Every finding on record at Coastal Oaks Special Care Center

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed in accordance with the facility's policies and procedures when an expired emergency medication kit was found stored in the medication store closet. This failure had the potential to result in reduced effectiveness and increased risk of side effects of the medications. Findings: During a concurrent observation and interview on 06/03/25 at 10:19 a.m. with the Director of Nursing, the facility's emergency drug kit was found stored in the medication storage closet with an expiration date of 6/2/25. The Director of Nursing stated the emergency kit should be replaced and not within the facility policy to have expired medications. During a review of the facility's policy and procedure (P&P) titled, Medication Storage: Storage of Medications, dated March 2024, the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers .are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy.

Based on observation, interview and record review, the facility failed to ensure the menu was followed as planned during lunch tray line (a system of food preparation in which trays move along an assembly line) when 2 residents (Resident 18 and 32) small portion diet were not followed. This failure had the potential not to meet the nutritional needs as planned to maintain normal body weight and acceptable nutritional values of residents. Findings: During a concurrent observation with the Dietary Manager (DM) on 5/06/24 at 11:58 a.m., of the lunch meal service in the kitchen steam table, part of the menu for the day (5/06/24),were cheesy mashed potatoes, carrots,and turkey. For the cheesy mashed potatoes, the scoops prepared for meal serving were #8 scoop (=1/2 cup) and a #16 scoop (=1/4 cup). For the diced and minced turkey, a 3-ounce spoodle was in place. During a concurrent observation and interview on 5/06/24 at 12:19 p.m., with the Cook (CK), in the kitchen, the meal cards for Residents 8 and 32 indicated ,small portion diet and 2 ounces of meat. CK was noted using scoop #8 (1/2 cup) for the potatoes served on the meal plates of Residents 8 and 32, in addition to 3 ounces of diced /minced turkey. When the meal carts were about to leave the kitchen, surveyor asked the Dietary Manager (DM) to check the meal plates of Residents 8 and 32. The DM, confirmed the meal plates of Residents 18 and 32, had 1/2 cup of mashed potatoes ( # 8 scoop), instead of 1/4 cup mashed potatoes as ordered prepared by using scoop # 16 for small portion diet and 3 ounces of diced/minced turkey. During an interview on 5/06/24 at 12:23p.m., with the CK, and with the DM translating the questions, CK stated, not being aware the scoop used for Residents 8 and 32 , for the small portion diet was #8 scoop , instead of scoop #16. Both residnets were also served 3 ounces of diced /minced turkey , instead of just 2 ounces as ordered. This was verified by CK, upon checking of the meal spreadsheet . During a review of the facility's DCC (Danish Care Center) Spring/Summer 2024 Diet Spreadsheet menu, dated 5/03/24, showed three ounces of roasted thyme turkey, 1/2 cup of cheesy potatoes, 1/2 cup (#8 scoop) sliced carrots for the regular diet, small bite size (SB6) diet and minced and moist (MM5) diet. It showed under the small portion diet 2 ounces roasted thyme turkey and 1/4 cup cheesy potatoes.

Based on record review and interview, the facility failed to maintain medical records for three of 3 sampled residents (Resident 46, 38 and 44) and for one unsampled resident (Resident 47) were in accordance with professional standards and practices when: 1). Resident 46, physician ordered supplement intakes were not documented in the medical record. 2). Resident 38, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage ((SNFABN) notice of Medicare coverage ending) signature of resident representative was not legible or identified. 3) . Resident 44, Resident-Facility Arbitration Agreement ((RFAA) opting for a private dispute resolution procedure instead of going to court agreement) signature of resident representative was not legible or identified. 4). Resident 47, SNFABN date of notification was omitted. These failures had the potential to eflect a resident's progress towards achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Records-Identifiable Information, Clinical Records, no date, the P&P indicated, Clinical records are complete, accurately documented, readily accessible and systematically organized. 1) During a review of Resident 46's May 2024 Physician Order Sheet, dated 4/01/2024, the Physician Order Sheet indicated Resident 46 to have house supplement (120cc) oral BID (twice a day) at lunch and dinner. During a review of Resident 46's ADL [activity of daily living] Verification Worksheet, date range 4/01/24 through 5/08/24, the ADL Verification Worksheet had only nine days with recorded intakes by the Certified Nursing Assistant (CNA). During a review of the facility's policy and procedure (P&P) titled, High Calorie/High Protein Supplements, dated 2022, the P&P indicated, Nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record, meal intake reporting records, and/or the medication administration record. During an interview on 05/08/24 11:49 a.m. with CNA1, CNA1 stated I have worked here almost 5 years, in charge of documenting breakfast, lunch and dinner, when we document the meal there is a section for supplements like the mighty shake. It is always the CNAs that document the meals. During an interview on 05/08/24 11:55 a.m. with the Director of Staff Development (DSD), DSD stated, after each meal the CNAs will document meals and supplements, supplements yes or no, then it will ask how much, the CNA will write the point system like the percentage, CNA training would be done on initial hire, chart audits, on the tray card will verify that it is on the meal ticket, or if they refused the supplement. I have a handout but not a policy. 2) During a review of Resident 38's SNFABN, dated 2/6/24, the SNFABN indicated, Signature of Patient or Authorized Representative, signature was illegible and without identification for the signature. During an interview on 5/8/24 at 10:50 a.m. with the Administrator (ADM), ADM reviewed the SNFABN and stated, the resident representative signature was illegible and should have been identified. 3) During a review of Resident 44's RFAA, dated 11/21/22, the RFAA indicated, Resident Representative/Agent Signature, signature was illegible and without identification for the signature. During an interview on 5/8/24 at 10;50 a.m. with ADM, ADM reviewed the RFAA and stated, the resident representative signature was illegible and should have been identified. 4) During a review of Resident 47's SNFABN, dated 2/6/24, the SNFABN indicated, Date, without a date. During an interview on 5/8/24 at 10:50 a.m. ADM, ADM reviewed the SNFABN and stated, the date the phone call was made should have been documented.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 22, 44, and 46) binding arbitration agreements had clearly stated the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and clearly stated the selection of a venue that is convenient to both facility and resident or resident representative. This failure had the potential to result in psychosocial harm in the event of an arbitration dispute. Findings: During a review of: Resident 22's RESIDENT-FACILITY ARBITRATION AGGREEMENT (RFAA), dated 7/8/21, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. Resident 44's RFAA, dated 11/21/22, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. Resident 46's RFAA, dated 4/7/23, the RFAA did not indicate the selection of a neutral arbitrator agreed upon by both facility and resident or resident representative and did not indicate the selection of a venue that is convenient to both facility and resident or resident representative. During an interview on 5/8/24 at 3 p.m., with the Administrator (ADM), ADM stated the required verbiage is not there.

