Every finding on record at Eastridge Nursing & Rehabilitation

Based on observations, interviews, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety as evidence by:1. Storing expired foods;2. Not cleaning small appliances after each use; and3. Not covering food before being transportedThis had the potential to affect 83 residents who ate food prepared in the kitchen.Findings:1.A review of the facility policy titled: Kitchen Food Storage Areas Policy and Procedure with a review date of 02/14/2025, read in part: Care of the Storeroom: 1.The staff will maintain care of the storeroom according to the following directions. C. Foods with expirations dates are used prior to the date on the package. An observation on 12/15/2025 at 09:30 a.m. revealed a container of peanut butter stored on a shelf in the dry food storage room with an expiration date of 11/15/2025. A container of cottage cheese was stored in the standup kitchen refrigerator with an expiration date of 11/22/2025.An interview was conducted on 12/15/2025 at 09:32 a.m. with S2DM (Dietary Manager). S2DM examined the container of peanut butter and cottage cheese and confirmed both were stored beyond their expiration dates and should have been discarded. 2.A review of the facility policy titled: Cleaning Instructions Food Preparation Appliances Policy and Procedure with a review date of 02/14/2025, read in part: Small appliances will be cleaned. after each use.An observation on 12/15/2025 at 09:40 a.m. was made of the fryer. The fryer had brown, dark brown, and orange cakey and crusty material on the outside of it. The body of the fryer had dark brown, orange, and white cakey material on it. The two fryer baskets had brown and orange cakey material on the handles. The grease inside the fryer had a dark brown to black film on top of it and it appeared to be thick and sludgy. An interview on 12/15/2025 at 09:42 a.m. was conducted with S2DW. S2DW confirmed the fryer and two fryer baskets had cakey and crusty material on the outside of it and thick and sludgy material on the inside over the grease. She stated the fryer had not been cleaned after it was last used on 12/12/2025. She stated that the body of the fryer had not been cleaned since she started working as the dietary manager approximately 6 months ago. 3.A review of the facility policy titled: General Food Preparation and Handling Policy and Procedure with a review date of 02/19/2025 read in part: Food items will be prepared to. keep free of injurious organisms and substances. 4. Food Service: b. prepared food will be transported to other areas in covered containers. On 12/15/2025 at 11:40 a.m. an observation was made of S2DM transporting one container of sausage and potatoes and one container of Brussel sprouts on a rolling cart from the kitchen, across a hallway, and into the dining/ service area. The two containers of food were not covered. An interview was conducted on 12/16/2025 at 10:30 a.m. with S2DM. She confirmed that she did not cover the container of sausage and potatoes or the container of Brussel sprouts prior to transporting them to the dining/ service area. She stated that she was aware of the facility policy and that she should have covered the food prior to transporting it from the kitchen to the dining/ service area.

Based on records reviews and interviews, the facility failed to ensure the residents' Minimum Data Set (MDS) assessments were accurately coded to reflect the residents' status for 3 (#4, #23, #38) of 35 sampled residents, as evidenced by:1. Failing to code Resident #4 for Level II PASRR (Pre-admission Screening and Resident Review);2. failing to code Resident #38 for receiving dialysis treatment; and3. failing to code Resident #23 for bed mobility and transfers Findings: 1. Resident #4 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to major depressive disorder, bipolar disorder, and type 2 diabetes. On 12/17/2025, a review of Resident #4's modified Annual MDS assessment with an Assessment Reference Date (ARD) of 03/13/2025, revealed the following in part: Section A1500. Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 0 was checked indicating no. Review of Resident #4's miscellaneous electronic documents revealed an OBH (Office of Behavioral Health) PASRR Level II Evaluation Summary and Determination Notice. Further review revealed Evaluation placement Recommendations in part: The individual has a serious mental illness and is recommended nursing home admission. Review of Resident #4's current care plan revealed a focus area dated 10/31/2024 in part: I have diagnosis of bipolar disorder.I have level 2. On 12/17/2025 at 8:53 a.m., an interview was conducted with S6SSD (Social Services Director). She stated the resident had a Level II PASSR. S6SSD printed a Level II PASSR with Resident #4's name that was dated 10/01/2020. On 12/17/2025 at 9:30 a.m., a review of Resident #4's modified Annual MDS assessment with an ARD of 03/13/2025 and an interview were conducted with S7MDS (Minimum Data Set Coordinator). She confirmed the resident was not coded for having a Level II PASSR, and stated the resident should have been coded as having a Level II PASSR. 2. Resident #38 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to chronic kidney disease, dependence on renal dialysis, and iron deficiency anemia. On 12/16/2025, a review of Resident #38's Annual MDS assessment with an ARD or seven day look back period of 09/24/2025, revealed in Section O0110. Special Treatments, Procedures, and Programs, that the resident did not receive J1. Dialysis or J2. Hemodialysis while a resident. Review of Resident #38's December 2025 Physician's Orders revealed an order that was written on 05/26/2025 that read in part: Hemodialysis.every Mon (Monday), Wed (Wednesday), Fri (Friday). Review of Resident #38's Medication Administration Record (MAR) for September 2025, revealed Resident #38 received hemodialysis during the seven day look back period of her Annual MDS assessment dated [DATE], on 09/17/2025, 09/19/2025, and 09/22/2025. On 12/16/2025 at 11:46 a.m., reviews of Resident #38's Annual MDS with a seven day look back period of 09/24/2025, and the resident's September 2025 MAR were conducted with S1CN (Corporate Nurse). She confirmed Resident #38 received hemodialysis within the seven days leading up to her Annual MDS. S1CN stated Resident #38's Annual MDS should have been coded yes for receiving dialysis, but was coded no for receiving dialysis. On 12/17/2025 at 9:24 a.m., an interview was conducted with S5MDS. She confirmed resident #38's Annual MDS with an ARD of 09/24/2025 was coded incorrectly for dialysis. 3. Resident #23 Review of Resident #23's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, generalized osteoarthritis, and morbid (severe) obesity. A review of Resident #23's care plan read in part .I require staff assistance for ADL's (Activities of Daily Living) related to incontinence, weakness, decreased mobility. I required two person assist with transfers via Hoyer lift. Further review of Resident's #27's care plan revealed the following interventions:.I require a Hoyer lift with x2 (two person) assist with transfers; I require assistance with bed mobility; I require assistance with transfers; I use a wheelchair for mobility. Review of Resident #23's progress note dated 11/25/2025 read in part.Resident sitting in dining room with 02 (oxygen) at 2L/NC (liters/nasal cannula). Further review of resident #23's medical record revealed a quarterly MDS assessment with an ARD (Assessment Reference Date) of 11/27/2025, which read in part . Section GG. Functional Abilities .B. Sit to lying was coded 88 which indicated Not attempted; C. Lying to sitting on side of bed was coded 88 which indicated Not attempted; E. Chair/bed-to-chair transfer was coded 88 which indicated Not attempted. On 12/17/2025 at 11:55 a.m., an interview and record review was conducted with S5MDS (Minimum Data Set Coordinator) who confirmed Resident #23 was dependent for bed mobility and transfers. S5MDS reviewed the referenced MDS assessment and confirmed sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer was indicated on the assessment as not attempted and was coded incorrectly.

