Every finding on record at Glenbrook

Based on interview and record review the facility failed to initiate nonpharmacological or behavioral intervention before initiating antipsychotic medications (medication to treat psychosis [mental disorder characterized by disconnection from reality]) for two of five sample residents (Residents 31 and 49).This deficient practice had the potential for Resident 31 and 49 to receive unnecessary antipsychotic medication or inappropriate dose for behavioral treatment.Findings:1. A review of Resident 31's admission Record indicated the resident was readmitted on [DATE] with diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory and other cognitive decline), dementia (loss of mental function such as thinking, memory and reasoning skills), delusional disorders (false belief of reality), depression, mild cognitive impairment and disorientation.A review of Resident 31's History and Physical (H&P), dated 2/12/25, indicated Resident 31 was alert to person and not to place and time.A review of Resident 31's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/11/25 Section C, Cognitive Pattern, indicated Resident 31's Brief Interview for Mental Status (BIMS) score was 10 out of 15 which indicated Resident 31 had moderate cognitive impairment. MDS section N, Medications, indicated Resident 31 was receiving antipsychotic medication.A review of Resident 31's Order Summary Report, indicated an active physician's order dated 2/28/25 for Olanzapine (generic name of medicine to treat schizophrenia [a severe brain disorder in which people interpret reality abnormally) tablet 2.5 mg (mg [milligrams-unit of dose]) to be given one tablet by mouth in the evening for psychosis manifested by paranoia that staff had conspiracy against her. A review of Resident 31's psychiatry notes dated 3/2/25 and 9/15/25, indicated to continue with Olanzapine 2.5 mg every evening. During an interview with the Director of Nursing (DON) on 09/17/25 at 9:47 AM. DON stated Resident 31 had no non-pharmacological or behavior intervention done before giving the Olanzapine medication. DON also stated, We are supposed to do that. During a concurrent interview and review of Resident 31's behavior monitoring sheet on 9/18/25 at 10:20 AM with Licensed Vocational Nurse (LVN 3). LVN 3 confirmed there that the behavior monitoring from 3/1/25 to 9/17/25 indicated no documented behaviors. A review of Resident 31's Medication Administration Record (MAR), from 3/1/25 to 9/17/25, indicated Olanzapine 2.5 mg was documented as given with no refusal recorded. During a concurrent interview and record review of Resident 31's progress notes on 9/18/25 at 3:20 PM with DON. DON confirmed no documentation of non-pharmacological or behavioral monitoring done before initiating the Olanzapine antipsychotic medication. DON also confirmed that the psychiatrist did not look at the nurse's behavior monitoring documentation when retaining or adjusting the dose of Olanzapine for Resident 31. 2. A review of Resident 49's admission Record indicated the resident was readmitted on [DATE] with diagnoses which included Parkinson's disease (neurological disorder that affects movement, balance and coordination), dementia and psychosis. A review of Resident 49's H&P, dated 1/31/25, indicated Resident 49 was alert and oriented to name only and did not have the capacity to make his own decision. A review of Resident 49's quarterly MDS dated [DATE], Section C, Cognitive Pattern, indicated Resident 49's BIMS score was 10 out of 15 which indicated Resident 49 had moderate cognitive impairment. MDS section N, Medications, indicated Resident 49 was receiving antipsychotic medication and no attempted gradual dose reduction was coded for Quetiapine Fumarate (generic name of medicine to treat mental disorder). A review of Resident 49's Order Summary Report indicated an active physician's order dated 1/31/25 for Quetiapine Fumarate tablet 25 mg. Take 25 mg by mouth at bedtime for hallucinations manifested by looking for his daughter because he was on plane and it was sinking and needed to evacuate. A review of Resident 49's new neurologist orders dated 5/14/25, indicated that Quetiapine Fumarate 0.5 mg tablet by mouth give one time a day for hallucinations. A review of Resident 49's MAR, from 7/1/25 to 9/17/25, indicated Quetiapine Fumarate was documented as given and no refusal was recorded. During an interview with the DON on 9/17/25 at 9:47 AM. DON stated Resident 49 had no non-pharmacological or behavior intervention done before giving the Quetiapine Fumarate medication. DON also stated, We are supposed to do that. During a concurrent interview and record review of Resident 49's behavior monitoring sheet on 9/18/25 at 10:25 AM with LVN 3. LVN 3 confirmed the behavior monitoring from 6/1/25 to 9/17/25 for Resident 49 indicated no documented behaviors. During a concurrent interview and record review with DON on 9/18/25 at 11:45 AM. DON was unable to find non-pharmacological or behavioral intervention prior to initiating Resident 49's Quetiapine Fumarate medication on his readmission on [DATE]. A review of the facility's policy and procedure revised on 10/2018 titled, XXVIII. PSYCHOTROPIC MEDICATION USE indicated, 1.) .a. Prior to the initiation of psychotherapeutic medication.Alternative, non-pharmacological interventions should be tried prior to the initiation of treatment.

Based on observation, interview, and record review, the facility failed to properly identify and provide necessary assistive devices for repositioning for one of the sampled residents (Resident 27).This failure had the potential to cause accident and injury to Resident 27.During a concurrent observation and interview with Resident 27 on 9/16/25 at 9:28 AM, Resident 27 was observed holding on to the bedside drawer while turning to their side. Resident 27 expressed difficulty repositioning in bed. Resident 27 had been using the bedside table drawer to assist in turning to their side.A review of Resident 27's admission Records dated 9/18/25, indicated Resident 27 was admitted on [DATE].A review of Resident 27's History and Physical (H&P), dated 9/5/25, indicated a chief complaint of fall which resulted in right femur fracture (a complete or partial break in a bone, often caused by excessive force, an accident, or repetitive stress). The H&P also indicated Resident 27 had the capacity to make own healthcare decisions.A review of Resident 27's Minimum Data Set (MDS - a standardized assessment tool) Section GG - Functional Abilities dated 9/5/25, indicated Resident 27 needed substantial/maximal assistance for bed mobility. During an interview on 9/16/25 at 9:40 AM with Certified Nurse Assistant 1 (CNA1), CNA1 stated Resident 27 was assisted with repositioning every 3 to 4 hours. CNA 1 further stated that Resident 27 would grab bedside table drawer when turning. CNA1 stated that it was not safe practice, and it could cause injury to Resident 27.During an interview on 9/18/25 at 9:12 AM, Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 27 did not have assistive device for positioning.During an interview with the Director of Nursing (DON) on 9/18/25 at 12:40 PM, DON stated that staff were expected to monitor safety and report incidents to LVN, Registered Nurse, and DON to address residents' needs. The DON confirmed that Resident 27's use of the bedside drawer when turning was not reported, and Resident 27's need was not addressed.A review of the facility's policy and procedure (P&P) titled Accidents and Incidents - Investigating and Reporting Procedure, dated 7/22/19, indicated: 1. An incident/accident report may be completed for the following: .Inappropriate use of devices for residents.

Based on interview and record review, the facility failed to notify the Office of the Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) before discharge for two of four sampled residents (Resident 5 and 7). This deficient practice had the potential to leave residents unprotected from improper discharge and deny them access to an advocate for their options and rights.1.During a review of Resident 7's History and Physical (H&P), dated 9/2/25, the H&P indicated Resident 7 was sent to the hospital on 8/24/25, and came back to the facility on 8/30/25. During an interview with the SSD on 9/18/25, at 10:11 AM. She stated the facility must send written notification to the ombudsman when resident was discharged or transferred. Medical records staff must send the notification. During a concurrent interview and record review with the (MRD) on 9/18/25, at 10:21 AM, MRD confirmed there was no written notification of transfer sent to the ombudsman. A review of the facility's policy and procedure titled Record Content.Transfer and Discharge Notice dated October 2024, indicated,. Section III – 38 . A written discharge notice must be provided to the residents and resident representative with a copy to the State Long Term Care (LTC) Ombudsman at least 30 days prior to discharge or as soon as possible. The copy of the notice to the Ombudsman must be sent at the same time notice is provided to the resident and resident representative. 2.During a review of Resident 5's admission Record dated 9/18/25, the admission Record indicated Resident 5 was admitted on [DATE], due to a fall resulting in left femur fracture (a complete or partial break in a bone, often caused by excessive force, an accident, or repetitive stress). During a review of Resident 5's History and Physical (H&P), dated 9/18/25, the H&P indicated Resident 5 had the capacity to make his own healthcare decisions. During a review of Resident 5's Interdisciplinary Discharge Summary – Social Services, dated 9/11/25, the Discharge Summary indicated Resident 5 was discharged to home on 9/15/25, with a discharge reason of met functional goals. There was no documented evidence in Resident 5's clinical record regarding the notification of the Ombudsman. During an interview on 9/18/25, at 4:42 PM, with the Social Services Director (SSD), SSD stated that Medical Records held the responsibility for notifying the Ombudsman of discharges. SSD stated being unaware of the specific timing required for such notifications. During a concurrent interview and records review on 9/18/25 at 5:10 PM, with Medical Records Director (MRD), the facility's policy and procedure (P&P) titled, Transfer and Discharge Notice was reviewed. The P&P indicated, .a. a written notice of discharge must be sent to the resident and resident representative and a copy to the State LTC Ombudsman at least 30 days prior or as soon as possible. MRD stated that no specific timeframe to when the Ombudsman gets notified.

