Every finding on record at Community Extended Care Hospital Of Montclair

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program to prevent the transmission of infectious organisms when staff failed to properly maintain urinary catheter drainage systems and ensure resident care equipment was stored in a manner that prevented contamination.1. Urinary catheter drainage bags for four residents were observed resting on the floor, creating risk for contamination of the closed urinary drainage system.2. Resident care equipment (bedpans and urinals) in shared bathrooms were not labeled, creating potential for cross-use between residents.These failures created conditions conducive to the transmission of multidrug-resistant organisms and catheter-associated urinary tract infections and had the potential to place residents at risk for acquiring infections.Findings: 1. During a concurrent observation and interview on 2/24/26 at 10:26 a.m. with Certified Nursing Assistant (CNA) 2, Resident 5 was observed in bed with urinary catheter drainage bag touching the floor. CNA 2 confirmed Resident 5's urinary catheter drainage bag was on the floor. During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included benign prostatic hyperplasia (noncancerous enlargement of the prostate gland). During a review of Resident 5's Physician's Orders, dated 2/2/26, the Physician's Orders indicated, Foley Catheter [indwelling tube inserted into the bladder to continuously drain urine into collection bag] every shift. During a concurrent observation and interview on 2/24/26 at 10:46 a.m. with CNA 3, Resident 47 was observed in bed with urinary catheter drainage bag positioned on the floor. CNA 3 confirmed Resident 47's urinary drainage bag was positioned on the floor. During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 47 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder (loss of normal bladder control due to nerve damage). During a review of Resident 47's Physician's Orders, dated 9/24/25, the Physician's Orders indicated, Closed system Foley Catheter [indwelling tube inserted into the bladder to continuously drain urine into collection bag] for Neurogenic Bladder (condition where nerve damage disrupts bladder control.) During a concurrent observation and interview on 2/24/26 at 10:49 a.m. with CNA 3, Resident 130 was observed in bed with urinary catheter drainage bag positioned on the floor. CNA 3 confirmed Resident 130's urinary drainage bag was positioned on the floor. During a review of the Resident Demographics (Face Sheet), the Face Sheet indicated Resident 130 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder (loss of normal bladder control due to nerve damage). During a review of Resident 130's Physician's Orders, dated 9/24/25, the Physician's Orders indicated, Foley Catheter [indwelling tube inserted into the bladder to continuously drain urine into collection bag] for neurogenic bladder (condition where nerve damage disrupts bladder control.) During an observation on 2/23/26 at 10:40 a.m. in Resident 52's room, the urinary drainage bag was observed touching the floor. During an interview on 2/24/26 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the urine drainage bag should not be touching the floor. During an interview on 2/25/26 at 1:43 p.m. with Infection Preventionist (IP), the IP stated that urinary catheter drainage bags should not touch the floor. IP further stated when urinary drainage bag or tubing touched the floor, contaminants could be introduced to the resident. During a review of the facility's policy and procedure (P&P) titled, Infection Control Program System, dated January 2023, the P&P indicated, The facility maintains written standards, policies and procedures for the infection control program, which includes.Standard and transmission-based precautions to be followed to prevent the spread of infection. 2. During a concurrent observation and interview on 2/24/26 at 10:57 a.m. with CNA 4, there was an unlabeled bedpan and unlabeled urinal in Resident 36's shared bathroom. CNA 4 confirmed the bedpan and the urinal were unlabeled and was unsure which resident the bedpan and urinal belonged to. During a concurrent observation and interview on 2/24/26 at 1:57 p.m. with CNA 5, unlabeled bedpan next to the toilet in Resident 3's shared bathroom. CNA 5 confirmed the bedpan next to the toilet was unlabeled and was unsure which resident the bedpan belonged to. During an interview on 2/25/26 at 1:43 p.m. with IP, the IP stated that bedpans and urinals should be labeled with resident's name and stored in the resident's designated closet. IP further stated that unlabeled bedpans and urinals left in the shared restroom could lead to cross contamination. During a review of the facility's P&P titled, Infection Control Program System, dated January 2023, the P&P indicated, The facility maintains written standards, policies and procedures for the infection control program, which includes.Standard and transmission-based precautions to be followed to prevent the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure food items were stored and used within labeled use-by dates when one opened food container dated 2/20/26 was found in the walk-in refrigerator on 2/22/26. This failure had the potential for food borne illnesses for residents.Findings:During a concurrent observation and interview on 2/22/26 at 9:40 a.m. with Trayline Aide (TA) in the walk-in kitchen refrigerator, one opened salsa container was found labeled with a date of 2/13/26 and to be used by 2/20/26. TA stated that the container should not have been in the walk-in refrigerator and should have been removed for disposal.During an interview on 2/23/26 at 8:06 a.m. with Dietary Supervisor (DS), DS stated food items that were past the date on the label should not have been stored in the walk-in refrigerator.During an interview on 2/25/26 at 10:13 a.m. with Registered Dietician (RD), RD stated food that was past the date labeled in the walk-in refrigerator can be a threat to resident's safety.During a review of the facility's policy and procedure (P&P) titled, LEFTOVER FOODS, dated 2023, the P&P indicated, Leftover foods will be stored and served in a safe manner .

Based on interview, and record review, the facility failed to ensure residents received medications as clinically indicated and free from unnecessary medications for two out of four sampled residents (Residents 1 and 2) when:1. Resident 1 did not receive prescribed medication that was intended to treat his medical condition.2. Resident 2 received a medication that was not intended for her and for which she had no clinical indication.These failures had the potential to cause harm when Resident 1 did not receive a prescribed medication, placing him at risk for an untreated medical condition and Resident 2 was exposed to unnecessary medication and possible adverse effects.1. During a review of Resident 1's admission Record (clinical record with demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of seizure (neurological disorder that results from abnormal activities in the brain) and acute kidney failure (A condition when the kidneys suddenly lose the ability to remove waste and balance your body's fluids and electrolytes).During a concurrent record review, and interview, on December 29, 2025, at 2:45 PM, with the Director of Nurses (DON), the DON reviewed and confirmed Resident 1's admission physician order list dated December 16, 2025, did not include Valproic Acid (a prescription medication used to prevent and control seizures). 2. During a review of Resident 2's admission Record, it indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of rhabdomyolysis (a condition when muscle tissue gets severely damaged causing pain, kidney damage, and dark urine output) and muscle weakness.During a concurrent record review, and interview, on December 29, 2025, at 3:00 PM, with DON, the DON reviewed and confirmed that Resident 2's admission physician order list dated December 16, 2025, indicated, Valproic Acid Oral Capsule 250 MG [milligram is unit of measure] Give 1 capsule by mouth three times a day for Seizures. The DON stated Registered Nurse 1 (RN 1) who handled the admission on [DATE], had mistakenly added the Valproic Acid order to Resident 2's records instead of Resident 1's.A review of the Facility's Incident Description dated December 22, 2025, indicated . Date of Incident Discovery: December 19, 2025. Type of Event: Medication Error - Misadministration of Anti-Seizure Medication. Findings Summary: Physician order for Valproic Acid [for Resident 1] was mistakenly entered for the wrong patient [Resident 2]. Patient [Resident 2] received 6 doses of Valproic Acid administered . between 12/16/25 and 12/19/25 [December 16, 2025, and December 19, 2025].A review of Resident 2's MAR (Medication Administration Record) for the period of December 16, 2025, to December 31, 2025, indicated .Valproic Acid . 250 MG. Give 1 capsule by mouth three times a day. was administered on December 17, 18, and 19, 2025. The initials provided confirmation the Valproic Acid was administered to Resident 2 as scheduled, for a total of nine doses unnecessarily and without clinical indication.During an interview on December 29, 2025, at 3:30 PM, with DON, the DON stated the facility does not have a written policy and procedure (P&P) for the admission process, including medication orders. The DON further stated, in practice, the facility reviews newly admitted residents' records on the following day to ensure completeness and accuracy of continuation of care, including medication orders and any other necessary care.During an interview on December 30, 2025, at 3:30 PM, with Registered Nurse 1 (RN 1), the RN 1 stated she is aware of her responsibility as the admission nurse to review hospital records and verify medication indications upon admission. RN 1 further stated, I am not sure how the mistake happened; I ended up putting the medication order to the wrong resident.During a follow up interview on December 30, 2025, at 3:30 PM, with RN 1, the RN 1 stated, It was my mistake that caused Resident [1] did not receive his Valproic Acid to manage his clinical condition that make Resident [2] received Valproic Acid that was unnecessary for her, unfortunately. RN 1 further stated she should have double checked the medication order against hospital discharged records and confirmed with the physician prior to entering the order, but she did not.During an interview on December 31, 2025, at 1:00 PM, the Administrator acknowledged the medication reconciliation practice error, stating Resident 1 did not receive his prescribed medication to manage his medical condition, and it was instead entered under Resident 2, who received six doses unnecessarily. The Administrator stated the facility expects the admission nurse to review hospital records and verify medication indications at admission and DON will review the admission chart the next business day after admission for accuracy and completeness. The Administrator also acknowledged that the facility does not have a written P&P governing the admission process, including medication orders upon admission. A review of Resident 1's MAR for the period of December 16, 2025, through December 31, 2025, indicated that Valproic Acid 250 mg, 1 capsule by mouth three times daily, was not initiated for Resident 1 until December 21, 2025, because the medication order had been entered under another resident (Resident 2). The MAR confirmed Resident 1 did not receive a total of twelve doses of his Valproic Acid required to manage his clinical condition.During an interview on January 2, 2026, at 2:00PM, with the Pharmacist, the Pharmacist stated that after a resident is admitted to the facility, the pharmacy typically reviews new admission medication orders within 4 to 8 hours or on the same day. The pharmacist stated that this review includes verification of medication strength, frequency, potential drug interactions, and clinical indication. The pharmacist further stated that it is not the pharmacy's usual process to review the hospital medication list, and that review of hospital discharge records is typically the responsibility of the facility.

