Every finding on record at Good Shepherd Health Care Center of Santa Monica

Based on observation, interview, and record review, the facility failed to ensure that staff-including the Director of Nursing (DON) and Registered Nurse (RN) 1-demonstrated the competencies and skills required to develop comprehensive, person centered care plans with measurable goals, individualized interventions, and defined evaluation timeframes for six of six sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 8, and Resident 33).This deficient practice had the potential to result in care that was not individualized to the resident's needs, inadequate monitoring of the resident's condition, failure to identify and address changes in condition, and an increased risk of adverse outcomes.Findings: 1.During a review of Resident 2's admission Records, the admission Records indicated Resident 2 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with the diagnoses including dementia, schizophrenia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's Physician Visit Progress note dated 5/13/2025, the progress note indicated Resident 2 does not have capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/ortouching/steadying and/or contact guard assistance as resident completes activity) with all activities of daily living (ADL) such as eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 2/24/2026 at 10:37 a.m. with Registered Nurse (RN) 1, RN 1 reviewed Resident 2's electronic and paper medical record. Review of care plan indicated no comprehensive, person-centered care plan addressing diagnoses schizophrenia and dementia, and the use of quetiapine (a medication to treat schizophrenia). 2.During a review of Resident 4's admission Record, the admission record indicated that Resident 4 was initially admitted to the facility on [DATE] and last re-admission was on 12/14/2025 with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), altered mental status and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident's 4's MDS dated [DATE], MDS indicated that Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. MDS indicated that Resident 4 required maximal assistance from staff for ADLs. During a concurrent interview and record review with Treatment Nurse (TXN) on 2/24/26 at 1:44 p.m., the TXN stated that Resident 4's treatments should be care planned. The TXN stated that Resident 4's skin check assessment was incomplete and that is the reason a care plan was not initiated for Resident 4's Triamcinolone Acetonide Cream (used to reduce inflammation, itching, and redness in various skin and inflammatory conditions.). 3.During a review of Resident 5's admission Records, the admission Records indicated Resident 5 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with the diagnoses including chronic kidney disease stage 4 (a disease when kidneys are severely damaged and working at only 15-29% of their normal capacity), Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a chronic condition where the heart muscle becomes too weak to pump blood efficiently). During a review of Resident 5's History and Physical (H&P) dated 9/1/2025, the H&P indicated Resident 5 did not have capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5 had moderate cognitive impairment (has some cognitive issues-such as occasional, minor mistakes in daily routines or difficulty recalling certain information-but still retains significant cognitive function). The MDS indicated Resident 5 required supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 5's Care Plans for dialysis treatment and nutrition/diet, the care plans indicated no documentation of measurable goals, individualized interventions and target timeframes. During a concurrent interview and record review on 2/25/2026 at 11:00 a.m. with Registered Dietician (RD), reviewed Resident 5's care plan for nutrition/diet care plan. The RD stated that the care plan did not indicate all measurable goals and interventions for Resident 5. 4.During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II DM, heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's MDS dated [DATE], MDS indicated that Resident 6's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 6 required maximal assistance from staff for ADLs. During an interview and record review on 02/24/2026 at 12:39 p.m. with RN 1, Resident 6's records were reviewed. RN 1 stated that there was no care plan for Resident 6's insulin use. RN 1 said this depends on the DON and that they follow the DON's policy, which is to include three interventions per system. RN 1 stated the interventions listed for Resident 6 were not sufficient. 5.During the review of Resident 8's admission Records, the admission records indicated Resident 8 was admitted to the facility on [DATE], with diagnosis that included but not limited to cerebral infarction, depression unspecified (a condition that causes a persistent feeling of sadness and loss of interest) and anxiety (mental condition characterized by excessive worry about real or perceived situations often lead to physical symptoms like increased heart rate and muscle tension). During the review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 needed partial/moderate assistance )helper does less than half the effort) for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, personal hygiene and need supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating, rolling on the side, sit to lying, lying to sitting, chair/bed transfer, tub/shower transfer and walking 10-150 feet. The MDS indicated Resident 8 has moderately impaired for cognitive skills for daily decision making and has a BIMS ([Brief Interview for Mental Status] - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 99 (BIMS score 99 - unable to complete due to resident condition). During a review of resident 8's care plan, the care plan indicated no measurable objectives and timeframes for Lorazepam (a medication to manage anxiety, insomnia - trouble falling asleep or staying asleep, and seizures - a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During an interview on 2/25/2026 at 8:40 a.m. with RN 1, RN 1 stated Resident 8's care plan was missing measurable outcomes and timeframes for Lorazepam. 6.During a review of Resident 33's admission Records, the admission Records indicated Resident 33 was originally admitted to the facility on [DATE], the readmitted to the facility on [DATE], with the diagnoses including chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), benign prostatic hyperplasia (enlarged prostate), chronic pain syndrome (pain that lasts longer than three months). During a review of Resident 33's H&P dated 2/5/2026, the H&P indicated Resident 33 has the capacity to understand and make decisions. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 had intact cognition (has normal, intact memory and orientation, allowing them to recall words and understand the date/location). The MDS indicated Resident 33 required Partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 33's Care Plan for suprapubic urinary catheter, the care plan indicated no documentation of measurable goals, individualized interventions and target timeframes. During an interview on 2/24/2026 at 11:00 a.m., RN 1 stated that basic care plans were developed within 72 hours of admission for all residents and generally included areas such as bowel and bladder care, activities of daily living (ADLs), smoking, pain management, skin care, fall prevention, and psychosocial needs. RN 1 explained that care plans were documented under broad, grouped categories; for example, when a resident started a new pain medication, the medication was added under the existing pain-related care plan rather than being addressed through a specific or individualized plan. RN 1 further stated that individualized care plans were created only for residents with a specific condition or when a medication carried a black box warning. RN 1 acknowledged that many interventions were written in broad, generalized terms, such as administer medications as ordered or monitor episodes of behaviors as ordered, and clarified that detailed instructions were located in the physician's orders rather than in the care plan itself. RN 1 reported that this was the facility's standard practice per Director of Nursing (DON) policy. During an interview on 2/24/2026 at 11:20 a.m., the Director of Nursing (DON) stated that care plan interventions were intended to provide general direction and guidance for staff. The DON explained that detailed interventions, specific monitoring requirements, and measurable goals were outlined within the physician's orders rather than in the care plan itself. The DON further stated that a medication specific care plan was required only when the medication carried a black box warning, and that for all other medications-including routine medications-interventions and potential side effects were addressed through the corresponding physician's orders During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered reviewed on 2/24/2026, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;c. Describe services that would otherwise be provided for the above, but are not provided due to theresident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of Preadmission Screening and Resident Review ([PASARR] - a federal rule requiring all nursing home applicants to be screened for mental illness or intellectual disabilities before admission) recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;g. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;I. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review, the facility failed to ensure:a. licensed staff completed proper documentation of disposal of non controlled medications indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) for one of one Medication Storage area. b. medications were administered as prescribed by the physician for two of four sampled residents (Resident 2 and Resident 42) when Licensed Vocational Nurse (LVN) 1 administered the incorrect dosage of sodium bicarbonate (used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) for Resident 42, and insulin (a hormone that removes excess sugar from the blood, produced by the body or given artificially via medication) administration was held without indication for Resident 2. These deficient practices placed the facility at risk for inaccurate medication reconciliation and increased the potential for drug diversion involving non controlled medications. Additionally, the failures in medication administration created the potential for clinically significant adverse outcomes, including elevated gastric or blood acid levels for Resident 42 and elevated blood glucose levels for Resident 2, which could result in further complications. Findings: During a concurrent observation and interview on 02/24/2026 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 1 in Medication Storage area, the pharmaceutical waste container was placed inside a locked cabinet. LVN 1 stated the medication disposal process was when non-controlled medication is discontinued, licensed nurse must document the prescription number, name of the medication, count, and have it witnessed by two licensed staff on the medication destruction record. During a concurrent interview and record review on 02/24/2026 at 11:47 a.m. with Director of Staff Development (DSD), Medication Destruction Record and facility's Policy and Procedures (P&P) titled Medication Discarding and Destroying Medications dated 02/24/2026 was reviewed. The P&P indicated that the medication disposition record will contain the following information; the resident's name; date medication disposed; the name and strength of the medication; the name of the dispensing pharmacy; the quantity disposed; method of disposition; reason for disposition; and signature of witnesses.DSD stated that the Medication Destruction Record indicated the following: 1.On 06/23/2025 and 06/24/2025, the destruction method and the second witness was incomplete. 2.On 8/27/2025 and 08/28/2025, the method of destruction and the licensed staff name was incomplete. 3.On 01/05/2026, the method of destruction, and the licensed staff name was incomplete. 4.On 02/01/2026, the licensed staff name and signature was incomplete. 5.On 02/21/2026, the number or quantity destroyed, method of destruction, and licensed staff name and signature was incomplete. DSD further stated that the medication destruction record log was incomplete, lacking reasons for disposition, the destruction method, and witness signatures with names or titles. DSD further stated that the facility's P&P was not followed. During an interview on 02/25/2026 at 12:48 p.m. with Director of Nursing (DON), DON indicated that the DON, DSD, and/or the licensed nurses handled the disposal of non-controlled medication. DON stated that the staff remove the medication from the cart and deliver it to the DON, who documents the medication count. DON added there should be two witnesses of licensed staff present at the disposal of the medication for accountability. B. During a review of Resident 2's admission Records, the admission Records indicated Resident 2 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with the diagnoses including dementia, schizophrenia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's Physician Visit Progress note dated 5/13/2025, the progress note indicated Resident 2 does not have capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 2 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with all activities of daily living (ADL) such as eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. During a concurrent interview and record review on 2/24/2026 at 11:20 a.m. with Director of Nursing (DON), the DON reviewed Resident 2's electronic medical records. The DON stated there was an order for Insulin Glargine solution 100 Unit/milliliter ([ml] – unit of measurement) to inject 20 unit subcutaneously (underneath the skin) at bedtime for DM, hold if blood sugar is less than 100. The DON stated medication administration record (MAR) indicated that on 2/21/2026 at 9:00 p.m. Resident 2's blood sugar level was 102 and Insulin administration had been marked with a code 5. The DON stated that code 5 was interpreted as Hold/see progress notes. Review of the progress notes dated 2/21/2025 indicated no documentation explaining why insulin was held, despite the physician's order parameters. The DON stated if insulin was not administered as ordered, the resident did not receive the therapeutic dose necessary to maintain safe and effective blood glucose control, which could increase the risk for hyperglycemia (high blood sugar levels) and other complications. During a review of the facility's P&P titled, Medication Administration, reviewed on 1/29/2026, the P&P indicated, Medications shall be administered safely and accurately by licensed nursing personnel in accordance with physician orders, accepted standards of practice, and regulatory requirements. The facility shall ensure proper storage, documentation, monitoring, and follow-up. Document omissions and reasons. During a concurrent observation and interview on 02/24/2026 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 1 in Medication Storage area, the pharmaceutical waste container was placed inside a locked cabinet. LVN 1 stated the medication disposal process was when non-controlled medication is discontinued, licensed nurse must document the prescription number, name of the medication, count, and have it witnessed by two licensed staff on the medication destruction record. During a concurrent interview and record review on 02/24/2026 at 11:47 a.m. with Director of Staff Development (DSD), Medication Destruction Record and facility's Policy and Procedures (P&P) titled Medication Discarding and Destroying Medications dated 02/24/2026 was reviewed. The P&P indicated that the medication disposition record will contain the following information; the resident's name; date medication disposed; the name and strength of the medication; the name of the dispensing pharmacy; the quantity disposed; method of disposition; reason for disposition; and signature of witnesses. DSD stated that the Medication Destruction Record indicated the following: On 06/23/2025 and 06/24/2025, the destruction method and the second witness was incomplete. On 8/27/2025 and 08/28/2025, the method of destruction and the licensed staff name was incomplete. On 01/05/2026, the method of destruction, and the licensed staff name was incomplete. On 02/01/2026, the licensed staff name and signature was incomplete. On 02/21/2026, the number or quantity destroyed, method of destruction, and licensed staff name and signature was incomplete. DSD added that the medication destruction record log was incomplete, lacking reasons for disposition, the destruction method, and witness signatures with names or titles. DSD further stated that the facility's P&P was not followed. During an interview on 02/25/2026 at 12:48 p.m. with Director of Nursing (DON), DON indicated that the DON, DSD, and/or the licensed nurses handled the disposal of non-controlled medication. DON stated that the staff remove the medication from the cart and deliver it to the DON, who documents the medication count. DON added there should be two witnesses of licensed staff present at the disposal of the medication for accountability.

Based on record review and interview, the facility failed to update two of five sampled residents (Resident 7 and Resident 50) advance directives (AD, a legal document indicating a person's preference regarding medical treatment and end-of-life treatment decisions) documentation. This failure had the potential to result in treatment delay and/or not meeting the residents' health care preferences and end of life wishes. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was readmitted on [DATE] (original admission [DATE]) with diagnoses including but not limited to chronic obstructive pulmonary disease (a chronic lung disease causing difficulty breathing), epilepsy (a brain disorder that may cause loss of consciousness or involuntary, violent movements of the body or a limb), and bipolar disorder (a mood swings that range from the lows of depression to elevated periods of emotional highs, sometimes called manic-depressive disorder). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated Resident 7's AD was available and reviewed. During a review of Resident 7's Physician Orders for Life-Sustaining Treatment (POLST) form, the POLST indicated Resident 7 had an Advance Directive (AD) dated [DATE] and was reviewed with Resident 7's Resident Representative on [DATE]. During a review of Resident 7's health record, the health record indicated a copy of Resident's AD dated [DATE]. During a review of the facility's AD acknowledgement form, dated [DATE], the AD acknowledgement form indicated Resident 7 had not executed an AD and declined to execute an AD. During an interview on [DATE] at 2:40 p.m. with Social Services Director (SSD), SSD stated the AD acknowledgment form was not filled out correctly to indicate Resident 7 had an AD as reflected on the MDS and POLST. SSD stated inconsistent information might result in confusion and failure to comply with the resident's wishes. SSD stated the incorrect information on the AD acknowledgment form was overlooked and it needs to be updated. During a review of the facility's policy and procedure (P&P) titled, Advance Directives and End-of-Life Decision-Making, unknown date, the P&P indicated interdisciplinary team responsibility to review and update AD quarterly and with significant change. B. During a review of Resident 50's admission Record, the admission Record indicated, Resident 50 was initially admitted to the facility on [DATE] with diagnoses including bronchitis (occurs when the airways of the lungs swell and produce mucus in the lungs), dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). During a review of Resident 50's History and Physical (H&P), dated [DATE] and timed at 9:39 a.m., the H&P indicated, Resident did not have the capacity (ability) to understand and make decisions. The H&P indicated, Resident 50's code status was Do Not Attempt Resuscitation (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50 required dependent assistance (helper does all of the effort) from two or more staff for activities of daily living (ADLs – toileting hygiene, shower/bathing). During a review of Resident 50's physician orders titled Order Summary Report (OSR), dated [DATE], the OSR indicated, DNR was ordered on [DATE]. During an interview and record review on [DATE], at 9:27 a.m., with SSD, Resident 50's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE] was reviewed. The POLST indicated, Resident 50 had order for Attempt Resuscitation (full treatment-prolonging life by all medically effective means). The POLST indicated, AD was missing information. The SSD stated that the POLST was not completed because there was missing signature from Resident's conservator. SSD stated, if POLST was not completed, the resident would be treated as full code and all life sustaining measures would be done during emergency per policy. The SSD stated that the nursing staff should follow the paper POLST and not the physician orders. During a concurrent interview and record review on [DATE] at 9:55 a.m., with Director of Nurses (DON), Resident 50's POLST dated [DATE], H&P dated [DATE] and physician orders active as of [DATE] were reviewed. The POLST indicated that Resident 50 was full code, while the H&P documentation that Resident 50 was DNR. The DON stated that upon admission, Resident 50 arrived at facility with DNR orders from the previous facility but without a current POLST confirming DNR status. The DON stated that staff should follow Resident 50's previous physician orders, even though the facility had not obtained a POLST confirming DNR status. The DON further stated that the current POLST in Resident 50's physical chart was not valid because it was missing signature from conservator (person legally appointed to manage financial and medical decisions for someone who is not able to do so themselves) and nursing staff should follow the physician orders from the previous facility. During a review of the facility's P&P titled, Advance Directives and End of Life Decision Making, revised (unknown date), the P&P indicated under nursing verify advance directive status upon admission and quarterly via POLST form, Ensure POLST are signed and filed, and communicate code status to interdisciplinary team via POLST form.

