Every finding on record at Fulton Gardens Post Acute, LLC

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 103 residents when;1) Staff did not have their facial hair covered while present in the kitchen;2) Opened cake mix, olive oil, shredded cheese, and five bags of pasta, were not labeled completely and accurately with open dates, use-by dates, or discard dates, and one previously opened bag of pasta was not securely sealed after opening; 3) The dry storage floor was worn with a black discoloration;4) Frozen hotdogs stored in the reach-in freezer had moderate ice crystal buildup or freezer burn, frozen turkey stored in the walk-in freezer had heavy ice crystal buildup or freezer burn, and frozen pork chops stored in the walk-in freezer had freezer burn, were not securely closed, and were left exposed to air; 5) A fry pan stored in a ready-to-use area had whitish residue, oil/grease buildup and worn surfaces; a steam table pan and three muffin tins stored in a ready-to-use area had moderate yellow residue and dark brown build up; and a blender stored in a ready-to-use area had visible moisture buildup and pooled water around the blade assembly;6) Two cutting boards used for food preparation had multiple deep gouges on the cutting surfaces; 7) [NAME] (CK) 1's apron tie contacted the cooked fish twice when transferring the fish from the sheet pans to a steam table pan, and CK 1's apron contacted the broccoli in the steam table while preparing a resident plate; and 8) Lunch meal plating ran out of standard heated dish plates with covers, leading to resident meals being served in disposable clamshell food containers. These failures had the potential to put residents at risk for foodborne illnesses (nausea, vomiting, and/or diarrhea). Findings: 1.During the initial kitchen tour on 4/28/26 at 8:25 AM, the Environmental Services Director (ESD) was observed walking inside the kitchen without a beard restraint (covering used to prevent beard hair from falling into food). During an interview on 4/28/26 at 8:30 AM with the ESD, the ESD stated that he was in the kitchen fixing a leaking drainpipe in the floor sink. During an interview on 4/30/26 at 2:28 PM with the Infection Preventionist (IP), the IP stated that staff were expected to wear protective covers for hair and facial hair, including beards, whenever they were in the kitchen to prevent loose hair from falling into food. The IP further stated that loose hair could contaminate food served to residents and could cause food borne illness. During a joint subsequent interview on 4/30/26 at 3:40 PM with the Dietary Supervisor (DS) and the Registered Dietitian (RD), the DS and the RD acknowledged that staff were expected to wear hair restraints, including beard covers, in the kitchen as hair could contaminate the food served to residents. During a review of the facility's policy and procedure (P&P) titled, DIETETIC SERVICE - BASIC KITCHEN SANITATION, revised in 1/2025, the P&P indicated, .To ensure that the facility's kitchen and food service areas maintain basic standards of cleanliness and sanitation to prevent food borne illness.Hair must be restrained. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated, .The facility follows proper sanitation.to reduce the potential for a foodborne illness outbreak.All food shall be protected against contamination. According to the 2022 Federal Food and Drug Administration (FDA) Food Code 2-402.11, Food employees shall wear hair restraints such as . beard restraints, . that are designed and worn to effectively keep their hair from . clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 2. During a concurrent initial kitchen tour observation, interview, and record review on 4/28/26 at 8:55 AM in the dry storage area, the food storage chart was reviewed with the DS. The following items were observed: There was a previously opened cake mix stored on a shelf, labeled with an open date of 4/21/26 and a use-by date of 5/6/26 and a box of olive oil with a faucet dispenser was stored on a shelf and labeled with an open date of 1/16/26 but did not include a use-by or discard date. A review of the food storage chart posted on the dry storage door indicated the recommended storage time for cake mix (biscuit, brownie, and muffin mix), was nine months, while the recommended storage time for olive oil (salad oils) was up to three months when stored in the refrigerator after opening. The DS confirmed the cake mix was not labeled according to the food storage chart and the olive oil lacked a use-by or discard date. The DS acknowledged that because the olive oil did not have a use-by or discard date, it was not discarded in a timely manner and remained in the dry storage area even though it may have exceeded the recommended storage time frame. The DS stated that the olive oil should have been refrigerated after opening and may no longer have been good for consumption. During a concurrent observation and interview on 4/28/26 at 9:14 AM with the DS in the dry storage area while doing the initial kitchen tour, five previously opened original bags of pasta were found stored on a shelf. Four bags of pasta were closed and labeled with open dates (2/5/26, 2/16/26, 4/13/26, and 4/17/26) but did not have use-by or discard dates. One bag of pasta labeled with an open date of 12/30/25 but did not have a use-by or discard date, was not securely closed, and was partially open to air. The DS confirmed the five bags of pasta did not have use-by or discard dates and confirmed one bag of pasta was not securely closed after opening. The DS stated kitchen staff were expected to label opened food items with the date opened and, with a use-by or discard date. The DS further stated the opened bag of pasta should have been tightly sealed after opening. During a subsequent observation and interview on 4/28/26 at 9:22 AM with the DS in the walk-in refrigerator while doing the initial kitchen tour, a previously opened and closed bag of shredded cheese stored on the left shelf was labeled with an open date of 4/26/26 and a use-by date of 5/1/26. The DS confirmed the use-by date was not consistent with the recommended storage time frame of one month from the open date. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated it was important to label opened food items with the date opened and a use-by date so staff could determine how long the products had been stored and discard them timely to prevent foodborne illness. The IP stated opened food items stored in the dry storage area should be securely closed after opening to prevent pest entry and contamination from pest feces, which could be harmful or infectious if consumed by humans. During an interview on 4/30/26 at 3:40 PM with the DS and the RD, the RD stated correct labeling of opened food items was necessary to ensure safe food products. Review of facility's policy and procedure (P&P) titled, DIETETIC SERVICE - BASIC KITCHEN SANITATION, revised in 1/2025, the P&P indicated .Label and date all food items. All food.must be stored in pest-proof containers. Review of facility's policy and procedure (P&P) titled, FOOD RECEIVING AND STORAGE, revised in 1/2026, the P&P indicated .Desirable practices include.removing foods not safe for consumption, keeping dry food products in closed containers. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated .All foods shall be.stored.and served to ensure all food is free from contamination.and shall be fit for human consumption. The Food and Drug Administration (FDA) Food Code 2022, 3-501.17 (A) (B) (C) (D) indicated required food labeling and dating. It states the day the original container is opened in the food establishment shall be counted as Day 1.The date marked shall not exceed a manufacturer's use-by date.mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. The Food and Drug Administration (FDA) Food Code 2022, 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container, 1/18/23 version, indicated, The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination. 3. During the initial kitchen tour on 4/28/26 at 9:14 AM in the dry storage area, the white tile floor was observed worn and had black discoloration. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated facility floors should be clean and free of discoloration, as floor discoloration could be from dirt or other build up that may harbor bacterial overgrowth and pests. The IP further stated that a floor that was not clean in the kitchen dry storage area increased the risk of food contamination. During a joint interview on 4/30/26 at 3:40 PM with the DS and the RD, the DS and the RD acknowledged that the floor in the kitchen dry storage area was an area of concern for cross-contamination (spread of germs from one surface or item to another), as the floor was worn with black discoloration. Review of facility's policy and procedure (P&P) titled, DIETETIC SERVICE - FOOD STORAGE, dated 1/2025, the P&P indicated .Food storage areas shall be clean at all times. The Food and Drug Administration (FDA) Food Code 2022, Section 6-501.12, titled Cleaning, Frequency and Restrictions, indicated .PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4.During the initial kitchen tour on 4/28/26 at 9:22 AM in the reach-in freezer, a closed clear plastic bag containing frozen hotdogs that had been removed from the original packaging had visible ice crystal buildup or freezer burn throughout the bag. During a subsequent interview with the DS, the DS confirmed freezer burn was present throughout the bag of hotdogs and indicated improper storage. During a concurrent observation and interview on 4/30/26 at 9:30 AM with the DS in the walk-in freezer while doing the initial kitchen tour, a closed clear plastic storage bag containing frozen turkey that had been removed from the original packaging had heavy ice crystal buildup or freezer burn covering most of the turkey inside the bag. A cardboard box containing a clear plastic bag of frozen pork chops in the original packaging was not securely closed, exposing the pork chops to air, and had visible ice crystal buildup or freezer burn covering portions of the light brown pork chops inside the package. The DS confirmed the turkey was heavily covered with ice crystals or freezer burn and the pork chops were not securely closed and were exposed to air. The DS stated food items stored in the freezer should be tightly or securely closed. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated that food not stored properly was at risk for contamination and could cause foodborne illness. During a joint interview on 4/30/26 at 3:40 PM with the DS and the RD, the DS and the RD acknowledged the frozen hotdogs, turkey and pork shops stored in the freezer had freezer burn, and the pork chops were not securely closed and were left exposed to air, which indicated poor food storage. The RD stated that freezer burn changed the taste, texture, and quality of food and that poor storage or exposing food items to air placed food at risk for cross-contamination. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated, .All foods shall be.stored.and served to ensure all food is free from contamination.and shall be fit for human consumption.All foods shall be protected against contamination. The Food and Drug Administration (FDA) Food Code 2022, 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container, 1/18/23 version, indicated, The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination. 5. During the initial kitchen tour and interview on 4/28/26 at 9:42 AM in the cook's area, a small shallow fry pan with a worn, coated cooking surface was stored in the ready-to-use area and observed with a whitish residue on the dark gray cooking surface. Multiple visible scratch marks and worn areas were present throughout the interior surface of the pan, with black residue along portions of the inner rim. During a subsequent interview with the RD, the RD stated that the fry pan had food debris and was not cleaned properly. During a concurrent observation and interview on 4/28/26 at 9:43 AM with the DS in the cook's area while doing the initial kitchen tour, a large steam table pan stored in a ready-to-use area had moderate amounts of dried yellowish food residue and dark discoloration along the interior sides and bottom corners of the pan, and it was sticky to the touch. Three muffin tins stored in a ready-to-use area had moderate yellow residue and discoloration around the inner edges and seams of multiple muffin cups. The DS stated that the steam table pan and the three muffin tins were not cleaned properly. During subsequent observation and interview on 4/28/26 at 9:44 AM with the DS and the RD while in the cook's area while doing the initial kitchen tour, a blender with the cap placed on top of the container was stored in a ready-to-use area, but when opened it was wet with visible water residue, moisture buildup, and pooled water around the blender blade assembly. The DS and RD confirmed that the blender was wet inside with pooled water at the bottom. The RD stated that the blender was stored wet and at risk for mildew (a type of mold that grows on wet or damp surfaces) growth. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated that staff were expected to clean kitchen equipment before storing it in a ready-to-use area. The IP further stated storing kitchen equipment with food residue or while wet placed the equipment at risk for mold and bacteria overgrowth, which could cause foodborne illness. During a joint interview on 4/30/26 at 3:40 PM with the DS and RD, the DS and RD stated that storing a fry pan, steam table pan, muffin tins that were not properly cleaned was a risk for cross-contamination and that a blender stored wet could develop mold and mildew. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated, .All equipment.shall be kept clean and maintained in safe condition.Equipment necessary for storage, preparation and service of food.shall be well-maintained. Review of facility's policy and procedure (P&P) titled, DIETETIC SERVICE - BASIC KITCHEN SANITATION revised in 1/2025, the P&P indicated .equipment shall be kept clean, maintain in good repair .Air dry all equipment . The Food and Drug Administration (FDA) Food Code 2022, 4-602.11, titled, Equipment Food-Contact Surfaces and Utensils, indicated, (A) Equipment food-contact surfaces and utensils shall be cleaned. The Food and Drug Administration (FDA) Food Code 2022, 4-604.14, titled, Wet Cleaning, Indicated, (A) EQUIPMENT FOOD-CONTACT SURFACES AND UTENSILS shall be effectively washed to remove or completely loosen soils. The Food and Drug Administration (FDA) Food Code 2022, 4-901.11, titled, Equipment and Utensils, Air-Drying Required, indicated, After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried. 6. During a concurrent initial kitchen tour, interview with the RD, and record review on 4/28/26 at 9:45 AM in the cook's area, the cutting board chart was reviewed. The RD confirmed the two cutting boards that were green and red had multiple deep gouges on the cutting surface. A review of the cutting board chart indicated that the red cutting board was used for meat, and the green cutting board was used for fruits and vegetables. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated that cutting boards should not have deep gouges because bacteria could penetrate the gouges which could not be reached through routine cleaning and could contaminate food leading to foodborne illness. The IP further stated that cutting boards with deep gouges should be replaced. During a joint interview on 4/30/26 at 3:40 PM with the DS and the RD, the DS and the RD acknowledged that the green and red cutting boards had deep gouges. The RD stated that deep gouges interfered with cleaning and affected the ability to properly sanitize the cutting boards. Review of facility's policy and procedure (P&P) titled, DIETETIC SERVICE - BASIC KITCHEN SANITATION, revised in 1/2025, the P&P indicated .equipment shall be kept clean, maintain in good repair. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated .All equipment.shall be kept clean and maintained in safe condition.Equipment necessary for storage, preparation and service of food.shall be well-maintained. The Food and Drug Administration (FDA) Food Code 2022, 4-501.12, titled, Cutting Surfaces, indicated, Wet Cleaning Indicated, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaces if they can no longer be effectively cleaned and SANITIZED, or discarded. 7.) During a subsequent visit to the kitchen on 4/29/26 at 11:20 AM in the cook's area, [NAME] (CK) 1 wore a white plastic apron tied at the waist with the bow in front. CK 1 took sheet pans from the oven and transferred the cooked fish to a steam table pan. As CK 1 was doing the transfer, the apron ties contacted the cooked fish twice. During an observation on 4/29/26 at 12:40 PM at the steam table area, CK 1 leaned forward while plating broccoli for a resident, causing the front of the apron to contact the broccoli and leaving a half fist-sized green residue mark on the left waist area of the apron. During an interview on 4/30/26 at 2:28 PM with the IP, the IP stated an apron worn by kitchen staff must be securely tied around the neck and waist, with the ties secured at the back, to prevent the apron ties from contacting food. The IP further stated the apron was not assured to be clean because it could have contacted dirty surfaces during kitchen operations, causing contamination of the food. During a joint interview on 4/30/26 at 3:40 PM with the DS and the RD, the DS and the RD acknowledged the apron contacted food during meal preparation in the kitchen. The RD stated the apron contacting cooked food placed the food at risk for cross-contamination. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated .All people engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. The Food and Drug Administration (FDA) Food Code 2022, 2-304.11, titled, Clean Condition indicated, Food employees shall wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles. 8.) During a subsequent visit to the kitchen on 4/29/26 at 1:00 PM at the steam table food area while kitchen staff were conducting the tray line (meal plating and meal distribution process), CK 1 used disposable clamshell food containers for the last four resident lunches instead of a heated plate with a plate warmer and cover. During a subsequent interview with CK 1, CK 1 stated the facility ran out of standard dish plates, which was why disposable food containers were used for the remaining residents' lunches. During a concurrent observation and interview on 4/29/26 at 1:05 PM with the RD in the steam table food area, the RD confirmed disposable clamshell food containers were used for the remaining residents because the facility did not have enough standard dish plates available during meal service. During a joint interview on 4/30/26 at 3:40 PM with the DS and the RD, the DS and the RD stated the facility served resident meals in disposable food containers after the facility ran out of standard dishware during meal service. The DS and the RD acknowledged the use of disposable food containers had the potential to affect food temperature during meal distribution and service, placing the food at risk for bacterial overgrowth. Review of facility's policy and procedure (P&P) titled, FOOD SERVICE, dated 1/2025, the P&P indicated .Tableware and tables, dishes, and utensils shall be provided in the quantity necessary to serve the clients. The Food and Drug Administration (FDA) Food Code 2022, 3-501.16, titled, Time/Temperature Control for Safety Food, Hot and Cold Holding indicated, .TIME/TEMPERATURE CONTAROL FOR SAFEZTY FOOD shall be maintained.

Based on observation, interview, and record review, the facility failed to ensure supplemental (additional) oxygen was administered in accordance with professional standards of practice for 2 out of 29 sampled residents (Resident 19 and Resident 80) when:1.Resident 19's oxygen humidifier bottle (a device designed to add moisture to dry oxygen from a concentrator, preventing irritation to the nose, throat, and airways during oxygen therapy) was empty and labeled with a date of 4/7/26 (observation was on 4/28/26) and there was no medical doctor order for the use of a humidifier to be used with oxygen therapy; and2.Resident 80's oxygen humidifier bottle was observed empty and was not labeled with a date.These failures had the potential to place Resident 19 and Resident 80 at risk for respiratory discomfort or distress that could negatively impact their health conditions. Findings: 1.a. A review of Resident 19's admission RECORD, indicated Resident 19 was admitted to the facility with multiple diagnoses including chronic obstructive pulmonary disease with acute exacerbation (CODP, a progressive, long-term long disease that restricts airflow, making it difficult to breathe),and type 2 diabetes mellitus (a chronic disorder characterized by high blood sugar in blood - people with diabetes have a higher risk of infection such as pneumonia [inflammation of the air sacs in one or both lungs]). During a concurrent observation and interview on 4/28/26 at 12 PM, with Certified Nursing Assistant (CNA) 1, in Resident 19's room, Resident 19's oxygen concentrator had an empty bottle humidifier. CNA 1 confirmed the finding. A review of Resident 19's medical record titled, Order Review History Report, dated 4/1/26 through 4/30/26, included following active orders: Oxygen at 1LPM [L/min, litter per minute, a unit of measurement] via NC [nasal cannula] to keep O2 [oxygen] sat [saturation]> [above] 90% [percentage- unit of measurement out of 100] as needed for SOB [shortness of breath] related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE [new onset]) EXACERBATION. started on 3/24/26. During a concurrent observation and interview on 4/29/26 at 8:55 AM with Licensed Nurse (LN) 6 in Resident 19's room, LN 6 changed the oxygen concentrator humidifier bottle. LN 6 confirmed the humidifier bottle was empty. LN 6 stated that humidifier bottles should have been replaced when it was no longer bubbling and should not be allowed to become completely empty before replacement. LN 6 explained that once humidifier bottle was empty, the oxygen delivered becomes dry air, which might irritate the respiratory system and contribute to breathing difficulties due to lack of moisture. LN 6 further stated Resident 19 had a diagnosis of COPD and breathing dry air could lead to exacerbation of the condition. 1.b. During a concurrent observation and interview on 4/28/26 at 12 PM with CNA 1 in Resident 19's room, Resident 19's oxygen concentrator had an empty bottle humidifier which was labeled 4/7/26. CNA 1 confirmed the finding. During a concurrent observation and interview on 4/29/26 at 8:55 AM with LN 6 in Resident 19's room, LN 6 was observed changing the oxygen concentrator humidifier bottle. LN 6 confirmed the humidifier bottle was empty and labeled 4/7/26. LN 6 further confirmed that the bottle was labeled RX (a common medical abbreviation for a prescription or a pharmaceutical drug that requires authorization from a healthcare professional) and stated that all RX items were considered medications and therefore should have a physician's order specifying administration and the replacement/change frequency. During a phone interview on 4/30/2026 2:51 PM with Medical Director (MD) 1, MD 1 stated her expectation was for nurses to obtain a physician's order for all items labeled as RX, prior to administration. MD 1 stated oxygen humidifier bottles labeled as RX should have had a corresponding physician's order. MD 1 further stated she reviewed and signed all orders; however, she overlooked and did not notice the absence of the order for the oxygen humidifier bottle. During an interview on 5/1/26 at 10:04 AM with the Infection Preventionist (IP), the IP explained that nurses were expected to administer oxygen, change oxygen tubing and masks as ordered by the physician, and check oxygen humidifier bottles every 24 hours. The IP stated that humidifier bottles should have been replaced according to manufacture guidelines and it was the responsibility of the nightshift (a specific block of time worked) nurses. The IP further explained that if a resident received 3 L/min or more of PRN (as needed) oxygen, a humidifier should be used to moisturize the airflow. The IP stated that Resident 19 had an active order to administer 1 L/min oxygen PRN, and added Resident 19 preferred the use of an oxygen humidifier for comfort and moisture. The IP stated that when the oxygen humidifier bottle became empty, the resident's airway passages could dry out, causing cracking inside the nose and resulting in nosebleeds. The IP further added based on her experiences, humidifier bottles should be replaced when they were no longer producing bubbles to prevent respiratory distress and/or damage to Resident 19's nasal passages from breathing dry air. During a review of Resident 19's medical record titled Care Plan Report, revealed a care plan titled Focus. resident [Resident 19] has Emphysema/COPD. Interventions/Tasks. Change oxygen humidifier in accordance with manufacturer's guidelines. and was initiated on 11/30/21. 2. During a review of Resident 80's admission RECORD, dated 4/9/26, the record indicated, Resident 80 was admitted to the facility with diagnoses which included necrotizing fasciitis (a rare, rapid, and life-threatening bacterial infection that destroys the skin, fat, and fascia [tissue covering muscle]), Fournier Gangrene (a rare, rapidly progressing, and life-threatening necrotizing fasciitis [flesh-eating infection] of the genital, perineal, or perianal regions), and chronic obstructive pulmonary disease (a progressive, treatable lung disease that causes obstructed airflow, making it hard to breathe). During an initial tour of Resident 80's room on 4/28/26 at 2.44 PM, an oxygen humidifier bottle was observed empty and without a label that indicated the date the humidifier bottle was set up for the resident's use. During an interview on 4/28/26 at 2:54 PM with Licensed Nurse (LN) 4, LN 4 acknowledged that the humidifier oxygen bottle was both empty and unlabeled. She explained that the bottle should have been replaced when it ran out and properly labeled, adding that she would change it immediately. During an interview on 4/29/26 at 4:27 PM with the Infection Preventionist (IP), the IP explained that an empty oxygen humidifier was ineffective and should have been replaced immediately when it was empty and should have also been properly labeled and dated. During an interview on 5/1/26 at 11:17 AM with the Director of Nursing (DON), the DON stated that an empty humidifier was not effective. The DON also explained that an oxygen humidifier bottle needed to be labeled, as without a label, date and time, it was impossible to know when it was last changed. The DON added that without a date and time, there was no way to determine how long the bottle had been in use. A review of the facility policy and procedure (P&P) titled, [Brand Name] AS0352 HUMIDIFICATION, revised January 2025, indicated, .The facility shall ensure that oxygen humidification.is provided, maintained and replaced in a manner that prevents infection, ensures proper device function, and complies with manufacturer instructions and accepted standards of practice.prefilled humidifier is designed for single-patient use and should be replaced whenever the sterile water is empty.

