to comprehend, or disability. During a review of a nursing progress note by LVN1 on 5/16/25, at 10:57 PM, it was indicated that education about the importance of nutrition for health and to rebuild strength was provided to RES1. During an interview on 5/29/25, at 11:17 AM, the Director of Staff Development (DSD) indicated that RES1's family brought in yogurt, that yogurt was a food preference choice made by RES1, that yogurt was a good source of protein, and that RES1 had been encouraged to choose foods high in protein. The DSD confirmed that LVN1 had documented in the medical record that RES1 had been educated about nutrition. During an interview on 5/29/25, at 11:18 AM, the DSD stated that LVN1 had worked at the facility since 1/17/22 and had completed the mandatory facility abuse training each year of employment. The DSD also stated that a facility investigation was completed after RES1's family reported that LVN1 had stated to RES1, you are going to leave here in a pine box. The DSD stated that LVN1 had provided dietary education to RES1 that included the statement, if you do not eat, you will die. The DSD stated that the statement LVN1 made to RES1 was abuse and indicated that LVN1 should not have made abusive statements to any resident. During an interview and concurrent employee file review with the Director of Nursing (DON), on 5/29/25, at 11:29 AM, the DON stated that LVN1 had made an abusive statement to RES1, that the abuse was overheard by another staff member, and that LVN1 had been placed on leave. The DON stated that LVN1 should not have made statements about death to RES1 while providing dietary education. A review of a document titled, Corrective Action Memo in LVN1's employee file indicated that the statements made by LVN1 were unacceptable, unprofessional, and a direct violation of the facility standards of care, resident rights, and abuse prevention policy. The DON stated that LVN1 had resigned from the facility. Based on interview and record review, the facility failed to prevent abuse to one resident (RES1), when a Licensed Nurse at the facility (LVN1) was verbally abusive while providing care to RES1. This failure had the potential to cause harm to all residents residing in the facility that had contact with LVN1. Findings: During a review of a facility policy titled, Abuse Prevention, Screening and Training Program, last revised 7/1/18, and in effect, indicated that the facility did not condone any form of abuse and would provide an environment free of abuse to all residents. Verbal abuse was defined as any oral, written, or gestured communication that is belittling or derogatory and directed at any resident regardless of age, ability to comprehend, or disability. During a review of a nursing progress note by LVN1 on 5/16/25, at 10:57 PM, it was indicated that education about the importance of nutrition for health and to rebuild strength was provided to RES1. During an interview on 5/29/25, at 11:17 AM, the Director of Staff Development (DSD) indicated that RES1's family brought in yogurt, that yogurt was a food preference choice made by RES1, that yogurt was a good source of protein, and that RES1 had been encouraged to choose foods high in protein. The DSD confirmed that LVN1 had documented in the medical record that RES1 had been educated about nutrition. During an interview on 5/29/25, at 11:18 AM, the DSD stated that LVN1 had worked at the facility since 1/17/22 and had completed the mandatory facility abuse training each year of employment. The DSD also stated that a facility investigation was completed after RES1's family reported that LVN1 had stated to RES1, you are going to leave here in a pine box. The DSD stated that LVN1 had provided dietary education to RES1 that included the statement, if you do not eat, you will die. The DSD stated that the statement LVN1 made to RES1 was abuse and indicated that LVN1 should not have made abusive statements to any resident. During an interview and concurrent employee file review with the Director of Nursing (DON), on 5/29/25, at 11:29 AM, the DON stated that LVN1 had made an abusive statement to RES1, that the abuse was overheard by another staff member, and that LVN1 had been placed on leave. The DON stated that LVN1 should not have made statements about death to RES1 while providing dietary education. A review of a document titled, Corrective Action Memo in LVN1's employee file indicated that the statements made by LVN1 were unacceptable, unprofessional, and a direct violation of the facility standards of care, resident rights, and abuse prevention policy. The DON stated that LVN1 had resigned from the facility.

Based on observations, interviews and record reviews, the facility failed to ensure staff were trained, competent and following their training when: *1. Staff did not clean fixed equipment (equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) according to policy or standards of practice. *2. Staff did not consistently follow professional standards of practice to avoid cross contamination during food production processes. (Cross Reference F812). *3. Staff did not follow standardized recipes. Findings: During a record review of facility onboarding checklist for dietary staff titled Food and Nutrition Services: New Employee Onboarding Checklist (undated), indicated dietary staff were trained on twenty-two topics. The document further indicated seven of the twenty-two topics pertained specifically to the kitchen and included: location of work order maintenance and how to complete forms; dress code; job description; location and use of dietary manual, therapeutic diets, menus, spreadsheets; monthly requirements and location of in-service calendar; SDS (safety data sheets) binder; and review of current dietary QAPI (Quality Assurance and Performance Improvement). Three (Dietary Aide - DA A, [NAME] B, [NAME] D) out of five (DA A, DA C, [NAME] A, [NAME] B, [NAME] D) sampled dietary staff completed this facility onboarding checklist. During a record review of facility competency checklist titled Rockport Competencies Verification - Dietary Aides (undated), indicated dietary staff were trained on 15 competencies and included: proper handwashing; dishwashing procedure; food temperature danger zone; how to test sanitizer with test strips; how to use a hairnet; how to report high temperatures for the refrigerators and freezers; and how to calibrate thermometers and record on log. Two (Cook A, DA C) out of five (DA A, DA C, [NAME] A, [NAME] B, [NAME] D) sampled dietary staff completed this competency checklist. *1. During the survey starting on 3/3/25 at 8:04 AM and continuing through 3/6/25 at 3:00 PM, the kitchen was not sanitary (Cross Reference F812). Review of the 2022 FDA Food Code 4-601.11 showed A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During observations in the kitchen beginning on 3/3/25 at 8:04 AM, multiple shelving units in the kitchen used to store food or clean equipment were not clean. The industrial mixer had areas of dried food on the bottom of the stand and behind the bowl. The blender had dried food on the motor base and control switches, and there was a wet, brown ring under the blades inside the blender. The steamer had dried food on the control knobs and inside of the handle. The kitchen timer and two thermometers used to check resident food temperatures had dried food and dust on them. Four out of four large pots were burnt on the bottom. There was tape residue (a source of cross contamination) on counters, refrigerators in food preparation areas and on stored clean empty food storage containers. Four out of eight knives in wall mounted knife rack had food residue on them. Dust and dried liquid were noted on top of white arctic air freezer pot lids were stored in the refrigerator/freezer room. During observations and concurrent interviews on 3/4/25 beginning at 9:01 AM, and on Regional Registered Dietician (RRD) and the DM confirmed gaskets inside the white arctic refrigerator, and the top of the refrigerator were dirty, and tape residue on counters and food storage containers was a potential source of cross contamination. They confirmed the base of the industrial can opener, the kitchen timer, thermometers, steamer, and shelving were not clean, and were a potential source of cross contamination. During a record review of facility policy titled Can Opener use and Cleaning 10/1/2014, indicated the can opener will be sanitized between uses. Facility policy further indicated shank of can opener was to be removed and scrubbed, rinsed with clean water, sanitized with sanitizing solution, and air dried. Facility policy also indicated the base plate attached to the counter was to be scrubbed with hot detergent solution and brush, sanitized, and air dried. Review of multiple policies (provided by the RRD) directed staff to use the following process to clean fixed equipment: wash with detergent, rinse with clean water, sanitize with sanitizing solution, and air dry. These policies included: Cart Cleaning (10/1/14), Sanitation of Reach-in Refrigerator (7/13/23), Can Opener Use and Cleaning (10/1/14). Review of the instructions on the Diversey J-512 Sanitizer product used in the kitchen directed that after cleaning equipment, to apply the sanitizer and Allow surfaces to remain wet for at least 60 seconds. Review of documents titled Cleaning Schedule, dated 1/1/25 through 2/28/25 showed daily and intermittent cleaning assignments for the AM Cook, PM Cook, AM Diet Aide, PM Diet Aide, and Prep Cook. Assignments directed staff to either clean, clean and sanitize, or wipe down the equipment and to disinfect all food contact areas. The Cook's assignments included cleaning equipment after each use, specifically listing the blender, mixer, and steamer, among other equipment. The Diet Aides assignments included cleaning the food (resident meal) carts and black utility carts among other equipment. The Prep [NAME] assignments included bring cart outside and hose off rack top to bottoms get free of debris. It also included to dust the fans on the windows. 2,198 out of 2,397 cleaning opportunities were signed off by staff as completed, yet equipment was not clean. During an observation on 03/03/25 at 09:05 AM, DA A was cleaning resident meal carts after breakfast. In a concurrent interview she explained the process they used to clean carts after they were emptied: She dipped the rag in the sanitizer (red) bucket and wiped down the cart. There was no other part of the process. All meal carts were pressure washed outside once monthly. During an interview with DA C, on 03/03/25 at 03:15 PM he was asked how he cleaned the meal carts. DA C stated they washed the carts using the green (soap) bucket, let the soap dry; then used the red bucket to sanitize. When asked to explain again, he stated after washing with the green bucket, he let it air dry and then he wiped it with the sanitizer solution and let it air dry. DA C did not include rinsing off the soap, and he did not know if the sanitizer was supposed to stay wet for any length of time to be effective. During an interview with [NAME] C on 03/04/25 at 09:25 AM she reported this process for cleaning carts: Wipe down with soap (green bucket), wipe down with sanitizer (red bucket), wait 60 seconds before placing anything on it. She stated there were no additional steps (rinsing) between applying soap and wiping with sanitizer. During an interview with the Dietary Manager (DM) and Regional Dietary Manager (RDM) on 03/05/25 at 03:03 PM, the DM was asked how carts should be cleaned. She stated they should be washed with soapy water, then wiped with sanitizer, and air dried. She was not aware the soap needed to be rinsed off or the sanitizer needed to remain wet for 60 seconds to sanitize effectively. *2. Staff did not consistently follow professional standards of practice to avoid cross contamination in food production processes. (Cross Reference F812). Glove Use: During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated proper hand washing should occur after touching bare human body parts other than clean hands and arm, and during food preparation, as often as necessary to prevent cross contamination when changing tasks. During an observation on 3/4/25 at 11:08 AM, [NAME] C was observed loading lunch meal trays with gloves on. [NAME] C scratched her face with gloved hands and continued to place items on trays without washed hands or changed gloves. [NAME] B was observed with elbow/forearm draped across Robocoupe (a food processer appliance) base during food preparation. During an observation and concurrent interview on 3/6/25 at 11:25 AM, DA A was observed with no gloves when she prepared dessert. DA A touched the tops and bottoms of the dessert bowls when she placed them on the tray. DA A was observed scratching her nose with one ungloved hand. DA A did not wash her hands. DA A continued to scoop red gelatin into the dessert cups ungloved. DA A stated she was not sure if she should wear gloves when she prepared the dessert cups. Apron Use: During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated staff were to wear clean aprons and change as often as needed. During an observation on 3/4/25 at 10:10 AM, observed Dietary Aide (DA) B with no apron, stretched over soiled counter to clean the counter and back splash. DA B sprayed water to rinse counter and back splash and admitted she was sprayed with overspray. She returned to meal tray assembly processes with her potentially contaminated clothing and no apron. During an observation on 3/4/25 at 11:46 AM, [NAME] B was observed with a black apron when she cleaned the Robocoupe bowl, lids and blades. [NAME] B wore the same black apron when she returned to food production. *3. Staff did not follow standardized recipes (Cross Reference F803, F804). During resident interviews on 3/5/25 from 9:52 am through 10:15 am, four out of four residents (Residents 15, 18, 59, 372) stated the food needed more seasoning or salt and/or the meat was difficult to cut with the provided knife. During an interview with [NAME] A on 03/03/25 at 11:40 AM, she explained the facility and corporation started new menus in June or July 2024. She