Every finding on record at Dinuba Healthcare

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1)'s care plan was implemented after a fall incident. This failure had the potential for Resident 1 to experience subsequent falls.Findings:During a review of Resident 1's IDT (interdisciplinary team-group of professionals who work together to provide comprehensive, patient-centered care)-Post Fall Review (IDTPFR) dated 2/3/26, the IDTPFR indicated, 2/3/2026 1:50 p.m. fall was unwitnessed.Approx (approximately) 1347 (1:47 p.m.) writer heard shouting from staff member that resident is found on the floor, noted to be bleeding.upon arrival residentis [sic] laying on right side in cradle positioning.Indicate all intervention recommendations and IDT Referrals.nonskid tape (adhesive tape with a textured, abrasive surface designed to increase traction and prevent slips and falls on slippery or hazardous surfaces) at bedside.During a review of Resident 1's Care Plan (CP) dated 2/4/26, the CP indicated, The resident is at risk for falls related to her poor balance.Interventions.nonskid tape at bedside.Date initiated.2/4/2026.During a concurrent observation and interview on 2/9/26 at 11:43 a.m., with Director of Nursing (DON), in Resident 1's room, Resident 1 was lying on the bed covered with a blanket. There was no nonskid tape at the bedside. DON stated the nonskid tape should have been placed at the bedside right away.During a review of the facility policy and procedure (P&P) titled Developing and Implementing Care Plans with the Interdisciplinary Team undated, the P&P indicated, Interventions.These are the specific actions or services that each discipline will provide to help the resident meet their goals.

Based on interview and record review, the facility failed to:Ensure their Advance Directive (legal document that specifies a person's medical care and end of life wishes, should the person become unable to communicate those wishes) questionnaire contained all the necessary regulatory requirements for five of eleven sampled residents (Resident 1, Resident 10, Resident 8, Resident 76, and Resident 3). 2.Ensure one of 22 sampled residents (Resident 13) had a signed and dated Advance Directive. These failures had the potential for residents' rights to formulate an advanced directive and for medical care wishes and/or end of life issues to not be honored.Findings: 1.During a record review on 1/6/26 at 2:26 p.m., Resident 1's Advance Directive Questionnaire (ADQ) was reviewed. The ADQ did not have a question that asked if Resident 1 wanted more information on how to execute an advance directive. During a record review on 1/6/26 at 2:34 p.m. Resident 10's ADQ was reviewed. The ADQ did not have a question that asked if Resident 10 wanted more information on how to execute an advance directive. During a record review on 1/6/26 at 2:37 p.m. Resident 8's ADQ was reviewed. The ADQ did not have a question that asked if Resident 8 wanted more information on how to execute an advance directive. During a record review on 1/6/26 at 2:45 p.m. Resident 76's ADQ was reviewed. The ADQ did not have a question that asked if Resident 76 wanted more information on how to execute an advance directive. During a record review on 1/6/26 at 3 p.m. Resident 3's ADQ was reviewed. The ADQ did not have a question that asked if Resident 3 wanted more information on how to execute an advance directive. During a concurrent interview and record review, on 1/7/26 at 9:58 a.m. with the Director of Nursing (DON), Resident 1's ADQ was reviewed. The ADQ indicated Resident 1 did not have an advance directive. DON stated ADQ did not ask if Resident 1 wanted information on how to execute an advance directive. During a concurrent interview and record review, on 1/7/26 at 10:01 a.m. with the DON, Resident 76's ADQ was reviewed. The ADQ indicated Resident 76 did not have an advance directive. DON stated ADQ did not ask if Resident 76 wanted information on how to execute an advance directive. During a concurrent interview and record review, on 1/7/26 at 10:05 a.m. with the DON, Resident 10's ADQ was reviewed. The ADQ indicated Resident 10 did not have an advance directive. DON stated ADQ did not ask if Resident 10 wanted information on how to execute an advance directive. During a concurrent interview and record review, on 1/7/26 at 10:08 a.m. with the DON, Resident 8's ADQ was reviewed. The ADQ indicated Resident 8 did not have an advance directive. DON stated ADQ did not ask if Resident 8 wanted information on how to execute an advance directive. During a concurrent interview and record review, on 1/7/26 at 10:11 a.m. with the DON, Resident 3's ADQ was reviewed. The ADQ indicated Resident 3 did not have an advance directive. DON stated ADQ did not ask if Resident 3 wanted information on how to execute an advance directive. 2. During a concurrent interview and record review on 1/6/26 at 2:40 p.m. with DON, Resident 13's Medical Record (MR) was reviewed. DON stated Resident 13 was admitted on [DATE] and there was no ADQ in Resident 13's MR. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment.Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representatives, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is a provided in a manner that is easily understood by the resident or representative.

Based on interview and record review, the facility failed to:Complete a care plan for smoking for one of one sampled resident (Resident 76). 2. Ensure a smoking assessment was available to facility staff. 3. Conduct an Interdisciplinary Team (IDT- various healthcare staff meet to share information and updates, collaborate to solve problems, and develop and update the resident's care plan) meeting that included Resident 76's smoking. These failures had the potential to jeopardize Resident 76's safety.Findings:1.During a concurrent observation and interview on 1/6/26 at 10:08 a.m. with Resident 76, in her room, Resident 76 stated a hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) aide took her outside to smoke three times a week. Resident 76 was unable to stop moving both of her arms in a shaking, tremor (uncontrolled movement) -like manor. Resident 76 stated she does not have Parkinson's (disease which causes involuntary tremors of body parts). Resident 76 stated her tremors were caused by too much chemotherapy (cancer treatment) . Resident 76 stated she smoked two cigarettes each time she was taken outside to smoke.During a concurrent interview and record review on 1/7/26 at 10:17 a.m. with Director of Nursing (DON), DON stated Resident 76 is on hospice care and is the only resident in the facility who had smoking privileges. DON stated the facility does not participate in any of Resident 76's smoking activities and that Resident 76's smoking activities are handled through the hospice agency contracted for her hospice care. Resident 76's facility care plan was reviewed, and DON was unable to find a care plan for smoking. 2. During a concurrent interview and record review on 1/7/26 at 10:17 a.m. with DON, Resident 76's hospice care binder was reviewed, and no smoking assessment was found. DON stated there was no smoking assessment in the binder. DON spoke with hospice agency and agency stated the completed smoking assessment would be sent to DON.During a concurrent interview and record review on 1/7/26 at 4:22 p.m. with DON, DON provided a copy of Resident 76's admission Smoking Assessment dated 10/16/25. DON stated the assessment had not been sent to them prior than today. 3. During a concurrent interview and record review on 1/7/26 at 10:57 a.m. with DON, Resident 76's Medical Record (MR) was reviewed. DON was unable to find IDT notes that addressed Resident 76's smoking. DON stated Resident 76's smoking should have been care planned by the facility and addressed in an IDT meeting. DON stated a smoking assessment should have been available to facility staff regardless of who completed the assessment. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 4/2012, the P&P indicated, This facility shall establish and maintain safe resident smoking practices. 