Every finding on record at Glendale Healthcare Center

Based on observation, interview, and record review the facility failed to properly wash dishware when the water temperature was lower than manufacturer specifications. This deficient practice has the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all medically compromised residents.Findings: During an observation on 2/18/2026 at 8:51 AM, Dietary Aide 1 (DA1) was operating a low-temperature dishwasher (commercial ware washers that clean at 120 -140 degrees Fahrenheit (F) water temperature and rely on chemical sanitizers) to wash plate ware from breakfast service where the water reservoir thermometer read 98 F. During a concurrent interview with Dietary Services Supervisor (DSS) she stated that water temperature varies during usage and should be 120 F at the beginning of dishwashing. During a concurrent record review, a poster issued by the manufacturer of the dishwashing machine placed on the wall facing where DA1 was working indicated It is recommended that 140 F water be used. Report to your supervisor if it is lower than 120 F or higher than 160 F. During a concurrent observation and interview on 2/18/2026 at 11:22 AM with the Maintenance Supervisor (MS) stated that there is second thermometer installed in the hot water inlet pipe behind the dishwashing machine which indicates the temperature of incoming water which should be at minimum 140 F. He states that the water heater is located on the second floor and is far enough to cause variations in heat when initiating the machine. MS states that incoming maintenance requests are made verbally and that he has not received any requests regarding low temperatures during the use of the dishwashing machine. During an observation on 2/18/2026 at 11:45 AM the hot water inlet thermometer (instruments used to monitor water temperature) as it enters a system has been marked with a thick black line at 140 F to indicate the appropriate temperature prior to filling the water reservoir in the dishwasher. During a concurrent interview, DSS reports that Diet Aides are supposed to drain and fill the machine once the inlet thermometer meets 140 F mark at minimum. During an observation on 2/19/2026 at 8:30 AM, Dietary Aide 2 (DA2) was operating the dishwashing machine while the sink reservoir thermometer showed a temperature of 98 F. DA2 notified the Dietary Services Supervisor (DSS), who performed a drain-and-fill, resulting in a temperature increase to 105 F. During a concurrent interview, the DSS stated the temperature should be at least 120 F to properly wash dishware and reduce the risk of cross contamination. Maintenance Staff (MS) was alerted and performed another drain and fill, draining the reservoir longer until the inlet thermometer reached 140 F and the reservoir reached 133 F. DSS stated staff had been educated on this procedure; however, she was unable to provide any in service records at the time of request. During a document review of the facility's Policies and Procedures titled Sanitation dated 11/2022 it states that dishwashing machines are operated according to manufacturer's instructions and indicates a wash temperature of 120 F. During a document review of the manufacturer's Parts Manual dated 9/2016 it states that failure to provide adequate water temperature to the machine will cause the machine to function improperly. During a document review of the manufacturer's Service Manual the operating procedures indicate that if water temperature gauge has not reached 120 F, drain water from the machine and continue to fill until proper temperature is attained.

Based on interview and record review, the facility failed to ensure annual skills competency assessments for four of seven sampled nursing staff (Licensed Vocational Nurse [LVN] 2, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) as required in their Facility Assessment (a yearly review that identifies the staff, equipment, and resources the facility needs to safely and effectively care of its residents). This deficient practice had the potential to place residents at risk for unmet care needs and care errors related to activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), hand hygiene (the practice of cleaning one's hands-either by washing with soap and water or using an alcohol-based hand sanitizer-to remove dirt, germs, and pathogens, thereby preventing the spread of infections), and measuring vital signs (VS) and intake / output (I/O). Findings: During a review of LVN 2's employee file, the file indicated LVN 2's last competency evaluation was done on 4/16/2024. During a review of CNA 4's employee file, the file indicated CNA 4's last competency evaluation was done on 8/16/2024. During a review of CNA 3's employee file, the file indicated CNA 3's last competency evaluation was done on 11/4/2024. During a review of CNA 2's employee file, the file indicated CNA 2's last competency evaluation was done on 12/14/2024. During a review of the Facility Assessment revised in 1/2026, the Assessment indicated the following facility resources needed to provide competent resident support and care daily and during emergencies: Competencies on Activities of Daily Living was required to be evaluated upon hire, annually, and as needed for CNAs and Licensed Nurses (LNs). Competencies on Infection Control - Hand Hygiene was required to be evaluated upon hire, annually, and as needed for all staff. Competencies on Measurements - Vital Signs (VS) and Intake and Output (I/O) was required to be evaluated upon hire, annually, and as needed for CNAs and LNs. During a review of the Director of Staff Development (DSD) and Infection Preventionist (IP) in-service (a training session provided by a facility to educate staff on specific skills, policies, or procedures they need to know to safely and correctly perform their jobs) binder, the in-services indicated the following: LVN 2's last competency evaluation on Hand Hygiene was last completed in 2024. CNA 2's last competency evaluation on ADL's, Hand Hygiene, and Measurements of VS and I/O was last completed in 2024. CNA 3's competency evaluation on Measurements of VS and I/O was last completed in 2024. CNA 4's competency evaluation on Measurements of VS and I/O was last completed in 2024. During an interview with the Director of Staff Development (DSD) on 2/19/2026 at 3:20 PM, the DSD stated skills competencies for nursing staff were done upon hire and once a year to ensure that all nursing staff were competent and able to perform their job duties correctly. The DSD stated it was important that staff's competency be regularly evaluated for the safety of the facility's residents. During another interview with the DSD on 2/19/2026 at 3:35 PM, the DSD stated she was not aware of the facility's Facility Assessment or the staff competency requirements outlined in it. During an interview with the Director of Nursing (DON) on 2/20/2026 at 8:12 AM, the DON stated the facility held an annual Skills Fair that assessed the nursing staff's competencies, but she was not aware that their Facility Assessment included the required topics of the nursing staff's annual competency assessment. During another interview with the DON on 8/20/2026 at 8:23 AM, the DON stated the previous Skills Fair was completed on 6/2026. The DON further stated that if any staff missed the Skills Fair, there should be a makeup day. However, the DON stated she was not sure if there was a makeup day completed for the previous Skills Fair. During an interview with the Administrator (ADM) on 8/20/2026 at 2:24 PM, the ADM stated that the Facility Assessment was revised annually as needed by the interdisciplinary team (IDT) which consisted of CNAs, LNs, DSD, and DON and was updated based on resident care needs and resident population. The ADM stated there would be a concern if the staff's competency was not completed based on the Facility Assessment. During a review of the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing revised on 8/2022, the P&P indicated competency requirements and training for nursing staff were established and monitored by nursing leadership with input from the medical director to ensure that Gaps in education were identified and addressed Tracking or other mechanisms were in place to evaluate effectiveness of training

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent complications (unexpected problems that may arise during treatment) of enteral feedings (liquid nutrition through a flexible tube that goes in directly into the stomach) for two of three sampled residents ( Residents 36 and 25) who was observed receiving enteral feeding continuously with head of bed (HOB) less than 30 degrees in accordance with the facility's policy and procedure titled Enteral Feedings - Safety Precautions This deficient practice had the potential to result in vomiting and/or aspiration pneumonia (severe lung infection) that could negatively affect Resident 36 and 25 qualities of life. Findings: 1. During review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included attention to gastrostomy (G-tube-a surgically placed device used to give direct access to the stomach for supplemental feeding), gastroesophageal reflux disease (GERD) (a chronic condition where stomach acid frequently flows back up into the esophagus (the tube connecting the mouth and stomach), causing regular heartburn, irritation, and damage), dysphagia (swallowing difficulties) and generalized muscle weakness. During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2026, Resident 36 cognitive skills (ability to make decisions) was severely impaired. The MDS indicated Resident 36 was dependent (helper does all the effort) to all activities of daily living (ADLs). During a review of Resident 36's care plan (CP) Resident requires tube feeding related to dysphagia dated 2/6/2026, intervention include elevate HOB 30 to 45 degrees during feeding with the goal to be free of complications related to tube feeding. During a review of Resident 36's order summary report (OSR), dated 2/18/2026 indicated; Resident 36 to receive feeding formula via G-tube at a rate of 60 cc/hour times 20 hours a day, and elevate HOB 30 to 45 degrees during feeding. 2. During review of Resident 25's admission Record indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included attention to gastrostomy tube (G-tube), dysphagia, and hemiplegia and hemiparesis (weakness or inability to move one side of the body). During a review of a Minimum Data Set, dated [DATE], Resident 25 cognitive skills was severely impaired. The MDS indicated Resident 25 was dependent to all activities of daily living. During a review of Resident 25's care plan Resident requires tube feeding related to dysphagia dated 2/11/2022, intervention include elevate HOB 30 to 45 degrees during feeding with the goal to be free of complications related to tube feeding. During a review of Resident 25's order summary report, dated 2/18/2026 indicated; Resident to receive feeding formula via G-tube at a rate of 65 cc/hour times 20 hours a day, and elevate HOB 30 to 45 degrees during feeding. During a concurrent observation and interview on 2/18/2025 at 9:42 AM with Licensed Vocational Nurse (LVN) 1, both Residents 36 and 25 were receiving continuous enteral feedings with their head-of-bed (HOB) elevated less than 30 degrees and receiving continuous enteral feeding. LVN 1 stated, Residents HOB should be elevated at least 30 degrees during enteral feeding but there were no guidelines posted on the bed to ensure the HOB was at least 30 degrees. LVN 1 stated, not ensuring Resident 36 and 25's HOB at least 30 degrees had the potential to result in vomiting and/or aspiration pneumonia. During a concurrent observation and interview on 2/18/2025 at 9:50 AM with the Nurse Consultant (NC) in Residents 36 and 25's shared room, both residents were receiving continuous enteral feedings with their head of bed (HOB) minimally elevated. Using an angle measuring device, the NC confirmed Resident 36's HOB was at 19 degrees and Resident 25's was at 22 degrees, both below the required minimum of 30 degrees. The NC stated that residents on enteral feeding must have their HOB elevated at least 30 degrees to reduce the risk of vomiting, fluid entering the lungs, and aspiration pneumonia. During an interview on 2/19/2026 at 8:52 AM, the Director of Nursing (DON) stated it was unacceptable for Residents 36 and 25, who were receiving continuous enteral feedings, to have their head of bed (HOB) elevated less than 30 degrees. The DON explained that inadequate HOB elevation increases the risk of vomiting and aspiration pneumonia, which could negatively affect the residents' overall health. A review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions dated 11/2018, indicated; in preventing aspiration, elevate the HOB at least 30 degrees during tube feeding and at least 1 hour after feeding.