Based on observation, interview, and record review, the facility failed to maintain essential equipment and safe operating condition, when the refrigerator gasket was found to have been torn. This failure resulted in the door not being able to seal appropriately and with potential to effect food temperatures. Findings: During a concurrent observation and interview on 05/08/24 at 02:46 p.m. of the snack shack refrigerator, the low-fat milk in the door was 48 fahrenheit (The standard scale used to measure temperature in the United States) when measured with the facility thermometer and verified by the Dietary Manager (DM) . The DM stated they took measurements to get a new refrigerator ordered. The DM Stated if they had seen the torn gasket then they would have notified maintenance about it for repair. During an interview and observation on 05/08/24 at 03:54 p.m. of the snack shack refrigerator, Facilities Manager (FM) stated he was not aware about the tear in the gasket. FM stated he would expect to be notified of this needing to be replaced by staff or in the maintenance logbook. During a review of the Maintenance Repair Log, dated 7/25/23 through 5/7/24, the Maintenance Repair Log did not indicate any reporting of the torn gasket for the snack shack refrigerator. During a review of the facility's policy and procedure (P&P) titled, Maintenance Preventative Maintenance Program, undated indicated, These goals are accomplished by detecting and correcting minor defects before they develop into serious problems and by performing the services necessary to prevent undue wear and subsequent breakdown.

Based on medication pass observation. record review, and interview the facility failed to ensure that it was free from a medication error rate greater than five percent when : 1. Resident 3 (Res 3) was ordered Aspirin (pain medication also use for blot clots) 81 mg delayed release (Enteric Coated -EC), but was given Aspirin 81 mg chewable. 2. Resident 46 was with orders for Aspirin 81 mg delayed release, but was given Aspirin 81 mg chewable. These failures resulted in a 5.41% medication error rate. Findings : During a medication pass observation conducted on 6/7/23, a total of 37 opportunites were observed /combination between two Licensed Nurses (LN), LN1 and LN2. 1. On 6/7/23, at 8:31 a.m., LN1 administered Aspirin 81 mg. chewable (form) to Res 3. During a review of the Medication Administration Record (MAR) for Res 3, on 6/7/23, at 10:27 a.m., the MAR indicated a physician order dated 11/24/22 of Aspirin 81 mg delayed release to be given one time daily for deep vein thrombosis (DVT - blot clots in veins) for prophylaxis. During an interview with LN1, on 6/7/23, at 3:12 p.m., regarding the medication pass for Res 3, on 6/7/23 when LN1 administered Aspirin 81 mg. in chewable form to the resident, LN1 opened up the medication cart and presented 2 bottles of Aspirin 81 mg. to the surveyor. Bottle #1 was labeled Aspirin 81 mg. EC and Bottle #2 was labeled Aspirin 81 mg. chewable. When LN1 was asked which Aspirin was administered to Resident 3 during medication pass on 6/7/23 at 8:31 a.m., LN1 verbalized, giving Res 3 the chewable form instead of the delayed release /enteric coated as ordered by the physician. 2. On 6/7/23, at 8:45 a.m., during a medication pass, LN1 administered Aspirin 81 mg chewable to Res 46. During a review of the MAR for Res 46, the MAR indicated a physician order dated 11/15/22 for Aspirin 81 mg. tablet delayed release (EC) to be given one time daily to the resident for DVT prophylaxis. During an interview with LN1, on 6/7/23, at 3:12 p.m., LN1 verbalized, administering Aspirin 81 mg chewable to Res 46 instead of Asprin 81 mg delayed release - EC. LN1 further verbalized, realizing the mistake only after administering the medication to the resident. Review of the facility's policy and procedure (P&P) titled Nursing Care Center Pharmacy Medication Preparation, not dated, chapter 7, the P&P indicated, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule .Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to ensure medications were stored at the right temperature in accordance with federal laws and the facility's policies and procedures. This failure had the potential for medications to lose potency and become ineffective. Findings: During a concurrent observation and interview, on 6/6/23, at 12:52 p.m., with the Director of Nursing (DON) and the Chief Nursing Officer (CNO), the medication refrigerator temperature was checked and noted to have the temperature read at 28 degrees Fahrenheit. The DON and CNO verified the temperature. The DON verbalized, the medication refrigerator was too cold and outside of temperature parameters. The CNO stated, It's too cold. Things will freeze. Insulin will crystalize below thirty-two degrees and no longer be effective. During a review of the facility's policy and procedures (P&P), titled, Nursing Care Center Pharmacy Storage of Medication, not dated, chapter 4, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring .A daily recorded temperature should be documented and signed off.