Based on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of three residents (Resident 1), when medical records for Resident 1 were requested by Resident 1 Power of Attorney (POA) but were not delivered within two working days of the request as per the facility ' s policy. This failure resulted in a violation of Resident 1 ' s right to have access to medical records as requested by POA. Findings: During a review of Resident 1 Face Sheet (Contain Resident 1 demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnosis that included cerebral infraction (a condition where blood flow to the brain is interrupted, causing brain tissue to die). During an interview on May 7, 2025, at 11:40 AM, with the Medical Record Supervisor (MRS 1), the MRS 1 indicated that the POA for Resident 1 requested the resident's documents on Thursday, April 24, 2025, and completed the necessary release form on the same day. On April 30, 2025, she reached out to Resident 1's POA to notify her that the documents were ready for collection, which Resident 1 ' s POA did on that day. The MRS 1 acknowledged that the release of the documents exceeded the 48-hour policy, recognizing that they had gone beyond the specified timeframe. Nevertheless, she asserted that she followed the established protocol, which required the Director of Nursing and nursing staff to review the chart, followed by an administrative review of the documents before their release. She admitted that adherence to protocol does not justify the failure to comply with the timeline. During a review of document titled, Resident/Resident Representative Request for Access to Protected Health Information indicated Resident 1 POA requested Resident 1 Medical Record signed by POA on April 24, 2025. During an interview on May 7, 2025, at 12:31 PM, with the Director of Nursing (DON 1), the DON stated that passing the dateline in releasing resident ' s medical record to the family is unacceptable because family needs to look at the documentation and that is their right. During a telephone interview on May 14, at 2:47 PM, with MRS 1, MRS 1 reported that the POA of Resident 1 collected the medication record on April 30, 2025, made a cash payment for the documents, and received a receipt in return. During a review facility document titled, receipt (document containing payment confirmation), dated April 30, 2025, the receipt indicated payment receipt for Resident 1 records. During a review of facility policy and procedures (P&P) dated titled, Release of Records indicated, .Copies or any portion of them should be available within 2 working days of the request with advance notice to the facility . Based on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of three residents (Resident 1), when medical records for Resident 1 were requested by Resident 1 Power of Attorney (POA) but were not delivered within two working days of the request as per the facility's policy. This failure resulted in a violation of Resident 1's right to have access to medical records as requested by POA. Findings: During a review of Resident 1 Face Sheet (Contain Resident 1 demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnosis that included cerebral infraction (a condition where blood flow to the brain is interrupted, causing brain tissue to die). During an interview on May 7, 2025, at 11:40 AM, with the Medical Record Supervisor (MRS 1), the MRS 1 indicated that the POA for Resident 1 requested the resident's documents on Thursday, April 24, 2025, and completed the necessary release form on the same day. On April 30, 2025, she reached out to Resident 1's POA to notify her that the documents were ready for collection, which Resident 1's POA did on that day. The MRS 1 acknowledged that the release of the documents exceeded the 48-hour policy, recognizing that they had gone beyond the specified timeframe. Nevertheless, she asserted that she followed the established protocol, which required the Director of Nursing and nursing staff to review the chart, followed by an administrative review of the documents before their release. She admitted that adherence to protocol does not justify the failure to comply with the timeline. During a review of document titled, Resident/Resident Representative Request for Access to Protected Health Information indicated Resident 1 POA requested Resident 1 Medical Record signed by POA on April 24, 2025. During an interview on May 7, 2025, at 12:31 PM, with the Director of Nursing (DON 1), the DON stated that passing the dateline in releasing resident's medical record to the family is unacceptable because family needs to look at the documentation and that is their right. During a telephone interview on May 14, at 2:47 PM, with MRS 1, MRS 1 reported that the POA of Resident 1 collected the medication record on April 30, 2025, made a cash payment for the documents, and received a receipt in return. During a review facility document titled, receipt (document containing payment confirmation), dated April 30, 2025, the receipt indicated payment receipt for Resident 1 records. During a review of facility policy and procedures (P&P) dated titled, Release of Records indicated, .Copies or any portion of them should be available within 2 working days of the request with advance notice to the facility .

Based on observation, interview, and record review, the facility failed to implement the care for one of three sampled residents (Resident 1), who required two - person assistance for repositioning and care, when Certified Nursing Assistant (CNA 1) provided care to Resident 1 on two separate occasions (September 28, 2024, and September 29, 2024.) This failure has the potential to compromise Resident 1 ' s physical safety, emotional well-being and trust in care services. Findings: During a review of Resident 1 ' s Admission Record (contains demographic and medical information),it indicated Resident 1, was initially admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (the lungs can ' t get enough oxygen into the body), tracheostomy (a medical procedure where a small hole is made in the neck and windpipe to help someone breath), and dependence on respiratory. During a review of Resident 1 ' s care plan titled ADL (Activities of Daily Living) Functional / Rehabilitation Potential, dated July 8, 2024, it indicated, impaired physical mobility and self - care r/t [related t0] scoliosis (when the spine curves sideways into an S or C) muscular dystrophy (a condition where the muscles in the body become weak and lose strength .roll left & right max of assistance ( a person needs a lot of help from one or more caregivers to do basic), approach plan .provide 2 person assist . During a review of Resident 1 ' s Minimum Data Set (MDS), Section C Cognitive patterns (items in the section are intended to determine the resident ' s attention, orientation and ability to register and recall new information), dated September 26, 2024, it indicated Resident 1 had a Brief Interview for Mental Status (used to determine functioning use to determine a resident cognitive functioning status) Score of 14 ( A score 13-15 indicates intact cognition.) During a review of Resident 1 ' s Minimum Data Set (MDS) Section GG functional Abilities and Goals, dated September 26, 2024, it indicted, Resident 1 was dependent (helps does all of the efforts, Resident does none of the efforts to complete the activity .or the assistance of two or more helper is required for resident to complete activity.) for toileting hygiene. During a concurrent observation and interview on October 9, 2024, at 2:14 PM, inside Resident 1 ' s room, Resident 1 was lying in bed with the head of the bed elevated to approximately 45 degrees. Resident 1 stated that over the weekend, CNA 1 provided care alone two occasions, despite her care plan requiring two-person assistance for repositioning and care. She further stated that this led to a commotion, prompting a Respiratory Therapist (RT) to enter the room and assist CAN 1. Resident 1 expressed frustration with CNA1 ' s action and reported feeling unsafe during these incidents. During a phone interview on October 9, 2024, at 5:57 PM, with CNA 1, CNA 1 stated first incident occurred on September 28, 2024.) CNA 1 stated he entered Resident 1 ' s room and attempted to change Resident 1 by himself. He further stated the situation escalated when Resident because upset, and a Respiratory Therapist (RT) overheard the commotion entered the room and assisted with the repositioning and care. CNA 1 stated he did not ask for help, and he was unaware of the two-person requirement. CNA 1 further stated the same incident occurred again on September 29, 2024. During a phone interview on October 10, 2024, at 9:23 AM, with Registered Nurse (RN 1), RN 1 states she did not informed CAN 1 of two - person assistance requirement for all residents in the subacute unit (a care area for patient who need require more medical support related to physical weakness or unable to help themselves and depend on medical equipment.) During a concurrent interview and record review on November 15, 2024, at 5:23 PM the facility ' s policy titled Care Planning - Interdisciplinary Team, dated January 2017, was reviewed. The policy indicated, The care plan is based on the resident ' s needs and the resident ' s comprehensive assessment and is developed by a Care Planning / Interdisciplinary Team .Nursing Assistants responsible for the resident ' s care .

Based on observation, interview and record review, the facility failed to respect the rights of one of the three sampled residents (Resident 1) when a Certified Nurse Assistant (CNA 1) turned on the light in Resident 1 ' s room without her permission on September 28, 2024. This failure had the potential compromise Resident 1 ' s sense of safety and dignity. Findings: During a review of Resident 1 ' s Admission Record (contains demographic and medical information) it indicated Resident 1, was initially admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (the lungs can ' t get enough oxygen into the body), tracheostomy (a medical procedure where a small hole is made in the neck and windpipe to help someone breath), and dependence on respiratory. During a review of Resident 1 ' s Minimum Data Set (MDS), Section C Cognitive Patterns (items in this section are intended to determine the resident ' s attention, orientation and ability to register and recall new information.), dated September 26, 2024, it indicated Resident 1 had a Brief Interview for Mental Status (used to determine functioning used to determine a resident cognitive functioning status) Score of 14 ( a core of 13-15 indicates intact cognition.) During a concurrent observation and interview, on October 9, 2024, at 2:14 PM, Resident 1, stated that CNA 1 entered her room, turned on the overhead light without asking for permission, and dismissed her concern about her medical condition. Resident 1, who was lying in bed with her head elevated to 45 - degree angle in a dimly lit room, expressed that her sensitivity to bright light made it uncomfortable for her when the light was turned on without her consent. During a phone interview on October 9, 2024, at 5:57 PM, with (CNA 1), CNA 1 confirmed that he turned on the light at Resident 1 ' s room without permission on September 29, 2024. CNA 1 acknowledged that he should have asked Resident 1 first to respect her preference. During a concurrent interview and record review on November 11, 2024, at 2:18 PM, with Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled Resident Rights Policy, dated September 2017, was reviewed. The policy indicated Facility must protect promote their rights each resident .To be free from mental and physical abuse .Participate in the development and implementation of his on her person. centered plan of care to include establishing goals and outcomes and to be informed in advance of changes to be plan of care. Also, the right to identify individuals to be included in are planning, the right to request meetings or revisions to the care plan .To be treated with consideration, respect and full recognition of dignity and individually, including privacy in treatment and in care of personal needs. To resident and receive services with reasonable accommodation of resident need and preferences unless to do so would endanger the health and safety of the resident or other residents . The DON stated the staff did not follow the policy.

Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of three sampled residents (Resident 1) was not adequately supervised following two prior falls within the facility. This failure resulted in Resident 1 falling for the third time and sustaining a red/purple discoloration in the left head area, left hip swelling (abnormal enlargement), and pain in the left hip/leg Findings: During an interview on October 17, 2024, at 12:54 a.m. with Resident 1 ' s granddaughter, she stated the nurse who informed her mother about the latest fall incident indicated Resident 1 was in the hallway in front of her room during the incident. in addition, Resident 1 relayed at that time, the wheelchair was not locked, which contradicts the staff ' s claimed the wheelchair was secured. During a review of Resident 1 ' s post-fall risk assessment dated [DATE], and July 25, 2024, indicated Resident 1 has history of falls within the facility prior to the latest incident on August 20, 2024. During an interview on October 17, 2024, at 12:24 p.m. with the Director of Nursing (DON) 1, DON 1 was asked whether Resident 1 should have been monitored closely by placing her room nearer to the station. DON 1 stated Resident 1 was already located closer to the nurses ' station. However, when it was pointed out that at that time of the fall incident on August 20, 2024, Resident 1 was not in her current room, which is near the nurses ' station, but rather in another room, which is farther away. DON 1 did not respond directly to this observation. During a review of the undated facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.

F689 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the facility's policy regarding safety and supervision of residents was implemented, when one of the four sampled residents (Resident 1) was not supervised during lunchtime, which potentially resulted to a change of condition leading to Resident 1 being transferred to a general acute hospital for evaluation and treatment. This failure had the potential to place a clinically compromised resident (Resident 1) at risk for aspirating when resident was not supervised by the staff during mealtime. Findings: During a review of Resident 1's History and Physical H&P) dated February 3, 2023, the H&P indicated that Resident 1 had a diagnosis that included paraplegia (loss of muscle function and senses of the legs and lower body), seizure (a sudden uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movement[uncontrollable shaking, with muscles contracting and relaxing repeatedly, however, some have mild symptoms without shaking] feelings, and level of consciousness), and dysphagia (difficulty of swallowing). During a review of facility provided document titled SBAR (stands for situation, background, appearance, review and notify.) communication form and progress notes for RNs/LVNS/LPNs (registered nurses, licensed vocational nurses & licensed practical nurses). It indicated Resident 1 was found unresponsive and necessitated initiation of a code blue (a hospital code for an emergency that requires resuscitation - the process of reviving a patient that lacks breathing or pulse). was initiated, and subsequently transferred to an acute hospital. During a telephone interview on July 3, 2024, at 4:03 PM, with the Speech Therapist (ST -a profession that work to prevent , assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders ) ST 1 stated Resident 1 did not require assistance with feeding at that time, but needed someone to be with him to ensure that he was following aspiration precautions (swallowing problems like choking while or after eating). During a telephone interview on July 8, 2024, at 4:03 PM, with the Director of Nursing (DON 1), DON 1 stated that she could not find any notes regarding Resident 1's condition during lunchtime or whether staff supervised or assisted the resident during lunch on August 29, 2023. However, DON 1 stated that she found a document in the nurse's notes dated August 28, 2023, the day before Resident 1 was transferred, indicating that Resident 1 was supervised while eating. During a review of the ST 1's evaluation and treatment plan for Resident 1 covering the certification period from August 16,2023 through September 10, 2023, it was noted that ST 1 recommended distant supervision and close supervision during mealtime. The document also mentioned that the resident was at risk for aspiration due to documented physical impairment. During a review of Resident 1's care plan for activities of daily living (ADL - activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking using the toilet, and eating.) dated February 2, 2023, the care plan indicated that Resident 1 required supervision while eating. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated May 2015, the P&P indicted, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment when a fire incident occurred on May 22, 2023. One of the facility's employee's battery pack caught on fire while it was stored in one of two oxygen storage rooms. This failure had the potential to cause smoke inhalation, burns, explosion, and even death to 133 residents in the facility. Findings: During an observation on May 31, 2023, at 10:17 AM, in the Oxygen Storage Room, by the Sub-Acute Unit (inpatient unit for residents needing services more intensive than typically provided in a skilled nursing facility), fifty-eight portable oxygen tanks were inside the storage room. The tile where the fire had occurred had black residue. During an interview, on May 31, 2023, at 10:31 AM, with Respiratory Therapist (RT 1), RT 1 stated he was checking on his patients, when he heard the fire alarm, he saw smoke coming from the oxygen storage room in the sub-acute unit . RT 1 further stated he grabbed a fire extinguisher and attempted to put out the fire, but the sprinkler system had already been activated. RT 1 stated his next step was to close the door to the oxygen storage room and start closing all the resident rooms doors. During an interview with the Sub-Acute RN, on May 31, 2023, at 10:42 AM, the Sub-acute RN stated the fire department came to the facility and asked the staff to step outside the facility. Sub-acute RN further stated the fire department stated that there was no need to evacuate the ventilated residents. Sub-acute RN stated she was informed by the fire department that the cause of the fire was a battery pack inside of an employee's backpack stored inside the oxygen storage room. During an interview with Respiratory Therapist 2 (RT 2), on June 2, 2023, at 3:55 PM, the RT 2 stated he left his backpack inside the oxygen storage room. RT 2 further stated he should not have left his backpack in the oxygen storage room. During an interview with the Director of Nursing (DON), on May 31, 2023, at 11:53 AM, the DON stated the expectation for employees is to store their belongings in the facility provided lockers. The DON further stated an oxygen storage room is not the expected location for employees to store their personal belongings. The DON stated there was no policy and procedure for the storage of employee's personal belongings. During a concurrent interview and record review on May 31, 2023, at 11:53 AM, of the facility's policy and procedure (P&P) titled 4.3 Hazards , dated March 2021, with the DON, the P&P was reviewed. The P&P indicated, You must immediately report any safety hazards you may observe to your supervisor, the DSD or Administrator. The DON stated the policy was not followed. During a concurrent interview and record review on May 31, 2023, at 11:53 AM, of the facility's P&P titled 4.4 Injury and Illness Prevention dated March 2021, with the DON, the DON reviewed the P&P which indicated, Conducting periodic safety inspections to find and eliminate unsafe working conditions or practices. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach while in bed in accordance with their policy and procedure for two out of three sampled residents (Residents 1 and 2). This failure has the potential to result into a delay in the provision of services and needs not being met for Residents 1 and 2. Findings: 1. During a review of Resident 1's medical record, the Resident Face Sheet (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (a conditions that adversely affect blood flow to the brain, can cause lasting brain damage and long-term disability), chronic systolic congestive heart failure (disease in which heart cannot pump blood efficiently and makes it difficult to breathe), and hypertensive (elevated blood pressure). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated January 30, 2023, indicated Resident 1 was assessed to be in need of extensive assistance (when Staff fully assists the person in accomplishing the task; person is unable to or minimally participates) with 1-person physical assistance with bed mobility, dressing, and personal hygiene. During an observation and concurrent interview, with Resident 1, on March 15, 2023, at 2:30 PM, Resident 1 was in her room, lying down in bed. Resident 1's call light was not within reach. When Resident 1 was asked to reach her call light, Resident 1 stated she was unable to reach her call light. During an observation and concurrent interview, with Certified Nurses Assistance 1 (CNA 1), on March 15, 2023, at 2:40 PM, in Resident 1's room, Resident 1's call light was not within reach of the resident. The resident's call light was clipped to the corner of pillowcase, close to the headboard of her bed, and was dangled down over the head bed frame to the floor. CNA 1 stated call light should be clipped within Resident 1's easy reach. 2. During a review of Resident 2's medical record, the Resident Face Sheet, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease,hypertensive, and hyperlipidemia (too many lipids (fats) in the blood). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 has severely impaired cognitive skills for daily decision making. Further review indicated Resident 2 was assessed to be in need of extensive assistance with 1-person physical assistance with bed mobility, dressing, and personal hygiene. Furthermore, the MDS indicated Resident 2's upper and lower extremity had impairment on one side. A review of Resident 2's care plan, dated July 14, 2022, indicated .Problem: at risk for pain/discomfort r/t [related to] .medical condition . (R) [right] sided weakness . During an observation, on March 15, 2023, at 3:00 PM, Resident 2 was in his room, lying down in bed. Resident 2's call light was not within his reach. When asked to reach for his call light. Resident 2 tried to reach it using his left hand (which was his strong side). Resident 2 was unable to reach the call light. During an observation and concurrent interview, with License Vocational Nurse (LVN 1), on March 15, 2023, at 3:10 PM, Resident 2's call light was wrapped up to the right side of Resident 2's bed grab bar (a device attached to the bed frame gives assistance in moving around and repositioning in bed), which was at Resident 2's weak side. The call light was dangled down to the floor. LVN 1 confirmed Resident 2's call light was not within the resident's reach. LVN 1 further stated Resident 2's call light should be clipped within Resident 2's left hand easy reach. During a concurrent interview and record review, on March 15, 2023, at 3:45 PM, with the Director of Nurses (DON), the DON reviewed the facility's policy and procedure (P&P) titled Call Lights revised January 2017, which indicated Policy: it is the policy of the facility to respond to the resident's requests and needs . Procedure: . When the resident is in bed or in the wheelchair or chair in the room staff should make sure that the call is within easy reach of the resident . The DON stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure the Food and Nutrition Services staff had appropriate competencies to prepare puree diets (food prepared with a smooth and moist consistency for residents who have difficulty chewing and/or swallowing) when a Cook (Cook 1) used an immersion mixer (a hand-held blender usually used to mix or blend single serving food portions in the container they are being prepared) to puree meat, rice, and soup from the Korean Diet menu which resulted in puree that was not smooth and did not hold its shape for four residents receiving a physician-ordered puree Korean Diet. This failure had the potential to result in choking or unpalatable texture that could potentially alter the nutrition status for medically compromised residents. Findings: During an observation with Cook 1, on February 7, 2023, at 11:18 AM, in the kitchen, Cook 1 was preparing to puree Korean steamed rice. Cook 1 added water to cooked rice in a pan and blended the rice and water mixture with an immersion mixer. The rice texture was thin, watery, and grainy. Cook 1 added more cooked rice into the metal pan and used the immersion mixer again. The pureed rice was runny and non-smooth in texture. During further observation with Cook 1, on February 7, 2023, at 11:23 AM, Cook 1 was preparing to puree Korean spinach soup. She used the immersion mixer to puree the soup. When she was done, the pureed soup was thin consistency with stringy chunks of spinach visible. During a subsequent observation with Cook 1, on February 7, 2023, at 11:29 AM, Cook 1 was preparing to puree Korean Chicken (Dak Bulgogi). She blended the chicken using the immersion mixer. The pureed chicken was stringy consistency with visible chicken chunks. During a tray line (an assembly line preparation of meal trays in the kitchen to be delivered to residents) observation and concurrent interview with Dietary Services Supervisor 1 (DSS 1), on February 7, 2023, at 12:10 PM, in the kitchen, DSS 1 inspected the pureed chicken and stated the chicken was not smooth and had chunks of chicken. DSS 1 stated Cook 1 should have pureed the chicken in a food processor or blender to ensure that it was smooth. During a follow up interview with DSS 1, on February 7, 2023, at 3:11 PM, DSS 1 stated staff were last trained for pureed food almost two years ago and Cook 1 did not have a one-on-one training by the DSS and no other in-service or training for preparing pureed foods was done. During an interview with the Registered Dietitian 1 (RD 1), on February 10, 2023, at 2:59 PM, the RD 1 stated she has not performed in-service for puree with Korean diet cooks. She further stated the expectation was that pureed food should be smooth and mashed potato texture. During a review of Inservice Education Record-Pureed Food, dated April 2, 2021, the training record indicated Cook 1 did not attend the training. During a review of the facility's diet manual titled RDs for Healthcare, Inc. Diet Manual for Long Term Care Facilities- Puree Diet, dated 2020, it indicated the texture of the pureed food should be of a smooth and moist consistency, able to hold its shape, and all foods are prepared in a food processor or blender. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, it indicated Policy: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure: 2. Recipes are specific as to . method of preparation .

Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The ice machine cooling compartment (where the ice is made) had a black colored residue that could be wiped away with a paper towel, which had the potential to contaminate the ice and cause foodborne illness (illness caused by ingestion of contaminated food or beverages). 2. The food preparation sink did not have an air gap (a separation in the drain pipe that ensures prevention of contaminated drain and wastewater from contaminating the sink) which had the potential to cause foodborne illness. 3. The middle sink of the three-compartment sink (three sinks used for manual dishwashing, one for washing, one for rinsing, and one for sanitizing dishes) had rust which had the potential to contaminate the water being used to rinse the dishes. 4. The dishwasher did not have a data plate affixed with the important manufacturer's information on wash and rise temperature and ppm (parts per million) of chlorine. This had the potential for staff to incorrectly operate the dish machine which could lead to dishes not being appropriately cleaned. 5. The dishwasher was not reaching appropriate wash and rinse temperature per the manufacturer guidelines which had the potential for dishes to not be washed properly and potentially cause foodborne illness. These failures had the potential to expose 86 medically compromised residents who receive food from the kitchen to foodborne illness due to cross-contaminations (the transfer for harmful substances or disease-causing microorganisms to food). Findings: 1. During a concurrent observation and interview with Dietary Services Supervisor 1 (DSS 1), on February 7, 2023, at 8:15 AM, in the kitchen's dry storage area, DSS 1 opened the ice machine for inspection. The interior of the machine was found to have black colored residue on the side wall of the compartment by the ice chute (where ice contacts the surface to fall into the ice bin) which was easily wiped off with a white paper towel. DSS 1 validated seeing the residue and stated it was maintenance responsibility to maintain the ice machine cleanliness. During a concurrent observation and interview with the Maintenance Manager (MM), on February 7, 2023, at 8:47 AM, the MM verified seeing the black residue on paper towel after wiping near the ice chute. During a review of a facility document titled Monthly Ice Machine Cleaning Log for 2023, it indicated the machine was last cleaned on January 5, 2023 (33 days since the inspection of the ice machine.). During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2018, it indicated the ice machine needs to be cleaned monthly and the date recorded when cleaned. During an interview with the Registered Dietitian (RD 1), on February 10, 2023, at 2:59 PM, the RD 1 stated the ice machine should be cleaned per cleaning schedule, and ideally there should be no build up in the machine. During a review of the Food Drug Administration (FDA) Food Code 2022, 4-601.11 titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, it indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. During a review of the FDA Food Code 2022, 4-602.11 titled Equipment Food- Contact Surfaces and Utensils, it indicated surfaces of utensils and equipment contacting food .icemakers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. During a review of the FDA Food Code 2022, 4-204.17 titled Ice Units, Separation of Drains, it indicated, the potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae . present a risk of contamination to the ice stored in the bin. 2. During a concurrent observation and interview with DSS 1, on February 7, 2023, at 8:45 AM, in the kitchen, a food preparation sink did not have an air gap. DSS 1 acknowledged the finding, and stated he was not aware the sink needed an air gap. During an interview with the RD 1, on February 10, 2023, at 2:59 PM, the RD 1 stated she was not aware of the requirement for an air gap. During a review of the facility's P&P titled, Accident Prevention- Safety Precautions, dated 2018, it indicated if a connection exists between the system and a source of contaminated water during times of a negative pressure, contaminated water may be drawn into and foul the entire system. An air gap is the most reliable backflow prevention device. All .food preparation sinks . and other equipment that discharge liquid waste or condensate shall be drained though an air gap . During a review of the FDA Food Code 2022, 5-402.11 titled Backflow Prevention, it indicated, (A) a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. In addition, 5-202.13 indicates, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 3. During a concurrent observation and interview with DSS 1, on February 9, 2023, at 9:45 AM, in the kitchen's dishwashing area, the three-compartment sink was inspected. The middle sink had a rust-colored area on its' interior lower left corner. DSS 1 verified the finding, and stated there was previously a hole in the middle compartment of the sink that had been repaired. DSS 1 stated the material they used to patch the hole was not stainless steel because stainless steel does not rust. During an interview with the RD 1, on February 10, 2023, at 2:59 PM, the RD 1 stated it was their expectation that the sink should not be rusted and should be avoided until fixed. During a review of the facility's P&P titled, Sanitation, dated 2018, it indicated, All equipment shall be maintained as necessary and kept in working order. 5. The [Food & Nutrition Services] FNS Director . will report any equipment needing repair to the maintenance man. 9. All . equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. During a review of the FDA Food Code 2022, 4-101.11, it indicated, Materials that are used in the construction of utensils and Food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashing [the process of cleaning and sanitizing the dishware used in the preparation or service of food]; (D) Finished to have a smooth and easily cleanable surface. In addition, Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. 4. During a concurrent observation and interview with Dish Washer (DW 1), on February 9, 2023, at 1:50 PM, in the kitchen, DW 1 was using a low temperature dish wash machine. The dishwasher did not have an affixed data plate with important manufacturer information. DW 1 verified there is no data plate present on dish wash machine. During an interview with the RD 1, on February 10, 2023, at 2:59 PM, the RD 1 stated they did not know having an affixed data plate was a requirement. During a review of the facility's P&P titled, Dishwashing, dated 2018, it indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. 9. The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations. *Please check your manufacturer's recommendations, which should be posted on your machine . During a review of the FDA Food Code 2022, 4-204.113 titled Warewashing Machine, Data Plate Operating Specifications, it indicated, A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machines design and operation specifications . During a review of the FDA Food Code 2022, 4-501.113 titled Warewashing Machines, Data Plate Operating Specifications, it indicated, the data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested and the information on the data plate represents the parameters that ensure effective operation and sanitation and that need to be monitored. 5. During a concurrent observation and interview with DW 1, on February 9, 2023, at 1:50 PM, in the kitchen, DW 1 was using a low temperature dish wash machine. DW 1 stated the appropriate wash and rinse temperature for their machine, and according to their policy, was 120 degrees Fahrenheit (unit of temperature measurement, F), rinse temperature is 140 degrees F, and chlorine (chemical for sanitation) is 50 ppm (parts per million). The disher water temperature gauge was inspected. The temperature was at 98 degrees F. The DW 1 verified the temperature during the wash cycle was below 120 degrees F. (22 degrees difference.) During a concurrent observation and interview with DSS 1, on February 9, 2023, at 1:52 PM, in the kitchen's dishwashing area, DSS 1 used a facility thermometer, and verified the temperature on wash cycle was 92 degrees F. (28 degrees F difference from 120 degree F.) During a review of the facility's P&P titled, Dishwashing, dated 2018, it indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. 9. The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations. *Please check your manufacturer's recommendations, which should be posted on your machine . If you cannot achieve this temperature, alert the dietetic supervisor, or cook who will alert the maintenance personnel and stop washing dishes. Low-temperature machine: If you do not have the manufacturer's recommendations, use the machine at a range of 120 to 140 F. During a review of the FDA Food Code 2022, 4-501.110 titled Mechanical Warewashing Equipment, Wash Solution Temperature, it indicated, (B) the temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than (120 F). During a review of the FDA Food Code 2022, 4-501.11 titled Mechanical Warewashing Equipment, Wash Solution Temperature, it indicated, the wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function of the temperature is too low. Therefore, the manufacturer's instructions must be followed.