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, (undated), the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure the safe administration of medications when:1. IV (Intravenous- method of delivering fluids, medicine or nutrition directly into a vein) Emergency Infusion Supply (E-kit- basic supplies for IV access, fluids, and antibiotics) was expired.2. Discontinued narcotics (a drug or substance that affects mood or behavior) were not stored safety.3. Medication was left unattended on top of the medication cart.These failures had the potential for medications to be administered incorrectly and unsafely.Findings:During a concurrent observation and interview on [DATE] at 3:10 p.m. with Assistant Director of Nursing (ADON), in medication storage cabinet in the hallway, there was an expired e-kit dated [DATE]. Upon reviewing the e-kit medications the following medications were expired:D5W (sterile IV solution contains 5% sugar in normal saline) 1000 ML (milliliters- unit of measure) expired on [DATE].NACL (sodium chloride 0.9%) 250 ML expired on [DATE].NACL 0.9% 1000ML expired on [DATE].NACL 0.45% 1000ML expired on [DATE].NACL 0.9% 100ML expired on [DATE].D5W-1/2 NS (normal saline) 20 meq (milliequivalent- unit of measure) Potassium (supplement) 1000 ml expired on [DATE].Ceftriaxone (to treat and prevent infection) 1 GM (gram) expired on [DATE].Vancomycin (to treat and prevent infection) 1GM expired on [DATE].Heparin Lock (method for keeping an IV open and flowing) 10U (unit) /ML 5 ml prefilled expired on [DATE].SOD CHL (sodium chloride) 0.9% 10ml prefilled syringe expired on [DATE].SOD CHL 0.9% 100ml expired on [DATE].ADON stated e-kit was expired on [DATE].During an interview on [DATE] at 3:40 p.m. with Pharmacist 1, Pharmacist 1 stated the facility should contact the pharmacy when the e-kit is close to expiring or when the e-kit was opened for any reason. Pharmacist 1 stated pharmacy never received any requests to replace the e-kit.2. During a concurrent observation and interview on [DATE] at 11 a.m. with Director of Nursing (DON), the facility's discontinued narcotic medications were reviewed. Narcotic medications were stored in DON's office in single lock drawer. DON stated the lock of the door to her office was the second lock. DON stated she and ADON were the only two people who had access to the office. DON stated the office door was always closed when nobody was in the office.During a concurrent observation and interview on [DATE] at 3:55 p.m. with ADON, DON's office door was open and there was no one present in the office. ADON stated the DON just stepped out of office. ADON stated there is no second lock for narcotics.3. During a concurrent observation and interview on [DATE] at 8:47 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 removed a Pro Stat (liquid protein for wound healing) bottle and placed it on top of the medication cart. LVN 1 then locked the medication cart and went into Resident 2's room. LVN 1 stated she should not have left the medication unattended and should have put the Pro Stat into the locked medication cart before walking away.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 11/2020, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart.

Based on observation, interview, and record review, the facility failed to ensure food was served according to the facility's policy and procedure for two of two sampled residents (Resident 84 and Resident 92). These failures had the potential to result in food borne illness to Resident 84 and Resident 92.Findings:During an observation on 1/5/26 at 12:24 pm, in the B-Wing hallway rehab dining room. Two residents' meal trays were seen on bed side tables, no staff or residents were present in the rehab dining room. The meal tray identification tickets indicated one of the meal trays belonged to Resident 84 and the second meal tray belonged to Resident 92.During a concurrent observation and interview on 1/5/26 at 12:27 pm, with Restorative Nurse Aide (RNA) 1, RNA 1 stated she had just taken a resident back to their room. RNA 1 stated, These two trays belonged to residents in their bedrooms, and I'm going to take them [resident meal trays] to them.During a concurrent observation and interview on 1/5/26 at 12:27 pm, with Dietary Manager (DM) 1, DM 1 arrived at the rehab dining room where the two resident meal trays were. DM 1 used a facility thermometer to check the temperatures of Resident 92's meal tray. The temperature of the pureed meat on the meal tray was 120 degrees Fahrenheit (F-unit of measuring temperature).During a review of the facility policy and procedure (P&P), titled Proper Temperatures for All Meals and Services, dated 2018, the P&P indicated, Holding Temperatures (Minimum Acceptable) . Ground Beef, Pork 140 F. Vegetables 140 F.

Based on observation, interview, and record review, the facility failed to ensure one of one Oxygen e-tank (highly flammable, compressed gas cylinder) was transported in a safe and secure manner by staff. This failure had the potential to result in injury and death to residents, staff, and visitors.Findings:During an observation on 1/5/26 at 12:47 pm, on the B-wing hallway, Certified Nurse Assistant (CNA ) 1 was seen walking down the hallway carrying an Oxygen e-tank by the straps of the fabric wheelchair Oxygen e-tank holder.During a concurrent observation and interview on 1/5/26, at 12:48 pm, with CNA 1 and Social Service Director (SSD), CNA 1 stated, We have a metal stand we use [to transport oxygen e-tanks]. SSD stated, Both residents [present in the hallway at the time] were dependent assistance, and were unable to ambulate without assistive device [unable to move without staff assistance in the event of an emergency].During a review of the facility policy and procedure (P&P) titled Oxygen Administration,(undated), the P&P indicated, Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand).

Based on observation, interview, and recorded review, the facility failed to follow its policy and procedure (P & P) titled, Assistance with Meals, for three of four sampled Residents (Resident 11, Resident 32, Resident 22) when the Certified Nursing Assistant's (CNA)'s was standing while assisting Resident 11, Resident 32, and Resident 22 during lunch meal. This failure had the potential for Resident 11, Resident 32, and Resident 22 to negatively impact their dignity while being assisted with meals.Findings:During an interview on 1/5/26 at 12:25 p.m. with CNA 3, CNA 3 stated there was usually two staff members assisting in the dining room. CNA 3 stated today she was the only one assisting in the dining room. During an observation on 1/5/26 at 12:37 p.m. in the dining room, CNA 3 was standing over Resident 32 while assisting her with feeding.During an observation on 1/6/26 at 12:33 p.m. in the dining room, CNA 4 placed a spoonful of pureed food into Resident 22's mouth while standing over her.During an interview on 1/7/26 at 1:41 p.m. with CNA 5, CNA 5 stated the process for assisting residents with feeding was to get a chair, sit, and sanitize hands between each resident.During an interview on 1/7/26 at 1:44 p.m. with CNA 4, CNA 4 stated CNA's are to be sitting when feeding a resident.During a concurrent interview and record review on 1/7/26 at 2:15 p.m. with Assistant Director of Nursing (ADON), the facility's P&P titled, Assistance with Meals, dated 3/2022 was reviewed. The P&P indicated, 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a not standing over residents while assisting them with meals. ADON stated she expected her staff not to stand over the residents while feeding.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- resident assessment tool) assessment was accurate for one of five sampled residents (Resident 76). This failure resulted in an inaccurate medical record.Findings:During an interview on 1/6/26 at 10:08 a.m. with Resident 76, Resident 76 stated a hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) aide took her outside to smoke three times a week. Resident 76 stated she smoked two cigarettes each time she was taken outside to smoke.During an interview on 1/7/26 at 10:17 a.m. with Director of Nursing (DON), DON stated Resident 76 is on hospice care and is the only resident in the facility who has smoking privileges. During a concurrent interview and record review on 1/7/26 at 11:11 a.m. with DON, Resident 76's MDS was reviewed. MDS Section J- Health Conditions question J1300, dated 11/20/25 was reviewed. Question J1300 indicated, Current Tobacco Use. No. DON stated the tobacco use MDS assessment was inaccurate.