Based on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan with measurable goals, individualized interventions and target timeframes for evaluation for six of six sampled residents (Resident 2, Resident 4, Resident 5, Resident 6, Resident 8 and Resident 33) addressing:Diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) and the use of quetiapine (a medication to treat schizophrenia) for Resident 2.The use of Triamcinolone Acetonide (topical corticosteroid used to treat various skin conditions by reducing inflammation) cream for scattered rash for Resident 4.Dialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and nutrition/diet for Resident 5.The use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for Resident 6. The use of lorazepam (medication to manage anxiety, insomnia - trouble falling asleep or staying asleep, and seizures - a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness for Resident 8.The use of urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for Resident 33.These deficient practices had the potential to result in a delay of nursing care and interventions for the residents.Findings:1.During a review of Resident 2's admission Records, the admission Records indicated Resident 2 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with the diagnoses including dementia, schizophrenia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's Physician Visit Progress note dated 5/13/2025, the progress note indicated Resident 2 does not have capacity to understand and make medical decisions.During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 2 required supervision or touching assistance (Helper provides verbal cues and/ortouching/steadying and/or contact guard assistance as resident completes activity) with all activities of daily living (ADL) such as eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear.During a concurrent interview and record review on 2/24/2026 at 10:37 a.m. with Registered Nurse (RN) 1, RN 1 reviewed Resident 2's electronic and paper medical record. RN 1 stated there was an order for quetiapine 25 mg to take 1 tablet by mouth every evening for schizophrenia, aggressive and combative behavior. Review of care plan indicated no comprehensive, person-centered care plan addressing schizophrenia, dementia and quetiapine use.2.During a review of Resident 4's admission Record, the admission record indicated that Resident 4 was initially admitted to the facility on [DATE] and last re-admission was on 12/14/2025 with diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), altered mental status and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain).During a review of Resident's 4's MDS dated [DATE], MDS indicated that Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. MDS indicated that Resident 4 required maximal assistance from staff for ADLs.During a review of Resident 4's Order Summary Report, the order summary report indicated an order dated 12/17/2025 for Triamcinolone Acetonide cream 0.1% apply to upper body topically everyday shift for scattered rash until 1/16/2026.During a concurrent interview and record review with Treatment Nurse (TXN) on 2/24/26 at 1:44 p.m., Resident 4's order summary and skin check assessment dated [DATE] was reviewed. TXN stated that upon admission a skin check was completed for Resident 4. The TXN stated that Resident 4's skin check assessment was incomplete and that is the reason a care plan was not initiated for Resident 4's Triamcinolone Acetonide Cream. The TXN stated that Resident 4's treatments should be care planned.During an interview with Director of Nursing (DON) on 2/25/2026 at 12:48 p.m., the DON stated that there should be a care plan developed for all residents on admission and revised as needed when new physician orders are given to nursing staff. DON stated that care plans are important because it indicates the care that was provided to the residents. The DON states that without a care plan, staff may not know what care or interventions the resident needs.3.During a review of Resident 5's admission Records, the admission Records indicated Resident 5 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with the diagnoses including chronic kidney disease stage 4 (a disease when kidneys are severely damaged and working at only 15-29% of their normal capacity), Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a chronic condition where the heart muscle becomes too weak to pump blood efficiently).During a review of Resident 5's History and Physical (H&P) dated 9/1/2025, the H&P indicated Resident 5 did not have capacity to understand and make decisions.During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5 had moderate cognitive impairment (has some cognitive issues-such as occasional, minor mistakes in daily routines or difficulty recalling certain information-but still retains significant cognitive function). The MDS indicated Resident 5 required supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear.During a review of Resident 5's Order Summary Report dated 5/28/2025 indicated order for renal (lower amounts of sodium (salt), protein, potassium, or phosphorus), no added salt (NAS), consistent carbohydrate ([CCHO] - a diabetes management plan that keeps blood sugar stable by eating roughly the same amount of carbs at the same times every day, rather than restricting them entirely) diet with regular texture, regular/thin liquid consistency. During a review of Resident 5's Care Plans for dialysis and nutrition/diet, the care plans indicated no documentation of measurable goals, individualized interventions and target timeframes.During a concurrent interview and record review on 2/25/2026 at 11:00 a.m. with Registered Dietician (RD), reviewed Resident 5's care plan for nutrition/diet care plan. The RD stated that the care plan did not indicate all measurable goals and interventions for Resident 5.4.During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II DM, heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 6's MDS dated [DATE], MDS indicated that Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 6 required maximal assistance from staff for ADLs.During a review of Resident 6's records titled Order Summary Report dated 02/25/2026, indicated a physician order for;Insulin Glargine (long-acting type of insulin that works slowly) Inject 10 unit subcutaneously (given under the skin) at bedtime for Type 2 DM Hold for Blood sugar less than 100 initiated on 12/26/2025.Insulin Regular Human (short-acting insulin used to manage high blood sugar) Inject as per sliding scale subcutaneously before meals for Type 2 DM initiated on 12/26/2025.During an interview and record review on 02/24/2026 at 12:39 p.m. with Registered Nurse (RN) 1, Resident 6's records were reviewed. RN 1 stated Resident 6 was receiving insulin and explained that monitoring blood sugar is essential for residents on insulin, including watching for signs of high and low blood sugar. RN 1 stated that creating care plans is part of her responsibility and that care plans provide guidelines for resident care. RN 1 stated that there was no care plan for Resident 6's insulin use. RN 1 said this depends on the Director of Nursing (DON) and that they follow the DON's policy, which is to include three interventions per system. RN 1 stated the interventions listed for Resident 6 were not sufficient.During an interview on 2/25/2026 at 12:48 p.m. with DON, the DON explained that each resident's care plan should focus on identifying needs, setting goals, and adding appropriate interventions. The DON stated that care plan was developed on admission and revised as needed and quarterly by Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need). The DON stated that residents receiving insulin must have a diabetes care plan that includes medication administration and monitoring for side effects, such as foot care and blood sugar checks. The DON added that without a care plan, staff may not know what care or interventions the resident needs.6.During the review of Resident 8's admission Records, the admission records indicated the facility admitted the resident on 4/3/2025 with diagnosis that included but not limited to cerebral infarction, depression (a condition that causes a persistent feeling of sadness and loss of interest) and anxiety (mental condition characterized by excessive worry about real or perceived situations often lead to physical symptoms like increased heart rate and muscle tension).During the review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 needs partial/moderate assistance for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, personal hygiene and need supervision and touching assistance for eating, rolling on the side, sit to lying, lying to sitting, chair/bed transfer, tub/shower transfer and walking 10-150 feet. The MDS indicated Resident 8 has memory problems, moderately impaired for cognitive skills for daily decision making.During a review of resident 8's care plan on 02/24/2026 at 2 p.m., Resident 8's care plan was missing measurable objectives and timeframes for lorazepam.During an interview on 2/25/2026 at 8:40 a.m. with RN 1, RN 1 stated that Resident 8's care plan was missing measurable outcome and timeframes for lorazepam.During an interview on 2/25/2026 at 9:55 am with DON, DON was unable to answer regarding Resident 8's care plan missing measurable outcomes and timeframes for lorazepam.During an interview on 02/25/2026 11:30 AM with RD, the RD stated that all care plans should have measurable outcome within certain timeframe.7.During a review of Resident 33's admission Records, the admission Records indicated Resident 33 was originally admitted to the facility on [DATE], the readmitted to the facility on [DATE], with the diagnoses including chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), benign prostatic hyperplasia (enlarged prostate), chronic pain syndrome (pain that lasts longer than three months).During a review of Resident 33's H&P dated 2/5/2026, the H&P indicated Resident 33 has the capacity to understand and make decisions.During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 had intact cognition (has normal, intact memory and orientation, allowing them to recall words and understand the date/location). The MDS indicated Resident 33 required Partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear.During a review of Resident 33's Order Summary Report dated 2/4/2026 indicated order for suprapubic (inserted above pubic bone) urinary catheter for urinary retention (the inability to fully empty the bladder, resulting in urine building up inside).During a review of Resident 33's Care Plan for suprapubic urinary catheter, the care plan indicated no documentation of measurable goals, individualized interventions and target timeframes. During an interview on 2/24/2026 at 11:00 a.m., RN 1 stated that basic care plans were developed within 72 hours of admission for all residents and generally included areas such as bowel and bladder care, activities of daily living (ADLs), smoking, pain management, skin care, fall prevention, and psychosocial needs. RN 1 explained that care plans were documented under broad, grouped categories; for example, when a resident started a new pain medication, the medication was added under the existing pain-related care plan rather than being addressed through a specific or individualized plan. RN 1 further stated that individualized care plans were created only for residents with a specific condition or when a medication carried a black box warning. RN 1 acknowledged that many interventions were written in broad, generalized terms, such as administer medications as ordered or monitor episodes of behaviors as ordered, and clarified that detailed instructions were located in the physician's orders rather than in the care plan itself. RN 1 reported that this was the facility's standard practice per Director of Nursing (DON) policy.During an interview on 2/24/2026 at 11:20 a.m., the Director of Nursing (DON) stated that care plan interventions were intended to provide general direction and guidance for staff. The DON explained that detailed interventions, specific monitoring requirements, and measurable goals were outlined within the physician's orders rather than in the care plan itself. The DON further stated that a medication specific care plan was required only when the medication carried a black box warning, and that for all other medications, including routine medications, interventions and potential side effects were addressed through the corresponding physician's ordersDuring a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered reviewed on 2/24/2026, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;c. Describe services that would otherwise be provided for the above, but are not provided due to theresident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of Preadmission Screening and Resident Review ([PASARR] - a federal rule requiring all nursing home applicants to be screened for mental illness or intellectual disabilities before admission) recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;g. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;I. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure ongoing assessment, monitoring, and accurate documentation of skin condition and wound healing for two of fourteen sampled resident (Resident 6 and Resident 29). This deficient practice resulted in untreated or unidentified skin breakdown, delayed interventions, and decline in the resident 6 and resident 29 condition. Findings: A.During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool) dated 01/01/2026, MDS indicated that Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. MDS indicated Resident 6 required maximal assistance from staffs for activities of daily living (ADLs – toileting hygiene, shower/bathing). The MDS also indicated that there were no other ulcers, wounds or skin problems documented. During a concurrent observation and interview on 02/23/2026 at 08:17 a.m. with Resident 6 was observed with generalized scab (crusty layer of dried blood that forms over a skin injury) of varying sizes on the neck and upper chest. Resident 6 stated having lesions (any area of abnormal or damaged tissue in or on the body) for several weeks and stated that they were occasionally itchy. During a review of Resident 6's medical record titled Professional Wound Specialists Progress Notes, the Nurse Practitioner (NP) documented that a follow up evaluation and ongoing wound care were completed for wounds on both lower legs, the abdomen, and the upper chest. The NP noted that the upper chest lesions appeared as small, scattered sores with pink to red wound beds and healthy granulation tissue, with no signs of infection During a review of Resident 6's records titled, Order Summary Report dated 02/25/2026, the physician order initiated on 2/16/2026 for hydrocortisone (medication used to reduce inflammation, itching, and swelling) external cream. The physician order indicated apply to face, neck and chest topically every day and evening shift for skin picking, until 03/03/2026. During a concurrent observation and interview of Resident 6's wound care on 02/24/2026 at 1:20 p.m. with Treatment Nurse (TXN), Resident 6 was observed with generalized scabs in upper chest, as well as on both arms and legs. TXN stated that Resident 6 was receiving hydrocortisone cream for the scabbed areas. During an interview with Certified Nurse Assistant (CNA) 1 on 02/24/2026 at 1:30 p.m., CNA 1 stated that Resident 6's generalized wound was not new, and that Resident 6 requested the staff handle her skin gently. During a subsequent observation and interview with Resident 6 on 2/24/2026 at 2:55 p.m., Resident 6 was scratching her left leg. Resident 6 reported itching and requested assistance to relieve the itching. During a concurrent interview and record review of Resident 6's medical records with TXN on 2/24/2026 at 1:44 p.m., the TXN stated that wound assessments include measuring the wound, noting its color, identifying the tissue type, and assessing any drainage. The TXN stated that skin assessments are essential for evaluating wound progression and determining appropriate treatment. The TXN stated that wound assessments are documented weekly, with the most recent entry dated 02/13/2026. The TXN further reported that an assessment was performed on 02/19/2026; however, it had not yet been documented. The TXN stated that assessments were documented for Resident 6's wounds on the right leg, left leg, and abdomen. The TXN stated there was no initial documentation of the generalized scabs and stated the assessment was planned for after completion of the hydrocortisone treatment. The TXN added that Resident 6 was provided distraction techniques to help prevent skin picking. During a concurrent interview and record review on 2/25/2026 at 12:48 p.m. with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Wound Assessment and Management, updated 01/20/2026 was reviewed. The P&P statement indicated the facility shall ensure assessment, documentation, treatment, and monitoring in accordance with applicable state regulations. DON stated according to facility's P&P that nursing responsibilities is to conduct skin assessment on admission, weekly and with significant change; measure and document wound characteristics; implement physician-ordered treatments; and notify physician of new or worsening wounds. DON stated that skin assessment is important to know how to treat the wound. DON stated she was not a certified wound nurse, so she does not know what kind of wound Resident has in the facility. DON further stated that the treatment nurse is responsible in conducting weekly wound assessments but follows the wound specialist's assessment if consulted. DON added that TXN missed his assessment for the generalized wound for Resident 6. DON stated that TXN did not adhere to the facility's P&P for wound assessment and management for Resident 6. B. During a review of Resident 29's admission Record, the admission record indicated that Resident 29 was initially admitted to the facility on [DATE] with diagnoses of bilateral (both) legally eye blindness (severe vision loss), dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident 29's MDS dated on 01/23/2026, MDS indicated that Resident 29 required substantial/maximal assistance (helper does more than half the effort) for ADLs and needs partial assistance (helper does less than half the efforts) for eating. During a review of Resident 29's Order Summary Repot (OSR), the OSR indicated an order dated 7/23/2025 indicated admit to Hospice care with admitting diagnosis of chronic renal failure (CKD-a longstanding disease of the kidneys leading to renal failure) under routine level of care. During a review of Resident 29's Skin Check assessment dated [DATE]b25 timed 9:10 p.m., the skin check assessment indicated that Resident 29 had right antecubital (area located directly in front of the elbow) open blister measuring 2.5 centimeter (cm- a metric unit of length) by 1.0 cm, right forearm open blister measuring 1.5 cm by 1.5 cm, left posterior (back) thigh open blister measuring 6 cm by 1.7 cm, left lateral (side) thigh open blister measuring 2.0cm by 1.0cm. During a review of Resident 29's Hospice Re-Certification assessment dated [DATE], the assessment indicated that Resident 29 was bedbound and confined to bed with multiple wounds. The assessment indicated a right forearm skin tear measuring 1cm by 4 cm, a left thigh skin tear measuring 2cm by 4 cm, and an ulcer behind left knee measuring 2 cm by 7 cm. During a concurrent interview and record review on 2/25/2026 at 9:30 a.m. with Treatment Nurse (TXN), Resident 29's wound care notes, skin assessments and care plan were reviewed. TXN stated that Resident 29 did not have any active wounds and that the resident's wounds had resolved in 2025. TXN further stated that the electronic record did not contain documentation indicating when the wounds were resolved. TXN stated that weekly wound assessments should have been done to monitor Resident 29's wound progress. TXN stated that once wounds are resolved, staff should document the resolution in a nursing note. TXN stated that Resident 29's care plan should have been resolved since Resident 29 no longer receives wound treatment. During an interview on 2/25/2026 at 9:42 with Certified Nurse Assistant (CNA) 3, CNA 3 stated that Resident 29 is not bedbound and can ambulate with assistance. CNA 3 further stated that she assists Resident 29 during showers and that Resident 29 does not have any open areas on the skin. During an observation on 2/25/2026 at 9:46 a.m. in Resident 29's room, CNA 3 was observed assisting Resident 29 to the restroom while holding both of the resident's hands and directing him. Resident 29's both arms were intact with no open wounds. During a concurrent interview and record review on 2/25/2026 at 12:48p.m. with the Director of Nursing (DON), hospice re-certification assessment and facility care plan was reviewed. The DON stated that Resident 29's re-certification assessment dated [DATE] was not accurate because Resident 29 does not have any open wounds and is not bedbound. DON stated that hospice team coordinates with the facility staff to ensure Resident 29 receives appropriate care but could not explain why the hospice documentation did not reflect Resident 29's current condition. DON stated that the treatment nurse is responsible in conducting weekly wound assessments but follows the wound specialist's assessment if consulted. During a review of the facility's policy and procedures (P&P) titled, Hospice Services Coordination dated 1/29/26, the P&P indicated coordination of care includes collaboration between hospice IDT and skilled nursing facility team, documentation of communication, quality assurance and performance improvement committee will review hospice coordination quarterly and track communication gaps.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was developed for two of two sampled residents (Resident 22 and Resident 29). This deficient practice had the potential to delay care and services that were specific to the residents' needs.1.During a review of Resident 22's admission Record, the admission record indicated that Resident 22 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), pulmonary edema (a condition caused by excess fluids in the lungs usually caused by a heart condition), and shortness of breath (SOB-an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). During a review of Resident 22's Minimum Data Set (MDS-a resident assessment tool) dated 12/28/2025, MDS indicated that Resident 22 required partial/moderate assistance from staff for activities of daily living (ADLs - toileting hygiene, shower/bathing). During an observation on 2/23/2026 at 9:33 a.m. Resident 22 lay in bed with oxygen concentrator at two (2) liters per minute and nasal canula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) in Resident 22's nose. During an observation on 2/24/2026 at 12:22 p.m., Resident 22 lay in bed with an oxygen concentrator running at 2 liters per minute, while the nasal cannula rested on their chin. CNA 3 entered the room, placed the meal tray on the bedside table, and then left the room. During a review of Resident 22's care plans, the care plans (in general) did not indicate a comprehensive care plan to address Resident 22's oxygen use and behavior of removing NC. During a review of Resident 22's Care Plan Report dated 4/15/2025 titled the resident has oxygen therapy due to COPD. The care plan interventions indicate provide oxygen as per Medical Doctor (MD) orders, provide medication as ordered, and monitor and assess for sign and symptoms of ineffective gas exchange. 2. During a review of Resident 29's admission Record, the admission record indicated that Resident 29 was initially admitted to the facility on [DATE] with diagnoses of bilateral (both) legally eye blindness (severe vision loss), dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident 29's MDS dated on 01/23/2026, MDS indicated that Resident 29 required substantial/maximal assistance (helper does more than half the effort) for ADLs and needs partial assistance (helper does less than half the efforts) for eating. During a review of Resident 22's Order Summary Report (OSR) dated 2/25/2026, the OSR included the following orders: a. Ordered on 11/25/2025, Oxygen concentrator to keep oxygen saturation greater than 92 percent as needed (PRN- given as needed or requested) at 2 to 5 liters per minute via nasal canula. b. Ordered on 7/23/2025, Turn every 2 hours. Cushion all body prominences with pillows. High fall risk. Bed at lowest position. During an observation on 2/23/2026 at 8:13 a.m. in Resident 29's room, Resident 29 did not have an oxygen concentrator at the bedside, nor were there any visual indicators showing the resident was legally blind. The resident's head rested on a white pillow, and no additional cushions were observed. During an interview and record review on 2/24/2026 AT 1:34 p.m. with Licensed Nurse (LVN) 2, Resident 29's care plan report was reviewed. LVN 2 stated that nursing staff who received orders for Resident 29's should of initiate care plan for oxygen and reposition every 2 hours. LVN 2 stated that Resident 29 does not have an oxygen concentrator at bedside because Resident 29 does not need oxygen. During an interview and record review on 2/24/2026 at 2:23 p.m. with Social Services Director (SSD), Resident 29's Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Conference Record dated 1/8/2026 was reviewed. The IDT conference record indicated that during the meeting Resident 29's care plans was reviewed. The SSD stated that Resident 29's care plan was reviewed, and no changes were made since the IDT members agreed to continue the same plan of care. During an interview on 2/25/2026 at 12:48 p.m. with the Director of Nurse (DON), The DON stated that she does not attend Resident 29's IDT meeting and the care plan should have been revised to meet Resident 29's care needs. The DON stated that there should be a care plan developed for all residents on admission and revised as needed when new physician orders are given to nursing staff. DON stated that care plans are important because it indicates the care that was provided to the residents. The DON states that without a care plan, staff may not know what care or interventions the resident needs. During a review of the facility's policy and procedures (P&P) titled, Care plans, Comprehensive Person-Center dated 02/24/2026, P&P indicated that, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing, and 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 that one of two sampled resident (Resident 29) was provided with assistive device to maintain independence in activities of daily living (ADL's). This deficient practice has the potential for Resident 29 unable to communicate with staff due to inability to know his surroundings.Findings: During a review of Resident 29's admission Record, the admission record indicated that Resident 29 was initially admitted to the facility on [DATE] with diagnoses of bilateral (both) legally eye blindness (severe vision loss), dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident 29's MDS dated on 01/23/2026, MDS indicated that Resident 29 required substantial/maximal assistance (helper does more than half the effort) for ADLs and needs partial assistance (helper does less than half the efforts) for eating. During observation on 2/23/2026 at 8:13 a.m. in Resident 29's room, Resident 29 was lying on his back in bed at lowest position, call light on the floor. Resident 29 did not have an oxygen concentrator at bedside or any visual sign indicating that Resident is legally blind. Resident head was resting on a white pillow, and no other cushions were observed. During an interview on 2/24/2026 at 12:45 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated that staff must do everything for Resident 29 because he is blind and is not able to select his own clothes or feed himself. CNA 2 stated that Resident 29 walks with assistance because he must be guided and should not be left alone. CNA 3 stated that staff cannot always stay with Resident 29. CNA 3 states that there should be a communication binder and a visual board at bedside for Resident 29. CNA 3 stated that when Resident 29 is in his room he cannot use the call light because he does not know how to use it. CNA stated that Resident 29 is continent of bladder and staff must borrow a walker from the therapy department to use when taking resident to the restroom. During an interview on 2/24/2026 at 2:23 p.m. with Social Services Director (SSD) in Resident 29's room, the SSD stated that Resident 29 has been seen once a year by the optometrist. SSD stated that the optometrist does not make any recommendations, the facility staff cannot implement any interventions to assist Resident 29's with activities of daily living. SSD stated that vision is important because it can affect activities of daily living if it is not addressed. SSD stated Resident 29 does not have a visual sign in the room indicating that resident is legally blind. SSD stated that there should be a visual sign to notify others of Resident 29's impairment. During a review of the facility's policy and procedures (P&P) titled, Resident Rights dated 1/29/2026, indicated that resident has the right to safe environment.

Based on interview and record review, the facility failed to ensure that infection prevention and control program was followed by failing to: Ensure that the antibiotic surveillance log (a record-keeping tool used by nursing homes to track, analyze, and manage infections among residents) was completed for Resident 4 and Resident 6.Ensure that the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written.These deficient practices placed the residents, staff and visitors at risk for exposure to and transmission of infectious organisms, incomplete monitoring and follow up of infections, missed trends or outbreaks due to lack of surveillance data analysis, and unsafe water conditions.Findings: 1a. During a review of Resident 4's admission Record, the admission record indicated that Resident 4 was initially admitted to the facility on [DATE] and last re-admission was on 12/14/2025 with diagnosis including heart failure (a condition in which the heart does not pump blood as well as it should), cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), altered mental status and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident's 4's Minimum Data Set (MDS-a resident assessment tool) dated 12/20/2025, MDS indicated that Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision were moderately impaired. MDS indicated that Resident 4 required maximal assistance from staff for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 4's physician orders titled Order Summary Report (OSR) dated 1/01/2026, the OSR indicated Mupirocin (topical antibiotic cream or ointment used to treat skin infections) External Ointment 2% was ordered on 12/24/2025 for left index finger. 1b. During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's MDS dated [DATE], MDS indicated that Resident 6's cognitive skills for daily decisions were moderately impaired. MDS indicated Resident 6 required maximal assistance from staffs for ADLs. During a review of Resident 6's medical records titled Order Summary Report indicated a physician order. Mupirocin initiated on 02/04/2026 for Right Lower Leg venous stasis ulcer (a wound that takes longer than usual to heal): cleanse with wound cleanser, pat dry, apply mupirocin to open area, cover with xeroform (petrolatum-impregnated gauze dressing), secure with kerlix (non-adherent wound dressing made of fine mesh gauze) and coban wrap (cohesive material that sticks only to itself) every day shift until 03/07/2026. B. Mupirocin initiated on 4/26/20205 for Abdominal wall non-pressure chronic ulcer: cleanse with normal saline, pat dry, apply Mupirocin ointment, cover with dry dressing daily for 30 days until 05/26/2025. During a concurrent interview and record review on 02/25/2026 at 09:56 a.m. with Infection Preventionist Nurse (IPN), Resident 4 and Resident 6 medical records were reviewed. IPN stated she was responsible for implementing and managing the facility's infection control program to protect residents, staff, and visitors. IPN added that she conducts surveillance, ensures compliance with protocols and oversees the antibiotic stewardship. IPN indicated that antibiotic stewardship was to ensure the appropriate use of antibiotics to prevent resistance. IPN stated that she does the surveillance the day after the antibiotic was ordered. IPN indicated in the medical records the following: 1.On the month of December 2025 and January 2026, the antibiotic surveillance was not completed when Resident 4 was receiving mupirocin. 2.On the month of April 2025 and February 2026, the antibiotic surveillance was not completed when Resident 6 was receiving mupirocin. IPN stated that mupirocin is considered an antibiotic and should have done surveillance for Resident 4 on December 2025 and January 2026; and for Resident 6 on April 2025 and February 2026. 2. During a concurrent interview and record review on 2/25/2025 at 12:15 p.m. with Maintenance Supervisor (MS), the water management plan was reviewed. The MS stated that he does not test the facility water for chlorine and pH levels. The MS states that pH testing is only conducted in the kitchen's dishwasher and not throughout the facility. During a subsequent concurrent interview and record review on 2/25/2026 at 12:25 p.m. with IPN, IPN stated that the maintenance supervisor was responsible for monitoring the water. The IPN further stated the facility did not have logs for water testing for temperature readings, water chlorine and pH and the results as indicated in the facility's WMP. The IPN added that failure to routinely test and document water quality, may allow the growth and spread of waterborne pathogens (bacteria, viruses, or parasites found in contaminated water), which could place residents, staff and visitors at risk for waterborne infections (illnesses caused by bacteria, viruses, or parasites from human or animal waste that contaminate drinking or recreational water) when used or ingested. During an interview on 02/25/2026 at 12:48 p.m. with Director of Nursing (DON), DON stated that the IPN is responsible for overseeing antibiotic surveillance to ensure compliance with the facility's infection control program. The DON stated that antibiotic use must be monitored carefully and should be prescribed only for confirmed infections supported by documented clinical evidence to prevent unnecessary antibiotic usage. The DON further stated that topical antibiotics are included in antibiotic surveillance The DON added that without documentation of infection outcomes in the surveillance logs, the facility is unable to evaluate treatment effectiveness or determine whether resident care needs are being met. During a subsequent interview on 2/25/2026 at 1:05 p.m. with the DON, The DON also stated that a professional conducts the facility's annual water testing. The DON reported awareness of the facility's Water Management Plan (WMP) but did not have detailed knowledge of its components. The DON stated that the maintenance supervisor is responsible for monitoring the water system, including checking the water source, inspecting for pipe leaks, and verifying water temperatures. The DON added that failure to monitor compliance with the WMP could compromise water quality and allow bacterial growth, including Legionella, which may expose residents to contaminated water and increase the risk of infection. During a review of the facility's P&P titled Antibiotic Stewardship revised on 12/2016, the P&P indicated that Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: Drug name; Dose; Frequency of administration; Duration of treatment; Start and stop date; or Number of days of therapy; Route of administration; and Indications for use. During a review of facility's WMP document, titled Water Safety Plan-2023, undated, the WMP indicated that, the plan aimed to control the growth and survival of Legionella and other waterborne pathogens in water systems and manage epidemics in the facility. Under the Task Scheduling and Verification Forms, it indicated that Following the planning chart, customized log sheets are provided for maintenance procedures. These log sheets, or an equivalent method of documentation should be utilized to demonstrate successful completion of program tasks.

Based on observation and interview, the facility failed to provide a private space for the Resident Council (RC) meetings for 5 of 5 residents.This failure resulted in the residents expressing discomfort to discuss issues and concerns openly and without fear of retaliation. Findings: During an observation on 2/24/2026 at 9:50 a.m. in the dining/activity room, the room was open to a hallway with access to the staff restroom, facility kitchen, and resident rooms. There was no barrier in the hallway entrance of the dining/activity room to give the residents privacy. During an interview on 2/24/2026 at 9:55 a.m. with Activity Director (AD). AD stated the dining/activity room is where Resident Council meetings are held, and a sign is posted to let staff know a Resident Council meeting is in progress. During an interview on 2/24/2026 at 10:10 a.m. with RC, RC members stated the facility offers the dining/activity room for their meetings. RC members stated the area is open to the hallway, and staff or other people passing by may overhear meeting discussions. RC members stated they do not feel free to openly discuss issues and concerns because meetings are not held in a private closed room. During a review of the facility's policy and procedure (P&P) titled, Resident Council Meetings, updated 1/29/2026, the P&P indicated RC meetings shall be held free from interference in an accessible and private location.