Based on observation, interview, and record review, the facility failed to follow the approved menus when: 1. Four residents receiving a Korean puree diet (food prepared with a smooth and moist consistency for residents who have difficulty chewing and/or swallowing) were served the incorrect portion size on their lunch tray for the following items: 1.a. 1/2 cup of pureed rice was served on February 7, 2023, and February 8, 2023. (The spreadsheet indicated to serve 3/4 cup.) 1.b. 1/4 cup of pureed beef/tofu was served on February 8, 2023. (The spreadsheet indicated to serve 1/2 cup.) 2. The recipe for pureed rice was not followed when the cook used water to puree rice. (The recipe indicated to use milk.) 3. Eleven residents receiving altered texture diets received the incorrect ordered texture when six residents receiving a dysphagia mechanical soft diet (foods are moist, mechanically altered or easily mashed for residents with difficulty swallowing) received a puree texture instead of indicated ground, and five residents receiving a mechanical soft diet (foods are a soft chopped or ground consistency for residents who experience chewing or swallowing limitations) received a regular chicken texture instead of indicated ground. These failures resulted in lower caloric content of meals served, a potential to contribute to a decline in nutritional status and undesirable weight loss when recipes are not followed for medically compromised residents, and a potential choking incident when foods of incorrect consistency are served. Findings: 1.a. During a tray line (an assembly line preparation of meal trays in the kitchen to be delivered to residents) observation on February 7, 2023, at 12:00 PM, in the kitchen, a Cook (Cook 1) served pureed steamed rice using a number 8 serving scoop (1/2 cup). During a review of facility document titled Daily Spreadsheet- Korean Menu Week 1, dated Tuesday- Day 3 (February 7, 2023), it indicated serve 3/4 cup of pureed steamed rice. 1.b During a tray line observation on February 8, 2023, at 11:59 AM, in the kitchen, Cook 2 served pureed steamed rice using a number 8 serving scoop (1/2 cup), and pureed beef/tofu using a number 16 serving scoop (1/4 cup). During a review of facility document titled Daily Spreadsheet- Korean Menu Week 1, dated Wednesday- Day 4 (February 8, 2023), it indicated serve 3/4 cup pureed steamed rice and serve pureed beef/tofu with a number 8 serving scoop (1/2 cup). During an interview with the Registered Dietitian (RD 1), on February 10, 2023, at 2:59 PM, the RD 1 stated her expectation was that cooks should follow portion sizes as stated in the menu. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2018, it indicated 2. Recipes are specific as to portion yield. During a review of the facility's P&P titled Pureed Foods, dated 2020, it indicated always puree food that is already prepared and portion per the recipe to meet the need of the diet and portion size. 2. During an observation with Cook 1, on February 7, 2023, at 11:18 AM, in the kitchen, Cook 1 was preparing to puree steamed rice. Cook 1 placed an unmeasured amount of steamed rice in a 2.7-quart metal pan and poured an unmeasured amount of hot water from a hot water dispenser into the metal pan. Cook 1 mixed the rice and water mixture with the immersion mixer (a hand-held kitchen blade grinder used to mix ingredients in the container they are being prepared). During an interview with RD 1, on February 10, 2023, at 2:59 PM, the RD 1 stated Cook 1 should have followed the recipe and used milk, and not water to puree the rice. During a review of an undated facility document titled Recipe- Pureed Starch (Rice, Pasta, Potatoes), it indicated, complete the regular recipe, measure out the total number of portions needed for puree diets, puree on low speed to a paste consistency before adding any liquid, gradually add warm milk, as indicated per the recommended amount to achieve the desired consistency, and the puree should reach a consistency slightly softer than whipped topping. During a review of the facility's diet manual titled RDs for Healthcare, Inc Diet Manual for Long Term Care Facilities, dated year 2020, it indicated water is not used since it dilutes flavors and results in poorly accepted products. During a review of the facility's undated policy and procedure (P&P) titled, Food Preparation, it indicated Policy: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure: 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 3. During a lunch tray line observation on February 7, 2023, at 12:00 PM, in the kitchen, Cook 1 served the regular Korean chicken with no texture alteration for mechanical soft diet trays and pureed chicken for dysphagia mechanical diet trays. During an interview with the RD 1, on February 10, 2023, at 2:59 PM, the RD 1 stated all cooks should be following the spreadsheet for texture and the chicken served for lunch should have been ground for mechanical soft and dysphagia mechanical diets. During a review of a facility document titled Daily Spreadsheet- Korean Menu Week 1, dated Tuesday- Day 3 (February 7, 2023), it indicated both the mechanical soft and dysphagia mechanical chicken to be served ground (cut up or chopped into very small pieces, often using a special machine) with a number 12 serving scoop (1/3 cup). During a review of an undated facility document titled Recipe- Korean Barbequed Chicken (Dak Bulgogi), it indicated For the following diets: grind chicken to desired texture, reheat to 165 degrees F and refer to spreadsheet for serving portion: Mechanical soft: serve with 1 oz sauce, broth, or gravy. Dysphagia mechanical: serve with 2 oz sauce, broth, or gravy. During a review of the facility's diet manual titled RDs for Healthcare, Inc. Diet Manual for Long Term Care Facilities- Mechanical Soft, dated 2020, it indicated ground is achieved by reducing to small fragments by friction, it is recommended to use a grinder/food processor to achieve the consistency of ground beef. The manual further indicated that meat should not be served in chunks for mechanical soft diets, and one should strive to individualize a resident's diet before going to a full puree texture.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube - a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented in accordance with the facility's policy and procedure, for three of four residents (Resident 84, 29 and 42) reviewed for G-tube when: 1. For Resident 84, a license nurse did not check for G-tube placement (listening to gurgling sound when flushing air through the G-tube to confirm the correct position) before administering medications. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise Resident 84's health. 2. For Resident 29, a licensed nurse did not flush the appropriate amount of water during G-tube medication administration in accordance with the physician's order. This failure had the potential to increase the risk for hyponatremia (level of sodium in blood is too low) and compromise Resident 29's health. 3. For Resident 42, a licensed nurse did not administer the tube feeding formula in accordance with the physician's order. This failure had the potential to increase the risk for malnutrition and compromise Resident 42's health. Findings: 1. During a review of Resident 84's clinical record, the Resident Face Sheet (contains demographic and medical information), indicated Resident 84 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), and gastrostomy status (a surgical operation for making an opening in the stomach), and chronic obstructive pulmonary disease (a group of lung diseases that makes difficult to breath). During a review of Resident 84's Physician Order, dated March 12, 2022, indicated Resident 84 had an order for nurses to Check placement and patency of tube [G-tube] prior to medication administration, Every shift; 07:00 AM - 03:00 PM, 03:00 PM - 11:00 PM, 11:00 PM - 07:00 AM. An observation of medication administration for Resident 84 by a Licensed Vocational Nurse (LVN 1) was conducted on February 9, 2023, at 9:50 A.M., in Resident 84's room. Resident 84 was lying in bed, watching television, with the head of the bed elevated. LVN 1 attached a syringe into the G-tube, checked for residual (fluid/contents that remain in the stomach), and proceeded to flush the G-tube with 30 mL (milliliters - unit of measurement) of water and administered Amlodipine (medication to treat high blood pressure) 5 mg (milligrams -unit of measurement). LVN 1 did not check for G-tube placement. LVN 1 stated he needed to check for placement before administering medication, but he forgot to do it. During a concurrent interview and record review with the Director of Nursing (DON), on February 9, 2023, at 1:49 P.M., the DON reviewed the facility's policy and procedure (P&P) titled, Enteral Tube Medication Administration, revised April 2008, which indicated, Procedures .D. Verify tube placement . 1) Use the following procedures: .a. Insert a small amount of air into the tube with syringe and listen to stomach with stethoscope for gurgling sounds. The DON stated the staff did not follow the policy. 46696 2. During a review of Resident 29's clinical records, the face sheet indicated Resident 29 was admitted to the facility on [DATE], with diagnoses which included chronic heart failure (an ongoing inability of the heart to pump enough blood through the body), and diabetes (a disease that affect how the body uses blood sugar). During an observation with LVN 3, on February 9, 2023, at 6:00 AM, LVN 3 was administering medication to Resident 29. The Levothyroxine (medication used to treat thyroid hormone deficiency) was given via g-tube by gravity (downward direction). LVN 3 used a drinking cup of water to administer the medication. LVN 3 did not measure the amount of water. The syringe was filled with water two times. The syringe was labeled 60 mL. LVN 3 then attempted to use a second cup to flush the medication, but Resident 29 refused. During a follow up interview and concurrent review of Resident 29's clinical record with LVN 3 on February 9, 2023, at 6:10 AM, LVN 3 reviewed Resident 29's physician order, dated February 9, 2023, which indicated, 30 mL water flush, pre [before] and post [after] medication administration and 150 ml water flush q [every] 6 hours. LVN 3 stated she used about 250 ml of water flush, and acknowledged Resident 29 did not receive the appropriate amount of water during G-tube medication administration. LVN 3 further stated Oh it says 150 ml (on the physician order). During a review of the facility's policy and procedure (P&P) titled, IIB13: Enteral Tube Medication Administration, dated April 2008, it indicated, . G. Flush the tube with at least 15-30 ml of water prior to medication administration. 45388 3. During a review of Resident 42's medical record, the Resident Face Sheet indicated, Resident 42 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (unable to move all arms and legs), aphasia (loss of ability to understand or express speech), dysphagia, and diabetes mellitus. During a review of Resident 42's Physician's Order, dated January 5, 2022, it indicated Resident 42 has an order to receive GLUCERNA 1.2 [Formula] via GT delivered through an enteral feeding pump [pump used to deliver formula at an optional rate] at 60mL/hr [hour] for 20 hrs to provide 1200 mL/day . enteral feeding pump to run from 12pm to 8 am . A concurrent observation and interview were conducted with LVN 1, on February 7, 2023, at 9:25 AM, in Resident 42's room. Resident 42 was lying in bed. A tube feeding, which was running at 60 mL/hr, was connected to Resident 42. Resident 42's tube feeding bottle, hanging on a stand close to his bed, was inspected. The tube feeding bottle was dated February 5, 2023, and with a start time at 12 PM (45 hours upon inspection). LVN 1 stated the tube feedings should have been completed and was not sure what happened. A concurrent interview and record review were conducted with the DON, on February 8, 2023, at 3:31 PM. The DON reviewed the facility's P&P titled, Medication Administration, dated May 2019, and Gastrostomy Tube Feeding via Continuous Pump, dated January 2017, and stated the policies were not followed. The DON further stated Resident 42's tube feeding bottle should have been completed by 5:00 PM on February 6, 2023. During a review of the facility's P&P titled Medication Administration, dated May 2019, it indicated, .Medications must be administered in accordance with the physician orders, including any required time frame . During a review of the facility's P&P titled Gastrostomy Tube Feeding via Continuous Pump, dated January 2017, it indicated, . It is the policy of the facility to provide nourishment via continuous pump to residents who are unable to obtain adequate nourishment orally, as ordered by the resident's attending physician .

