Every finding on record at Forest Hill Manor Health Center

Based on interview and record review, the facility failed to ensure services were provided that meet professional standards of quality when assessments of pressure sores were incomplete for 2 of 3 residents (Residents 1 & 2). This failure had the potential to compromise Residents' health and safety. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), peripheral vascular disease (PVD, slow progressive narrowing of the blood flow to the arms and legs), Protein Caloric Malnutrition (PCM, condition resulting in inadequate intake of protein and calories, and chronic kidney disease (CKD, a condition where kidneys cannot properly filter blood in the body). Review of Resident 1's initial body check on 3/14/26 indicated, she had stage 2 sacral pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound over the tail bone) measuring 0.3 centimeter (cm, unit of measurement) in length, 0.3 cm in width, and 0.1 cm in depth. There was no description of stage 2 sacral pressure ulcer. Review of Resident 1's weekly summary evaluation dated 3/21/26 indicated, there was no documentation of the measurement and description of stage 2 sacral ulcer. During an interview and medical record review with the Director of Nursing (DON) on 4/10/26 at 10:44 a.m., she confirmed that there was no documentation in Resident 1's medical record of the description of stage 2 sacral ulcer on 3/14/26, and no measurement and description of stage 2 sacral ulcer on 3/21/26. DON acknowledged facility's licensed nurses should have assessed and documented the measurement and description of Resident 1's sacral pressure ulcer such as the color, discharges, odor, surrounding skin and pain level to determine if it is improving or deteriorating. During an interview with Licensed Vocational Nurse A (LVN A) on 4/10/26 at 11:16 a.m., she stated that when assessing the pressure ulcer, the facility licensed nurse should include the measurement and description of the wound ulcer such as color, odor, discharges and pain level in the documentation. Review of Resident 2's medical record indicated he was admitted to facility on 3/31/26 with diagnoses including DM, PCM, and PVD. Review of Resident 2's initial body check on 3/31/26 indicated he had stage 2 sacral pressure ulcer measuring 0.75 cm in length, 0.5 cm in width and 0 cm in depth with redness and no drainage. Review of Resident 2's weekly summary evaluation dated 4/7/26 indicated there was no measurement and description of stage 2 sacral pressure ulcer. During an interview and record review with the DON on 4/14/26 at 2:50 p.m., she confirmed that there was no documentation in Resident 2's medical record of the measurement and description of stage 2 sacral ulcer on 4/7/26. DON acknowledged facility's licensed nurse should have documented the measurement and description of the stage 2 sacral ulcer. Review of the revised facility's policy and procedures dated 4/2018 titled, Pressure Ulcer /Skin Breakdown-Clinical Protocol indicated, the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, width and depth presence of exudates or necrotic tissue.