Based on observation, interview, and record review, the facility failed to ensure one of seven residents sampled for pressure injury prevention (Resident 1), who had multiple pressure injuries, received necessary treatment and services consistent with professional standards of practice when Resident 1's low air loss mattress (LAL- a medical support surface that uses a constant flow of air to reduce pressure, heat, and moisture on the skin to help prevent or treat pressure injuries) was set to an incorrect setting. Based on Resident 1's weight of 161 pounds (lbs- a unit of weight), the LAL setting should have been at level 3. During the survey observation, Resident 1's LAL setting was found to be set at level 4. This failure had the potential to cause further worsening of Resident 1's pressure injuries. A misconfigured mattresses that is not aligned with the resident's weight may also compromise the resident's stability while in bed, increasing the risk of accidents or injury. During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including a Stage 3 pressure injury (Full-thickness loss of skin. Dead and black tissue may be visible) of the right lower back and unstageable pressure injuries (a wound covered by slough [dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds] or eschar [dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off] that makes the depth impossible to determine) on his left heel and sacrum. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1 had severely impaired cognition (significant difficulty with memory and orientation) and required maximal assistance (helper does more than half the effort) for turning left and right, and dependent on staff (helper does all of the effort) for most cares such as toileting and bathing. The MDS also indicated Resident 1 was at risk of developing pressure injuries. During a review of Resident 1's untitled Care Plan (CP) initiated on 12/14/2025 and revised on 2/19/2026, the CP indicated Resident 1 was at risk of pressure injury development related to fragile skin, immobility, aging process, and disease process. The CP indicated interventions to use a low air loss mattress for wound management: Setting 3 (135 lbs - 170 lbs). During a review of Resident 1's Current Weights and Vitals dated 2/20/2026, the document indicated Resident 1's weight on 2/1/2026 was 161 lbs. During a review of the facility's undated low air loss manufacturer's guidelines titled, DermaFloat LAL (Low Air Loss) Model: Comfort Adjust Setting, the guidelines indicated to: Select the highest or most firm Comfort Adjust setting. For residents 135 lbs to 170 lbs, set to 3. Document comfort setting on pump label provided and re-evaluate comfort setting as needed. If a resident requests a comfort setting that falls outside the parameters provided, then provide education and document setting and rationale in plan of care. During an observation on 2/18/2026 at 10:48 AM, Resident 1's low air loss mattress was observed. A label to the top right corner of the LAL machine indicated, Setting: 3. The Comfort Adjust settings indicated numbers 1, 2, 3', 4, and 5. The number 4 on the Comfort Adjust setting of the machine was lit up with a blue light. During an interview with the Director of nursing (DON) on 2/19/2026 at 10:38 AM, the DON stated the label at the top of the LAL machine indicated what setting the LAL should be set to. The DON further explained that Resident 1's LAL setting was set to 4 but should have been set to 3 per the resident's weight and the LAL manufacturer's guidelines. The DON stated that not setting the LAL appropriately can cause more harm than good and can cause further skin breakdown for the resident. The DON stated she usually checked the residents' LAL settings to ensure they were appropriate, however she did not do that today. During a review of the facility's Policy and Procedure (P&P) titled Support Surface Guidelines, revised 2/2024, the P&P indicated: Redistributing support surfaces were to promote comfort for all bed- or chairbound residents, promote circulation, and provide pressure relief reduction. Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface such as. air-loss. when lying in bed.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 don (put on) an isolation gown (designed to protect healthcare workers from blood, bodily fluids, and contaminants by covering the torso, arms, and back) when providing care for one of one sampled residents (Resident 7) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a Sacro coccyx (near the lower back and spine) wound. This deficient practice had the potential to result in Resident 7 acquiring MDROs and/or spreading MDROs to other residents in the facility which could result in wide spread infection in the facility affecting their health and quality of life. Findings: During review of Resident 7's admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted with diagnoses that included pressure ulcer (skin injury due to prolonged unrelieved pressure) of sacral region , anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and end stage renal disease (person's kidneys cease functioning on a permanent basis). During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 11/19/2025, Resident 7 cognitive skills (ability to make decisions) was moderately impaired. The MDS indicated Resident 7 required set-up or clean-up assistance (helper sets up and clean up) with eating, and partial/moderate assistance (helper does less than half the effort) with toileting, bathing and personal hygiene. During a review of Resident 7's order summary report, dated 11/16/2025 indicated, Resident to be placed on Enhanced Barrier Precautions due to Sacro coccyx wound. During a review of Resident 7's care plan (CP) Resident requires Enhanced Barrier Precautions related to unhealed wound, dated 11/24/2025, intervention includes use of gown during high contact care activities such as brief changes. During an observation on 2/18/2025 at 12:02 PM by Resident 7's doorway, was an EBP signage indicating to use gown when performing brief changes to the Resident. During a concurrent observation and interview on 2/18/2025 at 12:05 PM with Certified Nurse Assistant (CNA) 1, in Resident 7's room (Resident 7 agreed to be observed during brief changing), observed CNA 1 touched and positioned Resident 7 to the side and changed the incontinent brief without wearing an isolation gown. CNA 1 stated, she forgot to wear a gown during her care, though she knows Resident 7 was on EBP isolation. CNA 1 stated, it is important to wear a gown when changing Resident 7's brief to prevent infection in the facility. During an interview on 2/19/2026 at 11:58 AM with the Director of Nurses (DON), DON stated, she was aware CNA 1 touched and changed Resident 7 briefs without wearing an isolation gown. DON stated, Resident 7 was on EBP isolation because of her unhealed Sacro coccyx wound, so wearing a gown is important during close contact care such as changing briefs to protect Resident 7 and other residents in the facility to acquire MDRO's and negatively affect their overall health and quality of life. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2022, the P&P indicated: a) enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents, b) EBPs employ isolation gown use during high contact resident care activities, and c) examples of high contact resident care activities requiring the use of isolation gown for EBPs include: providing hygiene and changing briefs

