Every finding on record at Grace Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (CP-a a detailed approach to care customized to an individual resident's needs) was developed and implemented for two of three sampled residents (Resident 1 and Resident 2) when:Resident 1 and Resident 2 did not have care plans for their high blood pressure (when the force of blood flowing through your blood vessels continues to be too high) and Resident 1 did not have a care plan for dysphagia (trouble swallowing) following an ischemic stroke (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it).These failures had the potential for Resident 1 and Resident 2 to have their symptoms of high blood pressure to go unidentified by staff. Resident 1 had the potential to have difficulty swallowing or eating his food and for signs choking to go unidentified by staff.Findings:During a concurrent observation and interview on 8/5/26 at 7:25 a.m. with Resident 1 in the dining room, Resident 1 was sitting in a wheelchair at a table eating a lollipop. Resident 1 stated he was admitted to [facility name] because had a stroke (a medical emergency that happens when blood stops flowing to a part of the brain). Resident 1 stated that he needed help to get better.During a review of Resident 1's admission Record (AR- a document containing resident profile information), dated 8/5/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included high blood pressure and dysphagia following cerebral infarction.During a concurrent observation and interview on 8/5/26 at 8:17 a.m. with Resident 2 in Resident 2's room, Resident 2 was lying in bed watching tv. Resident 2 stated he was sent to [facility name] by the hospital because he needs medical attention. During a review of Resident 2's AR dated 8/5/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included high blood pressure.During a concurrent interview and record review on 8/5/26 at 10:21 a.m. with the Minimum Data Set Nurse (MDSN), Resident 1's Care Plan Record (CPR) dated 8/5/26 and Resident 2's CPR dated 8/5/26 were reviewed. The CPR indicated Resident 1 did not have a care plan for the diagnoses of high blood pressure or dysphagia and Resident 2 did not have a care plan for the diagnosis of high blood pressure. The MDSN stated there were no associated care plans for Resident 1's high blood pressure or dysphagia or Resident 2's high blood pressure. The MDSN stated that every diagnosis should have a care plan. The MDSN stated that care plans help ensure the residents get the care they need. The MDSN stated without a care plan the residents are at risk of a decline in their health not being noticed. The MDSN stated not having care plans for residents' diagnoses does not follow the facilities Care Plan, Comprehensive Person-Centered policy.During a concurrent interview and record review on 8/5/26 at 1:10 p.m. with the Licensed Vocational Nurse/Assistant Director of Nursing (LVN/ADON), Resident 1's CPR dated 8/5/26 and Resident 2's CPR dated 8/5/26 were reviewed. The CPR indicated Resident 1 did not have care plans for diagnoses of high blood pressure and dysphagia following cerebral infarction and Resident 2 did not have a care plan for the diagnosis of high blood pressure. The LVN/ADON stated that every diagnosis should have a care plan. The LVN/ADON stated that care plans are important because without a care plan there is no guidance for the care of the residents. The LVN/ADON stated residents' condition could get worse because staff are not alerted to watch and treat those diagnoses. The LVN/ADON stated not having care plans for diagnoses does not follow facility Care Plan, Comprehensive Person-Centered policy.During an interview on 8/5/26 at 1:41 p.m. with the Administrator (ADM), the ADM stated the facility expectation was that each resident had care plans associated with every diagnosis, medication and behavior admission. The ADM stated missing care plans for Resident 1 and Resident 2 do not follow the facility's Care Plan, Comprehensive Person-Centered policy. The ADM stated care plans are important because they guide nursing staff to care for residents. The ADM stated if Resident 1 and Resident 2's high blood pressure was not monitored it could result in Resident 1 and Resident 2 suffering a stroke or a heart attack. The ADM stated without the guidance from care plans residents could be a risk for health concerns that could require hospitalization or even death.During a review of facility policy and procedure (P&P) titles, Care Plans, Comprehensive Person-Centered, revised date 03/22, the P&P indicated, . The Interdisciplinary team (IDT-group of experts from different fields who work closely together to solve complex problems, such as comprehensive patient care), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will: Include measurable objectives and timeframes; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for an average daily occupancy of 60 residents according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing. This failure had the potential to impact the quality of care and outcomes of residents who require advanced care activities such as assessments, developing and evaluating care plans, consulting with physicians, and administering intravenous fluids or medications.During a concurrent interview and record review on 7/24/26 at 12:58 p.m. with the Director of Nursing (DON), the Staffing Schedule (SS) dated 7/2026 was reviewed. The SS indicated there were no RN's scheduled during the AM shift on 7/1/26, 7/7/26, 7/8/26 and there were no RN scheduled during the PM shifts on Wednesdays, Thursdays, Fridays and Saturdays for the month of July. The DON stated the AM and PM shifts were 12 hour shifts. The DON stated RNs were required to do rounds (structured, regular checks by the RN to evaluate resident safety, manage care plans, and prevent medical issues) each shift. The DON stated RNs had more advanced scope of practice than Licensed Vocational Nurses (LVNs). The DON stated RNs were required to work eight consecutive hours