Based on observation, interview, and record review, the Registered Dietitian failed to demonstrate competency when the RD did not communicate current standards of practice to the facility's Medical Director, when the RD was aware a Low Concentrated Sweets (LCS) diet used at the facility was no longer nationally recognized, nor recommended to address residents diabetes. There were two of 12 sampled residents (Resident 48 and Resident 37) with an LCS diet order for nutrition care for diabetes. As a result, the RDs failed to utilize their expertise in the development of resident care policies and procedures to ensure that the facility provides care and services in accordance with current standards of practice, that address resident's diabetes diagnosis, and that provide clinical and technical direction to meet the needs of residents with a diagnosis of diabetes. Findings: During a concurrent observation and interview on 06/06/23, at 11:55 a.m., with Registered Dietitian (RD), in the kitchen, dietary staff were observed using a therapeutic menu/spreadsheet during the lunch trayline (a system of food preparation in which trays move along an assembly line). RD stated the therapeutic menu/spreadsheet that listed LCS meant low concentrated sweets diet and verified the doctors write diet orders for LCS for residents with diabetes in the medical record. RD stated, the LCS diet is incorporated into the facility's diet manual. RD stated, she was aware that LCS diet, along with NCS (No concentrated sweets) and/or RCS (Restricted concentrated sweets) diet was obsolete (out of date) and no longer recognized by the American Academy of Nutrition & Dietetics Nutrition Care Manual, and no longer recognized by the American Diabetes Association as an appropriate diet to treat people with diabetes. The RD stated, she does attend the facility-wide quality assurance meetings and stated she had not discussed that LCS diet used at the facility for care of residents with diabetes was an obsolete diet. RD stated, CCHO (Consistent Carbohydrate) diet was the current standards of practice recommended for nutrition care for people with diabetes. During a concurrent interview and record review on 06/06/23 at 12:20 p.m., with Corporate Registered Dietitian (CRD), in the kitchen, CRD reviewed the therapeutic menu/spreadsheet and verified LCS diet was used at the facility for nutrition care for residents with diabetes. CRD verified the facility's diet manual, menus/menu nutrient analysis and physician orders for care of those with diabetes utilize LCS diet. CRD stated, she was aware the LCS diet was no longer nationally recognized as an appropriate diet for care of persons with diabetes by the American Academy of Nutrition & Dietetics Nutrition Care Manual, and by the American Diabetes Association. CRD verified the Consistent Carbohydrate Diet (CCHO) was the current standards of practice for nutrition care for residents with diabetes. CRD verified the facility LCS diet was not a CCHO diet. CRD stated, We would need to change the diet corporate wide. CRD repeated that she was aware the LCS diet was obsolete and no longer a nationally recognized diet order for those with diabetes. During a review of the facility's Resident Listing Report, provided by the RD, the list included Resident 48, and Resident 37 were residing at the facility with a LCS diet order for diabetes. During a review of Resident 48's Comprehensive Nutrition Assessment (NA), dated 5/19/2023, the NA indicated, .RD obtained preferences and discussed new dx [diagnosis] of DM [diabetes mellitus] .current diet is regular [regular texture] lcs [low concentrated sweets] which appears appropriate at this time ., Taking Metformin [a medication used to treat high blood sugar levels] for DM. She would like to control it with diet 'as much as possible' . During a review of Resident 37's Face Sheet, dated 6/7/2023, Resident 37's diagnosis included, Type 2 diabetes mellitus . During a review of Resident 37's June 2023 Physician Order Sheet (PO), the PO indicated, Low Concentrated Sweets ., Order Date: 5/30/2023. During an interview on 06/07/23, at 09:46 a.m., with Medical Director (MD), MD stated, he was unaware the LCS diet was an obsolete diet per the American Academy of Nutrition & Dietetics as he relied on the Registered Dietitian's input and expertise related to the system for diet orders. The MD acknowledged he had not heard about the CCHO diet, and that LCS was no longer nationally recognized and stated he was interested in learning more from communication with the facility RD. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2022, the P&P indicated, Policy: The food service department will provide food of the quality and quantity to meet the nutritional needs of individuals. In accordance with the established national standards through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility's reasonable efforts, menus will reflect the needs of the population served. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Manual, dated as last approved on 3/14/2023, the P&P indicated, Policy: The therapeutic diet manual used in the facility will reflect current, evidence-based nutrition knowledge when available, and best practice recommendations where evidence is not available. The manual shall be available for use by the medical staff. It will be reviewed annually by the Continuous Quality Improvement (CQI) committee, including the facility medical director or designee, and revised at least every five years. Procedure: 1. The corporate registered dietitian nutritionist (RDN) will review available diet manual, select, and make recommendations for approval by the medical staff. The medical director or designee will approve the manual, along with the facility RDN, administrator, and director of nursing (DON). 2. The selected therapeutic diet manual will: a. Reflect current nutritional knowledge based on evidence-based research and/or best practice standards. B. Meet established national standards .E. Include information on the role of medical nutrition therapy (MNT) in treating various diseases and conditions. F. Provide clear guidelines for implementing diet orders . The facility's approval page for the Diet Manual, dated 3/14/2023, included the signatures of the Medical Director, and the RD. During a review of the facility's Diet Manual for Low Concentrated Sweets (LCS) Diet, last approved by the facility on 3/14/2023, LCS diet indicated, The Low Concentrated Sweets (LCS) diet is a liberalized diet for adults with abnormal blood glucose metabolism. This diet is similar to the regular diet modified to reduce total sugar intake. The LCS diet is not a calorie controlled or consistent carbohydrate meal plan and is not recognized as a valid diet for treatment of diabetes by the American Diabetes Association. Purpose: To provide a liberalized sugar restricted diet for the control of blood sugar. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2023, the NCM indicated, Obsolete diets and Diet Terminology; For condition Type 1 Diabetes and Type 2 Diabetes Obsolete Diet Name.No Concentrated Sweets diet, No Sugar Added, Low Sugar, Liberal Diabetic Diet. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2023, the NCM indicated, A consistent carbohydrate diet provides the same amount of total carbohydrate daily, distributed evenly across all meals and snacks. A consistent amount of carbohydrate at each daily meal is the goal. The exact amount and type of carbohydrate served is individualized by the registered dietitian nutritionist (RDN). The name of the diet used in your facility should no longer emphasize the restriction of sugar or sweets but rather emphasize consistent carbohydrates or carbohydrate controlled . During a review of Management of Diabetes in Longterm Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, dated February 2016, the article indicated, No concentrated sweets or no sugar diet orders are ineffective for glycemic [A measure of the increase in the level of blood glucose (a type of sugar) caused by eating a specific carbohydrate (food that contains sugar) compared with eating a standard amount of glucose] management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes .

Based on observation, interview and record review, the facility failed to follow the menu as planned, during lunch trayline (a system of food preparation in which trays move along an assembly line) when: 1. The small portion diet was not followed per the planned menu for one of 12 sampled residents (Resident 10). 2. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of pork carnitas in accordance with the facility's planned menu, and Diet Manual for SB 6 diet, for one of 12 sampled residents (Resident 25). This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place the resident at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 06/06/23, at 12:04 p.m., with Cook 1, in the kitchen, Cook 1 was observed to use a two (2)-ounce (oz.) ladle to serve pork carnitas (diced pork per the recipe) onto Resident 10's lunch meal plate. The 2-oz. ladle was in the pan of pork carnitas on the steam table. Cook 1 pointed to the handle of the ladle that indicated 2 oz. and verified it was used for the small portion diet orders. During an observation and interview on 06/06/23, at 12:07 p.m., with Dietary Manager (DM), DM verified with Cook 1 that she used a 2-oz. ladle to serve pork carnitas onto Resident 10's lunch plate. DM verified an incorrect portion was served, and DM stated, a # (number)10 scoop should have been used to serve Resident 10 pork carnitas as indicated on the planned menu for the small portion diet. DM pointed to a poster located on the wall near the trayline area that indicated, Scoop Sizes .#10 (3 1/4 [quarter] oz.) . DM verified the expectation was for the cook to follow the portion sizes per the planned menu/therapeutic spreadsheet. During a review of Resident 10's meal tray ticket (MTT), the MTT indicated, Small Prtn [Small Portion] .Pork Carnitas (#10 scoop) . During a review of the therapeutic menu spreadsheet, the small prtn diet indicated a #10 scoop should be used for the pork carnitas. Directions located at the bottom of the therapeutic menu spreadsheet indicated, No. [number] 10 scoop: 3-4 oz. During a review of Resident 10's Comprehensive Nutrition Assessment (NA), dated 06/02/2023, the NA indicated, Diet is regular with small portions, per resident request. During a review of Resident 10's June 2023 Physician Order Sheet (PO), the PO indicated, Regular, Small Portions .Per resident request ., Order Date: 9/29/2021. During a review of the facility's policy and procedure (P&P) titled, Portion Control, dated 2022, the P&P indicated, Policy: Individuals will receive the appropriate portions of food as outlined on the menu ., Procedure: 2. The menu's spreadsheet should list the specific portion size for each food item. Spreadsheets should be posted at the tray line so staff can refer to the proper portions for each diet ., 3 .Portions that are too small result in the individual not receiving the nutrients needed ., #10 scoop .ounce amount 3 1/4 ounces . 2. During a concurrent observation and interview on 06/06/23, at 12:12 p.m., with Cook 1, in the kitchen, Dietary Aide (DA) 2 called out Resident 25's diet order for SB 6 to the cook (Cook 1). Cook 1 was observed plating Resident 25's lunch meal plate. DA 2 was observed placing Resident 25's lunch plate onto the meal tray located in the meal delivery cart. DA 2 was asked to remove Resident 25's lunch plate, and DA 2 verified Resident 25's lunch plate with SB 6 diet order. Concurrently, Dietary Manager (DM) was asked to review Resident 25's lunch meal plate for accuracy. DM reviewed Resident 25's lunch meal plate and informed the cook that the pork carnitas pieces of meat needed to be smaller for SB 6 diet order. During a concurrent observation and interview on 06/06/23, at 12:15 p.m., with Registered Dietitian (RD) and DM, in the kitchen, RD observed the large pan of pork carnitas located in the steamtable and stated there were pieces of pork that were larger than 1/2 (half inch) in size that would not be allowed on a SB 6 diet. DM stated, the same serving pan of pork carnitas was used that held smaller pieces of pork that were 1/2 or smaller for SB 6 diets, as well as regular sized pieces of pork carnitas. DM stated Cook 1 was trained to serve the smaller sized pieces of pork carnitas that were located more in the center lower edge of the pan. DM acknowledged that there were larger pieces of pork that could easily be comingled or hidden underneath a layer of other pieces of meat. DM stated that a different cook would have put the pieces of pork carnitas that were 1/2 (inch) or smaller in its own pan, separate from the regular sized pieces of pork carnitas for the regular diets to ensure the SB 6 would have been served appropriately on a consistent basis. During a review of the recipe for Pork Carnitas (IDDSI [International Dysphagia [difficulty in swallowing] Diet Standardisation]), the recipe included directions that indicated, IDDSI Level 6- Soft & Bite Sized: Chop/cut food into pieces = 15mm (millimeters- a unit of measurement) by 15 mm in size . During a review of Resident 25's meal tray ticket (MTT), the MTT indicated, SB6 .Pork Carnitas . During a review of Resident 25's June 2023 Physician Order Sheet (PO), the PO indicated, Diet: Soft & Bite-Size-IDDSI Level 6 (Mech [mechanical] Soft, Chopped Meat) ., Order Date: 3/27/2023. During a review of Resident 25's Speech Therapy SLP [speech-language pathologist] Evaluation and Plan of Treatment, dated 3/24/ 2023, the SLP Plan of Treatment indicated, Without therapy pt [patient] at risk for .reduced PO [food eaten by mouth] safety and aspiration [food or liquid goes into the airway instead of the stomach] ., Recommended for the patient to swallow solids safely = Soft & bite sized. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Manual, dated as last approved on 3/14/2023, the P&P indicated, Policy: The therapeutic diet manual used in the facility will reflect current, evidence-based nutrition knowledge when available ., Be representative of the diets appropriate for and/or needed by the residents served . During a review of the facility's Diet Manual for the IDDSI Level 6 - Soft, Bite Sized Food (SB 6) diet, last approved by the facility on 3/14/2023, SB 6 diet indicated, This diet is used in the dietary management of dysphagia with food texture modification described as soft, tender, moist food with no separate think liquids. Foods should have a particle size no greater than 15 mm length by 15 mm width for adults . (15 mm by 15 mm is equivalent to 1.5 cm [centimeter] by 1.5 cm https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/6_Soft_Bite_Sized_Adult_consumer_handout_30Jan2019.pdf, 1.5 cm is equivalent to 0.59 (or 1/2 inch) https://grinebiter.com/centimeter/where-is-1.5-cm-on-a-ruler.html).