Based on interview and record review the facility failed to ensure three of four sampled residents (Residents 2, 44 and 11) knew the location of the survey results binder.This failure had the potential to keep residents, family members, and visitors from easily reviewing the most recent survey results and the facility's plan of corrections, which were essential for making informed decisions about living at the facility.During an interview on 9/17/25 at 2:30 PM, three of four residents polled at the resident council meeting did not know the location of the survey results binder.During a concurrent observation of the facility and interview with the Administrator (ADM) on 9/17/25 at 4:37 PM. The ADM verified the three locations of the survey results binders and confirmed there was no sign at one of the sites in the facility indicating where to find it. ADM stated that the facility did not have a policy and procedure regarding posting and accessibility of survey results. A review of the State of California-Health and Human Services Agency, Attachment F Resident [NAME] of Rights, Section 72527 Skilled Nursing Facilities indicated .g) Examination of survey results. A resident has the right to (1) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post notice of their availability.

Based on interview and record review, the facility failed to ensure one resident ' s (Resident 1) written care plan for transfers was consistently implemented. Resident 1 had an unwitnessed fall while transferring into a chair. Findings: A review of the Admission Record for Resident 1 reflected Resident 1 was admitted to the facility on [DATE] with diagnoses that included: unspecified dementia (a condition of decline in thinking ability and memory); diabetic neuropathy (a severe condition caused by high blood sugar, and symptoms can include sensations of pain, numbness or burning, loss of balance or weakness). On 9/20/24 an unscheduled visit was made to the facility in response to a report of Resident 1 falling and fracturing her left wrist. On 9/20/24 at 12:10 P.M. Resident 1 was interviewed in her room. Resident 1 is sitting up in bed, with a clean cast on her left wrist. Resident 1 stated her arm and cast is very awkward, and needs extra care. Resident 1 stated she was still working with therapy as much as she could, since she wanted to be independent. Resident 1 recalled the incident: (The facility) was showing a movie and I wanted to see it. I was helped to the community room by the girl who was helping me and was going to lead the exercises for us. Resident 1 stated, they tell me that I reached back and missed the arm of the chair, and the girl was distracted and didn ' t make sure I got the arm of the chair. My hand slipped off and down I went. I guess neither of us did our job. I don ' t remember the fall, just that all of a sudden, I was on the floor. On 9/20/24 at 1:10 P.M. Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated Resident 1 walked with her walker until recently. Resident 1 now needs assistance for everything except eating, and gets around in a wheelchair pushed by staff. CNA 2 stated he would see Resident 1 walk with her walker and transfer herself without problems, it seemed ok. CNA 2 stated he has access to (any) resident care plan to review for changes or updates in care. CNA 2 stated he used the information from the nurses and other CNA ' s. On 9/20/24 at 1:30 P.M. CNA 3 was interviewed. CNA 3 stated Resident 1 was always walking with someone when CNA 3 saw her. Also, staff was there to remind her to reach back when sitting, or Resident 1 would forget. CNA 3 stated, without a reminder, Resident 1 would keep both hands on the walker and sit. On 9/20/24 at 1:50 P.M. a joint interview and record review was conducted. The Director of Therapy (DPT) was interviewed, and recent therapy notes (Physical Therapy Treatment Encounter Notes and Occupational Therapy Treatment Encounter Notes) dated 9/1/24 through 9/5/24, and 9/8/24 were reviewed. The DPT stated Resident 1 prior to her fall needed to be assisted by 1 person when walking and transferring for supervision, reminders, and light touching assistance, if needed, for her safety. The DPT also stated Resident 1 was not walking safe or transferring by herself, nor any other Activities of Daily Living, such as bathing, dressing, and undressing. On 9/202/24 Resident 1's record was reviewed. Resident 1's Occupational Therapy Treatment Encounter Notes dated 9/2/24 and 9/4/24 reflected that Resident 1 needed education and reminders to feel for the chair with the back of her legs, lock her walker brakes, and reach back before sitting to increase safety. On 9/20/24 the nursing note dated 9/11/24 timed, 5:59 P.M. was reviewed. The note reflected Resident 1 was found lying on the floor in the sunroom with her walker next to her. The CNA stated she walked to the sunroom with the resident before finding Resident 1 on the floor. The activities assistant stated she saw Resident 1 try to sit down and slip and fall to the floor. On 9/20/24 the Care Plan for Resident 1 was reviewed. The Focus of .Dementia reflected the staff are to provide cuing, and reorientation as needed. The Focus of .risk for falls or injury. noted prior falls on 8/10/24 and 8/12/24. On 8/13/24 the care plan was revised for staff to provide partial to maximum assistance with ADL ' s (bathing, dressing, transfers, etc.).Offer toileting every contact to resident to be able to assist and avoid the tempt [sic] of self-transferring to toilet.be at standby assist to prevent fall and injuries. The Focus of ADL self-care deficit . : Staff assistance is listed as: TRANSFER: the resident (1) requires limited assistance by (1) staff to move between surfaces.