Based on observation, interview and record review, the facility failed to ensure a resident received adequate monitoring to prevent an elopement (leaving the facility without authorization) for one of two sampled residents (Resident 1). Resident 1's elopement assessment indicated she was at risk for elopement, and a care plan was not developed upon admission. On 6/27/25, Resident 1 eloped, was found the next day on 6/28/25 in the neighborhood, transferred to a hospital, was noted to have hypothermia (significant and potentially dangerous drop in body temperature with most common cause from exposure to cold weather) and sustained injuries of forehead laceration (cut) requiring suturing.This failure resulted in Resident 1 having multiple bodily scratches/abrasions, hypothermia, altered mental status, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), forehead laceration and urinary tract infection.Findings:Review of Resident 1's Nurse's Note, dated 6/27/25 at 11:23 p.m., indicated around 4 p.m. the resident was walking in the hallway back and forth and went into another resident's room. It indicated about 4:15 p.m., Resident 1 was not in her room, all staff were informed, and a search began, and at 4:39 p.m. the police were notified.Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/10/25, indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15, indicating she had memory problems and severe impairment in daily decision-making skills.Review of Resident 1's admission Elopement - Wandering (moving from place to place without a clear goal or direction) assessment dated [DATE], scored seven, indicating the resident was at moderate risk for elopement. Under Recommendations for Safety, it indicated routine rounding, bed to low position, and resident had a sitter (non-medical staff who provides continuous, one-on-one supervision for residents at risk of injury, such as falls) in the evening. There was no documented evidence a care plan was developed addressing Resident 1's risk for elopement.During an interview on 9/3/25 at 1:24 p.m., the director of nurses (DON) stated Resident 1 walked independently without assistive devices (i.e. cane, walker), had a sitter during the beginning of her admission because she was at high risk for fall. The DON stated on the day of elopement on 6/27/25, the family member did not visit, and Resident 1 was seen on the street (Fountain Street) by a visitor near the back exit walking uphill. The DON who reviewed the record stated Resident 1 was assessed at risk for wandering/elopement and a care plan should have been developed.During a tour and interview with RN A on 9/3/25 at 2:38 p.m. It was observed there are three exits including the main entrance leading to public street and one exit to a back pubic street. RN A during the tour of the facility stated none of the exit doors leading to public streets were alarmed.Review of Resident 1's Fall Risk Assessment form, dated 6/6/25, indicated the resident was at high risk for falls. A fall monitoring log to document hourly from midnight to 11 p.m. was initiated on 6/7/25 at midnight f or Resident 1. The monitoring log was not consistently completed; entries were missing on 6/12/25 from midnight to 2 p.m., 6/13/25 from 4 p.m. to 11 p.m.6/17/25 from 8 a.m. to 11 p.m., 6/18/25 from 8 a.m. to 2 p.m.,6/18/25 from 4 p.m. to 11 p.m., 6/19/25 and 6/20/25 from 4 p.m. to 11 p.m., 6/21/25 from 7 a.m. to 11 p.m., 6/23/25 from midnight to 7 a.m., 6/24/25 from 1 p.m. to 11 p.m., 6/25/25 from 4 p.m. to 11 p.m., and 6/26/25 from 4 p.m. to 11 p.m. with no explanation for no documentation. Also, the fall monitoring log dated 6/27/25 during the times Resident 1 was missing from 5 p.m. to 11 p.m., indicated Resident 1 was monitored for falls in the facility.During an interview on 9/3/26 at 2:40 p.m., the DON who reviewed the monitoring log acknowledged the monitoring entries were not complete.During an interview on 9/18/25 at 3:10 p.m., the certified nurse assistant (CNA) confirmed he initialed Resident 1's Monitoring Log on 6/27/25 from 4 p.m. to 11 p.m. The CNA stated Resident 1 was missing and he made a mistake in documentation in the fall monitoring log.During an interview on 9/25/25 at 11:07 a.m. the DON stated the facility did not have a wander guard (system with bracelets and sensors at doorway and a central platform that sends alerts to staff when a person approached a restricted area) and no alarm system.During an interview on 10/1/25 at 3:15 p.m., the social services director (SSD) stated Resident 1 had a sitter paid by the family on 6/6/25 from 7 a.m. to 7 p.m. The sitter service was discontinued on 6/10/25 after she discussed with a family member the resident did not need a sitter.Review of the Pacific Grove Police Department (PGPD) report, dated 6/27/25 at 9:29 p.m., indicated the California Highway Patrol activated a Silver Alert (pubic notification issued by law enforcement for a missing adult who is 65 or older and is considered at risk of harm due to their condition or the circumstance of their disappearance) for Resident 1 within a 3-mile radius of the area, a missing person flyer was posted on the PGPD's social media accounts for citizens to be on the lookout and volunteers were prompted to respond and conduct a systemized search for the resident. It indicated on 6/28/2025, at approximately 3:44 p.m., dispatch advised officers that a citizen reported that they located Resident 1. Resident 1 was not in a clear state of mind, the resident was talking and pointing about a dog but there was no dog in sight and when asked if she slept she stated Yes.Review of Resident 1's acute hospital emergency department (ED) note, dated 6/28/25 at 8:39 p.m., indicated the patient had multiple bodily scratches/abrasions including a gaping scalp wound requiring repair and possible fall and was likely out all night. It indicated a [NAME] (medical device used to raise a person's body temperature) was started given significant hypothermia. The ED Clinical Impressions included altered mental status, hypothermia, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), forehead laceration and urinary tract infection.Review of the Care Planning - Interdisciplinary Team (IDT, members of the health team who meet to discuss and plan residents' care) policy, revised September 2013, indicated the IDT was responsible for the development of an individualized comprehensive care plan for each resident.Review of the Wandering and Elopements policy, revised March 2019, did not address preventative measures to prevent elopement.During an interview on 9/3/25 at 1:51 p.m., the DON who provided the elopement policy stated policy addressed preventative measures.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened, undated, and unlabeled food items in the reach-in refrigerator; 2. There were undated and unlabeled food items in the food preparation area; 3. Pans used for food preparation and food service were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 24 of 24 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 4/21/25 at 9:20 a.m., accompanied by the registered dietician (RD), the following observations were made in the reach-in refrigerator: The following items were opened and undated: - 1 gallon of milk - 1 32-ounce carton of liquid eggs - 3 5-pound containers of sour cream - 1 gallon of Italian dressing and 1 gallon of coleslaw dressing - 1 gallon of maple syrup The following items were opened, undated, and unlabeled: - 3 pitchers containing yellow, orange and brown colored liquids - 3 glasses containing yellow liquid - 1 bowl containing a pink substance The RD confirmed the above observations and stated all food items should be dated with an open date and labelled. The RD stated the undated and unlabeled food items need to be discarded. Review of the facility's undated policy titled Guidelines for Storage - Date your products with Use By Dates indicated a list of food items with specific use by dates for refrigerated items. The list included: Milk 8-20 days; Sour Cream 2 weeks; Egg substitute 10 days; and Salad Dressings 3 months. 2. During an initial kitchen tour on 4/21/25 at 9:20 a.m., accompanied by the registered dietician (RD), the following items were observed in plastic containers on a shelf above the food preparation area: rigatoni noodles, lentils, rice, brown sugar, polenta, and panko breadcrumbs. The plastic bins were unlabeled and undated. The RD confirmed the observations and stated the bin's contents should be labeled and dated when they are placed in the containers. Review of the facility's undated policy titled Food Storage indicated Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetable, and broken lots of bulk foods. All containers must be legibly and accurately labeled. 3. During an initial kitchen tour on 4/21/25 at 9:20 a.m., accompanied by the registered dietician (RD), there were 13 metal pans of various sizes, observed to be stacked on a metal wire rack. The pans were stacked upside down inside of one another and were wet inside and outside of the pan's surfaces. The RD confirmed the pans were wet and she stated they should have been air dried before being stacked and stored. According to the 2022 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) to document medication administration as in accordance with the facility policy and procedures (P&P) and the availability of medication for three out of 13 sampled residents (Resident 10, Resident 9, and Resident 15). These failures had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally) and had the potential for untreated or worsening of patient's medical conditions. Findings: 1. A review of Resident 10's clinical record indicated Resident 10 was admitted to the facility with diagnoses including anxiety (Intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 10's physician's order indicated an order, dated 3/27/25, for diazepam (it can treat anxiety)5 mg (milligram, unit of measurement), 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. During a concurrent interview and record review on 4/22/25 at 2:27 p.m., with Director of Nursing (DON), the DON reviewed Resident 10's Controlled Drug Record (CDR) for diazepam 5 mg, the March and April 2025 Medication Administration Records (MARs) indicated, on 3 occasions, the nursing staff signed out one tablet on CDR, but did not document their administration on the MAR, as follows: 3/29/25 at 2100 4/02/25 at 1806 4/15/25 at 1700 The DON confirmed these findings that those dates are not signed for in the MAR. DON stated they [nurses] should sign the MAR and CDR. She further stated it's a proof the medication is given to the resident and notification also to the nurse if the medication is due to be administered. 2. A review of Resident 9's clinical record indicated Resident 9 was admitted to the facility with diagnoses including type 2 Diabetes Mellitus (DM, a condition which affects the way the body processes blood sugar). A review of Resident 9's physician's order indicated an order, dated 4/9/25, for Oxycodone-Acetaminophen (a potent controlled medication for pain )5-325 mg (milligram, unit of measurement), 1 tablet by mouth every 4 hours as needed for moderate to severe pain. During a concurrent interview and record review on 4/22/25 at 2:49 p.m., with Director of Nursing (DON), the DON reviewed Resident 9's Controlled Drug Record (CDR) for Oxycodone-Acetaminophen 5 -325 mg, the April 2025 Medication Administration Records (MAR) indicated, on 4/16/25 at 1912, the nurse signed out one tablet on CDR, but did not document the administration on the MAR. The DON stated the nurse should sign the MAR specially if it's a controlled substance. During a review of facility's P&P titled, Administering Medications Revised date 2019, the P&P indicated, .23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; .e. any complaints or symptoms for which drug administered was administered; f. any result achieved and when those results were observed; and g. the signature and title of the person administering the drug . During a review of facility's P&P titled, Controlled Substances revised April 2019, the P&P indicated, indicated in part, 10. upon administration: a. The nurse administering the medication is responsible for . (3) Time of administration . (6) signature of nurse administering medication . 3. During a medication administration observation on 4/22/25 at 4:26 p.m., Registered Nurse A (RN A), she was observed preparing medication for Resident 15. RN A stated Carbidopa-levodopa (combination medication used to treat Parkinson's disease [a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance, and posture] and related conditions.) for Resident 15 is not available. RNA A stated it was ordered from pharmacy. RN A further stated Resident 15 is not getting her 5:00 p.m. dose. A review of Resident 15's clinical record indicated Resident 15 was admitted to the facility with diagnoses including Parkinson's disease. A review of Resident 15's physician's order indicated an order dated 4/4/25, for Carbidopa-levodopa 25-100 mg (milligram, unit of measurement), 1 tablet by mouth before meals (0630,1130, and 1630). During a review of Resident 15's Medication Administration Record (MAR), the MAR indicated on 4/22/25 at 1630 RN A put chart codes 9=Other/see progress notes. During a review of Resident 15's Progress Notes dated 4/22/25 RN A documented Meds (medication) not on hand call Dr. (Doctor) ok to give when meds arrive. During an interview on 4/23/25 at 3;16 p.m., with the Director of Nursing (DON), the DON stated nurse should order 72 hours before they run out of medication. She further stated the resident should receive the medication on time and should have medications available all the time. During a review of facility's P&P titled, Administering Medications Revised date 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to ensure proper medication storage when the medication refrigerator temperature is below the acceptable range of 36 Fahrenheit (F) to 46 (F). These failures had the potential for residents to receive medications with reduced efficacy. Findings: On 4/21/25 at 9:46 a, m., an inspection of the medication refrigerator in Medication Room with the Director of Nursing (DON) observed the built up of thick ice inside the medication refrigerator and the temperature was 32 F. There were medications inside the refrigerator. The DON confirmed these findings, she stated the ice built up inside the medication refrigerator should not be that thick. During a follow inspection of medication refrigerator inside the Medication room on 4/21/25 at 1:57 p.m., with the DON, The DON checked the refrigerator temperature, and she stated the temperature was 28 F, she further stated the acceptable range for medication refrigerator temperature is 36 F to 46 F. She stated she will call the pharmacy. The DON confirmed the Medications inside the refrigerator were as follows. a. Unopened vial of insulin (used to control blood sugar) manufacturer's label indicated store refrigerator at 36 F to 46 F. b. One 60 ML (milliliter, unit of measure) compounded drug (a medication that is prepared by a pharmacist by mixing, combining, or altering ingredients to create a medication tailored to the needs of a specific patient) of Daptomycin (medication used to treat certain blood infections or serious skin infections). c. Two unopened bottle of latanoprost eyedrops (used to treat glaucoma [group of eye diseases that can cause vision loss and blindness]) the pharmacy label indicated to Stored unopened bottle under the refrigeration at 36 F to 46 F. d. Two vials of tuberculin (contains the solution used in a Mantoux test to detect exposure to tuberculosis) with manufacturer's label indicated store (in) refrigerator at (35 F to 46 F) Do not freeze. e. One small box of Emergency kit (E-Kit) inside the box was two vials of insulin and one vial of Lorazepam (medication used to treat anxiety disorders {excessive and persistent worry or fear that can interfere with daily life}). f. Two doses of influenza vaccine (a shot that helps protect against influenza viruses). During a concurrent interview and record review on 4/22/25 at 3:01 p.m., with the DON, the DON reviewed the medication refrigerator log for month of April 2025 which indicated NORMAL TEMPERATURE LOG OF THE REFRIGERATOR IS: 36 TO 46 DEGREE FAHRENHEIT (2-8 Degree Celsius). there were seven occasions that the temperature were below the acceptable range as follows: 4/08/25=34 F 4/12/25=34 F 4/14/25=34 F 4/15/25=34 F 4/16/25=34 F 4/18/25=34 F 4/21/25=34 F The DON stated the 34 F is not acceptable range and the nurse should have reported it. She further stated medication inside the fridge like insulin has temperature recommendations. A review of facility's policy and procedure titled Storage of Medications, revised 11/2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .

Based on observation, interview, and record review, the facility failed to ensure dignity and privacy was upheld for one of two sampled residents (Resident 179) when Resident 179's Foley catheter drainage bag, (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 179. Finding: During an observation on 4/21/25 at 10:46 a.m., in Resident 179's room. Resident 179 was observed lying on her bed. Her Foley catheter drainage bag was on the floor and the bag was left uncovered, yellow colored urine was visible from drainage bag. During a review of Resident 179's clinical record indicated Resident 179 was admitted to the facility with diagnosis including retention of urine (when bladder doesn't empty completely or at all). During a review of Resident 179's physician's order indicated an order for Indwelling Catheter: Foley Catheter size: FR 16 . dated 4/17/25. During an interview on 4/22/25 at 3:03 p.m., with the Director of Nursing (DON), the DON confirmed Resident 179's Foley catheter drainage bag was uncovered. She stated Resident 179's Foley catheter drainage bag should have a privacy bag cover when inside the room or outside. During a review of facility's policy and procedure (P&P) titled, Dignity revised February 2021, the P&P indicated, Residents are treated with dignity and respect at all times.12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping resident to keep urinary catheter bag covered .