Based on observations, interviews, and record review, the facility failed to follow the menu for 3 (#23, #36, and #71) out of 3 (#23, #36, #71) residents who required puree diets. Findings:A. On 12/15/2025 at 2:30 p.m., a review of the facility's policy titled, Pureed Policy and Procedure with a review date of 06/18/2025 read in part: Pureed Preparation: 1. Follow standardized recipes for accurate serving sizes and servings per batch; 3. Place desired number of portions to be pureed into food processor; 11. Determine proper scoop/ serving size. On 12/15/2025 at 10:55 a.m., a review of the recipe spreadsheet revealed a puree diet recipe of 4 ounces of red beans and 2 ounces sausage per resident for lunch. An observation on 12/15/2025 at 11:00 a.m. revealed S4CK (Cook) scooped unmeasured potatoes and sausage from a single pot and placed them in one container. An interview was conducted on 12/15/2025 at 11:03 a.m. with S4CK. S4CK stated that she did not measure the amount of potatoes or sausage. She stated I just eye ball it. She stated that she did not follow the recipe spreadsheet provided to her by the facility.An interview on 12/15/2025 at 11:08 a.m. with S2DM (Dietary Manager) revealed that the recipe spreadsheet for red beans and sausage serving size was used for the potatoes and sausage serving size for puree diet preparation. S2DM stated the serving size to be pureed in the food processor should have been measured for 2 ounces of sausage and 4 ounces of potatoes. B. On 12/15/2025 at 1:30 p.m., a review of the facility's policy titled: Accuracy and Quality of Tray Line Service Policy and Procedure read in part: All Meals are checked by food service personnel for accuracy, and by the employees serving the meals prior to serving to the individual. 7. Each meal will be checked for proper portion sizes.An observation on 12/15/2025 at 11:59 a.m. of the lunch menu revealed that one serving size was 6 ounces of combined sausage and red beans for the puree diet for one resident. An observation on 12/15/2025 at 12:10 p.m. revealed that S3CK (Cook) used a green handle 4 ounce spoodle to serve one serving of combined pureed potatoes and sausage for a puree diet tray. An interview was conducted on 12/15/2025 at 12:15 p.m. with S3CK. S3CK confirmed that she used a green handle 4 ounce spoodle to serve one serving of pureed potatoes and sausage for a puree diet tray. She confirmed that she should have used a 6 ounce spoodle to serve one serving per resident. An interview on 12/15/2025 at 12:20 p.m. was conducted with S2DM. She stated that the green handle 4 ounce spoodle should not have been used to scoop one serving size of potatoes and sausage for the puree diet tray. She stated the recipe spread sheet read that 6 ounces was one serving size for the puree diet tray. She stated that a 6 ounce spoodle should have been used to provide one serving for the puree diet tray.

Based on observations, interviews, and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) while providing high-contact care to 1 (Resident # 12) of 1 resident observed for facility staff adherence to EBPs. There was a finalized sample of 35 residents. FindingsReview of the facility's policy and procedure titled, Enhanced Barrier Precautions Policy and Procedure with a last reviewed date of 12/03/2025, revealed in part:Purpose to prevent the spread of potential infection by implementing Enhanced Barrier Precautions (EBP) when contact precautions do not apply. This approach recommends the use of EBP during high contact care activities for residents with indwelling medical devices.Procedure 1. EBP are indicated for residents with any of the following:1b. Indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO (multi-drug resistant organism) .ii. Indwelling medical device examples include .feeding tubes .4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities .g. device care of use ( .feeding tube .) 5. PPE is to be applied prior to performing the high-contact resident activity according to below and before moving to another resident. a. Perform hand hygiene. b. Put on a gown and gloves. c. After resident care, throw away gown and gloves in trash receptacle.On 12/17/2025 at 10:17 a.m., an observation was made of S8LPN (Licensed Practical Nurse) outside of the resident's room in the hallway preparing the supplies needed to provide enteral (tube feeding) hydration and nutrition to Resident #12. A PPE cart stocked with yellow isolation gowns was available outside the entrance to the resident's room. S8LPN failed to put on isolation gown prior to entering the resident's room.On 12/17/2025 at 10:21 a.m., an observation was made of S8LPN in Resident #12's room administering Resident #12's enteral hydration and nutrition through his indwelling medical device (feeding tube). S8LPN completed the tube feeding procedure without an isolation gown. On 12/17/2025 at 10:30 a.m., an interview was conducted with S8LPN who confirmed Resident #12 had a feeding tube therefore required EBPs. S8LPN stated EBP required staff to wear gloves and an isolation gown when accessing Resident #12's feeding tube. S8LPN confirmed she failed to wear an isolation gown when performing high contact care on Resident #12.On 12/17/2025 at 11:21 a.m., an interview was conducted with S9IP (Infection Preventionist) who verified S8LPN should have donned (put on) a gown when she administered Resident #12's tube feeding.

Based on policy review, record review, and interviews, the facility failed to ensure allegations of neglect was reported to the State Survey Agency within 2 hours upon learning of the allegation for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. Findings: On 03/25/2025 at 9:30 a.m., a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a reviewed date of 12/31/2024 read in part .7. Reporting/Response - the facility employee or agent, who becomes aware of abuse of neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or Director of Nurses. The facility administrator or designee shall complete a report to be made to the mandated state agency according to state guidelines upon notification of an alleged abuse. Immediately means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made. Review of the facility's investigative report revealed the following, in part: on 03/10/2025, Resident with incident in van resulting in a witnessed fall during transport. S4TA notified the facility that Resident #1 fell back in the facility van. Root cause identified as Q'straint (wheelchair securement system used in vehicles) not applied correctly. Review of SIMS (Statewide Incident Management System) report provided by the facility revealed the event occurred on 03/10/2025 at 11:50 a.m., was discovered on 03/10/2025 at 11:50 a.m., and was entered into SIMS on 03/18/2025 at 11:45 a.m. Resident #1 was the victim of alleged neglect and identified the perpetrator as S4TA. On 03/25/2025 at 2:15 p.m., a phone interview was conducted with S4TA. She confirmed she had transported Resident #1 to a doctor's appointment during which the resident sustained a fall. She stated that when securing the resident with the Q'straint (wheelchair securement system used in vehicles) system, she hooked the 2 back straps to the wheelchair frame. After that she hooked 1 front strap the resident's front right wheel and failed to use the second front strap. She confirmed she was aware she was not supposed to secure wheelchairs for transportation in this manner. She stated that during transport, she accelerated the van after coming to a stop, and when doing so, the resident and the wheelchair flipped backwards landing on her back on the floor of the bus. S4TA confirmed she received training on the correct use of the Q'straint system but did not follow it on this day. On 03/26/2025 11:30 a.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed the incident of Resident #1 falling while being transported in a facility bus. He stated that upon their investigation, they determined the fall was a result of S4TA's willful and neglectful improper use of the Q'straint system that resulted in an avoidable fall. S1ADM stated he was unaware of the need for reporting incidents that occurred in a facility's transportation vehicle until later despite having making the determination that the root cause of the fall was neglectful use of the Q'straint system.