Based on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 1) reviewed for anticoagulant (a medicine that prevented blood clots from forming in the bloodstream) and antiplatelet (a type of medicine that prevented platelets [a type of blood cell] from sticking together and forming a blood clot) medication by failing to implement a care plan for apixaban (also known as Eliquis, a type of medicine known as a blood thinner) and clopidogrel bisulfate (also known as Plavix, a medicine that prevented blood clots by making your blood cells [platelets] less sticky). These deficient practices had the potential for a lack of individualized care and to affect the quality of services provided to Resident 1.During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), atherosclerotic heart disease of native coronary artery (when plaque [a waxy buildup of fat, cholesterol, and other substances] forms in the arteries that supply the heart muscle with blood) and other specified disorders of veins (medical conditions that impair the normal function of the body's veins, leading to symptoms like swelling, pain, discoloration, and potentially serious complications like blood clots). During a review of Resident 1's Order Summary Report dated 9/3/2025, the Order Summary Report indicated apixaban oral tablet 2.5 milligram (mg, unit of weight), one tablet to be administered by mouth two times a day for cerebrovascular accident (CVA [also known as a stroke], when blood supply to a part of the brain was suddenly cut off, causing brain cells to die) prophylaxis (PPX, prevention or protective treatment). During a review of Resident 1's Order Summary Report dated 9/3/2025, the Order Summary Report indicated clopidogrel bisulfate oral tablet 75 mg, one tablet to be administered by mouth one time a day for coronary artery disease (CAD, a condition where the heart's arteries become hardened and narrowed). During a review of Resident 1's Skin assessment dated [DATE], the Skin Assessment indicated the resident had skin discoloration on the inner right upper arm and the top of the resident's left hand. The Skin Assessment indicated the resident had skin discoloration to the right and left lower extremities. During a review of Resident 1's Comprehensive (complete) Care Plan dated 9/3/2025, there was no Care Plan initiated to indicate Resident 1 was on the medication apixaban. During a review of Resident 1's Comprehensive Care Plan dated 9/3/2025, there was no Care Plan initiated to indicate Resident 1 was on the medication clopidogrel bisulfate. During a review of Resident 1's History and Physical (H&P) dated 9/4/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/8/2025, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impact their daily life). The MDS indicated Resident 1 was receiving an anticoagulant and an antiplatelet medication. During a concurrent interview and record review on 9/16/2025 at 4:46 PM, with licensed vocational nurse (LVN) 1, LVN 1 stated Resident 1 did not have a resident specific care plan initiated for the use of apixaban. LVN 1 stated without a care plan, there would not be a goal or specific interventions regarding the use of the specific medication, and the facility could not provide specific care required for Resident 1. LVN 1 stated Resident 1 could potentially bleed out and die. During a concurrent interview and record review on 9/16/2025 at 4:48 PM with LVN 1, LVN 1 stated Resident 1 did not have a resident specific care plan initiated for the use of clopidogrel bisulfate. LVN 1 stated without a care plan, there would not be a goal or specific interventions regarding the use of the specific medication and the facility would be lacking care since care was not resident specific. LVN 1 stated Resident 1 could potentially bleed out and die. During a concurrent interview and record review on 9/16/2025 at 5:14 PM, the Director of Nursing (DON) stated Resident 1 did not have a resident specific care plan for apixaban. The DON stated the resident should have had an apixaban care plan because Resident 1 was receiving that medication and the resident was at risk for bruising and discoloration. During a concurrent interview and record review on 9/16/2025 at 5:17 PM, the Director of Nursing (DON) stated Resident 1 did not have a resident specific care plan for clopidogrel bisulfate. The DON stated the resident should have had a clopidogrel bisulfate care plan because Resident 1 was receiving that medication and the resident was at risk for bruising and discoloration. During a review of the facilities policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P indicated The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, includes the resident's stated goals upon admission and desired outcomes; and reflects currently recognized standards of practice for problem areas and conditions. The P&P indicated Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observation, interview, and record review, the facility failed to assess, monitor, intervene and evaluate care of two out of three sampled residents (Residents 28 and 31) by failing to: 1.Ensure Resident 28's wound on the left eye was identified and assessed by facility to ensure resident received timely and appropriate care for behavior of self -inflicted wound and scratching under the left eye. 2. Ensure Resident 31's daily episodes of emesis (vomit) where documented, assessed for the root cause, monitored and reported to the primary physician. As a result of these deficient practices, Resident 28 could develop worsened skin and wound infection and severe pain. For Resident 31 frequent vomiting could result in dehydration (significant fluid loss in the body) and electrolytes (essential minerals in the body for the cells to function) loss that leads to and organ failures. Findings: 1. A review of Resident 31's Admission Record indicated the facility admitted the resident on 8/27/2021, with diagnoses that included gastro- esophageal reflux disease (Acid reflux, a condition where stomach acid flows back up into the esophagus), intervertebral disc degeneration (spine loses ability to cushion the vertebrae) and kidney disease. A review of Resident 31 ' s Minimum Data Set (MDS- A comprehensive assessment and screening tool) Dated 12/1/2024, indicated Resident 31 had severely impaired cognition (a mental process that take place in in the brain, including thinking, attention, language, learning, memory, and perception) and required maximal assistance, helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort with activities of daily living. A review of Resident 28's Admission Record indicated the facility admitted the resident on 9/08/202, with diagnoses that included obstructive pulmonary disease (damage to the lungs that limits airflow into and out of the lungs) and malignant neoplasm of brain (cancerous brain tumor). A review of Resident 28's History and physical, undated, indicated the resident is alert and oriented to person, place, time. A review of Resident 28's Order Summary Report, and clinical records indicated no evidence that the resident was monitored for mood/ behavior for self-infliction or scratching of the left eye. A review of Resident 28's care plan, dated 11/19/ 2024, indicated Resident 28 ' s had an actual unavoidable non healing impairment to skin integrity related to new left lower periorbital area self - inflicted scratch with Goal the resident will be free from complications new left lower periorbital area self - inflicted scratch. Interventions of Medication and/ or treatment as order by the physician, to monitor for side effects of the prescription and OTC (over the counter) drugs which could exacerbate the skin condition, and to report continued worsening of site, Signs and symptoms of infection and other signification issues to physician. T A review of Resident 28's care plan dated 11/19/ 2024 did not indicate the root cause of the resident's behavior of left lower periorbital area self - inflicted scratch and interventions to address the resident's behavior to prevent self - inflicted scratching. A review of Resident 28's Medication Administration Record indicated no monitoring for anxiety mood / behavior of self-infliction. During an observation on 1/21/2025 at 11:42 AM, Resident 28 had a left lower eye redness, with active bleeding and open tear visible. In a concurrent interview Resident 28 stated the wound/tear under her eye had been there for 4 days and no treatment had been provided. During an interview on 1/21/2025 at 11:52AM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there was no change in condition report documented and no treatment being provided that was ordered by the physician regarding Resident 28 ' s under the eye wound. LVN 3 stated the physician was not notified of Resident 28 ' s behavior of self -inflicted wound due to scratching on the left eye. During an interview on 1/21/2025 at 12:17 PM, with Licensed Vocational nurse (LVN) 3, stated she was unsure when Resident 28 developed current wound under the left eye. A review of the facility's policy and procedure titled Skin Tears - Abrasions (scrape) and minor breaks, Care of revised on 9/2013, indicated to notify physician of any abnormalities such as excessive bleeding, localized swelling, redness, drainage or tenderness or skin tears. 2. A review of Resident 31's Admission Record indicated the facility admitted the resident on 8/27/2021, with diagnoses that included gastro- esophageal reflux disease and intervertebral disc degeneration. A review of Resident 31's Minimum Data Set (MDS- A comprehensive assessment and screening tool) Dated 12/1/2024, indicated Resident 31 had severely impaired cognition and required maximal assistance with activities of daily living. A review of Resident 31's Care plan for gastroesophageal reflux disease initiated on 8/28/2021, indicated to monitor for poor appetite/ intake, as well as to observe for contributing factors of fluid volume depletion such as vomiting copious (large amount) secretions and notify MD (Medical Doctor) as needed. A review of Resident 31's Progress notes dated from 12/23/24 - 1/20/25, indicated no documentation of the root cause of Resident 31's daily regurgitation (vomiting). In addition, there was no documented evidence that the MD was informed or any change of condition (COC). During an observation on 1/21/25 at 11:14AM, observed Resident 31 motioning with hand to her mouth, and large bucket was next to her bed. During an interview on 1/21/25 at 11:14 AM, with Marketing Director, Marketing Director stated Resident31 has a bucket next to her bed to be used when throwing up in which he had witnessed Resident 31 vomiting frequently. During an interview on 1/21/25 at 11:22 AM, with Licensed Vocational nurse 3 (LVN)3, LVN 3 stated Resident 31 has frequent episodes of vomiting but is unsure if she has lost weight. During an interview on 1/23/2025 at 11:26 AM, LVN 3 stated Resident 31 vomits most days she works at facility, but she does not document in the resident ' s progress notes the frequency or duration of Resident 31's vomiting. LVN 3 further stated Resident 31's electrolytes were not being monitored. During an interview on 1/23/25 at 1:34PM, with Registered Nurse (RN)1, RN1 stated Nursing staff should be documenting how often and how many times Resident 31 was vomiting or regurgitating her food or liquids. RN 1 stated the MD should be notified if the Resident 31 was vomiting. During a concurrent interview and record review on 1/23/25 at 1:34 PM with Registered Nurse 2 (RN2), Resident 31 ' s Progress notes dated from 12/23/24 - 1/20/25 was reviewed and indicated no documentation had been done for Resident 31 ' s daily regurgitation (vomiting). Additionally, RN 2 stated there was no documentation in progress notes regarding daily vomiting or how long the resident had been having episodes of vomiting. RN 2 also stated there was no documented evidence that the primary physician was notified of Resident 31 ' s episodes of vomiting. A review of the facility ' s policy and procedure titled Change in a resident ' s condition or Status, Revised on 02/2021, indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/ mental condition and /or status (changes in level of care).