a day, seven days a week for 60 beds or more. The DON stated the facility had a 64 bed capacity and was recently licensed to expand the bed capacity to 101 beds. During a review of the facility's Daily Census (DC), dated 7/24/26, the DC indicated the total number of residents was 62. During a review of the facility's License, dated 6/17/26, the License indicated, License: 040000154. Effective: 6/17/26. Expires: 11/30/26. Licensed Capacity: 101. During an interview on 7/24/26 at 1:34 p.m. with the Administrator (ADM), the ADM stated the RN clinical skills had a higher scope of practice than the LVN and the facility did not have enough RNs to cover at least eight consecutive hours a day, seven days a week. The ADM stated the facility was licensed for a total of 101 beds last month and required more LVNs and RNs to provide sufficient staffing. The ADM stated the facility had posted LVN and RN positions and the facility was opened to staffing RNs from registry agencies (an organization or database that matches temporary healthcare workers with the healthcare provider). During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, dated 3/2026, the P&P indicated, Policy Statement: The facility provides sufficient nursing staff with the appropriate skills and competency necessary to provide nursing and related services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: Sufficient Staff. 1. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity of the residents and based on the facility assessment. During a review of the facility's document titled, RN Charge Nurse job description (RNJD), undated, the RNJD indicated, Job Summary: The charge nurse is to ensure that effective, efficient and comprehensive resident care is provided as prescribed by the physician and as required by this facilities policies to no more than 64 residents and to evaluate the duty performance of the CNA's (Certified Nursing Assistant) under their charge. The charge nurse reports to and is directly responsible to the DON (Director of Nursing) .

Based on interview and record review, the facility failed to designate an individual as the Infection Preventionist (IP) who is responsible for the facility's Infection Prevention Control Program (IPCP - a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment) for 62 residents and staff when the IP resigned in 6/2026. This failure had the potential for the development and transmission of communicable diseases and infections resulting in an unsafe, unsanitary, and uncomfortable environment for residents and staff.Findings: During a review of the facility's Daily Census (DC), dated 7/24/26, the DC indicated the total number of residents were 62. During an interview on 7/24/26 at 11:36 a.m. with the Director of Staff Development (DSD), the DSD stated she was the IP until 6/2026 after the previous DSD resigned in 4/2026. The DSD stated the IP position has been vacant since 6/2026, and no one has filled the position. The DSD stated the IP's duties and responsibilities were to ensure the facility's IPCP was implemented. The DSD stated the primary goal of the IPCP was to prevent the spread of infection. The DSD stated the IP was required to monitor the antibiotic stewardship program (a coordinated health system designed to measure, optimize, and improve how antimicrobial drugs are prescribed and used), provide in-services (training and education) on infection control such as hand hygiene and proper use of PPE (personal protective equipment such as gloves, gowns, and eye shields). The DSD stated the IP was required to monitor signs and symptoms of infected individuals and keep track of vaccinations administered to residents and staff. The DSD stated the only infection control activity she was currently working on was reporting to the NHSN (National Healthcare Safely Network) on tracking Covid, Flu and RSV (Respiratory Syncytial Virus - a very common germ that infects the nose, throat, and lungs with cold-like symptoms). The DSD stated no one was providing oversight of the IPCP. During an interview on 7/24/26 at 12:58 p.m. with the Director of Nursing (DON), the DON state there is no IP to provide oversight of the IPCP at the facility. The DON stated an IP was needed full time to check on residents with G-tube (gastrostomy tube - a flexible tube inserted directly into the stomach through the abdomen to deliver food, liquid, and medication) for infection, observe infection control practice, in charge of the antibiotic stewardship program, and keep a line list of staff and residents' vaccination. The DON stated the purpose of having a full time IP was to prevent the spread of infection. During an interview on 7/24/26 at 1:34 p.m. with the Administrator (ADM), The ADM stated there was not an IP since 6/2026 at the facility. The ADM stated the IP position was currently vacant and an interview for a full time IP was conducted on 7/15/26. The ADM stated an offer was given and he was still waiting for a response. The ADM stated the facility required a full time IP to implement the facility's IPCP. The ADM stated the IP was responsible to ensure staff followed infection protocol, enforce PPE, monitor and track the antibiotic stewardship program, and manage and monitor infection to prevent spread of infection. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Control, dated 10/2018, the P&P indicated, Policy Statement: This Facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: .2. The objective of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility.c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; d. establish guidelines for the availability of supplies and equipment necessary for standard and transmission-based precautions; e. maintain records of incidents and corrective actions related to infections; and f. provide guidelines for safe cleaning and reprocessing of reusable resident-care equipment. During a review of the Infection Control Nurse job description (ICNJD), undated, the ICNJD indicated, Position Description: The Infection Control Nurse will be a licensed nurse with clinical experience and a reasonable working knowledge of the principles of epidemiology and infectious disease. Position Responsibilities: . Clinical: Responsible for assessment and management of nursing care issues as related to residents in the area of infection control including but not limited to: 1. Performs resident assessments for appropriateness of resident's care with regard to infection control and adherence to isolation policies and procedures. 