Based on observations, interviews, and policy and procedure reviews, the facility failed to: 1. Maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses; 2. Store food in accordance with professional standards for food service safety; and 3. Wear an appropriate hair restraint; This had the potential to effect the 83 residents who ate meals prepared from the facility's kitchen. The facility's census was 86. Findings: Review of the facility's policy, Dry Storage Areas and Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. Care of the Store Room: 1.c. Foods with expiration dates are used prior to the date on the package. Canned and dry foods without expiration dates are used within six months of delivery or according to manufacturer's guidelines. Review of the facility's policy, Employee Sanitary Practices Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: All kitchen employees will practice standard sanitary procedures. Procedure: All employees shall: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Review of the facility's policy, Cleaning Instructions Slicers Policy and Procedure, with a last review date of [DATE], revealed the following in part: The slicer will be cleaned and sanitized after each use. Review of the facility's policy, Cleaning Instructions Fryers Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production. Review of the facility's policy, Cleaning Instructions Ice Machine and Equipment Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: The ice machine and equipment (scoops, etc.) will be cleaned on a regular basis to maintain a clean, sanitary condition. Procedure: 7. The ice scoop and any other removable parts will be washed and sanitized at least weekly or as needed in the dishwasher and allowed to air dry. Review of the facility's policy, Cleaning Dishes- Manual Dishwashing Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. Review of the facility's policy, Cleaning Instructions Floors, Tables and Chairs Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: Kitchen and dining room floors, tables and chairs will be kept clean and sanitary. Procedure: 1. Kitchen floors will be swept and cleaned after each meal. A thorough cleaning using disinfectant will be done at least daily. Review of the facility's policy, Cleaning Instructions Food Preparation Appliances Policy and Procedure, with a last review date of [DATE], revealed the following in part: Policy: Small appliances (such as mixers and food processors) will be cleaned and sanitized after each use. Procedure: 6. Clean the outer surface of the appliance with a clean cloth that has been moistened with hot, soapy water. Review of the facility's policy, Cleaning Instructions Food Carts Policy and Procedure, with a last review date of [DATE]: Policy: Food carts will be cleaned and sanitized after each use. Procedure: 1. Each day, the inside and outside of all food carts will cleaned and sanitized. An initial tour of the kitchen was conducted on [DATE] at 08:45 a.m. with S1ADM (Administrator) and S7DM (Dietary Manager) and revealed the following: 1. One container of Ready Care Thickener expired on [DATE]; 2. Three bags of hot dog buns without a date of expiration or a date received; 3. Two bags of hamburger buns without a date of expiration or a date received; 4. One ziplock bag of hamburger buns without a date of expiration or a date received; 5. Three containers of Silk Milk with an expiration of [DATE]; 6. A tray of ten small covered bowls in the refrigerator, containing food that was not labeled, and had no date of preparation; 7. One box of salad bags with an expiration of [DATE] 8. A Three tiered shelf holding clean cups contained dirt and dust on all shelves; 9. One tray of clean serving dishes and a rolling pin, with food residue on the rolling pin and crumbs on the tray; 10. Yellow residue in the bottom of the ice scoop holder connected to the ice machine; 11. Multiple spots of dried, burnt food residue in the bottom of the stove's collection receptacle; 12. [NAME] food splatter on the back and side wall of a food prep table; 13. Food residue and crumbs on the spice shelf; 14. [NAME] food residue and crumbs on the slicer; 15. Two spigots where lying on the floor connected to hoses for two juice containers; 16. Dried food on the front drawer of the stove; 17. Dried grease and food residue on the side panel of the fryer; 18. Crumbs at the bottom of rolling plate rack containing clean dishes; 19. [NAME] residue with dirt underneath a shelving rack holding clean dishcloths; 20. [NAME] serving dishes on a shelf with crumbs on them; 21. [NAME] food splatter on the wall behind the stove and steamer shelf; 22. A rolling shelf holding a steamer contained dried food debris on the bottom shelf and on the side bar; 23. Dried grease on the floor underneath the fryer; 24. A large stock pot on a clean shelf with dried food debris on the sides; 25. Clear containers utilized for plastic utensils with crumbs in the bottom of the containers; 26. A rolling cart for clean dishes containing food crumbs, food debris, and trash debris; 27. Dried food debris on a portable mixer; 28. Dried peanut butter on ziplock bag containing food in the dry storage area. S1ADM and S7DM both confirmed the observations of the tour. S1ADM and S7DM both stated that the noted items should have been cleaned, that expired items should not be present in food storage areas, and that the prepared food in the refrigerator storage should have been labeled and dated. On [DATE] at 10:30 a.m., another tour of the kitchen was conducted with the S7DM and revealed the following: 1. A return air conditioner vent with a thick layer of dust, located behind a shelving unit, was in direct contact with clean dish towels. 2. A fire alarm covered with a thick layer of dust was over a food prep table. S2DM confirmed these findings and confirmed that they should have been cleaned. On [DATE] at 12:48 p.m. and observation was made of S8DW (Dietary Worker) not wearing a beard restraint. At that time, S7DM confirmed that S8DW should be wearing a beard restraint.

Based on observation, interview, and record review, the facility failed to follow the recipe in order to meet the nutritional needs of the residents as evidenced by kitchen staff failing to: 1) Use the appropriate recipe to prepare a pureed food item 2) Ensure the appropriate sized scoops were used to serve pureed and mechanically soft food. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 8 residents who consumed pureed meals and mechanical soft meals from the kitchen. Findings: A review of the facility's policy Pureed Policy and Procedure, with a last review date of 04/10/2024, revealed in part: Purpose: The Pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their air way. This texture allows pureed food that is smooth and easily stays together. Policy: Pureed Preparation 1. Follow standardized recipes for accurate serving sizes and servings per batch. A review of the facility's policy Portion Control Policy and Procedure, with a last review date of 04/10/2024 revealed in part: Policy: Individuals will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. 3. Serve the food with ladles, scoops, spoodles and spoons of standard size. a. Portions that are too small result in the individual not receiving the nutrients needed. A review of the facility's policy Accuracy and Quality of Tray Line Service Policy and Procedure, with a last review date of 05/09/2024 revealed in part: Policy: Tray line positions and set up procedures are planned for efficient and orderly delivery. All meals are checked by food service personnel for accuracy, and by the employees serving the meals prior to serving the individual. 1. The menu extension sheet displays food items and amounts for each regular or therapeutic diet., 7. Each meal will be checked for: Proper portion size. 1. Review of the recipe for Pureed Dinner Roll revealed whole milk was the required liquid to be used. On 09/30/24 at 10:18 a.m., an observation was made of S9COOK preparing pureed dinner roll. S9COOK used water as the liquid to puree the dinner roll. 2. Review of Portion Sheet for Week 3 revealed the following listed portion sizes: Mechanical Soft Beans with ground ham- 6 oz (ounces) (3/4 cup); Pureed Beans with ground ham- 6oz (3/4 cup); and Pureed Peas- 1/3 cup On 09/30/2024 at 11:45 a.m., an observation of the serving line at lunch was conducted. The following scoops were used to serve residents on Pureed and Mechanically Soft diets: Mechanical Soft Beans- [NAME] scoop (1/3 cup); Pureed beans- [NAME] scoop (1/3 cup); and Pureed peas- Blue scoop (1/4 cup); On 09/30/24 at 12:56 p.m., an interview was conducted with S9COOK and S7DM. S9COOK stated that she has not used recipes to prepare pureed foods. S9COOK stated she has prepared pureed foods by memory of what she had been taught, and that she does not use measurements when cooking or preparing pureed foods. S7DM stated that the staff have a portion sheet for recommended scoop portions that is placed on the food prep table. S7DM stated that the cook is responsible for ensuring that the proper scoops are used, but S7DM stated that she selected the scoops herself today. On 10/01/24 at 08:23 a.m. an interview was conducted with S10RD. S10RD confirmed that S9COOK should have used a recipe to puree dinner rolls, and milk should have been used instead of water to puree according the recipe. She confirmed that the correct scoops were not used according to the portion size sheet for residents receiving mechanically soft and pureed diets. She confirmed that staff should have used the portion size sheet to select scoops for serving. S10RD confirmed that residents receiving mechanically soft and pureed diets may have not received the recommended nutritional needs.

