Every finding on record at City Creek Post Acute

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when:Dietary Staff did not practice properly for the storing and handling the thawing process of the health shakes (frozen nutritional supplement drinks pack individually in cartons, which provide additional calories and nutrients)Found kitchenware was stacked wet and stored away in the clean and ready-to-use areaThe blade of can opener was not well maintainedTwo of five cutting boards were not clean and stored away in the clean and ready-to-use cutting board rackTwo different sizes Teflon coating cooking pans were not well maintainedOne [NAME] with facial hair was not covered with facial hair restraintThese failures had the potential to cause food-borne illness which could cause illness in 90 out 90 medically vulnerable residents who consumed food from the facility kitchen. The census was 95.Findings:1. During the inspection of the walk-in refrigerator on 7/21/26 at 8:24 a.m., noted there were two buckets of health shakes with written labels indicated the pulled date (date pulled out from freezer for thawing in the refrigerator) on 6/23/26 and the used-by date on 7/23/26. A concurrent review of the manufacturer's storing and handling instruction printed on the health shake's carton, stated Store Frozen. Thaw at or below 40 degrees Fahrenheit (F). Use thawed product within 14 days, keep refrigerated which indicated the used-by date should be 7/7/26 and it was 14 days passed from 7/7/26. A concurrent interview with Dietary Manager (DM) and DM stated the health shake could store for a month after being pulled out from the freezer. A concurrent review of the manufacturer's instruction for the health shake with DM, and DM stated he was not aware of the instruction. DM confirmed and further stated the health shakes kept in the refrigerator for 14 days after pulled out from the freezer and the used-by date should be on 7/7/26. He stated he would discard all the health shakes and the staff needed in-service regarding the manufacturer's instructions. A review of facility policy and procedure titled, Procedure for Refrigerated Storage, dated 2023, indicated .Supplemental shakes which are taken from the frozen stated and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendations (specifications) for shelf life.2. During a kitchen inspection on 7/21/26 at 8:46 a.m., there were two half-sheet metal pans stacked wet and stored away in the clean and ready-to-use storage area. A concurrent interview with DM, DM confirmed and stated the metals pans should be completely air-dried before stored away to prevent mold growth.A review of facility policy and procedure titled, Dishwashing Machine Use, revised 2010, indicated the dishes should be air-dried after cleaned and sanitized.3. During a kitchen inspection on 7/21/26 at 8:47 a.m., it was noted the metal coating of the blade of the can opener was chipped and worn off. A concurrent interview with DM, DM confirmed and agreed the metal coating was chipped. He stated the blade needed to be replaced.A revie of facility policy and procedure titled, Can Opener and Base, dated 2023, indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade.Replace blade on can opener, as needed.4. During a kitchen inspection on 7/21/26 at 8:50 a.m., it was noted two out of five cutting boards with issues that were stored away in the clean and ready-to-use cutting board rack. The issues were:White cutting board observed there were two red spots or substances on the food contact surface. A concurrent interview with DM, DM stated the red substances were food debris.Green cutting board observed there was a seed and green substance stuck on the food contact surface. A concurrent interview with DM, DM stated the seed maybe cantaloup seed and the green substance was food debris and maybe vegetable.DM agreed the boards were not clean, and the staff should check before stored away.A review of facility policy and procedure titled, Sanitation, revised 2008, indicated, .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils.cutting boards will be washed and sanitized between uses.5. During a kitchen inspection on 7/21/26 at 8:55 a.m., it was noted there were 6-inch and 12-inch Teflon coating (a coating provides non-stick property) cooking pans with significant scratches and black buildups on the cooking surfaces. A concurrent interview with DM, DM confirmed and stated the cooking pans should be replaced. He stated the uneven cooking surfaces were hard to clean.A review of facility policy and procedure titled, Sanitation, revised 2008, indicated, .All utensils.equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.According to 2022 FDA Food Code, on section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, it stated, (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. In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits.6. During a kitchen inspection on 7/21/26 at 9:27 a.m., it was noted [NAME] (CK) 1 had a beard on his chin without facial hair restraint working at the cooking area preparing food. Observed there was no beard restraint available next or around the hair restraint at the entrance of the kitchen. A concurrent interview with DM, DM confirmed CK 1 had a beard on his chin and without facial hair restraint and stated CK 1 should wear one.A review of facility policy and procedure titled, Dress Code, dated 2023, indicated, .beards and mustaches (any facial hair) must wear beard restraint.

Based on observation, interview and record review, the facility failed to ensure the Contracted (35-hour/week) Registered Dietitian (RD) effectively monitored the dietetic service operations and provided frequently consultation to the Dietary Manager (DM). This failure had the potential to result in compromising the nutritional status of residents through the potential transmission of food borne illness, inappropriate preparation of diet textures, and incorrect plating of physician ordered diets and nourishment. There was a total of 90 out of 95 residents receiving meals from the facility kitchen.Findings:During the annual recertification survey from 7/21/26 to 7/23/26, multiple issues surrounding the delivery of dietetic services were identified:1. Meal distribution accuracy - the menu/recipes/meal spreadsheet/tray ticket were not followed, and the portion size of food items for the therapeutic diets were not served correctly (cross reference F803). 2. Dietary staff did not have proper skill to prepare the appropriate texture for IDDSI (International Dysphagia Diet Standardization Initiative, a global system that standardizes food textures and drink thickness for people with swallowing difficulties) level #6 Soft and Bite-size (food items should be chopped or cut into pieces size no larger than 1.5 centimeters (cm) by 1.5 cm. Food texture was designs for individuals who experiencing biting limitations but are able to chew food items for swallowing) and IDDSI Level #5 Minced and Moist [food items should be soft and moist (with all excess fluid drained), size no larger than 4 millimeters (mm) by 12 mm. Food texture was designs for individuals who experiencing biting, chewing, and/or swallowing limitations] (cross reference F805). 3. Food safety and sanitation practices were not followed (cross reference F812).Dietary staff did not practice proper storing and handling for the health shakes (nutrition supplemental drinks)Kitchenware was found stacked wet and stored away in the clean and ready-to-use storage areaThe metal coating of the blade of the can opener was chipped and worn offTwo out of five cutting boards were not clean and stored away in the clean and ready-to-use cutting board rackTwo different sizes Teflon coating cooking pans were not well maintainedOne [NAME] with facial hair was not covered with facial hair restraint4. Garbage disposal was not maintained in a safe manner (cross reference to F814). During an interview with the RD on 7/22/26 at 9:03 a.m., the RD stated she was contracted from a dietitian consulting company and worked 35-hour per week and was responsible for clinical work. The RD stated she worked two (8-hour/day) days onsite in facility and other two days she worked remotely. She stated by the contract, she was only responsible for clinical and not required to oversee food service, therefore she did not need to perform kitchen sanitation audit. The RD further stated she had to provide any in-service for the dietary staff unless Dietary Manager (DM) needed her to.A review of [RD Consulting Company] Consulting Agreement, signed on 7/12/2024, indicated the general duties for the RD were related to clinical work.A review of facility document titled, Job Description: Registered Dietitian, revised 9/1/16, indicated, Position.They (RD) also work closely with the Dietary Department to maintain good nutritional standards and process improvement. This position is responsible for overseeing regulatory compliance for county and state regulations. ability to instruct staff in correct procedures to be followed in the Dietary Department.effectively supervise dietary personnel.to plan and direct the food service operation to meet the individual needs of the resident.A review of facility document titled, Job Description: Dietary Service Manager, revised 9/1/16, indicated, .Develop policies and procedures for the Dietary Department, in consultation with the Registered Dietitian.Prepare menus and plan modifications as required by diet order, in consultation with the Registered Dietitian.

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed properly when one outside dumpster was not closed securely, and the surrounding area was littered with debris for a census of 95.This failure had the potential to expose the residents, visitors and staff to pests, odor, or diseases.Findings:During the entrance of the facility on 7/21/26 at 7:30 a.m., observed there was one of one dumpster bin with lids closed but one of the lids was cracked and created an opening. It was noted there were bags of trash inside the bin. There were soiled gloves, soiled masks and plastic wrappers observed on the ground around the dumpster bin.During a follow up observation and interview on 7/21/26 at 9:16 a.m. with the Dietary Manager (DM), the DM confirmed the dumpster lid with a crack and there was trash around the bin. The DM stated the lids should completely cover the trash bin securely. He further stated the maintenance department was responsible for monitoring the condition of the dumpster bin and the surrounding area.During a follow up observation and interview on 7/21/26 at 9:35 a.m. with the Maintenance Supervisor (MS), the MS stated he was responsible for the dumpster bin and the surrounding area. The MS stated he was not aware there was a crack on the lid of the trash bin and no one reported it to him. The MS confirmed there was trash around the dumpster bin.A review of facility policy and procedure titled, Food-Related Garbage and Refuse Disposal, revised 2017, indicated .All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored.Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.storage areas will kept clean at all times, and shall not constitute a nuisance.Outside dumpsters.free of surrounding litter.According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 5-501.15 Outside Receptacle, (A) Receptacles and waste handling units for refuse.used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. In addition, on section 5-501.115 Maintaining Refuse Areas and Enclosers, A storage area and enclosure for Refuse.shall be maintained free of unnecessary items and clean.