Based on observation, interview, and record review, the facility failed to ensure communication services were available for one of 22 sampled residents (Resident 58) who did not speak English. This failure had the potential for Resident 58's needs go unmet.Findings:During a concurrent observation and interview on 1/5/26 at 10:30 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 58's room, Resident 58 was speaking in her native language. CNA 2 stated Resident 58 speaks [NAME] (language spoken in [NAME]). CNA 2 stated there was no communication board or any picture board to know what Resident 58 was saying. CNA 2 stated she did not speak [NAME]. During an interview on 1/6/26 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not aware of any translation services offered by the facility. LVN 1 stated one staff member, Registered Nurse (RN) 1, spoke [NAME] and could communicate with Resident 58, when she was working. During a review of the facility's current January schedule, RN 1 was scheduled on January 1,2,3,4,13,14,15,20,21,22,25,26,27,28, and 31.During an interview on 1/6/26 at 3:20 p.m. with Activities Director (AD), AD stated Resident 58 does not speak English. AD stated staff use internet search engine to translate to speak to Resident 58. AD stated she was only aware of two words to communicate with Resident 58.During a review of Resident 58's Minimum Data Set (MDS-Resident Assessment Tool) Section A, dated 10/30/25, the MDS indicated, Language A. What is your preferred language? [NAME]. B. Do you need or want an interpreter to communicate with a doctor or health care staff? Yes.During a concurrent interview and record review on 1/7/26 at 4:10 p.m. with Director of Nursing (DON), the Language Scientific, dated 1/6/2026 was reviewed. DON stated language scientific was started on 1/6/26 and there were no translation services prior to 1/6/26.During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, dated 11/2020, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.

Based on interview and record review, the facility failed to ensure an activity assessment and activity care plan was completed for one of five sampled residents (Resident 10). This failure resulted in Resident 10 not having the opportunity to discuss his activity preferences and have his preferences honored. Findings:During an interview on 1/6/26 at 9:07 a.m. with Resident 10, Resident 10 stated he had never been asked if he wanted to participate in any activities. During an interview on 1/6/26 at 9:41 a.m. with Resident 10, Resident 10 stated he cannot voluntarily move his arms or legs due to a motorcycle accident and can only shrug his shoulders.During a concurrent interview and record review on 1/8/26 at 9:36 a.m. with Director of Nursing (DON), Resident 10's medical record (MR) was reviewed. DON stated she was unable to find an activities assessment or activities care plan. DON stated Activities Director (AD) is responsible for completing the activities assessment and activities care plan.During an interview on 1/8/26 at 9:45 a.m. with AD, AD stated she had not completed an activities assessment or activities care plan. During a review of the facilities policy and procedure (P&P), (undated), the P&P indicated, Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. 1. Residents are encouraged to choose the types of recreational, cultural, and religious activities and social events in which they prefer to participate. 2 The Interdisciplinary Care Team will evaluate the individual's personal history and preferences, and will consider his/her medical condition and prognosis in identifying relevant recreational and cultural activities. 3. When the Care Planning Team develops the resident's activity and social care plans, the resident will be given the opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care.

Based on observation, interview, and record review, the facility failed to ensure the transportation for one of five sampled residents (Resident 1) was arranged for a dialysis (a treatment or people whose kidneys are failing, removing waste products and excess fluid from the blood) appointment. This failure resulted in Resident 1 crying waiting for almost five hours (5 p.m. until 9:51 p.m.) waiting for transportation, late medication administration, and potential for adverse health outcomes and emotional distress. Findings: During an observation on 10/18/24 at 2:10 p.m. in Resident 1's room, Resident 1 was lying in bed sleeping with a feeding tube (tube mainly inserted into the stomach to provide route for enteral nutrition) connected, and a floor mat on the floor. During a review of the facility ' s Dialysis Transportation Log (DTL), dated August 22, 2024, the DTL indicated, Resident [1] left the facility at 2:30 p.m. [ to go to a dialysis appointment]. During an interview on 10/1/24 at 2 p.m. with Social Services (SS), SS stated the facility had a problem with the transportation and there was no established communication system for both the dialysis center and the facility. During an interview on 10/1/24 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she noticed Resident 1 was not in the facility at 8 p.m. (three hours overdue to be back to the facility). During an interview on 10/1/24 at 3:30 p.m. with Director of Nursing (DON), DON stated she got a call around 8:15 p.m. (three hours after dialysis) from Resident 1's husband that his wife (Resident 1) had not been picked up yet from the dialysis center to go back to the faiclity. DON stated, The expected time [for dialysis treatment] is 4 hours so she [Resident 1] should have been back around 5 p.m. During an interview on 10/1/24 at 3:43 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 looked tired when Resident 1 arrived at 9:51 p.m. During an interview on 10/1/24 at 3:46 p.m. with LVN 2, LVN 2 stated he had to call the physician to notify Resident 1's medication and feeding through the feeding tube was going to be administered late. During an interview on 10/03/24 at 10:52 a.m. with Dialysis Center Supervisor (DCS), DCS stated she tried to call the facility 12 times over a two-hour time frame. DS stated Resident 1 was emotionally stressed and crying. During a review of the facility ' s policy and procedure (P&P) titled, Transportation, Social Services dated 2008, the P&P indicated, Social services will help the resident as needed to obtain transportation.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure food was palatable, which affected 3 (Residents #6, #8, and #41) of 3 residents reviewed for food concerns and had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, reflected, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it served at a safe and appetizing temperature. Resident Council meeting notes, dated 05/03/2024, revealed the residents complained that Food is too tough and dry. Resident Council meeting notes, dated 06/07/2024, revealed the residents complained that Food is always cold, food has no taste, and Food is too dry. During an interview on 07/15/2024 at 12:14 PM, Resident #41 said the food at the facility was awful. According to an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview on 07/15/2024 at 2:40 PM, Resident #6 said the food at the facility was not good, and the meat was tough. According to a quarterly MDS, with an ARD of 05/04/2024, Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact. During an interview on 07/15/2024 at 3:55 PM, Resident #8 said the food at the facility was not good. According to a quarterly MDS, with an ARD of 05/08/2024, Resident #8 had a BIMS score of 13, which indicated the resident was cognitively intact. During an observation of the lunch meal service on 07/16/2024, a test tray was requested. The test tray was prepared and placed on a meal service cart at 11:56 AM. The test tray consisted of chicken, rice, and beets. The meal service cart left the kitchen at 12:00 PM, arrived on the unit at 12:02 PM, and staff began passing the trays at 12:03 PM. The last resident was served at 12:15 PM. At 12:25 PM, the meal tray was tested with the Dietary Supervisor. The Dietary Supervisor described the chicken as dry and said the rice had no flavor. During a follow-up interview on 07/16/2024 at 12:56 PM, Resident #41 stated the chicken was dry, and the rice did not have a taste. During a follow-up interview on 07/16/2024 at 12:57 PM, Resident #6 stated the chicken was dry and tasted like sawdust. Resident #6 stated the rice tasted as though staff had not used enough water when preparing it. During a follow-up interview on 07/16/2024 at 2:13 PM, Resident #8 said the chicken was dry and the rice did not have a flavor. During an interview on 07/17/2024 at 9:41 AM, the Dietary Supervisor said the chicken that was served on 07/16/2024 was dry, and the rice was bland. The Dietary Supervisor indicated the cook should have added broth to the chicken to maintain the moisture of the food. During an interview on 07/18/2024 at 9:09 AM, the Administrator said he expected the taste and presentation of the food to be acceptable.