Based on record review and interview, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1(#8) of 1 resident sampled for PASARR, out of a total sample of 23 residents. Findings: On 10/2/2024, a review of the facility's policy titled Pre-Admission Screening and Resident Review (PASRR) Policy and Procedure with a revision date of 06/18/2024 read in part: Purpose: To ensure completion of Pre-Admission Screening and Resident Review level two evaluations to assess the need for nursing facility placement and service, including planning and facilitation of behavioral health services. Pre-admission screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care . A review of Resident #8's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Unspecified Dementia, Anxiety, Major Depressive Disorder, and Schizoaffective Disorder. Further review of the resident's medical record revealed she was diagnosed with Schizoaffective Disorder on 05/24/2021 and there was no evidence a review had been submitted for a level 2 evaluation and determination. On 10/01/2024 at 2:57 p.m., an interview was conducted with S4SSD (Social Services Director) who confirmed she was responsible for submitting reviews to the OBH (Office of Behavioral Health) when a resident had a new qualifying mental illness. S4SSD confirmed that on 05/24/2021 the resident had a new diagnosis of Schizoaffective Disorder but she did not submit a review to the OBH for a level 2 evaluation and determination and should have.

Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standard of practice for 2 (Resident #12 and #19) out of 3 (Resident #12, #19, and #37) residents investigated for respiratory care. The facility failed to: 1. Store Resident #12's oxygen equipment in a sanitary manner, and 2. Provide continuous oxygen therapy for Resident #19. Findings: On 10/02/2024, a review of the facility's policy titled Oxygen Concentrator and Equipment Cleaning Policy and Procedure, with a revision date of 05/09/2024, revealed in part: Purpose: To keep Oxygen concentrator and equipment clean .Procedure .2. Store Oxygen tubing, cannula, and mask in bag when not in use. Review of Resident #12's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Hypoxemia, and Shortness of Breath. A review of physician's orders revealed an order written on 11/29/2023 for O2 (Oxygen) at 2 LPM (liters per minute) PER (by) NC (nasal cannula) PRN (as needed) SOB (shortness of breath) related to Hypoxia. On 09/30/2024 at 9:20 a.m., an observation and interview was conducted with Resident #12. The resident's nasal cannula was on top of the O2 concentrator and left exposed to air. The resident stated that staff applied her O2 tubing when she got short of breath and took it off when she was no longer short of breath. On 09/30/2024 at 9:20 a.m., an observation of Resident #12's O2 set up and an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed the resident's O2 tubing (nasal cannula) was left exposed to air and not stored in a bag. S3ADON stated that nurses are supposed to store the resident's O2 tubing in a bag when not in use. 47540 Resident #19 Review of Resident #19's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Heart Failure. Review of Resident #19's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 03, indicating her cognition was severely impaired. Section O: Special Treatments, Procedures and Programs was checked for oxygen therapy. Review of Resident #19's physician's orders revealed an order dated 11/05/2020 that read in part, oxygen at two liters per nasal cannula continuously . Review of Resident #19's comprehensive care plan with a focus that read in part, I have Chronic Obstructive Pulmonary Disease . I experience Shortness of Breath (SOB) while lying flat, upon exertion, and when at rest. I require use of Continuous Oxygen (O2) with ear cushions to by nasal cannula . On 09/30/2024 at 12:17 p.m., an observation was made of Resident #19 in the dining room eating lunch. Resident #19's oxygen concentrator was observed and it was turned off, and no amount of liters were infusing via nasal cannula. On 09/30/2024 at 12:25 p.m., an interview and observation conducted with S6LPN (Licensed Practical Nurse). S6LPN stated Resident #19 was supposed to receive oxygen via nasal cannula continuously. She confirmed that the resident's oxygen concentrator was off, and was not receiving any oxygen. On 10/01/2024 at 10:21 a.m., an interview with S5LPN. She stated that Resident #19 was on continuous oxygen. S5LPN stated Resident #19's oxygen concentrator was brought to the dining room with her by staff and she was supposed to receive oxygen while eating. She stated Resident #19 does not control the oxygen concentrator and that was turned on and off by the staff. On 10/01/2024 10:38 a.m., an interview with S2DON (Director of Nursing). She confirmed if a resident was ordered to be on continuous oxygen, this means the resident should receive oxygen at all times.

Based on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to document a fall in the resident centered plan of care for 1 (#1) out 3 (#1, #2, and #3) residents investigated for falls. Findings: On 07/09/2024, a review of the facility's policy titled Care Plan Policy and Procedure with a last reviewed date of 01/25/2024 read in part .Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches . a. It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans based on the follow areas; . x. Fall . Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Other Muscle Spasm, Pain, Ataxia and Cognitive Communication Deficit. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 05/15/2024 revealed the Brief Interview for Mental Status (BIMS) of 9, indicating her cognition was moderately impaired. Review of Resident #1's Incident Report dated 06/11/2024, revealed in part . S3LPN (Licensed Practical Nurse) was at nurse's station and heard yelling coming from down the hall. Upon entering the room where yelling was coming from resident in B bed was found face down near locked bed . Hematoma and swelling to upper left side of face redness present . sent to hospital for evaluation . Review of Resident #1's resident centered care plan revealed no documentation of focus areas related to the fall that occurred on 06/11/2024. On 07/09/2024 at 3:42 p.m., an interview was conducted with S2MDS/LPN (Minimum Data Set/ Licensed Practical Nurse) who confirmed Resident #1 had a fall on 06/11/2024. She stated that all falls should be documented in the Resident's plan of care. Review of Resident #1's plan of care was conducted with S2MDS/LPN, she confirmed the plan of care failed to reveal any documentation related to Resident #1's fall on 06/11/2024. On 07/09/2024 at 11:04 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed Resident #1 had a fall on 06/11/2024 and all falls are to be documented in the comprehensive plan of care.

Based on interview and record review, the facility failed to collaborate with a hospice agency to ensure a resident had a current hospice plan of care for 1 (#3 ) out of 3 (#1, #2, #3) residents investigated for hospice services. Findings: Review or Resident #3's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, Anxiety disorder, and Chronic Kidney Disease Stage 3. Review of Resident #3's June 2024 physician's orders revealed an order dated 06/06/2024 that read in part : Admit to . hospice dx (diagnosis) : terminal CAD (Coronary Artery Disease ). Further review of Resident #3's EHR and hard chart failed to reveal a hospice plan of care for the resident. On 06/17/2024 at 2:38 p.m., an interview and record review was conducted with S1DON (Director of Nursing). She stated that the hospice communications and documents were emailed to her by the hospice agency, and these communications and documents were scanned into each hospice resident's EHR. She also stated ADON (Assistant Director of Nursing), QA (Quality Assurance) nurse, and herself checked the hospice residents' charts weekly to ensure they were up to date with care plans. A review of Resident #3's EHR was then conducted with S1DON. S1DON confirmed that the resident's hospice plan of care was not in the resident's record.