Based on observation, interview, and record review, the facility failed to conserve the nutritive value and flavor of pureed food (a cooked food that has been ground, pressed, or blended into a smooth, thick, and creamy paste or liquid, often with a pudding-like consistency) for a total of six out of seven residents (Resident 6, Resident 9, Resident 15, Resident 63, Resident 64, and Resident 112) who received puree food from the facility kitchen, when the facility did not follow the recipe for pureed lemon rice pilaf (seasoned rice dish).This failure had the potential to affect the nutritive value, flavor, and consistency of the pureed food, which could lead to reduced food intake, malnutrition, and negative health outcomesFindings:During a review of the facility's daily cook's menu for lunch on 4/29/26, the menu indicated lemon rice pilaf would be served to residents on the following diets: regular, chop/easy chew, soft bite-sized, minced and moist (finely chopped and moist food), and pureed textures.During a joint concurrent observation and interview on 4/29/26 at 10:59 AM with [NAME] (CK) 1 and the Registered Dietitian (RD) in the kitchen by the cook's area, CK 1 measured ten and a half cups of rice pilaf from the steam table pan and placed into the container for the blender. CK 1 then added an unmeasured amount of thin yellow liquid from a full pitcher, which CK 1 stated was chicken broth, and blended the mixture for a few seconds. CK 1 stated more chicken broth was needed and added another unmeasured amount from the pitcher into the blender, then blended the rice pilaf and chicken broth again for a few seconds. CK 1 tested the blended rice pilaf for pureed texture by scooping the blended rice pilaf from the blender with a spoon and letting the mixture flow back into the blender. CK 1 was unhappy with the texture and stated it needed thickener (used to modify the consistency of foods and beverages). CK 1 proceeded to add two large scoops of thickener to achieve the correct pureed texture and blended the mixture again for a few seconds. The RD performed IDDSI (International Dysphagia Diet Standardization Initiative - standardized texture consistency testing for swallowing safety) testing and stated the texture for the pureed rice pilaf was not correct.During a concurrent interview and review of the facilities recipe for pureed lemon rice pilaf on 4/29/26 at 11:05 AM with the RD, the recipe directions indicated,.PLACE PORTIONS NEEDED OF PREPARED PRODUCT IN BLENDER/FOOD PROCESSOR. ADD 2 TBSP [tablespoon-unit measure] MILK FOR EACH PORTION. The RD stated the recipe for rice pilaf was not followed because unmeasured chicken broth was used instead of two TBSP of milk for each portion of rice pilaf. The recipe also did not indicate a need for thickener.During an interview on 4/30/26 at 3:40 PM with the Dietary Supervisor (DS) and RD, the RD stated pureed rice pilaf should not have additional thickener added. The DS and RD acknowledged not following the recipe for the menu item could affect the nutritive value, flavor, and consistency of the food, which could lead to reduced food intake, malnutrition, and negative health outcomes.Review of facility's policy and procedure (P&P) titled, ASSISTED NUTRITION AND HYDRATION, revised in 1/2025, the P&P indicated .The intent of this requirement is to provide staff guidelines to ensure that the resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status.Provide a therapeutic diet that considers the resident's clinical condition. when there is a nutritional indication.The Food and Drug Administration (FDA) Food Code 2022, 3-101.11 titled, Safe, Unadulterated, and Honestly Presented indicated, FOOD shall be safe, unadulterated, and.honestly presented.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 103, when:1. Resident 6 and Resident 80's urinals were not labeled to indicate whom the urinals belonged to; and2. Multiple boxes of soda were observed stored directly on the floor in Resident 19's room and the there were multiple dark brown/black stains on the floor;These failures had the potential to spread infection and cause health problems to the residents in the facility.Findings: 1a. During a review of Resident 6's admission RECORD, dated 4/9/26, the record indicated, Resident 6 was admitted to the facility with diagnoses that included Hemiplegia (severe or total paralysis affecting one side of the body) and Hemiparesis (mild or moderate weakness affecting one side of the body) and cognitive communication deficit (a communication impairment stemming from underlying cognitive issues, such as memory, attention, or executive function deficits). During an initial tour of Resident 6's room on 4/28/26 at 2:38 PM., a urinal was observed on the nightstand without a label indicating the resident's name. During a concurrent observation and interview on 4/28/26 at 2:54 PM with LN 4, LN 4 confirmed Resident 6's urinal was not labeled. LN 4 stated that an unlabeled urinal could lead to cross contamination of bacteria. 1b. During a review of Resident 80's admission RECORD, dated 4/9/26, the record indicated Resident 80 was admitted to the facility with a diagnosis that included necrotizing fasciitis (a rare, rapid, and life-threatening bacterial infection that destroys the skin), Fournier Gangrene, (a rare, rapidly progressing, and life-threatening necrotizing fasciitis [flesh-eating infection] of the genital, perineal, or perianal regions) and Cellulitis of corpus cavernosum and penis (a serious bacterial infection causing swelling, pain, warmth, and redness in the penile shaft, often in uncircumcised or immunocompromised individuals). During an initial tour of Resident 80's room on 4/28/26 at 2:41 PM, a urinal was observed on the bedside table without any label. During a concurrent observation and interview on 4/28/26 at 2:54 PM with LN 4, LN 4 confirmed the urinal was not labeled. LN 4 stated that an unlabeled urinal could lead to cross contamination. During an interview on 4/29/26 at 4:27 PM with the IP, the IP stated the urinal should have been labeled, as without proper labeling there was no way to know who the urinal belonged to. The IP stated without a proper label, the urinal could be used by another resident and could lead to infections. IP further stated it was important to have the urinals labeled to prevent the risk of infections. During an interview on 5/1/26, at 11:17 AM with the DON, the DON explained that failing to label the urinal posed a concern, as without proper identification, there was no way to determine who it belonged to, and another individual might inadvertently use it. 2a. A review of Resident 19's admission RECORD, indicated Resident 19 was admitted to the facility with multiple diagnoses including chronic obstructive pulmonary disease (CODP, a progressive, long-term long disease that restricts airflow, making it difficult to breathe), type 2 diabetes mellitus (a chronic disorder characterized by high blood sugar - residents with diabetes have a higher risk of infection such as pneumonia [lung infection]), and malignant neoplasm of prostate (a cancerous tumor in the prostate - residents with prostate cancer have a higher risk of developing infections). During a concurrent observation and interview on 4/28/26 at 12 PM with Certified Nursing Assistant (CNA) 1 in Resident 19's room, multiple boxes of soda were stored directly on the floor against the wall with the window. Several boxes were open, and visible dust accumulation was observed on the boxes. CNA 1 confirmed the sodas belonged to Resident 19 and stated staff routinely provide cans to the resident upon request. CNA 1 added Resident 19 was able to independently retrieve soda cans while sitting in his wheelchair, and there was a risk for Resident 1 to touch the floor while retrieving cans and to consume beverages from dusty cans, raising infection control concerns. During an interview on 4/28/26 at 12:12 PM with Resident 19, Resident 19 stated he had been diagnosed with cancer and reported that after each treatment he experienced weakness and was unable to transfer independently between the bed and wheelchair. Resident 19 stated he would ask staff to provide cans of soda from the boxes stored on the floor when needed. Resident 19 further stated he was also able to independently retrieve cans of soda from the boxes observed on the floor while seated in his wheelchair. During an interview on 4/29/26 at 8:55 AM with LN 6, LN 6 stated Resident 19 mostly requested staff assistance to obtain sodas from the boxes stored in his room; however, LN 6 also stated Resident 19 was able to independently retrieve soda cans from the boxes placed directly on the floor in his room. LN 6 further stated that consuming beverages from cans that might have accumulated dust could present infection control concerns and increase the risk of exacerbation of Resident 19's COPD due to exposure to dust particles. During an interview on 4/30/26 at 8:45 AM with LN 1, LN 1 stated that Resident 19 wanted to store boxes of soda on the floor in his room. LN 1 explained that Resident 19 was able to move independently while sitting in his wheelchair. LN 1 further stated there was an increased risk of dust accumulation and cross-contamination because of the boxes which were placed directly on the floor, particularly when Resident 19 independently opened the boxes and/or retrieved cans from them. 2b. During an observation on 4/28/26 at 12 PM in Resident 19's room, the floor was noted to be unclean with multiple dark brown stains presented around the bedside table area, located on the left side of Resident 19's bed between the privacy curtain (a curtain that can be pulled around the bed to provide privacy) and the bed. During an interview on 4/30/26 at 8:45 AM with LN 1, LN 1 stated residents' rooms should be kept clean and free from clutter daily and as needed when visibly unclean. LN 1 stated Resident 19 did not want anyone to move the boxes that were stored directly on the floor, which could potentially make it difficult to properly clean the room and contribute to infection control concerns. During an interview on 4/30/26 at 9:55 AM with the Housekeeping Lead (HKL), the HKL explained that residents' rooms, including Resident 19's room, were scheduled for cleaning every day to ensure cleanliness and prevent infections. The HKL stated that she worked four days per week and, when she was assigned to clean Resident 19's room, Resident 19 allowed her to clean and mop his room. The HKL further stated that she was unsure whether Resident 19 allowed other staff members to move the boxes stored directly on the floor to clean underneath them that might lead to infection control concerns. During an interview on 5/1/26 at 10:04 AM, the Infection Preventionist (IP) stated that it was Resident 19's preference to store all boxes of soda in his room, and he was encouraged to allow the facility to move them; however, he refused. The IP stated it was difficult to clean underneath the boxes stored directly on the floor, and housekeeping staff were unable to properly clean the area because Resident 19 did not want or allow staff to move them. The IP further stated that floors should be kept clean, and Resident 19 was particular about staff touching the boxes on the floor. The IP further added that there was a risk of pests' (mice or insects) activity when Resident 19's room was not properly cleaned, with an increased risk for cross-contamination and infection prevention concerns. During an interview on 5/1/26 at 10:43 AM with the Director of Nursing (DON), the DON stated Resident 19 had respiratory issues such as COPD, and there was a possibility that boxes stored directly on the floor in his room could accumulate dust, potentially worsening his respiratory condition. The DON added that pests, including cockroaches, could potentially nest between the boxes, particularly when the floor was visibly dirty. The DON further stated that Resident 19 was prone to infection due to his medical conditions and that the floor should be kept clean to help prevent infections. The DON further added that staff were expected to educate Resident 19 regarding those concerns and document the education provided. Review of the facility's policy and procedure (P&P) titled, INFECTION AND PREVENTION AND CONTROL, revised on January 2026, indicated, . The facility has an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. DEFINITION. Cleaning: The removal of visible soil (e.g., organic, and inorganic material) from objects and surfaces and it normally accomplished manually or mechanically using water with detergents.

Based on observation, interview, and record review, the facility failed to protect resident privacy when three tray tickets were thrown into the trash for a census of 103 residents who were receiving facility-prepared meals. This failure had the potential for the residents' personal and health information to be viewed and utilized by unauthorized individuals. Findings:During the initial kitchen tour on 4/28/26 at 9:52 AM, the Diet Aide (DA) 1 was washing the breakfast dishes. DA 1 removed the trays from the cart, dumped leftover food and paper products, including at least three residents' tray tickets, into the garbage can before separating like items for washing. When questioned, DA 1 stated dirty and/or wet tray tickets were put into the garbage without any other destruction occurring. During a concurrent review of the residents' tray tickets (from 4/29/26) and interview with the Director of Nursing (DON) on 4/30/26 at 2:39 PM, the DON agreed that the tray tickets included the following resident information: names, unit/room/bed, date, diet orders, food allergies, food and beverage texture requirements, and notes such as the need for assistive devices, portion sizes, and dislikes. The DON stated that the tray tickets contained resident identifiers and diet-related health information that should be protected. The DON continued that the expectation was that tray tickets were shredded before disposal, and that they should not be placed in regular garbage where unauthorized individuals could access them. The DON further stated this was not in compliance with privacy and confidentiality requirements under the Health Insurance Portability and Accountability Act Privacy Rule (HIPAA - established national standards to protect individuals' medical records and other individually identifiable health information, collectively defined as protected health information). During a subsequent interview on 4/30/26 at 3:39 PM with the Dietary Supervisor (DS) and Registered Dietitian (RD), the DS and RD acknowledged that residents' tray tickets contained confidential information and that placing them in the garbage was not appropriate. Review of facility's policy and procedure (P&P) titled, PRIVACY AND CONFIDENTIALITY, revised in 3/2023, the P&P indicated, .The resident has a right to personal privacy and confidentiality of his or her personal and medical records, including all provisions of the HIPAA Privacy Rule.Safeguarding the content of information.from unauthorized disclosure. The facility supports each resident's right.to privacy and confidentiality for all aspects of care and services. Resident medical information.shall not be in public view.

Based on observation, interview, and record review, the facility failed to develop and update comprehensive care plans (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) for 2 of 29 sampled residents when: 1. A care plan for shortness of breath was not updated to include new oxygen therapy interventions for Resident 74; and2. A care plan for dialysis care (a specialized medical treatment for patients with chronic kidney failure who receive treatments to filter waste and excess fluids from their blood) was not developed for Resident 124. These failures had the potential to place Resident 74 and Resident 124 at risk for not receiving effective, individualized care. As a result, these failed practices could negatively impact the health, safety, and well-being of Residents 74 and 124. Findings: 1.During a review of Resident 74's admission RECORD, the record indicated Resident 74's diagnosis included chronic obstructive pulmonary disease (COPD, airway inflammation in a resident with a progressive, incurable lung disease and damage to the airway, making it difficult to breathe), and personal history of pulmonary embolism (a sudden, life threatening blockage in one or more lung arteries, symptoms included sudden shortness of breath, sharp chest pain, and fainting or lightheadedness). During a concurrent observation and interview on 4/28/26 at 11:20 AM with the Licensed Nurse (LN) 6, LN 6 confirmed there was a sign outside of Resident 74's room that indicated oxygen was in use inside Resident 74's room and LN 6 verified Resident 74 was receiving oxygen for shortness of breath. During a concurrent interview and record review on 4/28/26 at 11:44 AM with LN 6, Resident 74's medical record titled, Order Review History Report [a list of the resident's ordered medications], dated 4/1/26 through 4/30/26 and all active care plans were reviewed. LN 6 confirmed the following order for Resident 74: . Administer O2 [oxygen] at 2 liters/min [liters per minute, a unit of measurement] via nasal cannula [a plastic tube with two prongs placed in the nostrils to deliver supplemental oxygen to patients with respiratory conditions] to maintain SaO2 [oxygen saturation] level at 90% [% is a percentage a number or ratio representing a part of a whole expressed as a fraction of 100] . was started on 3/17/26. LN 6 verified the physician's order for oxygen therapy. However, upon review of the care plan, LN 6 acknowledged that oxygen therapy was not included as an intervention for shortness of breath and/or respiratory distress. Additionally, the care plan had not been updated to reflect the initiation of oxygen therapy on 3/17/26. LN 6 acknowledged the findings and stated that care plans served as a framework for nursing care. LN 6 explained that nurses were responsible for developing care plans, implementing and updating interventions as needed, and using them as guiding tools to evaluate effectiveness. LN 6 further stated that the absence of appropriate care plan interventions suggested that necessary measures might not have been implemented to meet Resident 74's respiratory needs. During an interview on 4/29/26 at 12:05 PM with LN 4, LN 4 stated that care plans served as a communication tool to guide nursing staff in providing appropriate care to residents and in establishing goals aimed at improving outcomes and meeting individual needs. LN 4 explained that nursing staff were responsible for developing person-centered care plans and implementing appropriate interventions based on each resident's specific needs and goals. LN 4 further stated that care plans provided guidance and direction to ensure residents' needs were met, and that the absence of an updated and comprehensive care plan could result in a lack of coordination of care. During an interview on 5/1/26 at 10:43 AM with the Director of Nursing (DON), the DON stated care plans served as essential guidelines for nursing staff to ensure appropriate resident care. Additionally, the DON stated that care plans should be individualized and include person-centered goals and interventions aimed at improving residents' health conditions. The DON added nurses were expected to create, update, or resolve care plans as necessary, particularly when existing interventions were ineffective. The DON further stated that those expectations were not met without appropriate care plans and effective interventions for Resident 74 and it appeared that Resident 74 did not receive optimal care. During a review of the facility provided policy and procedure (P&P) titled, DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS, revised on January 2026, the review indicated, . POLICY STATEMENT: The facility develops a person-centered comprehensive care plan. developed and implemented to meet. and address the resident's medical, physical. needs. GUIDELINES. 1. a. The services that are to be furnished are to attain or maintain the resident's highest practicable physical. 2. Care plans must be person-centered and reflect the resident's goals. and desired outcomes. 2. During a review of Resident 124's admission RECORD, dated 5/1/26, the record indicated, Resident 124 was admitted to the facility with diagnoses including end stage renal disease (ESRD, the final, irreversible stage of kidney failure where kidneys function at less than 15% [percent - out of 100] of normal capacity) and type 2 diabetes mellitus (DM2, a chronic metabolic condition where the body develops insulin [a hormone produced by the pancreas] resistance or fails to produce enough insulin, resulting in high blood sugar levels). During an initial interview on 4/28/26 at 8:35 AM with Resident 124 while in her room, Resident 124 stated she was getting ready to go to her dialysis appointment. Resident 124 also stated her dialysis days were every Tuesdays, Thursdays, and Saturdays. During a review of Resident 124's Order Summary Report, active orders as of 5/1/26, the order indicated, .Hemodialysis Schedule 3 x [times] per week every T-TH-S [Tuesday, Thursday, and Saturday] at 10:25 AM Dialysis Center.Hemodialysis: Do not restrict fluids.Do not take blood pressure or blood draws on LEFT arm.Monitor access site Left upper AV fistula [a connection surgically created between an artery and a vein designed for long-term hemodialysis] for redness, swelling, drainage & [and] pain. Notify MD [Medical Director] if (+) [positive].Monitor intake and output [the amount of fluid that goes into the body and the amount of fluid that leaves the body] every shift.Monitor for presence of bruit [vascular sound] & thrill [palpable vibration] every shift.Vital signs [measurable body functions used to detect or monitor medical problems] pre [before] and post [after] dialysis in the evening every Tue, Thu, Sat [Tuesday, Thursday, and Saturday] for Post Dialysis.Vital signs pre and post dialysis one time a day every Tue, Thu, Sat for Pre Dialysis. During a review of Resident 124's Care Plan Report, dated 4/22/26, the report revealed that there was no care plan created or initiated for dialysis care to include the physician's orders listed above as measures of meeting Resident 124's dialysis needs. During an interview on 5/1/26 at 8:46 AM with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 124's care plan report did not include a dialysis care plan. The ADON stated there should have been a stand-alone dialysis care plan initiated to include interventions pertaining to dialysis care such as checking for the fistula access site, reviewing the body weight history before and after dialysis, checking for electrolyte (essential minerals the body needs to function) imbalance, and other measures necessary in providing care to Resident 124. The ADON also stated that without the care plan the interventions mentioned above could have been missed and could have affected the care of Resident 124. During an interview on 5/1/26 at 1:07 PM with the Director of Nursing (DON), the DON stated she expected the dialysis care plan to be initiated and implemented to achieve the goals instituted for Resident 124, and so the nursing staff could have used the care plan as a guideline in implementing dialysis care. The DON also stated the risk of not having a dialysis care plan was that the nursing staff would not have had the proper direction in providing care. During a review of the facility's Policy and Procedure (P&P) titled, DIALYSIS MANAGEMENT, revision date January 2025, the P&P indicated, .To provide residents who require dialysis care, services consistent with professional standards of practice, a comprehensive person-centered care plan which meets the residents' goals and preferences. During a review of the facility's Policy and Procedure (P&P) titled, BASELINE CARE PLAN, revision date January 2026, the P&P indicated, .The facility develops and implements a baseline care plan for each resident that includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care.Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission . During a review of the facility's Policy and Procedure (P&P) titled, DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS, revision date January 2026, the P&P indicated, .The facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and for the prevention of a pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for 1 of 29 sampled residents (Resident 2), when Resident 2's low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not correctly adjusted according to Resident 2's current weight. This deficient practice had the potential to delay wound healing and placed Resident 2 at increased risk for developing pressure injury and/or skin breakdown. Findings:During a review of Resident 2's admission RECORD, the record indicated Resident 2 was admitted to the facility with multiple diagnoses including end stage renal disease (final permanent kidney disease), peripheral vascular diseases (a slow, progressive blood circulation disorder that could slow wound healing process), and anemia in chronic kidney disease (a condition where the blood lacks enough healthy red blood cells, causing reduced oxygen delivery to organs and tissues that could impairs wound healing).During a concurrent observation and interview on 4/28/26 at 3:39 PM with Resident 2, Resident 2 was in bed on a LAL mattress, and the mattress setting was calibrated to 120 pounds (lbs.- a unit of measurement). Resident 2 stated the mattress was in use due to pressure injuries to his buttocks area (consists of two rounded muscles which are essential for walking, running, standing up from a chair, and a primary support for the body while in a seated position), with the purpose of promoting wound healing and preventing further skin breakdown.During a concurrent observation and interview on 4/28/26 at 3:44 PM in Resident 2's room, Licensed Nurse (LN) 8 confirmed Resident 2 was lying in bed on a LAL mattress which was adjusted to 120 lbs. LN 8 stated that nurses were responsible for checking the mattress setting each shift to ensure proper function and that the pump was supposed to be adjusted according to Resident 2's actual weight. LN 8 further stated that Resident 2 had existing wounds on the buttocks.During a subsequent concurrent interview and record review on 4/28/26 at 3:46 PM with LN 8, Resident 2's medical record titled, Weights and Vitals Summary, dated 4/28/26 was reviewed. The record indicated Resident 2's most recent post-dialysis (dialysis-a specialized medical treatment for patients with chronic kidney failure who receive treatments to filter waste and excess fluids from their blood) weight documented on 4/28/26 was 142 lbs. LN 8 acknowledged the findings and explained that the purpose of a LAL mattress was to relieve pressure on the wound, promote wound healing, and prevent further skin breakdown. LN 8 stated the LAL mattress pump should have been set according to Resident 2's actual weight and acknowledged the current mattress setting did not reflect Resident 2's actual weight. LN 8 acknowledged that inadequate pressure setting could contribute to worsening of existing wounds on the buttocks.During a review of Resident 2's medical record titled, Care Plan Report, contained a specific care plan initiated on 4/24/26 and titled, Focus. PREVENTATIVE: Resident [Resident 2] has high risk/or at risk for pressure injury development or skin impairment. contributing factors. fragile skin. easy skin breakdown, exposure to moisture r/t [related to] incontinence [inability to hold urine or stool]. prolong laying in same position. Interventions/Tasks. The resident [Resident 2] needs . pressure relieving/reducing mattress. LAL mattress for skin management. Additionally, the review revealed a care plan titled, Focus. The resident [Resident 2] has actual impairment to skin integrity, PI [Pressure Injury] on readmission to. Stage 2 PI [Pressure Injury that causes a partial loss of skin with an exposed, red-pink wound area]- left buttock. surrounding area of the open wound with non-blanchable, [does not turn white or fade when pressed] redness. contributing factors. impaired in mobility. prolong laying in same position. Interventions/Tasks. The resident [Resident 2] needs. pressure relieving/reducing mattress. LAL mattress.During an interview on 4/30/26 at 8:45 AM with LN 1, LN 1 explained the purpose of LAL mattress for Resident 2 was to promote wound healing and prevent further skin breakdown. LN 1 stated the mattress setting was adjusted from 120 lbs. to 160 lbs. LN 1 stated when the setting was at 120 lbs., the air pressure was too low, resulting in reduced air flow which could have allowed Resident 2's skin to be against the bed's metal frame, potentially worsening the existing wounds.During an interview on 4/30/26 at 9:41 AM with the Treatment Nurse (Tx Nurse), the Tx Nurse explained that upon admission, a LAL mattress was implemented for residents with stage 2 or higher PI, or for those at risk of developing pressure injuries. The Tx Nurse stated the purpose of the LAL mattress was to relieve pressure at the site of injury, to promote wound healing, and to prevent further skin breakdown. The Tx Nurse stated that when the LAL mattress was set at lower scale than the residents' current weights, the air pressure within the mattress was insufficient, as a result, the support provided was inadequate, potentially allowing residents' skin to be against their beds' frames, which could negatively impact the wound healing process.During an interview on 4/30/26 at 3 PM with the Environmental Services Director (ESD), the ESD stated he was notified by the nursing staff when there was an order to be placed for a LAL mattress on a resident's bed. The ESD stated once he was notified, he installed the mattress and set the air pressure according to the resident's current weight. The ESD further stated that when the pump scale did not allow for an exact weight setting, he adjusted the pressure to the next highest setting. The ESD further stated that if a resident's current weight was 142 lbs. and the pump scale included settings of 80 lbs.,120 lbs., and 160 lbs., he would have selected 160 lbs., in accordance with the manufacturer's guidelines.During an interview on 5/1/26 at 10:43 AM with the Director of Nursing (DON), the DON stated she expected nurses to adjust the LAL mattress pressure in accordance with the manufacturer's guidelines and the resident's comfort level. The DON further explained that when Resident 2 was lying on a LAL mattress set at a lower weight than current weight, there was a possibility that the wound healing process could have been delayed and/or the wound condition could have worsened.During a review of the facility provided undated LAL mattress operation manual for [Brand Name], the review indicated, . General. system is designed for prevention, treatment and management of pressure ulcers [localized damage to the skin and underlying soft tissue, usually over a bony areas of the body]. Weigh/Pressure set up. adjust air mattress to a desired firmness according to patient's weight.

Based on interview and record review, the facility failed to ensure the safe use of the medications for one out of five sampled residents (Resident 59) who's medical records were reviewed for the use of unnecessary medications, when Resident 59's physician's order for a lidocaine patch (a numbing agent used as a topical patch placed on the skin) did not follow the doctor's order and/or the manufacture specification for use.This failed practice could contribute to unsafe medication use, ineffective pain relief, and an adverse drug reaction (a harmful, unintended response to a medication occurring at normal doses).Findings:During a review of Resident 59's electronic medical record titled, admission Record, the record indicated Resident 59 was admitted to the facility with a diagnosis that included back and knee pain.During a review of Resident 59's electronic medical record titled, Discharge Summary and Orders, dated 2/2/26, the record from [Hospital A] indicated a Lidocaine 5% (percent, the amount out of 100) pain patch was to be applied once daily and then removed after 12 hours (drug free period). The medication start date was 2/3/26. During a review of Resident 59's electronic medical record titled, Medication Administration Record, (MAR, a document that contains medications ordered, given, and/or held) dated 2/26 through 4/26, the record indicated, Lidocaine External [outside of the body] Patch 4% (Lidocaine) Apply to affected area topically every 12 hours for Pain; Start date 3/26/26. The patch was scheduled for 9 AM and 9 PM without any drug free period time.During a concurrent interview and record review on 4/30/26 at 3:47 PM with Licensed Nurse 7 (LN 7) at the East nursing station, Resident 59's Order Summary Report, dated 1/2026 through 3/2026 was reviewed for a history of Lidocaine orders. The report indicated, - lidocaine 5% patch once daily at 9 AM and removal at 9 PM from 1/21/26 to 2/1/26,- lidocaine 4% patch once daily at 9 AM and removal at 9 PM from 2/2/26 to 3/26/26,- lidocaine 4% patch twice daily at 9 AM and 9 PM from 3/26/26 to 4/30/26LN 7 stated she entered the last order (3/26/26 through 4/30/26) into the computer on 3/26/26. LN 7 could not recall what prompted the order change. LN 7 stated she had not called the doctor to change the order.During a phone interview on 4/30/26 at 3:12 PM with the Medical Doctor (MD 1), MD 1 stated she was the medical director but had not closely monitored Resident 59. MD 1 stated she did not recall if she signed the monthly order review sheet (a monthly review of all physician orders) for the resident.On 4/30/26 at 11 AM, a phone call was made from the Department to Medical Doctor 2 (MD 2). MD 2 did not return the call. During an interview on 4/30/26 at 4:44 PM with Resident 59 in the facility's activity room, Resident 59 stated the pain patch was placed on her right knee and had not been effective or helpful in managing her knee pain.During an interview on 5/1/26 at 12 PM with Director of Nursing (DON) in her office, the DON stated she expected the nursing staff to discuss the need for medication change or the timing of the use of the medication with the care team and medical provider. The DON stated excessive use of lidocaine could cause side effects, change the effectiveness of the medication, and the nursing staff should have followed the standards of practice for safe medication usage.A review of the DailyMed (the official National Library of Medicine website providing up-to-date FDA [Food and Drug Administration]-approved drug labeling and package inserts) drug information based on FDA approved drug labeling and use, last accessed on 5/5/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=078bc9a3-41b7-26a4-e063-6394a90a200d, the drug information under Direction For Use indicated Remove patch from the skin after at most 8-hour application. A review of the facility's policy titled, Resident Care Supervised by a Physician, dated in March 2018, the policy indicated, . The physician supervises the medical care of residents by participating in residence assessment and care planning, monitoring changes in residence medical status and providing consultation or treatment when contacted by the facility. Supervision by the physician also includes, but is not limited to, prescribing medication and therapy, ordering a residence transfer to the hospital, conducting required routine visits or delegating to and supervising follow-up visits by NPP (Non-Physician Practitioner) .