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff utilized proper hand hygiene during meal service on 07/16/2024, which had the potential to affect all residents receiving meals from the dietary department, aside from the 12 residents with pureed diet orders, as the pureed trays were served by a different staff member. Findings included: A facility policy titled, Food Preparation and Service, revised in 11/2022, revealed the section of the policy titled, General Guidelines specified, 2. Cross-contamination can occur when harmful substances i.e. [id est, that is], chemical, or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. The section of the policy titled, Food Distribution and Service specified, 5. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents and 7. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. During an observation of the lunch meal service on 07/16/2024 beginning at 11:23 AM, [NAME] #1 used her gloved right hand to open the oven, and then used the same gloved hand to remove a grilled cheese sandwich and place it onto a resident's tray. She did not wash hands or change gloves. At 11:55 AM, [NAME] #1 was again observed using her gloved right hand to open the oven, then used the same gloved hand to place tater tots onto a resident's tray, then continued meal service without changing gloves or washing hands. [NAME] #1 was observed using her gloved right and left hand to pick up chicken breasts and place them on residents' trays. Without washing hands or changing gloves, [NAME] #1 continued using the same gloved hands to place rolls on residents' trays during the remainder of the meal service. During an interview on 07/16/2024 at 12:39 PM, [NAME] #1 said she knew that after touching multiple items, she should have changed her gloves. [NAME] #1 confirmed she did not change her gloves after opening the oven or touching food items with her gloved hands. During an interview on 07/17/2024 at 9:41 AM, the Dietary Supervisor said the cook should have asked her helper to open the oven and remove the food items. The Dietary Supervisor further stated the cook should have changed gloves after opening the oven and should not have touched multiple food items with the same gloved hands. During an interview on 07/18/2024 at 8:41 AM, the Director of Nursing (DON) stated that if dietary staff touched residents' food, they should change gloves. During an interview on 07/18/2024 at 9:17 AM, the Administrator said he expected dietary staff to follow better hand hygiene practices.

Based on record review, interview, and facility policy review, the facility failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) Form 10055 prior to being discharged from Medicare Part A skilled nursing services when residents had not exhausted all of their allotted Medicare days and planned to remain in the facility. The deficiency affected 2 (Resident #57 and Resident #61) of 3 residents reviewed for beneficiary notifications. Findings included: An undated facility policy titled, Medicare Advanced Beneficiary Notice revealed, Residents are informed in advance when changes will occur to their bills. The section titled Policy Interpretation and Implementation, revealed, 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered 'not medically reasonable and necessary', or 'custodial.' 1. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2024, revealed the facility admitted Resident #57 on 08/08/2023. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A SNF Beneficiary Notification Review, completed by facility staff after the survey entrance conference on 07/15/2024, revealed Resident #57's Medicare Part A Skilled Services Episode began on 09/07/2023 and the resident's last covered day of Part A services was 11/24/2023, which left the resident with 21 covered Part A skilled services days remaining. The document indicated that the facility staff did provide the resident a SNF ABN Form CMS-10055. Resident #57's medical record revealed no evidence of a SNF ABN Form CMS-10055 that was signed by the resident or responsible party, or that one was provided to the resident or responsible party. 2. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed the facility admitted Resident #61 on 01/10/2023. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. A Skilled Nursing Facility (SNF) Beneficiary Notification Review, completed by facility staff after the survey entrance conference on 07/15/2024, revealed Resident #61's Medicare Part A Skilled Services Episode began on 03/12/2024 and the resident's last covered day of Part A services was 05/01/2024, which left the resident with 49 covered Part A skilled services days remaining. The document indicated that facility staff did not provide a SNF ABN Form CMS-10055 to the resident. Resident #61's medical record revealed no evidence that indicated a SNF ABN Form CMS-10055 was provided to the resident or responsible party. During an interview on 07/16/2024 at 2:59 PM, the Social Service Director (SSD) stated she provided residents with a Notice of Medicare Non-Coverage (NOMNC) but did not know what the SNF ABN Form CMS-10055 was. She stated she would have to ask her supervisor about the form. During an interview on 07/17/2024 at 1:42 PM, the SSD stated if a resident was discharged from therapy services, then therapy staff would provide the notice of discharge. She stated that she assisted the Director of Rehabilitation Services (DORS) if he needed her to assist. During an interview on 07/17/2024 at 2:45 PM, the DORS stated that therapy staff provided discharge notices if they issued the last covered day of therapy. He stated that he would usually issue the notice of discharge about a week before the planned discharge date , but they definitely issued the notice within three days of discharge, to give himself some time if he could not reach the responsible party or the family. He stated that he provided the NOMNC; that was his standard of practice for all patients whether they were on Part A or Part B, whenever they finished therapy. He stated that he had heard of the SNF ABN Form CMS-10055 before but did not give that form when a resident was discharged . He stated that they issued the SNF ABN Form CMS-10055 when residents were admitted but not upon discharge from therapy services. He did not know when they should be given. He stated that he did not know it was regulatory to issue the SNF ABNs for residents who remained in the facility and had Part A benefit days remaining. During an interview on 07/18/2024 at 9:07 AM, the Director of Nursing (DON) stated if a resident was being discharged from Part A therapy, the DORS was responsible to provide the notices of discharge. She stated that he contacted the responsible parties and talked them through the resident's progress and the reasons for the decision to discharge and provided the NOMNC to the resident or the responsible party. She stated that she had not heard of the SNF ABN Form CMS-10055 prior to this survey. She stated she did not know anything specific about Resident #57's notices. She stated she did expect all notices to be provided as appropriate. During an interview on 07/18/2024 at 10:17 AM, the Administrator stated as far as notifications of a change in payor source when being discharged from Part A Skilled therapy, the NOMNC was provided at least 72 hours prior to the discharge. He stated that he was familiar with the SNF ABN Form CMS-10055; however, the NOMNC had been what they used. He stated that the SNF ABN Form CMS-10055 was not something that they had focused on as a facility, only the NOMNC. He stated that he had reached out to others in their corporation, and it was not something they had been doing as a whole. The Administrator stated that he expected that they provide notices of discharge from Part A skilled services timely and accurately within the appropriate timeframes, and that staff provided all relevant forms as directed by the regulations.