Based on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection for a census of 95 when: Licensed Nurse (LN) did not wear appropriate personal protective equipment (PPE, refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) for residents on contact precautions (refer to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment);Resident 15's respiratory equipment (nebulizer/aerosol facemask, a medical face covering used to deliver medication mist, moisture, or enriched oxygen directly into a patient's nose and lungs) was left uncovered and next to his used urinal;Resident 72's respiratory equipment (oxygen nasal cannula, a lightweight plastic device used to deliver supplemental oxygen through two small prongs placed into the nostrils) was left on the floor;Call buttons were on the floor and were not disinfected before clipping in reached for Residents 57, 72 and 100; Soiled briefs were left on the floor and not disposed of properly; Resident equipment was not disinfected after use during medication pass for Resident 81; and, Resident urine bag was touching the floor. These failures had the potential to result in patients' harm and the spread and transmission of infection and diseases. Findings: 1. During an observation on 7/22/26 at 12:48 p.m., in room [ROOM NUMBER], there was a posted signage by the room door which indicated contact precautions. The signage indicated what PPEs to wear, which included gloves and gowns, before room entry and remove PPE prior to room exit. Inside room [ROOM NUMBER] was LN 3 who stood next to the bed of Resident 202B. LN 3 was not wearing the required PPE while providing direct care and in close contact to resident who was on contact precautions for a suspected scabies (a contagious skin infestation caused by tiny, microscopic human itch mites that burrow into the upper layer of the skin to live and lay eggs) organism. During a concurrent observation and interview on 7/22/26 at 12:48 p.m. in room [ROOM NUMBER] with LN 3, LN 3 confirmed she did not wear the correct PPE indicated for contact precautions. LN 3 indicated she stood next and was in close contact with room [ROOM NUMBER]B resident during the provision of care. LN 3 stated wearing the complete PPE was important to prevent the spread of infection. 2. During an observation on 7/21/26 at 12:46 p.m. in room [ROOM NUMBER], Resident 15's respiratory equipment was left uncovered after breathing treatment use. In another observation on 7/22/26 at 3:34 p.m., Resident 15's respiratory equipment was left uncovered and placed next to a used urinal. During a concurrent observation and interview on 7/22/26 at 3:34 p.m., Resident 15 stated the respiratory equipment was left uncovered after his breathing treatment. During a concurrent observation and interview on 7/22/26 at 3:35 p.m. in room [ROOM NUMBER] with LN 2, LN 2 confirmed Resident 15's respiratory equipment was left uncovered and next to it was a used urinal. LN 2 stated the respiratory equipment should be covered after each use to prevent contamination from dust and dirt particles. LN 2 stated leaving the respiratory equipment next to the urinal was unsanitary. LN 2 stated contaminated respiratory equipment could expose the resident to respiratory infection or lung issues. LN 2 stated Resident 15's respiratory equipment should be kept clean, and the urinal should be placed in the holder for infection control and prevention. 3. During an observation on 7/23/26 at 9:16 a.m., in room [ROOM NUMBER], Resident 72's respiratory equipment was found on the floor. CNA 2 entered the room and picked up the respiratory equipment from the floor. During a concurrent observation and interview on 7/23/26 at 9:16 a.m. in room [ROOM NUMBER] with CNA 2, CNA 2 confirmed Resident 72's respiratory equipment was on the floor. CNA 2 stated respiratory equipment should not be left on the floor for Resident 72 who needed oxygen. CNA 2 stated the floor was dirty and respiratory equipment should be kept off the floor to prevent germs or infection getting into the equipment and into the lungs of the resident. 4. During an observation on 7/23/26 at 9:16 a.m., in room [ROOM NUMBER], Resident 72 and Resident 57's call light buttons were on the floor. The call light buttons were picked up by CNA 2 and clipped the call light buttons back to resident 72's left side of the foam mattress and Resident 57's call light button was clipped at the right side of the foam mattress. CNA 2 did not disinfect the call light buttons prior to clipping them back. During a concurrent observation and interview on 7/23/26 at 9:16 a.m., in room [ROOM NUMBER] with CNA 2, CNA 2 confirmed she picked up Resident 72 and Resident 57's call light buttons and clipped them back for use without disinfecting them. CNA 2 stated the call light buttons could harbor harmful germs and could transfer to the hands or mouth and could increase the risk or spread of infection for Resident 72 and Resident 57. 5. During an observation on 7/22/26 at 3:54 p.m., in room [ROOM NUMBER] entrance door, soiled diapers with urine and fecal materials were left on the floor. CNA 1 entered the room and picked up the soiled diapers. During a concurrent observation and interview on 7/22/26 at 3:54 p.m., in room [ROOM NUMBER] with CNA 1, CNA 1 confirmed she left the soiled diaper with fecal materials and urine on the floor. CNA 1 indicated she should have put the soiled diapers inside the trash bin or in the barrel. CNA 1 stated soiled diaper harbor harmful bacteria and leaving them on the floor could lead to floor contamination and bacterial growth and increased the risk of infection. During an interview on 7/23/26 at 3:28 p.m. with the Infection Preventionist (IP), the IP stated her expectations on the following: LN should wear the correct PPE for residents on contact precautions and ensure proper hand hygiene to prevent the spread and transmission of infection; On respiratory equipment left uncovered, respiratory equipment like nebulizer mask should be on the black antimicrobial bag, so it could not drop on the floor and could not get dirty and contaminated; On used urinals, urinals should be placed on the urinal holder, so it will not contaminate any space used by the resident; On respiratory equipment like oxygen nasal cannula found on the floor, nothing should be put back to the resident's nose because whatever bacteria that was on the floor could be transferred to the resident; On call light buttons found on the floor, high touched areas like call light buttons should be disinfected first prior to patients use; and On soiled diaper left on the floor, soiled diapers should be placed inside the trash bins until the CNA was ready to remove them. During an interview on 7/24/26 at 10:49 a.m., with the Director of Nursing (DON), the DON stated her expectations for infection control and prevention: LN should follow the infection control and prevention protocol for residents on contact precautions; Respiratory equipment like nebulizer masks should be placed inside the black bag or clean bag to prevent contamination; urinal should be placed on the urinal holder to prevent contamination; Respiratory equipment like oxygen nasal cannula should be changed when contaminated or was on the floor; Call light buttons found on the floor should be disinfected prior to placing them back for residents' use; and Soiled diapers should not be placed on the floor for infection prevention and control. A review of the facility's policy and procedure (P&P) titled, OXYGEN ADMINISTRATION, revised 1/2021, the P/P indicated, The purpose of this procedure is to provides for safe oxygen administration .8. keep the oxygen cannula and tubing used PRN {as needed] in a plastic bag when not in use . A review of the facility's P&P titled, ADMINISTERING MEDICATIONS THROUGH A SMALL (HANDHELD) VOLUME NEBULIZER, revised 10/2010, the P&P indicated, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the procedure: 27. rinse and disinfect the nebulizer equipment according to facility protocol, or: a. wash pieces with warm, soapy water; b. rinse with hot water; c. place all pieces in a bowl and cover with isopropyl (rubbing) alcohol soak for five minutes; d. rinse all pieces with sterile water (NOT tap, bottled or distilled); and e. allow to air dry in a paper towel. 29. When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it . A review of the facility's P&P titled, BEDPAN/URINAL, OFFERING/REMOVING, revised 2/2018, the P&P indicated, The purpose of this procedure is to provide the resident with bedpan and/or urinal assistance. Steps in the procedure: 1. Place the equipment on the bedside stand. Assistance with a urinal: 1. Be sure that it is clean and dry . A review of the facility's P&P titled, PERSONAL PROTECTIVE EQUIPMENT, revised 10/2018, the P&P indicated, Personal protective equipment appropriate to specific task requirements is available at all times. 3. The type of PPE required for a task is based on a: the type of transmission-based precautions. 6. Employees who fail to use PPE when indicated may be disciplined in accordance with personnel policies . A review of the facility's P&P titled, CALL SYSTEM, RESIDENT, dated 9/2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member. 3. The resident call system remains functional at all times . 6. On 07/22/2026 9:34 AM During a medication pass observation on Resident 81, Licensed Nurse 1 (LN 1) checked the blood pressure (BP) of Resident 81 with a manual BP machine (sphygmomanometer) and a stethoscope (medical tool used to listen to sounds inside the body, such as the heart, lungs, and blood flow). After completing the task of obtaining the BP, LN 1 stored the BP equipment and stethoscope into a plastic bag and put the equipment into the medication cart without sanitizing them. LN 1 confirmed that she did not wipe the blood pressure machine and stethoscope with a facility approved sanitation wipe. LN 1 stated, All equipment used on the residents must be sanitized after use. During an interview with the Infection Preventionist (IP) on 7/24/26 at 10 a.m. the IP confirmed that her expectations were all staff members practiced infection control by sanitizing all equipment used with residents' care and must be sanitized before storing or putting away the equipment. A review of facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident -Care Items, revised 6/2011, the P&P indicated, . Purpose .The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items .General Guidelines .3. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care.C. Non-Critical items are those that come in contact with intact skin but not mucous membranes . (1) non-critical resident care items include bedpans, blood pressure cuffs, crutches and computers 7. During an observation on 7/23/26 at 10:15 a.m. Resident 9's urinary catheter bag (UCB, plastic pouch that connects to a soft hollow tube inserted into the bladder to drain or collect urine) touched the hallway floor while Resident 9 wheeled and self-propelled down the hallway past multiple staff members into to the dining room. During an observation on 7/24/26 at 10 a.m. in the dining room, Resident 9's UCB was touching the dining room floor. Resident 9 stated, I do not like it [UCB] there [on the floor]. Resident 9, with a cup of coffee in her hand, bent over and attempted to lift the UCB off the floor and stated she could not reach the UCB. During a concurrent observation and interview on 07/24/26 at 10:02 a.m., in the dining room with Restorative Nursing Aide 1 (RNA 1), Resident 9's and Resident 83's UCBs were found hung underneath their wheelchairs and touching the dining room floor. RNA 1 confirmed Resident 9's and Resident 83's UCBs touched the floor, and stated, To avoid infection and breakage of the UCB, the UCB should not touch the floor. During an interview on 7/24/26 at 10:25 a.m. with the IP, the IP stated it was the expectation that the UCB should not be on the floor and that the UCB could pull on catheter and can burst. During an interview on 7/24/26 at 10:49 a.m. with the DON, the DON stated it was the expectation that the UCB should not touch the floor to avoid infection. A review of the facility's P&P titled, Catheter Care, Urinary, dated 8/2022, indicated, Infection Control.2. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview and record review, the facility failed to ensure the two dietary staff had proper skill to prepare the appropriate texture for IDDSI (The International Dysphagia Diet Standardization Initiative, is an international organization and it developed a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties) Level 6 Soft and Bite Size (SB6) texture (food items should be chopped or cut into pieces size no larger than 1.5 centimeters (cm, a measurement unit) by 1.5 cm. Food texture was designs for individuals who experiencing biting limitations but are able to chew food items for swallowing) and IDDSI Level 5 Minced and Moist (MM5) texture [food items should be soft and moist (excess fluid should be drained), size no larger than 4 millimeters (mm, a measurement unit) by 15 mm. Food texture was designs for individuals who experiencing biting, chewing, and/or swallowing limitations] food items.This deficient practice had the potential to increase risk for the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway). There were 14 residents on SB6 texture diets and two residents on MM5 texture diets, out of the 90 out of 95 residents consumed food from the facility kitchen.Findings:An observation of preparation of food items with SB6 and MM5 textures and concurrent interview with [NAME] (CK) 2 and Dietary Manager (DM) was conducted on 7/22/26 beginning at 10:18 a.m. CK 2 stated she had scalloped potato, mixed vegetables, and fish to make SB6 and MM5 textures. She stated she had to prepare 13 servings of SB6 and three servings of MM5.Observation of the SB6 scalloped potato preparation:CK 2 stated she would make 15 servings for SB 6 in case extra portions were needed. She stated one serving of regular texture of cooked scalloped potato was 1/2 cup [4 ounces (oz.)] and she would use a #8 scoop (a serving utensil could provide 1/2 cup) and scooped 15 servings into the food processor and grinded for few seconds. The final product looked like coarse puree texture with small lumps. The lumps were less than 1.5 cm by 1.5 cm. CK 2 did not confirm the texture with IDDSI critical tests (the practical and hands-on evaluations used to verify food textures. The core critical methods include the Fork Pressure Test, Fork Drip Test, Spoon Tilt Test.)A concurrent review of the facility recipe titled, Scalloped Potatoes, Week 4 Wednesday, dated 2026, indicated the SB6 texture for the scalloped potatoes should be chopped into pieces (1.5 cm x 1.5 cm) before preparing recipe (before cooked). It also stated, Utilize the critical tests and IDDSI audit to confirm texture meets level #6 specifications.Observation of the MM5 scalloped potato preparation:CK 2 stated there were three residents on MM5 texture and she would make five servings, and one serving was 1/2 cup or 4 oz. She used the #8 scoop to scoop five servings of regular texture of cooked scalloped potato in the food processor and grinded for few seconds. The final product looked like puree texture with tiny lumps, and the lumps were less than 4 mm by 15 mm. CK 2 did not confirm the texture with IDDSI critical test. A concurrent review of the facility recipe titled, Scalloped Potatoes, Week 4 Wednesday, dated 2026, indicated the MM5 texture for the scalloped potatoes should be minced into pieces of 4 mm by 15 mm before preparing recipe (before cooking). It also indicated to utilize the critical test and IDDSI audit to confirm the texture if meet the level #5 specifications.Observation of the SB6 Italian Herb Vegetables (mixed vegetables) preparation:CK 2 stated she would prepare 15 servings of SB6 for the mixed vegetables, and one serving was 1/2 cup or 4 oz. She stated she would use #8 scoop (1/2 cup scoop) as serving utensil and scooped 15 servings in the food processor. She grinded the mixed vegetables for few seconds. The final product looked like minced mixed vegetables with texture size less than 1.5 cm by 1.5 cm with excess fluid. A concurrent review the facility recipe titled, Italian Herb Vegetables, Week 4 Wednesday, dated 2026, indicated chopped all the vegetables into pieces of 1.5 cm by 1.5 cm in size before cooking. It also indicated use canned green beans instead of mixed vegetables. During an interview with DM on 7/22/26 at 10:39 a.m., DM reviewed the recipe and confirmed the size of the SB6 mixed vegetables were too small and were not appropriate, and he stated the recipe stated to chop not grind the vegetables. DM instructed CK 2 to restart preparing SB6 texture for the mixed vegetables. CK 2 used the regular texture cooked mixed vegetables to chop with knife into pieces.Observation of MM5 texture Italian Herb Vegetables preparation:CK 2 used the previous grinded vegetables as MM5 texture. Observed there was excess fluid and was not cohesive to hold the grind vegetables in shape. CK 2 was not aware the grind vegetables were too loose with excess fluid, and she added two pumps of liquid thickener when prompted. CK 2 did not confirm the texture with IDDSI critical test until asked.A concurrent review of facility recipe titled, Italian Herb Vegetables, Week 4 Wednesday, dated 2026, indicated the vegetable should be minced in pieces size of 4 mm by 15 mm before cooking and moistened with gravy or sauce at appropriate thickness as needed after cooked. It also indicated to use canned green beans instead of mixed vegetables. Observation of MM5 texture Fish Italiano preparation:CK 2 stated there were three residents on MM5 texture and she would prepare five servings of fish. She placed five cooked fish fillets in the food processor and grinded. The final product of MM5 texture for fish was with small pieces with approximately 4 mm in measurement and could hold in shape. CK 2 tested the MM5 texture fish with spoon tilt and fork pressure test when requested. An observation and concurrent interview with Dietary Aide (DA) 1 and DM on 7/22/26 at 11:17 a.m. Observed DA 1 poured the canned diced peach into a metal pan mixed with leftover crumbs from the previous regular texture Peach Crisp (dessert). DA 1 stated the [NAME] only baked enough for the regular texture of Peach Crisp dessert, and she added the diced peach mixed with the leftover crumbs to make the SB6, MM5 and puree peach dessert. She stated she was not aware she had to use the original Peach Crisp recipe to make SB6, MM5 and Puree textures. A concurrent review of the facility recipe titled, Peach Crisp, Week 4 Wednesday, dated 2026, with DA 1 and DM, DA and DM acknowledged and agreed the SB6, MM5 and Puree textures should use the original recipe. DM stated the staff should not deviate the recipes for SB6, MM5 and puree textures. DM instructed CK 2 and DA 1 to bake a new batch of peach crisp. During an interview with DM and Registered Dietitian (RD) on 7/22/26 at 1:34 p.m., DM stated the facility implemented the IDDSI diets system before he started working in the facility. DM stated he was not familiar with IDDSI until he started to work in the facility, and he stated he had gained some knowledge about IDDSI overtime. He stated he did not have any re-training of IDDSI for the dietary staff since they got the initial implementation training of IDDSI diets. RD stated she was aware of IDDSI diets and got training from webinars. RD stated she did not perform any training regarding IDDSI diets to the dietary staff. During a follow-up interview with DM on 7/22/26 at 2:46 p.m., DM reviewed the recipes of MM5 and SB6 textures for the scalloped potatoes. DM stated the CK 2 did not follow the recipes, and the textures were not appropriate. DM agreed the final products should follow the IDDSI critical test to ensure the appropriate textures before serving the residents. DM reviewed the recipe of Italian Herb Vegetables, DM stated he and the dietary staff were not aware the SB6 texture and MM5 texture used canned green beans instead of the mixed vegetables. For the Peach Crisp dessert, DM agreed the staff should not deviate from the original recipe. He further stated the dietary staff should have knowledge, good understanding of the recipes and appropriate skill to prepare for the IDDSI diets. DM stated the dietary staff needed re-training for the IDDSI diets.A review of the IDDSI training report, and it indicated CK 2 completed the training on 10/14/25 but DA 1 was not on the report. The training was instructed by the previous dietary manager.A review of Diet Manual, dated 2025, indicated as follows:IDDSI Level #6, Soft & Bite-sized: Food items should be soft and chopped into pieces no larger than 1.5 cm x 1.5 cm. This diet has both size and texture specifications that must pass IDDSI level #6 testing requirements (i.e. the fork test, fork pressure test). Definition of chopped: To cut up into small pieces no larger than 1.5 cm x 1.5 cm, verified by the fork test. Soft: Be able to mash with a fork as verified by the fork pressure test. IDDSI Level #5, Minced and Moist: Food items should be soft, moist without excess fluid (fluid should be drained), and minced to size no larger than 4 mm x 15 mm. The diet has both size and texture specifications that must pass IDDSI Level #5 testing requirements (use fork test for size, fork pressure for softness and spoon tilt test for cohesiveness and non-sticky). Definition of minced: To cut up into small pieces no larger than 4 mm wide x 15 mm long, verified by the fork test. Soft: Be able to mash with a fork as verified by the fork pressure test. A review of facility document titled, Job Description: Cook, revised 9/1/16, indicated, .follow recipes and prepared foods that correspond to menu cycles and recipes.attend in-service education.apply information to job tasks.A review of facility document titled, Job Description: Dietary Aide, revised 9/1/16, indicated, .following recipes and posted menus, for both regular, modified and therapeutic diets.A review of facility document titled, Job Description: Dietary Service Manager, revised 9/1/16, indicated, .to effectively manage the Dietary Department to assure that food service to residents is safe.and provides for their nutritional needs.Direct the facility's food service operation.Supervise preparation of food and service of residents' meals and nourishment in accordance with recipes and posted menus for both regular, modified and therapeutic diets.Ensure food served.in a form to meet the individual needs of the residents.Plan and conduct staff meetings and in-service education programs on dietary policies and procedures.ability to instruct staff in correct procedures to be followed in the Dietary Department.A review of facility document titled, Job Description: Registered Dietitian, revised 9/1/16, indicated, .ability to instruct staff in correct procedures to be followed in the Dietary Department.effectively supervise dietary personnel.to plan and direct the food service operation to meet the individual needs of the residents.

Based on observation, interview, and record review, the facility failed to ensure four out of 22 sampled residents (Resident 8, Resident 24, Resident 61, and Resident 97) with room changes were provided with a written explanation of the reason why the move was required, the opportunity to see the new room and meet the new roommate, or exercise their right to refuse the room change.This failure resulted in the residents' frustration with frequent room changes and had the potential risk of not maintaining their highest practicable mental and psychosocial well-being.Findings:A review of Resident 61's admission Record (AR) indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder (a mental health condition that involves excessive fear, worry, or nervousness that interferes with daily life) and major depressive disorder (a serious mental health condition defined by a persistent low mood, loss of interest in activities, and lasting changes in sleep and energy).A review of Resident 61's Minimum Data Set (MDS, a federally mandated assessment tool) dated 6/27/26, indicated Resident 61's thinking and memory skills were cognitively intact.During an initial observation on 7/21/26 at 1:08 p.m. in Resident 61's room, Resident 61's room was observed with packed personal belongings and the bed made. During a concurrent observation and interview on 7/22/26 at 7:39 a.m. with Licensed Nurse (LN) 4, Resident 61's bed was empty. LN 4 indicated Resident 61 had been transferred to acute care hospital.During a concurrent observation and interview on 7/23/26 at 9:55 a.m. in the 100s hallway, Resident 61 was observed seated in a wheelchair propelling herself towards her assigned room and asked the OT (Occupational Therapist), Where is my room, where am I being moved to, I can't remember the room number. Resident 61 indicated she had returned from the hospital and discovered her room had been changed, and stated, I don't know what's going on, I don't feel good about it, but what can I do about it? This is the second time I've been moved. Resident 61 indicated she was unaware of her right to refuse a room change and was unsure if she wanted to refuse at this time. The OT escorted Resident 61 to her new room in the opposite hallway of the facility.During a follow up interview on 7/23/26 at 10:25 a.m. outside of Resident 61's new room, Resident 61 stated, I can't deal with this [room change and new roommate] .I haven't met the new roommate [Resident 78]; I didn't get to see what room I was moving to.During an interview on 7/23/26 at 10:36 a.m. with Resident 61's new roommate, Resident 78 stated, I was notified about getting a new roommate this morning, but no one offered for us to meet. During a concurrent interview and record review on 7/23/26 at 1:33 p.m. with the Social Services Director (SSD) and the Social Services Assistant (SSA), the facility's Room Change Notification (RCN) was reviewed. The SSD stated, Room changes are initiated by the IDT (Interdisciplinary team, a group of professionals from different fields who work together, share information, and build a unified resident care plan) and then discussed during the stand-up (meeting, a short, daily team check-in where people share what they did yesterday, what they will do today, and any problems they face). The SSD confirmed the residents were not provided with an explanation in writing of why the room change was required or that it was included on the RCN.A review of Resident 8's AR indicated Resident 8 was initially admitted to the facility on 12/2725 with diagnoses which included anxiety disorder and cognitive communication deficit (a breakdown in communication caused by impaired mental processes like attention, memory, and executive function).A review of Resident 8's MDS, dated [DATE], indicated Resident 8 's thinking and memory skills were cognitively intact.During a record review on 7/23/26 at 2 p.m. the facility's room change report for the last 30 days was reviewed. The report indicated 60 residents had at least, if not more, than one room change within the last 30 days. The report indicated Resident 8 had changed rooms five times within the last 30 days.A review of Resident 8's requested RCNs indicated room changes on the following dates: 7/19/26, 7/18/26, 6/18/26, 5/29/26, 5/28/26, 5/9/26, 2/11/26, 1/15/26 and 1/12/26. The RCN did not include an explanation of why the room change was required. Resident 8 was unavailable for an interview.A review of Resident 97's AR indicated Resident 97 was initially admitted to the facility on [DATE] with diagnoses which included stroke and cognitive communication deficit.During an interview on 7/23/26 at 4:01 p.m. with Resident 97, Resident 97 stated, Staff just tell me they're going to move me, there's not much I can do about it. Resident 97 indicated he was unaware of his right to refuse a room change. Resident 97 confirmed he did not receive written information, which included the reason for the room change or an opportunity to see the new room or meet the new roommate, if applicable. Resident 97 further added, I was just notified that I'll probably be moving rooms again.A review of Resident 24's AR indicated Resident 24 was initially admitted to the facility on [DATE] with diagnoses which included major depressive disorder and cognitive communication deficit. During an interview on 7/24/26 at 11:01 a.m. with Resident 24, Resident 24 stated, Yes. They [facility] have moved my rooms a lot. They don't tell me why. Resident 24 confirmed she did not receive written information, which included the reason for the room change or an opportunity to see the new room or meet the new roommate.During a concurrent interview and record review on 7/24/26 at 12:05 p.m. with the Director of Nursing (DON), the facility's RCN and IDT Room Change (IDT RC) progress note were reviewed. The DON confirmed the RCN and the IDT RC did not indicate the reason for the change or that the residents had received an explanation in writing of why the move was required. The DON indicated residents should be given notification in advance when a room change was initiated by the facility, and stated, Residents should receive advanced notification when room changes are required and the opportunity to see the new room and meet their new roommate. We want to ensure their psychosocial wellbeing. This is their home.A review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, revised 3/21, the P&P indicated, Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. 1. Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered . 4. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given at least a _ hour/day advance written notice of such change. a. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. 5. Residents have the right to refuse to move to another room in the facility if the purpose of the move is: c. solely for the convenience of the staff.