Based on interview and record review the facility failed to ensure to provide documented evidence for two of four sample employees (Medical Director and Registered Dietitian (RD) Corona virus ([COVID-19] - contagious infectious disease) vaccination status and the provision of education on benefits and potential side effects.This failure had the potential to result in staff (refers to those individuals who work in the facility on a regular basis, this also includes individuals under contract) and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings: During a concurrent interview and record review on 2/25/2026 at 11:13 a.m., with Infection Prevention Nurse (IPN), the Employee's Vaccination Record 2025 was reviewed for the Medical Director and RD. The employee vaccination record indicated no documentation of COVID-19 vaccination status and provision of education on benefits and potential side effects of COVID-19 vaccine, and documentation that the COVID-19 vaccine was offered. The IPN stated that all staff members should be offered COVID-19 vaccine and if staff members refuse vaccine, it should be documented. The IPN states that it is important to know their vaccination status because they have contact with the residents and staff. During a review of the facility's policy and procedures (P&P) titled, Staff Vaccination Program, reviewed on 1/29/2026, the P&P indicated the following: policy applies to all employees, contractors, agency personnel, volunteers, and individuals providing services within the facility. Facility shall maintain a staff vaccination program consistent with CDC recommendations and regulatory requirements. Vaccination status shall be tracked, documented, and monitored to promote resident and staff safety.

Based on interview and record review, the facility failed to obtain a current informed consent from the resident or resident's representative at the time influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) vaccine (a preparation that is used to stimulate the body's immune response against diseases) was administered for one of four sampled residents (Resident 6). This deficient practice violated Resident 6 or Resident 6's responsible party's rights to make an informed decision. Findings: During a review of Resident 6's admission Record, the admission record indicated that Resident 6 was initially admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar), heart disease, venous insufficiency, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 01/01/2026, MDS indicated that Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. MDS indicated Resident 6 required maximal assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 6's record titled Order Summary Report dated 02/25/2026, indicated a physician's order initiated on 12/26/2025 of may have influenza vaccine 0.5 milliliters (ml- a unit of volume) intramuscular injection (IM- into a muscle) injection every year. During a concurrent interview and record review on 02/25/2026 at 09:56 a.m. with Infection Preventionist Nurse (IPN), Resident 6 medical records were reviewed. The IPN indicated that immunization is crucial for preventing severe illness when contracting disease. The IPN stated that obtaining an informed consent is important because it informs residents about the risks, benefits, potential side effects, and the consequences of not getting vaccinated. The IPN stated that informed consent should be obtained as soon as the vaccine becomes available. The IPN stated that informed consent for the influenza vaccine for Resident 6 was obtained on 09/25/2025 and it was administered on 01/24/2026. The IPN stated that a new informed consent was needed before giving the influenza vaccine on 01/24/2026, as the resident or their representative could have changed their mind since it was obtained four months ago. During a review of facility's Policy and Procedures (P&P) titled Influenza Vaccine, revised 10/2019, the P&P indicated that, prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record. During a review of facility's P&P titled Informed Consent, updated on 01/29/2026, the P&P indicated that informed consent must be obtained from residents or their legal representatives before starting treatments, procedures, medications, or care changes requiring consent under federal or state law. It also indicated that residents have the right to make informed care decisions. The P&P indicated that facility aims to inform residents of risks, benefits, and alternatives; comply with federal and state regulations; and promote ethical and person-centered care practices.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 18) received care in a manner that maintained the resident's dignity and respect when Registered Nurse (RN) 1 did not fully close the privacy curtains while providing personal care.This failure had potential to negatively affect the resident's sense of dignity and respect during the care.Findings:During the review of Resident 18's admission Record, the admission record indicated the facility admitted the resident on 8/6/2025 with diagnosis that included but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (neurological condition characterized by reduced muscle strength, or partial paralysis to one side of the body), cerebral infarction unspecified (loss of blood flow to a part of the brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During the review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/12/2026, the MDS indicated Resident 18's need supervision and touching assistance for eating, oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, personal hygiene, putting and taking off footwear, rolling left or right, sitting to laying, laying to sitting, walking 10-150 feet. The MDS dated [DATE] indicated Resident 18 is alert, oriented and has a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (normal cognitive/brain function).During an observation on 2/23/2026 at 8:44 am, in Resident' 18s room, RN 1 was about to provide personal hygiene care to Resident 18. RN 1 pulled the privacy curtain to provide the resident privacy during the care. The curtain was not completely closed didn't provide complete privacy for Resident 18.During an interview on 2/23/2026 at 8:44 am with RN 1, RN 1 stated that the curtain was not closed all the way and did not provide complete privacy to Resident 18. RN 1 stated that it is important to have privacy curtains closed completely to protect Resident 18's dignity. RN 1 stated that if the privacy curtain was short the maintenance must be notified.During an interview on 2/25/2026 at 9:55 am with DON, DON stated If any facility resident is exposed during the care is provided, due to curtain not pulled all the way or curtain being short, resident will feel embarrassed and feel bad and it will affect resident's dignity negatively. DON stated that the residents should get privacy when care is provided.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights dated 01/29/2026, the P&P indicated the facility residents have Right to dignity, respect, privacy, and confidentiality.During a review of the facility's Policy and Procedure (P&P) titled, Patient Privacy Curtains dated 01/29/2026, the P&P indicated Curtains must be fully drawn during personal care, treatments, dressing, and assessments.

Based on observation, interview and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 administered the correct dosage of sodium bicarbonate (used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) as ordered by the physician for one of three sampled residents (Resident 42).This deficient practice had the potential to result in elevated stomach or blood acid levels for Resident 42 which could lead to complications.Findings: During a review of Resident 42's admission Record, the admission record indicated that Resident 42 was initially admitted to the facility on [DATE], with diagnoses including epilepsy, chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), hypertension (HTN-high blood pressure), gastroesophageal reflux disease (the stomach acid flowing back into the tube connecting the mouth and the stomach) and type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool) dated 12/17/2025, MDS indicated that Resident 42's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 42 required maximal assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 42's medical records titled, Order Summary Report dated 02/25/2026, indicated a physician order that was initiated on 12/11/2025 for sodium bicarbonate oral tablet 650 milligrams (mg-unit of measurement) give two tablets by mouth three times a day for supplement. During a medication administration observation on 02/23/2026 at 09:12 a.m. with LVN 1, LVN 1 administered two tablets of sodium bicarbonate 325 mg to Resident 42. LVN 1 indicated that the order is sodium bicarbonate 650mg give two tablets by mouth three times a day. LVN 1 stated my bad. LVN 1 explained that not giving the ordered dosage reduces the medication's effectiveness as an antacid. During a concurrent interview and record review on 02/25/2026 at 12:48 p.m. with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled Medication Administration updated on 01/29/2026 was reviewed. The P&P indicated, Medications shall be administered safely and accurately by licensed nursing personnel in accordance with physician orders, accepted standards of practice, and regulatory requirements. The DON stated that licensed nurses must verify the five rights, assess the resident, and document during medication administration. The DON further stated that according to the facility's P&P, the five rights of medication administration include the right resident, right medication, right dose, right route and right time. The DON stated that adhering to the five rights of medication administration was important to ensure that residents receive the appropriate and effective care and treatment. A review of the facility's Policy and Procedures (P&P) titled Medication Administration updated on 01/29/2026, indicated that, Medications shall be administered safely and accurately by licensed nursing personnel in accordance with physician orders, accepted standards of practice, and regulatory requirements.

Based on observation, interview, and record review, the facility failed to receive input from the resident for their preferred foods for one of one sampled resident (Resident 1).This failure had the potential for the resident to lose weight because they were not receiving the foods they liked to eat.Findings: During the review of Resident 1's admission record, the admission record AR indicated the facility admitted the resident on 7/27/2024 and then readmitted on [DATE] with diagnosis that included but not limited to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), severe protein-calorie malnutrition (a severe condition resulting from insufficient intake of protein and calorie, can lead to muscle waste, fat loss, and functional decline) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During the review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 1 need supervision and touching assistance for eating, Resident 1 need partial/moderate assist for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, personal hygiene, putting and taking off footwear, rolling left or right, sitting to laying and laying to sitting. The MDS dated [DATE] indicated the resident is alert, oriented and has a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (normal cognitive/brain function). During an observation on 2/23/2026 at 12:17 pm, Resident 1 ate 4 ounces (oz) of Jello (gelatin dessert) from the lunch tray and didn't eat rest of the lunch meal. During an observation on 2/24/2026 at 12:49 pm, Resident 1 was served ground beef, vegetables and dessert. Resident 1 took 3 bites of the dessert and two bites of the meat and drank 4 oz of milk. During an observation on 2/25/2026 7:50 am, Resident 1 was served fried/scrambled eggs, potatoes, yoghurt, coffee and milk for breakfast. Resident1 ate half of the eggs, 3 oz of milk, 4 oz of juice and 4 oz of coffee. During an observation on 2/25/2026 at 12:42 pm, Resident 1 was served scrambled eggs, grounded carrots and mashed potatoes for lunch. Resident 1 ate two bites of scrambled eggs, two bites of mashed potato, 4 oz of juice and 4 oranges slices. During an observation on 2/25/2026 at 12:42 pm, Resident 1's meal card did not indicate the resident's preferred foods and non-preferred foods. During an interview on 2/25/2026 at 12:42 pm with Resident 1, Resident 1 stated she informed the staff in the past regarding her preferred food choices. Resident 1 stated she preferred fried egg, scrambled eggs, fruits and oatmeal for breakfast. Resident 1 stated that for lunch or dinner, she preferred egg salad, fresh fruits, fresh salad, hamburger patty and french fries crispy at the edges. Resident 1 stated she disliked chili, spicy foods and pureed/ground meat. Resident 1 stated she was served oatmeal for breakfast every day for breakfast when she came to the facility, she does not like oatmeal anymore. During an interview on 2/24/2026 at 10:58 am with Dietary Supervisor (DS), DS stated that the facility has the list of all resident's preferred and non-preferred food items. The assessment of the food preference is completed by DS upon admission and quarterly. During an interview on 2/24/2026 at 11:42 am with DS, DS stated that Resident 1's quarterly assessment on preferred foods was done on 1/17/25, 7/9/25, 9/17/25 and 1/13/2026. DS stated there was no assessment done besides those dates and quarterly assessments was missed between 1/17/25 - 7/9/25 and between 9/17/25 and 1/13/2026. During an interview on 02/24/2026 at 12:49 pm with DS, DS stated that not assessing residents for their food preference quarterly can affect the residents and residents can be at risk of not eating their meals which can eventually make residents at risk of losing weight. DS stated that the preferred foods assessment for the resident had documented American food as preferred food which is not specific enough. During a review of the facility's Policy and Procedures (P&P) titled Resident Rights dated 01/29/2026, the P&P indicated the facility residents have Right to dignity and respect. During a review of the facility's P&P titled Food Preferences and Resident Choice dated 01/29/2026, the P&P indicated that the facility will provide nutritionally adequate meals while incorporating resident preferences, cultural considerations, religious practices, and individualized dietary needs.

Based on observation and interview, the facility failed to: Ensure the dishwasher sanitizer machine had the correct chlorine concentration to clean the dishware. Date food items and discard expired food stored in the refrigerator and dry storage area. These failures had the potential to result in food borne illness in the residents. Findings:1.During and observation on 2/23/2026 at 8:06 AM in the kitchen, [NAME] 1 tested the chlorine concentration of the dishwasher sanitizer machine three times. The test strip indicated the chlorine concentration was 25 parts per million (ppm) all three times. During an interview on 2/23/2026 at 8:06 AM with [NAME] 1, [NAME] 1 stated the correct chlorine concentration level should be at least 50 ppm, and they need to adjust the sanitizer concentration if it is below 50 ppm. [NAME] 1 stated if dishes are not sanitized well the residents could get sick. During an interview on 2/23/2026 at 10:10 AM with Dietary Supervisor (DS), DS stated the chlorine sanitizer test reading should be at 50 ppm to ensure dishes have been sanitized well. DS stated they need to manually re-wash and re-sanitize dishes used for breakfast to ensure they are safe to use for the next meal; and not use dishwasher until they get the chlorine sanitizer level to 50 to 100 ppm. During a review of the facility's policy and procedure (P&P) titled, Kitchen Dishwashing and Sanitation, dated 1/29/2026, the P&P indicated the dishwashing machine chemical sanitizer should be 50 to 100 ppm. 2. During a concurrent observation and interview on 2/23/2026 at 7:51 AM with [NAME] 1 in the kitchen, there was a baking powder container with an unreadable expiration/used by date in the dry food storage cabinet next to the stove. [NAME] 1 stated unlabeled or expired food items should not be used and put in the trash. [NAME] 1 stated unlabeled food items could be expired and can make residents sick. During a concurrent observation and interview on 2/23/2026 at 7:53 AM with [NAME] 1 in the kitchen, the refrigerator to the left of the kitchen entrance had a lemon juice concentrate bottle labeled used by 2/18/2026. [NAME] 1 stated expired food items should be discarded, if used could make residents sick. During a concurrent observation and interview on 2/23/2026 at 7:54 AM with [NAME] 1 in the kitchen, the freezer to left of the kitchen entrance had broccoli florets bags with no expiration date (1 opened, 2 unopened) and Japanese vegetables bags with no expiration date. [NAME] 1 stated foods with no expiration date could be spoiled and if given to residents can make residents sick. During a concurrent observation and interview on 2/23/2026 at 7:58 AM with [NAME] 1 in the dry storage room outside the kitchen, there was a banana extract bottle with no expiration date. [NAME] stated unlabeled or undated food items should be removed and discarded. During a review of the facility's policy and procedure (P&P) titled, Food Use and Storage, updated 1/29/2026, the P&P indicated opened food items, and refrigerated and frozen food shall be labeled with product name, use by date, and date opened or prepared. P&P indicated facility shall discard all expired and spoiled food immediately.

Based on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (sq.ft) per resident in a single occupancy room. There were 23 out of 24 resident rooms in the facility that did not meet the requirement of 80 square 1 feet per resident.This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.Findings: During a review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on 2/23/2026, indicated the following 23 rooms provided less than 80 feet per resident:Rooms# Beds Room Size(ft.) Sq. Ft/Bed3 2 138.7 69.354 2 138.7 69.355 2 138.7 69.356 2 138.7 69.357 3 150.7 50.258 2 138.7 69.359 2 138.7 69.3510 2 138.7 69.3511 2 138.7 69.3512 2 138.7 69.3514 2 138.7 69.3515 2 138.7 69.3516 2 138.7 69.3517 2 138.7 69.3518 2 138.7 69.3519 2 138.7 69.3520 2 138.7 69.3521 2 138.7 69.3522 2 138.7 69.3523 2 138.7 69.3524 2 138.7 69.3525 2 138.7 69.35 The minimum square footage for a 2-bed room should be 160 Sq. Ft. The client accommodations analysis form indicated room [ROOM NUMBER] accommodated 1 resident, and rooms #3, #4, #5, #6, #8, #9, #10, #11,#12,#14, #15,#16,#17,#18,#19,#20,#21,#22, #23, #24, and #25 accommodated 2 residents each and room [ROOM NUMBER] accommodated 3 residents. During an observation on 2/25/2026 at 8:52 a.m., observations were made in rooms 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 that nursing staff had enough space to provide care to the residents, and the rooms had direct access to the corridors. There were no noted concerns with privacy, nursing care and/or safety to the residents.The facility presented a request for the continuation of the waiver for twenty-three (23) rooms, which did not meet the room size requirement of 80 square feet per resident in a double occupancy room and one hundred (100) square feet per resident in a single occupancy room [ROOM NUMBER]/23/2026.