Based on observation, interview, and record review, the facility failed to ensure the medication destruction policy was followed for one of eleven residents (Resident 24) reviewed for medication administration, when two licensed nurses disposed a controlled medication (medication or substances that is controlled by the government because it may be abused or cause addiction) in a pharmaceutical waste container (container used by facility to discard medications). This failure has the potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff. Findings: During a review of Resident 24's clinical record, the Resident Face Sheet (contains demographic and medical information), indicated Resident 24 was admitted to the facility on [DATE], with diagnoses which included, multiple sclerosis (a condition in which the body's immune system attacks the nerve cells in the brain and spinal cord), trigeminal neuralgia (condition that causes painful sensations on one side of the face) and osteoarthritis (degenerative joint disease). During a review of Resident 24's physician order, dated August 6, 2022, it indicated Resident 24 had an order for Hydrocodone-Acetaminophen [Norco] - Schedule II tablet; 5-325 mg [milligrams -unit of measurement], 1 tab [tablet] Every 8 Hours PRN [as needed] for trigeminal neuralgia pain. During a review of Resident 24's physician order, dated August 17, 2022, it indicated Resident 24 had an order for Tramadol - Schedule V tablet; 50 mg, 1 tab [tablet] Every 8 hours PRN for severe pain (7-10). During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 1), on February 9, 2023, at 9:05 A.M., in Resident 24's room, Resident 24 stated she had a pain level of 8 out of 10 in the pain rating scale (used to measures pain intensity where '0' represents no pain and '10' represents the worst pain) in her face due to trigeminal neuralgia. LVN 1 proceeded to administer Norco to Resident 24. Resident 24 refused Norco and requested to receive Tramadol instead. During a subsequent observation on February 9, 2023, at 9:15 A.M., with LVN 1, inside Resident 24's room, LVN 1 administered Tramadol to Resident 24 for pain, per Resident 24's request. During further observation and interview, on February 9, 2023, at 9:45 A.M., with LVN 1, outside Resident 24's room, LVN 1 asked LVN 2, to witness the destruction of Norco. LVN 1 and LVN 2 counted the contents of Norco in the bubble pack (a card that packages doses of medication within small bubbles, designed to help track medications) and signed the Antibiotic or Controlled Drug Record (document used to record the administration or destruction of a controlled drug for tracking purposes). Afterwards, LVN 1 and LVN 2 entered the medication storage room and disposed the Norco tablet onto the pharmaceutical waste container, which was located next to the refrigerator. The pharmaceutical waste container had four white round tablets and several pink capsules. The medications inside it were dry. There was no liquids or other substance inside the container. LVN 2 stated the facility do not mix the medications with liquids because they will be incinerated. During a telephone interview with the Pharmacist Consultant (PhC), on February 9, 2023, at 1:13 P.M., the PhC stated controlled medications must be kept in the possession of the DON until they were destroyed. PhC further stated controlled medications must be destroyed in the presence of the DON and the PhC and sign the disposition form. PhC further stated controlled medications must be irretrievable (unrecognizable) with liquid or flour to avoid unauthorized persons to take it. During a concurrent interview and record review, on February 9, 2023, at 1:32 P.M., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Medication Destruction, dated April 2008. The P&P indicated, .B. Controlled substances are retained in a securely locked area with restricted access until destroyed by the facility director of nursing or a registered nurse employed by the facility and a consultant pharmacist . D. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the disposition form . 1) Date of the destruction . 2) Resident's name . 3) Name and strength of the medication . 4) Prescription number . 5) Amount of medication destroyed . 6) Signatures of witnesses. DON stated facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure medications and medication carts (used to transport resident's medication) were properly secured when one of six medication carts was found unlocked and unattended by a licensed nurse. This failure had the potential to compromise the security of the medications, for potentially unauthorized staff and residents could access it in a highly vulnerable population of 128 residents. Findings: A medication administration observation for Resident 34 was conducted with a Licensed Vocational Nurse (LVN 3) on February 9, 2023, at 5:10 AM. The medication cart, where Resident 34's medication was stored, was by Resident 34's room door. LVN 3 turned her back from the medication cart, which had its top drawer open, and entered Resident 34's room to prepare for medication administration. LVN 3 stated, The drawer should be closed when my back is turned or away from the medication cart, and the drawers should be locked when I am not at the cart. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in The Facility ID1: Storage of Medications, dated April 2008, it indicated, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure the advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), were completed and available for one of four residents (Resident 112) reviewed for advance directives. This failure had the potential to result in a delay of treatment for Resident 112 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: During a review of Resident 112's clinical record, the Admission Record (clinical records with demographic information) indicated, Resident 112 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (long term inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (heart muscle doesn't pump blood as well as it should), and diabetes mellitus 2 (increased blood sugar level). During a review of Resident 112's Advance Directive Acknowledgement (ADA), dated December 23, 2022, and Social Service Advance Directive Department Note (SSADDN), dated December 15, 2022, it indicated Resident 112 had an advance directive. During a concurrent interview and record review with the Social Service Director (SSD), on February 8, 2023, at 10:55 AM, the SSD reviewed Resident 112's clinical record, and stated the advance directive was not in the chart. SSD further stated it should have been in the chart. During a concurrent interview and record review with the Director of Nursing (DON), on February 9, 2023, at 12:57 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Advance Directives, dated April 2017, which indicated, .The resident or their responsible party will be asked if the resident has completed an advance directive, and to provide a copy of the document for the resident's clinical record . The DON stated the facility did not follow the policy.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services in the skin conditions under Section M for one of three residents (Resident 116) reviewed for pressure injury (an open wound on the skin caused by a long period of constant pressure). This failure had the potential to cause inaccuracy in identifying Resident 116's care and support needs. Findings: During a review of Resident 116's Admission Record (document that contains demographic and clinical data), the Admission Record indicated Resident 116 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (when the respiratory system cannot adequately provide oxygen to the body), encounter for attention to gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach) and encounter for attention to tracheostomy (surgically created airway that is kept open with a breathing tube). During a review of Resident 116's Initial Nursing History and Assessment was conducted for Resident 116 on April 4, 2022, and Resident 116's MDS Admission Assessment (a comprehensive assessment for a resident that must be completed within 14 days after admission), dated April 18, 2022, on Section M titled Skin Conditions, it indicated Resident 116 did not have any unhealed pressure injury upon admission. During a concurrent interview and record review with the Minimum Data Set Nurse (MDS Nurse), on February 9, 2023, at 1:21 PM, the MDS Nurse reviewed Resident 116's clinical record and was not able to find any documentation that Resident 116 had any pressure injury upon admission. During a concurrent record review and interview with the MDS Nurse, on February 9, 2023, at 1:40 PM, the MDS Nurse reviewed Resident 116's MDS Quarterly Assessment (an assessment for a resident that must be completed every 92 days following the previous assessment), dated July 13, 2022, on Section M titled Skin Conditions which indicated Resident 116 had an unhealed pressure ulcer/injuries category stage 3 (sore that involved skin loss throughout the entire thickness of the skin) that was present on admission. The MDS Nurse stated, It was coded in error. The MDS Nurse further stated it should have not been coded as present on admission. During a concurrent interview and record review with MDS Nurse, on February 9, 2023, at 2:00 PM, the MDS Nurse reviewed the CMS (The Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument- provides guidelines and definitions for completing MDS assessment) manual, revised October 2019, and stated the facility did not follow the RAI manual. A review of the CMS RAI manual, revised October 2019, indicated .Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review . Steps 3: Determine Present on Admission For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. 1. Review the medical record for the history of the ulcer/injury admitted to the facility without a pressure ulcer/injury. During the stay .develops . pressure ulcer. This is a facility acquired pressure ulcer and was not present on admission.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services to ensure resident's abilities in activities of daily living was provided for two of eight residents (Residents 77 and 123) reviewed for position and mobility, when: 1. For Resident 77, the physician's order for Speech Therapy evaluation (an assessment to evaluate a resident's ability to swallow) was not carried out. 2. For Resident 123, the physician's order for a brace (a material used to support, align, or hold a bodily part in the correct position) for the right-hand contracture (a condition of shortening and hardening of muscle, tendons, or other tissues, often leading to deformity of joints) was not carried out. These failures had the potential to delay treatment for Resident 77 and 123, which could hinder them to maintain or improve their ability to carry out the activities of daily living. Findings: 1. During a review of Resident 77's clinical record, the Resident Face Sheet (contains demographic and medical information), indicated Resident 77 was admitted to the facility on [DATE], with diagnoses which included gastrostomy status (a surgical operation for making an opening in the stomach), quadriplegia (partial or complete paralysis of both arms and legs) and dysphagia (difficulty swallowing). During a concurrent observation and interview, on February 7, 2023, at 10:10 A.M., inside Resident 77's room, Resident 77 was lying in bed, watching television. Resident 77 had a gastrostomy tube (G-tube - a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) attached to his stomach. He stated was able to eat through his mouth before he was transferred to the hospital. He further stated when he returned to the facility, he could only receive nutrition via the G-tube, and not by mouth. During a review of Resident 77's Physician Order, dated February 2, 2023, it indicated Resident 77 had an order for ST [Speech Therapy] eval [evaluation] to return to PO [by mouth]. During a concurrent interview and record review with the Director of Rehabilitation (DOR), on February 10, 2023, at 10:30 A.M., the DOR reviewed Resident 77's health records, and was not able to find documented evidence to indicate a ST eval had been conducted to Resident 77. The DOR stated, I was not aware of the ST eval order. The DOR further stated the order was not followed up and conducted. During a concurrent interview and record review, with the DOR, on February 10, 2023, at 2:47 P.M., the DOR reviewed a facility document titled Job Description for Director of Rehabilitation, dated March 10, 2014, which indicated, Essential Functions . Perform initial patient evaluations and evaluates response to treatment interventions . Develops and manages the rehabilitation department that includes workstation inspections and assessment. The DOR stated her job description was not followed when Resident 77's ST evaluation was not done. 46709 2. During a review of Resident 123's Face Sheet, it indicated Resident 123 was admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis (degenerative joint disease) and muscle weakness. During a review of Resident 123's physician's order, dated January 17, 2023, it indicated Brace for Right hand contractures, PT/OT [physical therapy/occupational therapy] to evaluate for R [right] hand brace. During a review of Resident 123's care plan for Potential/Actual Alteration in Mobility, dated August 10, 2022, it indicated .Goal: . Resident will maintain/ improve functional mobility as long as possible within limitations of medical conditions . Approaches: . ROM [range of motion] during care; . Encourage participation with ADLS [activities of daily living]; . PT/OT/ST [physical therapy/occupational therapy/speech therapy] as needed . During a concurrent observation and interview, on February 10, 2023, at 7:55 AM, in Resident 123's room, Resident 123 was lying on her bed. She was not wearing a brace on her right hand. Resident 123 stated she does not have a brace, although she knows about the order since her physician told her about it. During an interview with the DOR, on February 10, 2023, at 9:52 AM, the DOR stated she just learned about the order for Resident 123's hand brace. (24 days after it was ordered). The DOR further stated there was a miscommunication between nursing and rehabilitation department for this order. The DOR stated We [Rehabilitation Department] missed this evaluation. During a concurrent interview and record review, with the DOR, on February 10, 2023, at 2:48 P.M., the DOR reviewed and acknowledged a facility document titled Job Description for Director of Rehabilitation, dated March 10, 2014, which indicated .Essential Functions: . Communicate with the referring physician and other professionals regarding patient's treatment program . Maintain progress notes and treatment plans on patients' treatments or referrals .