Based on record review, interview, and facility document and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #41 and Resident #63) of 2 residents reviewed for MDS discrepancies. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, reflected, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. An Admission Record revealed the facility admitted Resident # 41 on 08/02/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of schizophrenia. Resident #41's Preadmission and Resident Review (PASRR) Level I Screening, dated 08/03/2021, revealed the resident had a diagnosed mental disorder and received psychotropic medications. The Level I Screening was positive for a suspected serious mental illness (MI), and a Level II evaluation was required. Resident #41's Individual Determination Report, dated 03/24/2022, revealed the resident required nursing facility services due to a medical or mental health condition, and specialized services were recommended. However, an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, revealed Section A1500 was coded to reflect that Resident #41 was not considered to have a serious mental illness by the state Level II PASRR process. An Admission Record revealed the facility admitted Resident # 63 on 11/22/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of schizophrenia. Resident #63's Preadmission and Resident Review (PASRR) Level I Screening, dated 11/23/2022, revealed the resident had a diagnosed mental disorder and received psychotropic medications. The Level I Screening was positive for a suspected serious mental illness (MI), and a Level II evaluation was required. Resident #63's Individual Determination Report, dated 12/15/2022, revealed the resident required nursing facility services due to a medical or mental health condition, and specialized services were recommended. However, an annual MDS, with an ARD of 08/11/2023, revealed Section A1500 was coded to reflect that Resident #63 was not considered to have a serious mental illness by the state Level II PASRR process. During an interview on 07/17/2024 at 3:30 PM, MDS Coordinator #11 said she was not aware Resident #41 and Resident #63 had a diagnosis of schizophrenia. She confirmed both MDS assessments were inaccurate and indicated Section A1500 should have been coded as yes, the residents were considered by the state Level II PASRR process to have a serious mental illness. During an interview on 07/18/2024 at 8:46 AM, the Director of Nursing (DON) said she expected MDS assessments to be accurate. During an interview on 07/18/2024 at 9:24 AM, the Administrator said he expected MDS assessments to be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to post daily staffing in a conspicuous location and failed to update the posting with any changes due to changes in staffing. This had the potential to affect all residents that resided in the facility. Findings included: A facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 08/2022, revealed Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The section titled, Policy Interpretation and Implementation, revealed, 1. The number of licensed nurses (RNs [registered nurses], LPNs [licensed practical nurses], and LVNs [licensed vocational nurses]) and the number of unlicensed personnel (CNAs [certified nurse assistants] and NAs [nurse assistants]) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The policy revealed, Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift. The policy revealed, The charge nurse competes the form and posts the staffing information in the location(s) designated by the administrator. A facility document titled, Call-Ins for 2024 revealed that on 07/10/2024, 07/11/2024, 07/12/2024, and 07/16/2024, one LVN and one CNA called in. On 07/13/2024, two CNAs and one RN called in. On 07/14/2024, two CNAs called in and on 07/15/2024, one CNA called in. The Daily Report for Nursing Staff Directly Responsible for Resident Care forms for 07/10/2024 through 07/16/2024 revealed no alterations were made to the postings to reflect the staff that had called in and the changes in the total number of direct care staff providing resident care. An observation on 07/16/2024 at 3:50 PM revealed the Daily Report for Nursing Staff Directly Responsible for Resident Care form was found hanging on the wall across from the Administrator's office on the service hall. The posting was located in the administrative hallway to the left of the main lobby/entrance, in the corner by the fire door wall. There were only two resident rooms located in the administrative hallway. During an interview on 07/18/2024 at 8:26 AM, the Staffing Coordinator stated she was responsible for posting the daily staffing numbers. She stated that she posted it the morning for the whole day. She stated that she did not update the daily report for staffing hours as the numbers were just projected numbers. She stated the Human Resources (HR) Coordinator documented the actual staffing numbers when she completed the State's staffing form to ensure they had the correct staffing numbers per patient day (PPD). She stated that she did not know the staffing sheets needed to be updated each shift; she had never been told that. She stated that there were only two or three rooms on the hall where they posted the daily staffing numbers. The Staffing Coordinator stated that ever since she started working at the facility, that was where the posting numbers had been posted. She stated that she had never been told it needed to be posted where all could see. During an interview on 07/18/2024 at 8:43 AM, the HR Coordinator stated that the daily postings she got from the Staffing Coordinator were not updated with call in's, it was only what the Staffing Coordinator posted in the mornings. During an interview on 07/18/2024 at 9:24 AM, the Director of Nursing (DON) stated the Staffing Coordinator posted the daily staffing numbers and if she was not available, she would ask the Social Service Director (SSD) or the business office staff to post it. She stated that the Staffing Coordinator did come in on some weekends, but she would have to ask her if she posted it on the weekends. She stated that the Staffing Coordinator sent out daily reports to show call-ins at least two hours before each shift and sent it to each shift and the nurse on shift updated the posting on shift. She stated that nurses were to make the changes. She stated that she reviewed the staffing numbers every day. The DON stated that the posting was located on the hall outside the Administrator's office. She stated that they had four residents potentially on the hall, so only those residents and their families would see it. She stated that the posting was not really in a conspicuous area; she could see that very few people would see it. During an interview on 07/18/2024 at 9:54 AM, the Staffing Coordinator stated that on the weekends she printed the daily staffing numbers for Saturday and Sunday so the nurses could go through and pull the actual one. She stated that the nurses updated the forms if needed for any changes to the numbers. During an interview on 07/18/2024 at 10:27 AM, the Administrator stated that he could see how a very limited number of residents, visitors, and families would be able to see the staffing sheets where they were currently posted. He stated that the form should be updated with any call-ins per shift. He stated that he expected the staffing sheets to be as accurate as possible in real time when accurate information was provided.