stated many of the new recipes were off in their yields - either way too much or not enough for the servings planned. She stated the DM communicated to the corporate Dietitians about the problem recipes. They started the new menu in June or July 2024. She stated it was a constant battle and they found a lot of errors. During a review of facility policy titled Standardized Recipes 7/1/14, indicated food products prepared and served by the dietary department will utilize standardized recipes. Facility policy further indicated DM will monitor and routinely verify the recipes used by the cooks. Facility policy also noted recipe accuracy concerns will be reported to the Dietitian for evaluation and modification as necessary. During a concurrent observation and interview on 3/3/25 at 2:36 PM, [NAME] D prepared Ham and Swiss sandwiches for the dinner meal. Recipe called for one croissant, 1 ounce (oz) of ham (two slices), and 1 oz of Swiss cheese (two pieces). Observed [NAME] D as he made sandwiches with one slice of ham, one piece of American/Swiss pasteurized cheese, tomato, lettuce, and two slices of white bread. [NAME] D weighed one slice of ham, which equaled 0.5 oz. [NAME] D weighed one piece of American/Swiss pasteurized cheese, which equaled 0.5 oz. DM confirmed [NAME] D did not follow recipe. DM confirmed recipe called for two slices of Swiss cheese and [NAME] D used one piece of American/Swiss pasteurized cheese. DM confirmed [NAME] D should have used two slices of ham instead of one. DM confirmed the recipe did not call for lettuce and tomato. [NAME] D stated he was not sure why he did not follow the recipe. DM stated they did not use croissants because they could only buy them frozen and unsliced, and the croissants fell apart when staff sliced them. She added the FRD approved them to substitute white bread, so they used white bread every time that recipe was on the menu. When asked if their vendor had other croissant products that were pre-sliced, the DM replied yes, but corporate controlled their order guide and they were not allowed to order that. During a concurrent observation and interview on 3/4/25 at 9:26 AM, [NAME] B made Ranch-style chicken for lunch. Recipe called for baking sheet to be greased, chicken breasts to be baked for 15 minutes, removed from oven, covered in ranch dressing, and put back in oven. Observed [NAME] B pour cooking oil into baking sheet, placed chicken breasts on baking sheet, removed from oven after 15 minutes, temperature checked with thermometer, and placed back into oven. [NAME] B was not observed putting ranch onto the chicken breasts. During an observation in the cook's area on 03/04/25 at 11:26 AM, [NAME] C was pureeing cookies. She assembled the cookies, some milk, and got a small empty container that she filled with thickener. She didn't measure any of the ingredients. I think we need some more cookies. She added a little more thickener. When asked if she used a recipe, she stated I'm just used to doing milk with the cookies. When asked how much milk she was supposed to use she went and looked at the recipe, reported it should be one cup. When asked how she knew what portions to make, she stated she used 2 cookies per person, plus two extra cookies. She poured her pureed cookies with runny consistency into small dessert bowls. She stated she only added a little bit of thickener. She explained that usually, if she went by what the recipe said, the consistency didn't turn out like it was supposed to. During a concurrent observation and interview on 3/4/25 at 1:02 PM during test tray task, Regional Registered Dietitian (RRD) confirmed she did not taste ranch dressing flavor in the chicken breast. The RRD agreed the pureed cookie was stiff and gummy, and stated she thought it was probably because the cook had to rush to make a new batch for the pureed test tray. During an interview on 3/5/25 at 9:26 AM, [NAME] B stated she used ranch dressing on the chicken breast when she prepared Ranch Style Chicken. [NAME] B stated she did not drain the chicken after it baked for 15 minutes like recipe directed. [NAME] B confirmed she did not grease baking sheets according to recipe. [NAME] B confirmed she poured an unknown amount of cooking oil onto baking sheets. [NAME] B stated she did not use ranch dressing on some of the chicken because there were residents who were lactose intolerant at facility. [NAME] B stated she did not know why the chicken without ranch dressing was on the test tray. During a record review of 68 facility meals tickets dated 3/4/25, indicated zero out of sixty-eight residents as lactose intolerant, but one out of 68 showed dislikes other - dairy.

Based on observation, interview and record review the facility failed to ensure that recipes were standardized to provide a repeatable desirable product, yield and texture; that appropriate ingredients were available on the order guide to prepare recipes successfully and in compliance with their nutrient analysis; and to provide seasoning acceptable to the diet order and resident satisfaction. These failures had the potential to result in staff not following recipes because they didn't work or didn't produce the correct yield or consistency, and the potential to decrease resident satisfaction, meal intakes, and overall health status. Findings: Review of a facility policy titled Menus, revised 4/1/14 showed the facility provided meals that met the nutritional requirements defined by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designed in consideration of resident preferences, Dietary Department resources, and seasonal availability of foods. Food served should adhere to the written menu. It further stated substitutions could be made under variable circumstances including when an item or ingredient was unavailable, but it had to be comparable in nutrition value, including calories and other nutrients. In addition, permanent substitutions required menus, therapeutic spreadsheets, and recipes to be updated to reflect the changes. During an interview with the Regional Registered Dietitian (RRD) on 3/05/25 at 11:07 AM, she stated their menu had a four-week cycle that repeated each month and changed seasonally. They posted the menus week to week for resident's review. During an interview with the RRD on 3/05/25 at 11:30 AM - she provided copies of the weekly menus titled Week At-a-Glance Menu, (Weeks 1-4) dated 2025, for Fall, Winter, and Updated S/S. When asked what the S/S on the menus meant, she replied those were the summer menus. She stated was unable to provide the spring menu to us because it wasn't finished yet. RRD stated the spring menu cycle would start the last Sunday of March 2025 (3/30/25). During an interview with the Dietary Manager (DM) and Regional Dietary Manager (RDM) on 3/05/25 at 3:03 PM, they were asked about the new menus. The DM stated sometimes the menus were challenging, but she received help. She stated some ingredients were not available for purchase on the purchase guide. Some language in the recipes was different for describing scoop sizes. The yield was not always accurate, so they padded the count by 6 servings or so to make sure they had enough. During an interview with the Facility Registered Dietitian (FRD) on 03/05/25 at 3:55 PM, she stated there were valid concerns with the menu that she had discussed with the RRD and the RDM, including problems with the recipes. She stated the recipes called for a lot of different ingredients that were only used occasionally in small amounts. This was a problem for tight budgets when there were so many other things the DMs had to buy, and it was also a problem to store all those ingredients when kitchens were so small. The FRD stated she was not aware of the turn-around time for menu and recipe issues to be fixed by corporate. During an interview with the DM, RDM, RRD (on the phone), and FRD (on the phone) on 3/6/25 at 1:20 pm, the RRD and RDM stated it wasn't a problem that the spring menu hadn't been rolled out yet because it was available to the DMs for their review and planning on their corporate website. When asked if the cost of ingredients in relation to budget, and the kitchen's food storage capacity for the large number of menu ingredients was a problem for her department, the DM nodded her head yes. *1. Standardized recipes were not followed, and some ingredients specified in standardized recipes were not used in preparation of food for residents (Cross Reference F802, F803) A standardized recipe is a recipe that has been developed and tested using specific quantities of specific ingredients, with specific instructions, cook times and temperatures to ensure that a consistent product (appearance, flavor, texture, nutrient content) and number of servings (yield) is produced each time it is prepared. Review of a facility policy titled Standardized Recipes, dated 7/1/14, showed food products prepared and served by the dietary department will utilize standardized recipes. Facility policy further indicated DM will monitor and routinely verify the recipes used by the cooks. Facility policy also noted recipe accuracy concerns will be reported to the Dietitian for evaluation and modification as necessary. During an interview with [NAME] A on 3/03/25 at 11:40 AM, she stated their new menu was rolled out from corporate in June or July 2024. She stated many of the new recipes were inaccurate in their yields - either way too much or not enough for servings planned. She stated the Dietary Manager (DM) communicated with the corporate dietitians about problem recipes, but it was a constant battle, and the cooks found a lot of errors in the recipes. Review of a document titled Week at A Glance menu: Rockport Winter 2024, Week 1 showed dinner on Monday, Day 2 (3/3/25), the menu was to be Ham & Swiss on Croissant, Lettuce & Tomato, Condiments, Classic Macaroni Salad, Strawberries & Bananas with Whipped Topping, and Milk/Beverage. During a concurrent observation and recipe review on 3/3/25 at 2:36 PM, [NAME] D did not prepare the Ham & Swiss on Croissant dinner sandwiches according to recipe. He used less ham and cheese than specified in the recipe. He used white bread instead of croissants. He used American/Swiss pasteurized cheese instead of Swiss cheese. [NAME] D stated he was not sure why he did not follow the recipe. In a concurrent interview, the DM confirmed [NAME] D did not follow recipe. She stated they didn't use croissants because they could only buy them frozen and unsliced, and they fell apart when staff sliced them. She stated the RD approved the substitution of white bread instead of croissant, so they use white bread every time this recipe was on the menu. When asked if their vendor had other croissant products available that would work in the recipe, the DM stated yes, but corporate controlled their order guide and they were not allowed to order the croissants that would work. A review of the Nutrition Facts for [NAME] Round Top Bread, obtained through the facility's food vendor and provided by the RRD, showed two slices of the white bread used in the Ham & Swiss Croissant sandwich provided 200 calories. The Nutrition Facts for Croissant Butter Perfect Frozen showed one croissant provided 280 calories. Cumulative substitutions over time could potentially impact the nutrients provided to residents over time, when compared to the facility's nutrient analysis of the menu. During an observation on 3/4/25 at 9:26 AM, [NAME] B prepared a baking sheet of Ranch-style chicken for lunch. A concurrent review of the recipe titled Ranch Style Chicken Breast, dated 2025, called for one gallon plus two cups of Ranch Style Dressing to be added to 18 3/4 pound of chicken breasts. [NAME] B did not follow the instructions in the recipe. She added cooking oil that was not called for in the recipe, and she was not observed putting ranch dressing onto the chicken breasts (Cross Reference F802, F804). During an observation in the cook's area on 03/04/25 at 11:26 AM, [NAME] C was pureeing cookies. She assembled cookies, milk, and thickener. She didn't measure any of the ingredients. I think we need some more cookies. She added a little more thickener. She poured her pureed cookies with runny consistency into small dessert bowls. When asked if she used a recipe, she stated that if she went by what the recipe said, the consistency didn't turn out like it was supposed to. *2. Recipes did not consistently provide a palatable product During a concurrent observation and interview on 3/4/25 at 1:02 PM, the RRD and two surveyors evaluated a pureed regular diet lunch test tray, and a regular lunch test tray for appearance, flavor, and texture. The RRD confirmed she did not taste ranch dressing flavor in the chicken breast. The RRD agreed the potatoes tasted like they had no seasoning. The RRD agreed the pureed cookie was stiff and gummy, and stated she thought the cookie didn't turn out properly because the cook rushed to make a new batch for the test tray. A review of a recipe titled Roasted Red Potatoes showed it called for 10 pounds, 13 ounces of fresh red potatoes, one teaspoon of salt, (plus oil, paprika and pepper). A review of a recipe titled Mashed Potatoes with Gravy (PU4 = pureed) showed it called for Instant Mashed Potatoes, and brown gravy mix. No salt was included in the recipe. During an interview with the RRD on 3/5/25 at 9:26 AM, she confirmed the recipe for potatoes called for one teaspoon of salt for ten pounds, 13 ounces of potatoes. RRD agreed this was not enough salt. RRD agreed chicken from test tray did not taste like it had ranch dressing. During an interview on 3/5/25 at 9:52 AM, Resident 372 stated facility pork needed more seasoning. During an interview on 3/5/25 at 10:01 AM, Resident 59 stated she wished the food tasted a little better. During an interview with the DM, RDM, RRD (on the phone), and FRD (on the phone) on 3/6/25 at 1:20 pm, the DM and RDM agreed the facility had no residents with a 2-gram sodium diet order that would prompt elimination of salt from cooking. The norm was to try to liberalize sodium restrictions to a no added salt salt diet, which allowed salt during cooking, but no extra salt packet on the resident's tray.