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (percentage - number or ratio that expressed as a fraction of 100) with a census of 103 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 3 errors out of 32 opportunities which resulted in a facility wide medication error rate of 9.38 % for 3 out of 9 residents (Resident 19, Resident 27, and Resident 28) during medication administration observation.These failures may result in unsafe use of medications, medication errors, and not following the doctor's orders and manufacturer specifications.Findings: 1. During a medication administration observation with Licensed Nurse (LN) 6, on 4/28/26 at 8:55 AM, LN 6 poured 10 medications for Resident 19 into a cup. The medications included bicalutamide (cancer medication), amlodipine (blood pressure medication), Calcium plus Vitamin D3, doxycycline (antibiotic), hydralazine (blood pressure medication), ferrous sulfate (iron), metoprolol (blood pressure medication), multivitamin with minerals (includes Zinc as a mineral) acetaminophen/ hydrocodone bitartrate (pain medication) and loratadine (allergy medication). LN 6 administered all these medications with a cup of water.A review of the Resident 19's medication label for doxycycline, on the bubble pack (or blister pack, a type of protective packaging where drug is sealed in individual, transparent, plastic bubbles on a card) provided by the pharmacy, indicated, Take this medication at least 2 hours before or 2 hours after magnesium or aluminum containing antacids or other products containing calcium, iron or zinc.A review of Resident 19's Medication Administration Record, (MAR, a document that contains the physician ordered medications that were given or held) dated 4/1/26 through 4/30/26, indicated the administered medications were all timed to be given at 9 AM as follows:-Calcium-Vitamin D tablet scheduled and given at 9 AM-Multiple Vitamins-Minerals Tablet scheduled and given at 9 AM-Iron tablet 325 milligram (mg, unit of measurement) scheduled and given at 9 AM and 5 PM.-Doxycycline oral tablet 100 MG scheduled and given at 9 AM and 5 PM,During a concurrent interview and record review on 4/29 /26 at 10:53 AM with LN 1, Resident 19's MAR, dated 4/1/26 through 4/30/26 was reviewed. LN 1 stated that medications ordered to be given twice a day were usually scheduled for 9 AM and 5 PM. LN 1 confirmed that Resident 19 was taking iron, calcium, and a multivitamin that contained Zinc and that those medications and supplements were scheduled at the same time as Doxycycline. LN 1 stated the Doxycycline should be scheduled at 7 AM or two hours before the other medications. LN 1 stated the nursing staff did not have the medication information instructions when they received the new medication order or when they input the order in the computer system. LN 1 stated the nursing staff should have researched the medication information or changed the medication administration time. Review of DailyMed drug information based on FDA approved drug labeling and use, last accessed on 5/5/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3e7cf78f-3b48-4614-9fa4-c6d1e0c05a35, the drug information on doxycycline under Drug Interactions, indicated, Absorption of tetracyclines (class of drugs including Doxycycline) is impaired by antacids containing aluminum, calcium, or magnesium, and iron-containing preparations.2. During a medication administration observation on 4/28/26 at 9:37 AM with LN 4, LN 4 poured seven oral medications into a medication cup for Resident 27. The medications included Linzess (or linaclotide, medication for chronic constipation) with a label that indicated, TAKE ON AN EMPTY STOMACH and another medication called Carvedilol (or Coreg - a blood pressure medication) with a label that indicated, TAKE MEDICATION WITH FOOD. LN 4 administered all these medications with a cup of grape juice.During an interview on 4/28/26 at 9:40 AM with Resident 27, Resident 27 stated he already ate this morning about an hour ago (approximately 8:40 AM) and the staff had just picked up his breakfast tray.A review of Resident 27's Medication Administration Record, (MAR) dated 4/1/26 through 4/30/26, indicated, Linzess oral capsule 72 micrograms [MCG, a unit of measurement]; Give 1 capsule by mouth one time a day related to . CONSTIPATION.hold for loose stools; Start date: 12/3/24. The MAR indicated the medication was scheduled and given at 9 AM. The MAR did not indicate Linzess should be given and timed with an empty stomach.During a concurrent interview and record review on 4/28/26 at 10:04 AM with LN 4, Resident 27's MAR, dated 4/1/26 through 4/30/26 was reviewed. LN 4 stated for the medications with instructions to administer the medication with food, the medication should have been given within an hour of the resident eating. LN 4 stated for the medications that should have been administered on an empty stomach, the medications should have been given earlier, before the resident ate breakfast. LN 4 confirmed that she administered Linzess to Resident 27 after he ate breakfast. LN 4 confirmed that there were no instructions on the MAR to give the medication Linzess on an empty stomach as noted on the medication bubble pack label.Review of DailyMed (the official National Library of Medicine website providing up-to-date FDA [Food and Drug Administration] -approved drug labeling and package inserts) drug information based on FDA approved drug labeling and use, last accessed on 5/5/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=09beda19-56d6-4a56-afdc-9a77b70b2ef3 , the drug information on Linzess under Preparation and Administration Instructions, indicated, Take LINZESS on an empty stomach, at least 30 minutes prior to a meal, at approximately the same time each day.3. During a medication administration observation on 4/28/26 at 9:50 AM with LN 4, LN 4 poured Resident 28's oral medications that were due for 9 AM into a medication cup. The medications included metoprolol (blood pressure medication), midodrine (a medication to regulate blood pressure), citalopram liquid (depression medication in liquid form), and multivitamins (supplements). A review of Resident 28's Medication Administration Record, dated 4/1/26 through 4/30/26, the MAR indicated all medication orders scheduled at 9 AM were given by LN 4. An order for Vitamin D that was not administered during medication administration observation as follow: Cholecalciferol (vitamin D3, a supplement) Oral Tablet 125 MCG (or 5,000 units, a measure of product strength); Give one tablet by mouth one time a day for supplement. Vitamin D was scheduled for 9 AM.During a concurrent interview and record review on 4/29/26 at 11:42 AM with LN 4, Resident 28's MAR, dated 4/1/26 through 4/30/26 was reviewed. LN 4 stated she gave Vitamin D to Resident 28 on 4/28/26 and 4/29/26. LN 4 showed a bottle of 2000 international unit (IU, unit of measurement) of Vitamin D3 and stated that this was what she gave to Resident 28. LN 4 confirmed there was no 5000 IU of vitamin D3 on the medication cart. LN 4 stated she gave 2 tablets of Vitamin D3 (2000 IU) to Resident 28. LN 4 confirmed that the order was for 5000 IU of vitamin D3. LN 4 went to the medication room to get the 5000 IU Vitamin D3 but there was none. LN 4 then went to the central supply storage room to find the Vitamin D 5000 units and found one bottle.During an interview on 4/29/26 at 3:30 PM with LN 4 in the Director of Nursing (DON) office, LN 4 stated she wanted to clarify that she gave two and a half tablets of Vitamin D3 (2000 IU) to Resident 28 on 4/29/26. LN 4 did not explain why she did not use the vitamin D 5000 units from the supply room.During a concurrent interview and a record review on 4/29/26 at 3:24 PM with the DON in her office, Resident 19's MAR, dated 4/1/26 through 4/30/26 and the doxycycline medication label were reviewed. The DON confirmed the findings that doxycycline was given to Resident 19 together with iron, calcium and vitamins with minerals. The DON confirmed that the medication doxycycline's label indicated the medication should be taken at least two hours before or two hours after magnesium or aluminum containing antacids or other products containing calcium, iron, or zinc. The DON stated that she expected the nurses to communicate to the supervisor, to the DON, or the doctor and have the medication administration times changed. The DON stated the pharmacist should have reviewed it during drug regimen review (a structured, authorized, and ongoing evaluation of a patient's medication therapy conducted by a pharmacist). The DON stated the nursing staff was following the hospital orders, which did not include a warning or an instruction on the medication. The DON stated that she expected nurses to notify her or the supervisor if there was a warning in the medication label and they would make a correction to the administration time. The DON stated the timing of medication administration should have been based on drug information and the best practices for safe medication use. The DON stated she was not aware if the facility's computer system alerted the nurses for drug interaction or drug information. The DON stated she expected the nurses to administer the drugs with the correct dosage and if medication was out of stock, to request a refill. A review of the facility's policy titled, ADMINISTERING MEDICATIONS, revised January 2025, indicated .Medications must be administered in accordance with the orders.Medications must be administered in accordance with state and federal guidelines.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication cart and treatment cart (a secured cart that contains wound care treatment supplies) for a resident census of 103 when:1. The [NAME] Station treatment cart contained expired wound care supplies, and a one-time use normal saline (a sterile-germ free- mixture of water and salt) for wound care was found to be open and not discarded; and2. The [NAME] Station medication cart stored fleet enema (medications designed for insertion into the rectum) and was co-mingled with oral medications. These failures could result in unsafe and unsanitary medication storage and the risk of residents receiving contaminated or spoiled product or supplies.Findings:1.During a concurrent observation and interview on 4/28/26 at 3:41 PM with Licensed Nurse (LN) 1, an observation of the [NAME] Station treatment cart was conducted. The following supplies stored in the treatment cart were as follows: Sterile normal saline wound care solution was found to be opened and dated when the product label indicated it was for one time use and perineal spray lotion (a product used to clean and protect skin) expired on 2/28/26.LN 1 stated that once the normal saline package was opened, it was good for 24 hours. However, after LN 1 read the product label, LN 1 stated the normal saline was for a one-time use and LN 1 discarded the saline bottle. LN 1 stated expired products should not have been stored in active storage areas in the cart.During an interview on 4/29/26 at 11:50 AM with LN 3, LN 3 stated that the normal saline should have been discarded once it was opened and used for a resident. LN 3 stated if the normal saline was re-used after the one-time use, there would be an infection control concern and possible risk of cross contamination (moving bacteria from one location to another). LN 3 stated expired wound care items should have been checked for expiration dates and discarded if applicable.2.During a concurrent observation and interview on 4/28/26 at 3:58 PM with LN 2 at the [NAME] Station medication cart, the medication cart bottom drawer stored a fleet enema next to oral medications (in the same bin). LN 2 confirmed the findings. LN 2 stated that the enema should have been stored separately from the oral medications.During an interview on 4/29/26 at 3:24 PM with the Director of Nursing (DON), the DON stated one time use drugs should have been discarded after use. The DON stated expired medications and treatment care supplies should have been removed and discarded from the cart. The DON further stated that the enema found in the medication cart should have been separated from the oral medications and there should be a divider in the medication cart that separated the two routes of medications. A review of the facility's policy and procedure titled, LABELING OF BIOLOGICALS AND STORAGE OF BIOLOGICALS, revised January 2025, indicated, .The facility, in coordination with the licensed pharmacist, provides accurate labeling to facilitate precautions and safe administration of medications, and safe and secure storage.A review of the facility's policy and procedure titled, ADMINISTERING MEDICATIONS, revised January 2025, indicated, .Vials labeled as single dose, or single use will not be used on multiple residents. Such vials will be used only for one resident in a single procedure.

Based on interview and record review, the facility failed to ensure long term antibiotic use was clinically justified for safe use with monitoring and a nursing plan of care for 1 out of 29 sampled residents (Resident 56), when Resident 56 was prescribed doxycycline (an antibiotic, a medication used to treat infection) with full dosing regimen for over one year.This failed practice could contribute to unsafe antibiotic use, risk of developing resistance bugs (when antibiotic no longer can kill or suppress the bug), and ineffective use with side effects.Findings:A review of Resident 56's clinical record titled, admission RECORD, indicated Resident 56's diagnosis included diabetes (blood sugar disease), kidney disease, obesity (excessive body fat), and history of knee surgery with an infection. Review of the Resident 56's medical record titled, Medication Administration Record, (MAR, a record that indicates physician orders, medications administered and/or held) dated 4/26, the record indicated Resident 56 was on an ongoing antibiotic called doxycycline as follows: .Doxycycline . tablet 100 mg [milligram, a unit of measure]; Give 1 tablet by mouth two times a day for streptococcal [a type of bacteria or bug causing skin infection]; Start date 3/21/25 .During a review of Resident 56's clinical record titled, Order Summary for the history of doxycycline use, indicated Resident 56 was on doxycycline in 2024 as follows: 2/27/24 through 5/27/24, 7/23/24 through 8/12/24, 10/26/24 through 11/5/24 and 12/2/24 through 12/12/24.During a review of the Resident 56's medical record titled, Office/Clinic Note, dated 2/2/24, the record indicated Resident 56 visited an orthopedic (bone surgical specialist) doctor for complaint of right knee pain. The note under Assessment/Plan, indicated Resident 56 had Chronic PJI right knee, [PJI, Periprosthetic Joint Infection- infection of hardware inside the knee) mechanical (a physical or structural issue) complication of the right knee, and there was a recommendation for another surgical procedure.During a review of the Resident 56's medical record titled, Office/Clinic Note, dated 3/15/24, the record indicated Resident 56 underwent a surgery on her right knee for chronic PJI on 2/14/24. The note under Assessment/Plan, indicated wound healing was the most critical part of the recovery and there were some concerns about an eschar (a thick, dry, leathery layer of dead [necrotic] tissue, usually black or brown, that forms over deep wounds) around the incision site of the surgery. The note further indicated to continue with local wound care at the facility with a dry dressing.During a concurrent interview and record review on 4/30/26 at 1:40 PM with the facility's Infection Preventionist (IP), a letter found in Resident 56's electronic health record, sent from the facility's IP to the orthopedic doctor, dated 4/22/25 was reviewed. In the letter, the IP inquired from the orthopedist doctor to address and reassess the long-term antibiotic (doxycycline) use. The letter indicated, .As a long term care provider, we aim to ensure antibiotics are used appropriately, reducing antibiotic resistance and improving patient outcomes. We are writing to see if you are willing to reconsider the indefinite order for the above-mentioned antibiotic to adhere to McGeer criteria [McGeer criteria are standardized, evidence-based surveillance definitions used to identify infections in nursing homes. They are designed to differentiate true infections from colonization aiding in appropriate antibiotic use] and reduce resistance. The IP stated there was no response or clinical justification from the orthopedic provider. The IP nurse stated she did not escalate to the medical director when there was no response from orthopedic doctor.A review of the Resident 56's electronic medical record under Notes To Attending Physician, dated 3/14/26, written by the facility's Consultant Pharmacist (CP) to Medical Doctor (MD) 1, the note indicated, .When a resident is on prophylactic [preventive] antibiotic therapy. Risk versus benefit and medical justification statements are required . Please evaluate indication and document on dose/duration of therapy and if resident condition has improved/stabilized or underlying causes of symptoms have resolved and that the sign and symptoms are persistent or clinically significant to warrant medication use . The record had a handwritten note from the surgeon that indicated, Clarified with MD since 4/22/25 with order indefinite r/t [related to] sensitivity of streptococci species to tetracycline [an antibiotic- same class as doxycycline]. The note was initialed by a nurse and signed by a facility's provider.A review of the facility's nursing plan of care for Resident 56, last review completed on 4/10/26, the nursing plan of care did not address long term antibiotic use and the chronic surgical wound infection or wound care.During a phone interview on 4/30/26 at 3 PM with Medical Doctor (MD) 1, MD 1 stated she did not follow Resident 59 care closely as the Medical Director. MD 1 stated her review of the medical record indicated the antibiotic was used for chronic suppression and was ordered by the orthopedic doctor for the wound on Resident 56's knee. MD 1 acknowledged orders by the outside specialist consultants were reviewed and ordered by the facility's main doctor. MD 1 stated the facility did not contact her to address long term antibiotic use and the facility did not order any lab work or consult with an infection control specialist to re-assess long term antibiotic use.A phone call to Medical Doctor 2 (MD 2) was made on 4/30/26 and the phone call was not returned by the MD 2. During an interview on 5/1/26 at 12:22 PM with facility's Director of Nursing (DON) in her office, the DON stated the long-term antibiotic use should have been escalated to the facility's medical director for further testing or re-assessment.During an interview on 5/1/26 at 1:03 PM with the Administrator (ADM), the ADM confirmed there was no care plan for Resident 56's antibiotics.A review of the facility's policy and procedure titled, PHYSICIAN MEDICATION ORDERS, revised January 2025, indicated, .Physician's orders not specifying the number of doses, or duration of medication, may be subject to automatic stop orders.Medications subject to automatic stop orders shall be reported to the physician for continuation, discontinuation or change orders as needed.A review of the facility's policy titled, Antimicrobial Stewardship, dated 9/2016, the policy indicated, . The World Health Organization has reported that antimicrobial resistance is one of the major threats to human health. Especially because some bacteria have developed resistance to all known classes of antibiotics. According to CDC, improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. The policy further indicated, . It is the policy of . Care Center to implement antibiotic stewardship program (ASP) which will promote appropriate use of antimicrobials while optimizing the treatment of infection, at the same time reducing the possible adverse event . This policy has the potential to limit antimicrobial resistance in the post-acute care setting . The policy further indicated, .the ASP team may track compliance of physician and physician groups with the recommendation of ASP's team. The policy under Action indicated the facility may consider protocols to, optimized use and duration of antimicrobial therapy. The policy under Reporting section indicated, A designee of the ASP team will review and report findings to facility QA (Quality Assessment) committee who will then provide feedback to facility staff. Feedback will be given to physicians by the ASP team regarding prescribing pattern, cultures ordered, and antimicrobial prescribed, as indicated .

Based on observation, interview, and record review, the facility failed to provide a homelike environment for five of five residents (Resident 4, Resident 5, Resident 6, and Resident 7, and Resident 8) when,Resident 4 displayed episodes of aggression, and repeated yelling throughout the day and night and Resident 4 behavior care plans were not person centered, and staff were not able to address it; and, Multiple residents including Resident 5, Resident 6, Resident 7, and Resident 8 were negatively affected by Resident 4's continuous yelling and had reported to staff their frustration and lack of sleep and/or rest.This deficient practice had the potential to negatively affect the psychosocial (the mental, emotional, social, and spiritual effects of a disease) and physical well-being of the facility's residents. Findings:Review of Resident 4's admission RECORD, indicated, Resident 4 was originally admitted to the facility in the fall of 2023 with a diagnosis including but not limited to cerebrovascular disease (condition that affect blood flow to your brain), vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain, as can happen with a stroke), schizophrenia (A serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.) psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) not due to a substance or known physiological condition, generalized anxiety disorder (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), legal blindness (status that government agencies can grant when you have severe vision loss), and difficulty in walking. Review of Resident 4's BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) (a tool that healthcare providers use to assess a person's cognitive function), dated 7/18/25, indicated, Resident 4 had a BIMS score of 5, which indicated severe cognitive impairment (0-7 points, when a person has significant trouble with cognitive tasks, and will likely need extensive help from the others to navigate daily life). Review of Resident 4's Order Summary Report, indicated, .monitor for any combative behavior such as hitting and scratching staff, every shift for combative behavior.Order Date 11/4/23. Review of Resident 4's Behavior Care Plan, dated 11/6/23, indicated, .The resident has a behavior r/t increased agitation/combative w/ [with] screaming and yelling.Goal.The resident will have fewer episodes by review date.Interventions.Anticipate and meet the resident's needs.Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately.If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.Minimize potential for the resident's disruptive behaviors (Specify) by offering tasks which divert attention (Specify).Staff will provide one on one care in resident's room as staffing allows to promote calming environment for [name redacted, Resident 4] which decreases his disruptive behavior within the facility. During a phone interview and record review on 9/23/25, at 9:45 a.m., the ADON reviewed Resident 4's Behavior Care Plan and acknowledged the areas of the plan which said Specify were not filled out for specific disruptive behaviors and tasks that should have been offered to Resident 4. The ADON stated the care plan should be person centered. The ADON stated the expectation was that it was filled in with tasks such as offering of food and/or assisting behavior. The ADON stated the care plan was a guide for staff including how to manage behaviors and to prevent them for residents. The ADON stated the 'Intervention' section was not clear on what staff should do. The ADON acknowledged the last revision date was 6/6/24 and stated there should be a review date listed and should have been revised after the most recent altercation with Resident 3 in May of 2025. During a phone interview on 9/10/25, at 12:49 p.m., LN 2 stated Resident 4 would scream and scream if nobody was there with him. LN 2 stated Resident 4 needs someone there with him and it was important to let him know that someone was there as this provides comfort for him. LN 2 stated staff would push Resident 4 in his wheelchair to the dining room to keep him company. During an interview and record review on 9/10/25, at 1:55 p.m., the ADON stated Resident 4 was confused and tended to be aggressive. The ADON stated Resident 4 currently had a roommate. The ADON stated Resident 4 can stand up and he cannot see and on the night of 5/27/25 he might have gotten lost. The ADON stated Resident 4 was transferred to another room after the incident. Through review of Resident 4's clinical record the ADON stated Resident 4 had a BIMS score of 5 which indicated a severe cognition deficit. The ADON stated Resident 4 was receiving psychiatric care, but his family did not want him medicated with psychiatric drugs because they thought it made him overly sleepy and because of this his medications had been reduced. The ADON stated when Resident 4 was on the medications the psychiatrist had recommended, he was more pleasant. During an interview on 9/10/25, at 3:11 p.m., CNA 2 stated Resident 4 was always yelling, and he thought it was part of his mental health condition. CNA 2 stated he kept an eye on Resident 4, and he would not listen to staff. CNA 2 stated Resident 4 often yells out in his native language, and he cannot understand him. CNA 2 stated Resident 4 could walk with assistance. CNA 2 explained if staff use the proper soft voice soft, Resident 4 can be calm, and he likes staff to stay close to him. CNA 2 stated they take Resident 4 out of his room and place him by the nursing station. CNA 2 stated he was not sure if Resident 4 was blind. CNA 2 stated Resident 4's yelling bothers other residents and they will often begin yelling at Resident 4 to shut up. During an observation on 9/10/25, at 3:17 p.m., Resident 4 was observed in the hallway across from the nursing station, he was standing up from his wheelchair, and an alarm was heard. CNA 2 was observed running towards Resident 4 to assist him. During a concurrent observation and interview on 9/10/25, at 3:20 p.m., Resident 5's room door was observed to be closed, and a sign was attached to the door stating to knock prior to entering, the room was observed to be a few doors down the hall from Resident 4's room. Resident 5 was observed laying in her back and was wearing headphones. Resident 5 stated she had lived at the facility for many years and preferred to stay in her room due to her limited mobility. Resident 5 stated Resident 4 (name redacted) could not be controlled, and he was awake at all hours of the night and early morning and would start hollering nonstop. Resident 5 stated the hollering was at all hours, was sporadic, loud, and in different languages and would get everyone else worked up. Resident 5 stated in response the other residents would start yelling too. Resident 5 stated Resident 4 had been physically aggressive with another roommate and was hitting them. Resident 5 explained Resident 4 had hit a staff member and fractured their rib and had bit another staff member. Resident 5 stated she wore noise counseling headphones due to lack of sleep from the noise, and she had been woken up from her sleep due to Resident 4's yelling. Resident 5 stated the yelling, and noise affected her mental health and made her feel crazy and frazzled. During an interview on 9/10/25, at 3:27 p.m., CNA 3 stated Resident 4 screams and shouts and staff will ask him what the matter and he will say nothing. CNA 3 thought he was confused. CNA 3 stated Resident 3 screams very loudly throughout the day and night. CNA 3 explained it was very disturbing and disruptive to the other residents, and they could not get any sleep. CNA 3 stated Resident 4 had been like this the whole time he had been at the facility. CNA 3 stated Resident 4's medications help him, but he will refuse his medication. CNA 3 stated Resident 4 would shout out profanities to other residents and one time he tried to hit a resident. CNA 3 explained the incident that happened in his room and was an altercation with a roommate where Resident 4 hit the roommate. CNA 3 stated Resident 4 went through many roommates due to his shouting. CNA 3 stated Resident 4 shouts at staff but there was no altercation involving staff for over a year. During a concurrent observation and interview on 9/10/25, at 3:43 p.m., Resident 6 stated his room was across the hall from Resident 4's room (name redacted) and he had been at the facility for two weeks and could not sleep. Resident 6 stated Resident 4 kept him up all day and all night due to his yelling. Resident 6 stated he had complained to staff many times. Resident 6 stated the noise and lack of sleep had negatively affected his attitude. Resident 6 stated he could not hear the conversation when he was on the phone with his grandkids and this was upsetting. During a concurrent observation and interview on 9/10/25, at 3:45 p.m., Resident 7 stated Resident 4 (name redacted) yells throughout the day and night. Resident 7 stated he had an altercation with Resident 4 because he told him to shut up because he was about to get socked [to hit or strike very hard] up. Resident 7 stated he was angry because he could not sleep. Resident 7 stated he had karate chopped his table because of his frustration and having to listen to the guy constantly yelling. During a concurrent observation and interview on 9/11/25, 10:58 a.m., Resident 8 was observed in his wheelchair, leaving an adjacent room, and requested to speak to the surveyor. Resident 8 stated his room was two doors down from Resident 4's (name redacted) room and Resident 4 get up at 3:30 a.m. in the morning and he screams and yells at the top of his lungs for 13 hours straight. Resident 8 stated Resident 4 screams at night and during the day and it has been going on since he got here in July of 2025. Resident 8 stated this made him feel exhausted and tired. Resident 8 explained he tried to sleep in the morning but sometimes could not sleep at all. Resident 8 further explained the residents were angry. Resident 8 stated Resident 4 was agitated because he was blind and bored. Resident 8 stated even Resident 4's roommate would tell him to shut up'. Resident 8 stated Resident 4 was very disruptive, and this led to other residents constantly yelling out shut up and take my life. During a concurrent observation and interview on 9/11/25, at 10:38 a.m., Resident 4 was observed in his room, sitting in a wheelchair at the end of his bed. It was observed that Resident 4 had a roommate who was sleeping in his bed. Resident 4 stated he could not see, he needed help, and someone needed to take his hand and help him. Resident 4 stated he needed someone to bring him to school. Resident 4 stated there were no activities for him to do. Resident 4 repeated he needed someone to stand next to him and to hold his hand and it was too difficult for him to find out what to do. Resident 4 stated he had a problem with calling out, and if he needed help, he could talk with his mouth. During an observation on 9/11/25, at 10:45 a.m., in the hallway, outside of Resident 4's room an alarm was heard, staff members were observed running into Resident 4's room. During an interview on 9/11/25, at 10:50 a.m., CNA 8 stated he responded to Resident 4's wheelchair alarm and it went off because Resident 4 stood up and needed redirection. CNA 8 stated Resident 8 was very physically and verbally combative, disruptive, and not easily redirected. CNA 8 stated Resident 4 would curse other residents. CNA 8 stated Resident 4 could get up from his wheelchair and staff tried to redirect and called the family and he missed his family and was mean and angry. CNA 8 stated Resident 4 could not see, was blind. CNA 8 explained he would put music on, and it calmed Resident 4. CNA 8 stated Resident 4 would yell out for pretty much eight hours straight. CNA 8 stated other residents told him they cannot sleep and cannot rest because of the yelling at night. CNA 8 stated the nursing staff tried to redirect him, but he still screamed all night. CNA 8 stated staff have tried to have Resident 4 join activities and the assisted feeding program, but he was disruptive and caused the other residents to become more confused and disruptive, so they did not have him attend. During an interview on 9/11/25, at 1:31 p.m., LN 1 stated Resident 4 yells constantly and it was all through the day and night and has done so since admission. LN 1 stated residents complained they could not sleep, and administration were aware, and they had tried to adjust medications. LN 1 stated when Resident 4 goes to the activities room he will yell which aggravates the other residents, so he mostly stays in his room or by the nursing station. LN 1 stated Resident 4 was blind and if he has someone close by, he will stop screaming, as he just wants someone to talk to. LN 1 stated Resident 4 had never had a continuous one on one. During a phone interview on 9/11/25, at 12:20 p.m., Responsible Party (RP) stated Resident 4 had a stroke which caused him vision issues and was blind. RP 1 stated the nurses wanted to make Resident 4 take more drugs to sedate him. During a phone interview on 9/11/25, 12:30 p.m., LN 4 stated he worked nights and was primarily the desk nurse. LN 4 explained he created care plans and provides a resource in case the bedside nurses needed help. LN 4 stated he was familiar with Resident 4, and he was unpredictable, screamed a lot, and does not follow commands or listen. LN 4 stated Resident 4 could understand and communicate in English. LN 4 stated there were times he was confused and communicated nonsense. LN 4 stated other residents close to Resident 4's room were bothered by his shouting and complaining. LN 4 stated he was not really sure what to do about the situation. During a phone interview on 9/15/25, at 5:17 p.m., CNA 4 stated Resident 4 was pretty confused, tended to yell out throughout night saying hello or yelling out his family member's name. CNA 4 stated they will get calls from other residents that Resident 4 is keeping them up due to his yelling. During a phone interview on 9/15/25, at 3:25 p.m., CNA 5 stated she worked nights and Resident 4 was confused, did not sleep at night and was loud at night. CNA 5 explained Resident 4 would say Hello, Hello or Help, Help repeatedly. During a phone interview on 9/16/25, at 9:39 a.m., CNA 6 stated Resident 4 had been aggressive and abusive with staff including punching a staff member in the chest and another CNA in the face and had dragged and held another CNA down on the ground. CNA 6 stated staff were scared of Resident 4. CNA 6 stated Resident 4 could be violent and currently had a tab alarm on his wheelchair and bed alarm that rings when he gets up. CNA 6 stated Resident 4's bed and chair alarms were implemented after the incident with Resident 3. CNA 6 stated her opinion was no one should be sharing a room with Resident 4. CNA 6 stated people who cannot protect or defend themselves have been roommates with Resident 4 and she did not feel this was fair to them. CNA 6 stated Resident 4 will yell all the time and people cannot sleep which upsets all the residents. During a phone interview on 9/23/25, at 9:45 a.m., the ADON stated Resident 4 had resided in the facility since October of 2023, had dementia, was blind, was unpredictable, and yelled out a lot. The ADON stated Resident 4 does not use a call light due to being blind and will call out because he does not know who was there with him. The ADON stated Resident 4 needed reassurance that someone was there with him and when someone speaks to him it helps to calm him and stops him from yelling out. The ADON stated staff had been monitoring Resident 4's behavior since 2023 due to him being the aggressor in an altercation involving staff. The ADON explained the altercation occurred on 11/27/23 and after the altercation a staff member was assigned to provide one-on-one supervision for Resident 4. The ADON stated the one-on-one was always with Resident 4 and provided him with support and calmed him, so he was not disruptive to other residents. The ADON explained additionally the one-on-one was there to keep Resident 4's roommate safe. The ADON stated Resident 4's roommates tended to be confused and not alert. The ADON stated staff, including CNAs and LNs, were currently monitoring and charting Resident 4's behavior including cursing of others, disruptive sounds, disruptive screaming, and aggression. The ADON stated Resident 4's behaviors tend to manifest more during the night and morning shift. The ADON stated Resident 4 does not currently have a one-on-one staff member assigned to him providing constant supervision and was not sure when it was discontinued but thought it was sometime in the summer of 2024. The ADON explained she was not sure if administration conducted an IDT (interdisciplinary team meeting) prior to discontinuing Resident 4's one-on-one support and through review of Resident 4's electronic record, the ADON acknowledged she could not locate a progress note regarding this. The ADON stated she felt like the disturbance Resident 4's yelling caused other residents was mentioned in the daily stand-up morning meetings and administration meetings but could not recall when it was last discussed. The ADON explained Resident 4's yelling mostly affected the residents in the rooms next to him or located in the same hall. The ADON stated residents could hear him yelling. The ADON stated we have told residents they cannot move them to another location or room. The ADON stated the nurses have told her Resident 4 yelled at night, and it was constant, and residents complained they were not able to sleep. The ADON stated the issue came up recently and she felt like the Social Services was in charge of addressing the situation. The ADON stated the expectation for residents was they can rest at night and have a relaxing day and not listen to constant yelling. The ADON stated the expectation was if a resident was yelling staff needs to attend to that resident right away as yelling can be a stressor to others. During a review of a facility policy and procedure (P&P) titled HOMELIKE ENVIRONMENT, revised 1/2025, the document indicated, .The facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression.DEFINITIONS: Homelike Environment: is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment . facility environment should enhance the quality of life for residents, in accordance with resident preferences. Facility personnel strive for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable. During a review of a facility P&P titled DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS POLICY STATEMENT, revised 1/2025, indicated, .The facility develops a person-centered comprehensive care plan that are culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Resident's Goal: The resident's desired outcomes and preferences for admission, which guide decision making during care planning.Interventions: Actions, treatments, procedures, or activities designed to meet an objective.Person-Centered Care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.The interdisciplinary team develops the care plan with corresponding interventions for care that is in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences.Care plans shall include the discipline providing care or services, measurable objectives, and timeframes in order to evaluate the resident's progress toward his/her goal(s).

Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 3) right to be free from physical abuse and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) when, 1. Resident 3, with a diagnosis of paraplegia (inability to feel or move your legs, making it impossible to stand or walk) was placed in Resident 4's room as his roommate even though Resident 4 had a history of aggressive behavior towards staff and other residents. Subsequently, on 5/27/25, Resident 3 called repeatedly for staff assistance due to Resident 4 coming over to his side of the room and at approximately 2:20 a.m., Resident 4 walked over to Resident 3's side of the room, pulled his room curtain, grabbed Resident 3's call light and tossed it off the bed, grabbed his throat, and began choking him. 2. The facility failed to implement measures that would ensure residents in the facility were safe from Resident 4 by constructing an individualized plan detailing approaches to maintain the safety of Resident 3 and other residents in the facility. These failures resulted in Resident 3 feeling trapped and scared for his life, and had the potential to negatively affect Resident 3's psychosocial (the mental, emotional, social, and spiritual effects of a disease) wellbeing and/or cause him serious injury and/or death.1.Review of Resident 3's admission RECORD, indicated, Resident 3 was admitted to the facility late June/2025 with a diagnosis including but not limited to paraplegia, fusion of the cervical (neck) spine (surgery to connect two or more bones in the neck which prevents them from moving), contracture left hand (causes one or more fingers to bend toward the palm of the hand and can reduce movement and flexibility), and contracture right hand. Review of Resident 3's Care Plan, dated 5/22/25, indicated, .The resident has paraplegia r/t [related to] PERSONAL or HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA [temporary blockage of blood flow to brain and cause symptoms of stroke), AND CEREBRAL INFARCTION [blood flow to brain is stopped or reduced causing brain cells to die, can cause paralysis, memory loss, trouble talking, and may need help with self-care] , resulting in .SPINAL STENOSIS, CERVICAL REGION.Goal.The resident will maintain optimal status and quality of life within limitations through review date. Review of Resident 3's Care Plan, dated 5/22/25, indicated, .The resident had limited physical mobility r/t [related to] . CONTRACTURE.PARAPLEGIA.SPINAL STENOSIS.PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION.Goal.The resident will maintain current level of mobility. Review of Resident 3's Care Plan, dated 5/22/25, indicated, .The resident has altered respiratory status/Difficulty Breathing r/t DX [diagnosis] of Pneumonia [infection in the lungs which can cause difficulty in breathing] .Goal.The resident will have no complication related to SOB [shortness of breath] . Review of Resident 3's SBAR [which stands for Situation, Background, Assessment, and Recommendation (or Request), is a structured communication framework that can help teams share information about the condition of a patient that the team needs to address] Change of Condition, dated 5/29/25, written by Licensed Nurse (LN) 4, indicated, .Situation.alleged physical abuse.This started on.5/27/25.Primary diagnosis.Pneumonia.Assessment Details.CNA found resident (alleged abuser [name redacted, Resident 4]) at the victim's side of bed. Per victim, abuser hit him on the right hip and stomach. While victim tries to push abuser away, he grabbed his face, poke his left eye, and choke. Upon assessment, no post incident injury noted. No bruising or discoloration. Victim denies any pain. Orientation remains within baseline. Review of Resident 3's IDT [Interdisciplinary Team, a group of professionals who collaborate to accomplish a common goal] PROGRESS NOTES - INCIDENT / ACCIDENT, dated, 5/27/76, written by the Director of Nursing (DON), indicated, .On 5/27/25 approximately 0220 [2:20 a.m.], [redacted, Resident 4] standing beside [redacted, Resident 3] bed side. Immediately CNA [Certified Nurse Assistant] removed [redacted, Resident 4] aggressor away from [redacted, Resident 3]. CN [charge nurse] relocated [redacted, Resident 4] into rm [room number redacted] then went back inside [redacted, Resident 3] room for full body assessment, no scratches, or redness around his neck, no discoloration/redness to left eye but observed watery, no skin discoloration o right hip or RLQ [right lower quadrant] abd [abdomen]/stomach. [redacted, Resident 3] stated that [redacted, Resident 4] came to his side of the bed and sat down beside him on the right side and said press it press it, I know he can see because he kept saying press it to my call light then he threw my call light away from me. [redacted, Resident 3] tried to move his hand to tell him to get off from his bed butcan't [sic] move his arms so much, that's when [redacted, Resident 4] hit his right hip and RLQ abd/stomach, while [redacted, Resident 3 tries to push [redacted Resident 4] away, he [Resident 4] grabbed his [Resident 3] face, pressed his left eye and choke him. CN informed res. [Resident 3] he doesn't have any skin impairment like scratch or discoloration around neck, right hip or RLQ of abd/stomach, no discoloration to left eye however CN observed eye to be watery. CNA got wet wash cloth to wipe res [Resident 3] eyes and it was helpful and eased the stinging to left eye. CN notified res. [Resident 3] that [Resident 4] will be transferred to [redacted, room number] .then CN left res. [resident] to rest. Review of Resident 3's Social Services Progress Notes,, dated 5/27/25, indicated, .SS [Social Services] visited resident this morning to ask in regards the roommate incident. Resident mentioned roommate kept going back and forth to resident's side until roommate sat down next to resident. Roommate taped [sic, meaning tapped] resident to make it was on bed, then attempt hitting him in face, threw call light, placed hands around resident's neck, and [NAME] [sic, meaning poked] in resident's left eye. After assessment no injuries were noted besides left watery eye. Psychosocial support was provided. Psych services were offered as well to make sure resident was ok. During a phone interview on 9/10/25, at 2:53 p.m., Resident 3 stated he cannot move his legs due to being a paraplegic and had limited use of his hands due to a previous stroke. Resident 3 stated he was sharing a room with Resident 4. Resident 3 stated Resident 4 screams and hollers all day and night, and he could not get any sleep. Resident 3 recalled the altercation involving Resident 4 on 5/27/25, and stated it happened in the early morning around 3:00 a.m. Resident 3 stated Resident 4 had walked over to his side of the room, stood next to his bed and kept trying to hit him. Resident 3 stated he had used his call light prior to the altercation, to alert staff that Resident 4 was on his side of his room, and he did not want him there and he feared Resident 4. Resident 3 stated on the third incident of Resident 4 walking over to his side of the room that night, Resident 4 pulled his room curtain then grabbed his call light and tossed the call light off the bed. Resident 3 explained Resident 4 grabbed his throat and began choking him. Resident 3 stated he could not get away from Resident 4, felt trapped, was scared for his life and started hollering for help. Resident 3 stated every time Resident 4 came over to his side of the room, he felt scared, and he would use his call light and yelled out for help. Resident 3 stated staff came into his room to assist every time, and each time Resident 4 was over on his side of the room. Resident 3 stated staff told Resident 4 he was not supposed to be there. Resident 3 explained that staff told him they could not move Resident 4 to a different room because it was in the middle of the night. Resident 3 stated after Resident 4 choked him, staff came in and moved Resident 4 outside of the room and placed him in the hallway. Resident 3 stated there was a scratch on his neck after the altercation and police came and took a statement form him and spoke to Resident 4 as well. 2. Review of Resident 4's admission RECORD, indicated, Resident 4 was originally admitted to the facility in the fall of 2023 with a diagnosis including but not limited to cerebrovascular disease (condition that affect blood flow to your brain), vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain, as can happen with a stroke), schizophrenia (A serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.) psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) not due to a substance or known physiological condition, generalized anxiety disorder (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), legal blindness (status that government agencies can grant when you have severe vision loss), and difficulty in walking. Review of Resident 4's BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) (a tool that healthcare providers use to assess a person's cognitive function), dated 7/18/25, indicated, Resident 4 had a BIMS score of 5, which indicated severe cognitive impairment (0-7 points, when a person has significant trouble with cognitive tasks, and will likely need extensive help from the others to navigate daily life). Review of Resident 4's Order Summary Report, indicated, .monitor for any combative behavior such as hitting and scratching staff, every shift for combative behavior.Order Date 11/4/23. Review of Resident 4's Behavior Care Plan, dated 11/6/23, indicated, .The resident has a behavior r/t increased agitation/combative w/ [with] screaming and yelling.Goal.The resident will have fewer episodes by review date.Interventions.Anticipate and meet the resident's needs.Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately.If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.Minimize potential for the resident's disruptive behaviors (Specify) by offering tasks which divert attention (Specify).Staff will provide one on one care in resident's room as staffing allows to promote calming environment for [name redacted, Resident 4] which decreases his disruptive behavior within the facility. During a phone interview and record review on 9/23/25, at 9:45 a.m., the ADON reviewed Resident 4's Behavior Care Plan and acknowledged the areas of the plan which said Specify were not filled out for specific disruptive behaviors and tasks that should have been offered to Resident 4. The ADON stated the care plan should be person centered. The ADON stated the expectation was that it was filled in with tasks such as offering of food and/or assisting behavior. The ADON stated the care plan was a guide for staff including how to manage behaviors and to prevent them for residents. The ADON stated the 'Intervention' section was not clear on what staff should do. The ADON acknowledged the last revision date was 6/6/24 and stated there should be a review date listed and should have been revised after the most recent altercation with Resident 3 in May of 2025. The ADON stated her expectation for staff was they were to ask Resident 4 what he needed and stated his behavioral care plan should have been more specific so staff know how to care for Resident 4 and what interventions should be implemented to manage his behaviors. Review of Resident's 4's Behavior Management Care Plan, dated 1/30/24, indicated, .The resident uses psychotropic medications Depakote [mood altering medication] r/t [related to] Behavior management.Goal.The resident will have fewer episodes by review date.Interventions.The resident is on a behavior management program with (Specify: alternatives to prn [as needed] medication use).Monito/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Etc.) and document per facility protocol. Review of Resident 4's SBAR: Change of Condition, dated 5/27/25, written by LN 3, indicated, .Situation.physical aggression (initiated).This started on.5/27/25.Primary diagnosis.CEREBRAL VASCULAR DISEASE.Assessment Details.Resident unable to provide details of the resident. alert and verbally responsive to care. Review of Resident 4's IDT PROGRESS NOTES - INCIDENT / ACCIDENT, dated, 5/27/76, written by the DON, indicated, .On 5/27/25 approximately 0200 [2:20 a.m.], [redacted, Resident 4] had an alleged aggression (recieved0 from [redacted, Resident 4]. CN went to res [redacted, Resident 4] to ask about the incident, however res [sic, Resident 4] unable to provide description of the incident r/t cognitive impairment AEB [as evidence by] BIMS of 07 with confusion upon admission. Will continue plan of care.IDT rec [recommendation].separated both res [sic, residents] and transferred to another rm [room].by himself. During a concurrent interview and record review on 9/9/25, at 2:50 p.m., the Social Services Director (SSD) stated resident to resident altercations required the facility to complete a three day follow up which includes monitoring the resident for psychiatric changes. The SSD stated for residents who engaged in repeated resident to resident altercations the primary intervention would be a psychiatry consultation. During a phone interview on 9/10/25, at 12:49 p.m., LN 2 stated Resident 4 would scream and scream if nobody was there with him. LN 2 stated Resident 4 needed someone there with him and it was important to let him know that someone was there as this provides comfort for him. LN 2 stated staff would push Resident 4 in his wheelchair to the dining room to keep him company. During a concurrent interview and record review on 9/10/25, at 1:55 p.m., the ADON stated Resident 3 was bedbound, and could not get up, and required staff assistance to move and lift him off his bed or chair. The ADON explained Resident 3 could respond verbally and he was orientated and not confused, and had a BIMS score of 15 which meant he was cognitively intact. The ADON stated Resident 3 was paraplegic and previously had a spinal fusion and stroke and could not use his arms or legs. The ADON stated Resident 3 came into the facility for respite care (short-term relief for primary care givers), which was always a five day stay, and it provided his family an opportunity to take a break from caring for him. The ADON stated Resident 4 was confused and tended to be aggressive. The ADON stated Resident 4 currently had a roommate. The ADON stated Resident 4 could stand up, cannot see, and on the night of 5/27/25 he might have gotten lost. The ADON stated Resident 4 was transferred to another room after the incident. Through review of Resident 4's clinical record the ADON stated Resident 4 had a BIMS score of 5 which indicated a severe cognition deficit. The ADON stated Resident 4 was receiving psychiatric care, but his family did not want him overly medicated with psychiatric drugs because they thought it made him sleepy, and because of this his medications had been reduced. The ADON stated when Resident 4 was on the medications the psychiatrist had recommended, he was more pleasant. During an interview on 9/10/25, at 3:11 p.m., CNA 2 stated Resident 4 was always yelling, and he thought it was part of his mental health condition. CNA 2 stated he kept an eye on Resident 4, and he would not listen to staff. CNA 2 stated Resident 4 often yells out in his native language, and he cannot understand him. CNA 2 stated Resident 4 could walk with assistance. CNA 2 explained if staff use the proper soft voice soft, Resident 4 can be calm, and he likes staff to stay close to him. CNA 2 stated they take Resident 4 out of his room and place him by the nursing station. CNA 2 stated he was not sure if Resident 4 was blind. CNA 2 stated Resident 4's yelling bothers other residents and they will often begin yelling at Resident 4 to shut up.During an interview on 9/10/25, at 3:27 p.m., CNA 3 stated Resident 4 screams and shouts and staff will ask him what the matter and he will say nothing. CNA 3 thought he was confused. CNA 3 stated Resident 3 screams very loudly throughout the day and night. CNA 3 explained it was very disturbing and disruptive to the other residents, and they could not get any sleep. CNA 3 stated Resident 4 had been like this the whole time he had been at the facility. CNA 3 stated Resident 4's medications help him, but he will refuse his medication. CNA 3 stated Resident 4 would shout out profanities to other residents and one time he tried to hit a resident. CNA 3 explained the incident that happened in his room and was an altercation with a roommate where Resident 4 hit the roommate. CNA 3 stated Resident 4 went through many roommates due to his shouting. CNA 3 stated Resident 4 shouts at staff but there was no altercation involving staff for over a year. During a concurrent observation and interview on 9/11/25, at 10:38 a.m., Resident 4 was observed in his room, sitting in a wheelchair at the end of his bed. It was observed that Resident 4 had a roommate who was sleeping in his bed. Resident 4 stated he could not see, he needed help, and someone needed to take his hand and help him. Resident 4 stated he needed someone to bring him to school. Resident 4 stated there were no activities for him to do. Resident 4 repeated he needed someone to stand next to him and to hold his hand and it was too difficult for him to find out what to do. Resident 4 stated he had a problem with calling out, and if he needed help, he could talk with his mouth. During an observation on 9/11/25, at 10:45 a.m., in the hallway, outside of Resident 4's room an alarm was heard, staff members, including CNA 8 were observed running into Resident 4's room. During an interview on 9/11/25, at 10:50 a.m., CNA 8 stated he responded to Resident 4's wheelchair alarm and it went off because Resident 4 stood up and needed redirection. CNA 8 stated Resident 8 was very physically and verbally combative, disruptive, and not easily redirected. CNA 8 stated Resident 4 would curse other residents. CNA 8 stated Resident 4 could get up from his wheelchair and staff tried to redirect and called the family and he missed his family and was mean and angry. CNA 8 stated Resident 4 could not see, was blind. CNA 8 explained he would put music on, and it calmed Resident 4. CNA 8 stated Resident 4 would yell out for pretty much eight hours straight. CNA 8 stated other residents told him they cannot sleep and cannot rest because of the yelling at night. CNA 8 stated the nursing staff tried to redirect him, but he still screamed all night. CNA 8 stated staff have tried to have Resident 4 join activities and the assisted feeding program, but he was disruptive and caused the other residents to become more confused and disruptive, so they did not have him attend. During a phone interview on 9/11/25, at 12:20 p.m., Responsible Party (RP) stated Resident 4 had a stroke which caused him vision issues, and he was blind. RP 1 stated the nurses wanted to make Resident 4 take more drugs to sedate him. During a phone interview on 9/11/25, 12:30 p.m., LN 4 stated he worked nights and was primarily the desk nurse. LN 4 explained he created care plans and provides a resource in case the bedside nurses needed help. LN 4 stated he was familiar with Resident 4, and he was unpredictable, screamed a lot, and does not follow commands or listen. LN 4 stated Resident 4 could understand and communicate in English. LN 4 stated there were times he was confused and communicated nonsense. LN 4 stated other residents close to Resident 4's room were bothered by his shouting and complaining. LN 4 stated he was not really sure what to do about the situation. During an interview on 9/11/25, at 1:31 p.m., LN 1 stated Resident 4 yells constantly and it was all through the day and night and has done so since admission. LN 1 stated residents complained they could not sleep, and administration were aware, and they had tried to adjust medications. LN 1 stated when Resident 4 goes to the activities room he will yell which aggravates the other residents, so he mostly stays in his room or by the nursing station. LN 1 stated Resident 4 was blind and if he has someone close by, he will stop screaming, as he just wants someone to talk to. LN 1 stated Resident 4 had never had a continuous one on one. During a phone interview on 9/11/25, at 2:16 p.m., LN 3 stated Resident 3 was admitted to the facility for respite care, he could not walk, and his hands were contracted. LN 3 stated Resident 4 was legally blind and could walk. LN 3 stated she was working the night when CNA 5 (name redacted) found Resident 4 on Resident 3's side of the bed. LN 3 explained Resident 3 said Resident 4 (name redacted) had choaked him. LN 3 further explained Resident 3 stated Resident 4 had sat on his bed, threw the call light and tossed it to the side, then chocked him. LN 3 stated Resident 3 told Resident 4 to get out because it was his bed. LN 3 stated CNA 5 had witnessed Resident 4 standing on Resident 3's side of the room by Resident 3's bed. LN 3 stated the situation was not right. LN 3 stated she reported it to the police department, notified the medical doctor, and administration. LN 3 stated Resident 3 told her he felt frightened, and she told him they were relocating Resident 4. LN 3 stated Resident 4 felt like he could not get away or protect himself with his hands. LN 3 stated Resident 4 screamed and yelled a lot, tended to get aggressive and angry. LN 3 explained that CNAs would step away from him if he gets angry or physically aggressive. LN 3 stated other residents expressed frustration from Resident 4's yelling, and residents would say they could not get any rest, and it was not fair. LN 3 explained from the experience with Resident 3, and because Resident 4 currently had a roommate she would try to have a CNA stay with him when she could at night. During a phone interview on 9/15/25, at 5:17 p.m., CNA 4 stated Resident 4 was confused, tended to yell throughout the night saying hello or yelling out his family member's name. CNA 4 stated there was a few times when Resident 4 had gotten aggressive. CNA 4 stated there was an incident about a year ago with a CNA where Resident 4 choked her. CNA 4 explained Resident 4 tended to stand up and would wander to his roommate's side of the room. CNA 4 explained this will happen if a roommate responds to Resident 3's yelling by yelling back. CNA 4 stated staff would attempt to calm Resident 4 down. CNA 4 stated she was working on the early morning of 5/27/25, when the altercation occurred in Resident 3 and Resident 4's shared room. CNA 4 stated on that night Resident 4 was agitated and kept yelling out. CNA 4 stated Resident 3 was alert, and he had used his call light a few times to let us know that Resident 4 was coming over to his side of the room. CNA 4 stated we did our best to go over and calm Resident 4 down, but he was really confused. CNA 4 stated Resident 4 choked Resident 3. CNA 4 explained when LN 3 (name redacted) came to the room she saw redness around Resident 3's neck. CNA 4 stated in the past Resident 4 did have one-on-one for a month or two due to his tendency to get up and wander to his roommate's side. CNA 4 stated Resident 4 currently has a chair alarm but if staff hear yelling, they will respond to the room. During a phone interview on 9/15/25, at 3:25 p.m., CNA 5 stated she worked nights and Resident 4 did not sleep, was loud at night, and would say Hello, Hello or Help, Help repeatedly. CNA 5 stated Resident 4 was confused, can walk with assistance but sometimes will not wait for staff to assist him. CNA 5 stated Resident 4 could be aggressive towards staff or residents. CNA 5 stated other residents would complain about Resident 4's loudness and his roommates and neighbors would yell at him to stop and say, here we go again. CNA 5 recalled the altercation on 5/27/25 between Resident 4 and Resident 3 and stated Resident 4 was standing by Resident 3's bed. CNA 5 stated she did not remember if Resident 3 had called for help earlier regarding Resident 4 coming over to his side of the room. CNA 5 stated she could not recall if she saw Resident 4 choking Resident 3. CNA 3 stated Resident 3 was scared after the incident. During a phone interview on 9/16/25, at 9:39 a.m., CNA 6 stated Resident 4 had been aggressive and abusive with staff including punching a staff member in the chest and another CNA in the face and had dragged and held another CNA down on the ground. CNA 6 stated staff were scared of Resident 4. CNA 6 stated Resident 4 could be violent and currently had a tab alarm on his wheelchair and bed alarm that rings when he gets up. CNA 6 stated Resident 4's bed and chair alarms were implemented after the incident with Resident 3. CNA 6 stated her opinion was no one should be sharing a room with Resident 4. CNA 6 stated people who cannot protect or defend themselves have been roommates with Resident 4 and she did not feel this was fair to them. CNA 6 stated Resident 4 will yell all the time and people cannot sleep which upsets all the residents. During a phone interview on 9/23/25, at 9:45 a.m., the ADON stated Resident 4 had resided in the facility since October of 2023, has dementia, was blind, was unpredictable, and yelled out a lot. The ADON stated Resident 4 does not use a call light due to being blind and will call out because he does not know who was there with him. The ADON stated Resident 4 needs reassurance that someone was there with him and when someone speaks to him it helps to calm him and stops him from yelling out. The ADON stated staff had been monitoring Resident 4's behavior since 2023 due to him being the aggressor in an altercation involving staff. The ADON explained the altercation occurred on 11/27/23 and after the altercation a staff member was assigned to provide one-on-one supervision for Resident 4. The ADON stated the one-on-one was always with Resident 4 and provided him with support and calmed him, so he was not disruptive to other residents. The ADON explained additionally the one-on-one was there to keep Resident 4's roommate safe. The ADON stated Resident 4's roommates tended to be confused and not alert. The ADON stated staff, including CNAs and LNs, were currently monitoring and charting Resident 4's behavior including cursing of others, disruptive sounds, disruptive screaming, and aggression. The ADON stated Resident 4's behaviors tended to manifest more during the night and morning shift. The ADON stated Resident 4 did not currently have a one-on-one staff member assigned to him providing constant supervision and was not sure when it was discontinued but thought it was sometime in the summer of 2024. The ADON explained she was not sure if administration conducted an IDT (interdisciplinary team meeting) prior to discontinuing Resident 4's one-on-one support and through review of Resident 4's electronic record, the ADON acknowledged she could not locate a progress note regarding this. The ADON explained Resident 4 did not constantly have staff eyes on him and due to this and because he was unpredictable, she did not feel it was safe for him to have a roommate. The ADON stated she felt Resident 4 should have one-on-one supervision. The ADON stated if Resident 4 had a roommate he needed one-on-one to prevent Resident 4 from being aggressive and altercations engaging in altercations with the roommate. The ADON stated at night there were not as many staff working. The ADON explained on 5/27/25, Resident 3 could not get away due to his physical limitations. The ADON stated Resident 4 has delusions and thinks he was at war. The ADON stated Residents who share a room with Resident 4 have the right to feel safe in the facility. The ADON stated there was potential for future altercations involving roommates of Resident 4, especially if the roommate was cognitively or physically impaired and could not get away. The ADON explained there was a potential risk for them to get physically hurt by Resident 4 and this could lead to serious injury or fall. During a review of a facility policy and procedure (P&P) titled DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS POLICY STATEMENT, revised 1/2025, indicated, .The facility develops a person-centered comprehensive care plan that are culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Resident's Goal: The resident's desired outcomes and preferences for admission, which guide decision making during care planning.Interventions: Actions, treatments, procedures, or activities designed to meet an objective.Person-Centered Care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.The interdisciplinary team develops the care plan with corresponding interventions for care that is in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences.Care plans shall include the discipline providing care or services, measurable objectives, and timeframes in order to evaluate the resident's progress toward his/her goal(s). During a review of a facility P&P titled admission POLICY, revised 1/2025, the document indicated, .Abuse: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. During a review of a facility P&P titled ABUSE PROHIBITION AND PREVENTION PROGRAM, revised 4/2024, the document indicated, .The facility has policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property .PURPOSE .To provide staff guidelines to ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse.Serious bodily injury: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse (see sections 2011(19)(A) and (B) of the Act).PREVENTION. The facility strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property through.Providing residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed.Identification, correction, and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.Deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure the staff assigned have knowledge of the individual residents'