Based on interview and record review, the facility failed to notify the primary physician of the signitficant change of condition for 1 of 3 sampled residents (Resident 31) who had daily episodes of vomiting for unknown period of time. This deficient practice resulted in the resident's delay in treatment and monitoring to prevent fluid loss, discomfort and weight loss. Findings: A review of Resident 31's Admission Record indicated the facility admitted the resident on 8/27/2021, with diagnoses that included Gastro- esophageal reflux disease (Acid reflux, a condition where stomach acid flows back up into the esophagus), intervertebral disc degeneration (spine loses ability to cushion the vertebrae) and kidney disease. A review of Resident 31's Minimum Data Set (MDS- A comprehensive assessment and screening tool) Dated 12/1/2024, indicated Resident 31 had severely impaired cognition (a mental process that take place in in the brain, including thinking, attention, language, learning, memory, and perception) and required maximal assistance with activities of daily living. During a concurrent interview and record review on 1/23/25 at 1:34 PM with Registered Nurse 2 (RN2), Resident 31's Progress notes dated from 12/23/24 - 1/20/25 was reviewed and indicated no documentation had been done for Resident 31's daily regurgitation (vomiting). Additionally, RN 2 stated there was no documentation in progress notes regarding daily vomiting or how long the resident had been having episodes of vomiting. RN 2 also stated there was no documented evidence that the primary physician was notified of Resident 31's episodes of vomiting. During a concurrent observation and interview on 1/21/2025 at 11:22AM with Licensed Vocational Nurse (LVN) 3, in Resident 31's room, Resident 31 had bucket on ground next to bed. LVN 3 stated, she (Resident 31) has daily episodes of vomiting and uses the bucket when vomiting. During an interview on 1/23/25 at 1:34 PM, with Registered Nurse (RN)1, RN1 stated the staff should be documenting how often and how many times Resident 31 was vomiting or regurgitating her food or liquids and the primary physician should be notified if the resident was vomiting. A review of the facility ' s policy and procedure titled Change in a resident ' s condition or Status, Revised on 02/2021, indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/ mental condition and /or status (changes in level of care).

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) had an informed consent (the voluntary agreement of a resident or a resident's representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) prior to treatment of Amitriptyline (a medication used to treat depression [severe feeling of sadness and hopelessness] and neuropathic [damaged nerves] pain in adults). This failure violated the residents rights of Resident 19 or representative to make an informed decision about the treatments of Amitriptyline and its side effects such as increased agitation, irritability and worsened depression of the medication and any alternative treatments available. Findings: During a review of Resident 19's Admission Record (Face Sheet), dated 1/23/2025, the face sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (damage to many nerves throughout the body at the same time, causing symptoms like numbness, tingling, burning pain, and weakness) and pyogenic arthritis (a painful infection of a joint caused by bacteria). The face sheet indicated Resident 19 was self-responsible. During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool), dated 12/28/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated the resident was taking a high-risk drug classified as an antidepressant (a type of medicine used to treat clinical depression [a mood disorder that causes a persistent feeling of sadness and loss of interest.]). During a review of Resident 19's Order Summary Report, with an order date of 5/24/2024, the Order Summary Report indicated Resident 19 was ordered Amitriptyline oral (given by mouth) tablet 10 mg (milligrams-unit of measurement) 2 tablets by mouth at bedtime for neuropathic (nerve) pain. During a review of Resident 19's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated January 2025, the MAR indicated the resident had received Amitriptyline each evening from 1/1/2025-1/22/2025. During a review of Resident 19's Care Plan titled, The Resident ' s Overall Condition Requires Long-Term Care, with a revision date of 12/6/2024, the care plan indicated an intervention of resident will be encouraged to make decisions regarding life in facility. During a review of Resident 19's care plan titled, The Resident Uses Antidepressant Medication Amitriptyline Oral Tablet for Neuropathic Pain, with a revision date of 1/10/2025, the care plan indicated the resident/family/caregivers would be educated regarding the benefits, side effects, and toxic symptoms of the anti-depressant drug being given. During a concurrent interview and record review on 1/23/2025 at 1:38 PM, Resident 19 ' s clinical record from 5/24/2024 to 1/23/2025 was reviewed with Licensed Vocational Nurse (LVN) 2, the clinical record indicated there was no documentation that Resident 19 or any responsible party received education regarding the risks and benefits of Amitriptyline prior to its initiation on 5/24/2024. There was no indication that the resident or responsible party consented to the use of amitriptyline. LVN 2 stated Resident 19 did not have an informed consent for amitriptyline prior to the start of administering amitriptyline. LVN 2 provided a document titled Facility Verification of Informed Consent dated 1/23/2025, the document stated that it was for the use of amitriptyline and that informed consent was obtained from Resident 19 on 1/23/2025. During an interview and record review on 1/24/25 9:24 AM, the facility ' s policy and procedure (P&P) titled, Resident Rights, dated February 2021 was reviewed with Registered Nurse (RN) 1. The P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to self-determination and to be informed of and participate in his or her care planning and treatment. RN 1 stated that it was important to provide the resident with informed consent for psychotropic medication because it was a federal and state regulation and because the psychotropic medication can adversely affect the resident including behaviors and thoughts. RN 1 stated the facility should respect the patient ' s rights and inform them of their care. During a review of the facility ' s P&P titled, Psychotropic Medication Use, dated July 2022, the P& P indicated, When determining whether to initiate, modify, or discontinue medication therapy .The evaluation will attempt to clarify whether: the actual or intended benefit of the medication is understood by the resident/representative. The P&P also indicated, Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on interview and record review, the facility failed to develop a resident specific comprehensive care plan that reflected the resident's current needs and health status for two out of eight sampled residents (Residents 6 and 39) by failing to ensure: 1. Resident 6's care plan for her weight loss had no measurable objectives and time frames such as the target weights for the resident. 2. Resident 39 did not have a care plan to address the care and monitoring of the resident ' s intravenous (IV- a thin, flexible tube that is inserted into a vein) insertion site. This deficient practice placed Resident 6 at risk for further weight loss. For Resident 39, the resident had the potential to be at risk of complications associated with IV insertion such as bleeding, infiltration (leakage of fluid from the vein to the surrounding tissue causing pain and swollenness) and infection. Findings: 1. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included neck fracture (broken bone in the neck), history of falling, and malnutrition (lack of proper nutrition). A review of Resident 6 ' s History and Physical (H&P), dated 9/10/2024, indicated the resident has the capacity to make her needs known, but does not have the capacity to make medical decisions. The H&P also indicated the resident has poor appetite. A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/20/2024, indicated the resident has severely impaired cognition (ability to reason and thought process). The MDS also indicated the resident requires setup or clean-up assistance (helper sets up or cleans up) with eating. A record review of the Resident 6 ' s care plans included an entry for Resident 6 ' s weight loss, initiated on 10/16/2025, and revised on 1/22/2025. indicated Resident 6' s weight will return to baseline range between [blank] and [blank] lbs (pounds, a unit of measuring weight) by review date. The care plan did not provide documented evidence of Resident 6's baseline weight. During a concurrent interview and record review on 1/24/2025 at 9:31 AM with Registered Nurse (RN) 1, Resident 6 ' s care plan for weight loss was reviewed. RN 1 stated Resident 6 ' s care plan was incomplete because the goal of the care plan does not specify the target weight and had no measurable objectives and time frames such as weights. During a concurrent interview and record review on 1/25/2025 at 9:32 AM with RN 1, the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, was reviewed. RN 1 stated the P&P indicated the care plan must include measurable objectives and time frames, such as weights. 2. A review of Resident 39's Admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included surgical amputation (surgical removal of a body part), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). A review of Resident 39's H&P, dated 12/29/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 39's MDS, dated [DATE], indicated the resident has intact cognition. A review of Resident 39's Order Summary Report, dated 1/24/2025, included an order for the following: Meropenem [an antibiotic, a medication that treats infections] to administer via Intravenous Solution Reconstituted [medication in powder form mixed with a liquid solution] 1GM [GM, gram, a unit of measuring weight] Use 1 gram intravenously every 12 hours, ordered on 12/28/2024. A review of Resident 39's care plans did not have documented evidence for a care plan to address the monitoring and care for Resident 39 ' s IV catheter. During a concurrent observation and interview on 1/21/2025 at 9:22 AM, Resident 39 was observed lying in bed with an IV catheter (a small plastic tube inserted into the vein) on the right hand. Resident 39 stated the nurses use the IV catheter to administer medications. During a concurrent observation and interview on 1/21/2025 at 9:43 AM inside Resident 39 ' s room, RN 1 stated Resident 39 has an IV catheter on the right hand. During a concurrent interview and record review on 1/24/2025 at 9:29 AM with RN 1, Resident 39 ' s care plans were reviewed. RN 1 stated there was no care plan for Resident 39 ' s to address the care and monitoring for the IV catheter insertion site. RN 1 stated there should be a care plan for the IV catheter insertion site, because without it, staff would not know how to take care of the resident ' s IV catheter. During an interview and concurrent interview on 1/24/2025 at 9:32 AM with RN 1, the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, was reviewed. RN 1 stated the P&P indicated care plans must have measurable goals, such as a resident ' s weight. RN 1 also stated the P&P must reflect the resident ' s current condition, such as having a care plan for a resident ' s IV catheter. During a review of the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes. The P&P indicated the care plan includes the resident ' s goals and desired outcomes. The P&P also indicated care plans are revised as information about the residents and the residents ' conditions change.

Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 15 and 195) had a call light device (a device used to call for assistance) within reach. This failure had the potential to result in Residents 15 and 195 being unable to call for assistance when needed and not receive immediate care in the an emergency that could lead to falls, accidents and injury. Findings: a. During a review of Resident 15 ' s Admission Record (Face Sheet) dated 1/23/2025 , the face sheet indicated the facility admitted Resident 15 on 11/20/2019 with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left knee, and tear of meniscus (crescent shaped bands of thick, rubbery cartilage attached to the shinbone that act as shock absorbers and stabilize the knee) of the left knee. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decision making were severely impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting, oral hygiene, showering, personal hygiene, and lower body dressing. The MDS indicated the Resident was always incontinent (the involuntary loss of bladder or bowel control) and at risk for falls. During an observation on 1/21/2025 at 10:03 AM in Resident 15's room, the resident was observed sitting up in bed. The call light for Resident 15 was observed on the floor beneath the bed. During an interview on 1/21/2025 at 10:05 AM with Certified Nurse Assistant (CNA) 1 in Resident 15's room, CNA 1 stated the call light for Resident 15 was out of reach of the resident and should be within reach of the resident so the resident could call for help if needed. CNA 1 stated the resident could possibly fall out of bed and hurt themselves if the call light was out of reach. During a review of Resident 15's Care Plan titled Alteration in Musculoskeletal Status Related to Contracture of Left Knee, with an initiation date of 5/17/2021, the care plan indicated an intervention of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. b. During a review of Resident 195's Face Sheet dated 1/23/2025, the face sheet indicated the facility admitted Resident 195 on 6/26/2023 with a readmitted [DATE] with diagnoses including a history of falling, muscle weakness, dementia (a progressive state of decline in mental abilities), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints resulting in painful deformity and immobility). During a review of Resident 195's MDS dated [DATE], the MDS indicated the cognitive skills for daily decision making were severely impaired, and the resident required partial/moderate assistance (Helper does less than half the effort) with toileting and oral hygiene. The MDS indicated Resident 195 was at risk for falls. During an observation on 1/21/2025 at 10:19 AM in Resident 195's room, the resident was observed lying in bed with eyes closed. The call light for Resident 195 was observed on the floor beside the left side of the resident ' s bed. During an interview on 1/21/2025 at 10:25 AM with CNA 2 in Resident 195's room, CNA 2 stated the call light was out of reach for Resident 195 and the Resident could be injured if trying to get out of bed on their own. During a review of Resident 195's Care Plan titled May Put Bed in a Lower Position due to High Risk for Falls, with an initiation date of 12/20/2024, the care plan indicated an intervention of Attend to needs promptly. During an interview on 1/23/2025 at 10:10 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important for residents to have the call light within reach so the resident can call for help when needed and to prevent the resident from falling and being injured. During a concurrent interview and record review on 1/23/2025 at 9:04 AM with the Registered Nurse (RN) 1, the facility ' s policy and procedure (P&P) titled, Call Light Policy, dated January 2024 was reviewed. RN 1 stated the P&P indicated, the call light should be within reach of the resident and answered in a timely manner. RN 1 stated that when the call light is out of reach and the residents need assistance we won ' t know and be able to attend to them right away, a resident might fall and injure themselves if trying to get out of bed on their own.

Based on observations, interviews, and record reviews, the facility failed to ensure 1 of 3 sampled residents (Resident 28) was provided care and services to maintain good grooming and personal hygiene by ensuring the resident's nail was free of dirt. This deficient practice had potential to lead to skin infection and poor body image from having dirt underneath nails. Findings: A review of Resident 28's Admission record indicated the facility admitted the resident on 9/8/2020, with diagnosis that included malignant neoplasm of brain (fast growing Brain Tumor), acute respiratory failure (sudden condition that makes it difficult to breathe on your own), paralysis of vocal cords and larynx (unable to speak, swallow, or breath on own). A review of Resident 28's History and Physical (H&P), undated, indicated the resident was alert and oriented to person, place, time. A review of Resident 28's Minimum Data Sheet ( MDS, a standard assessment tool that measures health status), dated 12/14/2024, indicated the resident ' s cognition ( a mental process related to thinking, attention, language, learning, memory, and perception) was intact ( able to understand information, remember it, use it to make decisions, and effectively communicate those decisions). The MDS indicated Resident 28 needed partial /moderate assistance for upper body dressing and requires Substantial/ maximal assistance for personal hygiene tasks. A review of Resident 28's Care Plan Resident prefers to have long nails initiated on 7/14/2021 with a revision date of 1/10/2025, the Care Plan indicated, Activities Department will observe that nails are maintained and cleaned at least 1x a week. During a concurrent observation and interview on 1/21/2025 at 11:52AM with Licensed Vocational Nurse (LVN3) in Resident 28 ' s room. LVN 3 stated Resident 28 has dirt under nails. During a review of the facility's policy and procedure (P&P) titled, Fingernails/ Toenails, Care of, with a revised date of February 2018, the P&P indicated nail care includes daily cleaning and regular trimming. Further stating proper nail care can aid in the prevention of skin problems. Indicating dirt under nails should be wiped away and removed from each nail to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV- a thin, flexible tube that is inserted into a vein) catheter dressing was labeled with the date and time on when the IV dressing was changed, and the name or initial of the staff who changed the dressing. This deficient practice placed Resident 39 at risk of complications associated with IV insertion such as infection that can travel to the blood and result in sepsis (a severe life-threatening infection in the blood). Findings: A review of Resident 39 ' s Admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included surgical amputation (surgical removal of a body part), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). A review of Resident 39 ' s History and Physical (H&P), dated 12/29/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 39 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/2/2025, the resident has intact cognition. A review of Resident 39 ' s Order Summary Report, dated 1/24/2025, included an order for the following: Meropenem [an antibiotic, a medication that treats infections] Intravenous Solution Reconstituted [medication in powder form mixed with a liquid solution] 1GM [GM, gram, a unit of measuring weight] Use 1 gram intravenously every 12 hours, ordered on 12/28/2024. During a concurrent observation and interview on 1/21/2025 at 9:22 AM inside Resident 39 ' s room, Resident 39 was observed lying in bed with an IV catheter (a small plastic tube inserted into the vein) on the right hand that was covered by a white gauze dressing. The dressing did not have any labels that indicated the date and time for when it was applied, nor the name or initial of the nurse that applied the dressing. Resident 39 stated he does not remember when the IV dressing was changed. During a concurrent interview and record review on 1/24/2025 at 9:29 AM with RN 1, Resident 39 ' s entire medical records were reviewed. RN 1 stated there was no documented evidence that Resident 39 ' s IV catheter dressing was changed in the past 3 days. RN 1 stated the facility policy was to change the gauze dressings every 48 hours or when it gets soiled. During a concurrent observation and interview on 1/21/2025 at 9:43 AM inside Resident 39 ' s room, RN 1 stated Resident 39 ' s IV catheter dressing did not have any labels that would indicate the date, time, or the person that applied the dressing. RN 1 stated it is the facility ' s policy that IV catheter dressings should be labeled with the date and time for when it was applied, and the initials of the nurse that applied the dressing. During an interview and concurrent interview on 1/24/2025 at 9:34 AM with RN 1, the facility ' s policy and procedure (P&P) titled, Peripheral Catheter Dressing Change, dated 3/2023, was reviewed. RN 1 stated the P&P indicated that IV catheter dressing must be labeled with the date, time, and the nurse ' s initials. RN 1 stated not labeling the dressing could put the resident at risk for infections at the site because staff would not know if the dressing needed to be changed. During a review of the facility ' s P&P titled, Peripheral Catheter Dressing Change, dated 3/2023, the P&P indicated gauze dressing changes are changed every 48 hours or if the integrity of the dressing is compromised. The P&P also indicated the nurse must label dressing with date, time, and nurse ' s initials.

Based on interview, and record review, the facility did not ensure medical records are accurately documented for one of three sampled residents (Resident 1), the time of incident and vital signs recorded on Resident 1 ' s progress note (a type of documentation that is used to track and document patient's progress throughout treatment) and vital signs sheet (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) were not accurately documented per facility ' s policy. This deficient practice had the potential in miscommunication, provided inaccurate information affect to delivery of care and possible leading to the cause of death. Findings: A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing), heart failure (condition in which the heart is unable to pump enough blood to meet the body's needs), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs.) gastrostomy ( a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), dementia ( the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities.) and epilepsy (a common condition that affects the brain and causes frequent seizures). A review of Resident 1 ' s History and Physical Examination, dated 8/12/2024, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/30/2024, indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, bathing, toileting, personal hygiene, rolling left and right and lying to sitting. A review of Resident 1 ' s facility document titled Progress Notes, dated 8/30/2024 timed at 3:51 AM indicated at 1:00 AM RN 1 noted Resident 1 was having grunting sound, difficulty breathing, and oxygen saturation (the amount of oxygen you have circulating in your blood) was low at 85 percent with 2L of oxygen supplied via nasal cannula. The progress notes indicated, 911 emergency paramedics was called, evaluated Resident 1, and took Resident to GACH 1 for further evaluation. A review of Resident 1 ' s paramedic run report (means the response of an ambulance vehicle and personnel to an emergency or nonemergency for the purpose of rendering medical care or transportation) dated 8/30/2024, indicated paramedic dispatch was called at 12:25 AM, paramedic arrived at the facility at 12:29 AM, at 12:43 am Resident 1 ' s vitals were blood pressure 172/90, heart rate 137, respiratory rate 22 and oxygen saturation at 92% with 15 L of oxygen mask. At 12:48 am Resident 1 ' s blood pressure was 170/88. Heart rate 136, respiratory rate 22 and O2 saturation with 15 L O2 mask was 92 and paramedic left the facility at 12:50 AM to acute hospital. A review of Resident 1 ' s facility document titled Weights and Vitals Summary, dated range from 8/1/2024 to 8/31/2024. On 8/30/2024 at 3:42 AM, indicated Resident 1 ' s vital signs was blood pressure 186/124, heart rate 118, temperature 99.7 degrees, respiratory rate 20, and oxygen saturation 85 percent. A review of Resident 1 ' s GACH 1 document titled Emergency Document- MD, dated 8/30/2024, the document indicated Resident 1 arrived at GACH 1 emergency department at 12:55 AM. A review of Resident 1 ' s GACH 1 document titled Notification of Death, dated 8/30/2024, indicated, Resident 1 ' s date and time of death was 8/30/2024 at 2:05 AM and family was notified on 8/30/2024 at 2:10 AM. During an interview on 9/9/2024 at 1:30 PM with the Director of Nurses (DON) , The DON stated, timing of the Resident 1 ' s documentation was not accurate. A review of the facility ' s policy and procedure (P&P) titled Charting and Documentation revised 7/2017 , indicated; a) all services provided to the resident or any changes in resident ' s medical and physical condition shall be documented in the residents ' medical records, b)information document in the resident medical records includes changes in residents condition, and c) Documentation in the medical record will be objective (not opinionated or speculative), complete, and accura