Based on observation, interview and record review, the facility failed to provide skin and pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedures for one of three residents (Resident 1), by failing to: a.Implement interventions to prevent Resident 1 from developing a stage 1 coccyx (tailbone) pressure injury. b.Create, implement, and update individualized interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent Resident 1's coccyx stage 1 pressure injury discovered on 12/2/2024 from progressing to a stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (Large triangle bone above the tailbone) and coccyx on 12/18/2024. c.Develop individualized resident-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) interventions to address Resident 1's non-compliance with turning and activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. These deficient practices resulted in Resident 1 developing a stage 1 pressure injury which progressed to a stage 4 pressure injury in 16 days, requiring debridement (medical removal of dead, damaged, or infected tissue to improve healing, removal may be surgical, mechanical, or chemical therapy) of the pressure injury. Findings: A. A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/8/1998, with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), polyneuropathy (when multiple peripheral nerves become damaged) and overactive bladder (sudden urges to urinate that may be hard to control). A review of Resident 1's at risk for skin breakdown injury care plan, initiated 10/16/2024, indicated the resident was at risk for skin breakdown due to non-compliance with turning and repositioning, and ADL care. A further review of the care plan indicated the goal was for the resident's risk of skin breakdown to be minimized and the resident would cooperate. The care plan interventions indicated staff were to: - provide care and reposition with care rounds. - clean Resident 1's skin after each episode of incontinence. - encourage independent turning. - provide activities that allow for skin improvement. - provide education to resident, responsible party, and staff regarding special care. - provide pressure redistributing devices and assess for effectiveness. - provide skin care frequently. A further review of the care indicated there were no interventions to address what to do when the resident was non-compliant with turning and repositioning. A review of Resident 1's History and Physical (H&P), dated 11/11/2024, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 did not have any skin issues. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/19/2024, indicated the resident's cognition (ability to think, understand, and reason) was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, supports trunk or limbs, but provides less than half the effort) with bed mobility, oral hygiene, showering, dressing and personal hygiene. The MDS also indicated Resident 1 was always incontinent, at risk for developing pressure sores, and did not have any pressure ulcers present at the time of the assessment (11/19/2024). A review of Resident 1's Braden Scale (pressure sore risk predictor tool) dated 11/19/2024, indicated Resident 1 had a Braden score of 16 which indicated the resident in the at-risk category to develop a pressure injury. A review of Resident 1's Progress Note, dated 12/2/2024, indicated the resident was on monitoring for sacrum non-blanchable redness (blood flow does not return to skin when pushed down). The note also indicated the resident was encouraged to turn and reposition with assistance and the resident was kept clean and dry. A review of Resident 1's stage 1 sacrum pressure injury, initiated 12/2/2024, indicated the goal was for the wound to show signs of improvement. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning. - Encourage resident to frequently shift weight. - Evaluate skin for areas of blanching or redness. - Evaluate ulcer characteristics. - Keep skin clean and well lubricated. - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness. - Monitor nutritional status. - Monitor ulcer for signs of progression or declination. - Notify provider if no signs of improvement on current wound regimen. - Provide wound care per treatment order. - Refer to specialized practitioner for wound management. A review of Resident 1's Physician Assistant (a licensed health professional who works with physicians to provide patient care) Wound Care Note, dated 12/4/2024, was the initial evaluation of the wound (2 days after the identification of a stage 1 by facility staff). The Note indicated the wound was a stage 2 wound and measured 3.2 centimeters (cm) x 2.1 cm width x 0.8 cm (length x width x depth). The Note indicated Resident 1 received skin/tissue debridement (removal of dead skin tissue to help a wound heal) performed by sharp selective debridement using a curette (a surgical instrument designed for debriding biological tissue) and #15 blade (a surgical scalpel). A review of Resident 1's Physician's Order, dated 12/4/2024, for a treatment of the stage 2 pressure injury on the coccyx, cleanse the area with normal saline (a saltwater solution), pat dry, apply Calmoseptine ointment (a topical medication used to protect and heal irritated or damaged skin) then cover with a bordered dressing every day until 1/4/2025. A review of Resident 1's stage 2 sacrum(coccyx) pressure injury care plan, initiated 12/4/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order A review of Resident 1's Wound- Weekly Observation Tool dated 12/5/2024, indicated Resident 1 had acquired while at the facility a Stage 1 pressure ulcer on the coccyx (tail bone) that measured 3.2 centimeters (cm) x 2.1 cm x 0.8 cm. The Wound - Weekly Observation Tool also indicated the skin around the wound was macerated (skin is soft, soggy, or wet to the touch which occurs when the skin is in contact with moisture for too long). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/11/2024, indicated Resident's coccyx stage 2 pressure injury worsened to a stage 3 (full-thickness loss of skin. Dead and black tissue may be visible). The SBAR indicated the resident was seen by wound physician assistant with new orders given. A review of Resident 1's Physician's Order, dated 12/11/2024, indicated an order for the treatment of the stage 3 coccyx pressure injury, cleanse the area with sodium hypochlorite 0.25% (antiseptic, used prior to surgical procedures or for minor wound care to reduce risk of infection), pat dry, apply Mupirocin 2% ointment (a topical antibiotic used to treat skin infections caused by bacteria) and Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas), then cover with dry dressing every day until 1/11/2025. A review of Resident 1's Nurse's Note, dated 12/11/2024, indicated the resident was on monitoring for coccyx stage 3 pressure injury. The note indicated the resident was kept clean and dry, turned, and repositioned every 2 hours. A review of Resident 1's stage 3 sacrum pressure injury, initiated 12/11/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order - Refer to specialized practitioner for wound management A review of Resident 1's Wound- Weekly Observation Tool dated 12/12/2024 (one week later), indicated Resident 1's coccyx pressure ulcer was originally a stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) and was a stage 3 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the date of assessment (12/12/2024). The Wound Observation Tool indicated the wound was worsening. And the skin was devitalized (skin that is weak or no longer living, often due to injury or disease). The Wound Observation Tool indicated Resident 1's coccyx pressure injury measured 3.5 cm x 2.5 cm x 1 cm (an increase in size in length, width, and depth). A review of Resident 1's Nurse's Note, dated 12/13/2024, indicated the resident refused to be changed every hour. The Note further indicated the resident remained in the wheelchair does not want to be transferred into bed to get changed. The nurse explained the risks and benefits and the resident still refused. A review of Resident 1's Physician Assistant Wound Progress Note, dated 12/18/2024, indicated Resident 1 had a stage 4 pressure ulcer with necrosis of muscle and necrosis of bone. The Progress indicated the wound's healing status was declining. The note further indicated the wound underwent debridement and the type of tissue removed was necrotic subcutaneous tissue, devitalized subcutaneous tissue and necrotic muscle. A review of Resident 1's SBAR, dated 12/18/2024, indicated Resident 1's coccyx stage 3 pressure injury worsened to a stage 4. The SBAR indicated the resident was seen by a wound physician assistant with new orders given and carried out. The SBAR indicated the resident was medicated with Tylenol 650 mg 30 minutes prior to wound care. A review of Resident 1's Nurse's Note, dated 12/18/2024 timed at 6:29 PM, indicated the resident was on monitoring for a coccyx stage 4 pressure injury. The note indicated Resident 1 was turned and reposition every 2 hours. A review of Resident 1's stage 4 sacrum pressure injury care plan, initiated 12/18/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order - Refer to specialized practitioner for wound management A review of Resident 1's Wound- Weekly Observation Tool dated 12/19/2024 (two weeks after the initial assessment), indicated Resident 1's coccyx pressure ulcer was a Stage 4. The Wound Observation Tool indicated the wound went from a stage 4 from a stage 3 and measured 4.1 cm x 3.5 cm x 1 cm (an increase in length and width. A review of Resident 1's Physician's Order, dated 12/19/2024, for the treatment of the stage 4 pressure injury on the coccyx, cleanse the area with Dakins 0.25% solution (an antiseptic first aid cleaning solution for wounds), pat dry, apply Mupirocin ointment and Santyl, then cover with dry dressing every day for 30 days. A review of Resident 1's Nurse's Note, dated 12/22/2024, indicated the resident refused to be turned and repositioned during the shift. The Nurse's Note further indicated the nurse explained the risks and benefits, but the resident stated they were comfortable in their position. During an observation in Resident 1's room with Licensed Vocational Nurse 3 (LVN 3), on 12/28/2024 at 2:25 PM, Resident 1's wound care was observed. During the observation Resident 1 was noted with a Sacro-coccyx (wound over the sacrum and coccyx) pressure sore that was open, deep, and the skin surrounding the wound was red and macerated. During the wound care Resident 1 yelled out in pain. During an interview on 12/29/2024 at 10:28 AM, LVN 3 stated Resident 1 did not have a pressure ulcer on admission. LVN 3 stated on 12/2/2024, Resident 1 was noticed to have non blanchable redness on the sacrum, which then became a stage 2 and then became a stage 3 on 12/11/2024, nine days after the wound was initially found. During a concurrent record review of Resident 1's pressure ulcer care plans were reviewed. LVN 3 stated Resident 1's stage 1, stage 2, stage 3 and stage 4 coccyx pressure injury care plans interventions were all the same. LVN 3 stated care plans were to be updated with new interventions when previous interventions are not effective. LVN 3 stated a possible outcome from not revising the interventions was that Resident 1's wound could worsen. LVN 3 stated Resident 1's wound had progressed due to the resident refusing to turn every 2 hours. During a concurrent record review of Resident 1's noncompliance with turning care plan, 12/29/2024 at 10:28 AM, LVN 3 stated the care plan did not have individualized interventions to address the resident not turning. LVN 3 stated the care plan interventions could have included notifying the charge nurse or Resident 1's family member so they could attempt to convince the resident to turn. During a concurrent interview and record review on 12/29/2024 at 1:34 PM, the Director of Nursing (DON) stated Resident 1 was at increased risk for developing a pressure ulcer due to the resident's weight loss, so the facility provided the resident with a low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) in October 2024. The DON stated Resident 1 was noncompliant with turning. The DON reviewed Resident 1's pressure ulcer care plans, the DON stated the care plans were all similar. The DON stated care plans were to be individualized and person centered to effectively care for resident's problems and the care plan had to be updated when the interventions were not effective. A review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, reviewed 1/31/2024, indicated staff were to review the resident's care plan identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable and review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's P&P, Care Plans, Comprehensive Person-Centered, reviewed 1/31/2024, indicated a comprehensive care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was to be developed and implemented for each resident. The care planning process will include an assessment of the resident's strengths and needs, incorporate the resident's personal and cultural preferences in developing the goals of care. The P&P further indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach-in freezer temperature was at 30 degrees Fahrenheit ( F, a scale of temperature). 2. Turkey was stored on bottom of the beef. 3.Food preparation surfaces and kitchen equipment were not cleaned and sanitized. a.Reach-in refrigerator had food and dirt debris around the gasket. b. Reach-in freezer bottom shelves had dirt and food debris. c. Ice machine filter had dust and dirt buildup. d. Hood holes were not covered and had dust particles. e. Knife storage box had dust and food spillage. f. Mixer had food debris, food splashes and was stored on the floor. g. Scoop tray had food debris. h. Juice machine racks were sticky and dusty to touch. i. Food weighing scale was sticky to touch and had dirt and dust particles. j. Resident's vending machine had dust. 4. Utensils and kitchen equipment had cracks and scratches. a. Chopping boards had scratches. b. Eight (8) resident's tray had cracks and chips. c. Can opener blade have had chip. 5. Staff personal phone was on top of juice rack. 6. Three (3) dented cans were stored with non-dented cans. 7. Yogurt and juice were stored in the resident's refrigerator beyond the expiration date. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 46 of 46 medically compromised residents who received food and ice from the kitchen. Findings: a.During a concurrent observation on [DATE] at 5:28 p.m. of the reach-in freezer and interview with [NAME] 1, the reach-in freezer thermometer read 30 F and there was water dripping from the roof of the freezer. [NAME] 1 stated the reach-n freezer thermometer needed to be at 0 F to ensure the food items were frozen for infection control. During an interview on [DATE] at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), the freezer temperature was at 30 F and it was not okay and needed to be maintained at 0 F for infection control. During an observation on [DATE] at 6:08 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 52 F. During an observation on [DATE] at 7:27 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10 F. During an observation on [DATE] at 6:49 a.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10 F. During a concurrent observation and interview on [DATE] at 6:51 a.m. with Dietary Supervisor (DS), DS stated the freezer should be at 0 F so that the products are completely frozen. DS stated she needed to call the maintenance to check if the freezer was functioning well. DS stated residents could get sick because the food was thawed already if the freezer was not maintaining temperatures at zero or below. During a review of facility's Policies and Procedures (P&P) titled Procedure for Freezer Storage, reviewed [DATE], the P&P indicated, 1. Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0 F or lower. b. During an observation on [DATE] at 5:29 p.m. of the reach-in freezer, turkey was stored on the bottom of the meats with no trays in between. During an interview on [DATE] at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated kitchen staff stored poultry and meat separately and there was usually tray in between. [NAME] 1 stated he did not know why all the meats were not separately stored. [NAME] 1 stated it was important to store meats separately for infection control but did not know the potential outcome to the residents if the storage of meat hierarchy (a system that organizes or ranks things) was not followed. During an interview on [DATE] at 8:06 a.m. with DS, DS stated they stored pork, beef, chicken separately and ready-to eat foods on top of the shelves. DS stated chicken had to be on the bottom shelves so there would be no blood dripping to other foods. DS stated not storing chicken on the bottom shelf could cause cross-contamination. DS stated residents could get sick of foodborne sickness if meats were not stored based on hierarchy of food storage. During a review of facility's P&P titled Refrigerator Storage Chart, dated [DATE], the P&P indicated, All poultry (chicken, turkey, duck, fowls: stuffing made with food that require temperature control dishes with previously cooked food (casserole) are stored at the bottom of the shelve. c. 1. During an observation on [DATE] at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. During an interview on [DATE] at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. 2. During an observation on [DATE] at 5:53 p.m. of the reach-in refrigerator, the reach-in refrigerator gasket had dirt residue and buildup. During a concurrent observation and interview on [DATE] at 6:54 a.m. with DS, DS stated the freezer and refrigerator were cleaned every day and deep cleaned weekly. DS stated there was dirt debris in the refrigerator gasket and freezer shelves and it was not cleaned from the night prior. DS stated it was important to keep the food safe and avoid bacterial growth to prevent cross-contamination. DS stated residents could get foodborne sickness. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated [DATE], the P&P indicated (3) Refrigerator equipment should be routinely cleaned. 3. During an observation on [DATE] at 6:03 p.m. of the ice machine, the ice machine vent had dust and dirt buildup. During a concurrent observation and interview on [DATE] at 8:08 a.m. with DS, DS stated an outside company was scheduled to go to the facility to clean the ice machine filter every six (6) months. DS stated the ice machine filter had dust and needed to be cleaned so the machine could run smoothly and produce clean ice. DS stated the potential outcome would be contamination of ice. During a review of the facility's P&P titled Ice Chest Cleaning Procedure, dated [DATE], the P&P indicated All ice chest will be cleaned and sanitized before and after each use, and when contaminated or visibly soiled. 4. During an observation on [DATE] at 6:10 p.m. of the kitchen hood where Cooks were cooking hot foods, the hood had two holes that were not covered and there were dust and dirt buildup. During an interview on [DATE] at 8:10 a.m. with DS, DS stated the kitchen hood was an old-style hood and the open hole from the ceiling was directly over where food was cooked. DS stated it was not okay as dirt could fall in the food and there could be contamination of food as a potential outcome. 5. During an observation on [DATE] at 6:11 p.m. of the knife storage box, the knife storage box had dirt debris and white food splatter. During an interview on [DATE] at 8:12 a.m. with DS, DS stated the knife storage was scheduled for everyday cleaning. DS stated the storage box for knives was dusty and had food spill. DS stated kitchen staff needed to clean the storage box for knives to prevent cross-contamination. 6. During an observation on [DATE] at 6:13 p.m. of the mixer, the mixer internal parts had oil residue and amber discoloration particles. During an interview on [DATE] at 8:13 a.m. with DS and [NAME] 3, DS stated the mixer was used for baking desserts and cakes. [NAME] 3 stated the mixer had been used three days prior. DS stated the mixer was sticky due to food splashes and food debris. DS stated the staff needed to clean the mixer after each use to prevent cross-contamination. During a concurrent observation and interview on [DATE] at 12:26 a.m. of the mixer with DS, DS stated the mixer needed to be elevated so kitchen staff could clean the floor underneath. DS stated the mixer had to be six (6) inches (in., a unit of measurement) from the floor or the mixer would be dirty. DS stated the mixer could attract pests and bacteria resulting to cross-contamination. 7. During an observation on [DATE] at 6:14 p.m. of the scoop storage, the tray had white particles, dirty debris and was not covered. During an observation on [DATE] at 8:17 a.m. with DS, DS stated the container with scoops was clean however there were food debris on the container, and it was not covered. DS stated the container for scoops should have been covered and clean to prevent cross-contamination of food. 8. During an observation on [DATE] at 6:23 p.m. of the juice rack, the juice rack had dirt buildup and was sticky to touch. During an observation on [DATE] at 8:25 a.m. with DS, DS stated the juice area and juice rack had to be cleaned every day. DS stated the juice racks had juice spilled on the racks. DS stated it was important to clean the area to prevent cross-contamination and to avoid attracting pests and flies. DS stated food poisoning and contamination would the potential outcome for residents. 9. During an observation on [DATE] at 6:41 p.m. of the food weighing scale, the food weighing scale had dried up food and dirt. During an interview on [DATE] at 8:36 a.m. with DS, DS stated the staff were to clean the weighing scale after each use. DS stated the weighing scale felt sticky to touch and looked like it was not cleaned after the staff used it. DS stated it was not okay not to clean the weighing scale as it could cause cross-contamination. 10. During a concurrent observation and interview on [DATE] at 1:03 p.m. of the vending machine outside patio with DS, DS stated the vending machine has dust and it was not acceptable because it was used for food storage, and it could contaminate the food. During a concurrent observation and interview on [DATE] at 1:18 p.m. of the food vending machine with Administrator (ADM), ADM stated the outside company refilled the drinks for the vending machine and maintenance supervisor was responsible for cleaning the vending machine. ADM stated both employees and residents used the vending machine, and it was important to maintain its cleanliness to avoid contracting diseases. ADM stated the vending machine racks were dusty and the vending machine was dusty because it was located outside. ADM stated facility staff did not have the key to the machine so they could not clean it. ADM stated even if the shelves of the vending machine were dusty, it was okay, and nothing was wrong because the food products were sealed. During a concurrent observation and interview on [DATE] at 3:52 p.m. with Maintenance Supervisor (MS), MS stated the MS cleaned the outside of the vending machine but did not have the key to clean the inside. MS stated the vending machine was corroded and dusty on the inside and it was not acceptable as residents used it. MS stated the dust could get in the resident's hands, could go to the food and residents could get sick in their stomach as a potential outcome. During a concurrent observation and interview on [DATE] at 3:56 p.m. of the food vending machine with Activities Assistant 1 (AA 1), AA 1 stated the food vending machine was used by staff and residents. AA 1 stated she saw residents getting food and snacks in the vending machine. AA 1 stated the vending machine was dusty and it was not acceptable as the food product could touch the resident's hands. AA 1 stated residents could get sick from getting dirty food and contaminated food as a potential outcome. During a review of the facility's P&P titled Sanitation, dated [DATE], the P&P indicated, POLICY: The Food and Nutrition Services Departments shall have equipment of the type and in amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, lights, fixtures, and the good over stove, which will be cleaned by the maintenance staff. During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated,,d+[DATE].13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph ,d+[DATE].11 (D)(6). During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts [DATE]-306. d. 1. During an observation on [DATE] at 6:15 a.m. the chopping boards, the green, yellow, blue, and brown chopping boards had scratches. During an interview on [DATE] at 8:20 a.m. with DS, DS stated the chopping boards were worn out and had scratches. DS stated it was not okay to use chopping boards as the food could go in the scratches and surfaces that had scratches were hard to clean. DS stated bacteria could grow on the chopping board and could go to food causing cross-contamination. 2. During an observation on [DATE] at 6:25 p.m. of the dishwashing process, there were eight (8) trays that had cracks and chips. During a concurrent observation and interview on [DATE] at 8:34 a.m. of the resident's tray inside the carts with DS, DS stated the trays had cracks and it was not a good representation of the facility. DS stated the food debris could go in the cracks and the surface would be hard to clean causing cross-contamination. 3. During an observation on [DATE] at 6:29 p.m. of the can opener, the can opener blade had chip and crack. During an interview on [DATE] at 8:30 a.m. with DS, DS stated the can opener blade had a little crack and it was not okay because the blade crack residues could go in the canned foods. DS stated the can opener blade would be hard to clean so it could get bacteria on the cracks of the can opener that could cause cross-contamination. During a review of the facility's P&P titled Sanitation dated [DATE], the P&P indicated (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. (2) Plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. e. During an observation on [DATE] at 6:31 p.m. at the preparation areas, a cellphone was on top of the juice dispenser table. During an interview on [DATE] at 8:32 a.m. with DS, DS stated there were no use of personal cellphone allowed in the kitchen and it was not okay to put cellphones on work surfaces as cellphones might be dirty and could cause cross-contamination. During a review of facility's P&P titled Cellphone Use in the Kitchen for Communication, reviewed [DATE], the P&P indicated, To ensure the safe, sanitary, and efficient operation of the kitchen while allowing limited and appropriate use of cellphones for communication purposes. The use of cellphones in the kitchen is permitted under specific circumstances to facilitate necessary communication, provided it does not compromise food safety, hygiene, or the efficient functioning of the kitchen. f. During an observation on [DATE] at 12:55 p.m. of the dry storage area, observed three (3) dented cans were stored with non-dented cans in the disaster supply area and dietary supply. During an interview on [DATE] at 1:02 p.m. with DS, DS stated there was a designated area for dented cans so staff would not use dented cans because the food could be spoiled. DS stated residents could suffer from botulism (rare but serious condition caused by toxin that attacks the body's nerves) if they consumed food out of a dented can. During a review of the facility's P&P titled Food Storage-Dented Cans dated [DATE], the P&P indicated Food in unlabeled, rusty, leaking, broken containers or cans with side seam, dents, rim dents, or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyors for refund. All leaking is to be disposed immediately. During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under ,d+[DATE].12, honestly presented. ,d+[DATE].11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S,d+[DATE].11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. g. During an observation and interview on [DATE] at 3:59 a.m. of the resident's refrigerator in the activity room with the Activities Director (AD), AD stated the resident's refrigerator in the activities room was used for resident's food from the outside. AD stated they could keep resident's foods for three (3) days, and they must toss it out after 3 days if not consumed. AD stated they labeled the food with name, date received to ensure there were no expired food products. AD stated the orange juice had an expiration date of [DATE] and the yogurt had an expiration date of [DATE]. AD stated a chocolate cake and canned fruit was not labeled with name and date. AD stated residents could have a bad stomach and food poisoning as a potential outcome for consuming expired food products. During a review of the facility's P&P titled Food for Residents from Outside Sources, dated [DATE], the P&P indicated (5) Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, the refrigerator within the nurses' station, or resident's personal refrigerator. In Food and Nutrition Services Department, the policy on food storage will apply. Otherwise, if unopened refrigerated or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed in 30 days. During a review of Food Code 2022, the Food Code 2022 indicated, ,d+[DATE].17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

Based on observations, interviews, and record reviews, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: a.Ham and potato breakfast casserole was scooped instead of cutting it with a portion size of 2 1/2 x 2 inches ([in] unit of measurement) as indicated in the facility's spreadsheet and was served in a bowl instead of on the plate for regular texture consistency (texture with no restriction). The plates had no garnish. b.Puree diet (foods that are smooth and pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 received puree scrambled eggs instead of puree ham and potato breakfast casserole and the puree scrambled eggs was too dry. c.Puree wheat toast and puree raisin brand were too sticky. This failure had a potential to result in 46 of 46 facility residents being at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on regular diet would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Raisin bran 3/4 cup (c, household measurement) Ham and potato breakfast casserole 1 Wheat toast 1 slice Margarine 1 teaspoon (tsp, household measurement). Parsley sprig garnish yes Milk 8 oz a. During an observation on 12/28/2024 at 7:10 a.m. staff was using a scoop to serve ham and potato casserole for regular diet in trayline (an area where foods were assembled) service for breakfast. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the ham and potato casserole on the steamtable with Dietary Supervisor (DS), DS stated the staff should measure the ham and potato casserole to 2 1/2 x 2 in., however they were using a scoop to serve the breakfast casserole. DS stated the way staff presented the ham and potato casserole was not appetizing as it was served in a bowl instead of putting it on the plate. DS stated the residents would not eat it and it could lead to weight loss. DS stated the food was missing garnish for presentation. DS stated the staff was rushing and that was the reason the food was not properly served. During a concurrent observation and interview on 12/28/2024 at 7:51 a.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) with DS, DS stated the regular test tray appearance needed a nicer presentation and staff should have cut the casserole as the recipe indicated. DS stated staff should have served it with parsley to make it look appetizing. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation dated 1/31/2024, the P&P indicated POLICY: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedures: 1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific to portion yield, methods of preparation, quantities of ingredients, and time and temperature guidelines. 3. Food prepared will be sampled. The Food and Nutrition Service employee who prepares the food will sample it to be sure the food has satisfactory flavor and consistency. Use clean spoon or put a small portion of the food in a dish and taste from the dish. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Portion size 2 1/2 x 2 inches. Size Pan 10x2x2 in.=24 servings cut 4x6. 12x20x2 in. = 48 servings. Cut 6x8 and 5x8=8 servings, cut 2x4. b. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran 1/2 cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline, residents on puree diet received scrambled eggs. During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray, DS stated resident on puree diet were given puree scrambled eggs instead of puree ham and potato casserole. DS stated the puree eggs were dried up and needed to be moist. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the staff should have pureed the ham and potato casserole and it should have been prepared. DS stated the staff did not tell her why they did not prepare the puree ham and potato casserole. DS stated puree food and diet should be the same as regular diet because the amount of protein and nutrients should be the same. DS stated the regular puree scrambled eggs and casserole was not the same because it did not have the ham, potatoes, onions, and mustard. DS stated the taste of the puree eggs could have been affected causing poor food intake leading to weight loss as a potential outcome. During a review of the facility's P&P titled Standardized Recipes reviewed 1/31/2024 the P&P indicated Standardized recipes shall be developed and used in preparation of foods. (1) Only tested , standardized recipes will be used to prepared foods. (2) Standardized recipes will be adjusted to the number of portions required for a meal. (3) The Food Service Manager will maintain the recipe file and make it available to Food Services staff as necessary. (4) Recipes are periodically reviewed for revisions and updating. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Ingredients: frozen diced potatoes, shredded cheddar cheese, ham fully cooked and chopped, large, pasteurized eggs milk mustard, ground. The P&P indicated Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Casserole dated 1/31/2024, the recipe indicated, Ingredients: casserole per recipe, warm fluid such as milk, gravy, or low sodium broth. If needed: stabilizer: instant potato, non-fat dry milk, breadcrumbs, toast, instant cream or rice or farina, or commercial instant food thickener. Directions (1) Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. (2) Puree on a low speed to a paste consistency before adding any liquid. c. During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray with DS, DS stated the puree diet was not appetizing as the puree bread and puree raisin brand did not fall from the spoon tilt test (when scooped up with a spoon, the food should be cohesive enough to hold its shape). DS stated this means the puree bread and puree raisin brand were too sticky. DS stated the residents would not eat the puree food and would lead to weight loss as a potential outcome. During a review of the facility's recipe titled Recipe: Cinnamon Toast/Milk Toast/Wheat Toast/English Muffin dated 1/31/2024, the recipe indicated Pureed: Pureed following the pureed recipes in the Food Safety/Misc. section of Book 1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 1/31/2024, the recipe indicated (4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Cold Cereal dated 1/31/2024, the recipe indicated Ingredients: cold cereal of choice. Pureed/dysphagia: Pureed following the pureed recipes in Food Safety/ Misc. section book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Cold Cereal, dated 1/31/2024, the recipe indicated, (4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements.

Based on observations, interviews, and record reviews, the facility failed to ensure kitchen were routinely trained and possessed the necessary competencies to ensure the nutritional needs of residents were met. By failing to ensure kitchen staff: a.Followed the recipe for puree (foods that are smooth with pudding like consistency) ham and potato casserole for puree diet. b.Followed spreadsheet portion sizes for puree eggs. Residents were given two (2) ounces ([oz] a unit of measurement) instead of three (3) oz. c.Were aware of and able to verbalize the potential outcome of a dirty refrigerator and freezer during food storage. This failure had a potential to result in inadequacy of food and nutrients leading to weight loss and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 46 of 46 residents who received food from the kitchen and were on Puree and regular diets (diet with no restriction). Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran 1/2 cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were assembled on the trays), residents on puree diet received scrambled eggs. During an interview on 12/28/2024 at 10:10 a.m. with Dietary Supervisor (DS), DS stated ham and potato casserole puree was not given to residents on puree/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 4 instead staff gave puree plain scrambled eggs. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the [NAME] should have pureed the ham and potato casserole and the puree casserole should have been prepared. DS stated the staff did not tell her the reason why they did not prepare the puree casserole. DS stated puree food should be the same food on the regular diet because the amount of protein and nutrients should be the same for both diets. DS stated puree scrambled eggs and puree ham and potato casserole were not the same because the puree scrambled eggs did not have ham, potatoes, onions, and mustard. DS stated the residents on puree diet would not get enough protein and carbohydrates resulting to weight loss as a potential outcome. During an interview on 12/28/2024 at 12:04 p.m. with [NAME] 3, [NAME] 3 stated he did not make the puree ham and potato casserole because some residents did not eat ham and residents on renal diets (diet consistent of low salt, low potassium, and low phosphorus food) could not have ham, however some residents liked ham. [NAME] 3 stated he should have made the puree ham and potato casserole and separated some food for those residents who did not like ham. [NAME] 3 stated not following recipes would affect the taste of the food causing residents not to eat. [NAME] 3 stated the menu was new to him. During an interview on 12/28/2024 at 12:21 p.m. with DS, DS stated she talked to staff about recipes, spreadsheets and following the recipes unless the residents were allergic to any ingredients. DS stated she was not sure why the cook did not prepare the puree ham and potato casserole and did not follow the recipe today. DS stated she provided in-service to staff on how to read the spreadsheets and how to prepare puree food. During a review of the facility's P&P titled Standardized Recipes, dated 1/31/2024, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's Job Description (JD) titled [NAME] Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated POLICY: The cook prepares and serves food including texture modified and therapeutic diets according to the facility menu. The cook assists in proper receiving, storage, preparation, serving, sanitation, and cleaning procedures are followed. The cook reports to the Director of Food and Nutrition Services. The JD indicated cook qualification included knowledge of basic concepts of nutrition and diet management for regular, texture modified and therapeutic diets. Responsibilities included: Prepares food, including modified textures and therapeutic diets. Prepares food by methods that conserve nutritive value, flavor, and palatability. During a review of the facility's competency test titled Competency Test for Cooks and FNS Staff, dated 7/15/2024, the competency test included questions for food safety and sanitation but did not include following menus, spreadsheets, and recipe. b. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the trayline with DS, DS stated the staff used #16 scoops (2 oz) for puree scrambled egg instead of #12 scoop (3 oz). DS stated the portion size the staff gave the residents for breakfast was small than what the spreadsheet indicated. DS stated the residents would not get the right calories and nutrients the residents needed and could potentially lead to weight loss. During a review of the facility's Policies and Procedures (P&P) titled Portion Control, reviewed 1/31/2024, the P&P indicated To provide specific portion control information. Procedure: To be sure portions served equal portions sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilize by employees portioning the food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe books and on menu spreadsheet. (2) Ladles are sized according to their capacity. During a review of the facility's JD titled [NAME] Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated Responsibilities: Prepares, portions, and/or serves food using proper measuring equipment and serving utensils, while maintaining quality control-standards. c. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2) translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated 1/31/2024, the P&P indicated (3) Refrigerator equipment should be routinely cleaned. During a review of the facility's JD titled [NAME] Job Description dated and signed by [NAME] 1 on 9/9/1992, the JD indicated Qualifications: Ability to supervise Department of Food and Nutrition Services personnel and ensure sanitary conditions in the absence of the DS. Responsibilities: (6) Assures all food items are handles properly to meet safety and sanitation standards according to State and Federal regulations. Properly stores and refrigerates necessary items.