Based on observations, interviews, and record reviews the facility failed to ensure the nutritional status was monitored and acceptable parameters were maintained for one of one resident, (Resident 23), with unintended, unplanned severe weight loss of 16.43% in six months (9/4/22-2/4/23) when: 1) The resident's nutritional status was not reassessed, the laboratory values were not drawn, or the interventions were modified after five, ten, or fifteen percent of weight loss occurred, according to facility policy and standards of practice. 2) The resident was not placed on weekly weights from 9/1/2022-3/31/2023 to monitor weight status after a loss of five or ten percent of body weight, according to policy. 3) The resident's meals and snack/nourishment consumption were not monitored to determine the resident's actual food intake in order to evaluate nutrition status, according to facility policy. These failures had the potential to result in Resident 23 experiencing further functional decline, loss of lean body mass (the body weight that includes muscles, bones, and organs and excludes fat) and reduce the risk of developing chronic conditions such as diabetes (inability to manage blood sugar) and heart disease. The facility census was 57. Findings: According to the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, Treatment of unintended weight loss is imperative to ensure optimal outcomes for the older adult. Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death. Unintended weight loss often results in protein-energy undernutrition (low protein or calorie intake resulting in insufficient nutrient absorption), as the older adult loses critical lean body mass and is more prone to pressure ulcers (injuries to the skin and underlying tissue due to consistent pressure), infections (when a virus or bacteria enters the body and causes harm), immune dysfunction (when the body's system does not fight off infections or illness), anemia (low levels of oxygen in the blood), falls resulting in hip fractures (breaks or tears), and other conditions. Per the facility's Admission Record, dated 8/23/23, Resident 23 was admitted on [DATE] with diagnoses of hypertension (high blood pressure), depressive disorder (condition of sadness), and hyperlipidemia (high concentration of fat content in the blood). During an observation and interview on 8/21/23, at 11:12 A.M., Resident 23 was sitting in his room in a wheelchair. The resident looked physically thin. Resident 23 stated he has lost at least 40 pounds since he has been at the facility and thinks he needs a special diet but stated they won't listen to me. During an observation and interview on 8/21/23, at 12:23 P.M., of the lunch meal service in the dining room, Resident 23 was sitting in the dining room and received an entree of two Harissa marinated chicken breasts fillets chopped, 2 slices of Boston cream pie, a 4-ounce cup of cranberry juice, and a 4-ounce cup of milk. Resident 23 stated he did not like the lunch meal and gave it a thumbs down. Resident 23 consumed 1/2 of his soup, 3/4 of his chopped grilled chicken breast, and 2 slices of dessert pie. Resident 23 drank 1/4 cup of milk and 1/2 cup of cranberry juice. Resident 23 gave the dessert a thumbs up and stated, it tasted good. During a review of Resident 23's physician's ordered diet, dated 1/14/23, the diet order indicated Regular diet, Regular texture, mildly thick liquids. On 1/21/23, the diet order was updated to include Health shakes three times a day with meals. During a review of Resident 23's Weights and Vitals Summary, dated 8/22/23, the weight report indicated the following weights: 8/6/22- 152.6 pounds 9/4/22- 152.2 pounds* 10/1/22- 152.8 pounds 11/6/22- 149 pounds 12/3/22- 146 pounds 12/31/22- 137.6 pounds 1/8/23 - 137.4 pounds 2/4/23- 127.4 pounds* 3/4/23 - 130.3 pounds 4/1/23 - 131 pounds 5/6/23 - 130.7 pounds 6/3/23 - 130.2 pounds 7/1/23 - 126 pounds 8/5/23 - 126.3 pounds During a review of Resident 23's Physician's Progress Notes dated 6/3/23, the progress note indicated, Resident 23 .Diagnosis .poor fluid intake, Unexplained weight loss .5. Cognitive (related to thinking and reasoning) status .appears to have capacity to make his own medical and financial decisions. During a review of Resident 23's Minimum Data Set (MDS- a federally mandated clinical assessment of all residents in Medicare or Medicaid insurance program), section C- Cognitive Patterns, dated June 5, 2023, the MDS indicated, Resident 23 had a BIMS (Brief Interview of Mental Status) score of 15, which is the highest total possible score (00-15), and indicated the resident had a high mental capacity, as well as able to make medical decisions. During a review of Resident 23's Lab Results Report, dated 1/4/23, the basic metabolic panel (blood sample test of eight chemicals that break down food into nutrients for energy) results indicated the following lab values: *Hemoglobin (hgb)- 12.4 g/dL (grams per deciliter) (low); (normal range= 13 g/dL - 17.7 g/dL) *Neutrophils - 8.8 (high); (normal= 1.4- 7.0) A low hemoglobin (red blood cells containing iron that transport oxygen) value and high value for neutrophils (white blood cells). Low hemoglobin values may indicate the body is unable to receive enough oxygen, and high levels of neutrophils may indicate the body is under stress, and unable to effectively fight against infections. A pre-albumin (protein made in the liver and helps control how the body uses energy and is a sign of malnutrition) or albumin (measure of protein in the blood and indication of liver and kidney function) lab test was not ordered for Resident 23 when the resident experienced a five or ten percent significant weight loss, which occurred from 9/4/2022 - 2/4/23; or through 8/23/23 according to standards of practice. During an interview on 8/23/23 at 3:40 P.M., with resident 23's physician (PHYS), the PHYS stated Resident 23 had been on the Remeron mirtazapine (a drug to manage unhappy mood) since August 2022. The PHYS also stated monitoring pertinent labs such as prealbumin and albumin were important to monitor a person's nutrition status, especially someone with significant weight loss. PHYS acknowledged Resident 23 did not have an albumin or prealbumin lab test and stated it would have been important for monitoring nutrition status, that may have likely prevented further weight loss. During a review of Resident 23's Nutritional Screening and Assessment, dated 6/3/22, completed by the facility's Registered Dietitian (RD) indicated that the resident's target weight goal range was 150 - 165 pounds. The estimated daily nutritional requirements indicated the calories 1886 - 2264/day, protein 76-91/day and fluid 1886 ml/day (milliliters - one thousandth of a liter per day). During a review of Resident 23's Nutritional Risk Review dated completed 12/1/22 by the facility's Registered Dietitian (RD) indicated that the resident target weight goal range was 150 - 165 pounds and No significant weight change in 3 months. During a review of Resident 23's Nutritional Risk Review dated 3/2/23 completed by the facility's Registered Dietitian (RD) indicated that the resident's target weight goal range was 150 - 165 pounds. Significant weight change, negative -9.7 pounds/7% in 1 month and negative -21 pounds/14% in 3 months. Continue present regimen, health shakes TID (three times a day). During an interview on 8/23/23 at 10:25 A.M., with the Registered Dietitian (RD), the RD stated residents are placed on weekly weights and discussed at interdisciplinary meetings to provide interventions. The RD stated Resident 23 should have been on weekly weights when the significant weight loss was identified early at five or ten percent weight loss. The RD stated, although the resident received health shakes three times a day with meals, his food preferences were not received or documented by the food and nutrition department staff, which may have led to modifying his weight loss interventions. The RD also stated weight loss interventions such as fortified foods (the addition of calories and protein rich foods such as butter, milk, and other foods at meals), larger food portions, and additional foods and snacks offered at meals may have helped prevent further weight loss, once it was identified. The RD further stated earlier interventions may have possibly prevented the significant/severe weight loss because any gaps between intake and assessment to help minimize or prevent any unplanned weight loss. During an interview on 08/24/23 with Certified Nurse Assistant (CNA 1) at 10:55 A.M., the CNA 1 stated Resident 23 usually drank half of his health shakes, but she did not have a way to enter the morning and lunch snacks or health shake consumption into the computer system. CNA 1 stated she was unaware of how Resident 23's snacks/nourishments intake was fully assessed. During a record review of Resident 23's Activities of Daily Living (ADL) Eating report dated 6/29/23-8/22/23, the ADL intake Eating report indicated Resident 23 ate 50-75% of his meals. During a record review of the Nutrition-HS (hour of sleep) Snack report, dated 6/1/23-8/22/23, the intake HS Snack report indicated Resident 23 accepted the snack but consumed 50-75% of the snack five times. During a review of the facility's policy and procedure (P&P) titled, Weight Loss/Gain- A Change in Condition, dated 11/2010, the P&P indicated, Significant unplanned weight loss .is considered a change in condition when the intervention is tried and fails .5. Those residents who continue to have unplanned significant weight loss for 2 weeks are considered to have a change in condition .6. A change in condition precipitates a new MDS and a change in condition Nutritional Risk Review by the Dietary Manager or .Registered Dietitian. 7. Continue every nutritional intervention possible and continue weekly weights until the weight loss stabilizes over a 30-day period . During a review of the facility's policy and procedure (P&P) titled, Weight Management Guidelines, dated 2016, the P&P indicated, .Residents with significant weight variance should be identified and appropriate interventions implemented .8. Nursing should notify the physician and family of significant or severe weight loss .9. All .unplanned, and unavoidable weight loss should be care planned and have nutritional goals and approaches. The Dietitian, resident, and family must approve the weight loss .14. Follow best practice guidelines for interventions. Obtain resident preferences regarding interventions and individualize. Try food first 16.Closely follow the resident's .labs, skin, and other factors . During a review of the facility's policy and procedure (P&P) titled, Special Nutrition Program, dated 2018, the P&P indicated, .The Special Nutrition Program (SNP) is a fortified program that should provide for the increased nutritional requirements of residents who are underweight .experiencing significant weight loss, have poor intake and/or have low albumin .SNP breakfast, noon meal, evening meal .Approx. 880 to 1000 calories and 23 to 34 grams (unit measurement of mass) of protein .4.offer the resident one to two additional fortified foods per day per resident needs and preferences .each fortified food should furnish 200 calories or more and 6 grams of protein . During a review of the facility's policy and procedure (P&P) titled Criteria for Intervention with Abnormal Labs, dated 2017, the P&P indicated .they should be put on nutrition intervention list for the Dietitian for intervention and documentation .a. Hgb less than 12 g/dl (grams per deciliter) .d. Albumin less than 3.5 g/dl or as indicated as low based on the lab used or prealbumin less than 15 .a. Labs which can be indicators for dehydration are increased .Albumin . 45063