Based on observations, interviews, and record review, the facility failed to ensure all residents were consistently offered evening bedtime snacks per facility policy for four out of four sampled residents (Resident 372, 15, 59, 34). Facility also failed to ensure snacks were stocked at two out of two nursing stations per facility policy. This failure had the potential to negatively affect nutrition status and wellbeing of all residents. The facility census was 72. Findings: During a record review of facility policy titled Nourishment and Snacks 4/1/14, indicated Individual and/or bulk snacks are available at the nurse's station for consumption by residents. Additional snacks may be made available upon resident request. Facility policy further indicated rotation of snacks is indicated on the menu spreadsheet for hour of sleep (HS - nighttime) snacks .bulk HS snacks are provided to each nursing station daily. During an interview on 3/5/25 at 10:55 AM, Resident 372 stated he was not offered snacks by staff, but would like to be offered snacks and would take them if offered. During an interview on 3/5/25 at 10:55 AM, Resident 15 stated he was not offered snacks by staff, but would like to be offered snacks and would take them if offered. During an interview on 3/5/25 at 10:55 AM, Resident 59 stated she was not offered snacks by staff, but would like to be offered snacks and might want some if they were offered. During an interview on 3/5/25 at 10:55 AM, Resident 34 stated he had to ask for snacks from staff if he wanted them. Resident 34 stated staff did not offer him snacks. During an interview on 3/5/25 at 3:03 PM, Dietary Manager (DM) stated residents could receive snacks at 10:00 AM, 3:00 PM, and 7:30 PM. DM stated she entered snack preferences into her kitchen documentation and printed out labels to add to resident snacks. DM stated if a resident wanted a snack and kitchen was closed, staff could obtain a snack from either nursing station. DM stated snacks included sandwiches, cheese sticks, crackers, and fresh fruit. DM stated nursing staff informed her if nursing stations ran low on snack stock. During an interview on 3/5/25 at 3:45 PM, Licensed Vocational Nurse (LN) I at nursing station 2 stated residents could request snacks at night from staff. LN I stated if residents were not on the snack list, the charge nurse had a key to the kitchen and could retrieve snacks. LN I stated if nursing station 2 ran out of snacks, staff could get them at nursing station 1 or the charge nurse could restock the nursing station snacks from kitchen the kitchen. During an observation on 3/5/25 at 3:40 PM, nursing station 2 did not have resident snacks (sandwiches, cheese sticks, crackers, and fresh fruit) stocked in the refrigerator or freezer. During an observation on 3/5/25 at 3:42 PM, nursing station 1 did not have resident snacks (sandwiches, cheese sticks, crackers, and fresh fruit) stocked in the refrigerator or freezer.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: 1) Fixed equipment (Fixed equipment is equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) was not clean. 2) Apron was not changed between cleaning dishes and preparing food. Apron was not worn when soiled counter was cleaned. 3) Dietary staff touched face with gloved hands when trays were loaded onto cart and did not change gloves or wash hands. Dietary staff touched tops and bottoms of dessert bowls and scooped Jell-O into them without gloves. 4) Cabinets, floors and walls were uncleanable. 5) Evidence of roaches under one sink. 6) Chlorine concentration was outside of acceptable parameters. 7) Ice machine was not cleaned according to manufacturer recommendations. These practices had the potential to result in foodborne illness for residents from food prepared by the facility food services staff. Findings: 1) During an observation in the kitchen on 3/3/25 at 8:04 AM, rusted shelving was identified in fridge/freezer room where dried food was stored. A white, dried substance was identified on the same shelving unit. The industrial mixer had areas of dried food on the bottom of the stand and behind the bowl. The Extreme Blender had dried food on motor base, buttons and there was a wet, brown ring under the blades inside the blender. The steamer had dried food on the buttons and inside of the handle. The KitchenAid timer and thermometer used to temperature check resident food had dried food and dust on them. Three out of three large pots were burnt on the bottom and warped. The inside of all three large pots were pitted throughout. Three out of four nonstick frying pans had scratches and pitting throughout the cooking surface. One extra large pot was pitted on throughout the inside, had a burnt bottom, and a large, warped bubble on the base. There was tape residue on the stainless counter where staff taped recipes in food preparation area. Dust was noted on large green dish storage rack. The canned food storage racks in the Dietary Manager (DM)'s office were rusted. Four out of eight knives in wall storage had food residue on them. Dried liquid was noted on top of white arctic air freezer where lit pots are stored to dry in fridge/freezer room. During an observation on 3/3/25 at 10:58 AM, observed window by dishwashing sink with accumulated dust and dirt. Observed the window fan had dust collected on blades. Two out of three window fans were observed with accumulated dust. During an observation and concurrent interview on 3/4/25 at 8:57 AM, [NAME] B used a wood handled plastic bristle brush to butter rolls. [NAME] B stated brush was cleaned by dishwasher and sanitizer machine. Observed brush bristles were worn and broken. During an observation and concurrent interview on 3/4/25 at 9:01 AM, Regional Registered Dietician (RRD) confirmed top of gaskets in fridge/freezer room on white arctic fridge were dirty. RRD also confirmed top of fridge was dirty. RRD confirmed tape residue on stainless counter and containers on shelves in fridge/freezer room was a potential source of cross contamination. During a concurrent interview on 3/4/25 at 9:09 AM, DM and RRD confirmed there was dried food and food build up on the base of the industrial can opener and a potential source of cross contamination. DM and RRD confirmed KitchenAid timer and thermometers used to temperature check resident food on top of steamer were not clean. DM and RRD confirmed grease build up on hand and buttons of steamer. DM and RRD confirmed industrial mixer was not cleaned per manufacturer instructions. DM and RRD confirmed Extreme blender base was not cleaned and had food build up. RRD stated she saw dried food in blender buttons, cracks and crevices. During a record review of facility policy titled Can Opener use and Cleaning 10/1/2014, indicated the can opener will be sanitized between uses. Facility policy further indicated shank of can opener was to be removed and scrubbed, rinsed with clean water, sanitized with sanitizing solution, and air dried. Facility policy also indicated the base plate attached to the counter was to be scrubbed with hot detergent solution and brush, sanitized, and air dried. During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated the walls, ceiling, and floor should be maintained in good repair and regularly cleaned. Facility policy further indicated shelving should be .smooth and easily cleaned. 2) During an observation on 3/4/25 at 10:10 AM, observed Dietary Aide (DA) B with no apron, stretched over soiled counter to clean the counter and back splash. DA B sprayed water to rinse counter and back splash and was sprayed with overspray. During an observation on 3/4/25 at 11:46 AM, [NAME] B was observed with a black apron when she cleaned the Robocoupe (a food processor appliance) bowl, lids and blades. [NAME] B wore the same black apron when she returned to food production. During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated staff were to wear clean aprons and change as often as needed. 3) During an observation on 3/4/25 at 11:08 AM, [NAME] C was observed loading lunch meal trays with gloves on. [NAME] C scratched her face with gloved hands and continued to place items on trays without washed hands or changed gloves. [NAME] B was observed with elbow/forearm draped across Robocoupe base during food preparation. During an observation and concurrent interview on 3/6/25 at 11:25 AM, DA A was observed with no gloves when she prepared dessert. DA A touched the tops and bottoms of the dessert bowls when she placed them on the tray. DA A was observed scratching her nose with one ungloved hand. DA A did not wash her hands. DA A continued to scoop red Jell-O into the dessert cups ungloved. DA A stated she was not sure if she should wear gloves when she prepared the dessert cups. During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated proper hand washing should occur after touching bare human body parts other than clean hands and arm, and during food preparation, as often as necessary to prevent cross contamination when changing tasks. 4) During a concurrent observation and interview on 3/3/25 at 8:04 AM, observed worn finish on front of cabinet drawers and doors next to industrial mixer, front of cabinet doors at coffee station in corner, corners of walls in fridge/freezer room with chipped paint area. Observed floor in fridge/freezer room was damaged in three areas. DM confirmed these areas were damaged and uncleanable. DM stated there were no current plans to replace or repair these areas. DM stated Administrator (Admin) was aware of the issues. During an interview on 3/4/25 at 9:01 AM, RRD confirmed floors in fridge/freezer room were damaged and not a cleanable surface. RRD confirmed worn finish on front of cabinets and drawers in kitchen were not cleanable surfaces. During a record review of facility policy titled Floor Safety 11/1/2014, indicated that floors shall be maintained in a safe manner. 5) During an observation and concurrent interview on 3/3/25 at 8:04 AM, two roach pheromone pesticide boxes were observed under the sink at the coffee station. One box in the back right corner was dated 1/16/24. The second box was not dated. A dried brown, kidney-shaped object approximately 3/4 of a centimeter in length was observed next to the second box. Observed coffee ground substance scattered under the sink in both back corners and throughout the surface of the inside of the cabinet. DM stated there was not any pest issues. DM confirmed there were two roach traps under the sink and stated the pesticide boxes were a preventative measure. During an interview on 3/4/25 at 9:01 AM, RRD confirmed two roach traps under the sink in the kitchen. During an interview on 3/5/25 at 3:57 PM, Registered Dietician (RD) stated during the two monthly kitchen inspections she completed since the start of her employment in December 2024, she noted no pest issues in the kitchen. During an interview on 3/6/25 at 9:20 AM, Maintenance Technician (MT) stated he put the roach traps under the sink in the kitchen. MT stated he forgot about them. MT stated facility pest vendor treated outside of facility only. MT stated he looked at roach traps two months ago. MT stated he did not notify DM, RD or dietary staff of evidence of pests or roach traps. MT stated he should have consulted with facility pest vendor regarding evidence of roaches in kitchen. During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated area should be monitored routinely for pest activity. 6) During a concurrent observation and interview with DA C on 3/3/25 at 2:55 PM, DA C stated chlorine level in sanitizer machine need to be between 50-100 parts per million (ppm) on a test strip. DA C tested chlorine concentration, and it was observed that chlorine concentration was 200 ppm. DA C stated chlorine was too concentrated. DA C stated he did not know if that was a problem. DM stated, using too much chlorine is not a problem. DM stated if chlorine levels were too high, she would call the company to fix the machine. 7) During an observation on 3/3/25 at 3:25 PM, MT demonstrated his procedure to clean facility ice machine. MT stated facility policy was for ice machine to be cleaned monthly. MT stated he did not clean ice machine February 2025 because February was a short month. Observed Hoshizaki ice machine located in Harmony dining hall. MT stated ice machine was six months old. MT stated ice machine was last cleaned 1/30/25. MT confirmed he did not do the sanitizer process. MT stated he only does sanitization process with bleach every few months. MT stated he was not aware that both cleaning and sanitizing processes were required each time he cleaned the ice machine. Observed mineral deposit build up inside of ice machine. MT stated mineral deposit build up was difficult to avoid with area water supply. MT stated he last changed ice machine filter 12/30/24. MT stated he would try to change ice machine filter monthly in an attempt to avoid mineral deposit build up.