Based on observation, interview and record review, the facility failed to ensure the menu, spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet), recipe and tray ticket (a ticket displays along with resident's meal shows the prescribed diet, allergies, preferences (likes or dislikes), supplement(s) or adaptive devices if applicable) was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 7/21/26 and 7/22/26, when:During a dining observation on 7/21/26 found:Resident 21 received a bowl of slices of apple instead of apple square as dessert.Resident 43 did not receive health shake (nutrition supplement drink) as indicated on the tray ticket. B. During a meal service distribution on 7/22/26 found:Resident 58 with Level 5 Minced and Moist (MM5) texture {food texture designs for individuals who experience biting, chewing, and/or swallowing limitations. Foods prepared must be soft, moist (without excess fluid), and minced to size [no larger than 4 mm (millimeter - a measurement unit) x 15 mm]}, and low fat/low cholesterol diet (diet to manage heart disease or at risk for heart disease) received tartar sauce for fish instead of lemon slice or juice.Three residents (Resident 6, 71 and 75) with Renal 80-gram protein diet (diet designs for the individuals with renal insufficiency or kidney failure, usually low in minerals including potassium, sodium, and phosphorus, and limit with protein) did not receive salad with their meals.Resident 73 with Renal 80-gram protein diet receive salad with romaine lettuce instead of iceberg lettuce.Resident 59 with Regular diet with puree texture (food texture should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep, and usually prepares with blender or food processor. This diet is designed for individuals who have difficulty chewing or/and swallowing) and large portions who received 6 oz. (ounces, a weight measurement unit) instead of 3 oz.Resident 60 with Low Salt (NAS, no added salt) with MM5 texture received 3 oz. of MM5 scalloped potato instead of 4 oz. 27 residents with Regular diet or CCHO (Consistent Carbohydrate) diet (diet designs to manage blood sugar and diabetes) did not receive tartar sauce for fish. These deficient practices had the potential to result in compromising the medical and nutritional status of 36 out of 90 residents who consumed meals from the facility kitchen. The census was 95.Findings: A. During dining observation on 7/21/26 at 12:09 p.m. and 12:10 p.m. in the dining room: 1. It was noted Resident 21 with CCHO, Regular texture diet received a bowl of slices of soft apple with crumb on top for dessert. A concurrent review of the facility spreadsheet titled, Summer Menus, Week 4 Tuesday, indicated CCHO, regular texture diet should receive one serving of diet Glazed Apple Square with measurement of 2 inches x 2 inches x 1/2 inch height. During an interview with Dietary Aide (DA) 1 on 7/22/26 at 8:56 a.m., DA 1 stated she did not cut the dessert into square instead she used a #8 scoop (1/2 cup or 4 oz.) served the apple squares in small bowls for all regular texture diets. A review of the recipe titled, Glazed Apple Square, Week 4 Tuesday, dated 2026, indicated the portion size of one serving of the regular texture apple square was 2-inch x 2-inch x 1/2-inch as measurement. On the direction, indicated the dessert should be cut into square after cooled down after being baked. 2. It was noted Resident 43 did not receive health shake with his lunch meal. A concurrent review of Resident 43's tray ticket which indicated Resident 43 should receive health shake. During an interview with Dietary Manager (DM) on 7/21/26 at 12:14 p.m., DM confirmed Resident 43 did not receive health shake and Resident 43 should receive it with his meal. B. During the lunch meal distribution on 7/22/26 beginning at 12:10 p.m., it was noted as follows: 1. Resident 58 with Low fat/low Cholesterol diet with MM5 texture received tartar sauce for the fish. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Low fat/Low Cholesterol diet should receive lemon slice for the fish. 2. Resident 6, 71 and 75 with Renal diet did not receive salad with their meals. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Renal diet should receive 1/2 cup of Red and [NAME] Salad (use iceberg lettuce). 3. Resident 73 with Renal diet received salad with romaine lettuce with his lunch meal. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Renal diet should receive 1/2 cup of Red and [NAME] Salad (use iceberg lettuce). 4. Resident 59 with Regular diet with puree texture and large portion who received 6 oz. of puree fish instead of 4 oz. A concurrent interview with [NAME] (CK) 2 and she stated she used a #8 (1/2 cup = 4 oz.) serving scoop and scooped 1.5 scoops (6 oz.) for large portion puree fish. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Regular diet with puree texture and large portion should receive 1 scoop of #8 scoop (1/2 cup or 4 oz.) of puree fish. 5. Resident 60 with Low Salt (no added salt, NAS - a Regular diet without providing salt packet) diet with MM5 texture who received 3 oz. of MM5 textured scalloped potato instead of 4 oz. A concurrent interview with CK 1 and he stated he used #10 scoop (3 oz.) to serve the MM5 texture scalloped potato for residents who had Regular diet with MM5 texture. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Regular diet with MM5 texture should receive 1/2 cup (4 oz.) of MM5 scalloped potato. 6. 27 residents who were on Regular diet or CCHO diet did not receive tartar sauce for the fish. A concurrent review of facility spreadsheet titled, Summer Menus, Week 4 Wednesday, 7/22/26, indicated Regular diet and CCHO diet should receive tartar sauce for the fish. During an interview with the Registered Dietitian (RD) and DM on 7/22/26 at 1:34 p.m., the RD and the DM acknowledged the findings during the dining observation on 7/21/26 and lunch meal distribution on 7/22/26. The RD stated the staff should follow the recipes, tray tickets and spreadsheets to produce accurate meals and correct food items for the residents. DM stated the staff needed more training, and they had to understand and follow the spreadsheet and recipe. A review of facility document titled, Job Description, Cook, revised 9/1/16, indicated the essential job functions which included .Follow recipes and prepares food that correspond to menu cycles and recipes. A review of facility document titled, Job Description, Dietary Aide, revised 9/1/16, indicated the essential job functions which included .Serve food for meal delivery: read tray card (tray ticket). Check carefully for.specific instructions.Place on tray.correct type of food and texture as ordered by the diet with attention to serving modified and therapeutic diets, correct portion control, add correct condiments.special requested items. Recheck items on tray with tray card to ensure resident receives correct diet.A review of facility document titled, Job Description, Dietary Service Manager, revised 9/1/16, indicated the essential job functions which included .Supervise preparation of food and service of residents' meals and nourishment accordance with recipes and posted menus for both regular, modified and therapeutic diets.

Based on observations, interviews and record review the facility failed to ensure food and beverage intolerances and preferences were updated and honored for one of 22 sampled residents (Resident 111), when the facility repeatedly served whole milk to Resident 111 with lactose intolerance and disliked juice. These failures had the potential for Resident 111 to experience dehydration from inadequate fluid intake and develop a lack in confidence with facility staff when continually served items of intolerance or dislike. Findings:A review of Resident 111's admission Record indicated Resident 111 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (a chronic condition where blood sugar levels cannot be regulated) and chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly).A review of Resident 111's allergies included lactose intolerance (a digestive issue caused by low levels of the enzyme lactase, leading to bloating, cramps, and diarrhea after eating dairy).A review of Resident 111's Care Plan Report (CP, a formal, personalized roadmap outlining a resident's health needs, goals, and specific medical or nursing interventions), dated 7/21/26, indicated Resident 111 had dehydration or potential fluid deficit.A review of Resident 111's Diet Order and Communication (diet slip), dated 7/20/26, did not include information on Resident 111's food allergies, beverage intolerances and beverage preferences for meals.During a concurrent observation and interview on 7/21/26 at 12:43 p.m. with Resident 111 and Certified Nursing Assistant (CNA) 3 in Resident 111's room, Resident 111's lunch tray was observed with a plastic 8 ounce (oz, a unit of measurement) cup of milk and 8 oz cup of cranberry juice. Resident 111's tray ticket identified standing orders of 8 fluid oz of milk, whole and 8 fluid oz of juice, any. Resident 111 stated, I don't like or drink milk and I don't like cranberry juice. CNA 3 stated, I'll document on the tray ticket that [Resident 111] doesn't like milk or cranberry juice.During a concurrent observation and record review on 7/22/26 at 7:30 a.m. in Resident 111's room, Resident 111's breakfast tray was observed with one 8 oz cup of milk. Resident 111's tray ticket confirmed Resident 111 was served one 8 oz cup of whole milk.During a concurrent observation and interview on 7/22/26 at 12:58 p.m. with CNA 4, in Resident 111's room, Resident 111's lunch tray included an 8 oz glass of whole milk. Resident 111 reiterated that she does not drink milk. CNA 4 stated residents' food and beverage preferences are relayed to the kitchen staff or the Certified Dietary Manager (CDM) either in writing or verbally. CNA 4 indicated she would relay Resident 111's beverage preferences to the kitchen and update Resident 111's beverage preferences on the diet slip.During an interview on 7/22/26 at 1:40 p.m. with Licensed Nurse (LN) 4, LN 4 stated beverage preferences should be documented on the resident's diet slip under the food and beverage preference section. LN 4 further indicated the CDM and kitchen staff should also interview residents for their preferences when admitted or when requested.During a concurrent observation and interview on 7/24/26 at 9:16 a.m. with Resident 111, in Resident 111's room, Resident 111's breakfast tray included one 8 oz cup of whole milk and one 8 oz cup of cranberry juice. Resident 111 stated, All I want is no milk and no cranberry juice, how hard is that?During a concurrent interview and record review 7/24/26 at 9:24 a.m. with the CDM, Resident 111's diet slip was reviewed. The CDM confirmed Resident 111's diet slip did not include beverage intolerances or preferences. The CDM indicated he was unaware of Resident 111's beverage intolerances, dislikes and preferences. The CDM also indicated Resident 111's preferences had not been relayed to him, either verbally or in writing, by other facility staff. The CDM stated he expected residents to receive their preferred food and beverages during meals. The CDM stated, When residents are served foods and beverages they enjoy they maintain their dignity and strength.A review of the facility's policy and procedure (P&P) titled Resident Food Preferences revised July 2017, the P&P indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 8. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 106) received pain management in accordance with professional standard of care and comprehensive person-centered care plan, when pain medication was unavailable and not administered as ordered by the physician.This failure resulted in the decline of Resident 106's psychosocial well-being and had the potential risk of not maintaining Resident 106's highest practicable level of physical and mental health.Findings:A review of Resident 106's admission Record (AR) indicated Resident 106 was admitted to the facility in [DATE] with diagnoses which included muscle weakness and cognitive communication deficit (a breakdown in communication caused by impaired mental processes like attention, memory, and executive function).A review of Resident 106's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], indicated Resident 106's thinking and memory skills were cognitively intact.A review of Resident 106's admission History and Physical (H&P), dated [DATE], the H&P indicated additional diagnoses which included chronic pain (other, diverse long-lasting conditions such as fibromyalgia, neuropathic nerve damage, and visceral pelvic or abdominal discomfort which results in persistent pain), chronic pain syndrome (a long-lasting condition where continuous pain persists for more than three to six months, often accompanied by fatigue, sleep problems, and emotional distress), and low back pain (unspecified, lower back without a single known physical cause, specific disease, or nerve damage).A review of Resident 106's Care Plan Report (CPR, a formal, personalized plan of care and specific medical or nursing interventions), dated [DATE], indicated the following:Potential for alteration in comfort due to neuropathic pain, assess intensity of pain based on 1-10 scale, and provide medication as ordered;Alteration in musculoskeletal status related to fibromyalgia (a long-term medical condition characterized by widespread body pain when the brain and spinal cord change how they process pain signals, making the body feel pain much more strongly) and give analgesics (medications that relieve pain) as ordered by the physician;Risk for development of pressure ulcer/skin breakdown due to.back pain, arthritis.fibromyalgia and to monitor and manage Resident 106's pain, accordingly; andThe resident has actual/potential for pain: anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management.A review of the Order Summary Report (OSR, physician orders), dated [DATE], indicated orders for:Monitor Resident 106's pain using a numerical scale from 0-10, where 0 equaled no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain, every shift for Pain Management; and,Morphine Sulfate Oral Solution (MS, a strong narcotic pain medicine used to treat moderate to severe pain when other treatments do not work) every 4 hours as needed for moderate to severe pain from level 4-10 out of 10.A review of Resident 106's Weights and Vital Signs Summary, dated [DATE] - [DATE] indicated Resident 106 experienced a pain level greater than four 18 times.A review of the Nurse's Notes (progress notes documented by Licensed Nurses [LN]), dated [DATE] at 2:13 a.m. indicated Resident 106's MS was unavailable.During a concurrent observation and interview on [DATE] at 7:45 a.m. in Resident 106's room, Resident 106 complained that her pain medication was unavailable. Resident 106 stated some of her medication orders were not given. Resident 106 had tears in her eyes, and stated, I have an order for morphine solution, and they [nursing staff] aren't offering me that.they [LNs] tell me they don't have it [MS] here.During a concurrent interview and record review on [DATE] at 4:26 p.m. with LN 4, Resident 106's OSR was reviewed. LN 4 confirmed Resident 106's MS was not available in the medication cart's narcotic drawer. LN 4 confirmed Resident 106 had a current order for MS, and the medication had not been delivered from the pharmacy.During a follow-up interview on [DATE] at 9:33 a.m., Resident 106 stated, I haven't been getting my medication since I've been here. I've been asking for the morphine solution, but it hasn't been here.During a concurrent interview and record review on [DATE] at 10:29 a.m. with LN 5, Resident 106's OSR and the list of medications in the facility's ADU (automatic drug dispenser) was reviewed. LN 5 indicated all medications with an active order should be available for residents through the facility's ADU. LN 5 confirmed the MS solution was available in the ADU for Resident 106's use. LN 5 stated, I've never had an issue with medications, because they're always available from the pharmacy or in the ADU. LN 5 acknowledged pain medications should be available for resident use. LN 5 indicated if a medication was not delivered from the pharmacy in a timely manner the expectation was to follow up with the pharmacy and document the conversation in the resident's medical record. LN 5 acknowledged the importance of pain control, and stated, Residents who are in pain can have increased agitation, a decrease in their interests and participation levels and develop an overall concern with their care.During an interview on [DATE] at 11:42 a.m. with the Director of Nursing (DON) the DON stated medications should be available for residents when admitted to the facility. The DON indicated when medications were unavailable, LNs should check the ADU or contact the physician for an alternate medication. The DON acknowledged the MS solution was available in the ADU, and the LN should have administered Resident 106's pain medication as ordered. The DON acknowledged the importance of pain management and stated, It ensures the resident's overall wellbeing.During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 3/20, the P&P indicated, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 1 of 3 sampled residents (Resident 1), when Resident 1 returned to his room from the nurses ' station unattended and was unable to call for assistance to transfer from his wheelchair to bed when his call light was not within reach. This failure resulted in Resident 1's fall from his wheelchair and experienced bilateral feet pain and sustained an abrasion to the top of his left hand. Findings: During a review of Resident 1 ' s Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 1 was admitted to the facility in November 2024 with multiple diagnoses that included Encephalopathy (brain disorder), Dementia (memory decline), Abnormalities of Gait and Mobility (unusual walking patterns impacting a person's ability to move and perform daily activities), and Cognitive Communication Deficit (difficulties in communicating). During a review of Resident 1 ' s Minimum Data Set (MDS-A federally mandated resident assessment tool), dated 5/1/25, indicated, Substantial/Maximal Assistance - Helper does MORE THAN HALF the effort. Helper lifts of holds trunk or limbs and provides more than half the effort .from sitting in a chair, wheelchair, or on the side of the bed .to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 1 ' s care plan, initiated on 11/08/24, indicated the resident was at risk for falls related to gait and balance problems. Interventions included, Be sure The resident ' s call light is within reach and encourage the resident to use it .CNA for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. The resident needs a safe environment with .a working and reachable call light. During a review of Resident 1 ' s baseline care plan, dated 11/08/24, indicated, resident needs two persons physical assist for transfers. During a review of Resident 1 ' s Nurse Progress Notes, dated 4/22/25 at 10:19 a.m., indicated, Per RNA [Restorative Nursing Assistant], he [Resident 1] was placed across from the nurses station .It appears that resident wheeled himself back to his room and was attempting to transfer himself to bed when the fall occurred. During a review of Resident ' 1s IDT notes, dated 4/22/25 at 10:57 a.m., indicated, Preventative measures and interventions prior to fall event .call light in reach. During a review of Resident 1 ' s Post Fall Evaluation, dated 4/21/25 at 12:26 p.m., indicated, Date and time of fall 4/21/2025 11:25 [a.m.] .Location of fall .Resident ' s Room .Reason for fall .It appears that he was attempting to transfer himself back to bed .Injury details .An abrasion at top of left hand .Unwitnessed fall with abrasion at top of left hand and [complaint of bilateral] Feet pain .Indicators of Pain. During a concurrent observation and interview on 5/8/25 at 10:03a.m., in Resident 1 ' s room, Resident 1 was out of bed sitting in a wheelchair with a soft boot on his right foot. Resident 1 ' s call light was out of reach and was located on his bed. When asked how he gets help if needed and if he can reach his call light, Resident 1 attempted to reach back with his right arm and was not able to reach the call light. When asked if he was having pain, Resident 1 nodded and pointed to his right foot. During an interview on 5/8/25 at 10:08 a.m., with Certified Nursing Assistant (CNA 1), stated, To prevent falls .always check on them and give them the call light .should put the call light closer .should be with him. [Resident 1] usually stays in bed .he gets up in chair. He needs two person assist .to be safe .We bring him to the nurses ' station to monitor him. During a concurrent observation and interview on 5/8/25 at 10:23 a.m. in Resident 1 ' s room, with Licensed nurse (LN) 1, LN 1 confirmed Resident 1 ' s call light was not in reach and stated, The call light should be somewhere where he can reach it .We usually put him at the nurses ' station for close monitoring. During an interview on 5/8/25 at 10:42 a.m., with Resident 2 up in wheelchair, stated, He fell down once. He tried to get in bed by himself and he fell so I called the nurses. He couldn ' t get his call light. I called when he [Resident 1] fell . During an interview on 5/8/25 at 11:01 a.m., in the hallway on Unit 1, with Resident 1 ' s Restorative Nursing Assistant (RNA 1), stated, [Resident 1] is a fall risk. We take him to the nurses ' station to watch him because he is a fall risk. During an observation on 5/8/25 at 11:09 a.m., Resident 1 sat in a wheelchair in front on the nurses ' station. During an interview on 5/8/25 at 11:14 a.m., with Activities Director (AD), stated, Sometimes the residents are not alert and sometimes they try to stand up. Everyone has to have call bell on their chest or if up in wheelchair still have call light close to them or bring them close to the nurses ' station for monitoring. During an interview on 5/8/25 at 11:25 a.m. with Social Services Director (SSD), stated, He [Resident 1] was observed lying on the floor on left side. Nurse and CNA found him .[for fall risk interventions] [Resident 1] is usually sitting up at the [nurses] station .can ' t transfer by himself, expect call light to be close to him. During an interview on 5/8/25 at 1:15 p.m. with Director of Nursing (DON), stated When resident is a fall risk, we also put them at the nurses station to monitor them closely. During a review of the facility ' s policy and procedure (P&P) titled, Answering the Call Light, revised 3/21, the P&P indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. During a review of the facility ' s policy and procedure titled, Fall and Fall Risk, Managing, Revised March 2018, indicated, .The staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling .Fall risk factors .Resident conditions that may contribute to the risk of falls include: other cognitive impairment, pain, lower extremity weakness, functional impairments .Medical factors that may contribute to the risk of falls include: balance and gait disorders.