Based on observation, interview, and record review, the facility failed to ensure a safe environment was maintained for three of nine residents (Residents 34, 112, and 104) reviewed for accidents, when: 1. There was no oxygen sign posted outside Resident 34's room. (Resident 34 had an order to receive oxygen therapy.) 2. There was no oxygen sign posted outside Resident 112's room. (Resident 112 had an order to receive oxygen therapy.) 3. The facility's own smoking policy was not implemented for Resident 104, who was a smoker. These failures have the potential to increase the risk of injuries, which could threaten the welfare, health, and safety of Residents 34, 104, and 112. Findings: 1. During a review of Resident 34's clinical record, the Resident Face Sheet (contains demographic and medical information) indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (increased blood sugar level), heart failure (heart muscle doesn't pump blood as well as it should), and cardiomyopathy (enlarged heart). During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 4), on February 7, 2023, at 10:00 AM, Resident 34 was lying in bed. An oxygen concentrator [machine that delivers oxygen], with a transparent bag containing the nasal canula (tube used to deliver oxygen) tubing, was at the right side of his bed. There was no No Smoking/ Oxygen in Use sign posted outside Resident 34's room. LVN 4 stated there should have been a sign. During a concurrent interview and record review with the Director of Nursing (DON), on February 9, 2023, at 12:57 PM, the DON reviewed and acknowledged Resident 34's Physician Order, dated October 20, 2022, which indicated, .OXYGEN AT 2 L [liters- unit of measurement]/ MIN [minute] VIA NC [nasal canula] CONTINUOUSLY TO KEEP 02 [oxygen] SATURATION [Sat-level of absorption] > [greater than] 92% .Special instructions: INDICATION: .MAY TITRATE TO MAINTAIN 02 SAT < [below]92 % . The DON stated there should have been a No Smoking/ Oxygen in Use sign posted outside Resident 34's room. A review of the facility's policy and procedure titled, Oxygen Administration dated March 2017, indicated, .The following equipment and supplies are necessary when performing this procedure .No Smoking/ Oxygen in Use signs . 2. During a review of Resident 112's clinical record, the Resident Face Sheet indicated Resident 112 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease that causes obstructed airflow from the lungs), heart failure, and diabetes mellitus. During a concurrent observation and interview with LVN 4, on February 7, 2023, at 10:30 AM, Resident 112 was lying in bed, and was receiving oxygen therapy. There was no No Smoking/ Oxygen in Use sign posted outside Resident 112's room. LVN 4 stated they should have placed a No Smoking/ Oxygen in Use sign. During a concurrent interview and record review with the DON, on February 9, 2023, at 12:58 PM, the DON reviewed and acknowledged Resident 112's Physician Order, dated December 13, 2022, which indicated, .Oxygen at 2 L/MIN via NC PRN [as needed] to keep O2 Saturation > 92%. The DON stated there should had been a No Smoking/ Oxygen in Use sign outside Resident 112's room. A review of the facility's policy and procedure titled, Oxygen Administration dated March 2017, indicated, .The following equipment and supplies are necessary when performing this procedure .No Smoking/ Oxygen in Use signs . 43587 3. During a review of Resident 104's clinical record, the Resident Face Sheet indicated Resident 104 was admitted to the facility on [DATE], with diagnoses which included hepatic failure (damaged liver), anxiety disorder (feelings of fear, dread and uneasiness) and depression (persistent feelings of sadness and loss of interest). During a concurrent observation and interview, on February 7, 2023, at 11:10 A.M., inside Resident 104's room, Resident 104 was sitting on his wheelchair. He stated he was going to the smoking patio. He further stated he has been a smoker for [AGE] years. During a review of a facility provided document titled Smokers List, it indicated Resident 104 was an active smoker. During a concurrent interview and review of Resident 104's clinical records with the Registered Nurse (RN 1), on February 10, 2023, at 11:29 A.M., the RN 1 reviewed Resident 104's Smoking Screening, dated October 31, 2022, which indicated Resident 104 was a Non-smoker. RN 1 stated it was wrong because Resident 104 was an active smoker. RN 1 was not able to find documented evidence that a Smoking Safety Assessment [to determine the level of supervision needed while smoking], Care Plan ([to address resident's needs] and Smoking Contract [agreement between resident and facility to comply with smoking policies] was initiated and completed for Resident 104. During a concurrent interview and record review, with the DON, on February 10, 2023, at 11:49 A.M., the DON reviewed the facility's policy and procedure (P&P) titled, Smoking Policy, dated January 2017, and stated the policy was not followed. During a review of the facility's P&P titled, Smoking Policy, dated January 2017, it indicated, Smoking Safety Assessment . 1. All residents who want to smoke will be assessed to determine their level of supervision . a. Smoking Safety Assessment should be completed as soon as possible but within the first seven days of admission for residents who smoke/use tobacco products . b. Smoking Safety Assessment will be updated quarterly and as needed . c. A plan of care will be developed to address each resident's need and level of supervision . Smoking Contract . A. A Smoking Contract shall be developed and serve as an agreement between the resident and the facility .