Based on observation, interviews, and clinical record and facility documents review, the facility failed to provide adequate staffing to meet the resident's needs for eight of 28 sampled residents (Residents 29, 34, 28, 12, 25, 138, 3, and 9). These deficient practices resulted in inability to attain or maintain physical, and psychosocial well-being of each resident, leading to psychosocial harm for one resident (Resident 29) and physical harm in others (Residents 12, 28, and 34). In a Centers for Medicare and Medicaid Services (CMS) document (S & C-05-09), neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 Code of Federal Regulation C.F. R. §488.301). 1. Resident 29 had tooth pain and possible urinary tract infection, for which she did not get proper treatment. Resident 29 also did not get a wheelchair and eyeglasses. Resident 29 had psychological pain from not receiving her glasses, wheelchair and not being assessed for tooth and back pain and not given pain medication. Resident 29 stated the lack of mobility made her feel depressed and low. As a result, of Resident 29 not receiving her wheelchair, she stopped going to activities, stayed in her room and continued to suffer depression. 2. Resident 34 was not provided assistance with eating and drinking and suffered weight loss and dehydration, which resulted in hospitalization . 3. Resident 28 was not provided necessary incontinent care and repositioning. Resident 28 developed a stage II pressure sore (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) on his right buttock because staff were not changing the resident's incontinence brief when he urinated. 4. Resident 12, who was dependent, did not receive assistance with his meals. Resident's responsible party reported Resident 12 is usually assisted for a short portion with his meals but not for the entire meal. As a result, has suffered a weight loss 10.5% weight loss in six months. 5. Certified Nursing Assistant/Restorative Nursing Assistant 4 (CNA/RNA 4) and CNA/RNA 11 reported to the survey team they are unable to perform RNA duties because they are usually short of CNAs. The RNAs stated they therefore perform the duties of the CNAs who call in sick. According to the facility document titled, Restorative - Charting Record, for the month of (MONTH) (YEAR), there were twenty-four residents ordered to receive RNA services. There was an additional resident who had an order for [REDACTED]. 6. The Resident Council Minutes review of (MONTH) 29, (YEAR), indicated the residents had voiced concerns about inadequate staffing, over two weeks earlier. On (MONTH) 10, (YEAR) at 5:01 a.m., during an observation of the 11 p.m. to 7 a.m. shift of (MONTH) 9, (YEAR), there were only two nursing staff in the facility, (one licensed vocational nurse and one certified nursing assistant), on duty to care for all thirty-eight residents. A review of the facility's Resident Census and Condition of Residents Form (672), indicated the facility census was 38 and the conditions of the residents included: Seven were bedfast residents, twenty-three residents were in a chair all or most of the time; five residents ambulate with assistance or an assistive device, and six 38 residents were incontinent of bowel and bladder. These deficient practices had the potential to affect all 38 residents in the facility. Therefore, Immediate Jeopardy was declared on (MONTH) 10, (YEAR) at 5:14 p.m. in the presence of the Administrator and Director of Nursing. The Administrator and the Director of Nursing were informed of the immediate jeopardy related to insufficient number of staff, resulting in lack of resident care such as: diminished assistance with feeding, lack of provision of sufficient fluids, lack of timely incontinent care, lack of intervention for tooth pain and lack of provision of assistive devices (wheelchair and eyeglasses) for out of bed activities. A plan of action was submitted to the survey team by the Administrator on (MONTH) 10, (YEAR) at 8:42 p.m. After review by the survey team and in the presence of the Administrator, the survey team notified the facility the plan of action was not acceptable to remedy insufficient staffing to provide for residents' care and services. A plan of action was submitted to the survey team by the Administrator on (MONTH) 10, (YEAR) at 9:50 p.m. After the survey team reviewed, accepted and validated the plan of action in the presence of the Administrator was notified the plan of action was accepted. The plan of action included to immediately provide CNA staff, instead of two, one registered nurse and one licensed vocational nurse to work the oncoming 11 p.m. to 7 a.m. shift. An updated plan of action was presented to the team on (MONTH) 12, (YEAR) at 11:25 a.m. to address ongoing provision of sufficient staff. The plan included: 1. Place online posting positions on several online job platforms, local places of business and recruit from nearby nursing schools and career fairs to fill open positions. 2. Provide incentives to current employees by offering $50 to employees who are not late and do not call off within a month, and provide incentives to employees who refer new staff. 3. In-service staff regarding call-offs, advising employees to preferably call within four hours prior to starting their shift. 4. Provide a strategic parking plan to the city of Santa Monica and allocate funding to implement a transportation van to the staff and hire a driver to assist staff. 5. Increase CNA hourly pay rate. 6. For residents, pain would be re-assessed for pain by the Director of Nurses (DON) and determine if pain management regimen is appropriate. 7. of the residents who were incontinent of bowel and bladder. On (MONTH) 12, (YEAR) at 11:47 a.m., in the presence of the Administrator, the updated plan of action was reviewed, and accepted by the survey team. The Immediate Jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m. (cross refer F- 686 (pressure sore), F692 (Nutrition/hydration), F697 (Pain) and F725 (staffing), F790 (dental), F688 (mobility), F685 (vision), and F841 (Medical Director). Findings: a. During an observation and interview on (MONTH) 8, (YEAR) at 10:45 a.m., with Resident 9, who was alert and oriented, and his wife and roommate (Resident 3), both residents were observed in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she does not want to be in the bed all day but they had not assisted her. Resident 9 stated the 3 p.m. to 11 p.m. shift is a problem because they do not have enough staff. Resident 9 stated any shift on the weekend was a problem also. Resident 9 stated CNAs call in sick on the weekends and he has asked the ADM what could be done about this issue. Resident 9 stated sometimes there is staff from an agency but that there is no orientation and some of the staff are not aware of their needs. Resident 9 stated at times the CNAs answer the call lights and turn them off but do not return to take care of their needs since the call light is no longer on and they forget to return. Resident 3 stated she is sitting in urine but was unable to state for how long. Resident 9 stated the worse shift is the night shift. Resident 3 stated sometimes there is only 2 CNAs working and they do not have their needs tended to when there is 2 CNAs. Resident 3 stated he was concerned if there was a catastrophe and there were only 2 CNAs how would the facility evacuate the residents and remove them from danger. A review of Resident 9's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated (MONTH) 12, (YEAR), indicated Resident 9 was cognitively intact (mental processes) in daily decision-making. Resident 9 needed one- person limited assistance with transfer, walking, and dressing. A review of Resident 3's admission record indicated the resident was admitted to the facility on (MONTH) 14, (YEAR) and readmitted (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated (MONTH) 22, (YEAR), indicated Resident 3 was moderately impaired in cognition (mental processes) in daily decision-making. Resident 3 needed one person limited assistance with transfer, walking, and dressing. b. During interview with Resident 29, on (MONTH) 8, (YEAR), starting at 11:31 am, Resident 29 stated that there was not enough help, and that there were three residents in the facility that were constantly yelling. Resident 29 indicated that there are times she does not get a bath even a bowl of water to clean her face for several days. She stated in the concurrent interview, she did not always receive water pitcher for drinking water. c. During an observation on (MONTH) 9, (YEAR) at 6: 20 a.m. Resident 12 was heard saying hello, hello from room [ROOM NUMBER] down the hallway from room [ROOM NUMBER]. For approximately 10 minutes no one entered the room to assist the resident. During an observation on (MONTH) 9, (YEAR) at 6:50 a.m., Resident 12 was heard in his room saying, hello, hello. No one went into his room for 7 minutes. During an observation on (MONTH) 10, (YEAR) at 11:50 a.m., FM 2 was heard, saying, Where is my father's dentures? Where did you place the dentures. The DON came into the room attempting to give the FM 2 dentures that belonged to another resident. The DON pointed to the name on the door and said here are the dentures. FM 2 stated, These are not my father's dentures. Look this has another person's name on the container. The FM 2 looked for the dentures in Resident 12's dresser drawer and found them. During an interview with Resident 12's Family Member 2 (FM 2), on (MONTH) 10, (YEAR) at 12:08 p.m., she stated, That staff (referring to DON) tried to give me another resident's dentures. FM 2 stated they do not change Resident 12 when he is wet or has soiled himself and he has been wearing the same shirt for the last three days. FM 2 stated that staff do not assist Resident 12 with eating for the entire meal. FM 2 stated he is supposed to receive Ensure between meals but he does not. FM 2 stated either her or her brother assist Resident 12 with dinner in the evening because that is the worse time because very few residents get help with their meals. There were four unopened Ensure bottles sitting at this bedside. FM 2 stated they feed Resident 12 for a few minutes only. FM 2 FM 2 stated she asked the DSD why is there sometimes only one nurse taking care of the residents at night time. FM 2 stated she has been at the facility during the night and has seen staff not go into his room when he was saying, help help. FM 2 stated Resident 12 does not receive RNA. During a subsequent interview on (MONTH) 10, (YEAR) at 3:10 p.m., FM 2 stated Resident 12 does not receive RNA. CNA 4 stated he did not do RNA on (MONTH) 10, (YEAR) because he is working as a CNA and unable to do both CNA and RNA job duties. CNA 11 stated when the facility is short staffed he performs CNA duties even though he may have been originally scheduled as RNA. CNAs who were scheduled to work were not observed on (MONTH) 12, (YEAR) providing care during their shift. During an observation and interview with CNA 10 on (MONTH) 12, (YEAR) at 6:35 a.m., CNA 10 was observed sitting in a chair by the front door with a bag by her side for approximately ten minutes not doing anything. CNA 10 was observed at 7:05 a.m in the same chair , writing in a binder, doing her charting on the residents. When CNA 10 was asked why she had her bag beside her from 6:35 a.m. up until then, she stated she went to get her bag that had been in the break room to get potato chips. CNA 10 stated she finishes her work at 6:30 a.m. and sits in the chair to chart. When asked why she did not have any charting with her at 6:35 a.m., CNA 10 did not have an answer to the question. During an observation and interview on (MONTH) 12, (YEAR) at 6:47 a.m., Resident 12 was observed saying hello, hello from his room. CNA 3 and CNA 7 were observed standing outside Resident 12's room looking at a cellphone together. Surveyor went into the room. Then CNA 7 followed, the surveyor entering the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to Channel 4. CNA 7 turned the channel to 4 which was a news show. Resident 12 was quiet after that. CNA 7 stated he was hesitant to turn the channel because Resident 12's FM 2 wanted only news channels. d. During an interview with the facility's Ombudsman 1 (OMB 1) on (MONTH) 11, (YEAR) at 5:00 p.m., OBM 1 stated there was an anonymous report sent to her on (MONTH) 4, (YEAR), regarding the staffing shortage. The report indicated the residents had not been bathed since (MONTH) 30, (YEAR). The Ombudsman stated the family member and the residents were fearful of retaliation by the facility staff. One of the residents reported days would go by without water and calls for help go ignored. A review of the Resident Council Minutes, dated (MONTH) 20, (YEAR), residents had raised concerns in the (MONTH) meeting that other residents need to be changed after lunch to avoid unfavorable incidents. The facility's response was to provide in-service to CNAs to attend to resident's needs immediately. A review of the Resident Council Minutes, dated (MONTH) 22, (YEAR), indicated complaints about no RNA. Resident 138 stated that no RNA has been attending to him for the last few days. The review of the Resident Council Minutes dated (MONTH) 29, (YEAR) indicated Resident 25 expressed a concern that the facility was understaffed. The response is that the facility was staffed appropriately per staff census. During an interview with CNA 2 on (MONTH) 9, (YEAR) at 7:05 a.m., he stated many times the 11 p.m. to 7 a.m. shift only has two CNAs. CNA 2 stated there has been more than one occasion where he was the only CNA working during the 11 p.m. to 7 a.m. shift. On those nights he was the only CNA, and was providing care for thirty-eight residents. A review of the Nursing Staffing Assignment and Sign-In Sheet following dates only had one CNA: December 24, (YEAR), 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 1, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 9, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 1 CNA During an observation on (MONTH) 10, (YEAR) at 6:30 a.m., there was one LVN and one CNA working for the 11 p.m. to 7 a.m. shift. Resident 89 was in her room and yelling, Someone help me, I have no face, no hands. Resident 12 was heard saying, hello, hello, hello. But no one went to the residents' rooms. A review of the Nursing Staffing Assignment and Sign-In Sheet for (MONTH) 9, (YEAR), 11 p.m. to 7 a.m. shift indicated there was only one LVN and one CNA that worked that night. This was verified by the Employee Time Card for that day. During an interview with CNA 3, she stated she was the only CNA working on the 11 p.m. to 7 a.m. shift that she had just completed. CNA 3 stated there was another date in the month of (MONTH) (YEAR), that she worked by herself CNA 3 stated for at least six months she has only worked with 1 CNA or sometimes herself which includes weekends as well as weekdays. CNA 3 stated that working with another CNA she still has 19 - 20 residents to provide care for and that it's too much. CNA 3 stated it was difficult to get help during the times it is only her and the LVN working on the 11 p.m. to 7 a.m. shift when the LVN is passing medications during the 9 p.m. medication pass times and 6 a.m. medication pass times. CNA 3 was questioned how it was providing care when she worked with 2 other CNAs and she smiled and said that is the best. CNA 3 stated in (MONTH) (YEAR) and (MONTH) of (YEAR), she worked with two other CNAs but after that, many times it was only herself and another CNA or only herself and the LVN. On (MONTH) 10, (YEAR), at 7:22 p.m., during an interview with Family Member 1 (FM 1), he stated he brought butternut squash and jello to Resident 34 which she liked. She usually likes it. Tonight, she did not like anything except water. I am here almost everyday. The biggest problem is there is not enough nurses. They lack nurses especially on the weekends which is more noticeable. I slept and stayed here so many times to help her and give her needs. When I called for the call light, it took about an hour for them to come. They told me that they cannot attend to her because they are backed up with their other residents. So I sat there for an hour or so. Weekends seems to be the worst. Many people complained about it. The nurses here do their best but there is insufficient amount of nurses. There were numerous times that she wants water but nobody can give it to her often because they are busy. When the food comes, they are all busy. So, if there is an emergency, nobody attends the other residents. I used to buy the Ensure. They never gave it to her. If they have given it, maybe it is just a one time shot thing. No, but I buy it myself. Tonight, the Dietary Supervisor said that he brought Ensure for her. I kept asking for Ensure before but the staff gave me different reasons and have not provided her the Ensure, so I just bought it for her. In the last three months, I have not seen my wife been up from the bed or out of bed. In the last six months, she was not exercised by the staff. I believe my wife needs more and more care now. He also stated that there were many nights he stayed up and slept beside his wife just to attend to her needs. During an interview with the Administrator (ADM) on (MONTH) 10, (YEAR) at 9:17 a.m., she stated for the 11 p.m. to 7 a.m. shift, one licensed vocational nurse (LVN) and two CNAs. The ADM stated at night time there is at least two CNAs on duty and that is sufficient staffing because the residents were custodial, and the residents, during that shift did not receive that many medications. The ADM stated the 11 p.m. to 7 a.m. LVN assists the CNAs with their duties if they need assistance. During an interview with the ADM on (MONTH) 10, (YEAR) at 10:40 a.m., she stated the 11 p.m. to 7 a.m. shift required one LVN and three CNAs. The ADM stated we always have an extra CNA in case one calls in sick. The ADM was unable to explain why there was only 1 LVN and 1 CNA providing care for thirty-eight residents on the 11 p.m. to 7 a.m. shift that started on (MONTH) 9, (YEAR) at 11 p.m. and ended on (MONTH) 10, (YEAR) at 7:00 a.m. The ADM was informed that staff stated that the staff call in sick. A staff member who wanted to remain anonymous in an interview on (MONTH) 10, (YEAR) at 6:00 p.m., stated that other staff are made to clock out when they are still finishing their work at the end of their shift. During an interview with the ADM on (MONTH) 10, (YEAR) at 8:43 p.m., she stated the facility adheres to the state requirement of 3.2 nursing hours. When asked what happened the previous night when there was only one C N A working for the 11 p.m. to 7 a.m. shift, she stated there were two C N A s scheduled to work but one called in sick. When asked how many C N A s were to work for the upcoming 11 p.m. to 7 a.m. shift, she stated there were two C N A s scheduled and that was enough staff. When asked what happens if one of those staff calls in sick, the ADM stated she asks one of the 3 p.m. to 11 p.m. staff to stay over and work the night shift. When asked why two C N A s were enough when in an interview earlier on (MONTH) 10, (YEAR) at 10:40 a.m., she had stated three C N A staff were needed for the night shift, the ADM was unable to provide an answer. During an interview with the ADM on (MONTH) 10, (YEAR) at 9:48 p.m., the ADM stated there were going to be one LVN and three C N A s staff working that evening. A review of the Nursing Staffing Assignment and Sign-In Sheet for (MONTH) 10, (YEAR) on the 11 p.m. to 7 a.m. shift indicated there was one LVN and four C N A s that worked that night. The survey team verified this information by reviewing the Employee Time Card for that day. A review of the facility's census indicated there were thirty-eight residents onsite in the facility on (MONTH) 10, (YEAR). During an interview with the Ombudsman 1 (OMB 1) on (MONTH) 11, (YEAR) at 5:00 p.m., OMB 1 stated there was an anonymous report sent to her on (MONTH) 4, (YEAR) regarding the staffing shortage. The report indicated the residents had not been bathed since (MONTH) 30, (YEAR). The Ombudsman stated the family member and the residents were fearful of retaliation by the facility staff. One of the residents reported days would go by without water and calls for help go ignored. During an interview with the CNA 1 on (MONTH) 12, (YEAR) at 2:19 p.m., she stated she was the only CNA working on (MONTH) 1, (YEAR) for the 11 p.m. to 7 a.m. shift. This was verified by a review of the Nursing Staffing Assignment and Sign-In Sheet for (MONTH) 1, (YEAR) 11 p.m. to 7 a.m. shift indicated there was one LVN and CNA 1 that worked that night. During observation of Resident 34 from (MONTH) 8 to (MONTH) 10, (YEAR), the resident was not seen out of bed. She remained on the same supine position with the HOB elevated. The resident was left alone most of the time in her room. The staff sets up her meal, sometimes they will stay for about five minutes to help her eat or give her water and encourage her to eat and drink, and then will go away and return to her again after an hour to get her meal tray. There was no observed staff who consistently provided assistance with eating or taking fluids at her bedside to ensure the resident had sufficient intake. e. A review of the Resident Council Minutes, dated (MONTH) 22, (YEAR), indicated Resident 138 stated that no RNA has been attending to him for the last few days. A review of the Resident Council Minutes, dated (MONTH) 29, (YEAR) indicated Resident 25 expressed a concern that the facility was understaffed. The response is that the facility were staffed appropriately per staff census. A review of Resident 9's admission record indicated the resident was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 9's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated (MONTH) 12, (YEAR), indicated Resident 49 was cognitively intact (mental processes) in daily decision-making. Resident 9 needed one person limited assistance with transfer, walking, and dressing. A review of Resident 3's admission record indicated the resident was admitted to the facility on (MONTH) 14, (YEAR) and readmitted (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated (MONTH) 22, (YEAR), indicated Resident 3 was moderately impaired in cognition (mental processes) in daily decision-making. Resident 3 needed one person limited assistance with transfer, walking, and dressing. During an observation and interview with Resident 9, who was alert and oriented, and his wife and roommate, Resident 3 on (MONTH) 8, (YEAR) at 10:45 a.m., both residents were observed in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she does not want to be in the bed all day but they had not assisted her. Resident 9 stated the 3 p.m. to 11 p.m. shift is a problem because they do not have enough staff. Resident 9 stated any shift on the weekend was a problem also. Resident 9 stated CNAs call in sick on the weekends and he has asked the ADM what could be done about this issue. Resident 9 stated sometimes there is staff from an agency but that there is no orientation and some of the staff are not aware of their needs. Resident 9 stated at times the CNAs answer the call lights and turn them off but do not return to take care of their needs since the call light is no longer on and they forget to return. Resident 3 stated she is sitting in urine but was unable to state for how long. Resident 9 stated the worse shift is the night shift. Resident 3 stated sometimes there is only 2 CNAs working and they do not have their needs tended to when there is 2 CNAs. Resident 3 stated he was concerned if there was a catastrophe and there were only 2 CNAs how would the facility evacuate the residents and remove them from danger. A review of the facility's 672 there were seven bedfast residents, twenty-three residents who were in a chair all or most of the time, and five residents who ambulate with assistance or an assistive device. During an interview with CNA 2 on (MONTH) 9, (YEAR) at 7:05 a.m., he stated many times the 11 p.m. to 7 a.m. shift only has two CNAs. CNA 2 stated there has been one occasion where he was the only CNA working during the 11 p.m. to 7 a.m. shift. On that night he was providing care for thirty-eight residents. A review of the Nursing Staffing Assignment and Sign-In Sheet for these dates indicated the following: December 24, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 1, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 1 CNA January 5, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 2 CNAs January 7, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 2 CNAs January 9, (YEAR) 11 p.m. to 7 a.m. 1 LVN, 1 CNA During an observation on (MONTH) 10, (YEAR) at 6:30 a.m, there was one LVN and one CNA working for the 11 p.m. Resident 89 was in her room and yelling, Someone help me, I have no face, no hands. Resident 12 was heard saying, hello, hello,hello. But no one went to the residents' rooms. A review of Resident 12's admission record indicated the resident was admitted to the facility on (MONTH) 11, 2014 and readmitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 12's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated (MONTH) 9, (YEAR), indicated Resident 12 was severely impaired in cognition (mental processes) in daily decision-making. Resident 9 needed one person totally dependent on staff with transfer, walking, and dressing. According to the Nursing Staffing Assignment And Sign-In Sheet for (MONTH) 9, (YEAR) 11 p.m. to 7 a.m. indicated there was only one LVN and one CNA that worked that night. This was verified by the Employee Time Card for that day. The CNA who worked that night, LVN 11 verified during an interview on (MONTH) 10, (YEAR) at 7:00 a.m. that she was the only CNA working that night. During an interview with CNA 3 and the DS who was translating on (MONTH) 10, (YEAR) at 7:00 a.m., she stated she was the only CNA working on the 11 p.m. to 7 a.m. shift that she had just completed. CNA 3 stated there was another date in the month of (MONTH) (YEAR) that she worked by herself CNA 3 stated for at least six months she has only worked with 1 CNA or sometimes herself which includes weekends as well as weekdays. CNA 3 stated that working with another CNA she still has 19 - 20 residents to provide care for and that it's too much. CNA 3 stated it was difficult to get help during the times it is only her and the LVN working on the 11 p.m. to 7 a.m. shift when the LVN is passing medications during the 9 p.m. medication pass times and 6 a.m. medication pass times. CNA 3 was questioned how it was providing care when she worked with 2 other CNAs and she smiled and said that is the best. CNA 3 stated in (MONTH) (YEAR) and (MONTH) of (YEAR) she worked with 2 other CNAs but after that many times it was only herself and another CNA or only herself and the LVN. During an interview with the Administrator (ADM) on (MONTH) 10, (YEAR) at 9:17 a.m., she stated for the 11 p.m. to 7 a.m. shift , one licensed vocational nurse (LVN) and two CNAs. The ADM stated at night time there is at least two CNAs on duty and that is sufficient staffing because the resident's were custodial, and the residents, during that shift did not receive that many medications. The ADM stated the 11 p.m. to 7 a.m. LVN assists the CNAs with their duties if they need assistance. During a later interview with the ADM on (MONTH) 10, (YEAR) at 10:40 a.m., she stated the 11 p.m. to 7 a.m. shift required one LVN and three CNAs. The ADM stated we always have an extra CNA in case one calls in sick. The ADM was unable to explain why there was only 1 LVN and 1 CNA providing care for thirty-eight residents on the 11 p.m. to 7 a.m. shift that started on (MONTH) 9, (YEAR) at 11 p.m. and ending (MONTH) 10, (YEAR) at 7:00 a.m. The ADM was informed that staff have told the surveyor that they call in sick. Other staff are made to clock out when they are still finishing their work at the end of their shift. A review of the facility's census there were thirty-eight residents onsite in the facility on (MONTH) 10, (YEAR). On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ) was called at the facility under the section abuse/neglect. The IJ was not lifted that day. A review of the pain medication record indicated pain medications was not given to residents who had pain (Resident 29, Resident 15). Resident 34 had lost twenty-three pounds within six months due to staff not assisting the resident with eating and drinking. Resident 28 developed a sore on his right buttocks because staff were not changing the resident's incontinence brief when he urinated. The issue of inadequate staffing was voiced by the residents in the past resident council meetings. A plan of action was submitted to the survey team by the facility on (MONTH) 10, (YEAR) at 8:42 p.m. The survey team reviewed the plan of action. However, the plan of action did not ensure that the facility had adequate staffing for that night's CNAs for the 11 p.m. to 7 a.m. shift. During an interview with the ADM on (MONTH) 10, (YEAR) at 8:43 p.m., she stated the facility adheres to the state requirement of 3.2 nursing hours. When asked what happened the previous night when there was only one CNA working for the 11 p.m. to 7 a.m. shift, she stated there were two CNAs scheduled to work but one called in sick. When asked how many CNA were to work for the upcoming 11 p.m. to 7 a.m. shift, she stated there were two CNA sceduled and that that was enough staff. When asked if one of those staff calls in sick, the ADM stated she asks one of the 3 p.m. to 11 p.m. staff to stay over and work the night shift. When asked why two CNAs were enough when in an interview earlier at (MONTH) 10, (YEAR) at 10:40 a.m. she had stated three CNA staff were needed for the night shift, the ADM was unable to provide an answer. During an interview with the ADM on (MONTH) 10, (YEAR) at 9:48 p.m., she stated there were going to be one LVN and three CNA staff working that evening. According to the Nursing Staffing Assignment And Sign-In Sheet for (MONTH) 10, (YEAR) 11 p.m. to 7 a.m. indicated there was one LVN and four CNAs that worked that night. This was verified by the Employee Time Card for that day. During an interview with the CNA 1 on (MONTH) 12, (YEAR) at 2:19 p.m., she stated she has been the only CNA working on (MONTH) 1, (YEAR) for the 11 p.m. to 7 a.m. shift. This was verified by a review of the Nursing Staffing Assignment And Sign-In Sheet for (MONTH) 1, (YEAR) 11 p.m. to 7 a.m. indicated there was one LVN and CNA 1 that worked that night. A review of the policy and procedure titled, Answering the Call Light, revised (MONTH) 2010, indicated if staff have promised the resident they will return with an item or information, do so promptly. There was no specification for how long promptly was for. f. According to the admission record, Resident 13 was originally admitted on (MONTH) 1, (YEAR) and was readmitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR)