Based on record reviews and interviews, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately affected the resident's status for 2 (#1, #2) residents out of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #1's EHR (Electronic Health Record ) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Unspecified Atrial Fibrillation, and Dysphagia. Review of Resident #1's June 2024 physician's orders revealed an order dated 11/03/2023 that read in part: admitted with Hospice with diagnosis of end stage CVA (Cerebrovascular Accident). Review of section O of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident was not coded for hospice care. Review of Resident #2's EHR revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris , Alzheimer's Disease, and Dysphagia. Review of Resident #2's June 2024 physician's orders revealed an order dated 01/03/2023 that read in part: Admit to . hospice for terminal diagnosis of end stage CAD (Coronary Artery Disease). Review of section O of Resident #2's quarterly MDS assessment dated [DATE] revealed the resident was not coded for hospice care. On 06/17/2024 at 1:51 p.m., an interview and record review was conducted with S2MDS. She stated that if a resident received hospice services, it was documented in section O of the MDS assessment. A review of section O of Resident #1 and Resident #2's quarterly MDS assessments dated 03/21/2024 and 04/04/2024 was conducted with S2MDS. She confirmed that the residents' MDS assessments were not coded for receiving hospice services and they should have been.

Based on record review and interview, the facility failed to ensure the facility-wide assessment: 1. accurately identified the number of direct care nursing personnel needed to provide services; 2. included any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility; and 3. included an evaluation of its resources regarding its vehicles. This deficient practice affected 1 resident (#40) with a potential to affect a census of 81 residents currently residing in the facility. Findings: Review of the facility's policy, Staffing Guidelines Policy and Procedure revealed in part that a staffing guidance tool to be utilized to help maintain staffing according to the state and federal guidelines. Review of the facility's policy titled, Facility Assessment Tool Policy and Procedure revealed in part that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The assessment should be used to make decisions about direct care staff needs. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to prove the necessary person-centered care and services the residents require .The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. Further review revealed in part that race/ethnicity and culture needs, physical disabilities, acuity of the residents and vehicles regarding the resident population should be included in the assessment. At minimum, the individuals involved in the facility assessment should include the Administrator, Medical Director, Director of Nursing, and Representative of the Governing Body. Review of the Facility assessment dated [DATE] revealed facility had capacity for 90 residents. The average census was 83. The facility's census was 87. Review of the number of Direct Care Nursing Staffing section revealed: Day shift 2 RNs (Registered Nurses), 7 LPNs (Licensed Practical Nurses) and 12 CNAs (Certified Nursing Assistants). Evening shift 0 RNs, 0 LPNs and 1 CNA. Night shift 0 RNs, 2 LPNs and 6 CNAs. There was no information regarding how the facility determined the number of nursing staff needed for the resident population. The page titled, Culture Needs was void of information. There was no information addressing any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility. Review of the Resident Race/Ethnicity profile revealed 0% of the resident population was Asian. Review of the facility's resources assessment revealed vehicles: available upon request. There was no information regarding the number, type, or capacity of the facility's transport vehicles. Further review revealed review date of 11/01/2022. Attendees with signatures were noted for S5NFA (Nursing Facility Administrator), S2DON (Director of Nursing) and S6MD (Medical Director). Resident #40 Review of Resident #40's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Cerebral Palsy, Aphasia, and Severe Intellectual Disabilities. Review of the resident's annual MDS (Minimum Data Set) dated 07/19/2023 revealed her mental status could not be assessed because the resident was rarely/never understood. Further review of progress notes revealed resident resided in facility during the time the facility assessment was created. Review of the resident's demographics profile revealed Race- Asian; Birthplace-Vietnam; Religion -Roman Catholic. On 09/11/2023 at 12:17 p.m. a review of facility assessment was conducted S7RNCorporate (Registered Nurse Corporate) who stated that the facility assessment was completed by S5NFA, who was the administrator at the time, with S2DON and S6MD. She stated that the current assessment of the number of direct care staff needed per shift was not correct. She stated that the facility assessment had not been revised since 11/01/2022. On 09/11/2023 at 01:00 p.m., S7RNCorporate stated that an addendum was made to the facility assessment for Direct Care Nursing Staffing. Review of the addendum dated 09/11/2023 revealed the reason for addendum was to update for previous staffing numbers to reflect the actual numbers. The addendum was signed by S7RNCorporate and S1ADM (Administrator). S7RNCorporate stated that the facility required at minimum: Day shift 2 RNs, 7 LPNs and 12 CNAs Evening shift 0 RNs, 1 LPN, and 1 CNA Night shift 0 RNs, 2 LPNs and 6 CNAs She further stated that the number of nurses on the day shift consisted of both direct care LPNs and administrative nurses. On 09/12/2023 at 08:50 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing) and S4IPQA (Infection Preventionists Quality Assurance). S4IPQA stated that she was responsible for the CNA schedule. S3ADON stated that S2DON was responsible for the licensed nurse schedule. Both stated that they were not involved in the development or review of the facility assessment. S3ADON and S4IPQA reviewed the facility assessment and stated that the facility required a total of 3 LPNs during the day and 3 LPNs at night providing direct care in a 24 hour period. S3ADON stated that the total of 7 LPNs for the day shift on the facility assessment included the 3 floor nurses providing direct care, herself, S4IPQA, and 2 MDS (Minimum Data Set) assessment nurses. S3ADON confirmed facility assessment information regarding direct care staff was inaccurate. S4IPQA stated that there were a total of 12 CNAs scheduled on the day shift to provided direct care (8 assigned to the floor; 2 shower aides; 1 restorative aide; and 1 aide for transportation). S3ADON and S4IPQA stated that the number of direct care nursing staff assigned depended on the resident census according to a staffing tool provided by their corporate office. Both confirmed there was no information in the facility assessment explaining how the facility calculated the number of direct care staff needed to provide care to residents. A review of the untitled staffing tool provided by S3ADON revealed a chart with a column titled schedule and another titled do not fall below these numbers. Another column included a graduation of census numbers with corresponding numbers under columns titled D, N, and Total. The staffing tool did not indicate if it applied to nurses and/or CNAs. On 09/12/2023 at 11:47 a.m., S4IPQA confirmed the staffing tool she provided was the tool mentioned in the facility's policy. She stated that the staffing tool only applied CNAs to determine the number of CNAs required per census number. D indicated day shift; N indicated night shift, and the last column total was for the total number of CNAs for both shifts. She stated that they did not have a staffing tool for LPNs because they staff the same number of LPNs each shift daily. On 09/12/2023 at 01:18 p.m., S3ADON and S4IPQA confirmed number of direct care staff required was based on census and did not take into account the residents' acuity. S3ADON confirmed that the staffing guidance tool mentioned in the Staffing Guidelines policy was used for CNAs. S3ADON confirmed that there was no staffing tool for LPNs. S3ADON stated that the CNA staffing tool was based solely on census, and did not account for resident acuity level. S2DON was not available for interview during the survey. On 09/12/2023 at 01:49 p.m., a review of the facility's assessment was conducted with S1ADM. He stated that he assumed the role of the facility's administrator in February 2023, replacing S5NFA. He stated that when he assumed the role of Administrator, the Facility Assessment was reviewed by the corporate office. He confirmed that there were no revisions, corrections or updates made to the facility assessment at that time. S1ADM further stated that had not reviewed the assessment for accuracy when assuming his role. He confirmed that the culture assessment page was void of information. He confirmed the facility failed to assess any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility. He was informed at this time that Resident #40 was Asian and that there was no information in the facility's assessment to address any ethnic or cultural factors regarding her care. S1ADM reviewed the facility's direct care staffing assessment and confirmed it was inaccurate and required an addendum on yesterday 09/11/2023. He confirmed the assessment of LPNs on the day shift was not the accurate number of direct care staff required since it included administrative nurses. He stated that the facility utilized a staffing tool to determine the number of CNAs needed per shift and that there was no staffing tool for LPNs needed to provide direct care. He confirmed the resident acuity was not accounted for when determining the number of staff required. He stated that the facility did not have system or calculation used to determine the number of nursing staff needed to provide care based on the acuity level of the residents. A set number of nurses determined by the nursing department work daily regardless of census or acuity. He confirmed the assessment of the facility's vehicles failed to provide in detail of how many transportation vehicles the facility had, vehicle type, vehicle capacity, and information on accommodations needed for residents wheelchairs. He confirmed the facility assessment was not a complete assessment of the facility, its resources regarding vehicles, staffing needs, and cultural/ethnic/racial needs of the resident population.