Based on observation, interview, and record review, the facility failed to protect one of three sampled resident (Resident 1) to be free from physical abuse by another resident (Resident 2) when Resident 1 was slapped by Resident 2. This failure increased the potential for Resident 1 to feel emotional distress. Findings: Resident 1 was admitted to the facility in late 2024 with diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (an assessment tool), dated 10/24, the MDS indicated Resident 1's cognition was intact scoring 13/15 in the BIMS (Brief Interview for Mental Status) assessment. Resident 2 was admitted to the facility in late 2024 with diagnoses which included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), alcohol dependence, and chronic pain syndrome. During a review of Resident 2's MDS dated ,d+[DATE], the MDS indicated Resident 2's BIMS score was 15/15 which reflected the resident had intact cognition. During a review of Resident 2's Progress Notes [PN], dated 10/16/24 at 1:04 p.m. the PN indicated, .was notified of an incident involving a resident who allegedly slapped their roommate .the resident [Resident 2] stated that he slapped the roommate [Resident 1] due to the roommate's consistently loud behavior . During a review of Resident 2's PN dated 10/16/24 at 1:23 p.m. the PN indicated, Witness-[name of witness] .states he saw [Resident 2] get up and go over to [Resident 1] side and saw him make contact with his cheek across the face. During a review of Resident 2's care plan (CP) created on 10/17/24, the CP indicated, The resident is/has potential to be physically aggressive r/t [related to] Poor impulse control . During an interview on 10/28/24 at 11:34 a.m. with the Janitor (JAN), the JAN stated, I was in the room across from them. The gentleman .[Resident 2], he reached over and slapped .[Resident 1] with his hand. I saw him slap him on the head. I ran over and intervened and told him he can't do that .[Resident 1] was on his side of the room in his bed .He was sitting on the edge of his bed. [Resident 2] got up from his bed and walked over to [Resident 1] . During an interview on 10/28/24 at 11:42 a.m. with Resident 1, Resident 1 stated, .I was on the bed, he came around the curtain and slapped me .it irritated me .It felt like I got hit with a baseball mitt . During an interview on 10/28/24 at 12 p.m. with Resident 2, Resident 2 stated, .He took swings at me. That's when I did my little [gestured a slapping motion with his hand]. I did it like a reset. I have dealt with people with dementia before . In an interview on 10/28/24 at 12:27 p.m. with the Director of Social Service, the DSS stated, It's not tolerated when asked her expectations for abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, neglect, Exploitation and Misappropriation Prevention Program, dated 4/21, the P&P indicated, Residents have the right to be free from abuse .Protect resident from abuse .by anyone including .other residents .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. Water pitchers and accompanying cups were stored upright and uncovered; 2. Foods were not labeled with received, opened and use by dates; and 3. Hair was not completely covered by a hair net while serving food. This failure increased the risk for foodborne illness. Findings: 1. During an initial tour observation of the kitchen and interview on 10/14/24 at 8:18 a.m. with [NAME] 1, there were multiple water pitchers on a four shelf wire rack. Some had lids inverted, others had no lids. None were turned down or covered to avoid contamination. [NAME] 1 verified the observation and said, They are ready to go out later. During a concurrent observation and interview on 10/14/24 at 8:27 a.m. with Dietary Aide (DA) 1, DA 1 verified there were twenty pitchers on top shelf of wire rack without lids, open to dust and splatter and said, The ones [lids that are used as cups] that are upright should be turned down. On shelf two there were 21 pitchers with all cups stored upright and open to the air. On shelf three there were 20 pitchers stored upright with cups upright or no lid at all. On shelf four there were two pitchers with no lids. During a concurrent observation and interview on 10/14/24 at 8:50 a.m. with the Dietary Manager (DM), the DM verified the observation and said, Water pitchers should be stored upright with the lid [drinking cup] facing down. During an interview on 10/16/24 at 9:37 a.m. with the Registered Dietician (RD), the RD was asked her expectations for covering water pitchers and said, Pitchers should be covered or turned down so that nothing can contaminate the inside or the drinking cup . The policy and procedure (P&P) for storing water pitchers was requested but not provided. 2. During an initial tour observation and concurrent interview on 10/14/24 at 8:50 a.m. with [NAME] 1, there was a five pound clear bag of French fries unopened on top of a box in the reach-in fridge with no received or use-by date, a clear plastic bag of meatballs opened and partially used with no received, open or use-by date. [NAME] 1 verified observation and said, They should be labeled when opened. During a concurrent observation of the walk-in fridge and interview with the DM on 10/14/24 at 8:55 a.m., there were three loaves of bread on top of the bread rack with no received date, or use-by date. The DM verified the observation and said, All food should be labeled with the received date, open date and use-by date. During an interview on 10/16/24 at 9:37 a.m. with the RD, the RD was asked her expectations and said, All food that is delivered should be dated with the received date, an open date, and use-by date . During a review of the facility P&P titled, LABELING AND DATING OF FOODS, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated .Newly opened food items will need to be .labeled with an open date and used by date . 3. During a lunch meal observation in the kitchen on 10/15/24 at 11:15 a.m., DA 2 was observed cutting up peanut butter cake on a surface at the end of the steam table. On closer observation, it was discovered her hair net was halfway back on her head with the scalp portion of long braids showing through and uncovered. The DM verified the observation, assisted her to put her hair under the net by adding another net. It was observed that DA 2's hair net slipped uncovering her hair two more times during tray line. During an interview on 10/16/24 at 9:37 a.m. with the RD, the RD was asked her expectations for wearing hair nets and said, Any staff who walks in the kitchen door should have a hair net covering all hair. During an interview on 10/16/24 at 10:39 a.m., the DM said, She [DA 2] had 3 hair nets on and just didn't notice it had slipped. During a review of the facility P&P titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 11/22, the P&P indicated, Hair Nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils .

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control procedures and guidelines for nine of 30 sampled residents (Resident 32, 43, 29, 40, 42, 14, 81, 12, 291, 296), when: 1. Three unlabeled basins were found in the bathrooms of Resident 32 and Resident 43; 2. Three wheelchair armrests were in disrepair and unable to be sanitized for Resident 29, Resident 40, and Resident 42; 3. Two Licensed Nurses (LNs) with no PPEs (personal protective equipment) entered an enhanced standard precautions room and provided care to Resident 14; 4. An LN with no PPEs entered a transmission-based precautions room and picked up equipment used by Resident 81; 5. Resident 12's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) machine was found on the floor and was bagged; and 6.Resident 296's anti-microbial bag was unlabeled and undated. These failures had the potential to increase the transmission of infections. Findings: 1. Resident 32 was admitted to the facility in the fall of 2016 with diagnoses which a urinary tract infection Resident 43 was readmitted to the facility in the fall of 2020 with diagnoses which included urinary incontinence. During an initial tour observation on 10/14/24 at 9:58 a.m., two pink basins were on the bathroom floor and one basin was on the back of the toilet unlabeled in the bathroom shared by Resident 32 and Resident 43. During a concurrent observation and interview on 10/14/24 at 10:08 a.m., with Certified Nurses Assistant (CNA) 3, CNA 3 verified the three wash basins in the bathroom of Resident 32 and Resident 43 were not labeled and said, They should be labeled .The full time CNA should know to label them. During an interview with the Director of Nurses (DON) on 10/17/24 at 10:28 a.m., the DON was asked her expectations for the labeling of resident equipment and said, My expectation is that all patient equipment be labeled name, room number or both . The policy and procedure for the labeling of resident equipment was requested but not provided. 2. During a dining room observation on 10/14/24 at 11:48 a.m., the wheelchair armrests of Resident 29, Resident 40 and Resident 42 were in disrepair and unable to be sanitized. Resident 29 was readmitted to the facility in the winter of 2017 with diagnoses which included arthritis, muscle weakness and dementia (a chronic condition that causes a decline in mental functions, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). During a review of Resident 29's the Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/14/24, the MDS indicated Resident 29 had severe memory impairment and used a manual wheelchair. During a review of Resident 29's physician progress note (PPN), dated 8/21/24, the PPN indicated, sitting in a wheelchair . During a review of Resident 29's care plan (CP) titled, Self Care Deficit manifested by .Dementia with behavioral disturbances .bilateral [both sides] knee arthritis ., dated 1/11/19, the CP indicated, Assist/Encourage out of bed to wheelchair daily . During a review of Resident 29's occupational therapy evaluation (OT Eval), dated 7/13/24, the OT Eval indicated, Dependent in (sic) wheelchair ambulation . Resident 40 was readmitted to the facility in the spring of 2023 with diagnoses which included cerebral infarction (stroke), abnormality of gait and mobility, history of falling, syncope (fainting) and collapse. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 had severe memory loss and used a manual wheelchair. During a review of Resident 40's physical therapy evaluation (PT Eval), dated 7/10/24, the PT Eval indicated, To walk in the room or hallways .Unable Totally Dependent . Resident 43 was readmitted to the facility in the fall of 2024 with diagnoses which included cerebral infarction, Parkinson's Disease (a progressive brain disorder that causes movement problems, including tremors, stiffness, and difficulty with balance and coordination) and dementia. During a review of Resident 43's MDS, dated , 10/4/24, the MDS indicated she was alert and oriented, able to make her needs known, and used a manual wheelchair. During a review of Resident 43's CP titled, High complexity OT evaluation indicating 5 deficit areas of self-care including .functional ADL (Activities of Daily Living) transfers ., dated 10/2/24, the CP indicated, w/c [wheelchair] management . During a review of Resident 43's OT Eval, dated 10/8/24, the OT Eval indicated, Ambulation/Wheelchair .Patient can propel self short distances . During a concurrent observation and interview on 10/14/24 at 11:52 a.m. with the Rehab Director (RD), the RD verified the armrests of Resident 29, Resident 40 and Resident 43's wheelchairs were in disrepair and said, We will have Maintenance replace after lunch. During an interview on 10/14/24 at 11:52 a.m. with the Maintenance Assistant (MA), the MA said, The wheelchairs are cleaned monthly. Housekeeping rounds them up. Janitor power washes them. Rehab and Housekeeping will check them and they'd let me know if they need repairs and I'd repair them. We did see them when we power washed them last month and the water didn't seep through them so we hadn't replaced them yet. During an interview on 10/15/24 at 9:52 a.m. with the Infection Preventionist ( IP), the IP was asked her expectations regarding sanitizing the armrests of wheelchairs in disrepair and said, We probably can't sanitize 100% if the upholstery of the armrests is damaged. During a review of the facility document titled, LOGBOOK DOCUMENTATION (LB), dated 9/17/24, the LB indicated, Steps .Inspect wheelchairs for damaged .components .Armpads, check for cracks .Repair or replace as necessary . During a review of the facility document titled, MAINTENANCE LOG, dated, 2024, Resident 29, Resident 40 and Resident 43's wheelchair arm rest repairs were not found from 8/18/24 through 10/13/24. 38528 3. Resident 14 was admitted to the facility in the middle of 2024 with diagnoses which included stroke, prostate enlargement, and urinary tract infection. During a review of Resident 14's Order Summary Report (OSR), dated 9/3/24, the OSR indicated, Enhanced Standard Precautions r/t presence of [name brand] catheter. During a review of Resident 14's Nursing Care Plan (NCP), dated 9/3/24, the NCP indicated, Resident requires isolation/precautions .TYPE: Enhanced Standard Precautions .REASON: r/t presence of .[urinary]catheter .Staff will DON the appropriate required PPE [personal protective equipment which includes gloves, gowns, face masks, face shields) when entering room to provide any type of care or address needs .Staff will maintain required type of precautions at all times. During a concurrent observation and interview on 10/14/24 at 10:20 a.m., Licensed Nurse (LN) 1 and LN 2 entered the room and verified Resident 14 holding the urinary catheter bag on top of his abdomen. Resident 14 stated, Tight, tight, dirty and cloudy. LN 1 and LN 2 repositioned and touched Resident 14's body and the urinary catheter. LN 2 left the room while LN 1 stayed in the room and continued to reassure the resident. When asked if the room was on enhanced precautions, LN 2 stated, We should be wearing gowns and gloves. When asked if there was a resident contact when care was provided in the room, LN 2 stated, Yes. We should have worn gowns for infection control. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 8/22, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care or use ( .central line, urinary catheter, feeding tube .etc.). 4. During a concurrent observation and interview on 10/14/24 at 10:25 a.m., Contact Precautions signage was posted on Resident 81's room door which indicated, Everyone must: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves .put on gown .before room entry. Discard gloves .discard gown .before room exit. Resident 81 was in bed, awake and alert but hard of hearing. A blood pressure (BP) cuff equipment was found on top of the bedside table together with other personal belongings. During a concurrent observation and interview on 10/14/24 at 10:42 a.m., LN 3 entered Resident 81's isolation precaution room with no PPEs, picked up the blood pressure cuff equipment then came out of the room. When asked what the process was when entering an isolation room, LN 3 stated, I know. I went in there to pick up the blood pressure cuff. I should have put on gown and gloves. It's all about infection control. During an interview on 10/17/24 at 10:23 a.m. with the DON, the DON stated, The expectation in terms of infection control on transmission based isolation precautions for CNAs and staff in terms of entering and providing care, to follow whatever sign is in there, which includes enhanced standard precautions, to use the necessary personal protective equipment, gowns, gloves, face masks, to prevent the spread of infection. During a review of the facility's P&P titled, Isolation - Initiating Transmission-Based Precautions, revised 8/19, the P&P indicated, When Transmission-Based Precautions are implemented, the Infection Preventionist .Determines the appropriate notification on the room entrance door .that personnel and visitors are aware of the need for and type of precautions .Provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE .The signage informs the staff .before entering the room. 48175 5. Resident 12 was admitted early in 2024 with diagnoses that included chronic obstructive pulmonary disease (COPD chronic lung disease causing difficulty in breathing) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 12's Physician's Orders (PO), dated 10/11/24, the PO indicated, Change and Date Anti-Microbial Bag for Nebulizer and 02 Tubing Storage every nightshift every 1 month(s) starting on the 1st for 1 day(s) (sic). During a concurrent observation and interview on 10/14/24 at 11:26 a.m. in Resident 12's room with LN 7, LN 7 stated, . [Resident 12's] nebulizer should be stored in an anti-microbial bag. During a concurrent observation and interview on 10/15/24 at 9:12 a.m. in Resident 12's room with CNA 8, CNA 8 confirmed that Resident 12's nebulizer was on the floor and should have been stored in an anti-microbial bag to minimize any bacteria since Resident 12 had a lung infection. During a concurrent observation and interview on 10/16/24 at 2:15 p.m. with the DON in Resident 12's room, the DON stated, The expectation is to follow the infection control protocol .which is to ensure that equipment is stored and labeled properly . 6. Resident 296 was admitted in late 2024 with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (a condition where the prostate gland enlarges and causes urinary symptoms) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease. During a review of Resident 296's PO, dated 10/05/24, the PO indicated, [Brand Name, urinary Catheter] Change .Catheter bag q [every] week. During a review of Resident 296's CP, dated 10/7/24, the CP indicated, Use principles of infection control and universal/standard precautions. During a concurrent observation and interview on 10/14/24 at 11:42 a.m. with LN 8 in Resident 296's room, LN 9 confirmed that Resident 296's urinary catheter anti-microbial bag was undated and unlabeled. During an observation and interview on 10/15/24 at 8:08 a.m. with CNA 2 in Resident 296's room, CNA 2 stated, .The [urinary] catheter bag should be dated and labeled . During an observation and interview on 10/16/24 at 2:25 p.m. with the DON in Resident 296's room, the DON stated, .The staff went to get a pen .The expectation is to label and date the anti-microbial bag immediately after it's changed. The Facility was unable to provide a P&P upon request of the Department.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to one of 30 sampled residents (Resident 40) when staff did not monitor Resident 1 during mealtimes. This failure had the potential to cause Resident 40 to choke or aspirate fluids (accidentally inhaling fluids into the airways). Findings: Resident was admitted to the facility on in May of 2022 with diagnoses that included difficulty swallowing. During a review of Resident 40's Orders, dated 8/24, the Orders indicated, Swallow precautions: close supervision w/meals d/t [due to] impulsive/fast PO [oral] intake, sit upright, oral care, small sips/bites, singular/controlled sips of thin, slow intake, ensure oral cavity clearance, if pt [patient] coughs take a 45-60 second break before continuing, medication: whole. During a review of Resident 40's Rehab Therapy Notes, dated 8/24, the notes indicated, SLP [speech language pathologist] evaluated pt's swallow. Pt impulsive w/intake, fast pace, benefitting from max cueing. Pt to be downgraded to mech soft .Swallow precautions in place. During a concurrent observation and interview on 10/15/24 at 8:05 a.m., with Certified Nursing Assistant 8 (CNA 8), Resident 40 was brought his breakfast tray but was left alone in his room with no supervision while he ate. Resident 40 was also not easily visible from the hallway. Resident 40 consumed over 90 percent of his breakfast with no supervision. CNA 8 confirmed Resident 40 was not supervised during his breakfast and stated, [Resident 40] is usually monitored and is supposed to be watched so he doesn't choke. During an interview on 10/15/24 at 8:15 a.m., with Licensed Vocational Nurse 6 (LN 6), LN 6 stated, [Resident 40] needs to be closely monitored for eating but mainly drinking. He needs to be checked in case he starts coughing. Staff should check frequently. [Resident 40] might drink very fast and start coughing and might aspirate. During an interview on 10/15/24 at 8:43 a.m., with the SLP, the SLP stated, [Resident 40] was on regular and thin liquids and wasn't tolerating the current diet. After working with him, he was discharged [from speech therapy] and was assessed to be able to tolerate nectar thick liquids and mechanical soft diet with supervision .If he is eating in his room, staff should be monitoring him and checking in on him. [Resident 40] can be impulsive. It can be a risk for aspiration. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 4/2021, the P&P indicated, .Implementing interventions to reduce accident risks and hazards shall include the following .Ensuring that interventions are implemented .Monitoring the effectiveness of interventions shall include the following .Ensuring that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for one of 30 sampled residents (Resident 48) when a urinary catheter was discontinued and Licensed Nurses [LNs] continued documentation on monitoring and care. This failure resulted in inaccurate documentation for Resident 48 and had the increased potential for miscommunication among health providers who provided care. Findings: Resident 48 was admitted to the facility in late 2024 with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), right femur (thigh) fracture, and urinary bladder dysfunction. During a review of Resident 48's Order Summary Report (OSR), dated 9/22/24, the OSR indicated, [Name Brand of urinary catheter] catheter care QS [every shift]: Cleanse using warm water and soap and then rinse well with warm water every shift. During a review of Resident 48's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/25/24, the MDS indicated Resident 48 had mild memory impairment and had a urinary catheter in place. During a review of Resident 48's Nursing Care Plan (NCP), dated 9/30/24, the NCP indicated, Catheter present as evidenced by: [Urinary Catheter] .DX: .dysfunction of the bladder .Monitor indwelling catheter and change/ irrigate as ordered. During a review of Resident 48's Progress Notes (PN), dated 10/9/24, the PN indicated, .received written order to d/c [discontinue] [urinary catheter] and follow .removal monitoring for urinary retention .resident agrees but requested to have it done early in the morning. Assigned nurse made aware of order. There was no documented evidence in the PN the urinary catheter was removed the next day. During a review of Resident 48's Treatment Administration Record (TAR) for October 2024, the TAR indicated licensed nurses signed doing monitoring and urinary care from 10/10/24 to 10/15/24. During a concurrent observation and interview on 10/15/24 at 8:46 a.m. in Resident 48's room, Resident 48 in bed, awake, alert, oriented and verbally responsive, and stated, The [urinary] catheter has been removed. They took it out about a week ago today. The urologist [kidney doctor] .ordered to take it out .I haven't had the catheter since 10/9/24. During a concurrent interview and record review on 10/16/24 at 1:05 p.m. with LN 4, LN 4 stated, LN 4 verified Resident 48's urinary catheter was still documented in the TAR from 10/10/24 to 10/15/24 as signed and monitored, and stated, The treatment records indicates the nurses are still documenting cleaning and monitoring the urinary catheter. That should have been discontinued. During an interview on 10/16/24 at 1:19 p.m. with the Director of Nursing, the DON verified Resident 48's TAR which indicated the urinary catheter was signed by nursing doing care since the urinary catheter was discontinued, and stated, I will check what happened to that. The order was discontinued and the care plan was discontinued. That is inaccurate chart documentation. During a review of facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/17, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 62) was able to call for assistance when the call light was not in working order. This failure had the potential to result in unmet care needs for Resident 62 when her call light was not working. Findings: Resident 62 was admitted to the facility in late 2023 with diagnoses which included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (irregular heartbeat) and hypertension (HTN-high blood pressure). During an observation and interview on 10/14/24 at 9 a.m. in Resident 62's room, Resident 62 was observed in her bed, pushing her call light. She pulled back her bed covers to show her wet incontinence brief and stated, They are not coming .look at me. I have soiled pants and they need to be changed. Resident 62 pushed her call light again; the call light did not turn on in the hallway. During a concurrent observation and interview on 10/14/24 at 9:05 a.m. with Certified Nursing Assistant (CNA) 8, in Resident 62 room, CNA 8 confirmed the call light was not working and stated, It should be working she does need assistance . During an interview on 10/17/24 at 12:27 p.m. with the Director of Nursing (DON), the DON stated, I would expect that everyone should have a working call light or given another way to call out for help. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Lights, dated 9/22, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Be sure that the call light is plugged in and functioning at all times .