Based on observations, interview and record review, the facility failed to ensure overall systems were met for the Food and Nutrition Services in the kitchen when: a resident experienced an unplanned insidious severe weight loss of 16% in a six months; residents' food temperatures were not monitored for safety and palatability; kitchen staff did not perform tasks competently for food safety in food preparation, food storage, and sanitation for dishwashing and dish storage; kitchen staff did not monitor the temperatures in the dry storage room and emergency food supply room closet to ensure safe quality of the food supply; recipes were not followed for time and temperature control for food safety foods (TCS); and fruit fly pests were found in the kitchen. These failures placed all residents at risk for harm and exposure to contamination that had the potential to impair their nutrition and health status. The facility census was 57. Cross reference F692, F802, F803, F804, F812, F925 Findings: During the initial kitchen tour on [DATE] at 8:14 A.M., multiple observations and concurrent staff interviews were conducted in the kitchen for food safety, sanitation, cleanliness, and nutrition care, and food services delivery to residents. There were several deficient practices identified including a severe unplanned weight loss resident (Resident 23), menu and recipe compliance, dirty floors in the walk-in refrigerators and freezers, food debris on utensils, unchecked dish machine sanitation logs, unlabeled/misdated/expired foods in the refrigerators, and fruit fly pests in the dry storage and food preparation areas. During an interview on [DATE] at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD acknowledged the poor overall kitchen cleanliness, menu compliance, food safety and sanitation practices, and pest control practices, and stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. The DFS stated the kitchen staff should have cleaned their areas and performed their job tasks correctly because they had received in-services this year. The DFS stated the Dietary Hitlist completed daily by the Lead Cook (LCK), identified the areas in the kitchen such as labeling and dating of refrigerated foods and dish machine logs incorrectly completed during July-[DATE]. The DFS stated the staff know what they need to clean and how to follow menus and recipes but they may need to be reminded. The RD stated she worked an average of 16 hours a week in the facility. The RD further acknowledged there may have been alternative efforts to implement for the resident with severe unplanned weight loss, Resident 23, such as taking his food preferences within a couple of months of admission, and modifying the nutrition regimen within a few months when the significant weight loss was identified. The DFS and RD each stated they expect the food and nutrition services operations be carried out safely and effectively for the nursing home residents. According to the 2022 Federal FDA Food Code, section ,d+[DATE].11, titled Person in Charge, .(Q) Written procedures and plans, where specified by this Code and as developed by the Food Establishment .are maintained and implemented as required. During a review of the facility job description titled Food and Nutrition Services Director, dated [DATE], the job description indicated, .The Food and Nutritions Services Director is primarily responsible for providing effective food and nutrition services in the skilled nursing facility .Assures efficiency of food serving; compliance with local, state, and federal standards; sanitation, and hygiene . During a review of the facility job description titled Dietitian, dated [DATE], the job description indicated, .7. Through observation and evaluation, promote food production and services procedures that conserve nutritive value, flavor, appearance, quality, and are attractively served at the proper temperature . 45063

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. An ice scooper was left inside the ice machine. 2. The kitchen's clean dish storage area had dirty serving utensils and debris in tray with clean dishes. 3. A Lead cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 4. The floor in the walk-refrigerator and freezer had dirty label, brown stains, trash and other debris on the floor. 5. Fruit flies were in the flying around uncovered food in the kitchen and dry storage area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. The facility census was 57. Cross- reference F800, F802, F925 Findings: 1. During an initial kitchen tour on 8/21/23 at 8:25 A.M., an ice machine scooper was found inside the ice machine. During an interview on 8/21/23 at 8:30 A.M., with the Director of Food and Nutrition Service (DFS), The DFS stated he did not know which kitchen staff left the ice scooper inside the ice machine, but stated it should not have been left there because that was unsanitary. According to the 2022 Federal FDA regulations, ice needs to be stored and handled like food, and that means ice machines need to be regularly cleaned. Food Law . Chapter 4 specifies the ice machines and scoops must be cleaned and sanitized . 2. During an initial kitchen tour on 8/21/23 at 8:50 A.M., an observation the kitchen's clean dish storage area was conducted. The clean area with serving utensils, colored serving scoopers were observed to have small brown debris and residues. During an interview on 8/21/23 at 8:52 A.M., with the Executive Chef (EXC) and Director of Food and Nutrition Service (DFS), the EXC stated the serving utensils, scoopers, and eating utensils should not have debris and residues after washing them. The DFS stated the kitchen staff should have checked them before they were stored with clean dishes. According to the 2022 Federal FDA Food Code, section 4-601.11, .it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. According to the 2022 Federal FDA Food Code, section 4-602.11, titled Clean-Food Contact Surfaces, Equipment food contact surfaces of shall be cleaned at any time during the operation when contamination may have occurred. During a review of the facility's policy and procedure ( P&P) titled, Dry Storage- Dishes and Utensils, dated 2012, the P&P indicated .1.Spoon, knives, and forks shall be stored in containers .or shall be covered. 2. Storage areas should be cleaned and sanitized . During a review of the facility's policy and procedure (P & P) titled, Dish and Utensil Procedure dated 7/1/2014, the P & P indicated 9. Any dish, tray or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized 3. During the initial kitchen tour on 8/21/23 at 9:45 A.M., an observation of kitchen was conducted. Lead Cook (LCK) was observed preparing tuna salad. During an interview on 8/21/23 at 9:46 A.M., with LCK, LCK stated he made the tuna salad this morning. LCK stated he made the tuna salad from a canned tuna, celery, mayonnaise and relish. LCK stated he did not do the cool down process for the tuna, because it came from a canned tuna. During a review of the facility's policy and procedure ( P&P) titled, Standardized Recipes, dated 12/2013, indicated standardized recipes will be used for all products .7. HACCP (Hazard Analysis Critical Control Points) controls are also noted on recipes .Albacore Tuna salad Sandwich . 2. Combine tuna, mayonnaise, celery and relish: chill under refrigeration (41 degrees F) . According to the Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14, titled Cooling, .(B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. According to the 2022 Federal FDA Food Code, Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), the RD stated the tuna salad should have been prepared using food safe practices by following the recipe to chill the tuna down to 41 degrees before serving it. 4. During the initial kitchen tour on 8/21/23 at 8:45 A.M., an observation of the walk-in refrigerator and freezer floor and interview with the EXC was conducted. The floors in both walk in areas were dirty with stains, food debris, labels, and paper throughout. The EXC stated the walk-in refrigerator and freezer floors should be cleaned at all times. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the walk-in freezer and refrigerator floors in the kitchen should have been clean. 5. During the initial kitchen tour on 8/21/23 at 8:25 A.M., There were more than three fruit flies observed flying around the tray line counter area with exposed food. During a concurrent observation and interview on 8/21/23 at 8:45 A.M., with the Director of Food and Nutrition Service (DFS), in the kitchen, three flies were observed flying around throughout the kitchen. The DFS acknowledged the flies and stated there should be no fruit flies in the kitchen, to prevent cross contamination. The DFS stated he will call the pest control company to take a look at it. During a concurrent observation and interview on 8/21/23 at 9:40 A.M., with the Executive Chef (EXC), in the kitchen dry storage room, there were four fruit flies observed flying around on a large metal can of vinegar. The metal can did not have a top on it and contained a piece of clear, thin plastic wrapped around the opening. The EXC acknowledged the fruit flies and stated they've been flying around for a while, but they should not be in the kitchen at all. The EXC stated he will follow up with the pest control company to spray again. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. During a review of the pest company invoice records dated 8/23/2023, the invoices indicated a presence of drain flies in the kitchen, and Fruit flies come from specific sources .The two spices .were uncovered produce such as onions and the drains . During a review of the facility's policy and procedure (P & P) titled Pest Control, dated 3/1/18, the P and P indicated The Community shall implement a pest control program .1. Will help ensure that the community's residents .offers minimal risk of infection from unwanted insects. According to the 2022 Federal Food Code, section 6-501.111, stated .Controlling Pests .The premises shall be maintained free of insects, rodents and other pests . by . routinely inspecting the premises for evidence of pests .