Based on interview and record review, the facility failed to ensure one of 13 sampled residents (Residents 19) were free from unnecessary medication when Resident 19 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring. This deficient practice resulted in unmonitored medical condition. Finding: During a review of Resident 19's clinical record indicated Resident 19 was admitted to the facility with diagnosis including Diastolic congestive heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 19's physician's orders indicated an order for Lasix 20 mg, 1 tablet by mouth every 48 hours for swelling on feet, dated 4/12/24. A review of Resident 19's medication administration record (MAR) indicated the nursing staff did not monitor for swelling on the feet. During a concurrent interview and record review on 4/23/25 at 3:12 p.m., with the Director of Nursing (DON), the DON reviewed Resident 19's physician's orders and confirmed there was no monitoring for swelling on the feet. The DON stated Resident 19 should have monitoring for swelling to see the effectiveness of medication. During a review of the facility's policy and procedures titled, Medication Therapy, revised April 2007, indicated, 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2.Medication use shall be consistent with an individual's condition, prognosis, values, wishes and response to such treatments. 3. All medication orders will be supported by appropriate care and practices . 1. All decisions related to medications shall include appropriate elements of the care process, such as: a. Adequate detailed assessment .

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for two of seven residents (Resident 83 and 179) when: 1. Resident 83's intravenous (IV, within or into a vein) tubing was undated; 2. A Certified Nursing Assistant not wearing wearing Personal Protective Equipment (PPE, its equipment worn to minimize exposure to hazards in the workplace) during patient care and; 3. Resident 179's Foley catheter drainage bag (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) was on the floor and uncovered. These failures had the potential to place the residents at risk for developing an infection and the potential to result in transmission of infection in the facility. Findings: 1. Review of Resident 83's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (an illness caused by the body's response to an infection). During an observation on 4/21/24 at 11:33 a.m., Resident 83 had a peripherally inserted central catheter (PICC, a thin, soft, long catheter [tube] that is inserted into a vein in arm, leg or neck and the tip of the catheter is positioned in a large vein that carries blood into the heart) line on his left upper arm. The IV equipment was infusing (administering medication into a vein) medication and the IV tubing was undated. Review of Resident 83's physician orders, dated 4/20/25, indicated an order to give Ceftriaxone Sodium (antibiotic) 2 grams intravenously two times a day for sepsis for 36 days. Another physician order, dated 4/20/25, indicated PICC: Intermittent IV tubing change daily every day and evening shift. During an observation and concurrent interview with the director of nurses (DON) on 4/21/25 at 11:39 a.m., she confirmed Resident 83 was receiving Ceftriaxone Sodium via intravenous administration. The DON confirmed the IV tubing was undated and she stated the IV tubing should be dated. A review of the facility's policy titled Administration Set/Tubing Changes, revised April 2016, indicated The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment. The policy further indicated Label new tubing with date, time, and initials. 50855 2. During an observation on 4/21/25 at 10:16 a.m., inside Resident 179's room. CNA B stated she is doing patient care. CNA B walked towards the privacy curtains and closed it, she was observed not wearing PPE. After a few minutes she was observed going to the restroom inside Resident 179's room, she was holding a urinal with urine about 1/4 full, she was not wearing PPE. During an interview on 4/21/25 at 10:24 p.m., shortly after the observation outside Resident 179 room. CNA B was asked what patient care she provided to Resident 179. CNA B stated she change Resident 179's brief and empty the Foley catheter bag. CNA B confirmed she did not wear PPE while providing patient care to Resident 179. CNA B reviewed the signage posted outside Resident 179's door, the signage indicated Enhanced Barrier Precautions (EBP, an infection prevention strategy, particularly in nursing homes, that uses PPE to reduce the transmission of multi-drug resistant organisms {MDRO a germ that is resistant to many antibiotics}) .Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Changing briefs or assisting with the toileting, Device care or use: central line, urinary catheter . CNA B stated she should wear a gown when providing patient care to Resident 179. During a review of Resident 179's physician's order, dated 4/21/24 indicated Enhanced barrier precautions due to (High- contact resident care activities with, increased risk of MDRO acquisition due to presence of indwelling Foley Catheter. During an interview on 4/24/25 at 10:17 a.m., with the Infection Prevention Nurse (IP), the IP stated the CNA should wear PPE when doing direct contact like Foley catheter care and changing briefs. During a review of the facility's policy and procedures titled, Enhanced Barrier Precautions, dated 6/18/24, indicated, . Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-Contact Resident Care Activities include activities such as .Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . 3. During an observation on 4/21/25 at 10:46 a.m., in Resident 179's room. Resident 179's foley catheter drainage bag was observed on the floor and the drainage bag was left uncovered. During a review of Resident 179's clinical record indicated Resident 179 was admitted to the facility with diagnosis including retention of urine (when bladder doesn't empty completely or at all). During a review of Resident 179's physician's order indicated an order for Indwelling Catheter: Foley Catheter size: FR 16 . dated 4/17/25. During an interview on 4/22/25 at 3:04 p.m., with the Director of Nursing (DON) the DON confirmed that Resident 179's foley catheter bag was on the floor. The DON stated the Foley catheter drainage bag should not be touching the floor for infection control. During a review of the facility's policy and procedures titled, Catheter Care, Urinary, revised date 9/2014, indicated, .Infection Control .b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for 12 of 12 sampled residents (Residents 8,178, 179, 184, 181, 12, 132, 4, 20, 7, 13, and 6). The survey team expanded the sample and identified that a total of 25 resident had the bed rails. The facility failed to follow their bed rails policy when: 1.There was no documentation that alternatives for bed rails were attempted prior to installing bed rails for 25 of 25 residents; 2.There was no informed consent (the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 16 of 25 residents (Residents 183, 181, 8, 187, 186, 182, 180, 3, 132, 128, 129, 24, 20, 7, 131, and 6). These failures resulted in the residents and resident's RPs not being fully informed on the risks of the use of bed rails and had the potential to place the residents at risk of serious injury. Findings: During an observation on 1/16/24 at 10:55 a.m., Resident 8's bed had partial bed rails up on both sides. Review of Resident 8's face sheet (a document that gives resident's information at a quick glance) indicated Resident 8 was readmitted to the facility on [DATE]. The face sheet also indicated Resident 8 was self-responsible. Review of Resident 8's minimum data set (MDS, resident's clinical and functional assessment tool) assessment, dated 11/29/23, indicated Resident 8's had a brief interview for mental status (BIMS, an assessment used in nursing homes to monitor cognition) score of 14 (score of 13-15 indicates an intact cognition). Review of Resident 8's physician's order, dated 11/23/23, indicated Resident 8 had an order for bilateral (both sides) upper grab rails for bed mobility/positioning and/or transfer. Review of Resident 8's bed rail observation/assessment, dated 10/30/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. During an interview with Resident 8 on 1/18/24 at 1:30 p.m., Resident 8 confirmed the facility did not provide alternatives for bed rails. During an observation on 1/16/24 at 11:05 a.m., Resident 178's bed had bilateral, partial bed rails up. Review of Resident 178's face sheet indicated Resident 178 was admitted to facility on 1/12/24. The face sheet also indicated Resident 178 had an assigned RP. Review of Resident 178's MDS assessment, dated 01/18/24, indicated Resident 178 had a BIMS score of 12, (score of 8-12 indicates moderately impaired cognition). Review of Resident's 178's physician's order, dated 1/12/24, indicated Resident 178 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Resident 178 also had an order, dated 1/12/24, indicated Resident 178 was capable of understanding rights, responsibilities, and informed consent. Review of Resident 178's bed rail observation/assessment, dated 1/12/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 178 on 1/16/24 at 11:22 a.m., Resident 178 confirmed the facility did not use alternatives prior to use of bed rails. During an observation on 1/16/24 at 11:22 a.m., Resident 179's bed had partial bed rails up on both sides. Review of Resident 179's face sheet indicated Resident 179 was admitted to the facility on [DATE]. The face sheet also indicated Resident 179 was self-responsible. Review of Resident 179's MDS assessment, dated 12/29/23, indicated Resident 179 had a BIMS score of 9. Review of Resident179's physician's order, dated 1/7/24, indicated Resident 179 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 179's bed rail observation/assessment, dated 12/16/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 179 on 1/16/24 at 11:22 a.m., Resident 179 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:45 a.m., Resident 184's bed had partial bed rails up on both sides. Review of Resident 184's face sheet indicated Resident 184 was admitted to the facility on [DATE]. The face sheet also indicated Resident 184 was self-responsible. Review of Resident 184's MDS assessment, dated 1/20/24, indicated Resident 184 had a BIMS score of 13. Review of Resident184's physician's order, dated 1/14/24, indicated Resident 184 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 184's bed rail observation/assessment, dated 1/14/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 184 on 1/16/24 at 11:45 a.m., Resident 184 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:53 a.m., Resident 181's bed had partial bed rails up on both sides. Review of Resident 181's face sheet indicated Resident 181 was admitted to the facility on [DATE]. The face sheet also indicated Resident 181 was self-responsible. Review of Resident 181's MDS assessment, dated 01/13/24, indicated Resident 181 had a BIMS score of 14. Review of Resident 181's physician's order, dated 1/7/24, indicated there was no order for bed rails. Review of Resident 181's bed rail observation/assessment, dated 01/07/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to the installation of bed rails. During an interview with Resident 181 on 1/16/24 at 11:53 a.m., Resident 181 confirmed the facility did not provide alternatives for bed rails. During an observation on 1/16/24 at 12:15 p.m., Resident 12's bed had bilateral partial bed rails up. Review of Resident 12's face sheet indicated Resident 12 was admitted to the facility on [DATE]. The face sheet also indicated Resident 12 had assigned RP. Review of Resident 12's MDS assessment, dated 12/17/23, indicated Resident 12 had a BIMS score of 9. Review of Resident 12's physician's order, dated 12/11/23, indicated Resident 12 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Resident 12 also had an order, dated 12/11/23 indicated Resident 12 was capable of understanding rights, responsibilities, and informed consent. Review of Resident 12's bed rail observation/assessment, dated 12/11/23, indicated there was no documentation that the facility attempted alternatives prior to the use of bed rails. During an interview with Resident 12 on 1/16/24 at 12:15 p.m., Resident 12 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:48 a.m., Resident 182's bed had bilateral partial bed rails up. Review of Resident 182's face sheet indicated Resident 182 was admitted to the facility on [DATE]. The face sheet also indicated Resident 182 had an assigned RP. Review of Resident 182's MDS assessment, dated 1/16/24, indicated Resident 182 had a BIMS score of 14. Review of Resident 182's physician's order, dated 1/10/24, indicated Resident 182 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 182's bed rail observation/assessment, dated 1/10/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 182 on 1/16/24 at 11:48 a.m., Resident 182 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 12:10 p.m., Resident 187's bed had bilateral partial bed rails up. Review of Resident 187's face sheet indicated Resident 187 was admitted to the facility on [DATE]. The face sheet also indicated Resident 187 had an assigned RP. Review of Resident 187's MDS assessment, dated 11/30/23, indicated Resident 187 had a BIMS score of 4 (score of 0-7 indicates severe cognitive impairment). Review of Resident 187's physician's order, dated 11/24/23, indicated Resident 187 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 187's bed rail observation/assessment, dated 11/24/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview on 1/18/24 at 3:30 p.m., with Resident 187's RP, the RP stated Resident 187 had bed rails since the resident was admitted to the facility. During an observation on 1/16/24 at 11:59 a.m., Resident 