Based on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff performed hand hygiene when indicated according to accepted standards of practice and the facility's policy during medication administration. The deficient practice had the potential to affect a census of 81 residents. Findings: A review of the facility's policy titled Hand Hygiene Policy and Procedure read in part: Policy: Hand hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination .Procedure: 1. Hand Hygiene will be performed via utilizing hand sanitizer or hand washing in the following situations .c. Before and after direct resident contact .w. after removing gloves . On 09/12/2023 at 07:39 a.m., an observation was made of S8LPN (Licensed practical Nurse) performing a blood glucose test for Resident #55. S8LPN donned her gloves and attempted to check Resident #55's blood glucose without the test strips. S8LPN then removed her gloves, returned to the medication cart and picked up the blood glucose strips without sanitizing her hands. S8LPN returned to Resident #55's room, donned a clean pair of gloves without sanitizing her hands and checked the resident's blood sugar. S8LPN removed her gloves after she performed blood glucose test and did not sanitize her hands. On 09/12/2023 at 8:30 a.m., an observation was made of S8LPN administering medications to Resident #19. S8LPN prepared the resident's medications; donned a clean pair of gloves; and then administered the resident's inhaler and oral puffer. S8LPN did not sanitize her hands before she prepared and administered Resident #19's inhaler and oral puffer. On 09/12/2023 at 09:00 a.m., an interview was conducted with S8LPN. S8LPN confirmed that she had not sanitized her hands after removing her gloves to get the test strips for Resident #55 and that she should have sanitized her hands. S8LPN then confirmed that she had not sanitized her hands before she donned her gloves to administer Resident #19's inhaler and oral puffer. S8LPN stated that she should have sanitized her hands before and after she donned her gloves On 09/12/2023 at 09:15 a.m., an interview was conducted with S4IPQA (Infection Preventionist, Quality Assurance Nurse) S4IPQA confirmed that staff is supposed to sanitize their hands before donning and after removing their gloves.

Based on observation, record review and interviews, the facility failed to maintain dignity for 4 (Resident # 16, 19, 65, and 69) out of 33 sampled residents by failing to provide residents with homelike silverware/metal utensils for all meals. Findings: Review of the facility's policy, Resident Rights and Quality of Life Policy and Procedure revealed, in part, the following: Policy: All residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility . A resident has the right: . 22. To be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and care for his/her personal needs. Resident # 16 Review of Resident #16's (clinical/medical) record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of Resident #16's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact. On 09/12/2023 at 1:30 p.m., an interview was conducted with Resident #16. The resident stated the facility provided the residents with plastic utensils for approximately three months. She stated on 09/11/2023 during lunch was the first time residents received metal utensils. Resident #16 voiced that receiving plastic utensils made her feel frustrated. The resident stated living here is was supposed to feel like her home and at her home she would not use plastic utensils. 47965 Resident #19 Resident #19 was admitted to the facility on [DATE] with diagnoses that included in part: Hypertensive Heart Disease with Heart Failure, and Major Depressive Disorder. On 09/11/23 at 10:00 a.m., an observation and interview was conducted with Resident #19. The resident stated the facility provided plastic utensils with all her meals. Resident # 65 Review of Resident #65's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hypertension, Spinal Stenosis, and Deficiency of Vitamin E. Review of Resident #65's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact. On 09/11/2023 at 10:59 a.m., an interview was conducted with Resident #65 who reported the facility provided residents with plastic spoons and plastic forks for all meals. She stated last night the residents received ham for dinner and she was unable to cut her ham with the plastic utensils provided. She stated that made her feel mad to receive plastic utensils 44269 Resident # 69 Review of Resident #69's (clinical/medical) record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, and Muscle Wasting and Atrophy. Review of Resident #69's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact. On 09/11/2023 at 9:45 a.m., an initial interview was conducted with Resident #69 who stated the facility was providing plastic utensils with the meals served. Resident #69 stated she disliked eating with plastic utensils because it did not feel homelike. On 09/11/2023 at 1:35 p.m., a second interview was conducted with Resident #69. She stated the facility provided the residents with plastic utensils for three months. Resident #69 reported that she felt disappointed in the facility for providing the residents with plastic utensils. On 09/12/2023 at 2:04 p.m., and interview was conducted with S17DM (Dietary Manager). S17DM stated she was notified by S12AD (Activity Director) last week about several residents complaining about using plastic utensils with their meals. She stated she was unaware that her staff were putting plastic utensils on the meal trays. She stated there is no excuse why we were giving residents plastic utensils and I told my staff this is a dignity issue. S17DM confirmed that residents should not have received plastic utensils with their meals. On 09/12/2023 at 2:26 p.m., and interview was conducted with S1ADM (Administrator). S1ADM stated that he was unaware of the complaint from residents regarding residents using plastic utensils with their meals. He confirmed that residents should not have been provided plastic utensils and should have received metal utensils.

Based on interview and record review the facility failed to assess 1 (#74) out of 1 sampled residents for self-administration of medication in a final sample of 81 residents. Findings Review of the facility's policy titled, Medications-Self Administration Policy and Procedures revealed in part, Policy: In order to maintain the resident's high level of independence, the residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility . Procedure: 1. If a resident desires to self-administer medications, an assessment is conducted by the Interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process-a. Complete Self-Administration Assessment . Resident #74 was admitted to the facility on [DATE] with diagnoses that included Stage 5 Kidney Disease, Bipolar Disorder and Dependence on renal dialysis. Review of Resident # 74's electronic and paper medical record revealed no documented evidence that a medication self-administration assessment was conducted. On 09/13/2023 at 12:02 p.m., an interview was conducted with S15LPN (Licensed Practical Nurse). She stated that she was familiar with Resident #74. She confirmed that on the days that the resident goes to dialysis (Monday, Wednesday and Friday), she put the resident's 2:00 p.m. medications of Midodrine (medication for low blood pressure), Sodium Bicarbonate (an antacid), and Cyclopbenzaprine (muscle relaxant) in a plastic bag and send them with the resident to take at 2 p.m. while at dialysis. She confirmed Resident #74 self-administered the medications while at dialysis. She stated that she was not aware of how to check if a resident was competent to self-administer their own medications. On 9/13/2023 at 12:23 p.m., an interview with S3ADON (Assistant Director of Nursing) was conducted. S7RNCorporate (Registered Nurse Corporate) was present. S3ADON confirmed that Resident #74 was given medications to take while she was at dialysis. She confirmed that the resident self-administered these medications. S3ADON was asked to provide a copy of a completed medication self-administration assessment for the resident. At that time, both S3ADON and S7RNCorporate searched the resident's electronic record and was unable to find an assessment. S7RNCorporate stated that the assessment should have been completed by the MDS (Minimum Data Set) nurse. S14MDSCorporate was called and she attempted to locate Resident #74's medication self-administer assessment in the computer. S14MDSCorporate and S7RNCorporate confirmed that a medication self-administration assessment was not completed for Resident #74. On 9/13/2023 at 12:45 p.m., a telephone interview was conducted with the RN (Registered Nurse) at the dialysis center. She confirmed that Resident #74 was sent to the center with medications to take while at dialysis. She confirmed that the resident self-administered her own medications.