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. One of three sampled Certified Nursing Assistant's (CNA 1) failed to sanitize blood pressure (BP) cuff (an inflatable cuff, which measures the systolic (the measure of pressure within the arteries while the heart beats) and diastolic pressure (the measure of pressure your blood is exerting against the artery walls while the heart muscle is resting) after use. 2. One of three sampled CNA's (CNA 1) did not perform hand hygiene after providing resident care. These failures had the potential to result in the transmission of infection and communicable diseases to residents and staff. Findings: 1. During an observation on 1/3/24 at 2:10 p.m. CNA 1 entered room Resident 1's room with a BP machine and stated I'm gonna check your blood pressure. During an observation on 1/3/24 at 2:12 p.m. CNA 1 exited Resident 1's room with BP machine, walked down hallway A and entered Resident 2's room [ROOM NUMBER]. CNA 1 did not sanitize the BP cuff prior to placing the BP cuff on Resident 2's left arm. CNA 1 did not sanitize to BP cuff after use on Resident 2. During an observation on 1/3/24 at 2:19 p.m. CNA 1 took the BP machine out of Resident 2's room and walked into the dining room in hallway B where residents were partaking in different activities (coloring, bingo, and movies). CNA 1 walked over to Resident 3 who was watching a movie and informed Resident 3 that she was going to check his BP. CNA 1 did not sanitize the BP cuff prior to placing it on Resident 3's right arm. CNA 1 did not sanitize the BP cuff after the use on Resident 3 During an observation on 1/3/24 at 2:22 p.m. CNA 1 walked over to Resident 4 who was sitting in the dining room playing bingo and informed her that she was going to check her BP. CNA 1 did not sanitize the BP cuff prior to placing the BP cuff on Resident 4's left arm. CNA 1 did not sanitize the BP cuff after the use on Resident 4. During an interview on 1/3/24 at 2:25 p.m. with CNA 1, CNA 1 stated the BP machine and BP cuff are sanitized once per shift. During an interview on 1/3/24 at 2:31 p.m. with Infection Preventionist (IP), IP stated BP machine and BP cuff should be sanitized before and after each use. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, dated October 2021, the P&P indicated, The following categories are used to distinguish the level of sterilization/disinfection necessary for items used in resident care and those in resident's environment.c. Non-Critical items are those that come in contact with intact skin but not mucous membranes.(2) Most non-critical items can be decontaminated where they are used.2. Non- critical surfaces will be disinfected with an EPA- registered intermediate or low-level hospital disinfectant according to the label's safety precautions. 2.During an observation on 1/3/24 at 2:12 p.m. CNA 1 exited Resident 1's room after taking Resident 1's BP and did not sanitize her hands. CNA 1 walked down Hallway A and entered Resident 2's room without sanitizing her hands. CNA 1 proceeded to check Resident 2's BP. During an observation on 1/3/24 at 2:15 p.m. CNA 1 exited Resident 2's room and did not sanitize her hands upon exiting the room. During an observation on 1/3/24 at 2:19 p.m. CNA 1 walked into the dining room in hallway B where residents were partaking in different activities (coloring, bingo, and movies). CNA 1 walked over to Resident 3 who was watching a movie and informed Resident 3 that she was going to check his BP. CNA 1 did not perform hand hygiene before or after providing care to Resident 3. During an observation on 1/3/24 at 2:22 p.m. CNA 1 walked over to Resident 4 who was sitting in the dining room playing bingo and informed her that she was going to check her BP. CNA 1 did not perform hand hygiene before or after providing care to Resident 4. During an interview on 1/3/24 at 2:25 p.m. with CNA 1, CNA 1 was asked when should hand hygiene be performed. CNA 1 stated, I should do it more often. CNA 1 was made aware of the observations and stated, Yeah, I should have sanitized my hands. During an interview on 1/3/24 at 2:33 p.m. with IP, IP stated hand hygiene should be performed before and after touching residents. IP stated it is also expected to use hand sanitizer before entering and after leaving all resident rooms. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated March 2020, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Handwashing: soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents.i. After contact with resident's intact skin.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on observation, interview, and record review, the facility failed to supervise and monitor one of three sampled residents (Resident 1) when Resident 1 was outside of the facility during a hot weather. This failure resulted in Resident 1 eloping (to leave a healthcare facility without permission, authorization, or supervision) and being admitted to the hospital for two days due to heat stroke (a heat-related illness, occurs when the body can no longer control its temperature and the body's temperature rises rapidly). Findings: During a review of the facility's Risk Review Note (RRN-summary of investigation), dated July 6, 2023, the RRN indicated, [On 7/4/23] Resident [1] was observed by staff member to be sitting in the wheelchair in the front patio with another resident at approximately 4:10 p.m. Was noted to have left the premises at approximately 4:35 p.m. At approximately 5:10 p.m., fire department alerted staff he [Resident 1] was being transported to hospital after he was found in close by neighborhood. During an observation on 7/18/23 at 10:20 a.m., at the front patio of the facility, there was no fence and was open to the street, there were three random residents, propelling themselves via wheelchairs, and front wheel walker by the sidewalk of the facility. No staff were observed supervising the residents. During an interview on 7/18/23 at 10:25 a.m., with Director of Nursing (DON), DON stated, He [Resident 1] was sitting outside, from there [Social Services Designee/Certified Nursing Assistant (CNA) 1] noticed he was not here. The cops [police] came and told us they were taking him [Resident 1] to the hospital, he was admitted to the hospital for two to three days for heat exhaustion. Police and fire department alerted staff at 5:10 p.m. The resident [1] was a couple of blocks away in a nearby neighborhood. During an observation on 7/18/23 at 11:17 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair beside his bed. Resident 1's speech was garbled (unclear/distorted). Unable to be interviewed and had a limited mobility due to right arm weakness and difficulty walking. During an interview on 7/20/23 at 2:32 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Around 4 p.m., he [Resident 1] went outside [at the front patio]. At 4:35 p.m., we noticed he [Resident 1] wasn't outside. At 4:45 p.m., we got notification that EMS [Emergency Medical Service-also known as ambulance or paramedic services, are emergency services that provide urgent pre-hospital treatment, and stabilization for serious illness and injuries and transport to hospital] called and EMS stated they were taking him to the hospital. During a review of Resident 1's Minimum Data Set (MDS-assessment tool), dated May 26, 2023, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS) score was 7 (a score of 0-7 means severe cognitive impairment). Resident 1's MDS section G (Functional Status) dated July 18, 2023, was reviewed. The MDS indicated, Resident 1 required extensive assistance (full staff support) with one to two persons physical assist with Activities of Daily Living (ADL's- including but not limited to Transfer, Dressing, Eating, Toilet use, and Bathing). During a review of Resident 1's Progress Notes, dated July 18, 2023, the Progress Notes indicated, admitted : 2/25/22. Diagnoses: Metabolic Encephalopathy [a problem in the brain caused by a chemical imbalance in the blood], Cerebral Infarction [lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off], Cognitive Communication Deficit [speech impairment], Dementia [memory loss], Unsteadiness on feet, Psychotic Disturbance [severe mental disorders that cause abnormal thinking and perceptions], Mood Disturbance [feelings of distress], Anxiety Disorder [excessive feelings of worry], Schizoaffective Disorder [mental disorder], and Difficulty in walking. During a concurrent interview and record review on 8/3/23 at 3:30 p.m., with DON, Resident 1's Treatment Administration Record (TAR), dated July 2023 was reviewed. The TAR indicated, on 7/4/23 at 4:00 p.m. hourly check, the resident was on the (outside) patio. DON stated, At 4:35 p.m., family arrived, resident [1] was not in his room, and we started searching. At 5:10 p.m. the fire department [fire rescue service personnel] arrived and made the facility aware that resident [1] had been located and was being taken to the hospital. During an interview on 8/8/23 at 2:55 p.m. with SSD/CNA 1, SSD/CNA 1 stated she was assigned to monitor (check/watch) Resident 1 on 7/4/23 but did not witness him (Resident 1) leave the facility. SSD/CNA 1 stated, I don't know what was the temperature that day [7/4/23], but it was hot that day. According to the Weather Channel (weather.com), on 7/4/23, [at the location of the facility] had a temperature, Record High of 112 F (Fahrenheit-temperature measurement). When heat index reaches above 97 F, it's dangerous, and it can cause sunstroke, muscle cramps and heat