Based on observation, interview and record review the facility failed to ensure conditions essential to the sanitation of the kitchen were maintained when uncleanable surfaces were not repaired or replaced. This failure had the potential to result in cross contamination, the attraction of pests, and foodborne illness for all residents consuming food from the facility. Findings: A review of the Food and Drug Administration (FDA) 2022 Food Code, Section 4-202.16, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. A review of facility policy titled Maintenance Service, dated 1/1/12, showed The Maintenance Department maintains all areas of the building, grounds, and equipment .in compliance with current federal, state and local laws, regulations, and guidelines. During an observation in the kitchen on 3/03/25 at 8:04 AM, the floor in the refrigerator/freezer room was damaged and uncleanable in three locations. In addition, the walls, doorways, and doors in multiple kitchen locations had worn paint, chipped paint, creating uncleanable surfaces. During an observation in the cook's food preparation area on 3/03/25 at 8:35 AM, the wood cabinets were worn and uncleanable. The area under the corner sink did not have cleanable surfaces, was not clean, and contained two cockroach traps and evidence of cockroaches (Cross Reference F812, F925). [NAME] drawers in the cook's area held serving utensils and clean towels, had grime and gouges, were not clean or cleanable, and the cooks had difficulty opening and closing the drawers. The Formica surface in the corner food prep area was worn thin, and was broken near the trash can, creating uncleanable surfaces. In a concurrent interview, [NAME] A stated the wood drawers were often difficult to open and close. During an observation on 3/03/25 at 11:40 AM, [NAME] A had difficulty opening the cook's wood utensil drawer, and also the metal drawer near the two-compartment. During an observation and concurrent interview with the Regional Registered Dietitian (RRD) on 03/04/25 at 9:00 AM she confirmed the floor in the refrigerator/freezer room was damaged and stated, Not a cleanable surface. During an interview with the Maintenance Technician (MT) on 3/06/25 at 9:20 AM, he stated he did regular monthly inspections of the kitchen. He cleaned filters, coils, looked in corners and behind large equipment to ensure sanitation, checked grease traps, checked the vendor's weekly dish machine service was being done. He stated that as far as he knew, there was nothing in the works yet to replace the wood cabinets in the kitchen. When asked about the floor gouges, and the worn and chipped paint in the kitchen, MI stated I'm one person. I'm doing the best that I can. He stated he had no other maintenance staff to help, and he tried hard to juggle the budget to have what he needed to maintain the facility. 50363

Based on observation, interview and record review the facility failed to maintain an effective pest control program when: *1. The facility did not have an effective system in place to track and monitor pest control issues in the facility. *2. Cockroach traps, and evidence of cockroach presence were found in a cabinet under a food preparation sink in the facility kitchen. These failures had the potential to result in transmission of disease, or to trigger allergies or asthma for 72 residents living at the facility. Findings: The Food and Drug Administration (FDA) Food Code 2022, 6-501.111 showed: The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or, other means of pest control (D) Eliminating harborage conditions (conditions that encourage pests to live and grow). During a record review of facility policy titled Pest Control 1/1/12, indicated the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. Facility policy further indicated a pest control company will inspect the facility and grounds for pests that may cause damage to the facility .submit a written report to the Administrator (Admin) detailing its findings .submit a site-specific work plan for each area/department with recommendations on how to keep the facility pest-free .department staff are responsible for carrying out these recommendations to prevent pests in their respective areas. Facility policy also indicated any pesticides used must be placed in locations inaccessible to staff and away from food storage areas, and facility staff will report to the housekeeping supervisor any sign of rodents or insects. During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated area should be monitored routinely for pest activity. During an observation on 3/3/25 at 8:35 AM, two roach pheromone pesticide boxes were observed under the corner sink in the cook's food preparation area. One box in the back right corner was dated 1/16/24. The second, newer-looking box was not dated. A dried brown, kidney-shaped object approximately 3/4 of a centimeter in length was observed next to the second roach pheromone pesticide box. A black splatter-looking substance resembling cockroach droppings were scattered throughout the bottom, back, sides and corner surfaces inside of the cabinet under the sink. If any of the splatter existed back to placement of pheromone boxes, it had not been cleaned, and the surfaces under the sink were not maintained in a cleanable condition. In a follow-up interview with the Dietary Manager (DM) on 3/3/25 at 9:01 AM, she stated the kitchen had no problems with pests. During a concurrent observation of the interior cabinet under the cook's prep sink with the DM and Regional Registered Dietician (RRD), the DM and RRD confirmed the cabinet contained two cockroach pheromone boxes, and the DM stated they were a preventative measure. During an interview with the Maintenance Technician (MT) on 03/04/25 at 10:45 AM, he was asked about the facility's pest control program, and documentation of the pest control services over the past year were requested. The MT responded he had no records that provided much information about the facility's pest problems, the locations where past problems occurred, or what was done by the pest control company to eradicate the pests. He explained that when pest problems were identified, he sent text messages to their pest vendor, and the vendor came out and took care of it. He stated the facility received invoices for the service calls, but the invoices did not include any information about what pests were found, the location of pests, what was actually done to eradicate the pests, or monitoring to ensure the pest control was effective. MT stated the only records of pest details were in texts on his mobile phone. MT stated he was unaware of any pest issues in the kitchen. In a concurrent observation, MT was shown the evidence of cockroaches under the sink in the cook's prep area in the kitchen. MT stated he called the Pest control vendor who stated he would get help to pull the facility's service details up in his computer and would provide them to the facility. During an interview on 3/5/25 at 3:57 PM, the Facility Registered Dietitian (FRD) stated during the two monthly kitchen inspections she completed since the start of her employment in December 2024, she noted no pest issues in the kitchen. During an interview with the Accounts Payable staff (AP) on 03/06/25 at 07:55 AM, she confirmed she never received anything from the pest control vendor other than the invoice. She had never received any reports about the pest control services provided. A review of documents provided from the pest control vender to MT were titled Service Inspection Report from the facility pest control vendor showed the facility had been combating cockroaches since 8/16/24. The facility continued to have pests: 8/16/24 Treated outside perimeter for roaches 9/4/24 Treated outside perimeter for roaches 10/2/24 Treated outside perimeter for roaches 11/19/24 Treated outside perimeter for roaches During an interview with MT on 03/06/25 at 9:20 AM, he stated he put the cockroach pheromone traps under the sink in the kitchen. He just forgot about it. He stated the pest vendor treated the outside of the building only, but the facility put traps in interior locations and tried to remove food sources. When asked about monitoring of the cockroach traps in the kitchen, MT stated they were being monitored. He stated he looked at them about 2 months previously when a drain in the kitchen was clogged with grease. When asked if anything else should be done when pest problems were discovered, he stated he consulted with the pest control vendor and went from there. When asked why the area under the sink wasn't cleaned to remove existing contamination, and why it was not painted to create a cleanable surface he did not have an answer. He stated he did not notify the food service manager, the FRD or anyone else about the pest evidence in the kitchen or the traps put in place. MT stated he should have consulted with facility pest vendor regarding evidence of roaches in kitchen.