Based on observation, interview, and record review, the facility failed to implement appropriate safety measures to ensure a safe environment free of accidents or hazards and prevent elopement (form of unsupervised wandering that leads to the resident leaving the facility) for two of two residents (Resident 1 and Resident 2) when, 1. Resident 1 had a documented history of substance use disorder (SUD, a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine and can refer to the use of illegal substances, such as marijuana, methamphetamine and the misuse of legal substances such as alcohol or prescription medications) and was homeless, and there was not a plan in place to address Resident 1's risk of exit seeking or eloping behavior, nor was Resident 1 advised of the risk of leaving the facility early, and subsequently Resident 1 eloped from the facility in the early morning hours of 7/8/25, with his PICC (peripherally inserted central catheter, is a long, thin tube that's inserted through a vein in the arm and the tube is passed through to the larger veins near the heart and is used to give medications or liquid nutrition) line intact. As a result of the Resident 1s elopement, he did not finish his intravenous (IV) antibiotic (medication used to treat serious infections and administered directly into the person's bloodstream through a vein) treatment, scheduled to end on 7/30/25; and, 2. Resident 2 had a documented history of SUD and the facility did not have careplan in place to provided access to or offered drug counseling or other access to SUD support groups and to monitor Resident 2's visitors who may be under the influence of illicit drug (illicit drug includes not only illegal drugs but also prescription medications that are obtained or used unlawfully), and subsequently on 8/29/25, Resident 2 was visited by her boyfriend who was under the influence of drugs and assaulted Resident 2 in her room. These failures had the potential to result in Resident 1 and Resident 2 sustaining life-threatening injury and/or psychosocial (the mental, emotional, social, and spiritual effects of a disease) harm. 1.Review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility late June/2025 with a diagnosis including but not limited to osteomyelitis (bone infections), Type 2 diabetes mellitus (body cannot regulate blood sugar) with foot ulcer (open sore that often develops in people with diabetes), absence of right toes (surgical removal of toes), acquired absence of right toe(s), acquired absence of left toe(s), other stimulant abuse (stimulants have high addiction potential, example is methamphetamine, can cause anxiety, rapid heart rate, or fatal overdose), and abnormalities of gait (walking) and mobility.Review of Resident 1's ED [Emergency Department] Physician Notes, dated 6/18/25, indicated, .FROM [name redacted, shelter] FOR LOWER EXTREMITY PAIN. PT [patient] STATES HE HAS FOOT ULCER. PMH [past medical history] .AMPUTATION [surgical removal] OF ALL 10 TOES AND DM [diabetes mellitus] .Diagnosis this visit. Problem List/Past Medical History.Diabetic foot infection.Methamphetamine abuse (lab made stimulant with high addiction potential) .Review of Resident 1's Hospital History and Physical, dated 6/18/25, indicated, .[name redacted, Resident 1] is a 50yo [year old] homeless male.pt [patient] says his right stump has started to hurt more for past one day.Problem List/Past Medical History.Ongoing. Diabetic foot infection.Methamphetamine abuse.noncompliance with medication regimen.severe sepsis [life-threatening medical emergency}.suicide risk.Review of Resident 1's Hospital Discharge summary, dated [DATE], indicated, . Patient was seen and evaluated on the day of discharge. PICC line was placed on 6/24/25.He will continue to IV vancomycin [strong antibiotic used to treat bacterial infections] [1 g [gram, unit of measure] twice daily till 7/30/25.PICC line can be removed after this last dose. He will follow up with podiatry [medical specialty dedicated to conditions affecting the foot and lower leg] .Review of Resident 1'a Psychosocial Assessment/Social History/Discharge Planning, dated 6/27/25 and signed by the Social Service Director (SSD), indicated, .History of alcohol/substance use.No.Currently smokes .No.Living arrangement prior to hospitalization.shelter [temporary living situation for someone experiencing homelessness, providing a bed in a shared space] . Review of Resident 1's Wandering/Elopement Risk Evaluation,, dated 6/25/25, indicated, .RESIDENT EVALUATION FACTORS: Does the resident have the ability to walk or self-propel off the premises without assistance .No. Review of Resident 1' Smoking Risk Assessment, dated 6/25/25, indicated, .Does the resident currently smoke .Yes.Review of Resident 1' History and Physical Option, dated 6/26/25, written by the Medical Doctor (MD) 1, indicated, .he [Resident 1] will be on iv vancomycin till 7/30/35.via picc line.Review of Resident 1's Health Status Note, dated 6/29/25, indicated, .on monitoring for IV ABT [antibiotics]/osteomyelitis.also on monitoring for hyperglycemia [high blood sugar] with noncompliant with food.resident continue to request for food.education resident on the importance oof a balance diet for a diabetic resident.resident verbalized okay but continue to request for food. Review of Resident 1's Assessment Summary, written by LN 4, dated 7/8/25, indicated, SBAR [which stands for Situation, Background, Assessment, and Recommendation (or Request), is a structured communication framework that can help teams share information about the condition of a patient that the team needs to address] Communication for Changes in Condition.The change in condition, symptoms, or signs I am calling about is/are: elopement.Started on 7/08/25.Staffs observed that resident could not be located within the facility. Resident [Resident 1] was last seen by his primary nurse around 0310 [3:10 a.m.] on a black shirt in his wheelchair coming out from the patio. Also, one of the CNAs saw resident around 0320 [3:20 a.m.] asking if resident needs anything. Resident is AO4 [alert and orientated times four, meaning alter to person, place, time, and event], no signs of distress or eloping noted, PICC line present, Facility wide search conducted, code green initiated [meaning resident elopement], looked at the nearby park but resident still cannot be found. Police department notified.During an interview on 9/8/25 at 4:00 p.m., the Administrator (ADM) stated Resident 1 left in the middle of the night and as far as she knew he had not contacted his family, and she was not sure of his whereabouts. The ADM stated Resident 1 was admitted to the facility for IV antibiotics and was here from June 24th through July 8th. The ADM stated he was normally a night owl, and his mother said he was homeless prior to coming to the facility. During a concurrent interview and record review on 9/9/25, at 2:50 p.m., the SSD stated Resident 1 had a history of being homeless and prior to his hospital and facility admission he was living in a homeless shelter. The SSD explained the plan was for him to return to the shelter on discharge. The SSD stated Resident 1 decided to leave the facility unannounced in the middle of the night on 7/8/25. The SSD stated she spoke to Resident 1's mom and she said she was not concerned with his whereabouts. The SSD stated Resident 1 was being treated for osteomyelitis with IV antibiotics administered via a PICC line and had not finished his antibiotic course when he left the facility. The SSD confirmed Resident 1 left the facility with his PICC line intact. The SSD stated she had performed a risk assessment for Resident 1 on admission due to his current homelessness and was not aware Resident 1 had been using methamphetamines prior to him being admitted into the facility. The SSD stated if a resident voiced, they were drug seeking then staff would create a care plan to address the behavior. Through record review of Resident 1's Psychosocial Assessment/Social History/Discharge Planning, the SSD confirmed it was marked no for history of drug use. The SSD stated if a resident was using illicit drugs before their hospital admission, then the facility would want to address the drug use. The SSD explained they would want to offer the resident counseling and a psychiatry referral. The SSD stated Resident 1 was homeless and the shelter he was previously staying at would not take him back if he was actively using drugs or alcohol because sobriety was a condition of the housing agreement. The SSD stated he was living at the shelter a couple of months prior to being admitted to the hospital so she thought he was not using drugs. The SSD stated nursing staff would be looking at Resident 1's hospital discharge papers and not social services, so she was not aware of the hospital's documentation. Through record review of Resident 1's ED Physician Notes, the SSD confirmed the last date of methamphetamine use was 5/18/25. The SSD stated Resident 1 should have had a care plan addressing his methamphetamine drug use. The SSD stated the care plan would have included resources such as drug counseling and a psychiatric referral. The SSD stated Resident 1 should have had an addiction care plan and this was important so other staff are aware and could mitigate and intervene for drug seeking or exit seeking behaviors. The SSD acknowledged her role was to assist the residents with drug counseling, mental health, and housing.During an interview on 9/9/25 at 2:02 p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 was always nice to her. CNA 1 stated Resident 1 would complain of pain, and she would inform the nurse he wanted his pain medication. During an interview on 9/10/25, at 12:02 p.m., Licensed Nurse (LN) 1 stated Resident 1 never had visitors, and she remembered he smoked. LN 2 stated she did not ask residents about their living situation or if they engage in or have a history of drug use. LN explained this would be a role for social services. During an interview on 9/10/25, at 3:27 p.m., CNA 3 stated Resident 1 was here for IV medications and was quiet. CNA 3 stated there were signs Resident 1 was homeless such as he would gather extra towels, supplies, and food to keep. CNA 3 explained Resident 1 would ask for four to five sandwiches at a time. CNA 3 stated Resident 1 always had his bag packs and would hang them off his wheelchair and would take them with him when he moved about in the facility. During a phone interview on 9/11/25, 12:30 p.m., LN 4 stated he worked nights and was primarily the desk nurse. LN 4 explained he creates care plans and provides a resource in case the bedside nurses need help. LN 4 stated he was familiar with Resident 1 and was not aware he had a history of homelessness and could not remember if he had a history of drug use. LN 4 stated Resident 1 had no belongings with him when he was admitted into the facility. LN 4 stated he was working the night Resident 1 left the facility. LN 4 recalled the primary nurse told him the resident was last seen by a CNA. LN 4 stated Resident 1 usually slept during the day and was awake at night. LN 4 stated he administered Resident 1's IV antibiotics at midnight the night he left. LN 4 stated Resident 1's primary nurse informed him around 4:00 a.m. that he was missing. LN 4 stated a care plan would have been helpful to inform staff that he had a history of drug abuse so staff could have been focusing more on Resident 1's potential for exit-seeking behavior. LN 4 stated for residents who experience homelessness, he would do a care plan to address their homelessness so staff can plan for resources when they get discharged . LN 4 stated it was important to check a resident's medical diagnosis for alcohol or drug abuse. LN 4 explained he would create a care plan to address a resident's drug and alcohol abuse because it was important for interventions to be implemented including monitoring the residents for drug and/or alcohol withdrawal symptoms and exit seeking behavior. During a phone interview on 9/11/25, at 2:16 p.m., LN 3 stated she was Resident 1's LN or the supervisor the night he woke up and left the facility. LN 3 stated Resident 1 would ask staff for snacks at nighttime and would stay awake through the night. LN 3 stated she noticed Resident 1 was missing because she needed to check his morning blood sugar and could not locate him. LN 3 explained the CNA reported to her she last saw him at 3:30 a.m. coming back from the outside patio after a smoking break. LN 3 stated the guard checked the outside camaras which showed Resident 1 left through the front of the building, in his wheelchair, around 4:00 a.m. LN 3 recalled Resident 1 was outside in the patio a lot for that night. LN 3 stated she was not aware Resident 1 had a history of homelessness, and he never told her. LN 3 stated she would have wanted to know Resident 3 had a recent history of methamphetamine use. LN 3 explained it could have helped to prevent Resident 1 from leaving and she would have wanted to know if he was exit-seeking. LN 3 stated Resident 1 did take pain medication that night. LN 3 stated Resident 1 was not a typical resident due to him being younger and doing his own thing. LN 3 stated she would have wanted Resident 1's homelessness and illicit drug use to be addressed, and a plan of care developed. LN 3 stated if this was not done then the resident could relapse or have a feeling of uneasiness or go through drug withdrawals. LN 3 explained Resident was at risk for drug withdrawals and could have needed a mental health consultation or behavioral health or drug counseling. LN 3 stated resources would have been helpful. LN 3 explained Resident1 left with his PICC line and still required his IV antibiotic treatment. LN 3 stated she would have wanted him to complete his antibiotics prior to leaving. During a phone interview on 9/15/25, at 5:17 p.m., CNA 4 stated Resident 1 was in isolation due to MRSA (bacterial infection) and stated he had his own (private) room. CNA 4 stated Resident 1 did things for himself. CNA 4 stated Resident 1 did not listen and would go outside to the patio to smoke at night. CNA 4 stated we did have smoking times, and the last smoking time of the day was 8:00 p.m. CNA 4 stated the residents who were alert just go smoking on their own in the inside patio without staff supervision. CNA 4 stated she was working the night Resident 1 went missing. CNA 4 stated around 3:30 a.m., she was performing her rounds and saw Resident 1 watching television. CNA 4 stated around 3:40 a.m. she saw Resident 1 headed in the direction of the patio, and assumed he was smoking. CNA 4 explained around 4:30 a.m. she noticed he was not in room. CNA 4 further explained she went to the parking lot, and Resident 1 was not there. CNA 4 stated she informed the nurse she could not locate Resident 1. CNA 4 stated did not know Resident 4 was homeless and was not aware of his past illicit drug use. CNA 4 stated the nurses knew he would go hang out at night in front of the building. CNA 4 stated in the past staff had told Resident 1 not to go out the front door of the building at night. CNA 4 stated once out-front Resident 1 would not have been able to come back in due to the door locking. CNA 4 stated there was a doorbell outside that could be ringed. During a concurrent interview and record review on 9/9/25, at 4:36 p.m., the Assistant Director of Nursing (ADON) stated Resident 1 was alert and orientated and was receiving IV antibiotics for a wound infection. The ADON stated Resident 1 left the facility in his wheelchair in the middle of the night on 7/8/25. The ADON stated the facility had not heard from Resident 1 since. The ADON stated they called and reported his elopement to the police. The ADON stated Resident 1 treatment wise was very young to be in the facility. The ADON stated Resident 1 had uncontrolled diabetes and osteomyelitis and had a PICC or midline to administer his antibiotics. The ADON stated she was not aware Resident 1 had a history of homelessness or that he was using methamphetamines prior to being admitted to hospital. Through review of Resident 1's hospital discharge document History and Physical, the ADON acknowledged Resident 1 had a current problem list of methamphetamines use and was homeless. The ADON stated nursing staff, and social services should have reviewed Resident 1's hospital discharge paperwork and addressed his illicit drug use and current homelessness living situation with care plans and other interventions, The ADON stated staff would want to address Resident 1's psychosocial wellbeing and monitor resident for exit seeking behaviors, drug withdrawals, pain management adjustments due to the drug use, counseling for addiction and a psychiatric consult. The ADON stated the residents illicit drug addiction would need be care planned as it provided a guide for staff on how to care for the residents. The ADON explained homelessness and drug addiction caused risk factors for Resident 1, such as leaving the facility without finishing their scheduled antibiotic therapy, lack of wound care, and psychosocial aspects not being addressed and this ultimately resulted in him leaving. During a phone interview and record review on 9/23/25, at 9:45 a.m., the ADON reviewed Resident 1's Wandering/Elopement Risk Evaluation, and confirmed the answer to question 1 was marked 'No' related to the ability for Resident 1 to be mobile. The ADON stated this meant Resident 1 was not an elopement risk. The ADON stated the answer should have been marked 'Yes' due to Resident 1's ability to self-propel his wheelchair and was mobile in the facility. The ADON stated if the form had been answered correctly more questions would have been generated to accurately assess Resident 1's elopement risk. Through review of Resident 1's Psychosocial Assessment/Social History/Discharge Planning, the ADON acknowledged Resident 1 was identified as homeless in the form and some of the questions including Resident 1's History of alcohol/substance abuse was marked incorrectly as 'No' and should have been answered 'Yes' due to his medical diagnosis and hospital discharge paperwork. The ADON acknowledged the question Currently smokes? was marked incorrectly and should have been marked 'Yes'. The ADON stated her expectation was the form was filled out accurately so Resident 1's history of alcohol and substance abuse could have been addressed and care planned. The ADON stated Resident 1 had the potential for exit seeking behavior based on his recent history of being homeless and drug use. The ADON stated Resident 1's drug seeking and elopement risk should have been identified and care planned as he could have experienced drug withdrawals or suffered a relapse of drug use while in the facility. The ADON explained the drug seeking and potential elopement risk was important to care plan and address clinically so nursing staff were aware so the residents could be monitored, and staff can ensure measures were in place to keep the residents safe. The ADON confirmed Resident 1 left the faciity on 7/8/25, with his PICC line and did not finish his antibiotic treatment course which was scheduled to end on 7/30/25. The ADON stated for residents with a history of homelessness and recent drug use, nursing staff would have wanted to address the risks of leaving before their treatment ends. The ADON stated the risk for Resident 1 would have been at increased risk for infection from not completing his antibiotic treatment. The ADON stated that normally social service deals with homelessness and drug use, but she could see how this could affect the clinical nursing side of ensuring the care of the residents. 2.Review of Resident 2's admission RECORD, indicated, Resident 2 was admitted to the facility late July//2025 with a diagnosis including but not limited to ulcer with perforation (hole or break in the stomach and is a medical emergency), perforation of intestine (a hole or break in the wall of the gastrointestinal (GI) tract, which causes intestinal contents to leak into the abdomen), other psychoactive substance abuse (drug addiction), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can affect how a person feels, thinks and behaves and can lead to a variety of emotional and physical problems), and unsteadiness on feet.Review of Resident 2's Hospital Adult admission History, dated 8/21/25, indicated, .admitted From.Homeless.Transportation Issues.Yes.Alcohol.Current.Beer, Wine, Liquor.Substance Abuse.Current.Marijuana.Review of Resident 2's Order Summary Report, indicated, .Appointment with [Medical Doctor, name redacted] on 9/8/25 @ 3:30 pm.pt [patient] will arrange [name redacted, ride-hailing service] transport.Review of Resident 2's Health Status Note, dated 9/9/25, indicated, .Resident makes her appointment on 9/10/25.Resident arrange her transportation via [name redacted, ride-hailing service] .Review of Resident 2's Care Plan, dated 9/2/25, indicated, .Resident has discharge plans pending to a less restrictive environment. History of being homeless at risk for leaving AMA [against medical advice] .Goal. Resident will be discharged to less restrictive environment per MD's [medical doctor] order when deemed appropriate.Interventions.Invite resident/support person to care plans meetings as planned/and requested.Review of Resident 2's History and Physical Option, dated 8/30/25, written by the MD 2, indicated, .This is a medically complex patient.Patient has a history of hypertension, meth [methamphetamine] use.Review of Resident 2's Psychosocial Assessment/Social History/Discharge Planning, dated 9/2/25 and signed by the SSD, indicated, .Gender Female.History of alcohol/substance use.Yes.Have you ever experienced any physical/psychological trauma.NO.MOOD & BEHAVIORAL/MEDICATION RECEIVED.Resident Mood/Areas of Concern Review.Episodes of depression due to previous relationships and health concerns. Referral to psyc [sic, meaning psychiatrist, a medical doctor specializing in treating mental health conditions] was submitted.Psychiatric/ Psychological consult. [not marked] .Living arrangement prior to hospitalization.living alone.Location prior to hospitalization.Homeless. Review of the report indicated Resident 2 did not have a history of alcohol, substance use, and/or history of trauma, and contradicted to Resident 2's clinical medical record.Review of Resident 1's SBAR: Change of Condition, dated 8/30/25, written by LN 2, indicated, .Situation.Alleged Abuse from Boyfriend.This Started on.8/29/25.Other relevant information.Residents boyfriend noted with alleged drug abuse.Assessment/ Appearance.Appearance Details:. at 1905 [7:05 p.m.], resident reported that her boyfriend, [name redacted] visited her @ [at] 1900 [7:00 p.m.] and talked to her about money. The visitor was allegedly under the influence of drugs and got triggered when the resident's bedside phone started ringing, causing [name redacted, boyfriend] to get agitated. He began questioning the resident Who's calling you on the phone and grabbing her face by cheeks and pushing her onto the bed when the resident tried to move away. [name redacted, boyfriend] was reported to have threatened to slap her but didn't follow through. Resident also reported he called her a [redacted, derogatory term], and other names. Visitor last seen exiting the building @ 1902 [7:02 p.m] .Resident noted calm and cooperative with staff.but also requesting to ban [name redacted, boyfriend] and his friends from any future visits.Resident noted with discolorations to her cheeks upon assessment.During a concurrent observation and interview on 9/9/25, at 2:15 p.m., Resident 2 was observed in her room, Resident 2 stated she came to the facility for leg therapy after being discharged from the hospital for a foot infection. Resident 2 stated prior to coming here she was homeless and lived on the streets. Resident 2 stated her boyfriend came to the facility a few days after being admitted and was pacing back and forth in her room, was angry with her, and she could tell he was high on the drug fentanyl. Resident 1 stated she told him if he was not going to act right, he could leave, and he came over to her and grabbed her by the jaw, cussed her out and then left. Resident 2 stated she started to yell out and staff came into her room. Resident 2 stated her nurse told her she had visible marks on her cheeks, later the police came and last she heard her boyfriend was in jail. Resident 1 stated when she first was admitted the facility staff asked about her living situation, and she told them she was homeless. Resident 2 stated social services came and spoke with her and asked her if she had a history of drug use and she told them she shad used methamphetamines and had stopped using one week prior to entering the hospital. Resident 2 stated her nurse told her she had marks on her cheeks after the altercation. During a concurrent interview and record review on 9/9/25, at 2:50 p.m., the Social Services Director (SSD) stated Resident 2 was homeless, had a history of illicit drug use but no recent drug use. The SSD stated regarding Resident 2's boyfriend, he came in once, and was thought to be high on illicit drugs, and he grabbed Resident 2 by the face and shoved her. The SSD explained if a resident was using illicit drugs within the last 6 months the facility would want to provide a care plan for the drug use. Through review of Resident 2's current diagnosis, the SSD confirmed Resident 2 diagnosis of psychoactive drug abuse substance abuse. The SSD acknowledged Resident 2 should have had a drug addiction care plan, as the point was to make everyone aware and make necessary interventions. The SSD stated Resident 2 should have been offered a psychiatrist consultation and drug counseling. The SSD stated the risk to the residents if illicit drug use was not addressed was leaving the facility unplanned, return of drug abuse or relapse, or overdose. During a concurrent interview and record review on 9/9/25, at 4:36 p.m., the ADON reviewed Resident 2's electronic clinical record and confirmed Resident 2 had a diagnosis of substance abuse and stated the facility would need to put measures in place to address the diagnosis. Through a record review of Resident 2's hospital discharge paperwork, the ADON confirmed Resident 2's use of marijuana and alcohol and acknowledged this should have been addressed in a care plan and monitoring. The ADON stated they would want to protect residents with a history of drug use from visitors who might be bringing illicit drugs, alcohol, or marijuana into the facility. The ADON acknowledged this was for the safety of all the residents, visitors, and staff. The ADON stated staff would need to be observant about potential issues related to addiction, including exposure to illicit drugs and overdose. The ADON stated Resident 2 had previously been homeless and was partaking in illicit drug use so staff would want to monitor the residents for behaviors to prevent a negative outcome such as relapse of drug use. The ADON explained there should be follow-up for the mental health piece including drug counseling for the residents who have a history of homelessness and drug use. During an interview on 9/11/25, at 3:00 p.m., CNA 7 stated she was working the evening Resident 2' had an altercation with her boyfriend. CNA 7 stated she heard a female yelling and screaming while she was in a room across the hall. CNA 7 stated she went into Resident 2's room and asked her what was going on. CNA 7 stated Resident 7 told her she did not want her boyfriend to come into the building because he squeezed her face and pushed her into the bed. CNA 7 stated Resident 2 told her the boyfriend did it in the hospital too. CNA 7 stated Resident 2 told her she was scared of him but wanted to give him another chance. CNA 7 stated she reported the incident to the nurse. During a phone interview on 9/11/25, at 1:00 p.m., LN 2 stated he was Resident 2's nurse the evening when the alteration happened with her boyfriend. LN 2 stated a CNA came to him and told him Resident 2's boyfriend had been rough with her. LN 2 recalled Resident 2 stated her boyfriend was agitated, got physical and held her by her cheeks and pushed her onto the bed. LN 2 stated Resident 2 had discoloration on both sides of the cheeks. LN 2 stated he followed protocol including calling the police department and filing the abuse report. LN 2 stated Resident 2 told him she thought her boyfriend was under the influence of harder drugs like fentanyl and did not want to be around him or his friends requested he not be allowed in the facility. LN 2 stated for new admissions the night shift creates resident care plans. LN 2 stated Resident 2's former illicit drug use should have been care planned. LN 2 explained the care plans would help to inform staff of the needs of residents and staff should be aware that visitors could potentially bring illicit drugs or alcohol in the building for residents with addiction issues. LN 2 stated there was potential risk to the resident or others for exposure to illicit drugs or potential overdose. LN 2 stated the interventions were necessary due to the high risk of relapse and addiction was a very serious thing. LN 2 explained residents with addiction issues could exhibit exit seeking behavior such as wandering or leaving the facility.During a concurrent observation and interview on 9/11/25, at 1:32 p.m., Resident 2 stated yesterday she took a lift ride to her primary care doctor appointment and facility did not help her arrange the appointment or transportation. Resident 2 stated she had to wait two hours after her appointment to get a ride back and needed help getting her blood work done the doctor ordered. Resident 2 explained she could not get a ride there and needed help getting transportation to her medical appointments. Resident 2 stated she had shared with the nurses how difficult it has been to get her medical appointments arranged and trying to get her own transportation but no one from the facility has offered to help her. Resident 2 stated she tried to go to the Social Service office but has not been able to speak with anyone. Resident 2 stated she has anxiety about where she was going to live when she leaves because she doesn't want to go back to living on the streets. Resident 2 stated she would like to have drug counseling while at the facility. Resident 2 stated she loved the feeling of being sober and because of being sober her daughter had come around to visit her at the facility. Resident 2 explained it had been three years since she had spoken with her children. Resident 2 stated she was scared she was going to relapse. Resident 2 stated staff had not offered help with addiction, behavior, or housing support. Resident 2 stated she had been diagnosed with anxiety and was taking medications to help with it. Resident 2 stated she had PTSD and felt sad and would start to cry randomly.During an interview on 9/11/25, at 2:53 p.m., with the SSD and the ADON, the SSD stated the facility can provide transportation for residents with outside medical or other appointments and the assistant administrator helps with this. The ADON stated nursing staff could help schedule medical appointments. The SSD stated she could help with locating substance abuse programs and scheduling appointments for residents. The SSD stated for residents with a history of substance abuse within the last six months, staff would want to address this with the residents and develop interventions to be used in a care plan. The SSD explained residents who were agreeable to participate in a drug or alcohol abuse pro