Based on observation, interview, and record review, the facility failed to ensure the medical director is responsible for the implementation of resident care policies and the coordination of medical care in the facility. The medical director did not provide adequate oversight to ensure care and services to the 38 in-house residents in the facility met professional standards of quality. On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, 688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on (MONTH) 11, (YEAR) at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents. Findings: During the recertification survey, the following was identified: The facility failed to ensure food was stored in a sanitary manner when it stored food in an outside storage shed with unfinished walls and ceiling. The shed had exposed electrical wires and plumbing pipes, wooden shelving with peeling paint. This deficient practice had the potential to result in cross -contamination. (Cross refer F812). The facility failed to ensure therapeutic diets were served as ordered for Resident 29 who had a physician's orders [REDACTED]. (Cross refer F808). The facility failed to write menus in advance for a vegan diet and failed to follow the menu as written for residents on large and double portion diets. (Cross refer F803). The facility failed to ensure the Registered Dietitian was contracted for sufficient hours to carry out the functions of the food and nutrition services and ensure services meet professional standard of practice and the residents' needs. (Cross refer F801). The facility failed to promptly notify the physician of a urinary test result for Resident 29 resulting in delayed [DIAGNOSES REDACTED]. The facility failed to ensure pain management was provided for Resident 29. (Cross refer F697). The facility failed to ensure dental services were provided to Resident 29 who had toothache. (Cross refer F791). The facility failed to ensure residents who are not able to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal hygiene. Residents 29, 12, 34, 28, 9, and 3 were not assisted with eating, personal hygiene, and mobility due to insufficient Certified Nursing Assistants (CNAs). Resulted in weight loss for Residents 12 and 34, pressure ulcer for Resident 28, lack of mobility for Residents 29 and 3, and lack incontinent care for Residents 12, 34, 28, 9, and 3. (Cross refer F677, F686). The facility failed to prevent pressure ulcers for Resident 28. (Cross refer F686). The facility failed to assist in arranging provision of eyeglasses for Resident 29. Resident 29 was recommended eyeglasses since (MONTH) 12, (YEAR), and by. (Cross refer F685). The facility failed to ensure Resident 29 received a needed wheelchair to maintain or improve mobility independence. (Cross refer F688). The facility failed to have a contract with the hospice agency providing care to Resident 15 to ensure coordinated care. (Cross refer F849). The facility failed to establish a system of records for controlled medications to enable accurate reconciliation controlled medications for Resident 15. (Cross refer F755). The facility failed to ensure Residents 12 and 34 were provided the assistance required during meals to prevent weight loss and dehydration. (Cross refer 692). The facility failed to investigate Resident 12's injuries of unknown origin in a timely manner. (Cross refer F610). On (MONTH) 10, (YEAR), at 5:15 p.m., an Immediate Jeopardy situation was called on the areas of Sufficient Nursing Staff and Freedom from Neglect. A Review of the contract for Medical Director indicated, his services were contracted for in (MONTH) (YEAR). On (MONTH) 12, (YEAR), at 3:12 p.m., during a telephone interview, the Medical Director was informed on the identified deficient practices and quality of care concerns raised by residents, family, and other physicians. The Medical Director indicated he was not aware of any quality of care concerns and was not aware the facility had an undergoing survey or that an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation had been called due to inadequate staffing and neglect.