Based on interview and record review the facility failed to update an abuse care plan for one of two sample residents (Resident 1) with interventions to be implemented after a resident-to-resident abuse to ensure this incident does not reoccur. This facility failure places residents at risk of having an altercation or abuse incident with Resident 1. Findings: A record review for Resident 1 was conducted 3/3/22. The record indicated resident attempted to hit roommate on 2/24/22. The post abuse care plan titled [Name]requires the use of antipsychotic medications .MB behaviors of agitation with hitting towards other resident that cannot easily altered and is distressing to the resident, dated 2/24/22, contains interventions initiated (2/14/22) prior to the abuse incident date. During a Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . dated 2/24/22, with the director of nurses (DON) on 3/3/22 at 11:30 a.m., the DON confirmed that this was the care plan that was initiated or updated after the abuse incident. The DON was asked what were the interventions that were implemented after the abuse incident to ensure this incident does not occur with another resident. The DON verbalize several interventions e.g., sit resident in the wheelchair with the [NAME] bar= U-bar (a tall U shape bar in the upside-down position) which is placed behind the wheelchair preventing resident from entering other residents ' rooms. Redirection of resident to areas of higher visibility when awake. All staff to keep an eye on resident ' s whereabouts. Park resident in front of the nurses ' station . The DON was made aware the interventions she had just verbalized were not outline or documented on this care plan. DON was also made aware most of the interventions on this care plan were updated on 2/14/22 which was before the abuse incident. The DON acknowledged the interventions on this care plan we're not specific to prevent a future abuse incident. During a Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . dated 2/24/22, with the administrator (Admin) on 3/3/22 at 11:30 a.m., the admin acknowledged the care plan was not specific to the abuse incident. Admin stated Yes, I understand the care plan needs to be specific to the abuse incident with interventions to prevent another abuse incident.

Based on observation, interview, and record review, the facility failed to store foods in a manner consistent with professional standards for food safety when they failed to: [NAME] Ensure dented cans were not available for use B. Properly label bread items C. Ensure an appropriate air gap was present at the ice machine drain These facility failures had the potential to result in the contamination and/or altered quality of food products for all residents. Findings: a. During an observation, in the kitchen dry storage area, on 12/2/19, at 8:10 a.m., the following dented cans were observed alongside other foods readily available for use: Four cans of mandarin orange segments in light syrup, one can of condensed tomato soup, one can of condensed chicken noodle soup, and one can of grape jelly. b. During an observation, on 12/2/19, at 8:15 a.m., the following bread products were observed on a shelf in the dry storage area with no open date or labeling: One opened package of hot dog rolls, two opened packages of wheat bread, one zipper seal bag containing croissants, and one opened package of sourdough bread. During an interview, on 12/2/19, at 8:40 a.m., the Dietary Supervisor (DS) stated that cans are checked for dents as they come in from delivery, and these dented cans missed the check. The DS stated that dented cans should not be stocked, but instead placed on the DS's desk and returned to the vendor. The DS further indicated that bread packages should have an open date written on them. A review of the facility's policy titled, General Food Preparation and Handling, dated 2014, indicated, Foods are received, checked and stored properly as soon as they are delivered. The facility's policy titled, Food Storage, dated 2014, indicated, Food should be dated as it is placed on the shelves. c. During an observation, and concurrent interviews on 12/2/19s at 11:13 a.m., the ice machine drainage pipe was observed to be touching the side of the drain. The MS confirmed the drainage pipe was touching the side of the drain, and indicated there should be an air gap and that the pipe should be positioned so it does not touch the drain in order to prevent bacteria from going into the ice machine. During a review of the facility policy titled, 1. Icemaker, undated, indicated, Separate piping to approved drain. Leave a 2-inch (5-cm) vertical air gap between the end of each pipe and the drain.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records, or accurately document activities of daily living care, which included bathing and fingernail care, for one sampled resident (Resident 50) when the director of staff development (DSD) recreated the resident's Shower Day Skin Inspection form. This failure resulted in inaccurate assessment information being available to staff for reference and aid in the planning of Resident 50's care. Findings: During an observation, on 12/2/19, at 4:06 p.m., Resident 50 was observed with especially long fingernails. During a concurrent interview about the nails, Resident 50 stated, They're too long. During a review of the clinical record for Resident 50, the admission record indicated Resident 50 was admitted with [DIAGNOSES REDACTED]. A nurses note, dated 10/2/19, at 1:39 p.m. indicated, Resident scratched left wrist. A nurses note also indicated there were new orders for wound care and daily dressing changes until the scratch was healed. The note indicated that the resident's daughter was notified and requested resident fingernails be trimmed at the earliest convenience. During an interview, and concurrent review of the facility's, Shower Day Skin Inspection form, on 12/4/19, at 3:56 p.m., the director of nursing (DON) acknowledged that the check box for, bed bath, was marked and the check box for nail clipping labeled ,not needed, was not marked on the shower day inspection form dated 11/25/19. The DON stated that if nail clipping is not needed, the box on the form labeled, not needed, should be marked. During an interview, and concurrent review of the facility's, Shower Day Skin Inspection form, on 12/5/19, at 9:10 a.m. with the director of staff development (DSD), the DSD agreed there was a second, Shower Day Skin Inspection, form dated 11/25/19. The DSD stated that on the night of 12/4/19, the shower book was taken home for audit, and the 11/25/19 skin inspection form for Resident 50 was not in the book. The DSD stated that because it was unknown where the form had gone, a new form was reproduced on 12/4/19. The DSD admitted dating the form completed on 12/4/19, with the date 11/25/19, signing the form, and signing the certified nursing assistant's (CNA) signature. The DSD confirmed she did not assess Resident 50's skin on 11/25/19. The Administrator agreed a duplicate, Shower Day Skin Inspection form, was completed on 12/4/19, by the DSD, and indicated that the DSD should have dated the form 12/4/19, and labeled it as a late entry. The Administrator acknowledged that the information on the two forms, both dated 11/25/19, was not the same. The new form completed 12/4/19 had the, not needed, check box for fingernails marked and the shower was inaccurately marked.