Based on observation, interview, and record review, the facility failed to ensure the food preferences and allergies were accommodated for two of 30 sampled residents (Resident 48 and Resident 80), when: 1. Resident 48's food preferences were not honored; and 2. Resident 80's food allergies were not managed. These failures increased the potential risk for Resident 48 feeling disrespected and Resident 80 having allergic reactions from the food served. Findings: 1. Resident 48 was admitted to the facility in late 2024 with diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), right femur (thigh) fracture, and urinary bladder dysfunction. During a review of Resident 48's Progress Notes (PN), dated 9/27/24, the PN indicated, Dietary: LOW SALT, LOW FAT, LOW CHOLESTEROL diet, Regular texture, Thin Liquid consistency. Will continue to provide current diet orders and update preferences prn [as needed]. During a review of Resident 48's Nutrition Screen on Admission (NSA), dated 9/24/24, the NSA indicated, Food Likes: French toast, scrambled eggs, oatmeal, corn, meatloaf, beef stew .Food Dislikes: cream of wheat, squash, pork sausage. During a concurrent observation and interview on 10/14/24 at 9:57 a.m. in Resident 48's room, Resident 48 was in bed, awake, alert, oriented and verbally responsive, and stated, I just wanted you to know, I'm not myself personally satisfied with the food .I've lost about 12 lbs. since I've been here .The sausage that they served this morning, it was so hard, I couldn't cut it with the knife they gave me .I don't like sausage and they still give me .and that's a problem. During a concurrent observation and interview on 10/15/24 at 12:36 p.m. in Resident 48's room, Resident 48 stated, The food today not cold initially but I don't like fish too much. Meal ticket was not found on the meal tray to check the resident's likes, dislikes and preferences. The resident stated, I don't see it here. During an interview on 10/16/24 at 8:46 a.m. in Resident 48's room, Resident 48 was in bed, awake, and alert, stated, I told a young lady about my liking for hot oatmeal. I had an oatmeal yesterday but not today. Today, they gave me cream of wheat which I don't like. The dietitian has not been here to talk to me about my food preferences. During a review of Resident 48's breakfast meal ticket, the ticket indicated, Dislikes: [Name Brand]/CREAM OF WHEAT, PORK SAUSGAE (sic), SPINACH .Preferences: .Milk .OJ [orange juice]. Resident food preference [for oatmeal] was not identified in the meal ticket. During an interview on 10/16/24 at 9:06 a.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated, Before I pass and serve the meal trays, I make sure the nurse checks it then then I take the tray to the resident and do my own check of the tray and check the meal ticket if they have the right food, the right water to drink and also check what they like and don't like .[Resident 48] is alert and oriented. He knows everything. During an interview on 10/17/24 at 8:29 a.m. with the Administrator (ADM), the ADM stated, [The residents] have the right to have a food preference and follow whatever other dietary assessment or nutritional assessment from our dietary managers. 2. Resident 80 was admitted to the facility in late 2024 with diagnoses which included hypoxemia [low blood oxygen level], and post traumatic stress disorder, morbid obesity, and acid reflux disease. During a review of Resident 80's Baseline Care Plan (BCP), dated 9/7/24, the BCP indicated, Allergies: .seafood .Dietary Preferences: Will update as needed. During a review of Resident 80's NCP, dated 9/10/24, the NCP indicated, The resident is at risk for impaired nutritional status as well as increased risk for malnutrition .NOTE: SIGNIFICANT FOOD ALLERGIES, DIETARY AWARE: banana, mustard, nuts, papaya, seafood, squash, tomato, wheat flour, caffeine .Obtain food preferences . During a review of Resident 80's Nutrition Screen on Admission (NSA), dated 9/11/24, the NSA indicated, Allergies: papaya, mustard, seafood . During a concurrent observation and interview on 10/14/24 at 10:41 a.m. in Resident 80's room, Resident 80 was in bed, awake, alert, and verbally responsive, and stated, My only problem is when they give me food. They served me the things that I didn't like and allergic to. I already told them that I was allergic to fish, shrimp, lobster, and wheat bread but they still served me . During a review of Resident 80's lunch meal ticket on 10/15/24 at 12:38 p.m., the meal ticket indicated, Allergies: BANANAS/PAPAYA .NUTS, SEAFOOD . During an interview on 10/15/24 at 12:40 p.m. with CNA 3, CNA 3 stated, [Resident 80] had fish in her meal tray and told me she did not like fish in her diet. She was upset .She said this was not the first time that she got what she had asked for her meal. During a concurrent observation and interview on 10/15/24 at 12:50 p.m. with Resident 80 in her room, Resident 80 was in bed finishing her lunch meal, and stated, I don't know why they keep giving me fish. I already told them that I don't want it and they still keep giving me fish. I don't like seafood. I don't know if they know how to read. During an interview on 10/17/24 at 10:33 a.m. with the Dietary Manager (DM), the DM stated, When the meal tray is served during meals, the meal tickets are put in the meal tray to make sure the diet ordered is accurate and included in the meal tickets are the likes, dislikes and allergies because when we look at the meal tickets, it says their dislikes allergies and preferences. The meal tickets are still in there for staff to check. During a review of an undated facility's policy and procedure (P&P) titled, Food Preferences, the P&P indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods dislike will be given the appropriate food group. Condiments such as salt, pepper, and sugar are available at each meal unless contraindicated by the diet order .Food preferences can be obtained from the resident, family, or staff members. Updating of food preferences will be done as the resident's needs change and/or during the quarterly review.

Based on observation, interview, and medical record review, the facility failed to ensure necessary treatment, services, and equipment were provided for one of three sampled residents (Resident 1) to improve or maintain mobility, when: 1. Resident 1's concerns about his personal wheelchair were not addressed; and 2. Physician's order to get Resident 1 out of bed daily was not followed. These failures had the potential for Resident 1 to not maintain or improve his mobility and not attain his highest physical, mental, and psychosocial well-being. Findings: Resident 1 was admitted to the facility in the middle of 2020 with diagnoses: epilepsy (seizure disorder), hemiplegia (the loss of the ability to move and/or feel in parts of the body), and major depressive disorder. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/12/24, the MDS indicated Resident 1 had no memory impairment, used a wheelchair and was dependent on staff with transfers and mobility. During a review of Resident 1's Physician's Orders (PO), dated 4/21/24, the PO indicated, [Resident 1] to be up in w/c [wheelchair] daily . During a concurrent observation and interview on 6/12/24 at 9:30 a.m. in Resident 1's room, Resident 1 was lying in bed, awake, alert and verbally responsive. The posted signage on Resident 1's wall indicated, Please get resident up every day @[at]1030 hrs. Resident 1 indicated he had communicated to staff his personal wheelchair did not work and needed to be serviced because the wheelchair straps (a strip of material used to secure an individual) did not fit. Resident 1 indicated he did not want to be in his wheelchair without using the straps because it was not safe. During an interview on 6/12/24 at 9:56 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated Resident 1 had not been up in his wheelchair in the past 12 days. CNA 1 indicated she and other staff, in the past, have not asked Resident 1 to get up to his wheelchair, and stated, I did not see the sign on the wall. This is the first time I have seen the sign. During an interview on 6/12/24 at 10:03 a.m. with Licensed Nurse 1 (LN 1), LN 1 indicated Resident 1 had used his wheelchair in the past, but now, due to the issue with the straps, Resident 1 has not been using his wheelchair. LN 1 indicated the issue was communicated to the maintenance staff, but they were not able to fix the wheelchair. LN 1 indicated that physical therapy was not notified and have not evaluated Resident 1 since he started having an issue with the wheelchair straps. During an interview on 6/12/24, at 10:45 a.m., with the Rehabilitation Director (RD), the RD indicated Resident 1 received physical therapy services in February of 2024 and had used his wheelchair for three hours at a time, and stated, If I was notified about the wheelchair problem, I would have requested a physician's order to evaluate Resident 1's concern and the personal wheelchair to be corrected. During an interview on 6/12/24 at 11:06 a.m. with the Maintenance Assistant (MA), the MA indicated he checked the wheelchair but could not fix the ankle straps, and stated, The CNA and the nurse knew about the wheelchair issue. I did not notify management or physical therapy .I did not log it in the maintenance binder. During an interview on 6/12/24 at 12 noon with the Director of Nursing (DON), the DON stated, I have not heard of the wheelchair not working. If a resident keeps refusing care, the care plan is adjusted as necessary .I expect maintenance issues to be logged and communicated. During an interview on 6/12/24 at 12:13 p.m. with the Administrator (ADM), the ADM indicated when an equipment was broken or not working and the equipment was needed for resident care, he would be, notified and will find a solution to fix the problem. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, dated 3/18, the P&P indicated, Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. During a review of the facility's P&P titled, Assistive Devices and Equipment, dated 1/20, the P&P indicated, The resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment .Devices and equipment are maintained on schedule and according to manufacturer ' s instructions. Defective or worn devices are discarded or repaired.

Based on observation, interview, and record review the facility failed to ensure a safe and accident-free environment for one resident (Resident 1) of three sampled residents, when staff providing care to Resident 1 turned around to grab supplies, which were located out of reach, and resulted in Resident 1 falling off the bed. This failure resulted in Resident 1 obtaining a fracture to the left, fifth metacarpal (broken finger) and a closed head injury (a nonpenetrating injury to the brain colliding with and no break in the skull). Findings: A review of an admission record indicated Resident 1 was readmitted to the facility late 2022 with multiple diagnoses which included epilepsy (seizure), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), muscle weakness, and anxiety. A review of a Minimum Data Set (MDS, an assessment tool) dated 10/30/23, indicated Resident 1 had an impairment on one side of the lower extremity, and required substantial/maximal assistance (when the caretaker provides more than half the effort) to roll from the left to right side. An MDS, dated [DATE], indicated Resident 1 had mild memory problems. A review of Resident 1's care plan, dated 10/16/22, indicated, The resident is at risk for falls . [staff were to] Anticipate and meet the resident's needs . A review of Resident 1's Progress Notes (PN) dated 1/25/24 at 5 a.m., indicated, While CNA [Certified Nursing Assistant, 1] was giving care, resident was over turned and fell off the bed .Resident sustained a golf ball bump on the middle of forehead and a skin tear on the right arm below elbow. A review of Resident 1's PN dated 1/25/24 at 1:57 p.m., indicated, Writer received notification of return from acute with fall with possible injury Witnessed fall on 1-25-24 at [5 a.m.] .Stated Broken hand .Noted fracture . A review of Resident 1's emergency department visit note dated 1/25/24, indicated, .ARM PAIN .hematoma [blood pooling due to injury] to R [right] frontal head and R forearm .CLOSED HEAD INJURY .LEFT FIFTH METACARPAL .FX [fracture] .CAUSE OF INJURY, FALL . During a concurrent observation and interview on 2/8/24 at 10:49 a.m. in room [ROOM NUMBER], Resident 1 was lying in bed with a purple-colored bruise on the side of the left hand. Resident 1's bed was not in the lowest position as the bed height was above the surveyor's knee. There was no observed fall mat on the floor anywhere near the bed and both quarter rails were in the raised position. Resident 1 stated she remembered falling from the bed. During an interview on 2/8/24 at 11:18 a.m., with Licensed Nurse 1 (LN 1), LN 1 confirmed Resident 1 was a fall risk and was expectated to have: the bed in the lowest position, the side table and property within reach, the fall mat on the floor by bedside, wear anti-slip socks on both feet, and no clutter in the room. During a concurrent observation and interview on 2/8/24 at 11:42 a.m., with Certified Nursing Assistant 1 (CNA 1), by Resident 1's room, CNA 1 observed and confirmed Resident 1's bed was not in the lowest position. The CNA1 stated, .She's [Resident 1] a fall risk . The CNA1 stated Resident 1's bed should be in the lowest position, closest to the ground. During an interview on 2/8/24 at 11:50 a.m., with LN 1, LN 1 confirmed Resident 1's bed was not in the lowest position and it was expected to be in the lowest position. During an interview on 2/8/24 at 1:04 p.m., with the Unit Manager (UM), the UM stated, .I was getting off of shift during the incident, [LN 2's] told me [Resident 1] fell .[CNA 3] was providing care to [Resident 1] .[CNA 3] overturned the resident .normally they should be doing it in two [staff because] it is safe that way . The UM also stated, .[CNA 3] was written up because staff caused the resident fall .staff didn't do the right thing . During an interview on 2/8/24 at 1:20 p.m., with CNA 3, CNA 3 confirmed he/she was providing care to Resident 1 during the fall incident. CNA 3 stated, .Raised the bed to my waist height, turned over Resident [1] towards me, facing me .I turned around to get the brief and heard a 'thud' sound .Resident [1] fell off the bed . The CNA 3 also stated he/she should have placed the incontinent brief within reach to prevent the fall. During an interview on 2/8/24 at 2:14 p.m., with the Director of Nursing (DON), the DON stated, .[Staff are] expected to .ensure resident safety . The DON said it was expected for staff to ensure all necessary items are within reach during an incontinence brief change to ensure patient safety. The DON also said the facility had no specific fall prevention management plan. A review of the facility's policy and procedure titled, Fall Risk Assessment, revised March 2018, indicated, The nursing staff .will .identify .resident risk factors for falls and establish a resident-centered falls prevention plan .