Based on observation, interview, and record review, the facility failed to ensure two out of eight sampled residents (Resident 18 and Resident 370) received their showers as scheduled, and as needed. This failure had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and not identifying altered skin integrity. Findings: During a review of the facility's policy revised 1/1/2012, titled, Showering and Bathing, indicated a tub or shower is given to the residents to provide cleanliness, comfort, and to prevent body odor. Observe the skin is performed during the bath. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents' request for activities of daily living (ADLs, are activities related to personal care. ADLs include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. The facility's policy undated, titled, Residents' Rights, indicated each and every resident in the facility has the right to be treated courteously, fairly, and with the fullest measure of dignity. The facility's policy also indicated all residents receive a prompt response to all responsible requests and inquiries and all residents receive adequate and appropriate health care, and protected health services. During a review of Resident 18's medical record, the Admission Record, indicated Resident 18 was admitted to the facility on [DATE] for diagnosis that included bacteremia (bacteria in your blood), metabolic encephalopathy (problem in the brain with confusion), diabetes (too much sugar in the blood), end stage kidney failure, dependence on dialysis ( a treatment to remove wastes and excess fluid from the blood when the kidneys stop working properly), unspecified severe protein-calorie malnutrition (poor nutrition with not enough protein or energy the body requires), and depression (constant feelings of sadness and loss of interest). During a review of Resident 18's most current minimum data set (MDS, a resident tool assessment) dated 2/1/25, indicated Resident 18 had a BIMS (brief interview for mental status) score of 15 out of 15, indicating Resident 18 had no cognitive (ability to think, reason, and make decisions) deficits and was competent to make her on decisions. During an interview on 3/3/25 at 9:32 am, Resident 18 stated, I have only had one shower every seven to 10 days since I have been here, and that is not enough. During a record review of Resident 18's clinical record, a document dated February 2025, titled, Documentation Survey Report v2, indicated Resident 18 had only received one shower in December from 12/19/24 to 12/31/24. Resident 18 missed one shower on 12/21/24 that indicated Resident 18 was unavailable and one refusal documented on 12/25/25 with no follow up to coordinate showers on non-dialysis scheduled days. During a record review of Resident 18's clinical record, a document dated January 2025, titled, Documentation Survey Report v2, indicated Resident 18 had only received four of nine scheduled showers from 1/1/25 to 1/31/25. Resident 18 missed four showers on 1/4/25, 1/11/25, 1/18/25 and 1/24/25 that indicated Resident 18 was unavailable and one refusal documented on 1/22/25 with no follow up to coordinate showers on non-dialysis scheduled days. During a record review of Resident 18's clinical record, a document dated February 2025, titled, Documentation Survey Report v2, indicated Resident 18 had only received four of nine scheduled showers from 2/1/25 to 2/28/25. Resident 18 missed three showers on 2/5/25, 2/12/25, 1/18/25 that indicated Resident 18 was unavailable and two refusals documented on 2/15/25 and 2/22/25 with no follow up to coordinate showers on non-dialysis scheduled days. During an interview on 3/5/25 at 11:25 am, Licensed Nurse (LN) D confirmed Resident 18 had not received her showers or baths as scheduled since admitted to the facility and there had been no follow up for make-up days. LN D stated, I will change the shower days in the computer to make sure the schedule coordinates with dialysis days. There is no documentation there were further attempts by staff, or changes. The nurses are supposed to make sure the showers are completed as scheduled. The Certified Nursing Assistants (CNA) are supposed to update the nurse when any showers are missed. There is no documentation in the progress notes for any changes or follow up. During a review of Resident 370's medical record, the Admission Record, indicated Resident 370 was admitted to the facility on [DATE] for diagnosis that included Multiple Sclerosis (chronic disease that affects the brain and spinal cord, an autoimmune disorder with various symptoms and severity), surgical aftercare of the digestive system with a surgical wound (open layers to the skin from surgery to the abdomen) requiring a wound vac (Vac, a mechanical device that uses negative pressure to promote wound healing) heart failure (serious heart condition that occurs when the body cannot pump enough blood to meet the body's needs), unspecified mycosis (fungal infection), respiratory failure (when the lungs do not get enough oxygen into the blood) and diabetes. During a review of Resident 370's most MDS, dated [DATE], indicated Resident 370 had a BIMS score of 15 out of 15, indicating Resident 18 had no cognitive deficits and was competent to make her on decisions. During a concurrent interview and record review on 3/4/25 at 10:18 am, LN D confirmed Resident 370 had no showers or baths since the admission on 2/12/25. LN D stated, Resident 370's showers should be coordinated with the wound care nurse and the wound vac can be replaced after each shower. During an interview on 3/6/25 at 8:05 am, LN F confirmed he has never tried to coordinate showers or bathing with the wound care provided for Resident 370. LN F stated, I will talk to the CNAs from now on, and coordinate to make sure Resident 370 gets showers, and the dressing will be changed after the scheduled showers. I agree this should have been coordinated to make sure all care is provided. During an interview on 3/6/25 at 9:05 am, the Director of Nursing (DON) confirmed the showers for Resident 18 and 370 should have been made up, and no coordination of care had been initiated. DON stated, The showers should be provided on non-dialysis days for Resident 18, and the wound vac dressing changes should be completed right after the showers for Resident 370. I will make sure moving forward this coordination is completed upon admission and followed up on weekly.

Based on observation, interview, and record review the facility failed to ensure food was palatable and meat easy to cut with a knife when four out of four residents interviewed (Resident 15, 18, 59, 372) stated the food needed more seasoning or salt and/or the meat was difficult to cut with the provided knife. This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status. Findings: During an observation on 3/4/25 at 9:26 AM, [NAME] B prepared a baking sheet of Ranch-style chicken for lunch. A concurrent review of the recipe titled Ranch Style Chicken Breast, dated 2025, called for baking sheet to be greased, chicken breasts to be baked for 15 minutes, removed from oven, covered in ranch dressing, and put back in oven. Observed [NAME] B pour cooking oil into baking sheet, placed chicken breasts on baking sheet, removed from oven after 15 minutes, temperature checked with thermometer, and placed back into oven. [NAME] B was not observed putting ranch dressing onto the chicken breasts. During an observation and concurrent interview on 3/4/25 at 1:02 PM, the Regional Registered Dietitian (RRD), and two surveyors transported two test trays, one a regular diet and texture, and the second a pureed regular diet, to the Director of Staff Development (DSD)'s office for evaluation. Both trays were evaluated by the RRD and two surveyors. All present agreed the temperature of the foods were acceptable. During evaluation of the pureed tray, RRD stated if there was a dip in the mashed potatoes to hold some gravy, the plate would look nicer. RRD and surveyors agreed mashed potato tasted like it had no seasoning. RRD and surveyor agreed pureed cookie was sticky and gummy. On the regular tray, surveyor noted the chicken needed seasoning. RRD and surveyors agreed they could not taste ranch dressing flavor on chicken as recipe called for. RRD and surveyor agreed cubed potatoes had no flavor and needed seasoning. During a concurrent interview on 3/5/25 at 9:26 AM, RRD confirmed that recipe for potatoes called for one teaspoon of salt for ten pounds of potatoes. RRD agreed this was not enough salt. RRD agreed chicken from test tray did not taste like it had ranch dressing. During a concurrent interview on 3/5/25 at 9:26 AM, [NAME] B stated she used ranch dressing on the chicken breast. [NAME] B stated she did not drain the chicken after it baked for 15 minutes like recipe directed. [NAME] B confirmed she did not grease baking sheets according to recipe. [NAME] B confirmed she poured an unknown amount of cooking oil onto baking sheets. [NAME] B stated she did not use ranch dressing on some of the chicken because there were residents who were lactose intolerant at facility. [NAME] B stated she did not know why the chicken without ranch dressing was on the regular test tray. During a record review of 68 facility lunch meals tickets dated 3/4/25, indicated zero out of sixty-five residents as lactose intolerant. Further review showed one resident disliked Milk (beverage only), and Other dairy. Fourteen out of 68 lunch meal tickets showed a dislike Milk (beverage only). During a subsequent interview with the DM on 3/6/25 at 1:20 pm, DM stated they had one resident with no lactose on their tray ticket. She confirmed that dislikes Milk (beverage only), meant the resident didn't drink milk, but consumed it as an ingredient and liked another dairy. During an interview on 3/5/25 at 9:52 AM, Resident 372 stated facility chicken was way overdone. Resident 372 stated pork is also difficult to cut and needed more seasoning. During an interview on 3/5/25 at 9:54 AM, Resident 15 stated flavor of facility food is okay. Resident 15 stated facility served too much chicken, which was sometimes difficult to cut. During an interview on 3/5/25 at 10:01 AM, Resident 59 stated she did not like facility food. Resident 59 stated the meat served to residents was difficult to cut. Resident 59 wished food tasted a little better. During an interview on 3/5/25 at 10:15 AM, Resident 18 stated facility chicken is hard to chew and cut. Resident 18 stated she wished meat was easier to cut.