Based on observations, interview and record review, the facility failed to ensure kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Kitchen staff did not correctly label and date TCS (Time/Temperature Controlled for food safety) foods in a walk-in refrigerator and did not monitor the dry storage room by correctly labeling, dating, and checking the quality of the food supply. 2. A Lead Cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 3. A Dishwasher did not enter the dish machine wash and rinse temperatures on a log in a timely manner. These failures placed all residents at risk of cross contamination and the potential to acquire food-borne illnesses. The census was 57. Cross reference F800, F804, F812 Findings: 1. During the initial kitchen tour on 8/21/23 at 8:25 A.M., an observation of the walk-in refrigerator and interview with the Executive Chef (EXC) was conducted. There was a metal tray of soup ingredients on the first two shelves that included sliced tomatoes, sliced white onions and sliced green bell peppers. These were not labeled or dated. There was a large black plastic bin with spoiled green bell peppers and a large bin with red bell peppers. Each bin had three bell peppers with black and gray mold spots on them, and they were dated 8/18/23. Additionally, there was a case of asparagus uncovered, dated 8/19/23. The EXC stated the case of asparagus should had been covered with plastic wrap, and the molded bell peppers should have been thrown out. The EXC further stated, the kitchen staff member pours the new produce on top of the existing food items when they receive deliveries but they should have checked them first to prevent them from developing mold. During an interview on 8/21/23 at 8:45 A.M., with LCK, LCK stated these tray of soup ingredients should have been dated and labeled to prevent being used past the expiration date. During the initial kitchen tour on 8/21/23 at 9:05 A.M., an observation of the kitchen's dry storage room was conducted. There was a medium sized clear plastic uncovered container with a white sugar label on it and no date. There was also a metal canister with vinegar, without a date and clear plastic wrap stuffed in the opening. During an interview on 8/23/23 at 12:08 P.M., with the DFS, the DFS stated the expectation is for the kitchen staff to complete all labeling and dating of foods by the end of the day. According to the 2017 Federal FDA Food Code, Section 3-602.11 Food Labels.(A) Food packaged .shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling .and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .and date. During a review of the facility's policy and procedure (P&P) titled Labeling and Dating for Safe Storage of Food, dated 3/6/2020, The P and P indicated, . labeling and dating are critical in order to promote food safety .all products should be dated upon receipt . During a review of the facility's policy and procedure (P & P) titled Food Storage, dated 1/12/16, the P & P indicated, .1. Fresh vegetables should be checked and sorted for ripeness .4. Fresh vegetables .should be left in cartons .paper wrapping . it retards spoilage and loss of moisture .5. Rotate so that oldest produce is used first 2. During the initial kitchen tour on 8/21/23 at 9:45 A.M., an observation of kitchen was conducted. LCK was observed preparing tuna salad for the residents. During an interview on 8/21/23 at 9:46 A.M., with LCK, LCK stated he made the tuna salad this morning. LCK stated he made the tuna salad using a large can of tuna from the dry storage, chopped celery, mayonnaise and relish from the refrigerator. LCK stated he and did not do the cool down process for the tuna, because it came from a can. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), the RD stated the tuna salad should have been prepared using food safe practices by following the recipe to chill the tuna down to 41 degrees before serving it. During a review of the facility's policy and procedure ( P&P) titled, Standardized Recipes, dated 12/2013, indicated standardized recipes will be used for all products .7. HACCP (Hazard Analysis Critical Control Points) controls are also noted on recipes .Albacore Tuna salad Sandwich . 2. Combine tuna, mayonnaise, celery and relish: chill under refrigeration (41 degrees F) . According to the Federal Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14, titled Cooling, .(B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. According to the Federal Food and Drug Administration (FDA) Food Code 2022, chapter 3 Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. 3. During the initial kitchen tour on 8/21/23 at 8:40 A.M., an observation of the kitchen dishwashing area was conducted. The Dishwashing temperature log was already filled up for Breakfast and Lunch time. During an interview on 8/21/23 at 8:41 A.M. with Dishwasher (DW) 1, DW 1 stated he usually put the dishwashing temperature in the log after every meal. During an observation on 8/22/23 at 8:45 A.M., an observation of the kitchen dishwashing area was conducted. The Dishwashing temperature log was not filled up for 8/22/23. During an interview on 8/22/23 at 8:48 A.M., with DW 2, the DW 2 stated the dishwashing temperature log should have been filled up by the second dishwasher assigned for the day by this time. During an interview on 8/23/23 at 12:17 P.M. with DFS, the DFS stated dishwashing temperature logs must be completed daily, after each meal to ensure that the dishwashing machine is working and monitored. During a review of the facility's policy and procedure (P&P) titled Recording of Dishmachine Temperatures, dated 1/31/2017, the policy and procedure indicated 8.a. To ensure that the wash and rinse temperatures are properly monitored and controlled, a log must be completed by those who are directly involved in the dishwashing process. Entries must be made for each meal .

Based on interview and record review, the facility failed to ensure care/treatment was provided according to professional standards of practice for two of 15 sampled residents (Resident 3 and 45) when: 1. Licensed nurses (LN) did not respond to Resident 3's low blood glucose reading (a value less than 70 mg/dl [milligrams/deciliter]) by assessing the resident for signs and symptoms of hypoglycemia (low blood glucose/sugar) and notifying the resident's physician. In addition, LN did not clarify Resident 3's physician order related to a low blood glucose parameter. 2. A response to a change of condition related to nutritional assessment was not conducted in a timely manner. As a result, there was the potential risk to the residents' health and well-being. Findings: 1. A review of Resident 3's Admission Record indicated the resident was readmitted on [DATE] with diagnoses to include diabetes mellitus (the body's inability to regulate blood sugar) and dementia (a condition characterized by impairment of at least two brain functions, such as memory loss and judgment). A review of Resident 3's medication administration record for August 2023, indicated the resident had the following blood glucose readings: 65 mg/dl on 8/6, 67 mg/dl on 8/16, 58 mg/dl on 8/19, and 53 mg/dl on 8/22. A review of Resident 3's physician order for injectable insulin (hormone used to regulate blood glucose) dated 2/9/23, did not have a parameter for addressing a low blood glucose reading. On 8/23/23 at 2:51 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated it was a professional standard of nursing practice to assess a resident for signs and symptoms of hypoglycemia (such a sweating or loss of consciousness) when a blood glucose reading was less than 70 mg/dl. LN 1 reviewed Resident 3's clinical record and stated the resident's blood glucose readings on 8/6, 8/16, 8/19, and 8/22 were lower than 70 mg/dl and the resident should have been assessed by the registered nurse. LN 1 stated there was no documentation that an assessment for hypoglycemia had been done on those dates. LN 1 further stated for blood glucose levels to be 53 and 58 mg/dl that It's pretty low. LN 1 stated the standard of practice was to notify the resident's physician when a blood glucose reading was less than 70 mg/dl. LN 1 stated there was no documentation Resident 3's low blood glucose readings had been reported to the resident's physician. LN 1 stated since Resident 3's insulin order did not have a parameter for low blood glucose, the physician should have been called for clarification of the order. LN 1 stated low blood glucose levels were dangerous with a possibility of the resident losing consciousness and slipping into a diabetic coma (unable to wake). On 8/23/23 at 3:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated it was a professional standard of nursing practice to assess a resident having a blood glucose reading less than 70 mg/dl in order to check for signs and symptoms of hypoglycemia. The DON stated it was her expectation that the LN assessment be documented, and the physician notified when a resident's blood glucose reading was less than 70 mg/dl. The DON reviewed Resident 3's clinical record and stated this should have been done when the resident's blood glucose readings were less than 70 mg/dl. The DON stated Resident 3's insulin order should have been clarified to provide a parameter for a low blood glucose reading. The DON further stated the facility did not have a policy or procedure to guide diabetes and insulin management. The DON stated she expected the standard of practice to be followed. According to the American Nurses Association (professional organization for nursing standards) and the American Nurses Credentialing Center, undated, at https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process, the first step in the nursing process is assessment. According to [NAME] Nursing Center (professional guidance and procedures for nursing practice), Managing Acute Diabetic Complications dated November 2022, .The blood glucose level that defines hypoglycemia varies in each patient, a less than 70 mg/dl . is considered hypoglycemia in patients with diabetes .Hypoglycemic management protocol . A standardized nurse-initiated hypoglycemic treatment protocol to immediately address blood glucose levels less than 70 mg/dl . Reassessment of the insulin treatment plan if blood glucose drops below 70 mg/dl .Tracking and documentation of each episode in the medical record . 38542 2. Resident 45 was readmitted to the facility on [DATE] with diagnoses which included polyneuropathy (malfunctioning of several nerves in the body which could cause numbness, weakness and pain) per the facility's Admission Record. A review of Resident 45's records was conducted. A Weekly Pressure Injury Evaluation, dated 7/18/23, indicated Resident 45 acquired a pressure injury (breakdown of skin integrity due to pressure) on the left heel. A Weekly Pressure Injury Evaluation, dated 7/25/23, indicated Resident 45 acquired a pressure injury on the right heel on 7/18/23. A Weekly Pressure Injury Evaluation, dated 7/26/23, indicated Resident 45 acquired a pressure injury on the medial upper right buttock. A Nutritional Evaluation for a Significant Change of Condition was conducted by the Registered Dietitian (RD) on 8/18/23. On 8/24/23 at 9:31 A.M., an interview with LN 5 was conducted. LN 5 stated a newly acquired pressure injury was considered a change of condition. LN 5 stated the RD should have done an assessment definitely not a month after it was acquired. On 8/24/23 at 10:44 A.M., an interview with the DON was conducted. The DON stated when a resident developed new pressure ulcers, the RD had to assess within the week they were acquired. On 8/24/23 at 3:06 P.M., an interview with the RD was conducted. The RD stated the resident needed to be assessed within the week of a change of condition which included new pressure ulcers. Per the facility's policy and procedure titled, Nutritional Intervention for Pressure Injuries dated 12/13/16, .Procedures: 4 .There is an expectation that recognized .nutrition recommendation will be given to individuals at risk for pressure injuries which should be taken into consideration in assessment and developing the care plan .