Based on record review and interviews, the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in a facility. Findings: Review of the facility's policy, Grievance Policy and Procedure revealed, in part, the following: Purpose: To ensure each resident has the right to voice grievances with respect to treatment or care, that is, or fails to be furnished without discrimination or reprisal for voicing the grievances. To ensure each resident grievance will be followed up by prompt efforts to resolve grievance that the residents may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly and appropriate corrective action taken. Procedure . 6. Resident council or other resident meeting minutes are to be given to administration after completion of meeting. Any complaints made will be logged on the grievance form . 9. Social Services/Designee will complete follow up with family/resident as applicable . 11. All grievances will be logged on the grievance log. A review of the Resident Council Meeting Minutes was conducted and revealed notes by S12AD (Activity Director) for 08/03/2023 with the different complaints addressed; however there was no evidence the complaints were reviewed by S1ADM (Administrator) nor that the facility provided a response to the different complaints. A review of the facility's grievance log from 08/2023 failed to include the complaints addressed during the monthly Resident Council Meeting Minutes for 08/03/2023. On 09/11/2023 at 1:30 p.m., an interview was conducted with Resident # 16 who reported she was the President of Resident Council. Resident # 16 reported she attends the Resident Council monthly meetings regularly and all complaints are voiced during the monthly meetings with the S12AD present. On 09/12/2023 at 11:59 a.m., and interview was conducted with S12AD. S12AD confirmed she was the designated staff who sat in on the monthly Resident Council meetings. A review of the Resident Council Meeting Minutes from 08/03/2023 was reviewed with S12AD and she confirmed she had given a copy of all complaints during the monthly meeting to administrative staff. On 09/12/2023 at 2:21 p.m., an interview was conducted with S1ADM. S1ADM confirmed that he received a copy of the Resident Council Meeting Minutes from 08/03/2023. S1ADM confirmed that he was aware of the complaints and stated that S13SSD (Social Service Director) was responsible for the documentation of the facility's grievance log and resolution of grievances. S1ADM confirmed that the complaints from the Resident Council Meeting Minutes from 08/03/2023 was not logged on the facility's grievance log from 08/2023. On 09/12/2023 at 2:53 p.m., an interview was conducted with S13SSD. S13SSD confirmed that she should have started a Resident Council Meeting Minutes grievance for the complaints from 08/03/2023 and she did not.

Based on interviews and record review, the facility failed to ensure that the environment of a resident was free from accidents hazards by failing to lock a resident's bed. This deficient practice had the potential to affect 1 (#25) of 2 (#25 and #55) residents investigated for falls. Findings: Resident #25 was admitted to the facility on [DATE] with diagnoses in part: Peripheral Vascular Disease, Heart Failure, Osteoarthritis of Knee, and Unspecified Fracture of T11-T12 Vertebra. A review of Resident #25's Quarterly MDS (Minimum Data Set) dated 07/06/2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 5 that indicated the resident had severe cognitive impairment. A review of an incident reported by S18LPN (Licensed Practical Nurse) on 07/18/2023 at 7:00 p.m., revealed that the resident attempted to transfer herself from her wheelchair onto the side of her bed and the bed rolled away because it was not locked. The resident was found sitting upright between the bed and her wheelchair. An area of discoloration was noted to the lower aspect of her left rib cage and discoloration below her left knee. A review of Resident #25's Plan of Care revealed that the resident was care planned on 11/27/2019 for being at risk for falls due to weakness, decreased mobility, and a history of a fall with fracture. Interventions included the resident needed her bed locked and in a low position. On 09/13/2023 at 07:52 a.m., an interview was conducted with S18LPN. S18LPN stated that she found the resident on the floor on 7/18/2023 at 7:00 p.m., and the front of the resident's bed was in place but the back had rolled away from her. S18LPN stated that the resident's bed was supposed to be locked and was not.