Based on observation, interview, and record review, the facility failed to ensure physician orders for a suprapubic (S/P, a thin tube inserted directed into the bladder at the abdomen to drain urine) catheter changes and site care were obtained upon admission to the facility for one of three sampled residents, (Resident 18) for a new admission. This failure had the potential for a negative clinical outcome, re-hospitalization , and Resident 18 had specific skin treatment needs that were not identified in a timely manner. Findings: The facility's policy revised 8/22/2019, titled, Admission Criteria, indicated the facility admits residents upon the order of a physician who have medical needs that require skilled nursing care. The administrator or his or her designee responsible for screening resident for admission to the facility will ensure that the facility only admits residents whom it can provide adequate care. The facility's policy revised 1/25/2024, titled, Dialysis Management, indicated the facility should ensure that each resident receives care and services consistent with professional standards of practice. The facility's policy revised 4/15/2021, titled, Catheter-Care of Suprapubic Long Term, indicated the purpose of this policy is to provide ongoing care for residents who have a long-term suprapubic catheter to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. The suprapubic catheter care will be performed daily and as needed. During a review of Resident 18's medical record, the Admission Record, indicated Resident 18 was admitted to the facility on [DATE] for diagnosis that included bacteremia (bacteria in the blood), metabolic encephalopathy (problem in the brain with confusion), diabetes (too much sugar in the blood), end stage kidney failure, dependence on dialysis (a treatment to remove wastes and excess fluid from the blood when the kidneys stop working properly), unspecified severe protein-calorie malnutrition (poor nutrition with not enough protein or energy the body requires), and depression (constant feelings of sadness and loss of interest). During a review of Resident 18's most current minimum data set (MDS, a resident tool assessment) dated 2/1/25, indicated Resident 18 had a BIMS (brief interview for mental status) score of 15 out of 15, indicating Resident 18 had no cognitive (ability to think, reason, and make decisions) deficits and was competent to make her on decisions. During an observation and concurrent interview on 3/3/25 at 9:35 AM, Resident 18's S/P catheter site had a small amount of dried red-brownish colored drainage. Resident 18 stated, I don't have any follow up appointment for my S/P catheter to be changed and it is due this week. They have never changed it here at the facility, and they do not clean around the site. During a record review of Resident 18's medical record, an admission assessment, a re-admission assessment, and all progress notes from 12/19/24 to 3/4/25 did not contain pertinent information related to Resident 18's S/P catheter or site care needed to identify the need for specific physician orders for Resident 18's catheter care and treatment care needed for the S/P catheter. During a record review of Resident 18's record dated 3/4/25, titled, Order Summary Report, indicated there were no orders to change the S/P catheter, and there were no orders for the S/P catheter site care needed daily. During an interview on 3/5/25 at 4:01 PM, the Director of Nursing (DON) confirmed there was no S/P catheter orders for Resident 18 until 3/5/25 when they were added after calling the physician. During an interview on 3/6/25 at 7:55 AM, Licensed Nurse (LN) F confirmed he had completed the admission orders for Resident 18 on the original admission on 12/19/24 and the re-admission on 2/6/24 and did not do a physical assessment on Resident 18 to observe the S/P catheter for each admission. LN F stated, We have to treat a re-admission the same as the original admission, I did not assess [Resident 18] for either admission. There were no S/P catheter orders on the History and Physical (H&P), I look at the discharge summary. The floor nurse does the physical assessment for admissions. During an interview on 3/6/25 at 8:10 AM, LN A confirmed she had completed both physical admission assessments on Resident 18 and did not call the physician to obtain any orders related to S/P catheter changes or site care. LN A confirmed she did not review any records for Resident 18 to make sure the admission had been completed per the facility's policy LN A stated, I did see the S/P catheter, but I did not obtain any orders that were needed for maintenance, changes, irrigations in case it became occluded or site care. I confirm this was missed for [Resident 18]. During an interview on 3/6/25 at 8:25 AM, the DON confirmed the admission for Resident 18 was not complete and was missing pertinent treatments needed for S/P catheter changes, site care, and flush orders as needed. DON stated, I confirm the admission process needs improvement, we need a checklist and a process, and it is not okay to miss these important things on admission.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 43) received coordination of care to get out of bed daily, and at meals to improve quality of life, and to meet goals towards independence to discharge home. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being. Findings: During a review of a policy revised 8/21/2020, titled, Bowel and Bladder Training/Toileting Program, indicated the purpose for residents who are incontinent of bowel and/or bladder appropriate treatment and services to minimize urinary tract infections and to restore as much bowel and/or bladder function as possible to prevent skin breakdown and irritation, improve resident morale, and restore resident dignity and self-respect. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents' request for activities of daily living (ADLs, are activities related to personal care. ADLs include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. The facility's policy undated, titled, Residents' Rights, indicated each and every resident in the facility has the right to be treated courteously, fairly, and with the fullest measure of dignity. The facility's policy also indicated all residents receive a prompt response to all responsible requests and inquiries and all residents receive adequate and appropriate health care, and protected health services. During a review of a policy revised 5/25/24, titled, Pain Management, indicated a pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status The Licensed Nurse (LN) will complete a pain assessment for residents identified as having pain as follows: restlessness, distressed behavior, guarding of a body part, and refusal of care and repositioning. The goal for pain management will be resident centered and determined by the resident's acceptable level of pain. During a review of Resident 43's medical record, the Admission Record, indicated Resident 43 was admitted to the facility on [DATE] for diagnosis that included fracture of shaft of left humerus (a broken arm bone, located in the middle portion of the bone and connects to the shoulder), heart disease, pulmonary embolism (a blood clot that travels from a leg or other part of the body and lodges in the lung, blocking blood flow), polyneuropathy (damage or disease affecting many nerves of the body causing tingling, numbness, pain, and weakness), difficulty walking, unspecified severe protein malnutrition (poor nutrition with not enough protein or energy for the body's needs), high blood pressure, and depression (constant feelings of sadness and loss of interest). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 1/8/25, indicated that Resident 43 had a Brief Interview for Mental Status, (BIMS) score of 15 out of 15 and was cognitively intact (able to think and reason). This MDS also indicated Resident 43 required substantial/maximum assistance with all transfers OOB, bathing, and toileting. During a concurrent observation and interview on 3/3/25 at 2:18 PM, Resident 43 was still lying in the bed, hair not combed, hair disheveled. Resident 43 stated, I think they have given up on me, it is hard to get out of bed when you hurt, and I am not doing good in therapy. I have refused some days, but I have told them if I get my medicine first, I want to get up. Resident 43 added, I chose not to have surgery on my broken arm, but I can still use the bathroom if they get me there, I AM tired of this bed pan. I was at home living myself before I fell and broke my arm. I want to go back home. During an interview with Licensed Nurse (LN) D on 3/4/25 at 11:00 AM, LN D confirmed Resident 43's discharge plan is to go back home as soon as she gets stronger, and her arm is healed. LN D stated, You have to give the pain medicine before therapy, but she will go if you medicate her first. During an interview on 3/4/25 at 11:15 AM, the Administrator (Admin) confirmed there should be coordination of care between therapy and nursing to make sure Resident 43 meets all goals by not missing therapy related to pain for a safe discharge. Admin also confirmed Resident 43 could benefit from Occupational Therapy (OT) assisting with showers for self-care and to increase her independence. Admin also confirmed Resident 43 should be out of bed (OOB) for all meals and to toilet unless she refuses. During an interview on 3/4/25 at 11:25 AM, the Medical Director confirmed his expectations are Resident 43 is OOB for all meals, the nurses call for medication changes if pain is not managed to attend therapy, and the staff should assist Resident 43 OOB for all toileting unless she refuses. MD stated, Resident 43 has a broken arm, but there is no reason she cannot get OOB and build her endurance. I will go down and talk with Resident 43, and I will make medication changes if they are needed. During a concurrent observation and interview on 3/5/25 at 2:10 PM, Resident 43 could propel herself through the facility using her Right hand, and stated, I am glad to be up and getting around. During an interview on 3/6/25 at 12:50 PM, the Rehab Director (RD) confirmed Resident 43 could benefit with OT assisting with showers and toileting to promote independence. RD stated, I will add OT to assist with showers for Resident 43's Plan of Care right now.

Based on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistants (CNA)s, and the Licensed Nurses (LN)s had competent skills when: 1. CNAs and LNs did not provide Dementia care for Resident 35 when resident was left in the Dining room alone and fell . 2. LNs did not verbalize understanding of phosphorus binder medication administration for Resident 18 and Resident 373. 3. LN A was not able to verbalize instructions for use for an inhaler ordered for Resident 373. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being. These failures did result in a fall for Resident 35. Findings: 1. A review of the facility's policy revised 10/2017, titled, Dementia Care, indicated the purpose is to optimize the quality of life for individuals living with a diagnosis of dementia at the facility. It is the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best standards of practice for meeting health, psychosocial, and behavioral needs of residents living with dementia. This facility's policy also indicated the principles for dementia care include quality and quantity of staff-the facility will provide staff support and resources to meet the needs of the residents as determined by resident assessments and individual plans of care. Information collected about the residents' physical, functional, psychosocial, and environmental conditions may be used as a basis to understand how the resident expresses distress, pian, hunger, discomfort, thirst, anger and frustration. The residents' plan of care will be communicated across shifts and among caregivers and with the resident or representation. During a review of Resident 35's medical record, the Admission Record, indicated Resident 35 was admitted to the facility on [DATE] for diagnosis that included dementia, metabolic encephalopathy (problem in the brain with confusion), atrial fibrillation (irregular and fast heart rate), diabetes (too much sugar in the blood), insomnia (trouble falling asleep, staying asleep, or getting restful sleep), transient ischemic attacks (TIA, or mini-strokes caused by a brief blood flow to the brain with symptoms that end in 24 hours), major depressive disorder, recurrent (persistent feeling of sadness and loss of interest that can lead to emotional and physical problems), heart disease and repeated falls. During a review of Resident 35's most current minimum data set (MDS, a resident tool assessment) dated 1/9/25, indicated Resident 35 had a BIMS (brief interview for mental status) score of 8 out of 15, indicating Resident 35 had a severe cognitive (ability to think, reason, and make decisions) impairment. During a review of Resident 35's medical record, a document dated 2/3/24, titled, Care Plan, indicated the following intervention, Staff to escort resident out of dining/activity room when staff are not present to cue him not to stand on his own. During an interview on 3/5/25 at 9:49 AM, LN D confirmed the CNAs had not been trained on dementia care, and this training is needed. LN D stated, [Resident 35] was left alone in the dining room with no nursing staff, and he does try to get up on his own, this is why he fell . During an interview on 3/6/25 at 8:58 AM, CNA I stated, We do let [Resident 35] stay in the dining room by himself. If he is nodding off, then we will lay him down. During an interview on 3/6/24 at 9:08 AM, CNA J stated, I was not in the dining room when [Resident 35] fell , but [Resident 40] was in there. [Resident 40] told me about it. I heard he was trying to stand up. We let [Resident 35] stay in the dining room with other residents. We usually have a movie playing to keep them occupied, and [Resident 35] just stays in there. There is usually someone in activities in there, or in their office. During an interview on 3/6/25 at 9:15 AM, CNA K stated, Yes, [Resident 35] sits in the dining room for activities. We can leave him there, there is usually someone from activities in their office. During an interview on 3/6/25 at 9:36 AM, Resident 40 stated, Yes, I was in here when [Resident 35] fell . It was awful, it was a loud thud. They should make sure someone is in here, so it doesn't happen again. Activities Assistant (AA) M was in her office. What happens is they don't know when he nods off or tries to stand up. During an interview on 3/6/25 at 10:30 AM, the Director of Nursing (DON) confirmed the care plan for Resident 35 indicate to not leave Resident 35 in the dining room without staff present, and the staff need more training. DON stated, The staff should know, but we will do more training on dementia care, and we just had a training on falls. 2. A review of the facility's policy revised 1/2/2012, titled, Medication-Administration, indicated this policy is to ensure the accurate administration of medications for residents in the facility. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. A review of a facility job description undated, titled, LVN Job Description, indicated under general duties and responsibilities the LN provides nursing care as prescribed by the physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures. Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being. Provides clinical data and observations to contribute to the nursing plan of care. Attends in-services to and educational classes to maintain nursing skills competence, and current knowledge for standard of care and effective practices. The facility's policy revised 1/25/2024, titled, Dialysis Management, indicated the facility should ensure that each resident receives care and services consistent with professional standards of practice. During a review of Resident 18's medical record, the Admission Record, indicated Resident 18 was admitted to the facility on [DATE] for diagnosis that included bacteremia (bacteria in your blood), metabolic encephalopathy (problem in the brain with confusion), diabetes (too much sugar in the blood), end stage kidney failure, dependence on dialysis ( a treatment to remove wastes and excess fluid from the blood when the kidneys stop working properly), unspecified severe protein-calorie malnutrition (poor nutrition with not enough protein or energy the body requires), and depression (constant feelings of sadness and loss of interest). During a review of Resident 18's medical record, a document dated 3/5/25, titled, Order Summary Report, indicated Resident 18 was ordered Sevelamer (a phosphorus binder given before or with meals to bind the phosphorus in food for end stage kidney disease) HCL 800 milligrams (mg, a unit of measure) 1 tablet by mouth three times a day before meals. During an interview on 3/3/25 at 7:45 AM, Resident 18 stated, I AM so tired of my breakfast being cold waiting on my medication. It happens every day. During an interview on 3/6/25 at 7:50 AM, LN A stated, Yes, I got busy with other things and Resident 18's medication was just given; it was scheduled for 7:00 so I AM not technically late. LN added, I did not know it has to be given before or with meals, I did not know what this medicine is for. I will know from now on. During a review of Resident 373's medical record, the Admission Record, indicated Resident 373 was admitted to the facility on [DATE] for diagnosis that metabolic encephalopathy (problem in the brain with confusion), acute and chronic respiratory failure with hypoxia (lungs are not able to get enough oxygen to the blood), end stage kidney failure, dependence on dialysis (a treatment to remove wastes and excess fluid from the blood when the kidneys stop working properly), pulmonary hypertension (high blood pressure in the arteries of the lungs, causing the heart damage), and multiple myeloma (a type of cancer that effects the bone marrow, which produces antibodies to fight infections). During an interview on 3/5/25 at 11:30 AM, Resident 373's Family Member (FM) stated, I don't have any complaints about the facility except the medications he takes before he eats, I have been providing. I have been giving him his phosphorus binders we had from home at meals over the weekend, but I cannot be here for every meal every day. During an interview on 3/3/25 at 2:20 PM, LN D confirmed Resident 373 had received his phosphate binders from the family member and not the facility over the weekend and since his admission to the facility on [DATE]. During an interview on 3/4/25 at 1:30 PM, LN D confirmed the pharmacy was scheduled to deliver a new phosphate binder substitute the physician had approved and the facility will provide this medication moving forward before meals as ordered. During an interview on 3/6/25 at with LN D confirmed the medication Sevelamer had not been given as indicated to Resident 18 and to Resident 373 for proper uses and indications. LN stated, We will provide more education, and add instructions to the computer to make sure all phosphate binders are given properly by all nurses. During an interview on 3/6/25 at 10:45 AM, the DON confirmed more education is needed for dialysis residents and the use of phosphorus binders. DON added, I will make sure I do an in-service, and I will add specific medication administration instructions for all three dialysis residents, and any new admissions moving forward. 49934 3. A review of the facility's policy revised 1/2/2012, titled, Medication-Administration, indicated this policy is to ensure the accurate administration of medications for residents in the facility. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. During a review of Resident 373's medical record, the Admission Record, indicated Resident 373 was admitted to the facility on [DATE] for diagnosis that metabolic encephalopathy (problem in the brain with confusion), acute and chronic respiratory failure with hypoxia (lungs are not able to get enough oxygen to the blood), end stage kidney failure, dependence on dialysis (a treatment to remove wastes and excess fluid from the blood when the kidneys stop working properly), pulmonary hypertension (high blood pressure in the arteries of the lungs, causing the heart damage), and multiple myeloma (a type of cancer that effects the bone marrow, which produces antibodies to fight infections). During an observation of the medication pass on 03/05/25 at 08:05 AM on Station 1, Licensed Nurse (LN) A was preparing medication for Resident 373, which included an inhaler (a device that delivers medications into the airways to relieve congestion). LN A was asked if she was aware of what the proper procedure is for administering an inhaler. LN A stated, No. LN A was asked what the outcome would be of improperly administering the medication and she stated, The resident would not get the correct dose of medication. During an interview with the Director of Nursing (DON) on 03/06/25 at 11:58 AM, after describing the situation with LVN A and when asked if there is a competency issue the DON confirmed, Yes, there is. When asked to confirm if the resident would not get the proper dosage if the medications was administered incorrectly, he stated, Yes, the dosage would not be delivered properly to the resident.

Based on interview and record review, the facility failed to ensure a Care Conference meeting, to determine that a resident may be appropriate for a facility initiated discharge, occurred with the Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care), Physician, the resident and resident ' s responsible party (RP, an individual who assumes varying degrees of responsibility for the well-being of the resident) for one of two sampled residents (Resident 1) when Resident 1 ' s RP indicated she never had a meeting with the facility about Resident 1 ' s discharge therapy levels or training on how to assist Resident 1 with his mobility at home and Resident 1 was unable to make it into the house and could not stand or transfer. This failure had the potential for a decline in Resident 1 ' s physical, psychosocial, and mental well-being after discharge from the facility. Findings: A review of the facility ' s policy titled Transfer and Discharge revised 7/2/20, indicated (1) (F) If the IDT team and the Attending Physician determine that the resident may be appropriate for discharge, Social Services staff will coordinate the discussion of discharge with IDT, the resident and the responsible party. (1)(J) Social Service Staff may coordinate a care conference to discuss discharge needs, plans, and teaching, and will involve other IDT members as appropriate. A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted on [DATE] with diagnoses that included two fractures of the left leg, fracture of the fifth cervical (neck) vertebra (bone that makes up the spine), parkinsonism (a group of symptoms that include: slowness of movement, stiffness of muscles, and involuntary shaking movements), difficulty in walking, prostate cancer, anemia (low red blood cells), dementia (decrease ability to think, recall and make decisions), depression, and repeated falls. On 12/13/24 Resident 1 was transferred to the hospital due to a sustained fracture of the lower back from a fall while in the facility. On 12/16/24 Resident 1 was readmitted to the facility. Resident 1 ' s RP made health care decisions for him. A review of Resident 1 ' s admission Minimum Data Set (MDS, assessment tool to evaluate residents) dated 12/23/24, indicated Resident 1 ' s Brief Interview For Mental Status (BIMS, a tool to assess cognition [thinking, reasoning, and memory recall]) score was 8 which indicated moderate cognitive impairment. Section GG (which describes the residents ' ability to perform self-care [activities of daily living] and mobility items) indicated Resident 1 required moderate assistance with upper body dressing and personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, washing/drying face and hands). Resident 1 required maximal assistance with lower body dressing, toileting hygiene (cleaning self after going to the bathroom), showering, rolling left and right in bed, sitting to lying position, sitting to standing position, chair/ bed-chair transfer, and toilet transfer. Resident 1 was dependent for lying to sitting on the side of the bed and walking 10 feet was not attempted due to medical condition or safety concerns. A review of Resident 1 ' s progress note dated 1/7/25 at 12:14 pm, Social Service Director (SSD) documented SSD spoke with Resident ' s spouse, discussing options for discharge, Spouse is very worried about Resident ' s High Fall Risk, but shares she is confident she can manage his care alongside Home Health. She is wavering but is still discussing with Resident ' s family as they are concerned as well. A review of Resident 1 ' s progress note dated 1/14/25 at 11:25 am, indicated Patient discharged to home leaving facility at 11:20 am, with wife and son in attendance. During an interview with Family Member (FM) B on 2/4/25 at 8:59 am, FM B indicated that Resident 1 was discharged from the facility to home on 1/14/25 and was unable to make it into his house and could not stand or transfer. FM B indicated there was never a discharge meeting with the facility about his discharge abilities to determine if Resident 1 was appropriate for discharge. During a review of Resident 1 ' s Physical Therapy PT Discharge Summary filled out by the Physical Therapist Aide (PTA) for dates of service: 12/17/24 thru 1/13/24, discharge reason was discharged per Physician or Case Manager. The discharge summary indicated: *Resident 1 had not met the short-term goal of the ability to transfer from lying on the back to sitting on the side of the bed and with no back support Supervision or Touching Assistance in order to get in/out of bed and prepare for transfers. At discharge Resident 1 required substantial/maximal assistance (where helper does most of the work) to transfer from lying on the back to sitting on the side of the bed. *Five of five Long-Term therapy goals were not met upon discharge. *Resident 1 ' s living environment required him to step up one step to get into his house. One step (curb) was not attempted during therapy due to medical conditions or safety concerns. During a concurrent interview with PTA and record review on 2/4/25 at 2:51 pm, Resident 1 ' s Physical Therapy PT Discharge Summary was reviewed. PTA confirmed that Resident 1 had not met his therapy goals before discharge. PTA indicated she never saw Resident 1 walk due to him refusing therapy during his last two days in the therapy. During an interview with the Director of Rehabilitation (DOR) on 2/4/25 at 3:00 pm, DOR indicated Resident 1 ' s discharge was an impromptu because the wife wanted him to go home. The rehabilitation department was notified the day of Resident 1 ' s discharge that he was going home. The DOR indicated there was no training with the RP on how to assist Resident 1 with his needs. During an interview on 2/26/25 at 10:46 am, Social Service Director (SSD) indicated Resident 1 was discharged from the facility on 1/14/25. SSD stated, We met in our Medicare meeting (a meeting with the DOR, Medical Record Director, SSD, MDS, Business Office Director and Administrator and discuss resident ' s level of care) and from that meeting I was given the go ahead to start the discharge process. SSD was unable to provide a documentation of this meeting or a date when it occurred for Resident 1. During an interview on 2/26/25 at 11:40 am, Certified Nursing Assistant (CNA) indicated that after Resident 1 ' s fall CNA never saw him walk. CNA stated, Some days he (Resident 1) could transfer and some days he was too unsteady, and I had to ask for a second pair of hands to transfer him. He (Resident 1) was not stable enough to go home with his RP. During an interview on 2/26/25 at 11:46 am, Licensed Nurse (LN) A indicated Resident 1 was not safe to go home. He had poor safety awareness. He could walk but he was unstable. LN A indicated she assumed that at the care conference meeting they would have discussed this with the family. LN A was unaware if there was a care conference meeting with the RP. During an interview on 2/28/25 at 8:56 am, Resident 1 ' s RP stated, I said to them (the facility) ' When he (Resident 1) is ready to be released, I will want him to go home. ' I would ask ' when are you going to release him? ' Then all of a sudden, I got a call from (SSD name), and she said we had our meeting, and he (Resident 1) is good to go home. RP indicated she had not attended a meeting about discharge and had not discussed with anyone at the facility about Resident 1 ' s therapy level. RP stated, He (Resident 1) could not stand or transfer when he came home. RP indicated she signed some papers but did not know what they were. RP indicated Resident 1 was unable to make it into the house and could not stand or transfer. RP indicated Resident 1 was not safe to come home and she would have insisted that he stay longer to receive therapy if she knew he was not strong enough or safe to come home. A review of Resident 1 ' s IDT Care Conference meetings identified two care conference meetings for Resident 1 ' s entire stay at the facility. One on 11/5/24 for admission which identified to have included a nurse, the dietary department, the social worker, the activities department, the physical therapist and a family member in attendance at the meeting. A second meeting was identified on 12/18/24 for the second admission which identified that no one was in attendance for the meeting, but templets had been filled out by the dietary, activity director, a nurse, and therapy. There was no record of Resident 1 ' s discharge IDT Care Conference Meeting as per the facility ' s policy titled Transfer and Discharge. During a concurrent interview and record review with the Director of Nursing (DON) on 3/3/25 at 3:44 pm, Resident 1 ' s IDT Care Conference meetings were reviewed. DON indicated there was no IDT Care Conference meeting with the family concerning Resident 1 ' s discharge, level of care or care giver training concerning physical help that was needed for Resident 1 and there should have been.