Based on interview and record review, the facility failed to meet professional standards of quality for one of 3 sampled residents (Resident 1) when nursing staff did not follow the physician's order to manually irrigate (unplug) the foley catheter (a soft rubber tubing inserted into the bladder to drain the urine) every shift. This failure resulted in Resident 1 having persistent hematuria (blood in urine) and had the potential to cause complications. Findings: A review of Resident 1's 'Admission Record,' indicated Resident 1 was admitted to the facility from the hospital on 12/28/23, with multiple diagnoses including enlarged prostate (a walnut shaped male gland that causes urination difficulty when enlarged), urinary tract infection and hematuria. Resident 1's clinical record was reviewed as follows: Hospital documentation titled, 'SNF [ Skilled Nursing Facility] orders,' dated 12/27/23, indicated, Foley/Urinary Care orders .Please manually irrigate Foley every shift (q [every] 8 hours) or as needed . Physician's progress note, dated 12/29/23 and timed at 8:14 a.m., indicated, .Patient was admitted to skilled nursing facility with hematuria .Assessment and Plan: .Patient still has hematuria. I asked SNF to follow all discharge instructions. Physician's progress note, dated 1/4/24 and timed at 2:08 p.m., indicated, .He has ongoing hematuria which explains his anemia (lack of blood). Foley catheter supposed to be irrigated every 8 hours. Order was placed few days ago .I asked nurses to provide all medications and services as ordered . Physician's progress note, dated 1/9/24 and timed at 5:32 p.m., indicated, .last Wednesday [1/3/24] during rounds we figured out that Foley catheter was not flushed every 8 hours with 60 ml [milliliter, a unit used to measure volume] of solution as ordered by the urologist .During last visit on Wednesday patient had hematuria and blood clots. As of today 1/9/24, during my visit patient Foley catheter was clean, no clots, no hematuria, no sedimentation. It means that since we started to flush catheter following urologist order 3 times a day with 60 ml of solution hematuria gets better and no clots .Plan: We need to continue to flush Foley catheter 3 times a day with 60 ml of fluid until urologist change the order .we cannot discharge the patient until we have strong plan regarding Foley catheter management. I feel not comfortable to change order from flushing from 3 times a day to 2 or 1 times a day. This order must come from urologist [a specialist in urinary system conditions]. We need to continue monitor closely for hematuria, clots .Foley Catheter evaluation please see above note and follow urologist instructions. Please do not change above order until urologists makes recommendations . A further review of Resident 1's clinical record reflected a physician's 'SNF discharge summary,' dated 1/16/24 at 10:46 a.m., which indicated Resident 1 was admitted to the facility from acute hospital with an order to irrigate the foley catheter every 8 hours. The physician documented Resident 1's hematuria had resolved when the catheter was irrigated as ordered and as recommended by the urologist. During an interview with the Assistant Director of Nursing (ADON) on 1/16/24 at 5:04 p.m., the ADON confirmed that before 1/1/24, there was one note of irrigation in the nurse's documentation dated 12/28/23 at 5:00 p.m. When the ADON was asked what her understanding was for Resident 1's hospital order to irrigate his catheter every eight hours or as needed, she stated she would get back to the Department. During an interview with the Director of Nursing (DON) on 1/16/24 at 5:27 p.m., when she was asked about Resident 1's hospital order to irrigate the foley catheter, the DON confirmed, These are the orders to irrigate every 8 hours. The DON further indicated a Licensed Nurse (LN 1) had irrigated the resident's foley catheter on 12/28/23 at 5:00 p.m., on admission. The DON agreed Resident 1's hospital discharge orders directed nurses to irrigate the foley catheter every 8 hours. The DON did not confirm why the hospital orders were not followed. A review of the California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated the nurses' functions included administration of medications and therapeutic agents necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.

Based on interview and record review, the facility failed to adequately address the pain of one of three sampled residents (Resident 1), when Licensed Nurse (LN 1) and LN 2 failed to assess, reassess, evaluate and treat Resident 1's symptoms. This failure resulted in Resident 1 unnecessarily experiencing 10/10 (most pain imaginable) pain for five and one-half hours. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in the spring of 2023 with diagnoses which included fracture (break in the bone) of the carpal bone in both wrists (small bone in the wrist) head laceration (deep cut or tear in the skin), and pain right wrist. During a review of Resident 1's Order Summary Report (OSR), dated 4/1/23, the OSR indicated Acetaminophen (to treat mild pain) Oral Tablet 500 MG (milligram: a unit of measure). Give 2 tablets by mouth every 8 hours as needed for mild pain 1-3/10 [pain scale used to determine a resident's perceived level of pain, on a scale of 1-10 with 10 being the worst pain imaginable] . Further review of the order summary report indicated, .oxycodone HCl (a narcotic to treat pain) Oral Tablet 5 MG (Oxycodone HCl) Give 0.5 tablet by mouth every 4 hours as needed for moderate to severe pain 4-10/10 .oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth every 12 hours for moderate to severe pain . During a review of a document titled KHG-Admission Care Conference and Baseline Care Plan (KHG), dated 4/1/23 at 15:47 (4:57 p.m.), the KHG indicated, .Monitor pain and medicate as ordered. During a review of Resident 1's Progress Notes (PN), dated 4/2/23, the PN indicated that Licensed Nurse (LN 3) documented that Resident 1 had not received pain medication on 4/1/23 at 8 p.m., as ordered and had left AMA (against medical advice) the following morning 4/2/23 at 11:30 a.m. During a review of an untitled document, dated 4/1/23 and 4/2/23, designated by the Director of Nurses (DON) as the e kit inventory record (EIR), the EIR indicated there were six oxycodone 5 mg tablets available for emergency use. The DON further indicated oxycodone 5 mg had not been removed from the e kit on 4/1/23. During a review of Resident 1's PN, dated 4/1/23 at 2024 (8:24 p.m.), LN 2 documented Resident (sic) pain med oxycodone 5 mg is not available to dispense called pharmacy and spoke with pharmacy technician said medicine will be (sic) arrive at midnight informed to supervisor and patient about oxycodone . and routine tyneol (sic) 500mg (sic) (milligrams a unit of measure) 2 tab (tablets) given to patient . During a review of a document titled Delivery Manifest: City Creek 01, dated 4/2/23, the Delivery Manifest indicated oxycodone 5 mg 25 tablets were delivered for Resident 1 at 1:37 a.m. on 4/2/23. During a review of Resident 1's PN, dated 4/2/23 at 02:59 (2:59 a.m., a late entry), the PN indicated that LN 1 had documented Resident was requesting to leave AMA stating that she was in severe pain since she didn't receive her Oxycodone 5 mg (sic) at 8 pm, (sic) called the on call provider for an order and Alixa to pull it from the ekit, fortunately the supplies arrived, and resident received her Oxycodone 5mg at 0136 [1:36 a.m.]. During a review of the PN, dated 4/2/23 at 1514 (3:14 p.m.) the PN indicated Around 9:15 (sic) writer called by resident (sic) son as resident want (sic) to talk with writer, as writer arrived in room resident siting at (sic) bed, and state (sic) she would like to go home, as resident and family is not satisfied with patient services and care, as not able (sic) to get pain medication till midnight yesterday and situation handle (sic) by staff is not satisfactory for them). Explain (sic) resident and son, if they want to leave the building it will be AMA and risks involved choosing this option and also explain (sic) as resident leaving AMA, facility not able to get any medicine and they have to arrange own transportation and facility will not (sic) responsible for any future inconvenience. During an interview on 8/8/23 at 8:45 a.m. with LN 1, LN 1 indicated when she observed Resident 1 around 10:30 p.m. Resident 1 was complaining of severe pain in both wrists and requesting pain medication for wrist pain described as 10/10 on a scale of 0-10. LN 1 indicated the medication was not given because it was not available. LN 1 further indicated medications from the acute facility were often delayed, in which case the medication could be removed from the e kit (emergency drug kit) if approved by the pharmacy. LN 1 indicated she called the pharmacy around 10:50 p.m. - 11 p.m. to get the okay to remove medication from the e kit at which time she was told by the pharmacy technician the medication would be delivered by the pharmacy transport person at midnight. LN 1 further indicated she was going to remove from the e kit but about that time the doorbell rang, and it was the medication delivery person, who was delivering Resident 1's medications. LN 1 indicated she had documented on the Medication Administration Record (MAR), that she administered the oxycodone 5 mg at 2000 (8:00 p.m.) because that is when it was due. LN 1 stated the documentation in a facility progress note, dated 4/2/23, indicated she had administered oxycodone 5 mg at 01:36 (1:36 a.m.), which was when she actually administered the medication to Resident 1. During an interview on 8/10/2023 at 11:15 a.m. with the DON, the DON indicated oxycodone was in the e kit and could be removed by the LN if needed prior to delivery of the resident's medications. The DON further indicated it would not be a problem to obtain the oxycodone from the e-kit. During an interview on 8/14/23 at 2:45 p.m. with LN 2, LN 2 indicated Resident 1's routine oxycodone 5 mg was not available at 8 p.m. to administer to Resident 1 as it had not yet been delivered by the pharmacy. LN 2 further explained it was a routine medication as it was ordered every 12 hours. LN 2 indicated she explained to Resident 1 that it was not available. During an interview on 8/28/23 at 10:08 a.m. with Resident 1 and Resident 1's family member (FM), Resident 1 requested Department speak with her FM as my English is not good. In this interview the FM indicated Resident 1 had been admitted to the facility on [DATE] at approximately 3 p.m. FM indicated Resident 1 was having severe pain in both arms and was told by LN 2 that her pain medications were not available as they had not been received at the facility. FM indicated that the nurse (LN 2) offered Resident 1 acetaminophen [brand name] which Resident 1 agreed to take due to the severe pain in her arms. In a continuation of the interview with the FM at around 10-10:30 p.m., FM indicated that Resident 1 asked LN 1 for pain medication. The FM indicated that LN 1 informed Resident 1 her medication was not available, and Resident 1 would have to wait for a delivery. FM further indicated that at approximately 1:15 a.m., FM indicated to LN 1 that Resident 1 wanted to leave AMA as her pain was not being managed. FM indicated that at this time he was told by LN1 that Resident 1 could not leave the facility until morning as it was a liability to the facility, if Resident 1 left the facility during the night. FM further indicated to LN 1 that he was going to call the police as he believed Resident 1 was being held against her will as well as report elder abuse for withholding Resident 1's pain medication. FM indicated shortly after his threat to call the police LN1 medicated Resident 1 with oxycodone. FM further indicated prior to leaving the facility the next morning, the day shift nurses told him the medication could be easily obtained by the push of a button as the medication was locked in the facility cabinet. FM indicated that Resident 1 left the facility AMA at approximately 11:35 a.m. on 4/2/23. During a review of the facilities policy and procedure (P&P) dated October 2022, titled Pain Assessment and Management the P&P indicated, The pain management program is based on a facility- wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident ' s choices related to pain management. Pain management is defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes .Assessing the potential for pain .Recognizing the presence of pain .Identifying the characteristics of pain .Addressing the underlying causes of the pain .Developing and implementing approaches to pain management .Identifying and using specific strategies for different levels and sources of pain .Monitoring for the effectiveness of interventions; and Modifying approaches as necessary .Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. Acute pain should be assessed (or significant worsening of chronic pain) should be assessed every 30-60 minutes after the onset and reassessed as indicated until relief is obtained .Pain management interventions reflect the sources, type, and severity of pain. Pain management interventions shall address the underlying causes of the resident's pain .The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate .Contact the provider immediately if the resident's pain or medication side effects are not adequately controlled . During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2275 (b). The practice of nursing within the scope meaning of this chapter means those functions, including basic health care, that helps people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment .ordered by and within the scope of licensure of a physician .as defined by section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997State of California Department of Consumer Affairs. Pp.5).

Based on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of care when one of three sampled residents (Resident 1) was lifted back to bed by Certified Nursing Assistant 3 (CNA 3) after a fall, prior to being assessed by a Licensed Nurse (LN). This failure resulted in Resident 1 needing to be moved to a higher level of care due to a fractured sternum (broken breastbone). Findings: During a record review, it was noted that Resident 1 was admitted to the facility in the summer of 2022, with diagnoses that included unspecified fracture of left femur (thigh bone), generalized muscle weakness, epilepsy (a disorder in the brain causing abnormal nerve and muscle activity), schizoaffective disorder (a combination of symptoms that affects a person's ability to think, feel and behave clearly), anxiety disorder and age related osteoporosis (bones becoming weak and brittle) without pathological (caused by disease) fracture. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/5/22, the MDS indicated that Resident 1 had severe memory impairment. During an observation and interview with Resident 1, in Resident 1's room, on 10/25/22, at 10:35 a.m., Resident 1 stated that she had fallen, but did not get injured when she fell . Resident 1 stated she was injured when CNA 3 was picking her up after the fall. Resident 1 stated that CNA 3 was behind her with his arms under her armpits and when he lifted her up she felt and heard a pop, stating, He crushed my sternum. Resident 1 stated that she felt pain in her chest and was sent to the hospital. During a review of Resident 1's Post Fall Evaluation (PFE), dated 10/11/22, at 11:30 a.m., the PFE indicated in the Fall Details section, reason for fall try [sic] to self transfer and injury details no injury during fall but while transferring back to bed. Orders were received and Resident 1 was transferred to the hospital for further evaluation. During a review of Resident 1's CT (Computerized Tomography, a complex set of x-rays) chest report, dated 10/11/22, the CT chest report indicated, Acute nondisplaced fracture of the manubrium of the sternum (the broad upper part of the breastbone) with small amount of underlying hemorrhage (bleeding). During a review of Resident 1's (Name of Hospital) Admission/Discharge Information report dated 10/15/22, the report indicated that, Per report, patient assisted back up by care personnel and heard a crack upon lifting with associated shortness of breath and chest pain .ED (Emergency Department) workup revealed nondisplaced manubrial fracture .Patient was deemed stable for discharge to SNF (Skilled Nursing Facility) on 10/15/22. During a review of Resident 1's Progress Notes (PN), dated 10/15/22, 9:11 p.m., the PN indicated that Resident 1 was admitted to the facility from the hospital by medic ambulance. Resident 1's admitting diagnosis was sternum fracture. During an interview with CNA 1 on 10/25/22, at 11:08 a.m., in the hallway, CNA 1 stated that if a resident fell she would notify the LN immediately. During an interview with LN1 on 10/25/22, at 11:15 a.m., at the nursing station, LN1 stated if a resident had an unwitnessed fall he would assess the resident before moving, try to determine what happened, notify the physician and the responsible person (RP), communicate with the staff, update the care plan (CP), document the event and complete the change of condition (COC) form. During an interview with CNA 2 on 10/25/22, at 11:41 a.m., at the nursing station, CNA 2 stated that if he witnessed a fall or found a resident on the floor, he would instruct the resident not to move and tell the charge nurse. During a telephone interview on 10/26/22, at 1:30 p.m., with LN 3, LN 3 stated that on 10/11/22, CNA 3 came and reported that he assisted Resident 1 back to bed after finding her on the floor in her room. LN 3 went on to state that CNA 3 told her he heard a pop when assisting Resident 1 back to bed. LN 3 stated when she assessed Resident 1, Resident 1 was complaining of pain in her chest. LN 3 notified the physician and Resident 1 was sent to the hospital for further evaluation. LN 3 stated CNA 3 should have notified the LN immediately before moving the patient. During a review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, revised March 2108, the P&P indicated, .After a Fall .If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, .If an assessment rules out significant injury, help resident to a comfortable sitting, lying or standing position. During a review of a video included in the facility's orientation titled, Lesson 25, CNA Training-Fall Prevention and Restraint Alternatives, the instructor states, Do not move the resident until the nurse has checked the resident.