3's bed had bilateral partial bed rails up. Review of Resident 3's face sheet indicated Resident 3 was admitted to the facility on [DATE]. The face sheet also indicated Resident 3 was self-responsible. Review of Resident 3's MDS assessment dated [DATE], indicated Resident 3 had a BIMS score of 12. Review of Resident's 3's physician's order, dated 12/5/23, indicated Resident 3 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 3's bed rail observation/assessment, dated 12/5/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Resident 3 on 1/16/24 at 11:59 a.m., Resident 3 acknowledged that the facility did not provide alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:38 a.m., Resident 186's bed had bilateral partial bed rails up. Review of Resident 186's face sheet indicated Resident 186 was admitted to the facility on [DATE]. The face sheet also indicated Resident 186 had an assigned RP. Review of Resident 186's MDS assessment, dated 1/12/24 indicated Resident186 had a BIMS score of 15. Review of Resident 186's physician's order, dated 1/9/2024, indicated there was no order for the use of bed rails. Review of Resident 186's bed rail observation/assessment, dated 1/9/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 186 on 1/1/6/24 at 11:38 a.m., Resident 186 acknowledged there were no alternatives tried prior to the use of bed rails. During an observation on 1/16/24 at 11:42 a.m., Resident 180's bed had bilateral partial bed rails up. Review of Resident 180's face sheet indicated Resident 180 was admitted to the facility on [DATE]. The face sheet also indicated Resident 180 had an assigned RP. Review of Resident 180's MDS assessment, dated 1/7/24 indicated Resident 180 had a BIMS score of 0 (score of 0 indicates severely impaired cognition). Review of Resident 180's physician's order, dated 1/4/24, indicated there was no order for the use of bed rails. Review of Resident 180's bed rail observation/assessment, dated 1/4/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Resident 180's RP on 1/16/24 at 11:42 a.m., Resident 180's RP confirmed there were no alternatives provided prior to the use of bed rails. During an observation on 1/16/24 at 11:30 a.m., Resident 183's bed had bilateral partial bed rails up. Review of Resident 183's face sheet indicated Resident 183 was admitted to the facility on [DATE]. The face sheet also indicated Resident 183 had an assigned RP. Review of Resident 183's MDS assessment, dated 1/17/24, indicated Resident 183 had a BIMS score of 13. Review of Resident 183's physician's order, dated 1/11/24, indicated Resident 183 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 183's bed rail observation/assessment, dated 1/11/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview with Resident 183's RP on 1/18/24 at 2:10 p.m., Resident 183's RP stated Resident 183's bed had side rails since the resident was admitted to the facility. During an observation on 1/16/24 at 12:40 p.m., Resident 185's bed had bilateral partial bed rails up. Review of Resident 185's face sheet indicated Resident 185 was admitted to the facility on [DATE]. The face sheet also indicated Resident 185 was self- responsible. Review of Resident 185's MDS assessment, dated 1/7/24 indicated, Resident 185 had a BIMS score of 12. Review of Resident 185's physician's order, dated 1/1/24, indicated there was no order for the use of bed rails. Review of Resident 185's bed rail observation/assessment, dated 1/1/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 185 on 1/16/24 at 12:40 p.m., Resident 185 stated there were no alternatives provided by the facility prior to the use of bed rails. During an observation on 1/16/24 at 11:15 a.m., Resident 14's bed had bilateral partial bed rails up. Review of Resident 14's face sheet indicated Resident 14 was admitted to the facility on [DATE]. The face sheet also indicated Resident 14 had an assigned RP. Review of Resident 14's MDS assessment, dated 11/15/23, indicated Resident 14 had a BIMS score of 5. Review of Resident 14's physician's order, dated 11/17/23, indicated Resident 14 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 14's bed rail observation/assessment, dated 9/17/22, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 182's bed rail observation/assessment, dated 1/10/24 indicated there was no informed consent for the use of side rails. Review of Resident 183's bed rail observation/assessment, dated 1/11/24, indicated there was no informed consent for the use of side rails. Review of Resident 186's bed rail observation/assessment, dated 1/9/24, indicated there was no informed consent for the use of side rails. Review of Resident 187's bed rail observation/assessment, dated 11/24/23, indicated there was no informed consent for the use of side rails. During a concurrent interview and record review with the director of nursing (DON) on 1/18/24 5:47 p.m., the DON reviewed the bed rails assessments of the 25 residents and confirmed the facility did not have alternatives and there was no documentation for unsuccessful attempts to use alternatives prior to the use of bed rails. The DON further stated the facility should have tried alternatives and staff should have followed the facility's policy to document unsuccessful attempts of alternatives prior to use of bed rails. During an interview with the DON on 1/19/24 at 12:15 p.m., the DON confirmed informed consent was not obtained prior to the use of bed rails for Residents 8, 181, 183, 187, 186, 182, 180, and 3. The DON also confirmed there was no physician's order for the use of bed rails for Residents 180, 181, 185, and 186. The DON stated the staff should obtain a physician's order then obtain informed consent from the resident/RP prior to the use of bed rails. 46001 During an observation on 1/16/24 at 10 a.m., the beds of Residents 132,4,128,129,24,20, 130,7,13,131 and 6 were inspected. All 11 beds had partial bed rails bilaterally. Review of Resident 132's physician's order, dated 1/6/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 132's bed rails observation/assessment, dated 1/6/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to the use of bed rails. Review of Resident 132's MDS assessment, dated 1/8/24, indicated Resident 132 had a BIMS score of 12. During an interview with Resident 132 on 1/16/24 at 10 a.m., Resident 132 stated the side rails were already in placed since her admission to the facility. Review of Resident 4's physician's order, dated 12/20/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 4's bed rails observation/assessment, dated 12/20/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 128's physician's order, dated 1/8/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 128's bed rails observation/assessment, dated 1/8/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 129's physician's order, dated 1/10/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 129's bed rails observation/assessment, dated 1/10/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 24's physician's order, dated 12/19/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 24's bed rails observation/assessment, dated 12/19/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 20's physician's order, dated 12/23/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 20's bed rails observation/assessment, dated 12/23/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 130's physician's order, dated 1/15/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 130's bed rails observation/assessment, dated 1/15/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 7's physician's order, dated 10/24/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 7's bed rails observation/assessment, dated 10/24/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 13's physician's order, dated 12/15/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 13's bed rails observation/assessment, dated 12/15/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 131's physician's order, dated 1/12/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 131's bed rails observation/assessment, dated 1/12/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 6's physician's order, dated 12/24/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 6's bed rails observation/assessment, dated 12/24/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. During an interview with the DON on 1/18/24 5:47 p.m., the DON confirmed the facility did not provide alternatives to the 25 residents prior to the use of bed rails. During an interview with licensed vocational nurse B (LVN B) on 1/23/24 at 8:47 a.m., LVN B confirmed that all the beds rails were installed before residents were admitted to the facility and the facility did not attempt alternatives prior to the use of bed rails. During a concurrent interview and record review with the infection preventionist (IP) on 1/23/23 at 9:06 a.m., the IP reviewed the bed rails observation and assessment of Residents 132,128,129,24,20,7,131, 6 and confirmed that the eight residents did not have an informed consent prior to the use of bed rails. During a review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, revised December 2016, the P&P indicated, Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. Consent for side rails use will be obtained from the resident or legal representative, after presenting potential benefits and risks.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. The convection oven (a cooking device that heats food) located in the skilled nursing facility (SNF) pantry area was not kept in a sanitary condition; 2. No thermometer inside the freezer designated for the SNF residents; 3. The freezer temperature log was not completed, and multiple times, the temperature was ,d+[DATE] degrees above 0 Fahrenheit (F, a scale of temperature) degree; 4. The freezer designated for the SNF residents had multiple items unlabeled; 5. An opened bag of pasta was not labeled in the dry storage area; 6. The ice machine was not kept in a sanitary condition; 7. One faucet of the main kitchen was not well maintained; These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 25 residents who receives food from the facility. Findings: 1. During an initial kitchen tour observation and concurrent interview with the facility's registered dietitian (RD) on [DATE] at 10 a.m., the convection oven located in the skilled nursing facility (SNF) pantry area had dried brownish particles on the inside top part of the oven and the inner side of the oven door. The RD stated that the kitchen staff should keep it clean. 2. During an initial kitchen tour observation and concurrent interview with the RD and dietary service director (DSD) on [DATE] at 11 a.m., there was no thermometer inside the freezer designated to SNF residents, the DSD confirmed the observation. The RD stated that there should be a thermometer inside the freezer. 3. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on [DATE] at 11:08 a.m., the temperature log of the freezer designated for SNF residents was not completed, and multiple times, the temperature was ,d+[DATE] degrees above 0 Fahrenheit degree in the log. During a concurrent interview and record review with the RD on [DATE] at 9:10 a.m., the RD reviewed the freezer temperature log and confirmed that it was not completed. The RD stated that two staff did not initial the temperature log, and the kitchen staff should have kept the freezer temperature below 0 Fahrenheit degree. 4. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on [DATE] at 11:10 a.m., the DSD inspected the freezer designated for SNF food storage and identified the following: a) One bag of shredded cheese with no expiration date. b) One bag of fried potato strips with no expiration date. c) One box of 24 packages of puree breakfast with no open and expiration date. d) 14 packages of puree-linked shaped cooked sausages expired on [DATE] e) A bag of vegetable burger patty with no expiration date The RD stated all the food items in the freezer should have been dated and labeled. 5. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on [DATE] at 11:30 a.m., the DSD inspected the dry storage room in the main kitchen's basement and identified an opened bag of pasta without a label indicating the open and expiration dates. The RD stated that it should be labeled with open and expiration dates. 6. During an initial kitchen observation and concurrent interview with the RD and the DSD on [DATE] at 4 p.m., the ice machine lid had dark brownish particles. The RD stated that the kitchen staff should have kept it clean. 7. During an initial kitchen tour observation and concurrent interview with with the RD on [DATE] at 4:30 p.m., the faucer in the main kitchen had a leak (dripping with water). The RD confirmed the observation and stated the kitchen staff needed a new faucet. During a review of the facility's policy and procedure (P&P) titled Food Receiving and Storage, revised [DATE], the P&P indicated, Dry foods that are stored .labeled and dated (use by date) all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements . Refrigerators must have a working thermometer and be monitored for temperature according to state-specific guidelines . During a review of the facility's policy and procedure (P&P) titled Sanitization, revised [DATE], the P&P indicated, All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks .Ice machine and ice storage container will be drained, cleaned, and sanitized per manufacturer's instruction and facility policy . During a review of the facility's policy and procedure (P&P) titled Sanitization, revised [DATE], the P&P indicated, All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks . During a review of the facility's Freezer Temperature Logv(FTL) of 2023, the FTL indicated, temperature must be recorded at least twice during 24 hours period . must be 0 Fahrenheit degree (-18 celsius degrees) .