Based on interview and record review the facility failed to ensure they provided care and services for one of two residents (Resident 1) sampled for unplanned weight loss when: 1. Resident 1 was not weighed as per facility policy. 2. There was no weekly monitoring of Resident 1 ' s weight by an Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care) the first 10 weeks after admission. 3. Care plan titled Nutritional problem or potential nutritional problem was not reviewed or revised to reflect an actual weight loss and no interventions were added to his care plan. These failures delayed care and services needed for Resident 1 to prevent weight loss and had the potential to add to the cause of Resident 1 ' s 18.8-pound weight loss in two months. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted on [DATE] with diagnoses that included two fractures of the left leg, fracture of the fifth cervical (neck) vertebra (bone that makes up the spine), parkinsonism (a group of symptoms that include: slowness of movement, stiffness of muscles, and involuntary shaking movements), difficulty in walking, prostate cancer, anemia (low red blood cells), dementia (decrease ability to think, recall and make decisions), depression, influenza on 12/23/24 (during his admission at the facility) and repeated falls. On 12/13/24 Resident 1 was transferred to the hospital due to a fracture of the lower back sustained from a fall while in the facility. On 12/16/24 Resident 1 was readmitted to the facility. Resident 1 ' s Responsible Party (RP, a person who makes health care decisions for a resident) made health care decisions for him. A review of Resident 1 ' s admission Minimum Data Set (MDS, assessment tool to evaluate residents) dated 11/11/24 indicated Resident 1 ' s Brief Interview For Mental Status (BIMS, a tool to assess cognition [thinking, reasoning, and memory recall]) score was 7 which indicated severe cognitive impairment. A review of section K (which describes swallowing and nutritional status of a resident) indicated Resident 1 weighed 172 pounds on admission, had complaints of difficulty or pain with swallowing and was put on a mechanical soft diet (a modified diet with foods that are soft, easy to mash and can be cut into small pieces). A review of section GG (which describes the residents ' ability to perform self-care [activities of daily living] and mobility items) indicated Resident 1 required set-up or clean up assistance with eating. A review of Resident 1 ' s Comprehensive Care Plan on admission revised on 11/15/24, indicated Resident 1 had a care plan titled Nutritional problem or potential nutritional problem related to . and then listed Resident 1 ' s diagnoses. Care Plan Goals documented for Resident 1 were to maintain adequate nutritional status as evidenced by maintain weight within 5% of admission weight. Interventions were as follows: a. Monitor/record/report to MD (Medical Doctor) as needed for signs or symptoms of malnutrition (lack of nutrients): Emaciation (abnormally thin), muscle wasting, significant weight loss: a loss of three pounds in one week, greater than 5% (percent) weight loss in one month, and greater than 7.5% weight loss in three months. b. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. c. Provide, serve diet as ordered. Monitor intake and record every meal. d. Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. e. Weight on admission, then weekly x 4, then monthly/as needed. 1. A review of the facility ' s policy titled Evaluation of Weight and Nutritional Status revised date 1/30/25, indicated 1. The facility will maintain an acceptable nutritional status for residents per professional standards Residents who are at risk (for weight loss) should be weighed weekly include (but not limited to) the following: 1) Admissions/readmissions for the first 4 weeks. A review of Resident 1 ' s weights for the first 4 weeks after admission on 11/4/25 included. *Admission weight on 11/4/24 = 172.2 lbs.(pounds). *Week one weight on 11/6/24 = 172.2 lbs. * Week two weight on 11/14/24 = 175.6 lbs. *No weights documented for week 3 (11/17/24 thru 11/ 23/24.) *No weights documented for week 4 (11/24/24 thru 11/30/24). *No weight was documented on readmission from the hospital on 12/16/24. During a concurrent interview with the [NAME] Registered Dietitian (RRD) and record review on 3/3/25 at 2:30 pm, Resident 1 ' s weight record was reviewed. RRD indicated there were no weights documented for Resident 1 after his admission for week three and week four and there should have been. RRD also confirmed that Resident 1 was not weighed on his readmission 12/16/25 after his hospital stay and he should have been. 2. A review of the facility ' s policy titled Evaluation of Weight and Nutritional Status revised date 1/30/25, indicated 1. The facility will maintain an acceptable nutritional status for residents per professional standards by: e) Monitoring and evaluating the resident ' s response, or the lack of response to interventions. f) revising or discontinuing the approaches as appropriate or justifying the continuation of current approaches. Definitions . b) Weight Loss - unplanned weight loss in a resident. Significant weight loss (5% and or 5 pound in a month, 7.5% in three months, or 10% in six month), as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss Clinical Evaluation . b) Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, or is considered insidious (weight loss that occurs over time that does not meet the guidelines for significant weight loss) weight loss, will be evaluated by the IDT to determine the cause of weight loss/gain and the interventions required i) Once a weight gain or loss as described above is identified, the IDT will: 1. Identify and implement appropriate interventions; 2. Update and revise the Care Plan, as appropriate; 3. Notify the responsible party; 4. Notify the Attending Physician and 5. Notify the registered Dietitian d) Any resident meeting the criteria for physician prescribed weight loss and any resident at risk for weight loss or gain will be weighed and documented weekly. Weekly weights will be reviewed by the IDT. A continued review of Resident 1 ' s weight record during the time of his stay included: *12/1/24 weight = 168.6 lbs. *12/6/24 weight = 168.6 lbs. *12/13/24 weight = 164.8 lbs. (3.8 pounds lost in a week) *12/19/24 weight = 162.2 lbs. lbs. (10 pounds lost in a month equaling 5.81% loss) *12/26/24 weight = 158.2 lbs. (4 pounds lost in a week) *1/2/25 weight = 156.8 lbs. (11.8 pound lost for the month of December equaling a 6.99% weight loss) *1/9/25 weight = 153.4 lbs. (in two months, from 11/4/24 to 1/9/24 Resident 1 experienced an18.8-pound weight loss). A review of Resident 1 ' s weekly IDT weight variance meeting (meeting to discuss changes in a resident ' s weight) progress notes indicated there were no weekly IDT weight variance meetings for Resident 1 for the first 10 weeks after admission. There was no documentation of monitoring/recording or reporting to MD for the 3.8-pound weight loss in one week from 12/6/24 to 12/13/24 as per Resident 1 ' s intervention on his comprehensive care plan. There was no; 1. Identify and implement appropriate interventions; 2. Update and revise the Care Plan, as appropriate; 3. Notify the responsible party; 4. Notify the Attending Physician and 5. Notify the registered Dietitian when Resident 1 had a significant weight loss of 10 pounds in a month or 5.81 percent as noted on 12/19/25. Documented IDT weight variance meetings were done on: *12/27/25, identified an 8% weight loss (14 lbs.) since admission weight (11/4/25). interventions were to continue interventions. Monitor weight weekly. Root cause: Resident 1 tested positive for influenza on 12/23/24 and was readmitted from acute on 12/17/24. *1/3/25, identified an 8.9% weight loss (15.4 lbs.) since admission weight. Food intake was 25-75%. New interventions were to continue interventions, Monitor weight weekly, Med Pass (a high calorie nutritional drink in a reduced portion size). *1/10/25, identified weight loss of 3.4 lbs. in one week. New interventions were to Fortify diet (a diet that has been enriched with essential nutrients, such as vitamins, minerals and other micronutrients) and weekly weight and continue interventions. During a concurrent interview with the [NAME] Registered Dietitian (RRD) and record review on 3/3/25 at 2:30 pm, Resident 1 ' s weights and IDT weight variance progress notes were reviewed. RRD indicated that Resident 1 had a 3.8 weight loss for week of 12/6/24 thru 12/13/24. RRD indicated that Resident 1 was sent to the hospital on 12/13/24 due to a fall and he returned on 12/16/24. RRD stated an IDT review for weights should have been done on 12/16/24 when Resident 1 returned, and it was not done. RRD continued to indicate that a nutrition assessment, implementing care plan interventions and notifying the MD should have been done concerning Resident 1 ' s weight loss according to his care plan. RRD indicated that the facility did not have a Registered Dietitian (RD) from dates 11/12/24 to 12/27/24, when the new RD was hired. The RRD stated I was available, but I do not tend to cover centers(facilities). The RRD indicated there was not an RD covering and checking weights during that time. The facility is in charge and the IDT would be responsible for checking weights and updating the care plans. 3. A review of the facility ' s policy titled Comprehensive Person-Centered Care Planning revised November 2018, indicated, .the comprehensive care plan will also be reviewed and revised at the following times: i) Onset of new problems; ii) Change of condition A review of Resident 1 ' s care plans indicated there was no reviewed or revised weight loss care plan with implemented interventions to prevent weight loss for Resident 1. During a concurrent interview with the MDS Licensed Nurse (MDS LN) and record review on 2/28/25 at 3:55 pm, MDS LN indicated weight care plans were revised by the IDT weight variance team, (Registered Dietitian) RD, or the Director of Nursing (DON). MDS LN reviewed Resident 1 ' s Care Plans and indicated that there was not a weight loss care plan for Resident 1 and there were no updates with new interventions in his nutritional care plan. During a concurrent interview with the [NAME] Registered Dietitian (RRD) and record review on 3/3/25 at 2:30 pm, Resident 1 ' s care plan was reviewed. RRD confirmed that Resident 1 ' s care plan had not been reviewed and revised concerning his weight loss and it should have been. During a concurrent interview with the Director of Nursing (DON) and record review on 3/3/25 at 3:31 pm, Resident 1 ' s weights, IDT weight variance meetings and care plans were reviewed. The DON indicated he just started at the facility on 11/11/24 and he was not looking at weights in November and early December. Resident 1 ' s IDT weight variance meetings were reviewed, and DON indicated that Resident 1 ' s weight was trending down and there should have been an IDT weight variance meeting on readmission and there was not one done. Resident 1 ' s care plans were reviewed, and DON indicated there should have been an actual weight loss care plan with interventions implemented and there was not. DON stated, the missing weights and missing weekly weight IDT meetings was probably because of not having an RD and half of the IDT team was newer.