Based on observation, interview, and record review, the facility failed to ensure its residents have the right to be free from neglect. Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility failed to provide adequate staffing to meet the residents' needs for six of 28 sampled residents (Residents 3, 9. 29, 12, 28, and 34). This deficient practice resulted in an environment that promoted neglect of residents' care and services leading to psychosocial harm for one resident (Resident 29) and physical harm to other residents (Residents 12, 28, and 34). 1. Resident 29 had tooth and right flank (the side section between the lowest rib and the hip) pain and possibly a urinary tract infection [MEDICAL CONDITION], for which she did not receive treatment. Resident 29 was not provided with a needed wheelchair causing her to stop attending group activities and socialize. Resident 29 was not provided with needed eyeglasses. As a result, Resident 29 suffered unnecessary pain and became depressed and isolated. 2. Resident 12, who was dependent on staff with eating, did not receive the assistance needed with eating his meals. Resident 12's responsible party, Family Member 2 (FM 2), stated Resident 12 was usually assisted for a short portion of his meals but not for the entire meal. As a result, the resident suffered a slow progressive unplanned significant weight loss in four months and was dehydrated requiring transfer to a General Acute Care Hospital (GACH). Resident 12 was not provided with Restorative Nursing Assistant (RNA) program (assist residents in performing range of motion exercises, waking, eating, and special positioning techniques to maintain the residents' mobility and functions). RNAs 4 and 11 stated they were unable to perform RNA exercises to the residents as ordered by their physicians because they were usually short of Certified Nursing Assistants (CNAs) and the RNAs had to cover for the absent CNAs. 3. Resident 34, was not provided assistance with eating and drinking resulting in weight loss and dehydration and required hospitalization . 4. Resident 28 was not provided necessary incontinent care and repositioning. As a result, Resident 28 developed a Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure sore (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) on his right buttock. 5. A review of the Resident Council Meeting minutes, dated (MONTH) 22, (YEAR), indicated Resident 38 stated no RNA had been attending to him for the last few days. A review of the Resident Council Meeting minutes, dated (MONTH) 29, (YEAR) indicated Resident 25 expressed a concern that the facility was understaffed. The response was, the facility staffed appropriately per census. On (MONTH) 10, (YEAR) at 5:01 a.m., it was noted that during the 11 p.m. to 7 a.m. shift, there were two nursing staff in the facility, (one licensed vocational nurse (LVN) and one CNA) on duty to provide care to all residents in the facility. A review of the Resident Census and Condition of Residents Form (CMS - 672) provided by the facility on (MONTH) 9, (YEAR), indicated the census was 38 residents and the conditions of the residents included: - Seven residents were bedfast (confined to bed); - 23 residents were in a chair all or most of the time; - Five residents walked with assistance or an assistive device; and - Six residents were incontinent of bowel and bladder. These deficient practices had the potential to affect all 38 residents in the facility. An Immediate Jeopardy was declared on (MONTH) 10, (YEAR) at 5:14 p.m. in the presence of the Administrator and Director of Nursing (DON). The Administrator and the DON were informed of the Immediate Jeopardy related to neglect due to insufficient number of staff, resulting in lack of resident care such as: diminished assistance with feeding, lack of provision of sufficient fluids, lack of timely incontinent care, lack of intervention for tooth pain and lack of provision of assistive devices (wheelchair and eyeglasses) for out of bed activities. The Administrator submitted a plan of action on (MONTH) 10, (YEAR) at 8:42 p.m. which was not acceptable to remedy neglect of residents' care and services. The Administrator submitted a revised plan of action on (MONTH) 10, (YEAR) at 9:50 p.m. After the survey team reviewed, validated, and accepted the plan of action, the Administrator was notified the plan of action was accepted. The plan of action included to immediately provide three CNAs instead of two, one Registered Nurse (RN) and one LVN to work the oncoming 11 p.m. to 7 a.m. shift. An updated plan of action was presented to the team on (MONTH) 12, (YEAR) at 11:25 a.m. to address ongoing provision of sufficient staff. The plan included: 1. Placing online posting positions on several online job platforms, local places of business and recruit from nearby nursing schools and career fairs to fill open positions. 2. Providing incentives to current employees by offering $50 to employees who are not late and do not call off within a month and provide incentives to employees who refer newly hired staff. 3. In-servicing staff regarding call-offs, advising employees to preferably call within four hours prior to starting their shift. 4. Providing a strategic parking plan to the city and allocate funding to implement a transportation van to the staff and hire a driver to assist staff. 5. Increasing CNA hourly pay rate. 6. Re-assessing residents' pain by the DON and determining if pain management regimen was appropriate. On (MONTH) 12, (YEAR) at 11:47 a.m. in the presence of the Administrator, the updated plan of action was reviewed and accepted by the survey team. The Immediate Jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m. (cross refer F686 (pressure sores), F692 (Nutrition/hydration), F697 (Pain) and F725 (staffing), F790 (dental), F688 (mobility), F685 (vision), F838 (facility assessment), and F841 (Medical Director). Findings: 1. A review of the Face Sheet (Admission Record) indicated Resident 29 was admitted to the facility on (MONTH) 31, (YEAR) and readmitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 29's prior occupation was librarian. A review of the Minimum Data Set (MDS - standardized assessment and care screening tool) dated (MONTH) 9, (YEAR), indicated Resident 29's vision was impaired, was able to see large print but not regular print in newspapers/books. A review of the most recent Quarterly dated (MONTH) 6, (YEAR), indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. a. During the initial tour of the facility on (MONTH) 8, (YEAR) at 11:31 a.m., Resident 29 stated, I would like to be mobile. The resident stated she had been measured for a wheelchair about the same time as for her eyeglasses sometime in, (MONTH) or so but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On (MONTH) 10, (YEAR) at 9:33 a.m., during an interview, the Social Services Designee (SSD) stated she was not aware why Resident 29 was not provided with a wheelchair while her customized wheelchair was ordered. The SSD explained a Durable Medical Equipment (DME) company measured Resident 29 for a customized chair and the DME company had been waiting for physician approval. The SSD stated she was unaware of the outcome. On (MONTH) 10, (YEAR) at 11:10 a.m., during an interview, Resident 29 stated, It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore. A review of the Nursing Notes dated (MONTH) 29, (YEAR), indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated (MONTH) 4, (YEAR), identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and outing activities. On (MONTH) 10, (YEAR), at 10:57 a.m., during an interview, the Activity Designee (AD) stated she was not aware that reason for Resident 29's self-isolation could be related to the lack of a wheelchair. The AD stated she visits the resident weekly as part of the care plan. A review of the Social Services assessment dated (MONTH) 13, (YEAR), indicated Resident 29 had no significant behavior issues addressed at this time. On (MONTH) 12, (YEAR), at 10:07 a.m. during an interview, the Administrator stated she was aware Resident 29 had gained a lot of weight and could not fit into the facility's provided wheelchairs. On (MONTH) 12, (YEAR) at 12:30 p.m., during an interview, the DME company owner stated they were waiting for Resident 29's physician's approval. A review of a Physical Therapy Evaluation form dated (MONTH) 22, (YEAR), indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. The physical therapist documented Resident 29 required a tilt in space wheelchair (gives the user the ability to adjust the orientation of their wheelchair by allowing for the redistribution of pressure from one area to another by tilting the seating area) for mobility. On (MONTH) 12, (YEAR), at 1:37 p.m., during a telephone interview, Resident 29's attending physician (MD 1) stated she was not informed of a needed approval for a wheelchair and the DME did not send her an approval request. A review of the Activity Attendance Record for (MONTH) (YEAR), indicated Resident 29 attended bingo (MONTH) 2, 9, 13, 22, 25, 27 and 29. The Activity Attendance Record for (MONTH) (YEAR) indicated no participation in group or room activities. The Activity Attendance Record for (MONTH) (YEAR), was blank. Further record review indicated there was no plan of care developed for Resident 29's lack of mobility device since (MONTH) (YEAR). The interdisciplinary team (IDT- group of professional staff from different disciplines) did not address Resident 29's mobility problems and possible negative outcomes. (Cross refer F 688) b. During the initial tour of the facility on (MONTH) 8, (YEAR) at 11:18 a.m., Resident 29 stated her eyes were tested around, (MONTH) or so and she was yet to receive her new eyeglasses. The resident stated none of the staff she had asked were able to tell her the status of the eyeglasses. An Optometrist (a professional on examining the eyes) assessment dated (MONTH) 12, (YEAR), included recommendation for new eyeglasses for quality of life and improvement in vision. On (MONTH) 10, (YEAR), at 9:55 a.m., during an interview, the SSD was unable to indicate the status of the new glasses recommended by the Optometrist. On (MONTH) 10, (YEAR) at 10:21 a.m., the SSD presented an invoice which indicated Resident 29 needed to make a payment for the frames and glasses as the insurance company did not cover. The glasses had not been ordered for Resident 29. The SSD was unable to explain the lack of follow up and assistance in making arrangements for Resident 29 to obtain eyeglasses. A review of the Occupational Therapy assessment dated (MONTH) 17, (YEAR), indicated Resident 29 needed cueing to retrieve items on the floor due to poor vision. Further record review indicated there was no plan of care developed for Resident 29's lack of eyeglasses since (MONTH) (YEAR). The IDT did not address Resident 29's visual problem and lack of insurance coverage for the eyeglasses and make arrangements to assist Resident 29 in obtaining the needed eyeglasses. (Cross refer F 685) c. During the initial tour of the facility, on (MONTH) 8, (YEAR) at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already. A review of the physician's orders [REDACTED]. A review of the Dental Exam dated (MONTH) 29, (YEAR), indicated Resident 29 had complained of pain and the dentist ordered pain medication, [MEDICATION NAME] 275 milligrams (mg) twice a day for three days but according to the Medication Administration Record [REDACTED]. There was no documented evidence explaining why the medication was not administered as ordered. On (MONTH) 10, (YEAR), at 9:55 a.m., during an interview, the SSD stated a dentist treated Resident 29 but she was not aware of any new recommendations. There was no further Dental Examination in Resident 29's clinical record. After the Evaluator inquired, on (MONTH) 10, (YEAR), Dental Exam reports were faxed by the dental office. A review of the reports indicated Resident 29 was evaluated on (MONTH) 13 and (MONTH) 8, (YEAR). On (MONTH) 8, (YEAR), the dentist indicated Resident 29 was advised to notify the charge nurse or a social worker if she experienced pain or discomfort or if she needed to be seen by the dentist. (Cross refer F697 and F790) d. On (MONTH) 10, (YEAR) at 7 p.m., a [MEDICAL CONDITION] (a Bi-level positive airway pressure device - a pressure support ventilation to treat sleep respiratory problems) machine was observed on the nightstand next to Resident 29's bed. At the time of the observation, Resident 29 stated she did not use the prescribed [MEDICAL CONDITION] machine because it did not fit her. A review of the physician's orders [REDACTED]. On (MONTH) 1, (YEAR), the physician ordered [MEDICAL CONDITION] fitting and titration. Further record review indicated there was no plan of care developed addressing the unfitting [MEDICAL CONDITION] machine since (MONTH) (YEAR), and the IDT did not address arrangement made for the fitting of the [MEDICAL CONDITION] machine. (Cross refer F695) e. On (MONTH) 11, (YEAR) at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area (the side section between the lowest rib and the hip). Resident 29 indicated she had a urine test but was told it came back okay. A review of the result of a urine laboratory test (UA- urinalysis) collected on (MONTH) 9, (YEAR) indicated presence of three or more bacteria (microscopic living organisms that can be dangerous and cause infections). Further review of the nursing notes indicated there was no documentation Resident 29's physician was informed of the urine test result. After the Evaluator inquired, a repeat urinalysis test was ordered. The urine test result dated (MONTH) 20, (YEAR), indicated the presence of bacteria in Resident 29's urine. Resident 29 was prescribed antibiotics for UTI on (MONTH) 22, (YEAR), eleven days after the resident initially complained of right flank pain. A review of the facility's undated policy and procedure titled Prevention of Urinary Tract Infection: Indwelling Urinary Catheters, indicated urine collection bags will be emptied prior to the ends of each shift maintaining the closed system and using a separate collecting container for each resident. The amount of output will be reported to the charge nurse and recorded in the medical record per facility policy. Fluid will be offered and encouraged to maintain proper hydration. Intake and output records will be maintained each shift on a daily basis for all residents with indwelling catheters. (Cross refer F690) f. During the initial tour of the facility, on (MONTH) 8, (YEAR) at 11:18 a.m., Resident 29 complained she had toothache and when she asked nursing staff for pain medication, she would be told she had one already and it was not time for her next dose. Resident 29 stated no other medication was offered while she waited for the next dose. The resident added her pain was better managed during the day but it was difficult for her to get pain medication at night. On (MONTH) 11, (YEAR) at 3:30 p.m., during an interview, Resident 29 stated she had pain, pointing to her right flank area. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the MAR for the month of (MONTH) (YEAR) indicated Resident 29 received: - Three times on (MONTH) 18, 20, and 23 - Two times on (MONTH) 4, 12, 16, 17, and 24 - Once on (MONTH) 6, 8, 9, 11, 14, 15, 19, 21, 22, and 25. During the month of (MONTH) (YEAR), Resident 29 received her pain medication three times at night (11 p.m. to 7 a.m. shift). A review of the MAR for the month of (MONTH) (YEAR), indicated Resident 29 received [MEDICATION NAME] three times during the 11 p.m. to 7 a.m. shift. From (MONTH) 1 - 12, (YEAR), Resident 29 received [MEDICATION NAME] five times on the 11 p.m. to 7 a.m. shift. From (MONTH) 1 - 12, (YEAR), the pattern of pain medication administration was the same. Resident 29 received the pain medication a maximum of four times out of a possible six times in a day; and received pain medication five times on the 11 p.m. to 7 a.m. shift. A review of a physician's orders [REDACTED]. On (MONTH) 10, (YEAR) at 12:54 p.m., during an interview, LVN 4 stated she could not explain why [MEDICATION NAME] was not given to Resident 29 as ordered by the dentist. On (MONTH) 12, (YEAR), at 1:37 p.m., during an interview, MD 1 stated she was concerned Resident 29 may be forgetting she received pain medication and had referred the resident to the psychiatrist (physician who specializes in the prevention, diagnosis, and treatment of [REDACTED]. MD 1 stated she believed Resident 29 had an order for [REDACTED]. A review of the nursing notes indicated no evidence the referral to psychiatry was implemented. 2. A review of the Admission Record indicated Resident 12 was admitted to the facility on (MONTH) 11, 2014, and readmitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the MDS dated (MONTH) 9, (YEAR), indicated Resident 12 was severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent on staff for activities of daily living (ADLs - transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. a. On (MONTH) 8, (YEAR) at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On (MONTH) 9, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello, from his room. Resident 12 continued to say, Hello, hello for 10 minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 9, (YEAR) at 1:15 p.m., Resident 12 was heard screaming, Hello, can someone put food in my mouth? Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. On (MONTH) 9, (YEAR) at 1:18 p.m., during an interview, CNA 13 stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On (MONTH) 10, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello from his room. Resident 12 continued to say, Hello, hello for seven minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 10, (YEAR) at 12:08 p.m., four Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, FM 2 stated staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening and at nights the staffing was worst. On (MONTH) 10, (YEAR) at 11:50 a.m., FM 2 was in Resident 12's room saying, Where is my father's dentures? Where did you place the dentures? The DON entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, These are not my father's dentures. Look, this has another person's name on the container. FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in (MONTH) (YEAR). Another weight, with unspecified date, indicated 126 pounds. The resident had lost a total of 15 pounds in six months or 10.6%, of body weight, a severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated (MONTH) 9, (YEAR), indicated the resident's weight was 132 pounds. (Cross refer F692) b. On (MONTH) 8, (YEAR) at 4:43 p.m., during a telephone interview, the facility's assigned Ombudsman stated when she visited the facility on (MONTH) 31, (YEAR) at 8:30 a.m., Resident 12 was sitting in urine with a strong urine smell in the room. The Ombudsman stated LVN 1 told her she just changed Resident 12 a few minutes earlier. On (MONTH) 10, (YEAR) at 12:08 p.m., during an interview, FM 2 stated staff do not change Resident 12 when he is wet or soiled. FM 2 added Resident 12 was wearing the same shirt for the last three days. FM 2 stated she has asked the Director of Staff Development (DSD) the reason, some nights, there was only one CNA taking care of all residents. FM 2 stated she has been at the facility during the night and has seen staff not go into Resident 12's room when he is calling out, Help, help. (Cross refer F690) c. On (MONTH) 10, (YEAR) at 3:10 p.m., FM 2 stated Resident 12 did not receive RNA care. On (MONTH) 10, (YEAR), during an interview CNA 4 stated he did not do RNA on (MONTH) 10, (YEAR), because he is working as a CNA and unable to do both CNA and RNA job duties. During a concurrent interview, CNA 11 stated when the facility is short - staffed, he performs CNA duties even though he was originally scheduled as RNA. (Cross refer F688) d. On (MONTH) 12, (YEAR) at 6:47 a.m., Resident 12 was observed saying, Hello, hello from his room while CNAs 3 and 7 were observed standing outside Resident 12's room looking at a cellphone together. As the Evaluator approached the room, CNA 7 entered the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to a specific channel. CNA 7 turned the TV to the requested channel, which was showing news. Resident 12 was quiet after that. (Cross refer F677) 3. A review of the Admission Record, Resident 34 was originally admitted to the facility on (MONTH) 24, 2014 and was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nutritional assessment dated (MONTH) 7, (YEAR), indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and1,700 cc to 1,800 cc of fluid. The was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the physician's orders [REDACTED]. A review of the Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for altered nutritional status and weight loss included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. 2 Cal HN one can TID (three times a day) at med (medication) pass A review of the MDS assessment dated (MONTH) 14, (YEAR), indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in (MONTH) (YEAR) to 110 pounds in (MONTH) (YEAR) a total of 12 pounds weigh loss in four months. a. On (MONTH) 8, (YEAR), at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. On (MONTH) 8, (YEAR), at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On (MONTH) 9, (YEAR), at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. On (MONTH) 9, (YEAR), at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and LVN 4 stated 25 to 30%. On (MONTH) 9, (YEAR), at 8:55 a.m., during an interview, the RD stated Resident 34 ate less than 10%. On (MONTH) 10, (YEAR), at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On (MONTH) 10, (YEAR), at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. A review of Resident 34's CNA - ADL Tracking form indicated from (MONTH) 1 to (MONTH) 10, (YEAR), Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, Meals-Feeding the Resident dated (MONTH) 2009, indicated the resident is fed to ensure assistance is provided with eating, if needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. (Cross refer F692) b. A review of the SBAR (Situation, Background, Assessment, Recommendation) form dated (MONTH) 22, (YEAR), indicated Resident 34 had a decreased urine output. A review of the physician's orders [REDACTED]. A review of the Dehydration Risk assessment dated (MONTH) 14, (YEAR), indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for (MONTH) (YEAR). A review of the Intake and Output Record for the month of (MONTH) (YEAR) indicated 12 days were left blank. A review of the physician's orders [REDACTED]. On (MONTH) 9, (YEAR), the physician ordered to monitor Resident 34's intake and output. A review of the physician's orders [REDACTED]. On (MONTH) 10, (YEAR), at 7 p.m., during an interview and record review with LVN 6, the results of laboratory tests ordered on (MONTH) 8, (YEAR), were not found in the clinical record. On (MONTH) 10, (YEAR), at 7:11 p.m., a review of the faxed laboratory blood test results suggested dehydration. On (MONTH) 10, (YEAR), and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated (MONTH) 10, (YEAR), indicated R (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure residents who are not able to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal hygiene for six of 28 sampled residents (Residents 29,12, 34, 28, 9, and 3). Residents 29, 12, 34, 28, 9, and 3 were not assisted with eating, personal hygiene, and mobility due to insufficient Certified Nursing Assistants (CNAs). This deficient practice resulted in weight loss for Residents 12 and 34, pressure ulcer for Resident 28, lack of mobility for Residents 29 and 3, and lack incontinent care for Residents 12, 34, 28, 9, and 3. On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, 688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on (MONTH) 11, (YEAR) at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to maintain good nutrition, grooming and personal hygiene. Findings: a. A review of the Admission Record indicated Resident 29 was admitted to the facility on (MONTH) 31, (YEAR) and readmitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. A review of the most recent Quarterly dated (MONTH) 6, (YEAR), indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility on (MONTH) 8, (YEAR) at 11:31 a.m., Resident 29 stated, I would like to be mobile. The resident stated she had been measured for a wheelchair sometime in, (MONTH) or so but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On (MONTH) 10, (YEAR) at 11:10 a.m., during an interview, Resident 29 stated, It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore. A review of the Nursing Notes dated (MONTH) 29, (YEAR), indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated (MONTH) 4, (YEAR), identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and outing activities. A review of a Physical Therapy Evaluation form dated (MONTH) 22, (YEAR), indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. b.1 A review of the Admission Record indicated Resident 12 was admitted to the facility on (MONTH) 11, 2014, and readmitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the MDS dated (MONTH) 9, (YEAR), indicated Resident 12 was severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent on staff for activities of daily living (ADLs - transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. On (MONTH) 8, (YEAR) at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On (MONTH) 9, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello, from his room. Resident 12 continued to say, Hello, hello for 10 minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 9, (YEAR) at 1:15 p.m., Resident 12 was heard screaming, Hello, can someone put food in my mouth? Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. On (MONTH) 9, (YEAR) at 1:18 p.m., during an interview, CNA 13 stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On (MONTH) 10, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello from his room. Resident 12 continued to say, Hello, hello for seven minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 10, (YEAR) at 12:08 p.m., four Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, FM 2 stated staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening or at nights the staffing was worst. On (MONTH) 10, (YEAR) at 11:50 a.m., FM 2 was in Resident 12's room saying, Where is my father's dentures? Where did you place the dentures? The DON entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, These are not my father's dentures. Look, this has another person's name on the container. FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in (MONTH) (YEAR). Another weight, with unspecified date, indicated 126 pounds. The resident had lost a total of 15 pounds in six months or 10.6%, of body weight, severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated (MONTH) 9, (YEAR), indicated the resident's weight was 132 pounds. b.2 On (MONTH) 8, (YEAR) at 4:43 p.m., during a telephone interview, the facility's assigned Ombudsman stated when she visited the facility on (MONTH) 31, (YEAR) at 8:30 a.m., Resident 12 was sitting in urine with a strong urine smell in the room. The Ombudsman stated LVN 1 told her she just changed Resident 12 a few minutes earlier. On (MONTH) 10, (YEAR) at 12:08 p.m., during an interview, FM 2 stated staff do not change Resident 12 when he is wet or soiled. FM 2 added Resident 12 was wearing the same shirt for the last three days. FM 2 stated she has asked the Director of Staff Development (DSD) the reason, some nights, there was only one CNA taking care of all residents. FM 2 stated she has been at the facility during the night and has seen staff not go into Resident 12's room when he is calling out, Help, help. b.3 On (MONTH) 10, (YEAR) at 3:10 p.m., FM 2 stated Resident 12 did not receive RNA care. On (MONTH) 10, (YEAR), during an interview CNA 4 stated he did not do RNA on (MONTH) 10, (YEAR), because he is working as a CNA and unable to do both CNA and RNA job duties. During a concurrent interview, CNA 11 stated when the facility is short - staffed, he performs CNA duties even though he was originally scheduled as RNA. b.4 On (MONTH) 12, (YEAR) at 6:47 a.m., Resident 12 was observed saying, Hello, hello from his room while CNAs 3 and 7 were observed standing outside Resident 12's room looking at a cellphone together. As the Evaluator approached the room, CNA 7 entered the room and asked Resident 12 what he wanted. Resident 12 stated he wanted the TV to be turned to a specific channel. CNA 7 turned the TV to the requested channel, which was showing news. Resident 12 was quiet after that. c.1 A review of the Admission Record, Resident 34 was originally admitted to the facility on (MONTH) 24, 2014 and was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nutritional assessment dated (MONTH) 7, (YEAR), indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and 1,700 cc to 1,800 cc of fluid. Resident 34 was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the physician's orders [REDACTED]. A review of the Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for altered nutritional status and weight loss included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. 2 Cal HN one can TID (three times a day) at med (medication) pass A review of the MDS assessment dated (MONTH) 14, (YEAR), indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in (MONTH) (YEAR) to 110 pounds in (MONTH) (YEAR) a total of 12 pounds weigh loss in four months. c.2 On (MONTH) 8, (YEAR), at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. On (MONTH) 8, (YEAR), at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On (MONTH) 9, (YEAR), at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. On (MONTH) 9, (YEAR), at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and LVN 4 stated 25 to 30%. On (MONTH) 9, (YEAR), at 8:55 a.m., during an interview, the RD stated Resident 34 ate less than 10%. On (MONTH) 10, (YEAR), at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On (MONTH) 10, (YEAR), at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. A review of Resident 34's CNA - ADL Tracking form indicated from (MONTH) 1 to (MONTH) 10, (YEAR), Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, Meals-Feeding the Resident dated (MONTH) 2009, indicated the resident is fed to ensure assistance is provided with eating, if needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. c.3 A review of the SBAR (Situation, Background, Assessment, and Recommendation) form dated (MONTH) 22, (YEAR), indicated Resident 34 had a decreased urine output. A review of the physician's orders [REDACTED]. A review of the Dehydration Risk assessment dated (MONTH) 14, (YEAR), indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for (MONTH) (YEAR). A review of the physician's orders [REDACTED]. On (MONTH) 10, (YEAR), at 7:11 p.m., a review of the faxed laboratory blood test results suggested dehydration. On (MONTH) 10, (YEAR), and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated (MONTH) 10, (YEAR), indicated Resident 34's reason for transfer included weight loss, dehydration, increased BUN (blood, urea, nitrogen in blood), and poor appetite. A review of the GACH report from the Emergency Department (ED) dated (MONTH) 11, (YEAR), indicated Resident 34 was diagnosed with [REDACTED]. The plan was to admit the resident to medical service. The facility's undated policy and procedure titled Hydration, indicated it is the policy of the facility to maintain a resident's hydration by encouraging adequate fluid intake, in compliance with existing physician's orders [REDACTED]. d. On (MONTH) 8, (YEAR) at 11:18 a.m., Resident 28 was observed lying on his back in his bed. At the time of the observation, during an interview, Resident 28 stated he had blisters on his bottom that were painful at times. A review of the Admission Record indicated Resident 28 was admitted to the facility on (MONTH) 4, 2006 and readmitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the Care Plan developed for Resident 28's Risk for Pressure Ulcers dated (MONTH) 12, (YEAR), included in the interventions turning and repositioning Resident 28, at least every two hours, when in bed or in wheelchair and inspecting Resident 28's skin daily during routine activities of daily living (ADLs). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated (MONTH) 6, (YEAR), indicated Resident 28 had no memory problems, needed extensive assistance with bed mobility, transfers, and dressing, was totally incontinent of bladder and bowel functions, and had no skin problems. A review of the Braden Scale (a scale to assess the risk of developing a pressure ulcer) dated (MONTH) 7, (MONTH) 6, and (MONTH) 5, (YEAR), indicated a total score of 14 (moderate risk for developing a pressure sore). On (MONTH) 9, (YEAR), a review of the clinical record disclosed no documentation of Resident 28 having a pressure ulcer. On (MONTH) 12, (YEAR) at 2 p.m., during a telephone interview, Resident 28's physician, MD 1, stated Resident 28 had denuded skin (loss of the epidermis (outer layer of skin), caused by exposure to urine, feces, or body fluids). Physician 1 stated Resident 28 was sitting in his wet diaper for too long before being changed. Physician 1 stated the broken skin on the right buttock was reported to her on (MONTH) 11, (YEAR) and she examined the skin. Physician 1 stated the condition of the skin appeared to be older than one day. On (MONTH) 12, (YEAR) at 3 p.m., during an observation with the Director of Nursing (DON), Resident 28 was laying on his back. Resident 28 used the bed side rail to turn himself to the left side so the right buttock was exposed. Resident 28's right buttock Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin) was observed. There was broken skin measuring 2 centimeters (cm) in length by 1.5 cm in width with no depth, with a red base. The surrounding skin measured 10 cm by 4 cm of pink unbroken skin. Resident 28 was wet and was changed by CNA 2. Resident 28 stated he was last changed in the morning. e. A review of the Admission Record indicated Resident 9 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the MDS dated (MONTH) 12, (YEAR), indicated Resident 9 had no memory problem and needed one-person limited assistance with transfer, walking, and dressing. A review the Admission Record indicated Resident 3 was admitted to the facility on (MONTH) 14, (YEAR) and readmitted (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 3's MDS dated (MONTH) 22, (YEAR), indicated Resident 3 had moderately impaired cognition and needed one-person limited assistance with transfer, walking, and dressing. On (MONTH) 8, (YEAR) at 10:45 a.m., during an observation and interviews with Residents 9 and 3, who were roommates, both residents were in their beds. Resident 3 stated she had asked staff to assist her to the wheelchair because she did not want to be in the bed all day but staff did not assist her. Resident 9 stated there was not enough staff during the evening and night shifts and during the weekends. Resident 9 stated sometimes there was staff from an agency but the staff was not oriented and not aware of the residents' needs. Resident 9 stated, at times, the CNAs answer the call lights by turning them off and not providing the care requested. On (MONTH) 9, (YEAR) at 7:05 a.m., during an interview, CNA 2 stated many times during the 11 p.m. to 7 a.m. shift, there are only two CNAs to care for all the residents in the facility. CNA 2 stated on one occasion he was the only CNA working and there were 38 residents needing care. A review of the Nursing Staffing Assignment and Sign-In Sheet indicated during the 11 p.m. to 7 a.m., there was one CNA on (MONTH) 24, (YEAR) and on (MONTH) 1 and 9, (YEAR). There were two CNAs on (MONTH) 5 and 7, (YEAR). On (MONTH) 10, (YEAR) at 6:30 a.m., during an observation of the night shift, there was one LVN and one CNA working for the 11 p.m. to 7 a.m. Resident 12 was heard saying, Hello, hello. No staff attended to Resident 12's call for help. On (MONTH) 10, (YEAR) at 7 a.m., during an interview, CNA 5 stated, on multiple occasions, for the past six months she has worked alone or with another CNA and it was difficult to care for the residents. On (MONTH) 10, (YEAR) at 9:17 a.m., during an interview, the Administrator stated for the 11 p.m. to 7 a.m. shift, one LVN and two CNAs is sufficient staffing because the residents were custodial.

Based on observation, interview, and record review, the facility failed to ensure two of 28 sampled residents (Resident 29 and Resident 13) with limited mobility received appropriate services and equipment to maintain or improve mobility, including: 1. Failure to assist Resident 29 out of bed into a wheelchair to get out of bed and be able to leave the room and socialize as indicated Resident 29's assessment and plan of care. 2. Failure to promptly replaced Resident 29's lost/stolen wheelchair. 3. Failure to provide assistance Resident 29 in expedite the process of obtaining a custom-made wheelchair. 4. Failure to provide Resident 13 who was assessed with [REDACTED]. As a result, Resident 29, who had [DIAGNOSES REDACTED]. On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on (MONTH) 11, (YEAR) at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent decline in mobility and ROM. Findings: a. A review of the Face Sheet (Admission Record) indicated Resident 29 was admitted to the facility on (MONTH) 31, (YEAR) and readmitted on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 29's prior occupation was librarian. A review of the Minimum Data Set (MDS - standardized assessment and care screening tool) dated (MONTH) 9, (YEAR), indicated Resident 29's vision was impaired, was able to see large print but not regular print in newspapers/books. A review of the most recent Quarterly dated (MONTH) 6, (YEAR), indicated Resident 29 was alert and oriented, able to make decisions independently, and able to communicate her needs. During the initial tour of the facility on (MONTH) 8, (YEAR) at 11:31 a.m., Resident 29 stated, I would like to be mobile. Resident 29 stated she had been measured for a wheelchair about the same time as for her eyeglasses sometime in, (MONTH) or so but staff did not tell her when she would receive the wheelchair. Resident 29 indicated she had a wheelchair when she first arrived at the facility and while parked outside her room, it disappeared and since then Resident 29 has not had a wheelchair. Resident 29 stated when she asked the nurses to help her get a wheelchair, it takes a long time, resulting in her getting to activities late. Resident 29 stated she was told (did not specify who) not to come to bingo late so she stopped going. On (MONTH) 10, (YEAR) at 9:33 a.m., during an interview, the Social Services Designee (SSD) stated she was not aware why Resident 29 was not provided with a wheelchair while her customized wheelchair was ordered. The SSD explained a Durable Medical Equipment (DME) company measured Resident 29 for a customized chair and the DME Company had been waiting for physician approval. The SSD stated she was unaware of the outcome. On (MONTH) 10, (YEAR) at 11:10 a.m., during an interview, Resident 29 stated, It really hurt me when they took my wheelchair. It makes me depressed. It makes me low because I cannot go out of my room. When I had my wheelchair, I used to go out with my husband and he will take me around the block. I would go to activities and visit other residents, but I don't do that anymore. A review of the Nursing Notes dated (MONTH) 29, (YEAR), indicated Resident 29 used to attend activities and play bingo. A review of the Activity Care Plan dated (MONTH) 4, (YEAR), identified episodes of loss of interest in socialization and activity participation. The approaches included inviting Resident 29 to join in group activities and outing activities. On (MONTH) 10, (YEAR), at 10:57 a.m., during an interview, the Activity Designee (AD) stated she was not aware that reason for Resident 29's self-isolation could be related to the lack of a wheelchair. The AD stated she visits the resident weekly as part of the care plan. A review of the Social Services assessment dated (MONTH) 13, (YEAR), indicated Resident 29 had no significant behavior issues addressed at this time. On (MONTH) 12, (YEAR), at 10:07 a.m. during an interview, the Administrator stated she was aware Resident 29 had gained a lot of weight and could not fit into the facility's provided wheelchairs. On (MONTH) 12, (YEAR) at 12:30 p.m., during an interview, the DME Company owner stated they were waiting for Resident 29's physician's approval. A review of a Physical Therapy Evaluation form dated (MONTH) 22, (YEAR), indicated Resident 29 was referred for physical therapy due to recent decline in all safe mobility with weakness, fatigue, and risk for further decline. The physical therapist documented Resident 29 required a tilt in space wheelchair (gives the user the ability to adjust the orientation of their wheelchair by allowing for the redistribution of pressure from one area to another by tilting the seating area) for mobility. On (MONTH) 12, (YEAR), at 1:37 p.m., during a telephone interview, Resident 29's attending physician (MD 1) stated she was not informed of a needed approval for a wheelchair and the DME did not send her an approval request. A review of the Activity Attendance Record for (MONTH) (YEAR), indicated Resident 29 attended bingo (MONTH) 2, 9, 13, 22, 25, 27 and 29. The Activity Attendance Record for (MONTH) (YEAR) indicated no participation in group or room activities. The Activity Attendance Record for (MONTH) (YEAR), was blank. Further record review indicated there was no plan of care developed for Resident 29's lack of mobility device since (MONTH) (YEAR). The interdisciplinary team (IDT- group of professional staff from different disciplines) did not address Resident 29's mobility problems and possible negative outcomes. b. According to the admission record, Resident 13 was originally admitted on (MONTH) 1, (YEAR) and was readmitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR), indicated the resident's cognitive patterns were moderately impaired, needed extensive assistance from staff members for bed mobility, dressing, and personal hygiene, needed total dependence from staff members for transfer, locomotion on unit and off unit, toilet use, and bathing. The resident had an impairment on both sides of upper and lower extremities. The resident was always incontinent for bowel and bladder. Under Special Treatments, Procedures, and Programs (Restorative Nursing Programs), Resident 13 had five days of passive range of motion (ROM). The Interdisciplinary Progress Notes dated (MONTH) 28, (YEAR), indicated Resident 13's RP (responsible party) brought up his concern about the resident, apparently resident was not getting enough help from the staff because he came into occasions were resident's nourishment or drinks were just left sitting on the table without even straws. The Social Service Director (SSD) relayed the concern to the charge nurses and DON (Director of Nursing), and was told that resident would normally tell them to leave it there for later. SSD told the RP that he stated the resident did not usually ask for help, so better yet to put the straw in for resident or open the can automatically. SSD told the staff about this. On (MONTH) 12, (YEAR), at 2 p.m., during an observation, Resident 13 was lying in bed alert, awake, oriented to person, place, and time, able to answer questions, and had contractures on both hands. When asked if the facility staff had exercised her, she stated there was no one who had exercised her for more than two months. A review of the Nursing Staffing Assignment And Sign-In Sheet with the Administrator dated (MONTH) 16, (YEAR), indicated Certified Nursing Assistant 11 (CNA 11) was assigned to be the Restorative Nursing Assistant (RNA). He was also assigned to have one resident (room [ROOM NUMBER]A) as a CNA. A review of the Restorative-Charting Record dated (MONTH) (YEAR), indicated there were 24 residents who needed RNA services and was on RNA program. However, the staffing assignment was not signed by the Director of Nursing Designee. A review of the Joint Mobility Assessment (initial assessment) dated (MONTH) 27, (YEAR), indicated RNA for PROM (passive range of motion). On the Quarterly assessment dated (MONTH) 24, (YEAR), indicated continue with RNA as tolerated for PROM. A review of the Restorative-Charting Record dated (MONTH) (YEAR), indicated Resident 13 was not provided RNA services as assessed. On (MONTH) 16, (YEAR), at 4:07 p.m., during an interview with Certified Nursing Assistant 1 (CNA 1), stated that he worked as an RNA (Restorative Nursing Assistant) once in a while. When asked if he provided RNA services to the resident, he stated he did not. When asked if there is a decline of ADL (activities of daily living) of the resident, on what he will do, he stated he will report it to the charge nurse. The facility's policy and procedure titled Restorative ADL Program, restorative program will be conducted once per day, preferably in the morning. The program will be performed by a Restorative Nursing Aide (RNA). A physician's orders [REDACTED]. Residents may be referred for evaluation by any healthcare professional identifying resident need. Potential candidates included residents with physical limitations which included decreased range of motion, recent weight loss secondary to physical limitations or regression in medical status that increases physical limitations. The charge nurse on each resident care unit must have knowledge of the restorative ADL program and support its philosophy and practices. Licensed charge nurses are responsible for knowing what residents are participating in programs.