Based on staff interviews, and record reviews, the facility failed to ensure that one of three sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice when: The facility did not follow up on a stat (without delay) x-ray results and did not notify results of the stat x-ray to the physician timely, after Resident 1 fell off the bed while care was being provided and complained of pain on her left side. This failure resulted in Resident 1 sustaining a displaced humeral neck fracture (a break in the bone where the upper arm connects the shoulder) and a delay in treatment due to not following up on a stat x-ray, which could have resulted in damaged joints, bones, prolonged pain, and other complications. Findings During a review of Resident 1's Face Sheet, dated November 1, 2021, (current admission), with an original admitted [DATE], indicated Resident 1 was a [AGE] year-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Brief Interview for Mental Status, dated September 8, 2021, indicated a score of zero (severely impaired). During a review of Resident 1's Nurses Notes, dated November 12, 2021, at 1:30 PM, indicated, when the charge nurse returned from her lunch break, she was informed that while a certified nursing assistant (CNA 1) was providing care to Resident 1, and she had the bed elevated for proper body alignment. The CNA 1 reported she was reaching for wipes at the bedside when Resident 1 grabbed the bed rail with her right arm and slid off of the low air-loss mattress onto the floor on the left side of the bed. The Registered Nurse (RN 1) was called and assessed the resident who complained of mild pain on her left side. The licensed nurse notified the physician and orders were received for a stat x-ray of left shoulder, arm, pelvis, and knee. The resident was medicated with Tylenol (medication used for pain) due to complaint of mild pain. During a review of Resident 1's Nurses Notes, dated November 12, 2021, at 3:30 PM, the notes indicated the off-going nurse endorsed to the oncoming nurse that Resident 1 would be having a stat x-ray to her left side due to a fall and the off-going nurse was endorsed to follow up with the results. A continued review of Resident 1's radiology (x-ray) report date of service November 12, 2021, at 5:47 PM, indicated Resident 1 had a displaced humeral neck fracture (a broken bone in the upper arm). During a review of Resident 1's Nurses Notes, dated November 12, 2021, there was no documented evidence to show there had been follow up notification of the stat x-ray results to the physician by the evening shift (3 PM - 11:30 PM) or by the night shift nurse (11 PM - 7:30 AM). During a continued review of Resident 1's Nurses Notes, dated November 13, 2021, at 7:30 AM, indicated During endorsement with night shift nurse, charge nurse asked night shift nurse if x-ray results were received and reported. Night shift nurse reported not being endorsed of x-ray orders. This note also indicated the day shift nurse viewed the x-ray results which showed a displaced humeral neck fracture to the left upper extremity. The Medical doctor was notified, and an order was received to transfer Resident 1 via non-emergency ambulance to the hospital for further evaluation. Resident 1 was transferred to the general acute care hospital due to the x-ray results. During an interview on November 18, 2021, at 11:04 AM, with the Licensed Vocational Nurse (LVN 1), the LVN 1 stated Resident 1 fell on her left side, was in pain and that is why x-rays were done around 4:30 PM, when the radiology person came to do x-rays. LVN 1 said she endorsed to the oncoming nurse and Resident 1 was not transported until the next morning when LVN 1 came back. LVN 1 said the x-rays results should have been followed up on and she let supervisor know that the x-ray report was not followed up on. During a concurrent interview and record review, on November 18, 2021, at 2:10 PM, with the Administrator, Resident 1's Nurses Notes dated November 12, 2021, were reviewed. The nurse's notes indicated there was no follow up on stat x-rays on the evening or night shift. The Administrator confirmed she did not see any nurses' notes to show the nurses had followed up on x-ray reports until November 13, 2021, in the morning time. The Administrator stated the nurses should have followed up on the stat x-ray reports. During a concurrent interview and record review, on November 18, 2021, at 2:15 PM, with the Director of Nursing (DON), Resident 1's Nurses Notes dated November 12, 2021, were reviewed. The nurse's notes indicated there was no follow up on stat x-rays on the evening or night shift. The DON went through the nurses notes and stated there was no follow-on the stat x-ray for Resident 1 from the evening or the night shift. The DON stated he expected the charge nurses to follow up on stat x-ray results. He stated the nurses should have called the radiology company to follow up on stat orders. During an interview on November 18, 2021, at 4:07 PM, with the Licensed Vocational Nurse (LVN 2), LVN 2 who worked evening shift with Resident 1 stated she was aware of the stat x-ray orders, and she should have followed up on it. LVN 2 stated, I should have made a call to the diagnostic company and should have followed up on it. LVN 2 also confirmed that in her nurses notes she had not followed up on the stat x-ray orders. During an interview on November 18, 2021, at 5:41 PM, with the Licensed Vocational Nurse (LVN 3), the LVN 3 stated she stayed and did a double shift that night but was not endorsed anything about the stat x-ray. During an interview on November 18, 2021, at 5:45 PM, with the Administrator, she stated LVN 3 was not aware of stat x-ray orders because the report was endorsed to the wrong nurse. LVN 3 was asked to stay at the last minute as it was reported to the other night nurse. During an interview on November 18, 2021, at 12:30 PM, with the Certified Nursing Assistant (CNA 1), CNA 1 stated I did not know Resident 1 was a fall risk because there was no star sign on top of her bed, was also not on the list for residents who were at risk for falls. CNA 1 stated Resident 1 did not have any fall prevention interventions in place, there was no falling star sign. During a review of Resident 1's Fall Risk Evaluation, dated November 1, 2021, indicated a score of 10 and per the fall risk evaluation scoring, a total score of 10 or above represents a high risk for falls. During a review of Resident 1's Care Plan for fall, dated November 1, 2021, indicated, Problem: at risk for fall/injury related to cardiac (heart) medication, hypoglycemic (low blood sugar) medication, poor safety awareness, impaired balance during transition, gait problem such as unsteady gait, even with mobility aid or personal assistance, requires assistance with transfers, cognitive impairment. Goal: Will minimize/eliminate risk for fall/injury daily. Approach: Keep room well lighted and environment ordered and consistent. Maintain bed in the lowest/locked position and ensure chair brakes are applied during transfers in and out of bed/chair. Assess for side effects from medications, labs, diet as cause of fall . The care plan was updated, and handwritten to include bilateral floor mats on November 12, 2021, as an approach, following her fall. The facility's policy titled, Fall risk & prevention of injury to include pathological fractures, revised in March 2019, indicated, Policy: It is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. This includes minimizing risks for pathological fractures. Procedure: If the fall risk assessment score is ten (10) or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls, including falls with serious injury. Approaches to prevent falls and/or fractures may include: Use of a colored ID band to identify that the residents has been placed on the falling star program to alert staff that the resident has been assessed at high risk for falls. The facility's policy titled, Laboratory, Radiology and Other Diagnostic Services, revised in January 2017, indicated, Policy: It is the policy of the facility to obtain laboratory, radiology, and other diagnostic services to meet the needs of the residents. The facility is responsible for the quality and timeliness of the services. Procedure: The facility will promptly notify the ordering physician, physician assistant or nurse practitioner of the laboratory, radiology and other diagnostic results that fall outside of clinical reference ranges or per the ordering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to ensure a plan of care for one of 24 sampled residents (Resident 17) was develop to address the resident's diagnosis (finding out the cause of an illness) of depression. This failure resulted in the resident's decline in medical and psychological (a person's mental function) status such as continued depressed behavior of refusing treatment and care and refusing to eat. Findings: On November 19, 2014, at 2:25 PM, Resident 17 was observed up in wheelchair at bedside, alert and able to answer questions. Resident 17 was vomiting clear secretions into a plastic kidney shaped basin. During communication with the resident, Resident 17 stated she had been refusing breakfast, and her medications before going to [MEDICAL TREATMENT] (the use of a machine to remove waste from the blood) treatment. Resident 17 stated she was not feeling well and everyday she felt nauseated, congested and could hardly breath. Resident 17 stated she had been having pain on her left leg stump especially at night ([MEDICAL CONDITION] site) and she had [MEDICAL CONDITION] on both legs due to her diabetes (high blood sugar). Resident 17 was blind and had been receiving [MEDICAL TREATMENT] treatment three times a week from an outside [MEDICAL TREATMENT] clinic. A review of Resident 17's medical record on November 20, 2014 indicated the resident had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The resident's current minimum data set (MDS- a comprehensive assessment of the resident) dated October 9, 2014 indicated Resident 17's [DIAGNOSES REDACTED]. The psychosocial (a person's mental function and behavior as it relates/interact with society) assessment dated [DATE] indicated Resident 17's identified problems and psychosocial needs included manifestations of anxiety (verbalization of being anxious) and depression (verbalization of feeling depressed) related to 'terminal condition.' A review of the Certified Nursing Assistant (CNA) flowsheet records for November 2014 indicated Resident 17 had refused breakfast multiple times including lunch, dinner and food substitutes offered from November 9, 2014- present (November 20, 2014). The Medication Administration Record [REDACTED] . [MEDICATION NAME] (drug used to bind and decrease phosphorus from food taken)- refused 15 times. . Amlodepine (drug used to treat/lower high blood pressure)- refused 2 times. . [MEDICATION NAME] (drug used to treat/lower high blood pressure) refused once. . [MEDICATION NAME] (drug used to treat/control stomach acid)- refused once. . [MEDICATION NAME] ointment (drug used to treat chest/heart pain)- refused once. . [MEDICATION NAME] (drug used to control stomach acid)- refused once. . Folic Acid (a nutritional supplement)- refused once. The documented reasons of the resident's refusal included, "due to not eating breakfast; vomiting; and "I don't want to take it." A review of the resident's laboratory (lab) test results showed Resident 17's nutritional status had declined due to resident's non-compliance to care and treatment as evidenced by a gradual decline of the resident's blood [MEDICATION NAME] (a blood protein) level from 2.7 grams per deciliter (g/dL) on September 2, 2014; 2.4 g/dL on October 7, 2014; and 2.2 g/dL on November 11, 2014. (According to 'Lab Test On-line, 2001- 2014, by the American Association of Clinical Chemistry', the normal reference range for [MEDICATION NAME] is 3.5- 5.0 g/dL, and that low blood [MEDICATION NAME] level can be caused by malnutrition, gastrointestinal {refers to the stomach and intestines (gut)} disorders or long standing dehydration (abnormal loss of body fluid). The nurses' notes dated November 12- 20, 2014 noted Resident 17 was on a 'Fluid Restriction' program of 1500 cubic centimeters (cc) for 24 hours and could not be monitored due to "She wants her bottled water and juice always with her." The nurses' notes further indicated the resident's attending physician had been notified of the continued abnormally low [MEDICATION NAME] levels and resident's continued refusal to take prescribed medications with instruction given (by the physician) to "just continue to monitor" (the resident's refusal to take medications) and to change the diet to a high protein diet. There was no documentation to indicate the physician had been notified and aware of Resident 17's behavior of refusing to eat breakfast, lunch and dinner, and the inability of the staff to monitor the resident's fluid intake restrictions until November 20, 2014. The intake and output (I & O- Intake: include fluids taken by mouth and intravenous (thru the blood vessel; Output: include urine, emesis (vomit) and diarrhea) records for November 2014 did not include weekly evaluation (per facility guidelines) of the resident's fluid intake and output (such as the resident's average fluid intake and output) to determine whether or not the resident was meeting the 1500 cc fluid restriction. There was no documentation in the I & O record of the resident's episodes of vomiting as part of the resident's output, even though the Medication Administration Record [REDACTED]. A review of the resident comprehensive nursing care plan dated November 7- 11, 2014 showed there was no plan of care developed to address Resident 17's depression including non-compliance to care and treatment such as refusing to take prescribed medications and to eat and/or drink prescribed food and fluids. There was no documentation to indicate Resident 17 was referred for psychological and/or psychiatric evaluation and treatment (such as anti-depressant and/or anti-anxiety drug therapy). In an interview with the Registered Nurse (RN) Supervisor 1 (RNS 1)on November 20, 2014 at 9:20 AM regarding the resident's plan of care, she was asked if the interdisciplinary team (IDT- includes the RN, physician, social services designee (SSD), dietician, activity staff, and the resident) had developed a plan of care to address Resident 17's depression and non-compliance to care and treatment. RNS 1 reviewed the resident's medical record and was unable to find documentation of a plan of care that addressed the resident's depression and non-compliance to care and treatment. RNS 1 acknowledged there was no plan of care developed to address Resident 17's [MEDICAL CONDITION] including non-compliance to care and treatment. A review of the policy and procedure titled, "Psychosocial Assessment" provided by the facility reflected the following: "A psychosocial assessment must be conducted to assist in identifying (the) resident's personal and psychosocial needs which impact the Resident's Plan of Care... Pertinent medical [DIAGNOSES REDACTED]. (mood/behavior and psychosocial part of the) comprehensive care plan."