Based on policy review, record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) trainee was competent prior to performing resident care for 1 (#69) resident out of a finalized sample of 33 residents who were investigated for sufficient and competent staffing. Findings: Review of facility's policy and procedure, titled Staff Development and Training revealed, in part, Purpose: To ensure staff is trained and competent in the assigned job title to ensure resident and employee safety, compliance with federal and state regulations, . Orientation will be provided including the review of required policies and procedures the facility has developed to ensure that employee is successful in their job position. Procedure: 1. Designee provides employees with orientation training reviewing training materials and facility applicable policies 3. Competency form is started at the beginning of orientation and completed throughout the training process. The training time frame is specific to the employee level of training required. Once the competency is completed the employee can work without a preceptor or trainer . Review of S11CNA's personnel record revealed a hire date of 07/24/2023. There was no evidence available indicating S11CNA's competencies were evaluated. Review of the nursing staff schedule dated 07/27/2023 revealed S10CNA was training S11CNA on Hall A for the day shift (6:00 a.m.-6:00 p.m.) Review of Resident #69's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with the following pertinent diagnoses: Cerebral Infarction (Stroke), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-dominant Side, Other Lack of Coordination, Anxiety Disorder, Unsteadiness on Feet, Other Abnormalities of Gait and Mobility and Left Foot Drop. Review of Resident #69's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was assessed as having a BIMS (Brief Interview for Mental Status) score of 15 meaning her cognition was intact. Review of section titled, Functional Status, revealed Resident #69 was assessed as requiring two persons physical assistance for transfers. Resident #69 was assessed as having limitation in range of motion to her upper and lower extremity with impairment on one side. Review of Resident #69's current care plan revealed she required staff assistance for ADL's (Activities of Daily Living) related to left sided hemiplegia and left foot drop with interventions, in part, to assist with transfers. Review of the facility's grievance log revealed Resident #69 had filed a grievance on 07/28/2023 with the subject of grievance/complaint listed as CNA was too rough and resolution included Incident Report/Investigation and staff in serviced. Review of the form titled, Grievance/Complaint Report, dated 07/28/2023 at 8:00 a.m. per S2DON (Director of Nursing) revealed Resident #69 complained that S11CNA was too rough when attempting to transfer the resident from her bed to wheelchair and grabbed her lower leg where a bruise already existed and grabbed her right upper arm where she caused a bruise. Review of the incident and accident investigation report dated 07/28/2023 reported and prepared by S2DON (Director of Nursing) revealed: Incident type: bruise-hematoma; Narrative of incident and description of injuries read: Bruise noted to right upper extremity, dark purple and maroon in color. Resident complains of no pain. Resident noted on blood thinners. Resident states arm was held by S11CNA during transfers. Further review of incident and accident investigation report dated 07/28/2023 revealed immediate actions taken: assessed resident, vital signs taken, notification of provider and resident's responsible party. Review of handwritten statement per S10CNA dated 07/28/2023 read: Started shift on 07/27/2023 with trainee (S11CNA). S10CNA had gone into a Resident's room and S11CNA went into Resident #69's room to get her up and S16LPN told her to stop what she was doing to tend to Resident #69. S10CNA went finish getting resident up because Resident #69 was more comfortable with her. Resident #69 said she was very uncomfortable with S11CNA. Review of typed statement per S16LPN dated 07/28/2023 at 8:54 a.m. read: S16LPN worked 6:00 a.m.- 12:00 p.m. on 07/27/2023 and during morning medication pass, prior to breakfast, witnessed S11CNA go in to Resident#69's room to provide ADL care and get resident up for breakfast. While in Resident #69's room, at some point, S11CNA stuck her head out in the hall and asked S16LPN to call S10CNA to come to resident's room to transfer the resident into her wheelchair. S11CNA stated She doesn't want me to transfer her because she said I don't know how. S16LPN went to S10CNA and informed her that S11CNA needed her assistance to transfer Resident #69. Review of S11CNA's hand written statement dated 07/31/2023 revealed: Went to get Resident #69 up .S11CNA put her arms under resident's and resident stated that is not how they get her up; Resident told S11CNA how they get her up and then S11CNA took the pad and pulled resident to the edge of the bed like resident said to. After that resident said S11CNA was still not doing it right so S11CNA then went and got S10CNA. This all happened on 07/27/2023. On 09/11/2023 at 9:45 a.m. an interview was conducted with Resident #69. Resident #69 stated S11CNA attempted to get her out of bed before breakfast, but that she had to explain to S11CNA how to properly transfer her from her bed to her wheelchair because S11CNA was in training and newly hired. S11CNA notified S16LPN to get S10CNA to come assist the resident with the transfer. S10CNA then transferred the resident because she did not feel comfortable with S11CNA. On 09/12/2023 multiple attempts were made to contact S11CNA by phone at 7:30 a.m., 12:00 p.m. and 5:15 p.m. with no answer. On 09/13/2023 at 8:29 a.m., an interview was conducted with S10CNA who recalled working on 07/27/2023 and reported she was training S11CNA. S10CNA stated that was her first time training S11CNA. S10CNA stated Resident #69 had used her call bell to request assistance getting out of her bed and in to her wheelchair but S10CNA was in the middle of helping a different resident, so S11CNA went to assist Resident #69. S10CNA stated she was not aware she was not supposed leave S11CNA unsupervised. S10CNA confirmed S2DON in serviced all staff on 07/28/2023 that trainers were not to leave trainees unsupervised until all training was completed. On 09/13/2023 at 12:58 p.m., a phone interview was conducted with S2DON who stated S11CNA had just started and was training with S10CNA on 07/27/2023. S2DON explained that she was made aware that S11CNA was providing resident care unsupervised and she should not have been unsupervised until she was competent. On 09/13/2023 at 3:46 p.m., an interview was conducted with S4IPQA (Infection Preventionist, Quality Assurance Nurse) who stated she was responsible for scheduling orientation for newly hired CNAs. S4IPQA stated S11CNA was on her second day of training on 07/27/2023 and was scheduled to train again on 07/31/2023 and 08/01/2023 and orientation would have been scheduled for the following week. S4IPQA confirmed S11CNA did not have a competency checklist because S11CNA resigned on 07/31/2023.

Based on record review and interviews, the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in a facility with a census of 86 residents according to the resident census and conditions. Findings: Review of the facility's Grievance Policy revealed the following in part: Purpose: To ensure each resident has the right to voice grievances with respect to treatment or care, that is, or fails to be furnished without discrimination or reprisal for voicing the grievances. To ensure each resident grievance will be followed up by prompt efforts to resolve grievance that the residents may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly and appropriate corrective action taken. Procedure: 6. Resident council or other resident meeting minutes are to be given to administration after completion of meeting. Any complaints made will be logged on the grievance form. 9. Social Services/Designee will complete follow up with family/resident as applicable. 11. All grievances will be logged on the grievance log. A review of the Resident Council meeting minutes binder was conducted and revealed handwritten notes by S5AD (Activity Director) for 03/2022 thru 08/2022 with the different complaints addressed; however there was no evidence the complaints were reviewed by S1ADM (Administrator) nor that the facility provided a response to the different complaints. Further review of the Resident Council minutes binder revealed blank forms titled Resident Council Meeting Minutes with areas designated to include information regarding report/solutions to problems, concerns and complaints of last meeting, new problems, new complaints and new issues will be forwarded to the Department Heads. A review of the facility's grievance logs from 03/2022 through 08/2022 failed to include the complaints addressed during the monthly Resident Council meetings. On 08/29/2022 at 9:21 AM, an interview was conducted with Resident # 68 who reported she was the Vice President of Resident council and provided verbal permission to review Resident Council meeting minutes. Resident # 68 reported the facility's food was not seasoned consistently, meals were not served warm, and that she receives a lot of beans. Resident # 68 reported she attends the Resident Council monthly meetings regularly and she has voiced her concerns with the food provided multiple times. She reported S6DietSup (Dietary Supervisor) was present at one of the meetings a couple of months ago and listened to the residents' concerns. On 08/30/2022 at 9:55 AM, an interview was conducted with Resident #45 who reported she has gone to some of the monthly Resident Council Meetings and had complained about the facility's kitchen not making condiments readily available, meals mostly served cold and that suppers were skimpy. S5AD was interviewed on 08/30/2022 at 3:47 PM and confirmed she was the designated staff who sat in on the monthly Resident Council meetings. S5AD reported she did have a form titled Resident Council Meeting Minutes that she attempted to transfer her handwritten notes. A review of the Resident Council meeting minutes binder was reviewed with S5AD and she confirmed she had not used the designated forms. S5AD reported she was not aware the complaints voiced during monthly meetings were to be included on the facility's grievance log. On 08/30/2022 at 4:04 PM, an interview was conducted with S2DON (Director of Nursing). S2DON confirmed S5AD was designated staff responsible for documenting information discussed during the monthly Resident Council meeting and that any concerns would be documented as grievances. S2DON explained S1ADM is responsible for all food complaints and that S4SSD (Social Services Director) was responsible for documentation including the nature of the grievances and the resolution of the grievance/complaint. S1ADM was interviewed on 08/30/2022 at 4:23 PM and he reported S5AD informed him of specific grievances voiced during the monthly Resident Council meetings. S1ADM reported he was not aware he should be reviewing the Resident Council monthly meeting minutes. S1ADM was aware of the repeated complaints regarding the facility's kitchen and food. S1ADM explained S4SSD was responsible for the documentation of the facility's grievance logs and resolutions of grievances. On 08/30/2022 at 4:28 PM, S4SSD joined the interview and reported she had not received any grievances from the monthly Resident Council meetings. S1ADM confirmed the grievances voiced during the monthly Resident Council meetings should have been documented on the facility's grievance logs and had not been since he took over the Administrator role as of February 2022.