Based on interview and record review, the facility failed to develop a comprehensive care plan for three of 15 sampled residents (Residents 9, 3, and 46) . This facility failure had the potential for residents to not receive appropriate, consistent, and individualized care. Findings: 1. During a review of the clinical record for Resident 9, a document titled, Physician order [REDACTED]. Further review of the clinical record showed no care plan for oxygen administration. During an interview, on 12/3/19, at 4:07 p.m., the licensed nurse (LN 2) verified that Resident 9 has a PRN (as needed) order for oxygen, but does not have a care plan documented for oxygen use. 2. During a review of the clinical record for Resident 3, and concurrent interview with the assistant director of nurses (ADON), on 12/4/19 at 10 a.m., the history and physical for Resident 3 had documented [DIAGNOSES REDACTED]. The ADON confirmed there was no care plan for [MEDICAL CONDITION]. During a review of the facility's policy and procedure titled, Develop/Implement Comprehensive Care Plan, dated 3/1/18 indicated, Will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. 3. During a review of the clinical record for Resident 46, the admission record indicated Resident 46 was admitted [DATE], with [DIAGNOSES REDACTED]. The, Physician order [REDACTED]. The order notes indicated, Depression with melancholia manifested by verbalizing sad statements which causes distress to the resident and is not easily altered. A review of Resident 46's care plan for depression, dated 9/15/19, indicated the resident has, Depression with psychotic features of restlessness and agitation as manifested by verbal outburst and striking out at others. The care plan interventions for Resident 46 included: Monitor for side effects of anti-depression medications such as: Sedation, dry eyes, blurred vision, dry mouth, constipation, light-headedness, low blood pressure, confusion, urinary retention, tremors, agitation, photosensitivity, headache, and weight gain. During an interview, and concurrent record review on 12/4/19, at 2:30 p.m., the licensed nurse (LN 1) acknowledged there was no documentation in Resident 46's medical record about monitoring for antidepressant side effects. LN 1 indicated that the risks of not monitoring antidepressant side effects included not being aware of how many side effects the resident could be having. During an interview, on 12/5/19, at 9:45 a.m., the Medical Records Consultant (MRC) stated staff should have monitored antidepressant side effects for Resident 46. A review of the facility's policy titled, Drug Regimen is Free from Unnecessary Drugs/Free from Unnecessary [MEDICAL CONDITION] Meds/PRN Use, dated 8/26/2012, indicated, The effects and adverse effects of drug therapy shall be monitored by the prescribing physician, licensed nursing staff and reviewing pharmacist.