Based on observation, interview, and record review, the facility failed to ensure one of one outdoor refuse container (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was closed with a tight-fitting lid and kept covered in accordance with the facility's policy and procedure titled, Food Related Garbage and Refuse Disposal. This failure had the potential to attract insects and harborage of pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During an observation on January 23, 2024, at 9:00 a.m., in the presence of the Dietary Supervisor (DS) at the facilities parking lot, the outdoor refuse container was observed with no tight fitting/secured lid. During an interview on January 23, 2024, at 9:20 a.m. with the DS, she stated the dumpster container is supposed to be covered. During a review of the facility's policy and procedure titled, Food- Related Garbage and Refuse Disposal dated 2021 (revised October 2017), indicated, all garbage and refuse containers are provided with tight- fitting lids or covers and must be kept covered. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.

Based on interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection by failing to: 1. Ensure the facility monitors the water system for Legionella (bacteria most found in water, including groundwater, fresh and [NAME] surface waters that causes severe pneumonia [severe infection in the lungs]. Legionella is transmitted through breathing in Legionella-contaminated, aerosolized [the form of a fine spray] water and is also possible from breathing in Legionella contaminated soil or while drinking water) as evidenced by not conducting water testing for Legionella. 2. Ensure the staff was wearing the correct personal protective equipment (PPE- gown, mask and gloves) before entering a contact isolation (diseases spread by direct or indirect contact) precaution room for one of one sampled resident (Resident 34). This deficient practice had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility to the residents, staffs, and visitors. Findings: 1. During an interview and record review on 1/23/24 at 2:55 PM, with the Maintenance Supervisor (MS), the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised on 7/2017, was reviewed. The MS stated the facility did not conduct water testing for the presence of legionella. The MS stated he provided regular maintenance to the identified areas in the water system that could grow Legionella as indicated in the P&P, such as cleaning the shower heads every six months, assessing leaking pipes, cleaning the heating tank and checking the room water temperature every day. The MS stated he was following the P&P to ensure the water system in the facility would not grow Legionella, therefore, the facility did not need to test the water for Legionella. During an interview on 1/23/24 at 3:30 PM, with the Infection Preventionist (IP), the IP stated the facility had never had a Legionella case, so the facility did not do water testing for Legionella. The IP stated the staff followed the facility P&P's prevention measures for legionella, such as cleaning the heating tanks every day and cleaning and running the shower heads. The IP stated they monitored and made sure the staff do everything that was in the P&P, and by doing so, the water system in the facility should not be at risk for Legionella. The IP stated when the facility sees if there was a risk for Legionella, such as an incident of Legionella in the facility, then the facility will escalate to do the water testing. The IP stated the Centers for Disease Control and Prevention (CDC) did not require water testing for Legionella. During an interview on 1/23/24 at 3:35 PM, with the Administrator (ADM), the ADM stated she worked in this field (facility management) for over [AGE] years, and she had never heard of the requirement to test water for Legionella in the facility. The ADM stated the facility had never tested water for Legionella because there was no legionella incident in the past and they were doing everything on the facility's protocol to prevent Legionella, such as monitoring the water temperature, cleaning the heating water tank, checking the pipes, cleaning shower heads with vinegar. The ADM stated the facility was monitoring the staff were doing all the measures to prevent Legionella contamination. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised on 7/17, indicated the water management program included A system to monitor control limits and the effectiveness of control measures. 48143 2. A review of Resident 34's Admission Record indicated Resident 34 was originally admitted on [DATE] and readmitted to the facility on [DATE], with diagnoses of, but not limited to, hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (hemiparesis is a slight weakness in leg, arm, or face) following other cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left side of his body and sepsis (the body's extreme response to an infection) and elevated white blood cell count (immune system issue). During a review of Resident 34's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/25/23, the MDS indicated Resident 34 was able to follow simple commands, and required maximum assistance with the toilet, personal hygiene, change of position and transfer. During an observation on 1/22/24 at 9:09 a.m., in front of Resident 34's room, housekeeper (HK) was inside the room mopping the floor next to Resident 34's bed without wearing an isolation gown for the contact isolation precaution. There was a red Stop sign on the wall below resident's name tag indicating all who enter the contact isolation room should wear PPE, and wash their hands with soap and water before and after. The sign also cautioned visitors to check with the registered nurse before entering, due to a highly infectious disease contained in the room. There is also an isolation cart in front of Resident 34's room for PPE supplies for staffs and visitors. During an interview on 1/22/24 at 9:15 a.m., with HK, HK stated it is not right to clean the isolation room without wearing a gown. HK stated by not wearing a gown to clean inside the room, the person could spread germs and bacteria to other residents and staff. Hand washing is very important to stop the spread of infections. During an observation on 1/22/24 at 9:26 a.m., in front of Resident 34's room, Restorative Nurse Assistant (RNA) was observed delivering an IV (a way of giving a drug or other substance through a needle or tube inserted into a vein) pole to Resident 34's bed side without wearing any PPE for contact isolation precaution. RNA did not perform hand hygiene before leaving Resident 34's room. During an interview on 1/22/24 at 9:28 a.m. with RNA, RNA stated he did not see the red contact isolation signage in front of Resident 34's room. RNA stated he needed to wear PPE before entering the room and he was supposed to wash his hands before leaving the room. RNA stated wearing gowns, gloves and hand washing are very important to help to stop the spread of infection. During an interview on 1/22/24 at 10:33 a.m. with LVN1, LVN1 stated Resident 34 is in transmission-based precautions for vancomycin-resistant enterococci (VRE, resistant to some powerful antibiotics) urine for this re-admission on 1/10 /24. LVN1 stated everyone in the facility should follow transmission-based precautions (the type of precautions used to depend on the mode of transmission of a specific disease) for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection. A review of the revised policy and procedure dated September 2022, titled Isolation-Categories of Transmission- Based Precautions indicated staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Staff and visitors wear gloves (clean, non-sterile) when entering the room. Gloves are removed and hand hygiene performed before leaving the room. The policy also indicated when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of Centers for Disease Control and Prevention (CDC) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light device (an alerting device for nurses or other nursing personnel to assist a patient when in need) was maintained within easy reach for one of one sampled resident (Resident 344), in accordance with the resident's care plan. This failure resulted in Resident 344 not being able to ask for staff assistance on 1/22/2024. A potential for further decline in the resident's activities for daily living, self-esteem, and self-worth. Findings: A review of Resident 344's Admission Record indicated Resident 344 was admitted to the facility on ,d+[DATE]/ 2024, with diagnoses that included history of fall, fracture of sacrum (occurs when a bone called the sacrum breaks), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) During a review of Resident 344's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 9/22/2023, the MDS indicated Resident 344 was able to follow commands, and required limited assistance with the toilet, personal hygiene, change of position and transfer. A review of Resident 344's care plan titled Alteration in musculoskeletal status r/t sacral fracture, indicated Resident 344 had a potential for further injury related to fall risk, dated 1/11/24, indicated Resident 344 required assistance with transfer, mobility PRN (as needed) and required monitoring of fall. The care plan interventions indicated the Certified Nursing Assistant (CNA) will assist resident with transfer and mobility PRN, the CNA will anticipate and meet needs Resident 344, and the CNA will make sure Resident 344's call light was within reach and will respond to call lights promptly. During an observation on 1/22/2024 at 8:42 a.m., in the resident's room, Resident 344 was observed sitting at the right-side end of his bed asking for help, there was no CNA present to assist the resident. During an observation, Resident 344's call light device was placed on the floor near the left side of the headboard that the resident could not reach. During an interview on 1/22/2024 at 08:43 a.m., with Resident 344, Resident 344 stated he was not able to find his call light device. Resident 344 stated he needs help to look for his nail clipper. During an interview on 1/22/2024 at 8:48 a.m. with CNA 1, who was assigned to Resident 344 on 1/22/2024 during the 7 a.m. to 3 p.m., stated the call light should have been placed closed to Resident 344's bed for easy reach, so that the resident was able to get services in a timely manner. CNA 1 also stated this way, Resident 344 can be prevented from repeat falls. During a review of the facility's policy and procedure titled Call system, Residents dated September 2022, indicated each resident is provided with a means to call staff directly for assistance from his/her bed. The purpose of the call system is to provide a mechanism for residents to promptly communicate with nursing staff.