Based on observation, interview, and record review, the facility had a 10.53 percent (%, unit of measurement) medication error rate, when 4 medication errors occurred out of 38 opportunities during the medication administration, for three out of nine residents (Residents 12, 4 and 185). These failures resulted in the medications, not given in accordance with the prescriber's orders, manufacturer's specifications and medication administration's instructions, which resulted in residents, not receiving the full therapeutic effect of the medications or the proper administration of the medication and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation of Resident 12 with licensed vocational nurse C (LVN C), on 1/16/24 at 12:30 p.m., there was no available hydralazine hydrochloride (used to treat or control high blood pressure) tablet and LVN C was not able to administer the hydralazine hydrochloride oral tablet medication to Resident 12 because it was not available. Review of Resident 12's clinical records indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses including acute (rapid onset) on chronic (condition that gradually worsens over time) combined systolic (the heart muscle is weak and the ventricle can't contract normally) and diastolic (the heart muscle is stiff and the left ventricle can't relax normally) congestive heart failure (CHF, long-term condition affecting the left ventricle in which the heart can't pump blood well enough to meet the body's demands), type 2 diabetes mellitus (adult onset, high levels of sugar in the blood) and unspecified pulmonary hypertension (high blood pressure affecting the arteries in the lungs and in the heart). Review of Resident 12's physician's order indicated, Resident 12 had an order of hydralazine hydrochloride, 10 milligram (mg, a unit of measurement of mass) tablet by mouth, three times a day for hypertension (high blood pressure). During an interview with LVN C on 1/16/24 at 12:38 p.m., LVN C verified that the hydralazine hydrochloride tablet of Resident 12 was not available, that was the reason she missed giving the medication to Resident 12. LVN C further verified that the medication should have been available for the medication pass administration and should not be missed. LVN C then reordered to the pharmacy, the hydralazine hydrochloride medication of Resident 12. During an interview with the director of nursing (DON) on 1/17/24 at 10 a.m., the DON verified that residents' medications should be administered one hour before or one hour after the scheduled administration. The DON further verified that licensed nurses were responsible for the availability of the medication of the residents. The DON then stated that Resident 12 should not have missed her hydralazine hydrochloride. Residents should have at least 3-7 days' supply of their medications and nurses should refill their residents' medications immediately, if they noticed that the resident had less than 3-7 days' supply of the medication. 2. During the concurrent medication pass observation of Resident 4 and interview with licensed vocational nurse B (LVN B), on 1/18/24 at 8:15 a.m., LVN B administered 10 total tablets of medications to Resident 4. LVN B verified that there were only ten tablets of medications administered to Resident 4. Review of Resident 4's clinical records indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses including unspecified peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), essential primary hypertension (occurs, when having an abnormally high blood pressure, that's not the result of a medical condition) and unspecified hyperlipidemia (high levels of fat particles in the blood). Review of Resident 4's physician's order indicated, the following medications were scheduled to be administered to Resident 4 during the medication pass administration on 1/18/24 at 8:15 a.m.: a. carvedilol 12.5 mg tablet, 1 tablet by mouth, twice per day for coronary artery disease (CAD, is a narrowing or blockage of the coronary arteries), b. duloxetine hydrochloride 30 mg tablet, 1 tablet by mouth, twice per day for depression (persistent feeling of sadness or loss of interest), c. chewable aspirin, 81 mg tablet, 1 tablet by mouth, twice per day for prevention of stroke (brain attack), d. atorvastatin 20 mg tablet, 1 tablet by mouth, daily for hyperlipidemia (high cholesterol), e. folic acid, 1 mg tablet, 1 tablet by mouth, daily for supplement, f. furosemide 40 mg tablet, 1 tablet by mouth, daily for CHF, g. hydroxyzine 25 mg tablet, 1 tablet by mouth, three times per day for anxiety (feeling of fear), h. lisinopril 2.5 mg tablet, 1 tablet by mouth, daily for essential primary hypertension, i. multivitamins with minerals, 1 tablet by mouth, daily for supplement, j. potassium chloride, 1 tablet by mouth, daily for CHF and k. vitamin C 250 mg tablet, 1 tablet by mouth, daily for supplement. A total of 11 tablets of medications, scheduled to be administered during the medication pass administration on 1/18/24 at 8:15 a.m During an interview with LVN B on 1/18/24 at 2:05 p.m., LVN B verified that the atorvastatin tablet of Resident 4 was not available, that was the reason she missed giving the medication to Resident 4 and that's the reason, only 10 tablets, instead of 11 tablets were given, during the medication pass administration this morning. LVN B further verified that the medication should have been available for the medication pass administration and should not be missed. LVN B also stated that the medication should have been refilled already by the nurses. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that Resident 4 should not miss her atorvastatin tablet. The DON further verified that residents should have at least 3-7 days' supply of their medications and nurses should refill the medications right away if they don't have 3-7 days' supply of their medications. 3. During the medication pass observation of Resident 185 with LVN B, on 1/18/24 at 8:39 a.m., there was no available biotin (one of the B complex vitamins that supports the skin, hair and eye health) supplement tablet and LVN B was not able to administer the biotin supplement oral tablet medication to Resident 185 because it was not available. Review of Resident 185's clinical records indicated, Resident 185 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, type 2 diabetes mellitus (adult onset, high levels of sugar in the blood) and hypokalemia (low levels of potassium in the blood). Review of Resident 185's physician's order indicated, Resident 185 had an order of biotin extra strength oral disintegrating (breaking into small particles) tablet, 5000 microgram (mcg, unit of mass) tablet, give 1 tablet by mouth, one time a day for supplement. During an interview with LVN B on 1/18/24 at 8:50 a.m., LVN B verified that the biotin supplement tablet of Resident 185 was not available, that was the reason she missed giving the medication to Resident 185 during the medication pass administration. LVN B further verified that the medication should have been available for the medication pass administration and should not be missed. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that Resident 185 should not miss her biotin supplement. The DON further verified that residents should have at least 3-7 days supply of their medications and nurses should refill the medications right away if they don't have 3-7 days' supply of their medications. Review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 4. During the medication administration observation of Resident 185 with LVN B on 1/18/24 at 8:45 a.m., LVN B was observed administering restasis eye drops (used for long-lasting dry eyes) to Resident 185. LVN B administered the eye drop in Resident 185's left eye first, while her head was tilted back, then administered another drop to Resident 185's right eye without instructing Resident 185 to close eyes after each drop, then applying gentle pressure in the inner corner of the eyes. Review of Resident 185's physician orders indicated, Resident 185 had an order of restasis ophthalmic (pertaining to the eye) emulsion (a mixture of two or more liquids that are normally unmixable) 0.05 percent (%), instill 1 drop in both eyes, two times a day for dry eyes. During an interview with LVN B on 1/18/24 at 2:00 p.m., LVN B verified that the restasis eye drops were not properly administered to Resident 185. LVN B further verified that she did not give instruction to Resident 185 after administering restasis eye drops, for Resident 185, to close her eyes after each drop, then applying gentle pressure in the inner corner of the eyes, which she should have done. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified LVN should have administered the restasis eye drops to Resident 185 properly. The DON further verified that the LVN should have instructed Resident 185, after the first drop in the left eye while Resident 185's head was tilted back, to close the eyes, apply gentle pressure in the inner corner of the eye, before administering the second drop in the right eye. Review of the facility's policy and procedure titled, Installation of Eye Drops: Steps in the Procedure, revised January 2014, indicated, . If the resident is sitting up, tilt his/her head backward slightly . Drop the medication into the mid lower eyelid . Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye . Gently dry the eyelid with cotton ball if dripping occurs .