Based on observation, interview and record review, the facility failed to ensure that one of one sampled residents (Resident 368) was receiving the amount of oxygen ordered by the physician. This facility failure had the potential for Resident 368 to lose the drive to breathe on her own by administering too much oxygen. Findings: According to Fundamental of Nursing, by Potter and Perry, 7th Edition, Nurses follow physicians' orders, unless they believe the orders are in error or harm clients. During an observation and concurrent interview with a licensed nurse (LN 3), on 12/2/19, at 9:39 a.m., Resident 368 was noted to be receiving 3 liters of oxygen by nasal cannula. LN 3 verified that Resident 368 was receiving 3 liters of oxygen, and should only be receiving 2 liters, per MD orders. During a review of the clinical record for Resident 368, a document titled, Physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to provide necessary grooming for one of three sampled residents (Resident 50), who was observed with long, dirty fingernails. This failure had the potential to result in injury from scratching or infection. Findings: During an observation on 12/2/19, at 4:06 p.m., Resident 50 was observed with especially long fingernails. During a concurrent interview about the nails, Resident 50 stated, They're too long. During a review of the clinical record for Resident 50, the admission record indicated Resident 50 was admitted with [DIAGNOSES REDACTED]. A nurses note dated 10/2/19, at 1:39 p.m. indicated, Resident scratched left wrist. A nurses note also indicated there were new orders for wound care and daily dressing changes until the scratch was healed. The note indicated that the resident's daughter was notified and, requested resident fingernails be trimmed at the earliest convenience. During a telephone call on 12/3/19, at 11:01 a.m., Resident 50's daughter stated that she had requested the resident's nails be trimmed recently after the resident scratched her skin. During an observation, and concurrent interview, on 12/4/19, at 12:52 p.m., Resident 50 was observed with long and dirty fingernails. Resident 50 stated, My nails are too long and they have not been cut in the past couple of weeks. During an observation, and concurrent interview with a licensed nurse (LN 4), on 12/4/19, at 3:26 p.m., LN 4 indicated fingernails get cut on shower days, and acknowledged that Resident 50's nails needed to be cleaned, and probably should have been cut during the last shower if there was no refusal by the resident. During a review of the facility's, Shower Day Skin Inspection, forms for Resident 50, the forms indicated that the resident's two most recent shower days were 11/25/19, and 12/1/19. There is no documentation on the forms that nail care was refused by the resident.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored appropriately when the expiration date on a label on the medication card for [MEDICATION NAME] (a medication used to treat pain and burning during urination) was blackened out and altered, expired, and was found in the available current medications for one un-sampled resident (Resident 12). This facility failure had the potential to cause Resident 12 to not receive the full therapeutic benefit of the drug. Findings: During an observation, and concurrent interview, on [DATE], at 9:50 a.m., with a licensed nurse (LN 1) at the south nursing station medication cart, a medication [MEDICATION NAME] contained a blackened out expiration date on the pharmacy label. The date, ,[DATE], was hand written next to the blackened out expiration date, and did not contain identifying initials or name of the person who altered the pharmacy label. The written in expiration date indicated the [MEDICATION NAME] was expired for thirty-three days. The [MEDICATION NAME] was included in Resident 12's current medications, and available for Resident 12's use. LN 1 confirmed the pharmacy's expiration date on the [MEDICATION NAME] label was blackened out, was expired, and was included in the current medications for Resident 12's use. LN 1 indicated medication expiration dates may only be altered under the supervision of a pharmacist, and must contain identifying initials of the person altering the expiration date. LN 1 also confirmed the expired [MEDICATION NAME] should not be included in Resident 12's current medications and should have been removed. Review of the facility policy and procedure titled, Nursing Care Center Pharmacy Policies and Procedures General Guidelines, indicated in part, No expired medication will be administered to a resident. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date.

Based on record review and interview, the facility failed to provide written notification to the resident representative about a hospital transfer for two of two sampled residents (Resident 3 and 37). This facility failure had the potential for the representatives for Resident 3 and Resident 37 to not be informed of the medical necessity for transfer. Findings: The facility policy and procedure titled, Notice Requirements Before Transfer/Discharge, dated 03/01/2018 indicated, Will notify the resident and representative of the transfer or discharge. This notice shall be in writing and shall include the reason for transfer. During a review of the clinical record for Resident 3 and Resident 37, and concurrent interview with the facility assistant director of nursing (ADON), on 12/3/19 at 2:45 p.m., no transfer form was found to have been sent to either resident representatives. The ADON confirmed the transfer notifications had not been sent, stating I don't think we send anything.

Based on observation, interview, and record review the facility failed to ensure hot water in residents' bathrooms and sinks were maintained in a safe temperature of 120 degrees Fahrenheit or less according to the facility's policy. This facility failure had the potential to [MEDICAL CONDITION] injuries on residents and staff. Findings: During an observation and interview with a licensed nurse ( LN 1) and Maintenance Supervisor (MS) on 01/27/19 at 2:34 p.m. the hot water coming out of the sink faucet in the shared bathroom of Residents 30 and 24 was too hot. LN 1 and the MS placed their hands under the running hot water, and pulled their hands away quickly in less than a second. LN 1 and the MS indicated the hot water was with a hot temperature and unsafe for residents use. The MS placed a calibrated digital thermometer under the running hot water and the hot water temperature read at 120.8 degrees Fahrenheit (DF). LN 1 and MS indicated a temperature of 120.8 DF is unsafe for residents use and should be lower than 120.8 DF. During another observation and interview on 1/27/19 at 2:45 p.m., surveyor and LN 1 entered bathrooms for Rooms one, two, three, four, seventeen, eighteen, and nineteen. Water from the bathroom sinks were turned on and ran, but the water was too hot to place hands under. LN 1 confirmed the water was too hot and unsafe for residents 24, 30, 45 and 354. During an interview with the administrator on 1/30/19 at 8:17 a.m., the facility administrator confirmed the hot water temperature was not within safe parameter for residents safety and use. Review of the facility's hot water guidelines, revised 1/22/08, indicated hot water temperatures should not exceed 120 DF, and faucets delivering water in excess of 120 degrees shall be prominently identified with a warning sign. No warning signs were located by the bathroom sinks of Residents 24, 30, 45,and 354.

Based on observation, interview and record review, the facility failed to ensure the facility's water heater was maintained and functional to deliver safe hot temperature for residents use. This failure had the potential to cause accidents and injuries. Findings: During an observation and concurrent interview with a licensed nurse ( LN 1) and maintenance supervisor (MS) on 01/27/19 at 2:34 p.m., the hot water coming out of the sink faucet in the shared bathroom of Residents 30 and 24 was too hot. The MS placed a calibrated digital thermometer under the running hot water, and the hot water temperature read at 120.8 degrees Fahrenheit (DF). LN 1 and MS indicated a temperature of 120.8 DF is unsafe for residents use, and that the hot water temperature should be lower than 120.8 DF. During another observation and interview with LN 1 and MS on 1/27/19 at 2:45 p.m., the facility's outside North water heater gauges showed hot water temperature of 108 and 112 degrees Fahrenheit (DF). Inside Rooms one, two, three, four, 17, 18, and 19, the Surveyor and LN 1 turned on the hot water from the bathroom sinks. LN 1 and MS attempted to test the hot water temperature, but pulled their hands away quickly, and confirmed the water was too hot and unsafe. The MS indicated there was a discrepancy between the hot water temperature readings from the heater gauge compared to the actual hot water coming out of the residents bathroom faucet sinks, and that it needed to be fixed. The MS indicated the thermo coupling (a device that controls hot water temperature) inside the main hot water heater might not be working, and needed to be replaced/repaired.