Based on observation, interview, and record review, the facilty neglected Resident 1 when they failed to ensure adequate diagnostic imaging and evaluation were completed, for one of three sampled residents (Resident 1) when a femur (thigh bone) fracture remained undiagnosed for twenty-two days. This failure resulted in Resident 1 experiencing moderate to severe pain for twenty-two days. Findings: Resident 1 was admitted to the facility in the middle of 2021 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's, Brief Interview for Mental Status (BIMS, an assessment tool) dated 6/16/21, the BIMS indicated, a score of 9, on a scale of 0-15, indicating moderately impaired cognition (ability to think and process information). During a review of Resident 1's, Progress Notes, dated 7/29/21, at 3 a.m., the notes indicated, [R]esident had fall in her room. [S]he tried to get up of [sic] her bed. [S]he hd [sic] bump on her right forehead measures 3 cm [centimeters, a unit of measure] wide and 3 cm long. During a review of Resident 1's, Progress Notes, dated 7/30/21, at 1 a.m., the notes indicated, Went to hospital for pain to right lower extremity and sent to ER [emergency room ], patient came back with no new order. Per hospital notes CT [computed tomography, a procedure that involves specialized x-rays] C Spine [cervical spine, neck] .CT Head .XR [x-ray] Chest .were done . During a review of Resident 1's, Progress Notes, dated 7/30/21, at 12:07 p.m., the notes indicated, [MEDICATION(S)] 5-325 [5 milligrams of [MEDICATION(S)] and 325 milligrams of acetaminophen] given for pain management. During a review of Resident 1's, Progress Notes, dated 7/31/21, at 7:18 a.m., the notes indicated, Followed up with ER regarding procedures done on the right leg pain and spoke with ER MD [medical doctor]. Informed they did CT scan on hip but didn't do xray on right leg since he knew that there was an old fracture on the site. During a review of Resident 1's, Progress Notes, dated 7/31/21, at 12:23 p.m., the notes indicated, Right leg slightly swollen . During a review of Resident 1's, Progress Notes, dated 7/31/21, at 12:58 p.m., the notes indicated, XRay of Right Hip done, awaiting result, endorsed to the next shift. During a review of Resident 1's electronic, Order Summary Report, dated 7/1/21 through 7/31/21, the report indicated no order for CT scan. During a review of Resident 1's untitled pain Care Plan, dated 7/31/21, the plan indicated, Interventions. Notify NP [nurse practitioner] to transfer patient to ER for further evaluation .Notify MD if current regimen is ineffective. There were no revisions (indicators of updates, concerns, or changes in condition) noted for Resident 1's care plan from 8/1/21 through 8/20/21. During a review of Resident 1's, Progress Notes, dated 8/1/21, at 1:29 p.m., the notes indicated, Received X-RAY results [x-ray from 7/31/21] .there is evidence of [CONDITION(S)] [swelling] soft tissues [sic] upper right thigh. [C]alled on call nurse practitioner and received order to apply pack every 2hourly [sic] as needed. SSD requested to schedule appointment for CT scan for resident. [P]lease do follow up. During a review of Resident 1's paper chart, PHYSICIAN ORDERS, dated 8/1/21 at 1:29 p.m., the orders indicated, CT Scan for right leg Dx leg pain. The signature was illegible. During a review of Resident 1's, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's, Progress Notes [Social Service Notes], dated 8/2/21 at 9:58 a.m., the note indicated, Received communication from Nurse requesting to set up appointment for CT Scan. However, we cannot process due to lack of paperworks [sic] i.e. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's, Progress Notes, dated 8/2/21 at 10:51 p.m., the notes indicated, .received order to send patient out for blood transfusion .patient vitals [vital signs] assessed, WNL [within normal limits], but c/o [complained of] pain. Patient given PRN [as needed] [MEDICATION(S)] 5-325mg [sic] for rt [right] hip pain. During a review of Resident 1's, Progress Notes, dated 8/4/21 at 9:42 a.m., the note indicated, .unable to collect urine sample via straight Cath [catheter], resident start [sic] screaming in pain . During a review of Resident 1's, Progress Notes, dated 8/5/21, at 1 p.m., the note indicated, .Right leg slightly swollen . During a review of Resident 1's, Progress Notes, dated 8/12/21, at 10:29 a.m., the note indicated, New order from NP [name of NP], CT of right pelvic/leg .SSD [Social Service Director] to arrange appt [appointment]. During a review of Resident 1's, Progress Notes, dated 8/16/21, at 1:40 p.m., the note indicated, Patient noted to have elevated WBC [white blood cells, help the body fight infection and disease] .but leukocytosis [high white blood cell count] could be stress from increasing of pain .Patient has been stabilized and cleared by ortho [orthopedics, bone specialty doctors] .ASSESSMENT: right hip pain/acute [severe and sudden in onset] pain - on [MEDICATION(S)], [MEDICATION(S)]. During a review of Resident 1's, Progress Notes, dated 8/19/21 at 7:10 p.m., the note indicated, NP .acknowledged .(Surgeon) to do xray on right knee and right hip. Noted and carried out. RP [Responsible Party] made aware. During a review of Resident 1's, Radiology Interpretation, dated 8/19/21, the Radiology Interpretation indicated, ADDENDUM RIGHT KNEE .There is displaced spiral distal [furthest from the center of the body] femur [thigh bone] . During a review of Resident 1's, SBAR (Situation, Background, Assessment, Recommendation, a type of structured communication) Communication Form, dated 8/20/21, at 7 a.m., the, SBAR Communication Form indicated, Does the resident have pain? Yes. Is the pain? New. Description/location of pain: Right thigh (rear), /Right knee (rear). Intensity of pain: 6 .Recommendations of Primary Clinicians: Send resident to ER for evaluation .x-ray. During a review of Resident 1's, Progress Notes, dated 8/20/21 at 7:54 a.m., the note indicated, Xray result showed .femoral fx [fracture] .Received telephone order .to send pt [patient] to the hospital .[MEDICATION(S)] prn admin [administered] for pain at 0500 [5 a.m.] w/o [without] effectiveness. During an interview on 9/10/21, at 12:15 p.m., with Room & Board owner (RBO, Resident 1's prior landlord), the RBO stated her client (Resident 1) fell and fractured her right femur at the facility. The RBO stated she doesn't know when Resident 1 fell . The RBO stated, They [facility] told me she fell .she kept complaining about her right knee. The RBO stated in August when she visited the facility, Resident 1 was in pain for more than two weeks and that pain medication was not helping her. During an interview on 9/21/21, at 12:50 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated, In August the resident was in pain and screaming a lot. During an interview on 9/21/21, at 1:15 p.m., with Licensed Nurse (LN) 1, LN 1 stated on the day Resident 1 fell (7/29/21), they sent her to the emergency room and she came back the next day with no new orders. LN 1 stated, I called [the hospital] on 7/31 because the resident is in pain. LN 1 stated the hospital said there was no fracture. LN 1 stated on 8/21 the fracture was found and Resident 1's pain is better now per patient report (following 8/21/21 surgical repair). During an interview on 9/24/21, at 9:24 a.m., with LN 2, LN 2 stated, I only know of one fall in July. LN 2 stated Resident 1 had a lot of pain after the fall. LN 2 stated Resident 1 was, Screaming in pain in August .it [pain medication] didn't help that much .screaming all the time. LN 2 stated Resident 1 rated her pain 7-10. During an interview on 9/24/21, at 9:39 a.m., with LN 3, LN 3 stated the middle of Resident 1's right leg, not the hip or the knee, was painful (7/29/21-8/20/21), per Resident 1. LN 3 stated Resident 1 would scream and yell, It hurts! LN 3 stated Resident 1 is now fine with no complaints of pain (after 8/21/21 surgical repair of fracture). During an interview on 9/24/21, at 3:30 p.m., with LN 4, LN 4 stated Resident 1 would moan or yell in pain after the fall (7/29/21). LN 4 stated Resident 1 had a pain scale of, 'Usually a 5 or 6. During an interview on 9/24/21, at 5:10 p.m., with Nurse Practitioner (NP) 1, NP 1 stated Resident 1 had swelling near her right hip and increased pain (on 8/1/21). NP 1 stated she ordered a CT scan for Resident 1 (on 8/1/21). NP 1 stated upon her return to the facility (8/16/21), Resident 1 was still in pain and she, Never got results [of CT scan]. NP 1 stated, I cannot say why it didn't get done. On further examination of Resident 1 (on 8/16/21), NP 1 stated, the, Alignment (of Resident 1's leg) was not right. NP 1 stated she then ordered an x-ray of Resident 1's right knee which showed the fracture. During an interview on 9/27/21, at 11:10 a.m., with the Social Services Assistant (SSA), the SSA stated that on 8/1/21 LN 2 put in the facility's computer software communication area, Please schedule CT scan appointment for resident's [Resident 1] right hip. The SSA stated a lack of proper paperwork prevented it from being processed. The SSA continued by stating that on 8/3/21 she responded, Please provide Social Services a copy of the order for us to process. The SSA stated that on 8/11/21, We faxed a CT scan referral to [name of acute facility]. The SSA stated, Nothing was done [between 8/3/21 and 8/11/21]. The SSA stated, Social Services was supposed to follow up. I'm new here and we were so busy. I was supposed to follow up .I didn't. During an interview on 10/3/21, at 10:05 p.m., with LN 5, LN 5 stated, I have heard her scream or moan .she does go into pain whenever you would touch her or try to reposition her. LN 5 stated the usual process for getting a CT scan ordered was to get an order and contact Social Services who would find a facility where the CT could be done and arrange the transport. LN 5 stated that then Social Services would communicate to staff where and when the appointment was. During an interview on 10/5/21, at 9:20 a.m., with the Social Services Director (SSD), the SSD stated, When we send a referral we need an order .If I received a referral that didn't have an order, I would see the nurse directly to obtain the order. I would follow-up with the nurse to make sure to obtain the order. The SSD further stated that if the CT order was urgent or stat it would typically take three days to actually get the CT. The SSD stated that if the order was not marked as stat it would take 7-10 days to get the CT. The SSD stated, We would need to ask the doctor if we thought, 'Do we need to send the resident out to the hospital to get it [CT] faster?' The SSD stated, I don't believe this order [8/1/21] was marked as 'stat.' During an interview on 10/5/21, at 11:05 a.m., with the Director of Nursing (DON), the DON stated, nurses should definitely notify the doctor if there is a trend in severe pain, even if medications are temporarily relieving the pain, but the pain is coming back. The DON stated, It's a tricky one. The DON further stated, regarding the Social Services CT referral process, There might have been a delay. It sounds like she (SSA) didn't follow up on it. This is unfortunate. The DON stated, Nursing should probably have a overall long-term picture of her pain. During an interview on 10/5/21 at 12:05 p.m., with the Medical Director (MD), the MD stated the NP ordered a CT after Resident 1 fell on [DATE], and that the ED didn't include the right knee in the CT because of a prior known deformity there. The MD stated, We were mis-guided by ER. They should do the work-up we ask for. We would have expected ED to do the knee CT the first time. The MD stated, You always get the run-around when you try to get a CT scan in an outpatient setting when you're a nursing home. We could have done a better job if we had just sent her [Resident 1] out [to ED] again and obtained the knee CT more quickly. The MD also acknowledged that the situation was slowed by Social Services not following their process. The MD stated, You can't sit on a patient and wait 10 days if it's something acute. During a review of the facility's policy and procedure titled, Pain - Clinical Protocol, dated 2005, indicated, The physician and staff will identify individuals who have pain or who are at risk for having pain .the nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .The physician will help identify causes of pain .The physician will help identify the extent to which underlying causes of pain can be addressed or reversed .The physician will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain. During a review of the facility's policy and procedure titled, Abuse and Neglect - Clinical Protocol, dated 2005, indicated, Neglect as defined at 483.5 means, 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.' The policy further stated, The nurse will assess the individual .Assessment data will include .Pain Assessment .The nurse will report findings to the physician .the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear .along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect .the medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately.

Based on observation, interview, and record review, the facility failed to establish and implement an effective water management program (WMP) to prevent the development and spread of Legionella (a specific type of bacteria that causes a severe form of pneumonia or lung inflammation) when: 1. There was no evidence the facility had conducted a comprehensive risk assessment of the water system to identify areas at high risk for the development of water-borne pathogens (disease causing organisms) and no evidence the facility planned or implemented specific water testing protocols, (based upon the results of the risk assessment) to identify and respond to the presence of disease causing organisms. These failures resulted in the development and transmission of Legionella bacteria to 1 of 4 residents (Resident 1) and placed all residents in the facility at serious risk of severe respiratory infection. Resident 1 developed Legionella Pneumonia and [MEDICAL CONDITION] (a potentially life threatening condition caused by the body's response to a serious infection). Resident 1 required a 5-day hospital stay to treat the infection; and, 2. The facility failed to ensure staff followed the Sacramento County Public Health Department's (SCPHD) direction to avoid the use of ice from the facility's ice-machine during an active incident of Legionella identified in the facility's water system. This failure resulted in the determination of Immediate Jeopardy (Immediate Jeopardy represents a situation in which the facility's non-compliance has placed the health and safety of resident's in its care at risk of serious harm) due to the presence and likely transmission of a known pathogen to vulnerable residents who were able to obtain ice and water from the hydration cart. This failure placed them at immediate risk for legionella infection through inhalation or aspiration (breathing into the lungs) of contaminated water/ice from the ice machine. Immediate Jeopardy was called on 5/15/19 at 3:40 p.m. for a facility census of 96 residents. Findings: 1. The Admission Record dated 4/9/19, indicated Resident 1 was a [AGE] year-old female admitted to the facility in (YEAR) with diagnoses that included [MEDICAL CONDITION] (a disease affecting the body's immunity and ability to clean the blood and remove water), heart failure (a disease which affects the heart's ability to pump blood), and diabetes (a condition making it hard for the body to use sugar for energy). No diagnoses related to lung dysfunction were noted. Clinical record review of the facility Line Listing Report (a tracking list for infections), dated 4/19, indicated Resident 1 was sent to the hospital with shortness of breath and [MEDICAL CONDITION] (a condition where not enough oxygen is getting to the body's tissues) on 3/30/19. During her stay at the hospital, Resident 1 was diagnosed with [REDACTED]. On 4/4/19, after 5 nights at the hospital, Resident 1 returned to the facility with a [DIAGNOSES REDACTED]. Review of Center for Disease Control information related to Legionella indicated it causes a severe form of pneumonia that often requires hospitalization and is fatal in 10% of cases overall. Legionella is found in fresh water environments, and can be a health concern in human-made water systems (e.g. plumbing systems of large buildings) where conditions allow it to multiply and come in contact with vulnerable persons. People contract Legionella by inhaling aerosolized water droplets containing the bacteria, or aspiration of contaminated drinking water. (www.cdc.gov/legionella- (MONTH) 5, (YEAR)). During an interview with the public health nurse for the Sacramento County Public Health Department (SCPHD) on 4/11/19, beginning at 3:00 p.m. (as part of a facility, Sacramento County and State meeting group), she indicated Resident 1 came in contact with the legionella bacterium (a disease causing agent) while she was residing at the facility, based on her recent location and the incubation period of the legionella bacterium (incubation period is the time from the moment an infection enters the body until the appearance of the first symptom. Review of the CDC website revealed the incubation period is 2-10 days after exposure, with an average of 5-6 days (www.cdc.gov)). Administrative record review of the letter to the facility from the Environmental Management Department, dated 4/11/19, indicated the facility was required to implement the following control measures due to the legionella outbreak: - Avoid tap water for drinking and provide bottled water for patients/residents. Bottle water for staff is recommended. - Avoid ice from onsite ice machine(s) until ice machine culture results, collected by consultant, are available and negative. - Avoid using showers; patient/residents may receive sponge baths with tap water. Point of use filters (0.2 micron) may be installed by consultant on showers to allow temporary use. - Use sterile water for filling reservoirs of respiratory devices and rinsing respiratory equipment. - Use of tap water for dish washing may continue as usual. The administrative record for the facility was reviewed. The Legionella: PCR Methodology report (PCR- polymerase chain reaction - a laboratory technique used to detect pathogens responsible for infectious disease), dated 5/3/19, indicated the presence of legionella in the facility beauty shop at the hair sink. These results were preliminary and did not represent the results of the cultures obtained. Review of the facility policy and procedure titled, Legionella Water Management Program dated July, (YEAR) indicated, The water management team will consist of at least the following personnel .infection preventionist .administrator .medical director .director of maintenance .director of environmental services. The facility policy and procedure titled, Legionella Water Management Program dated (MONTH) (YEAR), indicated, .The water management program includes the following elements .A detailed description and diagram of the water system in the facility . The facility policy and procedure titled, Facility assessment dated (YEAR), indicated, The facility assessment will be reviewed and updated .at a minimum annually. The facility policy and procedure titled, Water Management Program dated (YEAR), indicated, .A risk assessment will be conducted by the water management team annually .The effectiveness of the management program shall be evaluated no less than annually . During an interview with the Infection Preventionist (IP), on 5/14/19, at 10:55 a.m., she stated she was unaware that a facility risk assessment of the water had been completed; she could not remember if a topic related to a water management program was discussed at the management level in the past year; and she knew nothing of testing protocols and acceptable ranges for control measures used in a water management program. During an interview with the Director of Environmental Services (DES), on 5/15/19, at 2:00 p.m., he stated he was on the water management team but he never did anything physical, just normal stuff like cleaning the ice machine and checking the water temperature. During a concurrent interview and record review with the Administrator Consultant (AC), on 5/17/19, at 4:25 p.m., he stated the facility document, Water System Infection Control Risk Assessment, dated 2/6/19, was given to him by the Facility Administrator (FA) to complete (because I'm) .kinda on the water management committee 'cause I'm familiar with the building. When asked about the form and how it was filled out, he stated, I decided on my own what that means .It wasn't clear to me .I just winged it. The AC did not state why there were no signatures under the section, List individuals who participated in this risk assessment, however, previous interviews with the IP and DES indicated they did not participate in the assessment. When asked about plumbing diagrams, he stated, We have remnants of the original building plan but the plumbing (specifications) are not in it. When asked if he could identify potential areas of bacterial growth in the water system, he stated, Well no, I could not tell you where there could be growth in the building since we don't have a plumbing schematic. When asked if he was aware of any testing protocols and acceptable ranges for control measures used by the facility, he stated, How would we know the ranges? I don't know the ranges. I am not an expert. (I) don't think anyone at the facility could put together protocols and parameters. After repeated requests of the Administrator for documentation, as of 5/15/19, no documented evidence of implementation of an effective water management program, facility risk assessment (including a detailed description and diagram of the water system in the facility as outlined in the facility's policy), or water testing protocols had been received by the Department. 2. During an observation of the kitchen on 5/15/19 at 12:30 p.m., the facility ice machine was operating, and the storage bin was full of ice. During an interview with Dietary Aide (DA 1) on 5/15/19, at 1:30 p.m., when asked what the ice from the ice machine was used for, she stated it was placed in a big bowl to keep nourishment (pint-sized dietary drinks in cartons) cool and also placed in an ice chest; the ice chest is placed on the hydration cart with cups and water; the hydration cart is then placed between the nurse's stations. During an interview with the Cook (CK 1) on 5/15/19 at 1:31 p.m., she stated ice from the ice machine is placed between food trays and sheet pans to cool things on the sheet pan and agreed with DA 1 that it (ice from the ice machine) is placed in coolers that are placed on the hydration cart. During an interview with CNA 1 on 5/15/19, at 1:43 p.m., when asked how the hydration cart is stocked, CNA 1 stated, The kitchen fills up the hydration cart. During an interview with Registered Nurse 1 (RN 1), at 1:52 p.m., she stated the kitchen staff fills up the hydration cart and that it is mostly for residents. An observation was made of the hydration cart as it sat between the nursing stations, on 5/15/19, at 1:55 p.m.; a plastic ice chest and large water jug were placed on a plastic cart, along with plastic cups and an ice scoop. The ice chest and water jug were at a level easily accessible to residents in wheelchairs. An observation was made of a facility nurse's station posting on 5/15/19 at 1:57 p.m The document, dated 4/10/19, indicated, .WHAT: Control Measures to be followed regarding water use from (SCPHD) .Do not use ice from the facility's ice machine . The facility's Administrator, Director of Nursing, and Director of Staff Development were informed of the Immediate Jeopardy on 5/15/19 at 3:40 p.m. The Immediate Jeopardy was a result of the facility's failure to implement specified control measures to prevent the spread of legionella when ice from the facility ice machine was made available for resident consumption at a hydration cart, contrary to the SCPHD direction to avoid ice from the ice machine until culture results were obtained. This failure placed vulnerable residents, able to access water from the hydration cart, at risk for legionella infection through inhalation or aspiration (breathing into the lungs) of contaminated water/ice from the ice machine. There was no documented evidence the facility received the results from cultures obtained from the facility's water supply prior to 5/16/19. An immediate corrective action plan was presented by the facility to the Department which included: - Water and ice for resident use will be brought in from outside the facility; - The ice machine will be emptied, the cooler (ice chest) at the hydration cart will be sanitized, and only ice from outside the facility will be placed in the cooler at the hydration cart; - All control measures will be followed as directed by the county; - In-service training will be provided to all staff to ensure they are aware of the reason for not using the ice from the facility ice machine; and, - The facility will continue to buy ice and water until the problem is resolved, and will be monitored by the facility Administrator, Dietary Service Supervisor, Director of Staff Development, Director of Nursing, and the Maintenance Supervisor. The immediate corrective action plan was accepted by the Department and the Immediate Jeopardy was removed on 5/16/19 at 2:20 p.m. based upon observed implementation of the plan.