Based on observation, interview, and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed vocational nurse C (LVN C) did not sanitize the blood pressure cuff and pulse oximeter, before she used them on Resident 12; 2. There was a personal food, placed on top of the medication cart 2; and 3. Resident 4's oxygen tubing had no label and was found on the floor. These failures could result in the spread of infection and cross-contamination that could affect the 25 residents residing in the facility. Findings: 1. During the medication pass observation with licensed vocational nurse C (LVN C) on 1/16/24 at 12:25 p.m., LVN C took Resident 12's blood pressure (measure of how forcefully, the blood goes through the arteries) and heart rate (frequency of heartbeat) prior to the administration of hydralazine hydrochloride (used to treat or control high blood pressure) and isosorbide dinitrate (used to treat heart failure) oral medications. LVN C did not sanitize (disinfect) the blood pressure cuff (device used to measure blood pressure) and the pulse oximeter (device used to monitor the amount of oxygen carried in the body) before using them on Resident 12. During an interview with LVN C on 1/16/24 at 12:35 p.m., LVN C verified that she did not sanitize the blood pressure cuff and pulse oximeter, and should have sanitized the equipments before using them on Resident 12. LVN C further verified that she would make sure to sanitize the blood pressure cuff and the pulse oximeter, before and after using them on residents, next time. During an interview with the director of nursing (DON) on 1/17/24 at 10:15 a.m., the DON verified that the blood pressure cuff and pulse oximeter should be sanitized before and after use with residents. The DON further verified that LVN C should have sanitized the blood pressure cuff and pulse oximeter before she used them on Resident 12. During an interview with the infection preventionist (IP), on 1/23/24 at 9:20 a.m., the IP verified that the blood pressure cuff and pulse oximeter should be sanitized, before and after use. Review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, indicated, Resident-care equipment, including reusable items . will be cleaned and disinfected according to current Centers for Disease Control (CDC, national public health federal agency, for the protection of public health and safety through the control and prevention of disease, injury and disability) recommendations for disinfection . Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 2. During the medication pass observation with LVN B on 1/18/24 at 8:15 a.m., noted that there was a food placed on top of the medication cart 2. During an interview with LVN B on 1/18/24 at 8:20 a.m., LVN B verified that it was her personal food, on top of medication cart 2. LVN B further verified that personal food should not be in the medication cart for infection control practices. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that nurses should not put their personal food in the medication cart for infection control. 46001 Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). Review of Resident 4's minimum data set (MDS, an assessment tool) dated 12/21/23 indicated her brief interview for mental status (BIMS, cognition level) score was 15(13 to 15 points suggests that cognition is intact). Review of Resident 4's physician's order summary indicated to administer oxygen 2L/min (l/min, liter per minute) as needed, starting on 12/26/23. During a concurrent observation and interview with certified nursing assistant (CNA) E in Resident 4's room on 1/16/24 at 11 a.m., Resident 4 was lying in her bed with a nasal cannula (NC, a plastic tubing that delivers supplemental oxygen) tubing, and part of the oxygen tubing was on the floor. The NC did not have a label indicating when it was first used or when it need to be changed. CNA E confirmed the above observation and stated the oxygen tubing should not be on the floor. During a concurrent observation and interview in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with a nasal cannula oxygen tubing, and part of the oxygen tubing was on the floor. Resident 4 stated the oxygen tubing had mucus (a sticky slippery substance) and was moist. During a concurrent observation and interview with the minimum data set coordinator (MDSC) in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with a nasal cannula oxygen tubing, and part of the oxygen tubing was on the floor. Resident 4 stated the oxygen tubing had mucus and was moist. The MDSC stated that the oxygen tubing should not be on the floor and needed to be changed to a new one because the oxygen tubing was moist with mucus inside. During an interview with the infection preventionist (IP) on 1/23/24 at 9 a.m., the IP stated the oxygen tubing should not be on the floor, which might cause infection, and the oxygen tubing required to be labeled with an open date and changed every seven days and as needed. Review of the facility's undated policy and procedure titled Departmental (Respiratory Therapy)- prevention of infection indicated .change the oxygen cannulae and tubing every(7) days, or as needed .

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for five of seven sampled residents (Residents 8, 178, 179, 181, and 184). This failure could lead to the delivery of unnecessary or inappropriate medical services against Residents 8, 178, 179, 181, and 184 goals and wishes. Findings: Review of Resident 8's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 8. Review of Resident 8's POLST form dated 10/30/23 indicated, section D for advance directive all three options, and physician signature were left blank, and not completed. Review of Resident 178's face sheet indicated, Resident 178 was admitted to the facility on [DATE]. Review of Resident 178's clinical record indicated, there was advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 178. Review of Resident 178's POLST form dated 1/12/24 indicated, section D for advance directive all three options were left blank, and not completed. Review of Resident 179's face sheet indicated, Resident 179 was admitted to the facility on [DATE]. Review of Resident 179's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 179. Review of Resident 179's POLST form dated 1/13/24 indicated, section D for advance directive all three options were left blank, and not completed. Review of Resident 181's face sheet indicated, Resident 181 was admitted to the facility on [DATE]. Review of Resident 181's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 181. Review of Resident 181's POLST form dated 12/30/23 indicated, section D for advance directive all three options were left blank, and not completed. Review of Resident 184's face sheet indicated, Resident 184 was admitted to the facility on [DATE]. Review of Resident 184's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 184. Review of Resident 184's undated POLST form indicated, section D for advance directive all three options, and physician's signature were left blank, and not completed. During a concurrent interview and record review of the advance directive for Residents 8, 178, 179, 181, and 184 with the facility's social service director (SSD) on 1/19/24 at 11 a.m., the SSD confirmed there were no documentation of advance directive for the above five residents. The SSD stated she should have verified, offered, assisted, and or obtained advance directive for the residents. During an interview with the director of nursing (DON) on 1/19/24 at 11:30 a.m., the DON stated the SSD should have verified, and assisted residents to obtain advance directive. The DON also stated the SSD should have documented the efforts to obtain advance directive as needed. The DON further stated staff should have completed POLST form for residents without blanks and obtained physician's signature. Review of the facility's P&P titled, Advance Directive, revised December 2016, the P&P indicated, Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of the facility's P&P titled, Do not Resuscitate Order, revised April 2017, the P&P indicated, A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law) and placed in the front of the resident's medical record.

Based on interview and record review, the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with a mental disorder [MD, a wide range of conditions that affect mood, thinking, and behavior] and residents with intellectual disability [ID, when there are limits to a resident's ability to learn at an expected level and function in daily life] or related disorders [RD]) screening was completed for one out of two residents. This failure had the potential for Resident 8 not to receive the required care and services. Findings: Review of Resident 8's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in residents who have experienced or witnessed a traumatic event or set of circumstances). Review of Resident 8's history and physical document from acute hospital (where residents receive immediate and short-term treatment for any critical or life-threatening injury, illness, and diseases) dated 10/9/23, indicated Resident 8's diagnosis of PTSD. Review of Resident 8's minimum data set (MDS, resident clinical, and functional assessment tool) assessment dated [DATE] indicated PTSD under psychiatric/mood disorder for resident's primary medical condition. Review of Resident 8's clinical record indicated there was no document for PASRR. During an interview with the director of nursing (DON) on 1/19/24 at 11:51 a.m., the DON acknowledged Resident 8 had diagnosis of PTSD. The DON also acknowledged that Resident 8's PASRR was not done. The DON stated facility should complete PASRR and refer residents as needed. During a review of the facility's policy and procedure (P&P) titled, Admission Criteria, revised March 2019, the P&P indicated, All new admissions and readmissions are screed for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid (joint federal and state program that provides health coverage to certain group of individuals) Pre-Admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for MD, ID, or RD.