Based on observation, interview, and record review, the facility failed to coordinate and communicate the care services of one of two sampled residents (Resident 6) with the hospice (an end-of-life care with focus on the resident's quality of life) staff as indicated in the facility's policy and procedure for hospice care titled, Hospice and Nursing Facility Services Agreement, This deficient practice had the potential to negatively affect the resident's psychosocial and physical well-being and/or delay the delivery of hospice care services to Resident 6. Findings: During a review of Resident 6's admission record indicated, Resident 6 was initially admitted to the facility on [DATE], and admitted to the hospice care and services on 8/15/2023, with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side, atherosclerosis heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow from the heart to the brain) and adult failure to thrive (weight loss, decreased appetite and poor nutrition, and inactivity). During a review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/27/2023, the MDS indicated the resident has impaired cognitive patterns (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), needed assistance from staff members for locomotion in and out of the bed, and was always incontinent of bowel and bladder. A review of Resident 6's POLST (a written medical order from a physician, that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness.) dated 8/15/2023 indicated Resident 6 was on selective treatment and was on no artificial means (treating medical conditions while avoiding burdensome measures, prefer to forgo the use of medically provided fluids and nutrition) of nutrition. A review of Resident 6's Physician's order, dated 8/15/2023 indicated Resident 6 began hospice with the current hospice service agency on 8/15/2023. During a concurrent interview and record review on 1/22/2024 at 2:01 p.m. with License Vocational Nurse (LVN)1, Resident 6's hospice binder did not include any hospice nurses' visiting notes, no care plans, no IDTs. (interdisciplinary team conference). LVN1 stated there were no hospice nurses' visiting notes, no care plans, no IDT in Resident 6's hospice binder. LVN1 stated nurses and staff will not be able to get an immediate update about Resident 6's latest conditions and care as there were no visiting notes in Resident 6's hospice binder. During a concurrent interview and record review on 1/22/2024 at 3:06 p.m. with the Director of Nursing (DON), Resident 6's hospice binder was reviewed with DON. The DON stated, Resident 6's hospice binder did not include any hospice nurses notes when they visited the residents, and no care plans, or IDTs in the hospice binder, which could result in the nurses and staff not able receive immediate update about Resident 6's latest conditions and needed care or services, as there were no records to indicate the agency staffs communicated with the facility staffs Resident 6's hospice binder. During an interview with Social Services Designee (SSD) on 1/25/2024 at 8:46 a.m., SSD stated she did not know there was no hospice nurses' visiting notes and care plans in Resident 6's hospice binder. SSD also stated the facility has no access to hospice's Hospice MD (HMD, hospice documentation system) from the facility. Hospice nurses have no access to the Point Click Care (PCC, facility documentation system). SSD stated that there is no way to get updated care information for Resident 6 due to absent of hospice nurse visiting notes, update care plan and updated IDTs. SSD stated there is no way to know if the hospice nurse had visited the resident on the scheduled dates. The facility's policy and procedure (P&P) titled, Hospice and Nursing Facility Services Agreement, dated 11/11/2022, indicated both parties shall maintain appropriated documentation of services provided under this agreement in accordance with applicable state and federal law and regulations and Accreditation Standards. Patients' medical records and documentation maintained by each Party shall be available for review and inspection by the other Party as necessary for the proper evaluation, screening, and provision of services to patients under this agreement.

Based on observation, interview and record review, the facility failed to ensure one of three sampled resident (Resident 28) or his/her representative was assisted to formulate an Advance Healthcare Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility, and the AD was maintained in the resident's clinical records at all times. This deficient practice had the potential to cause conflict with Resident 28's wishes regarding health care treatment especially in an event of emergency. Findings: During a review of Resident 28's Admission Record indicated the facility admitted Resident 28 on 8/27/21 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (high blood pressure). During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/2/23, indicated Resident 28 had severely impaired memory and cognitive (ability to think and reasonably) impairment. The MDS indicated Resident 28 required supervision or touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, and chair/bed-to-chair transfer, and substantial/maximal assistance with lower body dressing and personal hygiene. During an observation and record review on 1/22/24 at 11:51 AM, Resident 28's Advanced Healthcare Directive Acknowledgement Form (AHDAF) was flagged in Resident 28's in the paper clinical chart that was on the desk of the nursing station. Resident 28's AHDAF was observed blank without the physician's and resident's /representative's signature. During a concurrent interview and record review on 1/23/24 at 8:54 AM, with the Social Services Director (SSD). Resident 28's blank Advanced Healthcare Directive Acknowledgement Form (AHDAF) was reviewed. The SSD stated she had not completed Resident 28's AHDAF and she was going to call her responsible party (RP) today to follow up. The SSD stated the facility admitted Resident 28 on 8/27/21 and her AHDAF should be offered, completed, and followed up upon the resident's admission to the facility. The SSD stated it was important to inform the resident and his or her RP about their rights to formulate an Advance Healthcare Directive, so the facility would know If the resident had an advance directive or not upon admission and provide treatments as the resident's wishes. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 9/22, the P&P indicated, the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment and prior to or upon admission of a resident, the social service director, or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 2022, the P&P indicated, information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.