Based on interview and record review, the facility failed to prevent a significant delay in care and treatment, ensure identification and treatment of [REDACTED]. 1. Skin assessment, bathing, and personal hygiene in the form of a bed bath or shower was not provided for 23 days. 2. A person-centered plan of care was not revised and implemented for identified persistent aggressive and resistant to care behaviors. 3. Continuously monitored high risk aggressive behaviors and refusal of care continued without goal-oriented intervention, and steps were not taken to identify underlying causes of behaviors and identify alternatives to meet resident needs. These failures resulted in Resident 1 not receiving care and services to prevent and identify skin breakdown, a delay in assessment, and a delay in treatment that contributed to the development of a severe life-threatening skin infection requiring hospitalization and surgery. Findings: According to the Facesheet, Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 1's clinical record included: A facility document titled Short-Term Care Plan, dated 10/21/18, for increased combative and physically aggressive behaviors. Interventions listed included notifying the physician and resident representative, monitor vital signs and behavior, and to redirect resident and re-approach calmly. The care plan goal was Resident 1 will be calm, and contained no measurable objectives or timeframes. A physician's order, dated 10/22/18, to monitor resident's behavior manifested by physically aggressive behavior with staff every shift. A clinical document titled, Monitoring Administration Record, dated 11/1/18-11/30/18, showed physically aggressive behaviors towards staff charted on 22 of 30 days. A clinical document titled, Monitoring Administration Record, dated 12/1/18-12/31/18, showed physically aggressive behaviors towards staff charted on 22 of 31 days. A clinical document titled, Monitoring Administration Record, dated 1/1/19-1/31/19, showed physically aggressive behaviors towards staff charted on 21 of 31 days. A clinical document titled, Monitoring Administration Record, dated 2/1/19-2/28/19, showed physically aggressive behaviors towards staff charted for 14 of the 14 days the resident was present in the facility. A Minimum Data Set (MDS - an assessment tool), dated 11/18/18 and 2/13/19, indicated Resident 1 had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) and verbal behavioral symptoms directed at others (threatening others, screaming at others, cursing at others). A clinical document titled Interdisciplinary (IDT) Progress Notes, dated 1/19/18, contained no documentation regarding Resident 1's consistent aggressive and refusal of care behaviors. Monthly physician clinical notes dated 12/1/18, 1/7/19, and 2/1/19 signed by Resident 1's physician. All three notes contained no documentation regarding Resident 1's repeated physically aggressive and refusal behaviors. The physician noted the plan was to, Continue same medication and treatment plan .Patient is stable. A resident care plan titled, Potential for Skin Breakdown, initiated 11/30/18, with an intervention to shower/bathe 2 times weekly as scheduled, and the certified nursing assistant (CNA) to inspect skin at this time and notify licensed nurse of findings. This care plan had no problem identified of resident refusing showers/baths or being aggressive with care and no documentation of alternative interventions tried for resident's refusal. No nursing care plan was present in the clinical record related to combative behaviors or activities of daily living (ADL) care being refused with risks posed for declining condition. No nursing interventions were present related to alternatives to be attempted when resident was combative and refused or resisted ADL care. Nursing progress notes, dated 1/3/19, 1/18/19, 1/19/19, 1/20/19, 1/21/19, 2/9/19, and 2/14/19, indicated Resident 1 was agitated, physically aggressive, resistive to ADL care. A report titled Follow Up Question Report, dated 1/1/19-2/14/19, indicated for dates 1/24/19 and 2/4/19 Resident 1 had refused bathing. For dates 1/27/19, 1/28/19, 1/31/19, 2/6/19, and 2/7/19 the document contained a response documented as Not Applicable, which indicated no bath or shower had been given. A form titled Shower Day Skin Inspection, dated 1/21/19, indicated Resident 1 had a shower and skin was intact. A form titled Shower Day Skin Inspection, dated 2/14/19, indicated Resident 1 had a bed bath and scrotum was swollen. No other documentation that Resident 1 was given a shower or bed bath and subsequent skin check, or refused a shower or bed bath and skin check for the 23 days between 1/21/19 and 2/14/19 was present in the clinical record. No other documentation was present in Resident 1's clinical record that indicated the physician or Resident Representative was notified regarding resident's lack of hygiene care or skin assessments for the 23 days between 1/21/19 and 2/14/19. No documentation was present in Resident 1's record related to the facility's attempts to identify underlying causes of resident's behavior, steps taken to offer alternative care options or promote basic hygiene and skin assessments, and physician or resident representative notification of aggressive and refusal behaviors interfering with basic ADL care needs. A nursing progress note, dated 2/12/19, indicated a certified nursing assistant noticed during incontinence care Resident 1 had redness and swelling to scrotum and the physician and conservator were notified. A nursing progress note on 2/12/19, indicated nursing staff had received a faxed order from the physician to start Resident 1 on oral antibiotics for scrotum with swelling and redness and is hard and painful to touch. A nursing progress note, dated 2/13/19, indicated Resident 1 continued on antibiotics for scrotal area redness and swelling and there was no drainage noted. A nursing progress note, dated 2/14/19, indicated a physician examined Resident 1's scrotum and it was red, swollen and sore with an opening oozing moderate yellowish drainage and Resident 1 was to be transferred to an emergency room for evaluation. An emergency room initial physical exam, dated 2/14/19, directed Resident 1 appeared cachectic (a general physical wasting and malnourished appearance), distressed and had a sickly appearance. Resident 1 presented with severe scrotal swelling, redness and pain consistent with necrotizing (a flesh-eating bacteria) infection of the scrotum requiring emergency surgery, kidney failure, and dehydration. In an interview with Certified Nursing Assistant (CNA) 1 on 3/18/19 at 12:48 p.m., CNA 1 reported Resident 1 rejected (ADL) care most of the time. CNA 1 stated staff would try talking to the resident and offer care multiple times but if Resident 1 continued to refuse care, they would stop trying and report to the nurse. In an interview with Licensed Nurse (LN) 1 on 3/18/19 at 12:57 p.m., LN 1 stated Resident 1 could be very aggressive at times with (ADL) care and staff would try to re-approach resident when calm. LN 1 also stated for residents in general refusing care, they would try multiple attempts to re-approach resident and then notify the doctor and family about resident's refusal of care. In an interview with the Director of Staff Development (DSD) on 3/18/19 at 2:00 p.m., the DSD stated all residents are bathed twice per week on the evening shift. The DSD stated Resident 1 had extremely few showers or bed baths charted and that no showers or bed baths were documented for the 23 days between 1/21/19 and 2/14/19. A review of the facility policy titled Activities of Daily Living (ADL), revised (MONTH) (YEAR), directed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate .The resident's response to interventions will be monitored, evaluated and revised as appropriate. A review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), directed resident care plans will; .Incorporate identified problem areas .Aid in preventing or reducing decline in the resident's functional status and/or functional levels .Reflect currently recognized standards of practice for problem areas and conditions .The IDT must review and update the care plan when the desired outcome is not met. In an interview with the Director of Nursing (DON) on 3/25/19 at 2:33 p.m., the DON reported she was familiar with Resident 1 and he always had aggressive behaviors and refused (ADL) care. She stated the facility was monitoring the resident's behaviors every shift but was unable to locate or provide any further documented evidence related to interventions or assessment and care planning activities to provide adequate hygiene or steps taken to minimize consistent behavioral problems.

Based on observation, interview, clinical record review and the facility's smoking policy and procedure, the facility failed to ensure safety for 3 of 3 residents (Resident 46, 54 and 56), when Resident 46 had [MEDICAL CONDITION] his clothing, the residents were not assessed (for physical and cognitive ability to perform a task, e.g. ability to hold cigarette, light it, dispose ashes etc.) or evaluated for safety in smoking independently, were not supervised during smoking, the smoking area was not clearly marked and equipped with smoking protection devices and fire safety devices (fire extinguishers, protective smoking aprons, ash trays, etc.). Additionally, the residents smoked next to the facility wall adjacent to the medical records window and put out lit cigarettes into a trash can that contained flammable material, a potential fire hazard. These failures resulted in Resident 46 having [MEDICAL CONDITION] his clothing and had the potential to cause fire and placed all residents, staff and visitors in the facility at risk for serious harm including death for a census of 94. Findings: On 9/13/18 at 2:20 p.m., Licensed Nurse 3 (LN 3) and LN 6 were interviewed regarding the 4 residents documented as smokers during the survey entrance conference. LN 3 reported that only 3 residents were currently smoking (Resident 46, Resident 54 and Resident 56). The LN 3 and LN 6 stated they were not aware of who was responsible for evaluating the 3 residents for the ability to smoke safely. The LNs further reported they had never seen any smoking assessments or evaluation protocols used by the facility. During an interview with the Social Services Director (SSD) on 9/13/18 at 2:24 p.m., she stated she did not know who completed the smoking assessments or coordinated the smoking activity. The SSD stated she would ask the Administrator and returned and reported to the Department the Administrator had told her that, No smoking safety assessments are done. On 9/14/18 at 8:30 a.m., an observation was conducted of the backyard located behind the medical records office and a classroom. In the hallway leading to the exit door to the backyard, LN 3 was observed passing medications to residents. Resident 46 was observed as he held the entrance/exit door open for Resident 56 who was in his wheelchair. Resident 46 was observed with a lit cigarette held in his mouth as he held the door open. Then Resident 46 staggered back to a trash can located on the right side of his wheelchair next to the exit door. Resident 56 stated he was returning to his room after smoking. Resident 46 was then observed as he put out the lit cigarette by stroking the inside of the trash can and then placed the remainder of the cigarette in his left breast pocket. The trash can had a black plastic liner and visibly contained empty boxes, disposable food containers and used paper towels and was halfway full. A hole was noted on the inside of the upper portion of the plastic bag. Resident 46 then staggered to his wheelchair that was next to the the wall and close to the window of medical records office and sat down. During a concurrent interview with Resident 46 on 9/14/18 at 8:30 a.m., he stated he and his roommate, Resident 56 smoked together most of the times and they kept their own cigarettes and lighters. Resident 46's t-shirt was noted with 3 holes next to the left breast pocket and stated it was, From cigarette burns. Resident 46 stated there were no ash trays or protective aprons and no staff came out to supervise them during smoking. Resident 46 also reported there was another resident (Resident 54) who smoked and other residents who also came out in the backyard. Resident 46 stated he always sat at that corner with his peers. In an observation of the backyard on 9/14/18 shortly after 8:30 a.m., there were no ash trays, fire outbreak prevention devices, no protective smoking devices, no marked smoking area and no staff supervision for this large backyard. An interview and concurrent observation was conducted with LN 3 in the backyard on 9/14/18 at 8:45 a.m. LN 3 stated she was assigned to Resident 46, 54 and 56 and reported they came out to smoke on their own and kept their smoking paraphernalia. LN 3 further stated she had never seen any smoking aprons or fire extinguishers in the backyard. LN 3 stated she couldn't find the ash trays and pointed to the trash can. When LN 3 was asked about the holes in Resident 46's t-shirt, she asked the resident what caused the holes and he stated, From cigarette burns. LN 3 checked the resident's pocket and displayed a cigarette box containing one piece of cigarette and a lighter then returned them to his pocket. LN 3 did not observe Resident 46's chest area for any possible burned skin. An interview was conducted with Resident 56 on 9/14/18 at 8:50 a.m. in his room. Resident 56 stated he had just come from smoking with his roommate earlier and he kept his cigarettes and lighter. Resident 56 reported he had never seen or used a protective apron when smoking. During an interview and concurrent observation of the backyard with LN 6 on 9/14/18 at 9:05 a.m., she stated she doesn't know much about smoking safety and validated the smoking area was not marked, had no ash trays, no fire protective devices and no fire prevention equipment. LN 6 stated other residents and staff came out to spend time in the backyard. LN 6 reported the 3 residents who came out to smoke were not supervised and kept their own cigarettes and lighters. An interview was conducted with the assessment coordinator Registered Nurse (MDSC) on 9/14/18 at 9:15 a.m., and stated her department was not responsible for assessing residents for safety in smoking. The MDSC stated they only completed a 'Yes/No question' on tobacco use in a portion of the assessment tool. MDSC reported she had never seen any smoking safety assessment or evaluation tools used by the facility. A review of the clinical record for Resident 46 indicated he was admitted 2 years ago with multiple [DIAGNOSES REDACTED]. He had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 in the most recent annual assessment which indicated he had no memory impairment. His record did not contain any smoking safety assessments and his care conference notes had no reference to his smoking needs. A review of the clinical record for Resident 54 indicated he was admitted originally in the year 2014 with multiple [DIAGNOSES REDACTED]. He had a BIMS score of 15 out of 15 in the most recent quarterly assessment which indicated he had no memory impairment. Resident 54 had been interviewed on 9/11/18 during the resident screening and had stated he smoked and kept his own smoking paraphernalia. His record did not contain any smoking safety assessments and his care conference notes had no reference to his smoking needs. A review of Resident's 56 clinical record indicated he was admitted originally early this year with multiple [DIAGNOSES REDACTED]. He scored 9 out of 15 in the BIMS documented in the most recent Significant Change of Status assessment dated [DATE] which indicated he had memory problems. His record did not contain any smoking safety assessments and his care conference notes had no reference to his smoking needs. A review of the facility's 'Smoking Policy- Residents' dated as revised (MONTH) (YEAR) indicated, This facility shall establish and maintain safe resident smoking practices .Metal containers, with self-closing cover devices, are available in smoking areas. Ashtrays are emptied only into designated receptacles. The resident will be evaluated on admission to determine is he or she is a smoker or non-smoker. If a smoker, the evaluation will include: Current level of tobacco consumption; Method of tobacco consumption .Ability to smoke safely with or without supervision .A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff .Smoking is permitted in designated areas only. These areas are outside of the building no closer than 25 feet from any entry/exit door. During an interview with the Administrator on 9/14/18 at 9:15 a.m., she sated the residents who were currently smoking were not assessed or evaluated for safe smoking, were not supervised and kept their own smoking paraphernalia. The Administrator stated the smoking area was located outside of the facility in the backyard. An Immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of residents) was identified by the Department for the facility's failure to ensure residents were assessed for their ability to smoke safely independently resulting in a resident having multiple holes in his clothing from cigarette burns, lack of supervision during smoking resulting in a resident who used a wheelchair staggering to the door with his lit cigarette in the mouth and held the door open for his peer resident to return to the facility exposing other residents to cigarette smoke, lack of fire extinguishers and smoking aprons at the smoking area, smoking area not clearly marked resulting in residents smoking next to the wall of the facility and next to the medical records office window, ash trays not available resulting in a resident putting out a lit cigarette in a trash can and residents who may be unsafe to smoke independently keeping custody of their smoking paraphernalia. The facility's Administrator and Administrator consultant were informed of the IJ on 9/14/18 at 11:13 a.m. The facility's Administrator and Administrator consultant were informed of the IJ, and an interim plan of correction (P[NAME]) was presented to the Department which included assessments of the 3 residents who currently smoked, a smoking schedule that included staff supervision, a plan to identify and mark the smoking area, provision of fire extinguisher, smoking aprons, ash trays, safe storage of smoking paraphernalia and staff in-service on safety practices during smoking and a revised smoking policy and procedure. The current smokers were assessed, the smoking area was identified and marked, a fire extinguisher and smoking aprons, and ash trays were supplied to the smoking area, and staff on shift were inserviced regarding safety practices during smoking. The P[NAME] was accepted by the Department and the IJ was lifted on 9/14/18 at 4:10 p.m.