Based on interview and record review, the facility failed to develop a baseline care plan for two out of 12 sampled residents (Residents 4 and 20) within 48 hours of the resident's admission when: 1. For Resident 4, there was no care plan to address oxygen use; 2. For Resident 20, there was no care plan for bowel and bladder incontinence; 3. For Resident 20, there was no care plan to manage blood sugar to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). These deficient practices had the potential for delayed administration of necessary care and services. Findings: 1. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). Review of Resident 4's physician's order summary indicated administer oxygen 2 l/min (l/min, liter per minute) as needed, starting on 12/26/23. During an observation in Resident 4's room on 1/16/24 at 11 a.m., Resident 4 was lying in her bed with oxygen at 2 l/min via nasal cannula (NC, a plastic tubing used to deliver supplemental oxygen). During an observation in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with oxygen at 2 l/min via NC. During a concurrent interview and record review with the infection preventionist (IP) on 1/23/24 at 9 a.m., the IP reviewed Resident 4's care plan and confirmed that there was no care plan to address the oxygen care. The IP stated the licensed nurses should have completed the baseline care plan to address the oxygen use within 48 hours of the resident's admission. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON acknowledged the licensed nurses should have developed the baseline care plans for oxygen use within 48 hours of the resident's admission. 2. During a concurrent interview and record review with the IP on 1/19/24 at 12:11 a.m., the IP reviewed Resident 20's care plan and confirmed that there was no care plan for bowel and bladder incontinence. The IP stated that Resident 20 was mixed for continence and incontinence and sometimes incontinent for both bowel and bladder. The IP stated licensed nurses should have developed the baseline care plan to address the bowel and bladder issue within 48 hours of admission. 3.Review of Resident 20's clinical record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (high blood sugar) without complications. During a concurrent interview and record review with the IP on 1/19/24 at 12:13 a.m., the IP reviewed Resident 20's care plan and confirmed that there was no care plan for blood sugar management to monitor hyperglycemia and hypoglycemia. The IP stated that Resident 20 kept receiving insulin to control his blood sugar, and licensed nurses should have developed the baseline care plan to manage his blood sugar level to prevent hyperglycemia and hypoglycemia within 48 hours of admission. During an interview with the DON on 1/23/24 at 10:05 a.m., the DON acknowledged the licensed nurses should have developed the baseline care plans for Resident 20 to address the bowel bladder issue and blood sugar management within 48 hours of the resident's admission. Review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, revised in December 2016, indicated To assure that the resident's immediate care needs and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

Based on observation, interview, and record review, the facility failed to ensure to follow physician's order for oxygen (colorless, odorless, and tasteless gas supports life) rate administration for one of three sampled residents (Resident 181). This failure had the potential to compromise Resident 181's health, and well-being. Findings: Review of Resident 181's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 181 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when lungs are unable to pass enough oxygen to the blood, or when fail to remove carbon dioxide [colorless and odorless gas humans breathed out] from the blood), acute pulmonary edema (fluid build up in the lungs), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident 181's physician's order dated 1/7/24 indicated, Oxygen: At 2 Liters/Min (l/min, oxygen measured in liters per minute) via Nasal Cannula (NC, a medical device to provide supplemental oxygen to residents) Every Shift. During an observation on 1/16/24 at 11:53 a.m., noted Resident 181's room air concentrator (RAC, a medical device that take in air from the room and filter out nitrogen to provides higher amounts of oxygen) oxygen rate was set at 4 l/min via NC. During an interview with registered nurse A (RN A) on 11/16/24 at 11:56 a.m., RN A acknowledged Resident 181's RAC was set at 4l/min oxygen via NC. During a second observation on 1/19/24 at 8:32 a.m., noted Resident 181's RAC oxygen rate was set at 4l/min via NC. During a concurrent review of Resident 181's physician's order for oxygen and interview with licensed vocational nurse B (LVN B) on 1/19/24 at 8:35 a.m., LVN B confirmed Resident 181's RAC oxygen rate was set at 4l/min. LVN B also confirmed Resident 181 had an order for oxygen 2l/min. LVN B adjusted Resident 181's RAC oxygen rate to 2l/min and stated staff should have verified and followed Resident 181's physician's order for oxygen use. During an interview with the director of nursing (DON) on 1/19/24 at 11:38 a.m., the DON stated staff should have set Resident 181's RAC at 2l/min. Review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised July 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use and failed to obtain an informed consent for one of 12 sampled residents (Resident 4). These failures had could lead to the administration of unnecessary medication to the resident. Findings: Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and unspecified depression. Further review of Resident 4's clinical record indicated a physician's order, dated 12/20/23, for Diazepam 10 milligrams (mg., a unit of measurement) every 8 hours as needed (PRN) for anxiety. The order did not have a stop date. During a concurrent interview and record review with the infection preventionist (IP) on 1/18/24 at 2:35 p.m., the IP reviewed the physician's order and stated that PRN psychotropic medication orders should be limited to 14 days. During a concurrent interview and record review with the IP on 1/23/24 at 9:15 a.m., the IP confirmed that no documentation indicated that Resident 4 signed the informed consent to take Diazepam PRN for anxiety. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON stated that there should be a 14-day limit for PRN psychotropic medication and that the facility should have obtained informed consent upon starting the medication to prevent administering unnecessary medication to the resident. Review of the facility's policy and procedure dated 2007 titled, Medication Monitoring, Medication Management, indicated .Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; PRN orders for psychotroic drugs are limited to 14 days .A resident and /or representative has the right to be informed about the resident's condition, treatment options, relative risks, and benefits of treatment .

Based on observation, interview, and record review, the facility failed to ensure, discontinued medications were properly discarded and not kept in the medication cart when: 1. For Resident 2, discontinued 30 tablets of montelukast sodium (medication used to prevent breathing difficulties) 10 milligram (mg, unit of measurement), and 53 tablets of hydrocodone-acetaminophen 5-325 (controlled medication for pain) mg, were kept in medication cart 2; and 2. For Resident 78, discontinued 26 tablets of oxycodone hydrochloride (controlled medication for pain) 5 mg, and 23 capsules of pregabalin (controlled medication that can treat nerve and muscle pain), 25 mg, were still in medication cart 2. These failures had the potential for residents to receive discontinued medications and controlled medication diversion. Findings: During an observation and inspection of medication cart 2 with the minimum data set coordinator (MDSC), on 1/17/24, at 2:35 p.m., noted discontinued 30 tablets of montelukast sodium 10 mg, and 53 tablets of hydrocodone-acetaminophen 5-325 mg were kept in the medication cart 2. Review of Resident 2's clinical records indicated, Resident 2 was initially admitted to the facility on [DATE] and was discharged from the facility on 1/10/24. During the continued observation and inspection of medication cart 2 with the MDSC, on 1/17/24 at 2:35 p.m., noted discontinued 26 tablets of oxycodone hydrochloride 5 mg, and 23 capsules of pregabalin 25 mg, were still in the medication cart 2. Review of Resident 78's clinical records indicated, Resident 78 was admitted to the facility on [DATE] and was discharged from the facility on 12/28/23. During an interview with the MDSC, on 1/17/24 at 2:45 p.m., the MDSC verified the above observation and stated the discontinued medications should have been removed in the medication cart. The MDSC further stated the montelukast medication should have been placed in the bin for discontinued medications and the controlled medications should have been placed in the locked cabinet in the director of nursing's (DON) office. During an interview with the DON, on 1/19/24 at 4:45 p.m., the DON verified that the discontinued medications should have been removed in the medication cart. The DON further stated that the controlled medications should have been placed in the locked cabinet in the DON's office. Review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised April 2019, indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . Disposal of controlled substances must take place immediately, no longer than three days, after discontinuation of use by the resident. Review of the facility's policy and procedure titled, Discontinued Medications, revised April 2007, indicated, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. The nurse receiving the order to discontinue a medication is responsible for notifying the dispensing pharmacy of the discontinuation. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies.

Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time personnel to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food-borne illness for 25 residents eating facility-prepared foods. Findings: During an interview with the registered dietitian (RD)on 1/16/24 at 11:56 a.m., the RD stated that he was a part-time employee of the skilled nursing facility (SNF). The RD further stated the kitchen belongs to the Assistant Living(AL), under a different company and all the kitchen staff, including the dietary service director were under the AL. During an interview with the dietary service director (DSD) on 1/17/24 at 11:56 a.m., the DSD stated that he worked as a full-time DSD for the AL since January 2023. The DSD further stated the AL and the SNF belongs to two different companies and he was not a SNF employee. Review of the facility's documents indicated there was no written policy and procedure for kitchen management. During an interview with the administrator (ADM) on 1/22/24 at 12:44 p.m., the ADM confirmed there was no written kitchen management policy and procedure. The ADM stated that the SNF did not have a kitchen to cook and all kitchen staff were AL employees. The ADM further stated that the SNF had a part-time RD and did not have a full-time DSD. Review of the California Code, Health, and Safety Code - HSC S 1265.4 indicated that a licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations.