Based on observation, interview, and record review, the facility failed to provide necessary services in activities of daily living (ADL) to maintain good personal hygiene by ensuring the toenails were not thick and discolored and the fingernails were trimmed for one of two sampled residents (Resident 21) who had long untrimmed fingernails and toenails. This deficient practice had the potential for Resident 21 not to receive necessary services to maintain and achieve their highest potential and wellbeing. Findings: 1. A review of Resident 21's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses frailty (the condition of being weak and delicate), diabetes mellitus (high blood sugar) and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/23/2023, indicated Resident 21's cognitive skills (ability to tik, reason and make daily decisions) was severely impaired. The MDS indicated Resident 21 was dependent (helper does all the effort) on staff with maximal assistance (require helper assist more than half of effort) for lower body dressing, putting on/taking off footwear, moderate assistance (require helper assist less than half of effort) for toilet use hygiene, shower personal hygiene. During concurrent observation and interview on 1/22/24 at 10:20 AM, all of Resident 21's fingernails were long, about 4-5mm (millimeter- a unit of measurement) long, with long discolored thick toenails on left and right big toes, 4th toes of both feet had toenails measuring 8 to 9 mm long that curved to 3rd toe. In an interview, Resident 21 stated his nails had not been trimmed for a long time. A review of Resident 21s Care Plan (CP) initiated on 11/10/21, indicated Resident 21 had alteration in physical functioning due to medical conditions and required extensive assist with bed mobility, dressing, locomotion, personal hygiene. The CP goal included Resident 21 will be kept comfortable and ADL needs will be met daily x 3 months and the resident will be participate/assist with ADLs to the highest degree possible within physical and medical current level of function by next review. The CP was revised on 8/29/23 with the target date 2/1/24. During a concurrent observation and interview on 1/24/24 at 8:46 AM with Director of Nursing (DON) in Resident 21's room, with Resident 21's permission, the DON assessed Resident 21's fingernails which were long and measuring about 4-5 mm long from the tip of finger. The DON immediately called one Certified Nursing Assistant to trim Resident 21's fingernails. In an interview the DON stated she will ask podiatrist (physician and surgeon who treats the foot, ankle, and related structures of the leg) to come to see Resident 21 as soon as possible for his long, discolored, and thick toenails. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living , supporting, dated 03/2018, the P&P Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to provide sufficient fluid to maintain proper hydration and health for one Random Sample Resident 13 (RSR 13) by failing to: 1. Ensure that RSR 13 who was assessed at risk for dehydration, had poor oral intake, unable to request fluids due to cognitive impairment and who received diuretics (medications that increase urine output), was provided the volume of fluid (1580-1896 cc) daily at set intervals. 2. Monitor RSR 13's health conditions and dehydration-associated indicators, such as abnormal laboratory test results, weight loss, skin conditions, urinary tract infection [MEDICAL CONDITION], and notify the physician to obtain treatment instruction(s) and to provide timely interventions to correct the reduction or depletion of fluid volume accordingly. This deficient practice resulted in RSR 13's transfer to GACH, for treatment of [REDACTED]. RSR 13 was hospitalized for [REDACTED]. Findings: According to the admission record, RSR 13 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. enough blood to meet the body's needs), and gastro-[MEDICAL CONDITION] reflux disease (stomach contents come back up into your esophagus causing heartburn),[MEDICAL CONDITION], acute kidney failure. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated October 2, 2015, RSR 13, had intact cognitive skills, incontinent of bowel and bladder, and had a height and weight of 63 inches and 196 pound respectively. A review of the care plan for risk of dehydration (fluid volume deficit) related to diuretic (medication that increase urine output) initiated on September 12, 2014, not revised/updated until November 14, 2016, indicated the goal was to minimize further risks of dehydration as evidence by good to fair skin turgor and moist mucous membranes daily through next review for three months. The interventions included to keep fluids nectar thick within easy reach, assist to consume as needed, observe for contributing factors of fluid volume depletion such as poor appetite and intake, offer food substitute if intake is below 50 percent, report when meals were refused, and to refer to dietitian for evaluation and recommendations. However, the plan of care was incomplete in that it did not indicate the resident ' s daily fluid requirement, the volume of fluid to be provided to the resident at a set interval and to maintain a fluid intake and output record. A review of the Registered Dietitian's (RD) Nutritional Assessment record dated July 15, 2015, indicated RSR 13's daily fluid requirement was 1580-1896 cc ' s. A review of the RD's reassessment record dated September 29, 2016, indicated RSR 13 ' s daily fluid intake was increased to 1740-2136 cc per day for an specified reason written on the clinical record. Despite the increased fluid needs, the licensed nursing staff did not update the plan of care to indicate the increase in fluid intake, to monitor the resident ' s hydration status by means of an intake and output record. In addition, there was no documented evidence that indicated RSR 13 was provided 1740-2136 cc per day from October 1, to November 2, 2016. On November 13, 2016 at 5:30 p.m., during an interview, the DON stated RSR 13 was not drinking enough fluid, not eating enough, and resident was very weak. When asked if there was documentation of resident's intake and output record when resident was not drinking or eating enough, DON stated No. The Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated October 2, 2016, indicated RSR 13's cognition status has changed to severely impaired, required limited assistance and one person assist for eating, and had no impairment to upper and lower extremities. Although the MDS dated [DATE], indicated RSR 13 had impaired cognitive skills, and a [DIAGNOSES REDACTED]. A review of the literature indicates, Patients with dementia are at high risk for eating and feeding difficulties and inadequate food and fluid intake. Depending on the severity of their cognitive impairment, they may forget to eat, forget they have eaten, fail to recognize food, or eat things that are not food. They may have difficulty with specific tasks (e.g., removing plate covers and wrappings, knowing what the utensils are for and using them, moving food or fluid to their mouth, chewing, and swallowing). They may have difficulty initiating the eating/drinking process, or they may start eating, get distracted, and fail to finish meals (AJN, August 2008, Vol. 108 No 8 pages 51-52). There was no documented evidence that indicated the facility had developed a plan of care based on assessed needs of the resident to meet the resident's challenges to access food and fluids independently, in order to ensure adequate hydration. A review of the physician orders [REDACTED]. These medications have the potential to deplete the resident ' s fluid. However, while RSR 13 was on three diuretics, the licensed nursing staff did not update the plan of care to include interventions to closely evaluate the resident ' s hydration status. The plan of care did not include useful interventions to monitor the resident and to ensure the daily fluid intake as assessed by the RD was met. On November 13, 2016 at 5:30 p.m., during an interview, the DON stated RSR 13 while taking three diuretics that could cause her to be dehydrated, was not drinking or eating enough. Further review of the physician orders [REDACTED]. Resident requires supervision during intake, slow rate during oral intake, and alternate liquids and solids. However, during a lunch observation, on November 11, 2016 at 12:10 p.m. RSR 13 was not assisted or supervised to ensure she consumed adequate fluid intake. According to the Certified Nursing Assistant documentation, resident consumed only 20 percent of meal. On November 11, 2016 at 12:10 p.m., during a lunch observation, RSR 13 was feeding herself in the dining room. The resident consumed the four ounces of milk, 10 percent of the four ounces of juice, and 75 percent of the eight ounces of water. The resident did not eat her entree. RSR 13 wheeled herself out of the dining room. There were three staff members in the dining room (two Certified Nursing Assistants (CNAs) and one Restoration Nursing Assistant (RNA), but none of them was assign to the resident to assist the resident consume her fluids. A review of the fluid intake with meals for the month of October, 2016, indicated RSR 13 had an average daily fluid intake of 831 cc. This was an average of daily fluid intake deficit of 810 cc (1740-831= 810). However, the plan of care was not updated with interventions to increase the resident's fluid intake. A review of the Laboratory test results dated October 5, 2016, had the following indicators for dehydration: 1. An elevated BUN (blood urea nitrogen- a test measures the amount of nitrogen waste in your blood) 44 mg/dl high (reference range 7-23 mg/dl) 2. Creatinine (an important indicator of renal/kidney health) 1.5 mg/dl high (reference range 0.6-1.4 mg/dl) 3. An increased BUN/Cr ratio of 29 (reference range 5-20 mg/dL). A BUN/Cr ratio greater than or equal to 25:1 mg/dL is an indicator for actual dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, Page 47. While the resident had insufficient fluid intake to maintain hydration from October 1, to October 5, 2016, as evidence by the above abnormal laboratory test results, there was no documented evidence that indicated the physician was notified in order to obtain treatment instruction(s). A review of the urine specimen test result reported to the facility on [DATE], indicated [MEDICATION NAME] was positive and many bacteria which indicate RSR had a UTI. The resident was treated with oral antibiotic on October 10, 2016 at 6:43 p.m. The first dose of antibiotic was administered on October 11, 2016, two days after the result of the urine specimen. Following the order of the oral antibiotic to treat the UTI, the RD's instruction to provide 1740-2136 cc per day was not implemented. A review of the faxed document sent to the physician on October 18, 2016, indicated the resident was losing weight approximately seven pounds, not eating well, family providing meals but resident refusing it, resident was eating approximately 20 percent of all meals. According to the physician's response dated October 18, 2016, received via fax, orders for laboratory tests for complete blood count (CBC), chemistry, urine analysis, urine culture was obtained. A review of the Laboratory test result dated October 19, 2016 indicated the following: 1. An elevated blood Sodium of 137 mEq/L (reference range 135-145) 2. An elevated BUN 63 mg/dl high (reference range 7-23) 3. An elevated Creatinine mg/dl 2.0 (reference range 0.6-1.4) 4. An increased BUN/Cr ratio 32 (reference range 5-20 mg/dL). A BUN/CR ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47). 5. Urinalysis test result indicated positive [MEDICATION NAME] (reference range negative), trace leukoestrase (reference range negative), WBC (white blood cells) of 2-5 (reference range negative), and many bacteria (reference range none), suggestive of UTI. The urine test results were faxed to the physician. However, there was no follow-up to obtain treatment instruction(s). 6. A urine osmolality of 301.8 mosm/kg (reference range 275-295 mosm/kg). Urine osmolality is used to measure the number of dissolved particles per unit of water in the urine. Urine osmolality is useful in assessing hydration status (Nursing Care Ready Reference Resident Assessment Protocol Pages 53- 55). A review of another Laboratory urine test result dated October 21, 2016, indicate RSR 13's urine specimen resulted in positive [MEDICATION NAME], moderate leukoestrase, WBC greater 100 (reference range 0-2), and many bacteria (reference range none). The physician was notified and an order to administer [MEDICATION NAME] 1 gram I.M. (intramuscular antibiotic) daily for five days was obtained. One of the complications associated with dehydration is urinary tract infections (AJN, American Journal of Nursing: June 2006 - Volume 106 - Issue 6, pages 40-49. A review of the fluid intake with meals for the month of November, 2016, indicated RSR 13 had an average daily fluid intake of 1492 cc, and therefore, resident had a fluid deficit of 248 cc per day for November 1 and 2, 2016. A review of the last laboratory test results dated November 3, 2016, indicated the following: 1. An elevated blood Sodium 151 mEq/L 2. An elevated blood BUN 105 mg/dl critical high 3. An elevated blood Creatinine 3.6 mg/dl BUN/Cr ratio 29 4. A urine osmolality of 345.5 mosm/kg (this is higher than previous of 301.8 mosm/kg) which indicated RSR 13's urine was more concentrated. Although the resident's laboratory test results indicate critical signs of dehydration, treatment for [REDACTED]. Delayed treatment of [REDACTED]. 99-Issue 5 page 66-69). A review of the Change of Condition record dated November 3, 2016, indicated RSR 13 was transfer to the general acute care hospital (GACH) dated GACH due to abnormal laboratory results. A further review of the History and Physical from the GACH dated November 3, 2016, obtained from the GACH indicated RSR 13 was brought to the emergency department because of abnormal laboratory test results. A review of the History and Physical (H&P) from the GACH dated November 3, 2016, indicated RSR 13 was noted to have UTI [MEDICAL CONDITION] (a systemic infection in which the body has a severe response to bacteria), dehydration, and acute kidney injury. According to the H&P, the resident had an elevated BUN level of 106 mg/dl and Creatinine 3.7 mg/dl., elevated Sodium of 149 mEq/L RSR 13 was hospitalized for [REDACTED]. Cross refer to F315