Based on observation, interview, and record review, the facility failed to maintain professional standards of quality care for one out of four sampled residents (Resident 1) when, Resident 1's prescribed medications were left unattended at her bedside, and a diagnostic test ordered to determine the cause of her illness was not completed in a timely manner. These failures had the potential for harm to Resident 1 and other residents who could gain access to her medications and to cause a delay in Resident 1's medical treatment. Findings: A review of Resident 1's ADMISSION RECORD, indicated she was admitted to the facility with diagnoses which included type 2 diabetes mellitus (chronic disease that affects blood sugar levels) and hypertension (high blood pressure). During a concurrent observation and interview on 2/18/25, at 10:50 AM, Resident 1 was observed sitting up in bed with her tray table in front of her. Resident 1 stated she had been coughing so much that she could not take her morning medications. Resident 1 pointed to a plastic cup containing two capsules and six tablets and stated the nurse had left the medication with her. A review of Resident 1's Medication Administration Record, (MAR) for February 2025, indicated Resident 1 had one medication due at 8 AM- metformin (for diabetes, to be given with meals) and seven medications due at 9 AM as follows: Aspirin ( for stroke prevention) Multivitamin with minerals (supplement) Cranberry tablet (for urinary tract infection prevention) Folic acid (supplement) Lisinopril (for high blood pressure) Vitamin D3 (supplement) Gabapentin (for nerve pain) During an interview on 2/18/25, at 11:03 AM, Licensed Nurse (LN) 3 stated that medications should not be left at a resident's bedside unless the resident had an order to self-administer medication. LN 3 stated she was allowed to leave Resident 1's medications with her since she was alert. During a concurrent interview and record review on 2/18/25, at 12:10 PM, the Minimum Data Set (a federally mandated resident assessment and screening tool which identifies care needs) Coordinator (MDSC) reviewed Resident 1's Self-Administration of Medication Assessment, dated 10/24/23. The MDSC confirmed the assessment indicated Resident 1 could safely self-administer Bengay (a cream used for muscle or arthritis pain). The MDSC further confirmed the assessment did not indicate Resident 1 could self-administer any other medications. The MDSC stated Resident 1's medications should not have been left unattended in her room. The MDSC further stated medications should be administered one hour before and one hour after they were prescribed and no later than that. During an interview on 2/18/25, at 12:34 PM, the Director of Staff Development (DSD) stated there was a risk to residents if medications were left at their bedside. The DSD further stated another resident could have entered the room and taken Resident 1's medications. The DSD stated there was also the potential for Resident 1 to choke on her medications. The DSD further stated the LN should always stay with the resident when they were taking their medications. During a concurrent interview and record review on 2/18/25, at 12:50 PM, LN 3 confirmed the medications left at Resident 1's bedside were metformin, gabapentin, aspirin, cranberry tablet, folic acid, and lisinopril. LN 3 confirmed the medications should have been administered between one hour before or one hour after their scheduled time. LN 3 stated the medications should not have been left at the bedside as she would not know if Resident 1 had taken them. LN 3 further stated medications left at the bedside could be a potential choking hazard, or another resident could enter the room and take the medications. A review of a facility policy titled, ADMINISTERING MEDICATIONS, dated 3/23, indicated, .To provide employees with guidelines for the safe and timely administration of medication per physician order .Medications must be administered in accordance with the orders .medications must be administered in accordance with state and federal guidelines . b. A review of Resident 1's clinical document titled, SBAR [Situation, Background, Assessment/Appearance, Request] : Change of Condition, dated 1/16/25, indicated, .The change in condition, symptoms, or signs I am calling about are .productive cough and sore throat .This started on 1/16/25 .Reported to MD .1/16/25 0600 [6 AM] . A review of Resident 1's Order Details, dated 1/17/25, at 3:27 PM, indicated .Chest Xray to r/o [rule out] PNA [pneumonia, an infection of the lungs] . A review of Resident 1's RADIOLOGY [x-ray] REPORT, indicated, .service date 1/19/25 .report date 1/20/25 .Conclusion: Slight bilateral upper lobe infiltrates [ a condition where substances like blood, pus, or protein build up in the upper lobes of both lungs]. Clinical correlation [connecting symptoms with test results] is advised .Clinical or repeat examination follow up is advised . A handwritten note on the radiology report indicated, .ZPAC [ an antibiotic medication to treat infection] order carried out on 1/21/25 . A review of Resident 1's Order Details, dated 1/21/25, at 7:02 AM, indicated, .Azithromycin [antibiotic] Tablet 250 mg [milligrams] .for infection . A review of Resident 1's progress notes dated 1/23/25, at 10:19 AM, indicated, .Reached out to [Business name] Labs re: CXR [regarding chest x ray] for resident performed on 1/19/25. Confirmed routine order received from our MD [Medical Doctor] for CXR on 1/17/25, order placed via business email by LN. [Business name] confirmed closed Friday and Saturdays for Labs, but open 24/7 [24 hours per day/7 days per week] for x-rays. Stated routine (normal) x-ray orders done within 8-24hrs [hours] and would only be rescheduled by [Business name] if no staff available to come out to facility. [Business name] rep [representative] confirmed they have no notes on file for any request by facility to reschedule CXR from date order was submitted on 1/17/25 and that no confirmation was sent to facility about rescheduling . During an interview on 2/18/25, at 11:03 AM, LN 3 stated when an x-ray was ordered a requisition was sent to the x-ray provider. LN 3 further stated the provider was not open on Fridays and Saturdays. LN 3 stated they had to be on top of them and good communication was needed to get x-rays done. During an interview on 2/18/25, at 12:10 PM, the MDSC stated when an x-ray was ordered and had not been completed in a timely manner the nurse on each shift should call the x-ray provider and follow up. The MDSC further stated if the x-ray still was not done the LN should escalate the issue to the Director of Nurses. The MSDC stated it was her expectation that the LNs would have followed up on Resident 1's x-ray order to prevent a delay in her care. A review of a facility job description titled, Licensed Vocational Nurse (LVN), dated 10/16, indicated, .The licensed Vocational Nurse (LVN) is responsible for managing the residents' care plans and supervising resident care activities. Both care management and supervisory responsibilities must be executed in accordance with state and federal regulations and facility policies and procedures .Report all care ordered but not delivered .to the Director of Nursing .Complete medication and treatment passes as applicable in a timely manner and in accordance with state and federal regulation and facility policy . A review of a facility policy titled, LABORATORY SERVICES, dated 3/23, indicated, .Laboratory, radiology, or other diagnostic services ordered by the physician will be completed in a timely manner; and abnormal results will be reported to the physician in a timely manner to ensure results can be acted upon quickly .The facility strives to meet the needs of residents with regard to the quality and/or timeliness of providing laboratory services and reporting laboratory results .

Based on observation, interview, and record review, the facility failed to ensure the menu and recipes were followed during the lunch meal preparation on 1/8/25, for 94 residents who received food prepared in the facility kitchen when: 1. The recipe for Asian Cucumber Salad was not followed; 2. The recipe for Asian [NAME] Rice was not followed; and, 3. The Asian smooth sauce was not prepared. These failures had the potential to affect the flavor of the food, with the potential for inadequate food intake, and could negatively affect the residents' dining experience. Findings: 1. Review of the facility document titled, Winter Menu, for Wednesday 1/8/25 indicated, .Beef & Broccoli Asian [NAME] Rice Asian Cucumber Salad Pot Sticker Glazed Apricots . During a concurrent observation and interview on 1/8/25, at 10:26 AM, with the Dietary Service Supervisor (DSS) during lunch preparation, the DSS stated the facility had eight cucumbers available, which were not enough to make 100 servings of Asian Cucumber Salad as listed on the menu. The DSS cut and peeled approximately eight cucumbers, then mixed those cucumbers with sliced red bell peppers, white onions, and two cans of three bean salad. After all items were mixed, the DSS added Italian dressing. The DSS stated when items ran out, they substituted them for something they had in stock. A review of a facility document titled, Standard Winter 2025 Salad, Asian Cucumber, listed the recipe and ingredients. The document indicated for 100 servings, 3 gallons of cucumbers sliced and peeled were needed. In addition to the cucumbers the following items were listed in the recipe: rice vinegar, honey, sesame oil, red crushed pepper, and salt. During an interview on 1/9/25, at 12:11 PM, with the DSS, when asked about the substitution of ingredients, the DSS stated the changes to the menu needed to be approved by the RD to assure a balanced diet was provided for the residents. During an interview on 1/9/25, at 1:35 PM, with the Registered Dietician (RD), the RD stated when there were necessary changes to the meals, they needed to be approved by the RD. The RD stated adding the three-bean salad to the residents' lunch was not approved by him, and this practice did not meet his expectations. The RD stated not following the recipe could result in poor intake and weight loss. A review of a facility provided document titled, Menu Changes, indicated, .The Dining Services Director is responsible for the supervising meal preparation and service to assure the menu is followed and served as planned .The substitution must be of equal nutritional value . 2. During a concurrent observation and interview on 1/8/25, at 10:21 AM, with the DSS, the DSS explained the rice located in a large metal pan in the steamer was prepared with brown rice and seven quarts of water. The DSS stated once the rice was finished steaming in the water, it would be done and ready to serve. During an observation on 1/8/25, at 12:10 PM, of the lunch tray line, the Asian [NAME] Rice was served without adding the other ingredients. A review of a facility provided document titled, Standard Winter 2024-25 Rice, Asian Brown, indicated, .Ingredients: Low sodium chicken stock, brown rice, low sodium soy sauce, sesame oil, and sliced green onions . A review of a facility document titled, Menu, dated 1/1/2019, indicated, .Menus are planned to meet the state and federal guidelines .Menus are written following the guidelines for persons 51+ years of age .Menus are reviewed and approved by the consultant dietician indicating that the menu is nutritionally adequate. The Dining Services Director is responsible for supervision meal preparation and service to assure the menu is followed and served as planned. 3. During a concurrent observation and interview on 1/8/25 at 11:30 AM, with the DSS after the food preparation was completed, the DSS was asked if the menu item Asian Smooth Sauce was prepared. The DSS stated they did not prepare the sauce. During an observation on 1/8/25, at 12:10 PM, of the lunch tray line, there was no Smooth Sauce, or an alternative placed on the trays for residents who required soft, bite sized, minced, moist, and ground consistency. A review of a facility provided document titled,Standard Winter 2024-25 Rice, Asian Brown, indicated, Soft & Bite Size, Minced and Moist, Ground .Mix Extremely Thick, Smooth Sauce that keeps the rice from separating into individual grains.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served to meet the needs of 94 residents who received food from the kitchen during the lunch meal on 1/8/25 when: 1. Residents on regular portion diet received less than the required amount; 2. 12 Residents with orders for chopped and easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct amount of Beef and Broccoli; 3. Residents on a pureed diet received the incorrect portion of Asian Beef and Broccoli, and did not receive Potstickers; 4. Three Residents on a large portion diet did not receive the correct amount of Asian Beef and Broccoli and Asian [NAME] Rice; 5. Residents with orders for Consistent Carbohydrate Diet (CCHO-helps manage blood sugar levels) received the incorrect portion size of Asian [NAME] Rice; and, 6. 14 Residents requiring fortified (added calories) diet did not receive the added items to increase calories. These failures had the potential to result in residents not receiving adequate nutrients, which could lead to unplanned weight loss or gain, vitamin imbalances, and further compromise their medical status. Findings: 1. During an observation on 1/8/25, at 12:10p.m., of the lunch tray line, residents with an ordered regular diet received their Beef and Broccoli serving via tongs and kitchen staff used a #10 (3/8 cup) scooper for the Asian [NAME] Rice. During an interview on 1/9/25, at 11:29 AM, with the Dietary Aide (DA) 1, DA 1 stated during tray line the spreadsheet with serving sizes should be followed. DA 1 stated the spreadsheet indicated the #8 (1/2 cup) scoop should be used to serve the starch item for residents on a regular diet. A review of a facility document titled, Daily [NAME] Menu Meal: Noon, indicated serving directions for residents on regular portion diets should receive 2/3 cup of Asian Beef and Broccoli and scooper #8 (1/2 cup) portion of Asian [NAME] Rice. 2. During an observation on 1/8/25, at 12:10 PM, of the lunch tray line, kitchen staff placed broccoli on the plate using tongs and Asian Beef using a 3/8 cup scoop for residents requiring chopped and easy to chew and soft bite sized diets. A review of a facility document titled, Daily [NAME] Menu Meal: Noon, indicated the portion size for Asian Beef and Broccoli for residents on an ordered chopped and easy to chew and soft bite sized was a #6 scoop (2/3 cup). For the residents on minced and moist diets, the scoop size was #8 (1/2 cup). 3. During an observation on 1/8/25, at 12:10 PM, of the lunch tray line, residents with an ordered puree texture diet received a #12 scoop (1/3 cup) of Asian Beef, 1/3 cup Broccoli, 1/3 cup of mashed potatoes, and no potstickers. A review of the facility document titled, Daily [NAME] Menu Meal: Noon, indicated the serving size for residents on a pureed diet was a #8 scoop (1/2 cup) for Asian Beef and Broccoli, and Potstickers #20 scoop (3 tablespoons). 4. During an observation on 1/8/25, at 12:10 PM, of the lunch tray line, plates were prepared for three residents requiring large servings. Kitchen staff used a #10 (3/8 cup) scooper for Asian Beef, Asian [NAME] Rice, and added one tong of broccoli for each plate. A review of the facility document titled, Daily [NAME] Menu Meal: Noon, for the meal served on 1/8/25, indicated the portion size for residents requiring a large portion diet was two #8 scoops (total one cup) of Asian Beef and Broccoli, and two #8 scoops of Asian [NAME] Rice. A review of a facility policy titled, Menu Planning, dated 1/1/2019 indicated, .The Large Portion diet provides for the normal nutritional needs of residents .Additional servings of basic foods and other foods such as fats, sugars, and sweets are added to complete the menu and meet caloric needs of the individual .Meat .at least 6 meat or meat alternatives .Fruits and Vegetables .5 or more servings . 5. During an observation ,on 1/8/25 at 12:10 PM, of the lunch tray line, plates were prepared for residents with an ordered CCHO diet. Kitchen staff placed Asian [NAME] Rice on the plates using a #10 (3/8 cup) scoop. During an interview on 1/9/25, at 11:29 AM, with the Dietary Aide (DA) 1, DA 1 stated during tray line the spreadsheet with serving sizes should be followed. DA 1 stated the #8 (1/2 cup) scoop was to be used to serve the starch for residents on a regular diet, not for those requiring controlled carbohydrates. A review of the facility document titled, Daily [NAME] Menu Meal: Noon, for the meal served on 1/8/25, indicated the portion size for residents requiring CCHO was a #12 scoop (1/3 cup) of Asian [NAME] Rice. 6. During a concurrent observation and interview on 1/8/25, at 12:10 PM, during the lunch tray line, staff prepared the trays for residents with an ordered fortified diet. No items were added to provide additional calories. The Registered Dietician (RD) confirmed the findings and asked DA 2 to call out to the cook when making trays, however the fortified diets continued to be prepared without additional calories. During an interview on 1/9/25, at 12:11 PM, with the DSS, the DSS confirmed the residents on a Fortified diet did not receive their lunch as ordered. The DSS stated this did not meet his expectations. A review of a facility document titled, Fortified Diet, dated 2017, indicated, The Fortified diet provides nutrient dense foods for residents requiring extra protein and calories who are unable to consume adequate amounts of food .Additional servings of basic foods and other foods such as fats, sugars, and sweets are added to complete the menu and meet the caloric needs of the individual .

Based on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 94 residents who ate facility prepared meals when: 1. Stove and oven contained grease, build-up of food particles, and white, black, and brown colored grimy areas; 2. Over-ripe and spoiled produce was available for use in the walk-in refrigerator; 3. Food was stored in the refrigerator beyond the use by date (UBD) and food marked on the box Keep Frozen was stored in the refrigerator; 4. Food was not stored and maintained at the proper temperatures in the walk-in refrigerator and walk-in freezer; 5. Food was not stored and maintained at the proper temperatures at the East Station refrigerator designated as Unit Refrigerator/Resident Outside Food and freezer temperatures were not monitored; 6. Unit Refrigerator/Freezer located at the [NAME] Station was not clean and was broken with missing parts. Resident food inside the refrigerator was not labeled properly, and freezer temperatures were not monitored; 7. A visibly ill employee was preparing food for use and was not performing hand hygiene after coughing into hands; and, 8. Unwashed mushrooms with visible dirt was prepared and served. These failures placed residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 1/7/25, at 7:57 AM, with the Lead Cook/Dietary Aid (DA) 1, the stove was noted to have layered black, white, and yellow debris with various types of food particles. The silver-colored back portion of the stove had a dark brown substance that appeared to be dripping down toward the stove burners. Below the stove the two-compartment oven was observed with aluminum foil on the bottom of each compartment and layers of splattered drippings and food particles that were tan, white, brown, and black found inside ovens. The side of the oven/stove was observed to have layers of a dark liquid type of substance. DA 1 confirmed the oven and stove were not clean. DA 1 stated the stove and oven were usually cleaned weekly but due to staffing they had not been cleaned on schedule. DA 1 further stated it was last cleaned the week of 12/9/24 - 12/15/24 and should be cleaned weekly. During a concurrent interview and record review on 1/7/25, at 9:07 AM, with the Dietary Service Supervisor (DSS), the DSS confirmed the stove and oven was not clean and did not meet his expectation. The DSS obtained and reviewed the cleaning log for the kitchen. The DSS further stated the stove, and oven was supposed to be cleaned weekly and was last cleaned on 12/9/24 according to the log titled Daily Cleaning Schedule. The DSS further stated it was not cleaned on schedule due to staffing issues. Review of the facility policy titled, Infection Control -Principles of Sanitation, revised 1/19, indicated, .the purpose of sanitation is to remove soil .the most common of soils - dirt, grease, food particles, etc .Follow proper sanitary procedures in cleaning equipment . Review of the facility policy titled, Infection Control -Cleaning Procedure -Range, revised 1/19, indicated, .Range .Person responsible for cleaning: [NAME] .When to clean: Weekly . Review of the FDA 2022 Food Code, under section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated, .(A) Equipment Food-Contact surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris 2. During the initial kitchen tour on 1/7/25, at 8:24 AM, the walk-in refrigerator had the following items observed available for use. The findings were confirmed with the DSS: a. 10 of approximately 75 tomatoes were mushy to touch, had broken skin, and had a fuzzy black and green substance on them. b. 4 of approximately 30 lemons were discolored, noted to be decreased size and had a white and green fuzzy substance on them. c. 3 of approximately 50 oranges had a black and green fuzzy substance on the stems, and brown spots on them. 3. During the initial kitchen tour on 1/7/25, at 8:24 AM, the following items were observed stored in the walk-in refrigerator. The findings were confirmed with the DSS: a. A left over cherry pie dated 12/29/24 was available for use. The DSS stated it should have been disposed of after three days. b. An opened box of Garlic Texas Toast and an unopened box of breadsticks which stated Keep Frozen was observed in the refrigerator. The box was not labeled with a date when it was removed from the freezer. c. One large clear container labeled marinara sauce with a UBD of 12/30/24 - 1/2/25 was observed in the refrigerator. d. One large clear container labeled cranberry sauce with a UBD of 11/24/24 was observed in the refrigerator. During an interview on 1/9/25, at 1:35 PM, with the Registered Dietician (RD), the RD stated the status of the over ripe, mushy, tomatoes, lemons and oranges did not meet his expectations. The RD further stated the foods in the refrigerator which were over ripe or were past the UBD, and foods that were labeled to keep frozen and not dated with the removed date from the freezer, were not safe for consumption. The RD explained the risk to the residents was foodborne illness. Review of the facility policy, Food Management Services -Dining Services, revised 1/19, indicated, .All food items in refrigerators are properly dated, labeled .Once opened, frozen food is dated, labeled, and wrapped .Frozen food will be cooked from the frozen state unless thawing is necessary .Canned fruits, vegetables, and juices are not stored in open cans. After opening, the food is transferred to non-corrosive containers with tight fitting lids, dated and labeled. Discard after 72 hours .Sort stored produce regularly and discard any damaged or spoiled pieces .Sort stored produce regularly and discard any damaged or spoiled pieces . Review of The Food and Drug Administration (FDA) Food Code 2022, under section 3-501.17 (A) (B) (C) (D), indicated, .the day the original container was opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . (https://www.fda.gov/media/164194/download) 4. During the initial kitchen tour on 1/7/25, at 8:23 AM, the following temperatures were observed for the walk-in refrigerator and the walk-in freezer. All findings were confirmed with the DSS. a. On 1/7/25, at 8:23 AM, the external thermometer of the walk-in refrigerator read: 42 degrees Fahrenheit (F - a unit of temperature measure). The internal thermometer of the walk-in refrigerator read: 44 degrees F. (Normal refrigerator temperature 32-41 degrees) b. On 1/7/25, at 8:35 AM, the external thermometer of the walk-in freezer read: 8 degrees F. The internal thermometer of the walk-in freezer read: 6 degrees F. (Normal freezer temperature 0 degrees or below) c. On 1/7/25, 9:13 AM, a subsequent observation of the external thermometer of the walk-in refrigerator read: 44 degrees F. The internal thermometer of the walk-in refrigerator read: 46 degrees F. d. On 1/8/25, at 3:02 PM, a follow-up observation of the external thermometer of the walk-in refrigerator read: 44 degrees F. The internal thermometer read: 44 degrees F. e. On 1/8/25, at 3:03 PM, a third observation of the external thermometer of the walk-in freezer read: 10 degrees F. The internal thermometer read: 6 degrees F. During an observation and interview on 1/8/25, at 3:01 PM, with the DSS, the DSS confirmed the temperatures were still out of safe food storage range and stated the commercial walk-in refrigerator and freezer maintenance company was contacted and was coming out to see why the temperatures were out of range. During an interview on 1/8/25, at 4:18 PM, with the Maintenance Service Director, the MSD stated the servicing agency had to calibrate the refrigerator and freezer condensers to activate at a 2-degree difference rather than the 5 to 10 degrees difference the condensers were set to. The MSD also stated the sensor probe thermometer for the freezer was in the far back behind a box and was not open to free-flowing air. During an interview on 1/9/25, at 1:35 PM, the RD stated the walk-in refrigerator and walk-in freezer temperatures did not meet his expectation and needed to be in the required temperature ranges. The RD further explained the risk to the residents was spoiled food that can cause foodborne illness. Review of the facility policy Food Service Management -Perishable Storage, revised 1/19, indicated, .The refrigerator is maintained in a temperature range of 34 degrees to 41 degrees F .A thermometer is displayed in each refrigerator and freezer . Review of an online document published by the Center for Disease Control (CDC) titled, About Four Steps to Food Safety, dated 4/24, indicated, .Keep your refrigerator at 40 degrees F or below and your freezer at 0 degrees F or below . https://www.cdc.gov/food-safety/prevention/index.html#:~:text=Bacteria%20can%20multiply%20rapidly%20if,food%20that%20reach%20room%20temperature 5. During observations of the unit refrigerator and freezer located at the East Nurse station, in a room labeled Oxygen Supply, on 1/8/25, at 12:52 PM, the following was observed and confirmed by the DSS and Assistant Administrator (AADM): a. Temperature in the refrigerator was out of range reading 55 degrees F. b. No temperature monitoring or log for the freezer. c. No thermometer inside the freezer. During an interview on 1/8/25, at 12:55 PM, the DSS observed and confirmed the temperature at 55 degrees F, was unsafe and out of range. The DSS and AADM confirmed there was no thermometer inside the freezer and no monitoring or log of monitoring of the freezer temperature. The DSS stated nursing was responsible to monitor and log the temperatures for the unit refrigerators and freezers. The DSS and AADM also confirmed a singular ice cream sandwich was unlabeled and undated inside the freezer. The DSS stated it should have the residents name and date labeled on it. During an interview on 1/9/25, at 1:35 PM, the RD stated temperature of the East Station unit refrigerator did not meet expectations. The RD further stated the risk to the residents was foodborne illness. The RD stated it was best practice to monitor the freezer temperature with a thermometer. During an interview on 1/10/25, at 12:14 PM, with the Director of Nursing (DON), the DON stated it was the expectation for food to always be labeled with resident name and date received prior to going into the unit/resident refrigerators. The DON explained nurses check the unit refrigerators and freezers, but they did not monitor the freezer temperature. The DON expected monitoring of the unit's refrigerator and freezer temperatures. The DON further stated the temperature of the East unit refrigerator was not acceptable because it was too warm. The DON explained food was expected to be thrown out after three days to prevent foodborne illness. Review of the facility policy titled, Menu Planning -Food from Outside Source, revised 1/18, indicated, .hold or transport foods containing perishable ingredients at 41 degrees F or less . Review of the facility policy titled, Food Service Management -Perishable Storage, revised 1/19, indicated, .The refrigerator is maintained in a temperature range of 34 degrees F to 41 degrees F .A thermometer is displayed in each refrigerator and each freezer .The temperature of all cold storage equipment is checked and recorded daily .all food items in refrigerators are properly dated, labeled . 6. During observations of the unit refrigerators and freezer located at the [NAME] Nurse station in a room labeled Utility on 1/8/25, at 12:59 PM, the following items were observed and confirmed by the DSS: a. No temperature log for temperature monitoring posted for the freezer. b. The freezer contained approximately 15 frozen TV dinners which were not labeled with the received date. A poster on the door to the refrigerator indicated, .Residents food needs to have name and date . c. The refrigerator and freezer were not clean with splattered unidentifiable brown liquid, multiple layers of food particles, dirt, caked on debris and hair observed inside the refrigerator and freezer. d. The refrigerator had a broken shelf with missing parts, and the freezer had a broken piece of plastic inside the door. During an interview on 1/8/25, at 12:59 PM, the DSS confirmed the unit refrigerator and freezer located at the [NAME] Nurse station utility room was dirty and needed to be cleaned. The DSS confirmed the resident food in the freezer was not labeled properly, missing the date. The DSS confirmed there were missing and broken pieces of the refrigerator and freezer. The DSS stated he did not see a log monitoring the freezer temperatures and explained nursing staff was responsible for monitoring and cleaning the unit refrigerator and freezers. During an interview on 1/9/25, at 1:35 PM, the RD stated the dirty unit refrigerator and freezer should be cleaned and does not meet expectations due to the risk for foodborne illness to the residents. The RD stated it was best practice to monitor the freezer temperature with a thermometer. During an interview on 1/9/25, at 3:18 PM, the MSD stated the refrigerator and freezers were supposed to be cleaned by the janitor once a week, but no longer than two weeks. The cleaning process for the unit refrigerators and freezers included a food safe cleanser, where all the shelves and surface areas were cleansed. The MSD confirmed the dirty unit refrigerator at the [NAME] Nurses station does not meet expectations. The MSD further stated the dirt and debris in it could cause contamination. During an interview on 1/10/25, at 12:14 PM, with the Director of Nursing (DON), the DON stated it was the expectation for food in the unit refrigerator and freezer to be labeled with resident name and date received. The DON explained nurses check the unit refrigerators and freezers, but they did not monitor the freezer temperature. The DON expects monitoring of the refrigerator and freezer temperatures and stated monitoring was important to prevent spoiled food, especially foods that need to be frozen. Review of the facility policy titled, Daily Cleaning Schedule, dated 12/9/24 to 12/15/24, indicated .Item: Reach in Fridge .Reach in Freezer .Frequency .Daily . Review of the facility policy titled, Food Service Management -Perishable Storage, revised 1/19, indicated, .A thermometer is displayed in each refrigerator and each freezer .The temperature of all cold storage equipment is checked and recorded daily .all food items in refrigerators are properly dated, labeled . Review of the facility policy titled, Food Service Management -Equipment Maintenance, revised 1/19, indicated, .The Dining Services Director will periodically check all equipment and report items needing repair to the maintenance .The maintenance department routinely monitors all equipment for proper functioning and safety . Review of the FDA 2022 Food Code, under section 4-601.11, indicated, .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, version 1/23, indicated, (A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . 7. During observation and interview on 1/8/25, at 9:20 AM, DA 1 was observed with red eyes, coughing, and runny nose while preparing the residents lunch meal. DA 1 stated she did not feel well today still. DA 1 was observed coughing into her hands. DA 1 stated she became ill last week and was taken off work by her doctor for three days and put on antibiotics. DA 1 further stated they were currently short staffed in the kitchen. DA 1 was observed touching her eyes and eyeglasses while sniffling, DA 1 did not wash her hands after touching her face or personal items and continued food preparation. During an interview on 1/8/25, at 9:54 AM, the DSS was advised by DA 1 she did not feel well. The DSS stated he would move DA 1 to another area of the kitchen. During a follow up interview with the DSS on 1/9/25, at 12:10 PM, the DSS stated they did not have a kitchen sick policy, they left it up to the individual staff member to self-screen. During an interview on 1/9/25, at 8:05 AM, with the Infection Preventionist (IP), the IP stated it was her expectation for staff who work in the kitchen and prepare food to use their own judgement regarding coming to work. The IP further stated if they were showing signs of illness like coughing, sneezing, runny nose to test for Covid and to not show up to work sick. The IP further explained it was important for staff to follow protocol and guidelines for hand washing, it was important because it lowered the risk for residents and staff getting sick, and then being short staffed. Review of facility policy titled, Infection Control -Dining Services Employee Health Standards, revised 1/19, indicated, .Each dining services employee shall report the information about their health and activities as it relates to diseases that are transmissible through food in a manner that allows the Dining Services Director (DSD) to reduce the risk of foodborne disease transmission .Proper hand washing procedures .The PIC [person in charge] must understand the requirements for excluding and reinstating food employees who work with food and with highly susceptible populations with increased risk .older adults with compromised immune systems .According to FDA Food Code, food establishments in health care .nursing homes .are required to take additional precautions to prevent the transmission of foodborne illness . Review of the FDA 2022 Food Code, under Section 2-401.12, titled, Food Contamination Prevention, indicated, .Food employees experiencing persistent sneezing, coughing, or a runny nose that causes discharges from the eyes, nose, or mouth may not work with exposed food . Review of the FDA 2022 Food Code, under Section 2-301.14, titled, When to Wash, indicated, .(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms .(D) Except as specified in 2-401.11(B), after coughing, sneezing .(I) After engaging in other activities that contaminate the hands . 8. During an observation and interview in the kitchen on 1/8/25, at 9:20 AM, DA 1 was observed preparing mushrooms from a cardboard box. The mushrooms had visible layers of dark brown dirt particles. DA 1 stated she diced them and planned to wash them after they were diced. At 10:25 AM the unwashed diced mushrooms were observed being added to the beef mixture on the stove by the DSS. During an interview on 1/9/25, at 11:29 AM, DA 1 stated the mushrooms were supposed to be washed prior to being cut. DA 1 explained she forgot to tell the DSS she did not wash them. During an interview on 1/9/25, at 12:11 PM, the DSS stated the unwashed mushrooms did not meet his expectation. The DSS further stated all fruits and vegetables should be washed prior to being prepared. During an interview on 1/9/25, at 1:35 PM, the RD stated the expectation was for the produce to be fully washed prior to resident consumption. Review of the facility policy titled, Food Service Management -Refer to Food Preparation-General, revised 1/19, indicated, .Wash all vegetables in cold water and chill before preparing. Use only vegetables in good condition . Review of the FDA Food Code 2022, under Section 3-302.15 indicated, .Washing fruits and vegetables .raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption .

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when: 1. Licensed Nurse (LN) 1 did not wear the required personal protective equipment (PPE -gown, gloves, eye protection, and/or facemasks used to prevent the spread of germs) for Resident 72 on Enhanced Barrier Precautions (EBP - infection control intervention to reduce transmission of resistant germs through gown and glove use during high-contact resident care activities) while providing gastrostomy tube (G-tube - a feeding tube that was surgically inserted into the resident's stomach to allow access for food, fluids, and medications) care; 2. A sterile wound dressing was stored open in a treatment cart; 3. Resident 89's room did not have an EBP sign posted, and the PPE supplies were not available outside the door to the room; and, 4. LN 9 did not wear the appropriate PPE when accessing a peripherally inserted central catheter (PICC- a tube inserted into a vein and guided into a large vein above the heart, used to administer intravenous medication) for Resident 77. These failures had the potential to spread infection and cause health problems to the residents in the facility. Findings: 1. During a concurrent observation and interview on 1/7/25, at 12:11 PM, in Resident 72's room, LN 1 was observed preparing to care for Resident 72's G-tube. LN 1 entered Resident 72's room, washed her hands, applied gloves, and began the procedure. After the procedure, LN 1 removed her gloves and was shown the sign posted on the door that indicated EBP Isolation. LN 1 confirmed she did not wear the required PPE when she cared for Resident 72's G-tube. LN 1 stated they were supposed to wear a gown and gloves when caring for G-tubes to prevent infection. During an interview on 1/9/25, at 8:05 AM, with the Infection Preventionist (IP), the IP stated the expectation was for staff to wear the required PPE while they rendered care to the residents. The IP explained the purpose for PPE was to prevent the transmission of bacteria from staff to resident, or from resident to staff. The IP further stated it was important for staff to follow guidelines to prevent the spread of infection. During an interview on 1/10/25, at 7:53 AM, with the Director of Nursing (DON), the DON stated her expectation was for the staff to wear the required PPE when providing care to residents with G-tubes and other indwelling devices (relating to a device that is left inside the body, such as a tube). The DON further stated the risk to residents and staff was cross- contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). The DON explained it was important to wear PPE to prevent infection and the spread of multi-drug resistant organisms (MDRO- infections that are resistant to three or more drugs that kill infections). Review of the facility policy and procedure (P&P) titled, Enhanced Barrier Precautions, implemented 4/24, indicated, .refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .For all residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: feeding tube . 2. During a concurrent observation and interview on 1/8/25, at 11:35 a.m., with LN 7 at the [NAME] Unit Treatment Cart, an opened [Brand Name] sterile dressing package was found in the second drawer of the treatment cart. LN 7 stated that she opened the package and prepped to do a dressing change on a resident, but the resident went to take a shower. LN 7 further stated the dressing should have been discarded. LN 7 explained that if the opened dressing was used to do a resident wound dressing change, the risk was infection because the dressing was not sterile. LN 7 then discarded the opened dressing. During an interview on 1/9/25, at 8:24 a.m., with the IP, the IP stated staff followed EBP guidelines during wound care. The IP further stated that opened dressings should be discarded (thrown away) if not used. During an interview on 1/9/25, at 10:58 a.m., with the DON, the DON stated the expectation was that when wound care was done, staff would throw away any opened dressings that were unused. The DON stated the risk of using opened dressings for wound care was infection by cross- contamination. The DON confirmed the facility policy was not followed. A review of the facility P&P titled, Dressing Change Clean-Aseptic, dated December 2024, indicated, .15. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface .25. Discard disposable items . A review of the facility P&P titled, Infection Prevention and Control Program, revised 10/24/22, indicated, .the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements . Review of the online manufacturer instructions for [Brand Name] titled, [Brand Name] Waterproof Foam Island Dressing for Senior Care Facilities, indicated, .Waterproof Bordered Foam Dressing .sterile unless opened or damaged . http://dermarite.com/product/bordered-foam/ A review of an online document published by the Centers for Disease Control and Prevention (CDC) titled, Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings Module 8: Wound Care Facilitator Guide, last updated 4/12/24, indicated, .Any unused disposable supplies that enter the patient's/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area .If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident (e.g., in a designated cabinet in the patient/resident's room) . https://www.cdc.gov/healthcare-associated-infections/php/toolkit/icar.html 3. A review of Resident 89's ADMISSION RECORD, indicated Resident 89 was admitted to the facility in 2024 with diagnoses which included end stage renal disease (a condition when the kidneys have completely stopped working) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). Review of Resident 89's care plans, initiated on 1/4/25, indicated .Enhanced Barrier Precaution Related to PERMACATH RUC .Goal .Will minimize risk and complications of infection .Interventions .Promote proper EBP signage .Health Teaching to resident, family members and staff about importance of Enhanced Barrier Precaution including proper hand hygiene and wearing of personal protective equipment (PPE) during high-contact resident activities . A review of Resident 89's orders, dated 1/6/25, indicated .Enhanced Barrier Protection due to PERMACATH RUC [right upper chest] every shift . During a concurrent observation and interview on 1/10/25, at 11:44 AM, with Certified Nurse Assistant (CNA) 2, CNA 2 confirmed Resident 89's door did not have a sign for EBP. CNA 2 further stated that she did not wear gloves or any PPE when she changed or assisted Resident 89. CNA 2 stated that she was never told by staff to take any EBP precautions when taking care of Resident 89. CNA 2 explained that a resident without EBP in place would be at risk of getting infections and cross- contamination if EBP were not followed. During a concurrent observation, interview, and record review on 1/10/25, at 11:55 AM, with LN 3 outside Resident 89's room, LN 3 confirmed there was no signage posted on Resident 89's door for EBP. LN 3 further confirmed the PPE bin was currently located inside; in the middle of Resident 89's room. LN 3 stated Resident 89's EBP sign should have been posted on the door and the PPE bin needed to be placed outside of the resident's room by the doorway. LN 3 acknowledged Resident 89's had an order for EBP due to his permacath. LN 3 stated that if EBP were not in place then Resident 89 would be at risk of infection. LN 3 further stated that hand hygiene and PPE were important to avoid cross- contamination and infection. During an interview on 1/10/25, at 12:03 PM, with the IP, the IP stated that EBP was mainly in place for residents with indwelling devices (medical device, such as a tube or catheter, that is inserted into the body and left there for a period of time to drain fluids or deliver medication), chronic (long term) open wounds, catheters, G-tubes, PICC lines, wound vac (a treatment that uses suction to help wounds heal) and exposed dialysis ports. The IP further stated Resident 89 was the only resident with a permacath in the facility. The IP explained if a resident was on EBP then the EBP sign should be posted on the door. The IP stated if a resident was on isolation, the PPE supplies should be placed outside of the resident's room near the door. The IP further stated she expected staff to follow the guidelines for EBP. During on 1/10/25, at 12:41 PM, with the DON, the DON stated if an order for EBP was in place then there should have been signage for EBP placed on the resident's door. The DON further stated the PPE bin needed to be close to the door for staff to wear PPE upon seeing the EBP sign. The DON stated the risk of not following the EBP was the potential for infection and cross- contamination due to Resident 89 having an exposed dialysis port. The DON stated all staff members who took care of Resident 89 should have been aware of the EBP order in place and should have followed the precautions. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 4/1/24, indicated .Purpose .to ensure the use of Enhanced Barrier Precautions as required in the care of residents .Procedure .EBP are used in conjunction with standard precautions and expand the use of PPE to donning [to put on] of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .VIII. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: A. Dressing .B. Bathing/showering .C. Transferring .F. Changing briefs or assisting with toileting . Review of an online document published by the Centers for Disease Control (CDC) titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, indicated .When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies .Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) .For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .Make PPE, including gowns and gloves, available immediately outside of the resident room . https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html 4. During a concurrent observation and interview on 1/8/25, at 11:40 AM, with LN 9 in Resident 77's room, an EBP sign was posted on the door. LN 9 was observed accessing Resident 77's PICC line wearing a mask and gloves. After accessing the PICC line, LN 9 removed her gloves and washed her hands. LN 9 was shown the EBP sign posted on the door which indicated, .ANYONE PARTICIPATING IN ANY OF THESE SIX MOMENTS MUST ALSO: DON [put on] GOWN .caring for devices and giving medical treatments . LN 9 stated she was supposed to have worn a gown when accessing Resident 77's PICC line. LN 9 specified the risk of not wearing correct PPE was cross- contamination to other residents and staff. LN 9 confirmed she did not wear the required PPE when accessing Resident 77's PICC line. During an interview on 01/9/25, at 8:12 AM, with the IP, the IP stated staff should wear gown and gloves when accessing a PICC line. The IP further stated the risk of not following EBP guidelines was transmitting infection to other residents and staff. A review of the facility policy titled, Infection Prevention and Control Program, revised 11/10/21, indicated, .Infection Control Policies and Procedures .Prevent, detect, investigate, and control infections in the Facility .Prevent the further spread of infection . A review of the facility policy titled, Enhanced Barrier Precautions, implemented 4/24, indicated, .EBP .expand the use of PPE to donning of gown and gloves during high-contact resident care activities .are indicated for residents with any of the following .indwelling medical devices .Indwelling medical device examples include central lines .EBP should be used for any residents who meet the above criteria .

Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) was followed based on facility policy and national standards for a resident census of 104 when: 1. McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) was not followed for prescribing antibiotic(s) for Resident 31; and, 2. Antibiotic outcomes (the result of antibiotic use for the infection) were not measured. During a concurrent interview and record review on 1/9/25, at 3:17 PM, with the Infection Preventionist (IP), an ASP spreadsheet titled, ANTIBIOTIC/INFECTION SURVEILLANCE, dated 12/24, was reviewed. The IP stated the spreadsheet was maintained by adding residents' names and information to the document when residents were prescribed antibiotics. The IP further stated McGeer Criteria was used for infection surveillance (the systematic collection, analysis [detailed examination of the elements of something], and interpretation of data about infections). The IP confirmed all 28 boxes (for each line corresponding to a resident's name) under the heading Met McGeer Criteria and Physician Justification for Prescribing were marked. The IP confirmed 11 boxes were marked under the column heading Diagnostic Tests Ordered. The spreadsheet logged the name of residents' admitted (date resident admitted to the facility), onset date (the date infection was noticed), date ordered (the date of the antibiotic order), Antibiotic Name/Dose/Route/Days (antibiotic order details). The log did not consistently include the duration of the antibiotic (or total days of antibiotic therapy) for every antibiotic ordered, did not include the date of Diagnostic Tests Ordered (a biological sample sent to a laboratory to determine the type of germ causing the infection), and did not include an outcome (tracking antibiotic prescribing, side effects, and resistance patterns) or stop date for the antibiotic. The IP stated the duration (how long a medication should be taken) of antibiotic therapy was not consistently documented as it was specified by a doctor as part of the medication order. The IP stated she did not monitor for outcome of antibiotic use. The IP stated this information used to be part of the spreadsheet specified in the facility's ASP (IC - 02 - Form B - Antibiotic Tracking Sheet) but was no longer included on the spreadsheet currently in use. During a concurrent interview and record review on 1/9/25, at 3:17 PM, with the IP, an Infection Prevention and Control Summary Record, dated 1/2/25, was reviewed. The Infection Prevention and Control Summary Record indicated .Number of total infections .28 .Number of infections cultured (a biological sample sent to a laboratory to determine the type of germ causing the infection): 6 . During a concurrent interview and record review on 1/9/25, at 3:17 PM, with the IP, Resident 31's Antibiotic Surveillance - UTI [urinary tract infection-an infection in any part of the urinary system] (Without Catheter [a tube inserted into the bladder to drain urine]), assessment form was reviewed in the facility's computer system. The IP stated the Antibiotic Surveillance assessment form indicated two criteria for infection must be met to meet McGeer Criteria. The IP confirmed Resident 31's assessment indicated she had met both required criteria, having signs and symptoms of an infection and a positive laboratory culture, but no laboratory specimen was sent out for testing. During a concurrent interview and record review on 1/10/25, at 9:35 AM, with the IP, an ASP spreadsheet titled, ANTIBIOTIC/INFECTION SURVEILLANCE, dated 1/2/25, was reviewed for Resident 31. The IP stated no outcome monitoring was documented. The IP stated a specimen was not collected for this course of antibiotics even though Met McGeer Criteria was marked on the spreadsheet. The IP stated the McGeer Criteria marked as met on the spreadsheet was marked in error. The IP confirmed outcomes or follow-up activity responses for antibiotic use was not currently followed in the facility. During an interview on 1/13/25, at 10:15 AM, with the Pharmacist Consultant (PC), the PC stated diagnostic tests needed to be done when antibiotics were prescribed because if not done, it could lead to antibiotic resistance (when bacteria or other microorganisms develop the ability to survive antibiotics or other drugs that are used to treat them). The PC stated drugs (antibiotics) were becoming so resistant new drugs (antibiotics) could not be created fast enough; the bacteria were evolving and adapting faster than new medication could be made, leading to Multiple Drug Resistant Organisms (MDRO - a microorganism that is resistant to multiple antibiotics increasing risk of a more severe infection). The PC stated if the facility was not ordering culture and sensitivity (a laboratory test that checks for bacteria and determines which antibiotics will best treat the infection) laboratory tests when prescribing antibiotic medication they may be prescribing the incorrect medication. The PC confirmed if he did not see the laboratory results for culture and sensitivity testing (when antibiotics are prescribed), he would say the facility was out of compliance with the McGeer criteria. Review of a facility policy titled, Antibiotic Stewardship Program, revised 1/1/17, indicated, .Purpose .To limit antibiotic resistance in the post-acute care setting, improve treatment efficacy and resident safety .Policy .designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use .The IP will collect and analyze infection surveillance data and monitor the adherence to the ASP .Recommendations will be communicated to the Attending Physician .Tracking .The IP will be responsible for infection surveillance and MDRO tracking .The IP will utilize IC - 02 - Form B - Antibiotic Tracking Sheet .The IP will measure and report outcomes and success rate at monthly/quarterly ICC meetings . Review of a facility policy titled, Antibiotic Stewardship Interventions revised 1/17 indicated, .Broad Interventions .All clinicians should perform a review of antibiotics 48 hours after antibiotics are initiated to answer these key questions .Does this patient have an infection that will respond to antibiotics .is the patient on the right antibiotics .Can a more targeted antibiotic be used to treat the infection (de-escalate) .Infection and Syndrome Specific Interventions .Urinary Tract Infections (UTI's) .Many patients who get antibiotics for UTI's actually have asymptomatic [without symptoms] bacteriuria [presence of bacteria in urine] and not infections . Review of an online document published by the Centers for Disease Control and Prevention (CDC) in 2015, titled, Core Elements of Antibiotic Stewardship for Nursing Homes indicated, . Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics [antibiotics that are taken to treat infections throughout the body] when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate .Harms from antibiotic overuse are significant for the frail and older adults receiving care .These harms include risk of serious diarrheal infections from Clostridium difficile (a bacteria that causes diarrhea and inflammation of the colon-the longest part of the large intestines, which is an organ in the digestive system) increased adverse drug events (harm caused by appropriate or inappropriate use of a drug) and drug interactions (a change in the way a drug acts in the body when taken with certain other drugs), and colonization (when bacteria are present on or inside a person's body, growing and multiplying, but without causing any noticeable symptoms or illness) and/or infection with antibiotic-resistant organisms . (https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf)

Based on interview and document review, the facility failed to provide required nutrition and hydration care and/or services to five of 14 sampled Residents (Residents 1, 2, 3, 4 and 5) when: 1) Resident 1's initial plan of care did not include specific interventions to prevent weight loss and dehydration, known from his medical history to be risks for the resident, 2) After a severe weight loss of more than 15 pounds (6.9% of his previous weight) in a week, Resident 1 was not assessed by nurses in a timely manner and the physician was not promptly notified, 3) Plan of care interventions were not implemented or reassessed to prevent further weight loss and decline, contributing to an additional loss of 20 pounds (9.7% of Resident 1's previous weight), and 4) Following the identification of severe weight loss for Residents 1, 2, 3, 4 and 5, written care plans were not personalized and lacked parameters and identified timeframes for the evaluation or the success of interventions. These failures contributed to severe weight loss for Resident 1, the potential for inadequate nutritional intake resulting in significant health problems for Residents 2, 3, 4 and 5, and possible significant harm up to and including the death of residents. Findings: 1) Review of the Admission Record indicated Resident 1 came to the facility on [DATE] with [DIAGNOSES REDACTED]., weight loss, increased fatigue and progressive functional decline), Stage 2 pressure injury (wound caused by unrelieved pressure resulting in damage to underlying tissue; a Stage 2 wound involves partial thickness skin loss with an inner skin layer exposed), muscle weakness, and depression. Additionally, he was diagnosed with [REDACTED]. Resident 1 was being treated with medications which cause fluid loss including [MEDICATION NAME] and as-needed [MEDICATION NAME]. 1A) Review of Resident 1's initial care plan reflected a 6/21/20 intervention for Dietary consult (consultation by an RD- Registered Dietitian) and other actions as follows: Monitor meal intake. Date Initiated: 6/20/20, Diet as ordered and monitor % of intake and appetite. Date Initiated: 6/21/10, Encourage fluid intake and meal intake. Date Initiated: 6/21/20, Encourage fluids as tolerated if not contraindicated. Date Initiated: 6/21/20, Monitor for poor appetite/intake and notify MD (Medical Doctor) PRN (as needed). Date Initiated: 6/21/20, Monitor/document/report to MD PRN for .weight loss .Date Initiated: 6/21/20, Monitor Weight and notify MD of significant weight changes. Date Initiated: 6/21/20, Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications (medications used to treat thought disorder processes or alter behavior): refusal to eat .loss of appetite, weight loss .Date Initiated: 6/21/20, and Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Date Initiated: 6/22/20. The initial care plan did not include specific guidelines for identifying the presence of a problem with appetite, meal intake or weight loss, or when and how staff should intervene for suspected problems, including physician notification and the frequency of weights. The facility's RD initially assessed Resident 1 on 6/26/20. In the 11:11 a.m., 6/26/20 initial Nutritional Risk Assessment, the RD noted in the Identification of Risk Factors section that prior to his admission, Resident 1 had previously experienced an unplanned weight loss of >5% (greater than 5 per cent) in 1 month; (or) >7.5% in 3 months; (or) >10% in 6 months. The resident's Current Food and Fluid Intake was described as <50%. The Pressure Sore & (and) Other Skin Condition and Swallowing difficulties sections were marked No. Resident 1 was noted to have Nutritional Risk Related to .[MEDICAL CONDITIONS] .T2DM (Type 2 diabetes mellitus- adult onset diabetes), Depression .[MEDICAL CONDITION] .[MEDICAL CONDITION], Adult FTT, Anorexia .Generalized Muscle Weakness, Poor appetite/intake ongoing several months, reported significant weight loss. Nutritional goals included improved intake of 51 to 100% of meals taken, 2160 milliliters (ml, a unit of measure) of daily fluid intake, and no sig wt variance x 90 days (no significant weight variance for 90 days). During a 12:58 p.m., 9/8/20 interview, the RD indicated that difficulty swallowing was also a risk for developing a nutritional problem. She indicated Resident 1 was at risk for further weight loss at the time of her initial assessment. In a 1 p.m., 9/11/20 email communication, the RD calculated that Resident 1's average meal intake in the period immediately prior to her initial assessment, 6/21/20 - 6/25/20, had been only 25% and his fluid intake from meals averaged only 600 ml daily. In an 8:34 a.m., 9/9/20 interview, the RD stated she was not aware Resident 1 had been admitted with a pressure injury. The RD indicated that with pressure injuries, residents often need increased protein in the diet, multivitamins, Vitamin C, and protein supplements. In a 10:06 a.m., 9/15/20 interview, the RD confirmed that on 6/26/20 she had set a goal of 51% - 100% for Resident 1's meal intake. However, she described the intake goal range as just a reference for my progress which was not typically communicated to nursing. No additions to or changes in the nutritional care plan were noted in the record by the RD on the initial care plan. On 7/9/20, two interventions were added to Resident 1's nutritional care plan: Nutritional approaches per RD recommendations and ordered by physician, and Encourage good nutrition and hydration in order to promote healthier skin. During the 9/9/20 interview, the RD acknowledged that the initial care plan did not address Resident 1's nutritional risk. The RD noted that she could have added 'at nutritional risk' to the care plan. 2) Review of Resident 1's Weight Summary revealed a weight of 221.6 pounds on 7/6/20. On 7/12/20, his weight was measured at 206.3, a loss of 15.3# (pounds)/6.9% in one week according to 1:23 p.m., 7/16/20 IDT (Interdisciplinary Team) Progress Notes - Weight Variance & Nutritional Condition. In a 12:58 p.m., 9/8/20 interview, the RD stated this was considered a significant weight loss for Resident 1. Review of 7/12/20 to 7/16/20 Assessments, Progress Notes and Miscellaneous sections of the medical record were reviewed and reflected no further documentation of Resident 1's weight loss until the 7/16/20 IDT notes which stated, Appetite remains poor. Still with coccyx (lower back) stage 2 pressure wound. Started on health shake (a calorie-dense dietary supplement) TID (three times daily). Weekly weights and RD consult. There was no documentation indicating a review of percentages of meal intake, snacks and fluids had taken place. In addition, no plan was outlined to address possible causes of weight loss and review preferences for intake with the resident. A 1:58 p.m., 7/16/20 SBAR (Situation/Background/Assessment or Appearance/Request) - Change of Condition Progress Note documented physician notification of the weight loss. Orders were given between 1:32 p.m. - 1:45 p.m., 7/16/20 for a daily multivitamin, health shakes three times daily, Vitamin C and two dietary supplements to aid in wound healing, as well as for monitoring the percentage of Resident 1's meal intake. In a 10:06 a.m., 9/15/20 interview, the Director of Nursing (DON) confirmed the significant weight loss of 7/12/20 but was unable to locate medical record documentation indicating the physician had been notified of the change prior to 7/16/20. The DON stated that a physician should be notified of a significant weight loss as soon as you note the weight loss. The facility's 8/13/19 Assessment and Management of Resident Weights policy indicated, The DNS (Director of Nursing Services) or licensed nurse will .Notify the physician and dietitian of significant weight changes; and .Document notification in the nurses' notes The 1/1/17 Change of Condition Notification policy reflected, The Facility will promptly inform .the resident's Attending Physician .when the resident endures a significant change in their condition .The Licensed Nurse will notify the resident's Attending Physician when there is .A change in weight of five pounds or more within a 30-day period 3) After the 7/12/20 weight loss, the RD reassessed the resident on 7/17/20. In a 10:54 a.m., 7/17/20 progress note, the RD noted that Resident 1 should continue to be weighed weekly and that oral intake and weights should be monitored. During the 10:06 a.m., 9/15/20 interview, the DON confirmed that IDT intended weekly weights of Resident 1 to continue after the 7/12/20 weight loss. In the same interview, the RD confirmed her expectation that weekly weights would continue after 7/17/20 for at least an additional four weeks and until the resident was stable. Weekly weights recommended by the IDT and RD were not documented after that time, however. After the 7/12/20 weight loss, Resident 1 was next weighed on 7/19/20 with a documented measurement of 207.9 pounds. Another weight was not noted until 5:06 p.m., 8/7/20, after the Department's 12:35 p.m., 8/7/20 visit. The resident's weight was measured at 187.8 pounds, a loss of an additional 20.1 pounds (9.7% decrease since 7/19/20) later noted by the RD in a 6:45 p.m., 8/13/20 Progress Note to be a significant (severe) 15.3% weight loss over 30 days. In an 10:06 a.m., 9/15/20 interview, the DON confirmed there were no weights documented in the medical record between 7/19/20 - 8/7/20. In a 2:11 p.m., 8/13/20 interview, the RD stated she did not reassess Resident 1's nutritional status during weekly 7/24/20, 7/31/20 or 8/7/20 onsite or remote facility consultation days. During a 12:58 p.m., 9/8/20 interview, the RD indicated she did not automatically reassess residents with significant weight loss on her next facility workday the following week. She stated she would assume (resident weights) were stable if they weren't triggered on the Weight Report, a tool used by nursing leadership to identify residents with significant weight changes. The RD reflected she probably should have followed up on Resident 1 after his initial weight loss. In a 3:02 p.m., 8/21/20 interview, the DON stated it would be an expectation that after having consulted for a significant weight loss, the RD would reevaluate the following week to determine if planned interventions had been successful. In a 1:35 p.m., 8/13/20 interview, the RD stated she was not aware of the resident's second weight loss which occurred six days earlier. The RD assessed the resident soon after the interview and in a 2:11 p.m., 8/13/20 interview stated Resident 1's appetite had been variable and hadn't significantly improved since his admission. The RD identified that Resident 1 didn't like the texture of the health shakes ordered on [DATE] and that a substitution would be requested. In addition, the RD recommended additional staff assistance with the resident's meal, snack and fluid intake as needed, and increasing the frequency of Resident 1's iron and Vitamin C supplements. In a 12:58 p.m., 9/8/20 interview, the RD noted that Resident 1's intake didn't improve after the initial 7/6/20 - 7/12/20 weight loss. The RD reported, He had more refusals (of meals). He didn't like the food. The RD stated of the 7/20/20 - 8/7/20 period, There were lots of '0 - 25%s' (meals in which the resident ate less than 25% of the serving). There were lots of refusals (of meals). The RD indicated snack intake during this time included some refusals at the end of July and more refusals in early August. Supplement intake decreased with the resident refusing health shakes at the beginning of August. In a 1 p.m., 9/11/20 email communication, the RD calculated that Resident 1's meal intake between 7/20/20 - 8/7/20 averaged only 33% of the meals served and 25% of the snacks offered. On 7/16/20, Resident 1's physician ordered 4-ounce (120 ml) sugar-free health shakes, a dietary supplement, three times daily. Review of the Medication Administration Record [REDACTED]. Intake amounts were as follows: - 8/3/20, 240 ml, - 8/4/20, 120 ml, and - 8/5/20 - 8/7/20, 180 ml, During the 10:06 a.m., 9/15/20 interview, the DON was unable to find medical record documentation that the physician or RD had been notified of Resident 1's continuing poor oral intake prior to discovery of the second severe weight loss documented on 8/7/20. Review of the facility's 8/13/19 Assessment and Management of Resident Weights policy indicated, Weights are obtained upon admission .then weekly for four (4) weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT) .Significant weight changes are .5% in one (1) month .Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight .loss including goals for care .The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change 4) Review of care plans for Residents 1, 2, 3, 4, and 5 reflected failures to 1) establish monitoring parameters for nutritional care interventions, including conditions for which the licensed nurse, RD, and/or physician should be notified, and 2) set target dates by which interventions should be reevaluated for success. During an 8:34 a.m., 9/9/20 interview the RD stated that nurses and the Dietary Manager take on care planning for the most part. She added that she had the liberty to add to the care plan as needed. 4A) Following the identification of Resident 1's first severe weight loss on 7/12/20, his nutritional care plan was revised by a nurse on 7/16/20 with interventions including: - Diet as ordered (no details as to action to be taken if resident was not eating adequately, and setting the point at which action should be taken), - Snacks, (no details regarding how to monitor consumption), and - Supplements/nourishment as ordered´ (no details regarding how to monitor consumption and when/to whom to report if resident was not taking per physician order). After the second severe weight loss of 8/7/20, Resident 1's nutritional care plan reflected no RD participation until 8/18/20, when the following interventions were added: - Monitor weekly weights then qmonth (sic, every month) if stable, (no detail as to action to be taken for weight changes and at what point that action should take place), and - Offer substitute if intake < / = (less than or equal to) 75%, In an 8:34 a.m., 9/9/29 interview, the RD acknowledged she did not add to Resident's care plan until August. 2020 and stated she could have added 'at nutritional risk' to an earlier care plan. 4B) Review of Resident 2's Admission Record indicated [DIAGNOSES REDACTED]. The resident was also diagnosed with [REDACTED]. During a 9:16 a.m., 9/9/20 interview, the RD acknowledged the Weight Summary reflected Resident 2 had decreased from 157.5 pounds on 7/1/20 to 148.4 pounds (9.1 pounds) on 8/7/20. The RD confirmed that her 5:24 p.m., 8/14/20 Dietary/Nutritional Progress Note described this loss as a 5.8% decrease in one month and confirmed it was a significant weight loss. Review of the medical record reflected that after the severe weight loss was identified, nursing staff members updated the resident's nutritional care plan beginning 8/7/20. Interventions included: - Monitor for S/S (signs/symptoms) of dehydration (no guidelines for how to monitor and the action to be taken if observed), - Encourage >75% (more than 75%) intake of each meal (no guideline for what to do if intake was not >75% or how long to monitor intake before taking action), - Snacks, and - Supplements/nourishment as ordered. The nutritional care plan did not reflect RD participation. In a 9:16 a.m., 9/9/20 interview, the RD stated, It doesn't look like we .updated the care plan for the recent weight loss. 4C) The Admission Record listed dementia (a chronic [MEDICAL CONDITION] loss of brain function), [MEDICAL CONDITIONS] (sore in the stomach lining) and muscle weakness among the [DIAGNOSES REDACTED]. During a 9:20 a.m., 9/9/20 interview, the RD acknowledged Resident 3's Weight Summary reflected a decreased from 221 pounds on 7/4/20 to 208.4 pounds (12.6 pounds) on 8/7/20. The RD indicated her 7:49 a.m., 8/14/20 Dietary/Nutritional Progress Note described the loss as a 5.7% decrease in one month and confirmed it as a significant weight loss. An 8/7/20 nutritional care plan developed by nurses after the resident's severe weight loss included the following among its interventions: - Encourage >75% intake of each meal, - Snacks, and - Supplements/nourishment as ordered. The weight loss care plans did not reflect RD input until 9/10/20. In a 9:20 a.m., 9/9/20 interview, the RD indicated there were not enough interventions in the weight loss care plan and said she missed that (care plan) again. 4D) The Admission Record for Resident 4 listed [DIAGNOSES REDACTED]. The resident had a feeding tube into his stomach for a previous eating problem but the tube was not currently being used for nutrition. During a 9:25 a.m., 9/9/20 interview, the RD acknowledged the Weight Summary reflected Resident 4 had decreased from 167.1 pounds on 7/1/20 to 150.4 pounds (16.7 pounds) on 8/7/20. The RD confirmed that her 8:27a.m., 8/14/20 Dietary/Nutritional Progress Note described this 16.7 pound loss as a 10% decrease from his previous measurement and confirmed it was a significant weight loss. An 8/7/20 nutritional care plan written by nursing staff members after the resident's 8/7/20 severe weight loss reflected the following interventions: - Encourage >75% intake of each meal, and - Supplements/nourishment as ordered. The weight loss care plan did not reflect RD participation in development. During a 9:25 a.m., 9/9/20 interview, the RD stated there should have been a care plan for the resident's history of weight gain and losses. 4E) Resident 5's Admission Record noted [DIAGNOSES REDACTED]. The resident was diagnosed with [REDACTED]. In a 9:35 a.m., 9/9/20 interview, the RD acknowledged Resident 5's Weight Summary reflected a decrease from 144 pounds on 7/5/20 to 131.6 pounds (12.4 pounds) on 8/7/20. The RD indicated her 12:06 p.m., 8/14/20 Dietary/Nutritional Progress Note described this loss as a 8.6% decrease in one month and confirmed it was a significant weight loss. A care plan developed on 8/7/20 by nursing staff after Resident 5's severe weight loss of 8/7/20 included the following interventions: - Encourage >75% intake of each meal, - Snacks, and - Supplements/nourishment as ordered. There was no evidence of RD contribution to the weight loss care plan until 9/11/20. In a 9:35 a.m , 9/9/20 interview, the RD acknowledged that she could have added to the care plan. Review of the facility's 11/1/17 Care Planning policy reflected, The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing .needs .The resident has the right to receive the services and/or items included in the plan of care