Based on observation, interview and record review, the facility failed to ensure a visitor wore the proper personal protective equipment (PPE) while in contact with one of one sampled resident (Resident 8) on isolation precaution. As a result, there was a potential for spread of infection. Findings: Resident 8 was readmitted to the facility on [DATE] with diagnoses which included sepsis (blood infection) per the facility's Admission Record. On 8/21/23 at 3:12 P.M., a joint observation with Certified Nurse Assistant (CNA) 4 was conducted. Resident 8's room had a sign indicating Resident 8 was on Enhanced Barrier Precautions (everyone must perform hand hygiene and wear gown and gloves for certain activities with the resident). Resident 8's family member was observed going inside the room and sat on the resident's bed without the proper PPE. CNA 4 stated she did not know if Resident 8's family member should be wearing PPE while sitting on the resident's bed. On 8/22/23 at 9:29 A.M., an interview with Resident 8 was conducted. Resident 8 stated her visitors did not wear PPE when they were inside the room. On 8/24/23 at 10:50 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 8's family member should not have sat on the resident's bed without the proper PPE due to the precautions in place. On 8/24/23 at 11:11 A.M., an interview with Infection Preventionist (IP) 1 was conducted. IP 1 stated Resident 8 was on enhanced barrier precautions due to the presence of a multi-drug resistant organism in the urine. IP 1 stated it would have been better if Resident 8's family member was wearing the proper PPE while she was sitting on the resident's bed. IP 1 stated the staff should have educated the family member not to sit on the bed [without PPE] in general. Per the facility's policy and procedure titled, Enhanced Standard Precautions Guidelines, dated 10/24/22, .High-Risk residents: Wear gowns and gloves .associated with the greatest risk for MDRO contamination .hands, clothes, and the environment: changing bed linens .contact with environmental surfaces .

Based on observation, interview and record review, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. This failure led to two (2) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status. Cross reference F800, F802, F804 Findings: During the initial kitchen tour on 8/21/23 at 8:30 A.M., an observation of the kitchen was conducted. A large pot of baked potato soup and smaller pot of baked potato soup were observed inside the tall warmer equipment. The large pot on the top shelf was the regular baked potato soup and the smaller pot had the other baked potato soup. During an interview on 8/21/23 at 8: 35 A.M. with LCK, the LCK stated the baked potato soup in the large pot would be served for lunch today for the regular diets and the small pot was the pureed baked potato soup. LCK stated he prepared omitted the bacon from the pureed potato soup because it would be to hard the chew. During an interview on 8/23/23 at 12:16 P.M., with DFS and the Registered Dietitian (RD), the DFS stated kitchen staff needs to follow a recipe, per policy and procedure, including recipe for therapeutic diets like Pureed, because the residents will receive fewer calories and proteins, if recipe is not followed. The DFS stated the Cook should have used sausage as a substitution for bacon if needed to include the proper nutrition. The RD stated the soup should be listed on the menu for the residents to view and it is important to know for nutrient analysis. During a review of the facility's daily spread sheet titled Week 1-Day 2, Monday 8/21/23, the regular Diet lunch meal was 6 Oz Baked Potato soup, 2 Pkgs crackers, 1 cup Tomato and spinach salad, feta cheese and bacon vinaigrette, 3 oz Harissa marinated chicken, #8 five spice couscous, #8 butterred zucchini. The Pureed (PU4) lunch meal included 6oz of PUREE baked potato soup (omit skins and Bacon), plain crackers (PUREED with soup), Chilled steamed vegetables PUREE#12, Harissa marinated chicken PUREE #6, Five spice couscous PUREE#8 Butterred zucchinni PUREE#10. The daily Baked Potato soup was not listed on the daily or weekly menu. During a review of the facility's Report/Book 6 document titled Baked Potato Soup recipe, Recipe # SSOO37, indicated omit bacon and prepare with peeled potatoes ( no skins) refer to PUREED Soup recipe (#P26) for PUREED (PU4). During a review of the facility's policy and procedure (P&P) titled Standard Menu Information Regarding Calorie and Protein Levels, dated 9/29/15, indicated regular diet average calories = 2500 cal, Average protein 90-100 gm . During a review of the facility's policy and procedure ( P&P) titled, Standardized Recipes, dated 12/2013, indicated standardized recipes will be used for all products prepared .

Based on observation, interview and record review, the facility failed to ensure that one of eight sampled residents (Resident 361) reviewed for medication administration, received the medication in accordance with the physician's orders. This failure had the potential for the for Resident 361 to experience unexpected medication side effects or decreased drug action. Findings: During an observation on 8/23/23 at 9:38 A.M., licensed nurse (LN) 2 gave Resident 361 Aspirin 81 (milligram) mg chewable using a plastic spoon. Resident 361 swallowed the medication and did not chew the chewable Aspirin. LN 2 did not provide instructions to Resident 361 and the resident did not chew the Aspirin before swallowing. An interview on 8/23/23 at 9:42 A.M., with LN 2 was conducted. LN 2 stated that Resident 361 should have been instructed that the Aspirin was chewable and needed to be chewed first before swallowing to help with absorption. A review of Resident 361's physician's order on 8/23/2023 indicated an order for Aspirin chewable 81 milligram 1 tablet daily. During an interview on 8/25/2023 at 2:00 P.M., with the Director of nursing (DON), the DON stated that the licensed nurse should have followed the Physician's order and provide instructions to Resident 361 before the resident took the medication. A record review of the facility's Policy and procedure titled, Medication Administration, dated 11/2027, indicated . I. transcribing of medication orders, medical records and medication administration, #4 Nursing must read and compare POS and MAR being given and charted each time medication are administered. #5 If directions on medication do not exactly match order on MAR, must clarify orders, and direction change sticker and notify pharmacy of changes .

Based on observations, interview and record review, the facility failed to ensure the kitchen and dry storage room was free of pests. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. The facility census was 57. Cross- reference F800, F802, F812 Findings: During the initial kitchen tour on 8/21/23 at 8:25 A.M., there were three flies observed flying around the tray line counter area. During a concurrent observation and interview on 8/21/23 at 8:45 A.M., with the Director of Food and Nutrition Service (DFS), in the kitchen, three flies were observed flying around throughout the kitchen. The DFS acknowledged the fruit flies and stated there should be no fruit flies in the kitchen, to prevent cross contamination. The DFS stated he will call the pest control company to come out and look at it. During a concurrent observation and interview on 8/21/23 at 9:40 A.M., with the Executive Chef (EXC), in the kitchen dry storage room, there were four fruit flies observed flying around and an uncovered open 5-quart plastic bin with white sugar inside. The bin was unclosed with a red lid hanging off the top. The EXC acknowledged the fruit flies and stated they've been flying around for a while, but they should not be in the kitchen at all. The EXC stated he will follow up with the pest control company to spray again. During an interview on 8/23/23 at 12:16 P.M., with the Director of Food and Nutrition Services (DFS) and Registered Dietitian (RD), both the DFS and RD stated the kitchen should be free of bugs and pests and kitchen staff need to keep the kitchen clean to avoid pests. During a review of the pest company invoice records dated 8/23/2023, the invoice indicated the presence of drain flies in the kitchen, and Fruit flies come from specific sources .the two spices . find were uncovered produce such as onions and the drains . According to the 2022 Federal Food Code, section 6-501.111, .Controlling Pests .The premises shall be maintained free of insects, rodents and other pests . by . routinely inspecting the premises for evidence of pests . During a review of the facility's policy and procedure (P & P) titled Pest Control, dated 3/1/18, the Pest Control indicated .The Community shall implement a pest control program .1. Will help ensure that the community's residents .offers minimal risk of infection from unwanted insects.