exhaustion. During an interview on 8/11/23, at 5:05 p.m., with DON, DON stated, No hydration assessment was done [when Resident 1 was outside at the patio]. All departments [heads] participate in rounding however due to being a holiday [7/4/23], no management [department heads] was in the facility. Social Services Designee was his CNA [SSD/CNA 1] that day. During a review of Resident 1's Care Plan, undated, the Care Plan indicated, The resident is an elopement risk r/t [related to] history of attempts to leave the facility unattended, impaired safety awareness. Interventions: Distract resident from wandering, monitor for fatigue [exhaustion], provide structured activities. During a review of Resident 1's EMS [Emergency Medical Service/Ambulance] Care Summary (ECS), dated July 4, 2023, the ECS indicated, at 5:13 p.m., [Resident 1's] blood pressure [pressure of circulating blood against the walls of blood vessels] was 160/100 [normal blood pressure is below 120/80]. Heart rate was 160 [normal heart rate is 60 to 100 beats per minute]. Temperature was 100.2 degrees [normal body temperature is 97.6 - 99.6 degrees] Fahrenheit [unit of measurement]. During a review of hospital records of Resident 1, the Emergency Department Note (EDN), dated July 4, 2023, the EDN indicated, Ambulance offload time 7/4/2023 at 5:49 p.m. Vital signs are notable for Tachycardia [increased heart rate] of 142 beats per minute, febrile [elevated temperature] at 101.1 degrees Fahrenheit. Final Diagnosis: Heat Stroke and sunstroke [a severe heat illness that results in an elevated body temperature]. Altered Mental status [Confusion]. Disposition [plan]: admit to observation. During a review of hospital records of Resident 1, the History and Physical Report (H&P), dated July 4, 2023, the H&P indicated, [Resident 1's] chief complaint was heat exposure, pt [Patient - Resident 1] was found outside sitting on wheelchair for unknown amount of time. GCS [Glasgow Coma Scale-a scale used to objectively describe the extent of impaired consciousness of trauma patients] of 9 [score of 9-12 means moderate impairment], pt [Patient - Resident 1] is nonverbal. PT [Patient - Resident 1] is Tachycardic [increased heart rate] in the 150's [normal heart rate is 60 - 100]. Assessment/Plan: Altered mental status [confusion], Heat Stroke. During a review of Resident 1's hospital records Discharge Summary (DCS), dated July 6, 2023, the DCS indicated, Dates of service: 7/4/23 to 7/6/23 [stayed two days in the hospital]. Diagnosis: Heat Stroke. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 2017, the P&P indicated, The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision. During a review of the facility's policy and procedure (P&P) titled, Resident Hydration and Prevention of Dehydration, dated 2017, the P&P indicated, Nurses will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids.

Based on observation, interview, and record review, the facility failed to ensure staff did not use residents' nutrition freezer to store personal food items. This failure had the potential to cause food-borne illness and affect the residents' health. Findings: During a concurrent observation and interview on 5/10/22, at 9:55 AM, with Licensed Vocational Nurse (LVN) 2, at the C wing nurses' station, an unlabeled and undated frozen food bowl was observed in the freezer section of the residents' nutrition refrigerator. LVN 2 stated the frozen food bowl should have been dated and labeled. During an interview on 5/11/22, at 2:16 PM, with Director of Nursing (DON), the findings of a frozen food bowl in the C wing nurses' station freezer were reviewed. DON stated, the frozen food bowl was a staff member's food. DON stated, the residents' refrigerator/freezer was not to be used to store staff food items. DON stated, no frozen foods, requiring reheating, were to be stored in the residents' freezer. Staff were not allowed to reheat food items for residents. During a review of the facility's policy and procedure (P&P) titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, dated 2018, the P&P indicated, Only foods purchased from vendors will be accepted into the Department of Food and Nutrition Services for storage.

Based on interview and record review, the facility failed to develop and update the person-centered comprehensive care plan for three of 24 sampled residents (Resident 7, Resident 51, and Resident 58). This failure had the potential for unmet care needs. Findings: 1. During a review of Resident 7's Admission Record (AR), dated 2/2/17, Resident 7 was initially admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, on 5/11/22, at 2:29 PM, with Director of Staff Development (DSD), Resident 7's Emergency Department Discharge Instructions (EDDI), dated 4/11/22, were reviewed. The EDDI indicated, Resident 7 was admitted to a local hospital for Altered Mental Status (AMS- alteration in mental status characterized by acute onset and impaired attention). DSD stated, Resident 7 was seen by the nurse lying in bed, with opened eyes but not verbally responding. DSD stated, Resident 7 was sent to the hospital and was diagnosed positive for Cannabis (marijuana). During an interview on 5/12/22, at 2:45 PM, with the Director of Nursing (DON), DON stated the family gave Resident 7 Cannabis gummies. DON stated, the facility's Interdisciplinary Team (IDT-different types of facility staff working together to share expertise, knowledge, and skills to impact patient care) should develop a care plan regarding Resident 7's change in condition to prevent rehospitalization . 2. During an interview on 5/10/22, at 2:25 PM, with Resident 51, Resident 51 stated he had diabetes. Resident 51 stated, he was aware he needed to take care of his eyes because of his diabetes. Resident 51 stated, he had glasses, but he hadn't seen anyone about his eyes since his admission almost a year ago. During an interview on 5/11/22, at 3:18 PM, with Social Services Assistant (SSA), SSA stated, We only use an optometrist (eye doctor). If the optometrist writes out a referral, then we send out to the community. Optometry comes quarterly and he was just here. SSA stated, she schedules residents to see the optometrist based on the MDS (Minimum Data Set- a comprehensive assessment screening tool) and the last time a resident was seen. SSA stated, Resident 51 had not been seen by the optometrist. SSA stated, The optometrist would catch any issues (with the eyes of diabetics). During a concurrent interview and record review, on 5/11/22, at 3:24 PM, with SSA, Resident 51's care plan (CP), dated 5/9/21, was reviewed. The CP indicated, The resident has Diabetes Mellitus . Goal. The resident will have no complications from diabetes through the review date. SSA stated, no interventions were found for monitoring Resident 51's eyes for complications from diabetes. SSA stated, there should have been an intervention related to monitoring eyes of diabetic residents in the care plan. 3. During a concurrent interview and record review, on 5/11/22, at 3:35 PM, with SSA, Resident 58's CP, dated 3/4/21, was reviewed. The CP indicated, The resident has Diabetes Mellitus . Goal. The resident will have no complications from diabetes through the review date. SSA stated, no interventions were found in Resident 58's diabetic care plan for monitoring eyes for complications of diabetes. SSA stated, a diabetic care plan should contain this intervention. During a review of standards of care from the National Eye Institute titled, Diabetic Retinopathy, dated 3/25/22, the standards indicated, Diabetic retinopathy is the most common cause of vision loss for people with diabetes . [CONDITION(S)] (the lens of the eye becomes cloudy causing blurred vision). Having diabetes makes you 2 to 5 times more likely to develop [CONDITION(S)] . Having diabetes nearly doubles your risk of developing a type of [CONDITION(S)] (increased pressure in the eyeball causing gradual los of sight) called open-angle [CONDITION(S)] . If you have diabetes, it's very important to get regular eye exams. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: . h. Incorporate risk factors associated with identified problems . m. Aid in preventing or reducing decline in resident's functional status and/or functional levels . o. Reflect currently recognized standard of practice problem areas and conditions . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . 14. The IDT must review and update the care plan: a. when there has been a significant change in condition.