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve the resident food in a sanitary manner when: 1. The walk-in refrigerator did not maintain perishable, potentially hazardous food (PHF) at a safe temperature. The unsafe food was served to the residents. 2. There was a general lack of cleanliness throughout the kitchen. 3. The ice machine was not clean and had a significant buildup of a black residue in the ice maker. 4. Three floor drains were observed to lack an air gap to prevent a backflow of waste water into the ice machine, steam table and the coffee maker. 5. The laminate finish on the cupboards and countertops was broken in multiple areas creating a surface that was not smooth and easily cleanable. 6. Resident dishware was stained and unsightly. 7. Staff personal items were stored in the resident food preparation areas. 8. Food was not stored off the ground. 9. The door from the kitchen to the outside did not maintain a seal to prevent the potential entry of pests. These failures resulted in spoiled food being served to residents. It also had the potential to cause food borne illness in residents who were medically compromised. On 8/6/13 at 4:50 p.m., the Department determined Immediate Jeopardy of residents in the facility existed related to the systemic failure of the dietary staff and the Dietary Services Supervisor (DSS) to ensure the residents' potentially hazardous refrigerated food was stored at 41 degrees Fahrenheit (F) or less to prevent the potential for food borne illness. This occurred when the walk-in refrigerator was not working, the equipment failure occurred sometime between 5:00 p.m. on 8/4/13 and 5:30 a.m. on 8/5/13 when the refrigerator temperature was 65 degrees F and the dietary staff and the DSS continued to serve the unsafe food to the residents. This put the residents at risk for food borne illness. The Department team met with the Administrator to advise him of the Immediate Jeopardy. An acceptable plan of correction that included repair of the walk-in refrigerator so that food temperatures were maintained at less than or equal to 41 degrees F and the unsafe potentially hazardous food was discarded and replaced. The Immediate Jeopardy was abated on 8/6/13 at 6:15 p.m. with the Administrator as the result of the acceptable plan of correction. Findings: 1. During an interview and tour of the kitchen on 8/6/13, at 8:30 a.m., the Dietary Services Supervisor (DSS) stated that the walk-in refrigerator was not working since the day before when the morning cook came in to work. She stated that the temperature in the refrigerator was 65 degrees Fahrenheit (F) yesterday morning. The walk-in freezer door, inside the walk-in refrigerator, was propped open so the cold air from the freezer maintained the refrigerator temperature. The temperature inside the walk-in refrigerator was 37 degrees F. The temperature inside the walk-in freezer was 20 degrees F. All the food in the freezer remained frozen solid except 2 five gallon containers of ice cream were soft, not solid. During the initial tour of the facility the same day, at 8:55 a.m., Random Resident 20 complained that she received sour milk with her breakfast. During a concurrent interview with the DSS, she confirmed that the resident was served sour milk. During an interview with Dietary Staff 1 (DS 1) the same day, at 9 a.m., she stated that she first noticed the walk-in refrigerator temperature was 65 degrees F the day before at 7:30 a.m. During a further interview with the DSS the same day, at 9 a.m., she stated that when the cook came to work at 5 a.m. the previous day, the walk-in was at 60 degrees F. Later when the DSS arrived, she threw out anything that was "open or suspect". She stated that she opened the freezer door inside the walk-in so the colder air from the freezer would keep the refrigerator cold and informed the maintenance supervisor that the refrigerator was not working. She stated that she threw out the milk that was "on top" and kept "anything with sweat on it because it was still cold." She verified that she did not take temperature of all the potentially hazardous food to ensure it was still safe. During further observation of the walk-in refrigerator the same day at 9:05 a.m., the following items were noted: a bowl of soup dated 7/31/13, 3 five pound containers of sour cream, one dated 8/2/13, and two dated 7/10/13; two boxes of hard cooked eggs dated 8/2/13; two cases of pasteurized shelled eggs dated 7/21/13 and 8/2/13; a large beef brisket, approximately 5 pounds, dated 8/2/13; a large bag of chopped salad mix, dated 8/3/13 that had turned brown and wilted; a container of chopped garlic packed in oil, undated; two 32 ounce containers of yogurt dated 7/24/13; 3 eight ounce containers of cream cheese, undated; a large bag of shredded cheese dated 8/2/13; five pounds of sliced cheese, undated; a large bag of parmesan cheese, dated 8/4/13; 5 crates of eight ounce cartons of milk; 2 cases of liquid egg; and various fresh fruits and vegetables. During a concurrent interview with the DSS, she stated that the dates on the food indicated the date it was received or the date it was opened. She further stated that all the food in the refrigerator had been delivered on or before 8/2/13. She verified that all the food in the refrigerator had been there when the refrigerator wasn't working the previous day. During a follow-up interview with the DSS the same day at 9:45 a.m., she stated that the beef brisket in the walk-in was there since 8/2/13. It was supposed to be for dinner on 8/4/13, but the cook didn't need it so it wasn't cooked. The DSS stated that she would probably cook it for dinner and serve it as the alternate menu item for the residents. During an interview with the Registered Dietitian (RD) on 8/6/13, at 1:40 p.m., she stated that she was not told that the walk-in refrigerator was not working until that morning. She wasn't told that the temperature was 65 degrees F at 5:20 a.m. on 8/5/13. She stated that the DSS had told her, "She should have thrown everything away but she would get in trouble for what it would cost to throw the food away." During an interview with the DSS the same day at 3:30 p.m., she verified that she had said this to the RD. During a follow-up interview with the DSS on 8/6/13, at 3 p.m., she stated that she threw away some of the milk on 8/5/13, but other items that were still cold to the touch and the packaging was not bulging were not discarded. She stated that she did not check the temperature of those foods. During a telephone interview with Dietary Staff 2 (DS 2) on 8/6/13, at 4:15 p.m., she stated that she was the morning cook on 8/5/13. She stated that she checked the walk-in refrigerator temperature at 5:20 a.m. and it was 65 degrees F. She further stated, "We (DS 1 and her) waited for (the DSS) to come. She came in about 7:30 a.m. We told the Maintenance Supervisor." She also stated, "We noticed the milk from the walk-in was hot so we added ice to it." She verified that they did not discard any of the food from the walk-in refrigerator before preparing and serving breakfast on 8/5/13 to the residents. She confirmed that the residents were served scrambled eggs and milk from the walk-in refrigerator that was 65 degrees F at 5:20 a.m. and was not working properly. A review of the facility's "Refrigeration Temperature Log" (dated August 2013) indicated the last temperature recorded for all the refrigerators in the kitchen was on 8/4/13 "PM". The walk-in refrigerator temperature was recorded at 39 degrees F. No temperatures were recorded for 8/5/13 and 8/6/13. During an interview with the DSS on 8/6/13, at 4:30 p.m. she verified that the PM refrigerator temperature from the log was recorded at about 4:30 or 5 p.m. on 8/4/13. She confirmed that no other refrigerator temperatures were recorded on the log after that. A review of the facility's "Daily Food Temperature Sheet" (dated 8/5/13) indicated directions to the staff that "Serving temperature for cold food items - 41 degrees F or less." It further directed the staff, "Milk/coffee hot water temps to be recorded at each meal..." The form was blank for breakfast on 8/5/13. No temperatures were recorded for the meal. There was no milk temperature recorded for lunch or dinner either. During an interview with the DSS on 8/6/13, at 4:30 p.m., she confirmed that the breakfast temperatures were not recorded on 8/5/13. She stated that they should have been recorded and that the milk temperature should have been recorded for lunch and dinner too. She confirmed that once the walk-in refrigerator stopped working, there were no documented temperatures of the potentially hazardous foods to ensure that the residents did not receive food that was unsafe and could cause food borne illness. She confirmed that 3 meals on 8/5/13 and 2 meals on 8/6/13 had been served to residents using food from the refrigerator that wasn't working overnight the previous day. A facility policy titled "Food Safety in Receiving and Storage" (dated 8/6/12) indicated the purpose of the policy was that "Food is received and stored by methods to minimize contamination and bacterial growth." It stated "Cooler and freezer temperatures will be checked 2 times daily using the internal thermometers and recorded." It further stated "The temperature of refrigerators shall be maintained at 41 degrees or below...." A facility policy titled "Safe Food Temperatures" (dated 8/6/12) indicated "All tray line food temperatures are checked and recorded on the Daily Food Temperature Sheet at the onset of each meal." 2. During the tour of the kitchen on 8/6/13, between 8:30 and 9:45 a.m., a general lack of cleanliness was observed. A white handwashing sink had a gray tint from an accumulation of dirt; the cupboards where dry cereal was stored had a significant accumulation of crumbs; 2 cupboard drawers that contained clean cooking utensils had an accumulation of crusted food debris; the microwave was not clean and contained 2 two bowls of soup from the previous day; a cupboard that contained pots and pans had drips of food on the doors and the shelf inside was dusty; the floor under the 2 compartment sink was dirty; the pipes adjacent to the stove had a build-up of grease that appeared old; the stove burners had a build-up of grease that appeared old; the ceiling vents above the stove area had an accumulation of dust and peeling paint; a cart adjacent to the stove that contained 8 gallon sized containers of liquids (such as vinegar, soy sauce, vanilla flavoring and pancake syrup) had a significant accumulation of dirt and food debris; multiple white floor drains were noted to be brown and dirty; the food shelves in the walk-in refrigerator were rusted; the floors and shelves in the dry storage room had a significant accumulation of dust and food debris; the screen door leading to the outside had an accumulation of dirt; a trash can lid adjacent to the handwashing sink was noted to have a significant accumulation of dirt and food debris; the table mounted can opener had dry and sticky debris on the cutting blade; and the floor throughout the kitchen, especially under equipment and along the walls had an accumulation of dirt and food debris. A facility policy titled "Sanitation and Infection Control in Food Service" (dated 8/6/12) indicated "The Dietary Services Director develops, implements and monitors a cleaning schedule that assigns cleaning responsibilities to specific individuals. Cleaning tasks are initialed as they are completed. The Dietary Services Director/designee will check the cleaning schedule at the end of each shift to assure assignments have been completed." During a concurrent interview with the Dietary Services Supervisor, she confirmed the findings and agreed that the kitchen was not clean. She stated that the can opener was supposed to be cleaned after each use, but verified that it didn't appear to have been clean in a while. She was unable to state why the kitchen was not clean. During a concurrent interview with the Registered Dietitian (RD), she verified that the soup in the microwave was from the previous day and that the microwave had not been cleaned since the soup was placed in it. 3. During an observation of the ice machine and concurrent interview with the Maintenance Supervisor (MS) on 8/7/13, at 2 p.m., the ice maker was not clean. A clean paper towel swipe of the ice making components produced a significant black residue and a gelatinous residue. Also noted was a significant accumulation of rust colored stain and white crusty build-up. The MS stated that he cleaned the ice machine every month. He stated that the last time it was cleaned was on 7/10/13. He said that he regularly saw the build-up of black, white and rust residue in the ice maker every month. During further interview he stated that he doesn't normally use a sanitizer. After reading the manufacturers instruction for the use of sanitizer, he stated that he sometimes got a sanitizer from a local home improvement store and used it. He was unable to state if the sanitizer was food safe or not and he could not remember the name of the product. He stated that he did not have a copy of the manufacturer's instructions for cleaning and sanitizing the ice machine. A facility policy titled "Ice Machine and Scoops" (dated 8/6/13) indicated cleaning of the ice machine monthly included a step to "Sanitize the inside with a clean cloth that has been saturated with a sanitizing solution." The policy does not direct the staff to use a food safe sanitizer. A review of the manufacturer's instruction for the use of sanitizer indicated chlorine bleach was to be mixed with warm water and poured in the water tanks. This solution was to be run through the machine's wash and drain cycle to sanitize the ice maker. 4. During a tour of the kitchen and the resident dining room adjacent to the kitchen on 8/6/13, from 8:30 through 9:45 a.m., 3 floor sink/drains were observed with pipes or hoses draining in the drains and no air gaps were maintained. The floor drain under the steam table had a drain hose from the steam table that was in the drain/sink. The floor drain under the coffee maker contained a [MEDICATION NAME] pipe from the coffee maker down in the floor drain/sink. The ice maker in the resident dining room had a pipe that was in the floor drain/sink. No air gaps were maintained on these three drains. According to the 2009 Food Code, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. An air gap is important in preventing contaminants in the drain/sink from flowing into the potable water system in the event of negative water pressure situation. During an interview with the Maintenance Supervisor on 8/8/13, at 1:30 p.m., he indicated that he did not know what an air gap was or why it was necessary. 5. During a tour of the kitchen on 8/6/13, between 8:30 and 9:45 a.m., two cupboard and food preparation countertop areas were noted to have a laminate finish that was broken and peeling in multiple areas. This resulted in these surfaces to be not smooth, nonporous and easily cleanable. Also noted was a wall adjacent to the 2 compartment sink and a wall behind the coffee maker that both appeared to have water damage and were not smooth, easily cleanable During a concurrent interview with the Registered Dietitian, she verified the observations. According to the 2009 Food Code, materials used in the construction of food contact surfaces and non-food contact surfaces must be finished to have a smooth easily cleanable surface. They must also be resistant to pitting, chipping, crazing, scratching, distortion and decomposition. It further states that food contact surfaces shall be free of breaks, open seams, cracks, chips, pits and similar imperfections. Food contact surfaces and non- food contact surfaces that don't meet these requirements provide potential harbor for foodborne pathogenic organisms. Surfaces which have such imperfections allow microorganisms to attach and form bio films which are resistant to cleaning and sanitizing efforts. 6. During a meal preparation observation on 8/7/13, at 1 p.m., several rose colored insulated plate holders were noted to be gray colored from excessive wear. The observation was concurrently verified by the Dietary Services Supervisor. She stated that the resident dishware was old and stained. According to the 2009 Food Code, equipment, food contact surfaces, non-food contact surfaces and utensils, shall be clean to sight and touch. 7. During a tour of the kitchen on 8/6/13, between 8:30 and 9:45 a.m., a decorated plastic drinking cup was noted in a cupboard stored with resident food. Also observed was a set of keys and a cellphone in another cupboard where resident food was stored in a food preparation area. During a concurrent interview with the Dietary Services Supervisor, she stated that the cup should not be there and it was an employee's personal cup. She also stated that employee personal items were supposed to be stored in the office, not in the kitchen. A facility policy titled "Kitchen Security" indicated that "Employee lockers and coats are discouraged in the kitchen storage areas. The facility's administration should make attempts to secure lockers and staff storage areas away from the Dietary Department. 8. During an observation in the kitchen on 8/6/13, at 9:15 a.m., boxes of dry food were noted on the floor by the back door. The boxes included cornbread mix and oatmeal. During a concurrent interview with the Dietary Services Supervisor, she stated that the boxes were delivered on the previous day. She stated that the staff had not put the boxes away. She verified that the food boxes should not be stored on the floor. A facility policy titled "Food Safety in Receiving and Storage" (dated 8/6/12) indicated that for "Dry Storage Guidelines: Food will be stored at least 6 inches off the floor..." 9. During an observation in the kitchen on 8/6/13, at 9:20 a.m., the door to the kitchen leading to the outside was open. A screen door was closed in its place. There was a gap in the seal at the bottom of the screen door that was a potential for pests to enter the kitchen. During a concurrent interview with the Dietary Services Supervisor, she verified that there was a gap. A facility policy titled' "Pest Control" (dated 8/6/12) stated "Gaps and cracks in doorframes and thresholds, and floor and walls are repaired." According to the 2009 Food Code, outer openings of a food establishment shall be protected against the entry of insects and rodents by: filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight-fitting windows; and solid, self-closing, tight-fitting doors.

Based on observation, interview, and record review, the facility failed to ensure an assistive device was used according to the resident's assessment and facility policy for 1 of 19 sampled residents (7). Resident 7 was transferred using a mechanical lift by a single staff member, contrary to her identified need for 2-person assistance for all transfers. This failure resulted in a fall which caused 2 fractures of the resident's upper arm bone, and partial dislocation of her arm from the shoulder, which had to be corrected under anesthesia at a hospital. Findings: Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS, an assessment tool), dated 7/28/12, described the resident as having intact cognition and requiring extensive assistance of 2 people in order to transfer. The MDS reflected the resident's weight to be 239 pounds. During the Initial Tour of the facility on 10/2/12 at 8:55 a.m. Resident 7 was observed lying in bed, her right arm was observed to be in a sling and her shoulder was observed to have extensive bruising. During a concurrent interview on 10/2/12 at 8:55 a.m. Resident 7 stated she "fell in the shower on Thursday." The resident complained of pain in her arm and hand, which had become worse over the past 24 hours, and was not relieved by the routine pain medications she had been taking prior to the injury. Review of the clinical record for Resident 7 included: - A "Physical Therapy Evaluation" dated 6/18/06 indicated the resident's "Activity Level of Function: total care, transfer from bed to chair (with) mechanical lift." - A "Transfer & Mobility Assessment Form" initially dated 7/20/06, described the resident as requiring "extensive assistance, 2 plus person(s) assistance needed to transfer or ambulate. Able to bear some weight for periods of time but needs support assistance for safety. Minimum to moderate & two plus person assistance." The form included 3 subsequent transfer assessments, dated 1/12/07, 12/17/07 and 4/21/08, which were documented at the same level of assistance for transfer. - A care plan dated 7/20/06, "Resident's decreased functional mobility places resident and care giver at risk for injury during transfers." The care plan was updated on 5/29/09 to use another lift, one that supported the resident going from seated to a standing position, commonly referred to as a sit-to-stand lift. - An undated "Interim Plan of Care," known to the facility staff as the Cardex, documented the resident required the use of a mechanical lift and the assistance of "2 person." - An undated "Resident Lift Assignment" indicated the resident required "Extensive Assist...2 plus person(s) assistance needed to transfer or ambulate." - A care plan titled "Risk For Injury Related to Falls," dated 5/11/12, included the goal: "Resident will be free from injuries related to falls through 11/12." - A physician's orders [REDACTED]. Hydrocodone/acetaminophen was a strong pain medication. Review of a fax notification to the physician, dated 9/27/12, described "...An assisted fall today...no injury noted." An assisted fall indicated staff was present during the incident and eased the resident to the ground, to some extent, to reduce injury. Review of a Nurse's Note, dated 9/29/12, (late entry made 9/30/12 at 10:45 p.m.)indicated "Turned resident on (right) side....(complained) of pain right shoulder, shoulder slightly swollen, warm to touch...request X-ray of right shoulder." Review of a radiographic report (X-ray) for the right shoulder, dated 9/30/12, indicated "Results: Acute fracture right humeral head and neck with mildly displaced fracture fragments and inferior subluxation and mild inferior displacement of the fractured right humeral head." The humerus is the upper arm bone, connected to the shoulder and elbow, the report described 2 or more fractures and partial dislocation of the arm. In an interview with Resident 7 on 10/2/12 at 4:38 p.m. she was asked about the fall and stated, "Nobody was helping (Certified Nursing Assistant 1), just her and me." In an interview with Certified Nursing Assistant 1 (CNA 1) on 10/3/12 at 8 a.m., CNA 1 stated she transferred Resident 7 from her wheelchair to the toilet, and back to the chair, after lunch on 9/27/12. CNA 1 stated the resident's right knee gave out, and her leg slipped off the lift, then CNA 1 "Got behind her and released the sling and lowered her to the ground." CNA 1 stated no other staff were assisting her to do the transfers. During the lift observation CNA 1 stated, "She couldn't drop her arm off the bar because she's paralyzed, and I was behind, lowering her." In an observation and accident simulation with CNA 1 on 10/3/12 at 8 a.m. 2 unpadded metal bars were observed to support the upper body under the arm pits, during transfer. These 2 bars were horizontal, approximately 8 inches long, with another shorter piece, approximately 3 inches long, near the outside of the bar, pointing up, to prevent the arm from slipping off the end of the bar. CNA 1 confirmed the resident's arm became hung up on the metal bar that went under the arm as she was lowered to the floor. In an interview with the Director of Staff Development (DSD) on 10/3/12 at 10:30 a.m. the DSD stated, "The standing lift is always a 2 person transfer." The DSD stated Resident 7, "Should have had 2 staff for transfer with a lift." In an interview with the Director of Nurses (DON) on 10/4/12 at 4:15 p.m. she stated, for transfers using a lift, "Normally (needs) another CNA unless rehab had determined another (way)."