Based on observation, interview, and record review facility failed to ensure a glucometer (a medical device used to read blood sugar level in the system by extraction of blood sample via finger prick) was cleaned after use on residents and before storage. This facility failure had the potential to cause transmission of bloodborne infection among residents and staff. Findings: During an observation, concurrent interview, and record review on 01/28/19 at 11:54 a.m., a licensed nurse (LN 2) performed blood sugar check on Resident 354. After the procedure, LN 2 returned to the medication cart and stored the glucometer inside without cleaning. LN 2 confirmed not cleaning the glucometer after use on Resident 354 prior to storage inside the medication cart. During a review of the glucometer document with LN 2, the manufacturer's guide titled, Evencare G3 Blood Glucose Monitoring System indicated in part . The Evencare G3 meter should be cleaned and disinfected between each patient use . LN 2 confirmed failing to clean the glucometer after use and before storage. During an interview with the administrator (ADM) on 1/30/19 at 8:17 a.m., the ADM indicated the facility policy is to clean and disinfect the glucometer after using on residents and follow manufacturer's guidelines of cleaning between resident use. The ADM indicated the facility takes that to mean the glucometer should be cleaned and disinfected before each resident use. Review of the Centers for Disease Control and Prevention (CDC) Infection Prevention During Blood Glucose Monitoring and Insulin Administration indicated blood glucose meters should not be shared. If it must be shared, the device should be cleaned and disinfected after every use. The facility policy and procedure titled Infection Prevention and Control, revised 3/1/2018, indicated in part . Glucometers will be cleaned per manufacturer's recommendations and will be cleaned after use.

Based on record review and interview, the facility failed to provide the assistance of two staff for transferring as indicated by the plan of care for one of three sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall which required a second surgery to the knee previously operated on. Findings: Record review on 6/18/13 revealed Resident 1's [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE] revealed Resident 1 had the ability to make herself understood and could clearly understand others. Resident 1 required extensive assistance of two staff for transferring and using the toilet. A fall risk assessment dated [DATE] showed the resident to be at risk for falling. The certified nursing assistant (CNA) care plan dated 4/22/13, revealed Resident 1 required the assistance of two staff and the use of a walker for transfers. A physical therapy note dated 5/9/13 stated Resident 1 was able to safely complete transfers from the bed to the commode and the wheelchair using a walker and required moderate to maximum assistance of two staff. An occupational therapy note dated 5/8/13 indicated Resident 1 required minimal to moderate assistance of two persons for sit to stand transfers using a walker. The resident continued to complain of pain in her left knee (the recently replaced knee joint) which made it difficult for Resident 1 to advance her right leg to take a step. Taking a step required maximum assistance of two therapists. A nursing note dated 5/9/13 at 5:55 a.m. revealed licensed nurse (LN 1) was summoned to Resident 1's room by a CNA and Resident 1 was observed on the floor in a sitting position. A nursing note dated 5/9/13 at 12:15 p.m. indicated Resident 1's left knee was painful, red and swollen. Interventions included elevating the left leg on a pillow. A nursing note dated 5/9/13 at 5 p.m. indicated Resident 1's left knee was warm to touch and the resident had increased pain and swelling. Resident 1 had been up to use the bedside commode. An order was obtained to send the resident to the emergency room . During an interview on 6/20/13 at 4:05 p.m. Resident 1 stated the morning of the fall (5/9/13) she woke up before 6 a.m. and turned the call light on to use the bedside commode (BSC). A female "helper" (CNA 1) came into Resident 1's room and said she would help the resident to the BSC. Resident 1 indicated she told the CNA she needed two people to help her. The CNA responded that it was not very far and Resident 1 could make it. Resident 1 indicated she took two or three steps and told the the CNA she was falling and went down on her left knee then fell backwards. During an interview on 6/19/13 at 8 p.m. LN 1 confirmed she was the charge nurse for Resident 1 on 5/9/13, the morning the resident fell . LN 1 indicated CNA 1 was transferring Resident 1 to the BSC when Resident 1's left knee buckled and the resident landed on it during the transfer. LN 1 confirmed CNA 1 should have asked for help to transfer the resident. During an interview on 6/20/13 at 5:30 p.m. the director of nursing (DON) confirmed that Resident 1 fell on her left knee which was the knee Resident 1 recently had surgery on. The DON confirmed only one CNA was transferring Resident 1 when the fall occurred. The DON also confirmed Resident 1's plan of care for transfers and toileting required the assistance of two staff. During on interview on 10/14/13 at 10:30 a.m. Physician 2 indicated the dislocation (abnormal separation in the joint, where two or more bones meet) of Resident 1's left knee prosthesis (artificial device that replaces a missing part)occurred secondary to the trauma experienced when Resident 1 fell . Physician 2 further indicated receiving physical therapy or transferring from the bed to the BSC would not have caused the dislocation of the prosthesis. During an interview on 10/22/13 at 12 noon Physician 3 indicated it had to be something fairly traumatic like a fall to cause the dislocation of Resident 1's left knee prosthesis.