Based on observation, interview, and record review, the facility failed to assess one of 18 sampled residents (15) on multiple opportunities after the resident's fall incident. Such failure resulted in Resident 15's [MEDICAL CONDITION] to go unnoted for six days and sustained severe pain for six days. Findings: During an observation on 10/09/17, at 10:20 AM, Resident 15 was in bed lying on her right side facing the wall. At 12 PM, the resident was in bed awake lying on her right side. Certified Nursing Assistant (CNA) 2 was at the bedside attempting to feed Resident 15 her lunch. Resident 15 refused lunch and pushed CNA 2's hand away. CNA 2 stated Resident 15 had only eaten 50 percent of her breakfast, I don't know why she refuses her food now. During a review of the clinical record for Resident 15, Minimum Data Set (MDS-an assessment tool), dated 9/18/17, indicated Resident 15 had a [DIAGNOSES REDACTED]. The Nurses Notes, dated 10/6/17, at 6:49 PM, was reviewed. It indicated Resident 15 had a witnessed fall at 6:40 PM. Resident 15 had lost her balance while stepping backwards and landed on her left side. Resident 15 sustained a skin tear to her right hand and was placed on a 72 hour monitoring (observing and checking any change in medical/mental condition and level of care) after the fall on 10/6/17. The clinical records indicated Resident 15 had no complaints of pain, but her behaviors of crying, yelling out, and restlessness prompted the staff to administer [MEDICATION NAME] (anti-anxiety medication) for three consecutive days (10/7/17, 10/8/17, and 10/9/17). The clinical records also indicated Resident 15 had no episodes of these behaviors prior to the fall incident. There was no documented evidence during the behavior episodes, the physician was notified for further assessment and evaluation of Resident 15's change of condition. During an interview with Restorative Nursing Assistant (RNA) 1, on 10/12/17, at 10:35 AM, she stated an attempt was made to transfer Resident 15 into a wheelchair for her scheduled weight on 10/9/17. RNA 1 stated, She (Resident 15) was screaming during the process of getting up in the chair with one leg on the floor. She was in pain. RNA 1 stated she had reported the incident to the Director of Nursing (DON). During an interview with CNA 2, on 10/12/17, at 11:10 AM, she stated she worked with Resident 15 on 10/9/17, three days after the witnessed fall. CNA 2 stated Resident 15 was scheduled to be showered and would usually have no difficulty standing up for showers, but on 10/9/17, She couldn't stand up, she was in pain. She was screaming, saying 'pain' and touching her right leg and then both legs. I think she was in a lot of pain that she didn't know where the pain was anymore. CNA 2 stated she had reported the incident to the the nurse on duty. During an interview with CNA 4 on 10/12/17, at 2:16 PM, she stated she worked with Resident 15 on 10/10/17, four days after the witnessed fall. CNA 4 stated it was unusual for Resident 15 to stay in bed all day, She is usually up walking. The Nurses Notes, dated 10/9/17, at 2:45 PM, were reviewed. The notes indicated Upon entering room resident (Resident 15) was in bed lying on right side with eyes closed, no apparent distress. Upon assessment of lower extremities, resident began to yell. Upon passive ROM (range of motion), resident started to cry out. When asked where the pain was resident did not reply only continued to cry. Resident 15 was placed on 72 hour monitoring for lower extremity pain. During an interview with a Registered Nurse (RN) 2, on 10/12/17, at 2:29 PM, she stated, She (Resident 15) was restless that morning (10/9/17), she was given [MEDICATION NAME]. She was guarded when moving her lower extremities. RN 2 stated she notified the physician, and was given an order for [REDACTED]. No I didn't tell him she couldn't stand up. The Rehabilitation Referral note, dated 10/10/17, was reviewed. It indicated Pt (patient-Resident 15) in bed-refused to follow any requests to get OOB (out of bed)-crying and very agitated-unable to assess at this time. The Nurses Notes, dated 10/11/17, at 11:44 AM, indicated Writer and therapy assistant attempted to assess resident due to not wanting to ambulate, became upset, crying, holding right lower extremity. noted right knee to be slightly swollen. staff provides needed care with occ (sic) episodes of guarding her extremities and crying. The clinical records indicated Resident 15 was only given [MEDICATION NAME] on 10/9/17 at 1:31 PM. During an interview with Licensed Vocational Nurse (LVN) 1, on 10/12/17, at 3:01 PM, she stated she observed Resident 15 on 10/11/17 (six days after the witness fall), in her room, lying in bed, her right side facing the wall, in a fetal position, holding both legs. LVN 1 stated, She didn't let me assess her, she was crying, saying leave me alone. She wouldn't let me turn her or anything. During further review of the Nurses Notes, dated 10/11/17, at 1:02 PM, it indicated Resident 15's attending physician was notified and gave an order for [REDACTED]. Resident 15 had a surgical operation done on 10/12/17 to repair the [MEDICAL CONDITION]. During an interview with the Director of Nurses (DON), on 10/12/17, at 3:30 PM, she stated she was notified of the fall on 10/6/17. The DON stated, I was told she (Resident 15) fell and was able to move all extremities. I wasn't aware she was crying during the passive range of motion until I went through the notes on Monday (10/9/17). The DON stated she had not assessed Resident 15 after she was made aware of Resident 15's complaint of pain, crying, and pushing staff away. The DON stated, I was told she was crying, was able to move both legs, no one told me she was guarding her legs. That's new for her. Yeah, she should have been sent out sooner. The facility policy and procedure titled Change in a Resident's Condition or Status undated, indicated A significant change of condition is a decline or improvement in the resident's status that: Ultimately is based on the judgement of the clinical staff. Acute changes include: Incident with injury of any kind this includes skin tear, bruise or pain. Change in baseline condition. New behavior. The policy and procedure titled Pain Assessment and Management undated, indicated Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; c. Changes in gait; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Guarding, rubbing or favoring a particular part of the body; f. difficulty eating or loss of appetite; Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including; (4) Fractures.