Based on observation, interview, and record review, the facility failed to accommodate food preferences, and food allergies for two out of seven sampled residents (Resident 7, and 4), when: 1. For Resident 7, milk was not provided in her lunch tray, and; 2. For Resident 4, she was allergic to egg whites and had eggs in her breakfast tray. This failure had the potential for decreased meal intake, adverse effects from food allergies, and negative effect on health and well-being for sampled residents. Findings: During lunch observation in the facility's dining room on 1/16/24 at 12:18 p.m., noted Resident 7 had only one glass of water with ice next to her lunch plate. During an interview with Resident 7 on 1/16/24 at 12:24 p.m., Resident 7 stated there was no milk served for lunch and prefers milk during lunch every day. During a concurrent interview, and record review of Resident 7's lunch tray card with the activity director/restorative nursing assistant (RNA, interact with residents, provide, maintian physical functioning, and prevent further impairment) (AD/RNA) on 1/16/24 at 12:30 p.m., the AD/RNA acknowledged Resident 7 prefers milk, and there was no milk served. The AD/RNA stated dietary staff should have provided skim milk (milk made when all the milkfat removed from whole milk) to Resident 7 to follow her preference for skim milk during lunch. Review of Resident 7's lunch tray card for 1/16/24 indicated, Standing Orders: 8 fl oz (fl oz-fluid ounce: unit used to measure fluid volume) Beverage, 8 fl oz Milk Skim. Review of Resident 7's minimum data set (MDS, resident clinical and functional assessment tool) dated 10/30/23 indicated Resident 7 had a brief interview for mental status (BIMS) score of 15 (score of 13-15: intact cognition). During a concurrent interview and record review of Resident 7's lunch tray card with the facility's registered dietitian (RD) on 1/17/24 at 2:30 p. m., the RD confirmed Resident 7 prefers skim milk during lunch and confirmed resident's food preferences documented in the lunch tray cards. The RD also stated dietary staff should have served skim milk to Resident 7 during lunch to accommodate her food/liquid preferences. Review of facility's policy and procedure (P&P) titled, Resident Food Preferences, revised July 2017, the P&P indicated, The food service department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 46001 2. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). During an interview with Resident 4 on 1/16/24 at 11 a.m., Resident 4 stated that she was allergic to egg whites but had eggs in her breakfast tray on 1/8/24. Resident 4 stated she reported this to her nurse, who took a picture and took the tray away. During an interview with Resident 4 on 1/18/24 at 9:15 a.m., Resident 4 stated that she was allergic to egg whites, but she had scrambled eggs in her breakfast tray on 1/17/24, and certified nursing assistant D (CNA D) removed the scrambled eggs. During an interview with CNA D on 1/18/24 at 9:20 a.m., CNA D stated that Resident 4 had a scrambled eggs in her breakfast tray, and he removed the scrambled eggs before Resident 4 started to eat. During an interview with licensed vocational nurse (LVN) C on 1/19/24 at 9:45 a.m., LVN C stated that Resident 4 was allergic to egg whites, and she checked Resident 4's meal by herself during her shift. She confirmed that Resident 4 had a scrambled eggs in her breakfast tray on 1/8/24, and she took a picture and removed the scrambled eggs before Resident 4 started to eat. During an interview with the registered dietitian (RD) on 1/19/24 at 03:18 p.m., The RD confirmed that Resident 4 was allergic to egg whites and stated that all kinds of food made with eggs should not be on the resident meal plates. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON stated that eggs should not be served to Resident 4 because it might cause rashes, hives (a rash with raised red patches), stomach cramps, vomiting and anaphylaxis (a severe allergic reaction that can be life-threatening and requires immediate medical attention). Review of Resident 4's Nutritional Risk Assessment -V 2 dated 12/30/23 indicated that Resident 4 had Food Allergies/Intolerance: egg whites and shrimp (both give swelling/edema. Review of the facility's undated policy and procedure titled, Food Allergies and Intolerances indicated .Food allergies are immune system responses to allergens(foods), [NAME] antibodies to food attach to mast cells in body tissue (e.g., skin, nose, throat, lungs and gastrointestinal tract) and basophils in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, and inflammatory compound .Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat .

Based on interview and record review, the facility failed to do a fall risk assessment after two falls, failed to develop a fall intervention based on the resident's mental status, and failed to implement the bowel and bladder program care plan for one of 12 residents (Resident 4). These failures resulted in Resident 4's fall with right femoral neck fracture (broken right hip), occipital abrasion (wound on the back of the head caused by rubbing or scraping), and left elbow skin tear. Findings: Review of Resident 4's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 9/6/18, indicated he had a BIMS (Brief Interview for Mental Status) score of 4 (a score of 0 to 7 indicates severe cognitive impairment) and required extensive assistance (staff provide weight-bearing support) for bed mobility, transfers and toileting. The MDS also indicated Resident 4 wandered (moved aimlessly from place to place), and the wandering placed him at significant risk of getting to a potentially dangerous place. Review of Resident 4's admission fall risk assessment, dated 6/28/18, indicated Resident 4 had a total score of 50 (a score of 51 or greater indicates high risk for falls). There was no documented quarterly fall risk assessment in Resident 4's clinical record. The quarterly fall risk assessment should have been completed in 9/2018. Review of Resident 4's nurse's note, dated 7/19/18, indicated he had an unwitnessed fall in his bathroom. The note indicated Resident 4 was non-compliant with using his call bell and asking for assistance. Review of Resident 4's Incident/Accident Report, dated 7/19/18, indicated Resident 4 took off his tab alarm (device attached to the resident that makes noise when the resident attempts to get up without assistance), went to the bathroom and fell . The report further indicated to prevent fall recurrence, the facility implemented the intervention of placing Resident 4's tab alarm in a location where it was more difficult for him to deactivate it. Review of Resident 4's clinical record indicated the facility did not complete a fall risk assessment after he fell on [DATE]. Review of Resident 4's nurse's note, dated 8/18/18, indicated a licensed nurse Heard patients tab alarm at 8:00 a.m. and as I was going into his room to assist he slid off edge of bed to floor onto his bottom . Review of Resident 4's Incident/Accident Report, dated 8/18/18, indicated after Resident 4 fell , the intervention implemented to prevent fall recurrence was, Reminded patient no to get up by himself. Forgetful & needs freq (frequent) reminders. There were no other interventions documented on the report. Review of Resident 4's clinical record indicated the facility did not complete a fall risk assessment after he fell on [DATE]. Review of Resident 4's record indicated he had a care plan, dated 10/9/18, that indicated, Bowel and bladder program to assist with getting resident to the restroom safely. There was no documentation in the clinical record to show the facility had been implementing a bowel and bladder program. Review of Resident 4's nurse's note, dated 11/18/18 at 2:55 p.m., indicated a certified nursing assistant (CNA) went to check on Resident 4 and saw him fall backward. According to the note, Resident 4 was noted to have an abrasion to the lower occipital area and the nurse obtained a steri-strip (small bandage used to close or stabilize wounds) for his elbow. There was no documentation in Resident 4's clinical record indicating the facility implemented any new interventions after this fall. Review of Resident 4's nurse's note, dated 11/18/18 at 10:32 p.m., indicated he was being monitored for the fall he experienced during the previous shift. The note indicated, Noted to have an abrasion and skin tear to left elbow and abrasion to back of head . Review of Resident 4's nurse's note, dated 11/19/18, indicated he screamed out when the licensed nurse attempted to examine his right hip. Review of Resident 4's X-ray (image of the internal components of the body) report, dated 11/20/18, indicated he had an acute right femoral neck fracture with mild superior displacement (bone was out of normal alignment). During an interview with CNA H on 11/20/18 at 2:38 p.m., she confirmed she was the CNA for Resident 4 when he fell on [DATE]. CNA H stated on the day of the fall, she assisted Resident 4 back to bed after lunch. She stated she heard things falling and heard a thud, so she ran to Resident 4's room and saw him lying on his back with his head against his cabinet. CNA H stated this incident occurred a little bit after 2:30 p.m. During an interview with licensed vocational nurse G (LVN G) on 11/21/18 at 7:37 a.m., she stated Resident 4 was confused and would try to get up without assistance. According to LVN G, no matter how many times staff reminded him, Resident 4 would still try to get up. LVN G explained when staff provided reminders to Resident 4, he would retain the information for about 5 minutes and then forget. During an interview with registered nurse A (RN A) on 11/21/18 at 7:51 a.m., she stated Resident 4 was forgetful and would not remember to use his call light even if staff reminded him. She stated if staff reminded Resident 4 not to get up without assistance, he would not remember. RN A stated reminding Resident 4 not to get up was not an appropriate intervention for him. During an interview with the director of nursing (DON) on 11/21/18 at 8:32 a.m., she reviewed Resident 4's clinical record and confirmed that after he fell on [DATE], the only new intervention implemented was to remind him not to get up by himself. She confirmed there was no documentation that a bowel and bladder program had been implemented for Resident 4. She also confirmed there was no documentation in Resident 4's record of any new fall prevention interventions after he fell on [DATE]. The DON stated she had not had a chance to work on Resident 4's most recent fall and no new interventions had been put in place. The DON stated fall risk assessments should be done upon admission and quarterly, but she was not aware they needed to be completed after fall incidents. She confirmed the facility did not complete Resident 4's quarterly fall risk assessment in 9/2018 and did not complete fall risk assessments after he fell on [DATE] and 8/18/18. The facility's policy, Falls and Fall Risk, Managing revised 3/2018, indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The policy further indicated, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. According to the policy, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The facility's policy, Assessing Falls and Their Causes revised 3/ indicated, Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly. The policy further indicated when a resident falls, completion of a fall risk assessment and appropriate interventions taken to prevent future falls should be documented in the medical record.