Based on observation, interview and record review, the facility failed to ensure one of 8 residents (Resident 357) reviewed for psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) usage had proper indication for the use of an anti-anxiety medication (a type of psychiatric medication which are available on prescription to treat Anxiety, and in a range of other psychotic disorders). This failure resulted in Resident 357's continued use of an anti-anxiety medication without proper indication and possible exposure to the medication's side effects. Findings: A review of Resident 357's Admission Record indicated that Resident 357 was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Depression (a common and serious medical illness that negatively affects how you feel, the way you think, and how you act). During a record review of Resident 357's physicians order, dated 8/22/2023, indicated an order for Buspar (a medication that treats anxiety which helps think clearly, relax, worry less and take part in everyday life) 5 mg (milligrams) twice a day. The physician order also indicated that Resident 357 was placed on Buspar due to worry about her son who is hospitalized with Covid (a large group of viruses that causes illness ranging from the common cold to more severe diseases). An interview with Resident 357 was conducted on 8/23/23 at 10:58 A.M. Resident 357 was alert and stated, I take Buspar for my anxiety and my doctor told me I needed the medication. My son was in the hospital for Covid, I know I must stop taking it when my son gets out of the hospital. Resident 357 further stated she worries too much about anything that can happen to herself, her son, her family and mostly everything else due to worsening or declining health and medical issues. A review of the Geropsychiatry (psychiatry of old age, subspecialty of psychiatry dealing with the study, prevention, and treatment of neurodegenerative, cognitive impairment, and mental disorders in people of old age) note from 8/22/2023, indicated that Resident 357 stated that she had been very anxious and somewhat depressed lately. The note indicated that Resident 357 was anxious about her physical decline and now worried about her son who was hospitalized with Covid. The note also indicated that she felt depressed related to her physical disability. During an interview on 8/23/2023 at 2:30 P.M., with licensed nurse (LN) 2 stated that the indication for the use of Resident 357's Buspar was incorrect. LN 2 stated that accurate behavior monitoring for psychotropic medication was important to determine medication effectiveness. During an interview on 8/23/23 at 3:30 P.M., with the Director of nursing (DON), the DON stated that monitoring of the specific behavior for psychotropic medications was important to evaluate the effectiveness of the medication. During an interview on 8/24/2023 at 2:40 P.M., with the social service director (SSD), the SSD stated it was important for anxiety medications to have the specific monitoring behavior in addressing Resident 357's anxiety. A review of the facility policy titled, Psychoactive Medication Management Process, last revision dated 7/10/2019, indicated, Philosophy . the facility will implement systems for monitoring side effects, adverse reactions and behaviors. Procedures . #5 Behavior monitors will be in place to monitor effectiveness of medications.

Based on observation, interview and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when holding temperatures on the steam table and resident trays were below acceptable range. These failures had the potential to result in decreased food intake and further compromise the nutritional status of medically vulnerable residents in the facility. The facility census was 57. Cross reference F692, F800, F802, F803 Findings: During a kitchen observation and interview on 8/21/23 at 11:48 A.M., with Cook 1 (CK1) and the EXC of the steam table, the temperature of lunch meal main entree Harissa Marinated Chicken was at 153 degrees F. CK1 stated the temperature of the chicken entree was 165 degrees F right after cooking, but she never re-checks it or logs the final cooking temperature. CK 1 stated she takes the temperature again when the food is on the steam table. The EXC stated CK 1 should have checked to ensure the holding temperature was safe to make sure it was at the steam table. During a record review on 8/22/23 at 11:20 A.M., of the resident council meeting minutes, seven residents (10, 39, 18, 47,43, 356, 35) attended. Residents complained hot foods being served at lukewarm temperatures and not hot enough, especially food in the dining room. During a test tray observation on 8/22/23 at 11:25 A.M., with the Registered Dietitian (RD), the Director of Food and Nutrition Services (DFS) and the Executive Chef (EXC), the lunch meal regular diet and pureed diet trays were tested for temperature, taste, and palatability. Once all residents on the unit received their trays and were eating at 11:43 A.M., the temperatures were taken of the foods by the DFS and two Surveyors using the facility thermometer and compared with the Surveyor's thermometer. The temperatures were within three degrees of each other. The regular diet meal food temperatures from the Surveyor's thermometer included: Beef Tenderloin 120.3 degrees Fahrenheit (F); [NAME] Red Potatoes 111 degrees F; Brussels sprouts 114 degrees F; Chicken soup 141 degrees F. The puree diet temperatures were as: beef puree 133.7 degrees F; mashed potatoes 132 degrees F; brussels sprouts puree 119 degrees F; chicken pureed soup 124.1 degrees F. The temperatures of the regular and pureed diet food items varied between warm and lukewarm. The DFS, EXC and RD also tasted each food item with the surveyors. The pureed food items were not flavorful and according to the DFS, tastes grindy and not like the regular diet foods. The pureed brussels sprouts did not have the taste and flavor of brussels sprouts. The DFS stated the pureed brussels sprouts could use more seasoning to improve palatability. The temperature of the apple juice was at 71.6 degrees F. The DFS stated the juice should have been cooler before it is served to the residents. According to the 2022 US Food and Drug Administration (FDA) Food Code, Section 3-403.11, titled Reheating for Hot Holding, When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens can multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of Clostridium perfringens that may grow in meat, poultry, or gravy if these products were improperly cooled. According to the 2022 Federal FDA Food Code, Annex section 3-501.16, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. During a review of the facility's policy and procedure (P & P) titled, Food temperatures, dated 2014, the P & P indicated, .Foods should be served at proper temperature to insure food safety and palatability .3. Record reading on food temperature Chart at beginning of tray line and end of tray line .4. Acceptable serving temperatures are: .Meat, entrees greater than or equal to 140 degrees F (Fahrenheit), potatoes greater than or equal to 140 degrees F, Vegetables greater than or equal to 140 degrees F, and Milk, juice less than or equal to 41 degrees F . 8. Palatability of foods determines appropriate temperature at bedside or tableside food Resident's surveys will determine their acceptability.

Based on interview and record review, the facility failed to develop and implement a care plan for bladder scanning for one of three residents (Resident 1) when: 1. Resident 1's bladder scanning, and straight catheterization were not done as ordered by the physician. 2. The Licensed Nurses (LN) did not follow their straight catheterization procedure. 3. The facility did not educate their nurses on bladder scanning and straight catheterization. As a result, Resident 1 had a change of condition and was transported to the hospital where he was treated with intravenous (IV) antibiotics for a urinary tract infection, sepsis (blood infection), and urinary retention. Findings: A review of Resident 1's undated facility face sheet was conducted. Resident 1 sustained a fall at home, which resulted in a collar bone fracture. After stay in the hospital the resident was admitted to the facility on [DATE], with diagnoses which also included a history of type 2 diabetes mellitus (condition of having elevated blood sugar), and stage 3 kidney failure (a moderate amount of kidney damage due to chronic kidney disease). 1. On 4/7/22, a review of Resident 1's facility record was conducted. The record titled Order Summary Report indicated on 2/26/21, Resident 1's physician ordered, Bladder scan every 8 hours. May straight cath (catheterization) if over 400 cc (cubic centimeter) . Per Resident 1's Treatment Record for February and March 2021, the order stated, Bladder scan every 8 hours. May straight cath if over 400 cc and report to MD as needed for Bladder discomfort. Hours: PRN (as needed). Per the treatment record Resident 1's bladder was scanned only twice in 6 days, on 2/27/21 and 3/4/21. Further review of Resident 1's Progress Notes indicated that Resident 1 was straight cathed for 1000 cc of clear urine on 2/27/21, and 1400 cc of cloudy colored urine on 3/4/21, resident noted to be having chills, temperature was recorded at 98 degrees Fahrenheit and blood pressure at 100/53, the physician was notified, and an order was obtained for an antibiotic and a urine culture. Per the record titled Progress Notes dated 3/5/21 at 5:38 A.M., Resident 1 was difficult to arouse, blood pressure was 72/35 and he was non-verbal. Physician 2 (PH 2) ordered for Resident 1 to be transferred to the emergency room for further evaluation. On 4/18/22 at 4 P.M., an interview and concurrent record review was conducted with License Nurse (LN) 1 [in person] and the Director of Nurses (DON) [via phone]. LN 1 stated the physician's order, written for Resident 1 on 2/26/21 to bladder scan was a PRN (as needed) order and not a regular routine every 8-hour order. LN 1 was insistent and repeated that the order was PRN, and the bladder scanning did not need to be done every 8 hours. The DON stated the order clearly indicated the physician wanted Resident 1 to be scanned every 8 hrs. The DON stated the nurses did not follow the physician's order. The DON stated if Resident 1 was retaining urine and he needed the bladder scanning as ordered to prevent bladder and/or kidney infection and possible kidney failure. The DON stated the licensed nurses should have bladder scanned Resident 1 every 8 hrs. as ordered. The DON stated the nurses should have also contacted the physician when the resident was having that much urine retention at one time. On 5/2/22, a review of Resident 1's acute care hospital record was conducted. The record titled Hospital Medicine Discharge summary dated [DATE], indicated that Resident 1 was admitted to the acute care hospital on 3/5/21, from the facility with UTI, sepsis, acute renal failure (kidneys not functioning), and urinary retention. He was treated with IV antibiotics and was discharged to home on 3/10/21, with an indwelling catheter and a recommendation for outpatient urology follow up. On 5/17/22 at 12:09 P.M., a phone interview and concurrent record review was conducted with Physician (PH) 1. PH 1 stated it was his expectation that facility was going to bladder scan Resident 1 every 8 hours and then straight cath the resident if the bladder scan read more than 400 cc in the bladder per his 2/26/22 order. PH 1 stated his order was not a PRN (as needed) order. PH 1 stated Yes, that is a problem if the resident was retaining 1400 cc of urine and not straight cathed. PH 1 stated if continuous bladder retention was occurring and not addressed it could lead to bladder discomfort and could result in renal failure, UTI (urinary tract infection), or post obstructive nephropathy (kidney dysfunction). PH 1 stated he would have expected a phone call from the facility if resident was having continued amount of urine retention. A facility document review was conducted. The document titled Required Services revised 8/02/2021 indicated, .(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated . 2. A review of a facility document was conducted. The document titled Catheterization, Intermittent, Male Resident with a revision date of 2010 indicated, .Do not remove more than 800 mL (milliliters) of urine at one time . On 4/18/22 at 4 P.M., a phone interview and concurrent record review was conducted with License Nurse (LN) 1 and the facility's Director of Nursing (DON). LN 1 stated she did not follow the policy when straight catheterizing Resident 1 when she removed over 1400 cc of urine from his bladder. LN 1 stated she should have stopped at 800 cc. LN 1 was unable to give a rationale as to why she should not remove more than 800 cc. The DON stated catheterizing someone for more than 800 mL could cause infection, pain, possible renal failure and was just too big of a shift in fluid at one time in the body. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff Development (DSD). The DSD stated the licensed nurses should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications. 3. On 5/9/22 at 7:07 A.M., a phone interview was conducted with License Nurse (LN) 3. LN 3 stated the facility had a new bladder scanner when Resident 1 was at the facility. LN 3 stated he did not receive formal training from the facility on the new bladder scanner. LN 3 stated he did not remember receiving any education from the facility on straight catheterization of a resident. LN 3 stated if the bladder scanner said a resident had 1500 cc in a resident's bladder, he would straight catheterize them and remove 1300 cc to 1500 cc from their bladder if there was an order to straight catheterize the resident. On 5/17/22 at 10:51 A.M., the facility's Director of Nursing (DON) confirmed via email that LN 1, LN 2, LN 3, and LN 4 who cared for Resident 1 while at the facility did not receive any education or competency evaluation on bladder scanning or straight catheterization of a resident prior to June 2021. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff Development (DSD). The DSD stated it was very important for the Licensed Nurses (LNs) to have education on bladder scanning and bladder catheterization. The DSD stated if the LNs do not catheterize a patient correctly it could lead to bladder infections and kidney problems. The DSD stated if the LNs do not know how to use the bladder scanner properly the LNs may not be able to identify if the resident is retaining urine. The DSD stated if the LNs do not identify if the resident is retaining urine it could lead to the resident getting a bladder infection and/or kidney problems. The DSD stated if the resident is retaining urine the nurse should call the doctor to let them know. The DSD stated the LNs should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications.