Based on observation, interview, and record review, the facility failed to ensure its residents receives care consistent with professional standards of practice, to prevent pressure ulcers from developing for one of 28 sampled residents (Resident 28). Resident 28 was not repositioned and kept clean and dry as per plan of care and assessment due to lack of Certified Nursing Assistants (CNAs). This deficient practice resulted in Resident 28 developing a Stage II (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure on the skin). On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F688, and F692 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on (MONTH) 11, (YEAR) at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent development of pressure ulcers. Findings: On (MONTH) 8, (YEAR) at 11:18 a.m., Resident 28 was observed lying on his back in his bed. At the time of the observation, during an interview, Resident 28 stated he had blisters on his bottom that were painful at times. A review of the Admission Record indicated Resident 28 was admitted to the facility on (MONTH) 4, 2006 and readmitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the Care Plan developed for Resident 28's Risk for Pressure Ulcers dated (MONTH) 12, (YEAR), included in the interventions turning and repositioning Resident 28, at least every two hours, when in bed or in wheelchair and inspecting Resident 28's skin daily during routine activities of daily living (ADLs). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated (MONTH) 6, (YEAR), indicated Resident 28 had no memory problems, needed extensive assistance with bed mobility, transfers, and dressing, was totally incontinent of bladder and bowel functions, and had no skin problems. A review of the Braden Scale (a scale to assess the risk of developing a pressure ulcer) dated (MONTH) 7, (MONTH) 6, and (MONTH) 5, (YEAR), indicated a total score of 14 (moderate risk for developing a pressure sore). On (MONTH) 9, (YEAR), a review of the clinical record disclosed no documentation of Resident 28 having a pressure ulcer. On (MONTH) 12, (YEAR) at 2 p.m., during a telephone interview, Resident 28's physician, MD 1, stated Resident 28 had denuded skin (loss of the epidermis (outer layer of skin), caused by exposure to urine, feces, or body fluids). Physician 1 stated Resident 28 was sitting in his wet diaper for too long before being changed. Physician 1 stated the broken skin on the right buttock was reported to her on (MONTH) 11, (YEAR) and she examined the skin. Physician 1 stated the condition of the skin appeared to be older than one day. On (MONTH) 12, (YEAR) at 3 p.m., during an observation with the Director of Nursing (DON), Resident 28 was laying on his back. Resident 28 used the bed side rail to turn himself to the left side so the right buttock was exposed. Resident 28's right buttock Stage II pressure ulcer was observed. There was broken skin measuring 2 centimeters (cm) in length by 1.5 cm in width with no depth, with a red base. The surrounding skin measured 10 cm by 4 cm of pink unbroken skin. Resident 28 was wet and was changed by CNA 2. Resident 28 stated he was last changed in the morning. During an interview with the DON on (MONTH) 12, (YEAR) at 4 p.m., the DON asked the Evaluator for the measurements taken during the pressure sore observation because she did not document the measurements when the pressure sore was identified earlier in the day. On (MONTH) 9, (YEAR) at 7:05 a.m., during an interview, CNA 2 stated many times during the 11 p.m. to 7 a.m. shift, there are only two CNAs to care for all the residents in the facility. CNA 2 stated on one occasion he was the only CNA working and there were 38 residents needing care. A review of the Nursing Staffing Assignment and Sign-In Sheet indicated during the 11 p.m. to 7 a.m., there was one CNA on (MONTH) 24, (YEAR) and on (MONTH) 1 and 9, (YEAR). There were two CNAs on (MONTH) 5 and 7, (YEAR).

Based on observation, interview, and record review, the facility failed to ensure its residents maintain acceptable parameters of nutritional status such as body weight and residents are offered sufficient fluid intake to maintain proper hydration and health for two of 28 sampled residents (Residents 12 and 34), including: 1. Failure to ensure Residents12 and 34, who were assessed as needing assistance with eating, were provided the assistance required during meals. 2. Failure to ensure Resident 34 was offered and assisted with drinking enough fluids. 3. Failure to ensure Resident 12 was provided with dentures needing to improve chewing and eating. 4. Failure to develop and implement a plan of care to instruct staff to assist Resident 34 with eating as indicated Resident 34's comprehensive assessment. 5. Failure to monitor Residents 12 and 34's intake of nourishment to ensure the adequate intake. 6. Failure to develop prompt interventions to address Residents 12 and 34's poor consumption of food. 7. Failure to monitor Resident 34's intake and output to promptly develop interventions to prevent dehydration. 8. Failure to implement the facility's policy on Meals-Feeding the Resident, by not providing assistance with eating, until the resident has had enough food or until the meal is finished and not leaving the resident during meal assistance unless there was an emergency. 9. Failure to implement the facility's policy on Intake and Output (I&O), by not maintaining accurate record of Resident 34's fluid balance, not evaluating weekly the I&O to determine adequacy and if not adequate, notify the physician and implement corrective actions. 10. Failure to implement the facility's policy on Reporting Lab Results, by not promptly report to the physician Resident 34's laboratory test results. 11. Failure to implement the facility's policy on Hydration, by not encouraging adequate fluid intake. As a result, Resident 12 sustained severe weight loss and Resident 34 sustained weight loss, dehydration, and urinary tract infection requiring transfer to a General Acute Care Hospital (GACH) for medical care. On (MONTH) 10, (YEAR) at 5:01 p.m., an immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called under F725 cross refer to F600, F677, F686, and F688 in the presence of the facility Administrator and Director of Nursing. An acceptable plan of action was re-submitted to the survey team on (MONTH) 11, (YEAR) at 11:25 a.m., and validated through observation interview and record reviewed to verify facility compliance. The immediate jeopardy was abated on (MONTH) 12, (YEAR) at 11:50 a.m., when the facility was able to demonstrate knowledge of adequate staffing to ensure necessary care and services are provided to each residents to prevent of weight loss and dehydration. Findings: a. A review of the Admission Record indicated Resident 12 was admitted to the facility on (MONTH) 11, 2014, and readmitted (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated (MONTH) 9, (YEAR), indicated Resident 12 was severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was dependent on staff for activities of daily living (ADLs - transfers, mobility, personal hygiene and eating). Resident 12 needed one-person assistance with eating. On (MONTH) 8, (YEAR) at 11 a.m., during the initial tour of the facility, Resident 12 was observed sleeping in his bed. Next to him was a container of nourishment (nutritional drink) and two other containers of Ensure, a commercial liquid nutritional supplement. The drinks were not cold. On (MONTH) 9, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello, from his room. Resident 12 continued to say, Hello, hello for 10 minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 9, (YEAR) at 1:15 p.m., Resident 12 was heard screaming, Hello, can someone put food in my mouth? Upon arrival to his room, Resident 12 was observed with an unfinished food tray on the table by his bed. There was no staff in Resident 12's room. On (MONTH) 9, (YEAR) at 1:18 p.m., during an interview, Certified Nursing Assistant 13 (CNA 13) stated Resident 12 became upset after a family telephone call, and asked CNA 13 to leave the room, and he did. On (MONTH) 10, (YEAR) at 6:20 a.m., Resident 12 was heard twenty feet away saying, Hello, hello from his room. Resident 12 continued to say, Hello, hello for seven minutes. No staff entered Resident 12's room to assist him during this time. On (MONTH) 10, (YEAR) at 12:08 p.m., four Ensure bottles were observed, sitting at Resident 12's bedside. At the time of the observation, during an interview, Family Member 2 (FM 2) stated staff do not assist Resident 12 with eating throughout the entire meal but for few minutes. FM 2 stated he is supposed to receive Ensure between meals, but he does not because staff do not assist him to drink it. FM 2 stated either her or her brother assisted Resident 12 with dinner since during the evening or at nights the staffing was worst. On (MONTH) 10, (YEAR) at 11:50 a.m., FM 2 was in Resident 12's room saying, Where is my father's dentures? Where did you place the dentures? The Director of Nursing (DON) entered the room attempting to give FM 2 a set of dentures that belonged to another resident. FM 2 stated, These are not my father's dentures. Look, this has another person's name on the container. FM 2 looked for the dentures in Resident 12's room and later found them in Resident 12's dresser drawer. A review of the Weight Record indicated Resident 12 weighed 141 pounds in (MONTH) (YEAR). Another weight, with unspecified date, indicated 126 pounds. The resident had lost a total of 15 pounds in six months or 10.6%, of body weight, a severe weight loss. A review of the Registered Dietician's (RD) quarterly notes dated (MONTH) 9, (YEAR), indicated the resident's weight was 132 pounds. b.1 A review of the Admission Record, Resident 34 was originally admitted to the facility on (MONTH) 24, 2014 and was readmitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nutritional assessment dated (MONTH) 7, (YEAR), indicated Resident 34 was 66 inches tall and weighed 122 pounds. Resident 34 was assessed as requiring 1,870 cubic centimeters (cc) of fluids and 1,824 calories in 24 hours. Resident 34's diet provided 2,500 calories and1,700 cc to 1,800 cc of fluid. The was assessed at risk for excessive weight loss and the food intake was poor. A review of a Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for self-care deficit did not address the need to assist Resident 34 with eating. A review of the physician's orders [REDACTED]. A review of the Care Plan dated (MONTH) 7, (YEAR), developed for Resident 34's risk for altered nutritional status and weight loss included in the approaches serving diet as ordered, giving nutritional supplements and snacks as ordered, encouraging increased fluid intake, dietary evaluation as needed, monitoring meal intake every meal, assessing skin turgor and mucous membrane for any signs and symptoms of dehydration, and laboratory tests as need. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of the MDS assessment dated (MONTH) 14, (YEAR), indicated the resident's cognition was moderately impaired, had poor appetite, and needed total assistance from staff members for bed mobility, eating, and transfers. A review of the Monthly Weights indicated Resident 34's weight decreased from 122 pounds in (MONTH) (YEAR) to 110 pounds in (MONTH) (YEAR) a total of 12 pounds weigh loss in four months. b.2 On (MONTH) 8, (YEAR), at 12:40 p.m., Resident 34 was observed lying in bed, sipping water from a cup that she could barely hold. The lunch tray had a small glass of water, a small glass of milk, a bowl of soup, and a loaf of bread soaked in milk in a bowl. There was no staff assisting her. On (MONTH) 8, (YEAR), at 12:45 p.m., CNA 4 was observed helping Resident 34 with eating. On (MONTH) 9, (YEAR), at 8:14 a.m., during an observation, Resident 34 was in bed with the breakfast tray at her side. There was no staff assisting Resident 34 with eating. Resident 34 communicated through a hand gesture indicating she would like to eat. Resident 34's call light was located at the right side of her pillow, above her shoulder, out of Resident 34's reach. On (MONTH) 9, (YEAR), at 8:49 a.m., during an interview regarding the percentage of food Resident 34 ate, the DON stated 60% and Licensed Vocational Nurse 4 (LVN 4) stated 25 to 30%. On (MONTH) 9, (YEAR), at 8:55 a.m., during an interview, the RD stated Resident 34 ate less than 10%. On (MONTH) 10, (YEAR), at 6:15 p.m., during dinner observation, Resident 34 had a dinner tray barely touched at her side and there was no staff assisting her with eating. CNA 4 entered the room and took the tray away indicating Resident 34 ate less than five percent of her dinner. CNA 4 did not offer Resident 34 assistance with eating or a substitute meal. On (MONTH) 10, (YEAR), at 7:22 p.m., during an interview, FM 1 stated biggest problem in the facility was the lack of staff especially on the weekends. There were numerous times when Resident 34 wanted water, but nobody could give it to her often enough because they were busy. FM 1 stated he used to buy Ensure to Resident 34 but they never gave it to her. FM 1 also stated many nights he stayed at Resident 34's beside to attend to her needs. A review of Resident 34's CNA - ADL Tracking form indicated from (MONTH) 1 to (MONTH) 10, (YEAR), Resident 34's percentage (%) of meal intake ranged from refusal to 60%. There was no documented evidence Resident 34 was offered substitutes. The percentage of nourishment intake was not recorded. A review of the facility's policy and procedure titled, Meals-Feeding the Resident dated (MONTH) 2009, indicated the resident is fed to ensure assistance is provided with eating, if needed. Do not leave the resident unless it is an emergency. Continue feeding until the resident has had enough food or until the meal is finished. Do not serve the meal until you are ready to feed the resident. Tell the resident that you are going to feed him or her a meal. If you are going to be seated during the feeding process, position a chair where it will be convenient for you and the resident. If the resident wishes to eat later, or cannot eat now, check with the charge nurse about serving the resident at a later time. Alternate foods and liquids. Encourage the resident to eat all the meal, but do not force him or her to eat. Place the call light within the resident's reach. Percentage of diet consumed is recorded on the Daily Diet Percentage sheet and the CNA notes. Report any deviation in appetite to the charge nurse and record in the licensed nurse's notes. Update the resident's plan of care as necessary. b.3 A review of the SBAR (Situation, Background, Assessment, and Recommendation) form dated (MONTH) 22, (YEAR), indicated Resident 34 had a decreased urine output. A review of the physician's orders [REDACTED]. A review of the Dehydration Risk assessment dated (MONTH) 14, (YEAR), indicated Resident 34 had a moderate risk for dehydration. Further review of Resident 34's clinical record disclosed no documented record of intake and output for (MONTH) (YEAR). A review of the Intake and Output Record for the month of (MONTH) (YEAR) indicated 12 days were left blank. A review of the physician's orders [REDACTED]. On (MONTH) 9, (YEAR), the physician ordered to monitor Resident 34's intake and output. A review of the physician's orders [REDACTED]. On (MONTH) 10, (YEAR), at 7 p.m., during an interview and record review with LVN 6, the results of laboratory tests ordered on (MONTH) 8, (YEAR), were not found in the clinical record. On (MONTH) 10, (YEAR), at 7:11 p.m., a review of the faxed laboratory blood test results suggested dehydration. On (MONTH) 10, (YEAR), and upon insertion of the IV by the DON, Resident 34 had labored breathing. MD 1 was notified and ordered transfer of Resident 34 to a General Acute Care Hospital (GACH). The Resident Transfer Record dated (MONTH) 10, (YEAR), indicated Resident 34's reason for transfer included weight loss, dehydration, increased BUN (blood urea, nitrogen), and poor appetite. A review of the GACH report from the Emergency Department (ED) dated (MONTH) 11, (YEAR), indicated Resident 34 was diagnosed with [REDACTED]. The plan was to admit the resident to medical service. The facility's policy and procedure titled, Intake and Output dated (MONTH) 2005, indicated the purpose of intake and output (I&O) records is to maintain an accurate record of the resident's fluid balance, suggest various diagnosed and influence the physician's choice of therapies. I&O records are also significant in monitoring residents with GT, drainage collection devices or those receiving IV infusions. The following residents require measurement and documentation of I&O every shift including a 24 hour total and weekly evaluation on the following that included all residents with indwelling catheters for a minimum of the first 30 days, all residents with specific physician's orders [REDACTED]. Nursing assistant will total the amount of fluid consumed with each meal before removing the meal tray. Also, record nourishments and fluids taken between meals and report. The licensed nurse will total I.V. and tube feedings on the I&O form. Measure the urine and record amount on the I&O form. If the resident has a collection bag the nursing assistant will empty bag at end of shift and write total amount on the I&O form. Prior to the shift's end, the I&O totals from the worksheets are reported to the licensed nurse and recorded on the permanent I&O record. I&O worksheet will be replaced after all three shifts have used it for a 24-hour period of time. The shift totals are recorded on the 24-hour I&O record in the resident's chart by the night shift. The I&O is to be evaluated on the weekly evaluation form in the resident's charts to determine adequacy. If not adequate, or if excessive for physical condition of the resident, the physician is to be notified and corrective action needs to be taken. However, this was not implemented. The facility's undated policy and procedure titled, Reporting Lab Results, indicated it is the facility's policy to report laboratory and x-ray results to primary physician. Results from laboratory and/or x-ray exams that are abnormal shall be promptly reported to the physician. Lab and /or x-ray results may be faxed to the physician's office as a form of physician notification. The facility's undated policy and procedure titled Hydration, indicated it is the policy of the facility to maintain a resident's hydration by encouraging adequate fluid intake, in compliance with existing physician's orders [REDACTED]. Each resident shall receive a minimum of 1,000 cc of fluid provided by the Dietary Department on their meal trays, unless such amount is contraindicated to physician's orders [REDACTED]. Fluids shall also be provided to residents during medication administration, unless contraindicated. Additional beverages will be distributed during the day (during activity social programs), unless otherwise indicated by the physician or contrary to resident's preference. Upon initial and ongoing assessment, residents determined to be at high risk for dehydration shall be placed on a 72-hour monitoring of intake and output to obtain baseline data of hydration status and identify any problems of poor hydration status. Based on the results of 72-hour intake and output monitoring residents whose fluid intake is less than 1,200 cc per day will be referred to primary physician and Dietary Department for further interventions. Licensed nurse shall be responsible for monitoring of resident's intake and output. Referral shall be made for RD Consult to ensure appropriate plan of care and nursing interventions will be carried out to address specific resident needs. Physicians will be called for residents noted to have manifestations of dehydration (poor skin turgor, dry mucous membrane, etc.). RD Consultation and follow-up will be obtained to ensure resident needs are met. Nursing, dietary, and activity departments shall coordinate for the development and implementation of facility specific hydration program to ensure residents are assisted in maintaining proper hydration. Example of such included fluid administration/offering by resident's bedside, water pitcher placed at each nursing station, for easy access of fluids, fluid administration/offering during medication administration, and fluid administration/offering incorporated with daily activity social programs (such as coffee or tea socials). Director of Staff Development shall include in his/her scheduled orientation programs, information dissemination on resident's hydration status and facility-specific hydration program to meet needs of residents.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement / modify the plan of care interventions when necessary for one of three sampled residents (Resident 1). Resident 1, who was assessed with [REDACTED]. This deficient practice resulted in the resident sustaining a bruise to the right leg, was transferred to the general acute care hospital (GACH) and treated for [REDACTED]. Findings: On 7/20/17, an unannounced visit was made at the facility to conduct a complaint investigation regarding an accident or incident that occurred involving Resident 1. A review of the admission record indicated Resident 1 was admitted to the facility, on 3/28/17, with [DIAGNOSES REDACTED]. A review of Resident 1's plan of care, dated 3/31/17, indicated the resident was at risk for self-care deficit and required assistance with activities of daily living (ADL's). The plan of care interventions and approach indicated to assist the resident with good personal hygiene, and assist the resident with showers. The mode of transfer such as manual assist, hoyer lift (a mechanical or power lift), or other devices for transfer remained blank; not specifying what would be the most effective mode of transfer for the resident. A review of the Minimum Data Set (MDS - an assessment and care planning tool), dated 4/7/17, indicated Resident 1 had unclear speech, and rarely had the ability to understand others. Resident 1 was assessed as being totally dependent for transferring from bed, chair or wheelchair, and with personal hygiene. The MDS indicated Resident 1 was assessed as being impaired with functional limitation in range of motion to both upper and both lower extremities. According to the SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication), dated 7/11/17, at 11 a.m., indicated the Certified Nurse Assistant 1 (CNA 1) informed the Registered Nurse Supervisor that Resident 1 fell out of the sling while transferring the resident back to bed after receiving a shower. The sling broke and the resident's legs and buttocks slid and fell to the floor. The SBAR form indicated an ice pack was applied to Resident 1's right leg where it was noted to have an injury, and at 11:15 a.m., Resident 1's physician was notified of the incident with orders to continue applying ice pack to the resident's right leg. A review of Resident 1's Licensed Personnel Progress Notes, dated 7/11/17, at 11 a.m., indicated the resident was on the floor in the room with CNAs next to the resident. The resident was alert making eye contact. A large hematoma (collection of blood outside of blood vessels commonly caused by an injury to the wall of a blood vessel), was observed to the resident right lower extremity. The progress notes indicated Resident 1 was transferred back to bed. A review of the physician order, dated 7/11/17, at 2:05 p.m., indicated an order to transfer Resident 1 to the general acute care hospital (GACH) via 9-1-1 emergency. A review of the acute care records computerized axial tomography (CT scan) of the resident's pelvis, dated 7/11/17, indicated Resident 1 had a new comminuted intertrochanteric fracture (hip fracture) involving the right hip. On 7/20/17, at 11:15 a.m., an interview was conducted with CNA 2, who stated he was assisting CNA 1 to transfer Resident 1 from the shower chair to the bed with the hoyer lift, after giving the resident a shower. CNA 2 stated the resident's hoyer lift sling was left on the resident while the resident showered. After showering the resident, both CNA's attached the wet sling and straps to the hoyer lift hooks while lifting the resident. CNA 2 stated the strap snapped on one side causing Resident 1 to fall with both hips and legs hitting the floor. CNA 2 stated they did not check the straps for loose stitching or tears. A review of Resident 1's clinical record conducted with the Administrator and Director of Nurses indicated no documented evidence of an investigation report of the incident or that the Department of Public Health was notified of the incident that led to Resident 1's right hip fracture. A review to the Proactive medical products instructions for the hoyer lift full body sling, indicated a warning indicating to inspect sling (s) for wear, tears, and loose stitching. The medical products instructions bleached, torn, cut, frayed, or broken slings were unsafe and may result in injury. During an interview, on 7/20/17, at 12:30 p.m., the Maintenance Supervisor stated he reviewed the hoyer lift log bi-weekly which indicated no repairs or concerns. The Maintenance Supervisor stated the nurses would verbally inform him if there was a problem. A review of facility's policy and procedure for Accidents and Incidents, undated, indicated it was the policy of the facility to implement and enforce all safety procedures and rules to ensure the safety and well-being of residents. Facility shall implement measures to prevent, monitor and record accidents and incidents whenever possible. Incases where it is unavoidable and accidents or incidents occur, the facility would provide emergency treatment, arrange for transportation to an acute hospital, prepare and file all required reports and records and conduct a thorough investigation of the accident or incident to prevent recurrence. An investigation report shall be submitted to the Administrator and Director of Nurses for further review and action. The Administrator of Director of Nurses shall report to the Department of Public Health and/or other State and local agencies any unusual accident or incident. The policy and procedure further indicated the Director of Nurses, Director of Staff Development, Nurse Supervisors, Charge Nurses and Certified Nurse Assistants shall also be responsible for monitoring resident's immediate environment for any safety or accident hazards such as wet/slippery, or malfunctioning equipment. Bruises and discoloration are among the list of accident or incident occurrences pertaining to the policy.