Based on interview and record review, the facility failed to address one of two sampled residents' (Resident 1) fall on 2/7/21 and provide new fall preventative interventions to prevent Resident 1 from falling again. As a result, Resident 1 was at risk for further fall incidents. Findings: According to Resident 1's Admission Record, Resident 1 was admitted to the facility on [DATE] with the diagnoses including History of Falling and Cognitive Communication Deficit (difficulty with thinking and how someone uses language). According to Resident 1's Progress Notes, dated 2/2/21, .Reported by attending CNA (Certified Nursing Assistant) and evaluated patient sitting on her buttocks in the bathroom of her room .Patient recently had multiple falls . According to Resident 1's Fall Risk assessment, dated11/3/20, .Score: 10 .Total score of 10 or above represents HIGH RISK . According to Resident 1's Physician/Practitioner Progress Notes, dated 11/5/20, .Chief Complaint: Recurrent falls .Assessment and Plan: .1 .She (Resident 1) will continue to have fall risk . On 2/8/22, at 10:25 A.M., a telephone interview and joint record review was conducted with the Director of Nursing (DON). The DON stated Resident 1 was a high fall risk. According to Resident 1's Care Plan, .The resident has had an actual fall with r/t (related to) Poor Balance, Psychoactive (alter brain function) drug use, Unsteady gait .02.02.2021 Unwitnessed fall during self ambulation (walking)/toileting .Date Initiated: 01/28/2021 . According to Resident 1's Care Plan, .The resident is at risk for falls r/t Hx (history) of fall, Gait/balance problems, confusion, impulsiveness, lack of safety awareness .Date initiated: 11/04/2020 . The DON stated could not find new fall preventive interventions in Resident 1's care plans following the fall on 2/2/21. The DON stated new interventions should have been added to minimize Resident 1's risk of falls and injury. The DON stated the facility's policies on assessing and preventing falls were not followed. According to the facility's document titled, Falls Intervention Policy and Procedure, dated 7/23/19, .Policy: .Residents with a history of falls during the past three months, actual fall during length of stay and/or triggered on the falls risk assessment will have a plan of care to address fall safety .Steps following a fall .5. Review and update causative factors, interventions, care plan and fall assessment will be completed .7. Nursing staff will make appropriate interventions upon the completion of the report to minimize reoccurrence of a fall or to minimize injury . According to the facility's document titled, Assessing Falls and Their Causes, dated 10/2010, .Documentation .When a resident falls, the following information should be recorded in the resident's medical record: .6. Appropriate interventions taken to prevent future falls .

Based on interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, there was a potential for Resident 1 to have not received needed medical care. Findings: According to Resident 1's Admission Record, Resident 1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) and 420 on 2/27/21 at 1745 (5:45 P.M). According to Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin [MEDICATION(S)] (fast-acting insulin) Solution Inject as per sliding scale (the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges): .401-999 = 12 units Call MD (administer 12 units and call the physician) . On 2/2/22, at 4:15 P.M., an interview and joint record review with the Director of Nursing (DON) was conducted. The DON reviewed Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/3/22, at 2:50 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated Resident 1 was already eating breakfast before the blood sugar check on 2/1/21. LN 1 stated should have called Resident 1's physician right away but did not. LN 1 stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/3/22, at 3:00 P.M., a joint interview and record review was conducted with LN 2. LN 2 stated a telephone call to a physician would have been documented in Resident 1's progress notes on 2/27/21 but was not. LN 2 stated probably forgot to call Resident 1's physician. LN 2 stated it was important to make the physician aware of Resident 1's condition to prevent risk to Resident 1's health. According to Resident 1's physician orders, dated 11/8/20, .Insulin [MEDICATION(S)] Solution Inject as per sliding scale: .401-999 = 12 units Call MD, subcutaneously (under the skin) as needed for Diabetes . According to Resident 1's physician orders, dated 11/25/20, Blood Sugar check before breakfast, before lunch and dinner and HS (at bedtime). See sliding scale. Before meals and at bedtime for diabetes . According to the facility's policy titled, Required Services, dated 8/2/21, .(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe (physician), shall be carried out unless contraindicated .

Based on observation, interview, and record review, the facility failed to implement their Abuse Investigation Policy for one resident (1) when the Abuse Coordinator was not notified immediately. This failure had the potential to place the resident at risk for abuse. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A report of allegation of verbal abuse between an employee and Resident 1 was received from the facility on 3/25/21 that occurred on 3/19/21. An observation of Resident 1 was conducted on 4/6/21 at 12:30 P.M. Resident 1 was in her room asleep in bed. An interview was conducted with certified nursing assistant (CNA) 1 on 4/6/21 at 9:17 A.M. CNA 1 stated the verbal abuse occured on a Friday (3/19/21). CNA 1 stated Resident 1 was at the nursing station and heard CNA 2 yelling at Resident 1 to shut up. CNA 1 stated, The incident happened on 3/19/21 and I didn't report it until 3/24/21; the facility was not told until 3/24/21. I heard CNA 2 say a loud shut up to Resident 1. I meant to tell someone, but I wasn't feeling well, so I didn't say anything until Wednesday; I feel bad and I had the training; not reporting it put the Resident at risk. An interview was conducted with CNA 2 on 4/8/21 at 11:34 A.M. CNA 2 stated, It happened at 6:10 A.M. at the end of the shift; the Resident was sitting in the nursing station and was talking and talking and talking. I asked her to do me a favor and turn your voice down and be quiet. An interview was conducted with the director of nursing (DON) on 4/6/21 at 9:19 A.M. The DON stated, CNA 1 should have notified us right away, the first duty is to prioritize the patients; CNA 1 is a mandated reporter. A review of the facility's policy, dated 7/20/20, titled, Elder Abuse Prevention, Identification Investigation and Reporting indicated, .Policy: It is the policy of the Community that each resident shall be free from abuse .III Prevention: If an employee has reason to believe that any form of abuse has or will occur, they shall immediately report .