2. Performs clinical rounds for surveillance to verify status of resident, treatment, and necessary follow-up care needs and staff development. 3. Surveillance rounds to examine the environment factors that may impact on infection control issues. 4. Reviews culture reports and follow-up procedures. 5. Performs surveillance rounds to ensure that nursing personnel are performing in accordance with infection control procedures an standards. 6. Investigates outbreaks of infection and assesses presences/absence of cross-contamination, and related data. 7. Evaluates data for indicators of cause of infection. 8. Interacts with nursing and laboratory personnel to coordinate and facilitate services.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice according to the facility's policies and procedures (P&P) titled, Enteral Nutrition, Administering Medications, and Nutrition (Impaired)/Unplanned Weight Clinical Protocol, for two of three sampled residents (Resident 1 and Resident 2) when the facility failed to ensure tube feedings and water flushes were administered as ordered by the physician and Registered Dietitian (RD). Nursing staff did not administer Resident 1's tube feeding and free water flushes according to physician orders. Nursing staff did not administer Resident 2's tube feeding as ordered on 7/10/26 at 2:43 a.m. The tube feeding was not infused as prescribed and nursing staff were unable to demonstrate the ordered volume was delivered. Nursing staff did not ensure documentation accurately reflected administration of enteral nutrition as ordered, including documentation of feeding completion and administration consistent with physician orders. These failures resulted in residents not consistently receiving physician-ordered nutrition and hydration and had the potential to contribute to inadequate nutritional intake, dehydration, weight loss, and deterioration in Resident 1 and Resident 2's health status. Findings: During a review of Resident 1's admission Record, (AR-a document with personal identifiable and medical information), dated 7/7/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), quadriplegia (refers to the partial or total loss of sensory and motor function in both arms, legs, and torso), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joint to shorten and become very stiff), dysphagia (difficulty swallowing), sepsis (is a life threatening reaction to an infection), and gastrostomy (G-tube- a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) assessment, dated 6/29/26, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMs- assessment of cognitive status for memory and judgment assessment) assessment score was NA out of 15 which indicated Resident 1 was unable to complete the assessment. Resident 1 was dependent (helper does all the effort) on daily living and with personal hygiene (habits to maintain cleanliness such as bathing, dressing and toileting.During a review of Resident 1's Order Summary Report (OSR), dated 7/7/26, the OSR indicated, Resident 1 had a gastrostomy tube (a feeding tube inserted directly into the stomach though the abdominal wall). During a concurrent observation and interview on 7/7/26 at 8:35 a.m., in Resident 1's room, Resident 1 was observed lying in bed with continuous tube feeding (TF) [brand name] 1.5 being administered via G-tube, connected to a feeding pump infusing (the continuous introduction of fluids, medication, or nutrients directly into the body) at 50 ml/hr (milliliters per hour-unit of measurement). Resident 1 was nonverbal (unable to speak) and had limited moved to upper and lower extremities (limbs of the body such as the arms and legs) due to contractures. During a concurrent interview and record review on 7/7/26 at 10:00 a.m., with Registered Nurse (RN) 2 and the Assistant Director of Nursing (ADON), Resident 1's Electronic Medical Record (EMR), progress notes, Nutrition/Dietary notes were reviewed. Review of Progress notes indicated Resident 1 was sent to the hospital on 5/22/26, after staff reported Resident 1 was unresponsive. The ADON and RN 2 confirmed a Change in Condition assessment was completed on 5/22/26. Review of the Registered Dietitian (RD) Nutrition/Dietary note dated 5/27/26 indicated Resident 1 experienced severe weight loss over a six-week period and the RD was informed the accuracy of Residents 1's weight was due to the scale used calibration. The ADON stated Resident 1 returned to the facility on 5/28/26. Review of RD Nutrition/Dietary Note dated 6/4/26, indicated Resident 1 experienced an additional seven-pound weight loss within one week of returning to the facility. The RD recommended discontinuing the current enteral feeding order and initiating [brand name enteral supplement] 1.5 at 55 ml/hr for 20 hours (provides 1100 ml volume) daily with continuous free water flush at 30 ml per hour for 20 hours. The ADON stated nursing staff previously entered the RD's recommendations incorrectly, resulting in Resident 1 receiving 20 ml per hour instead of the recommended 50 ml per hour from 5/30-6/4/2026. The ADON was unable to provide an explanation for the incorrect physician order entry. RN 2 confirmed Resident 1 had significant weight loss, multiple wounds, and diabetes mellitus. RN 2 stated inadequate nutritional intake could contribute to delayed wound healing and worsening of the resident's overall condition. During a review of Resident 1's OSR, dated 7/10/26, the OSR indicated, Enteral Feed Orders.[brand name] 1.5 kcal at 55ml/hour x 20 hours (provides 1100 ml volume, 1650 kcal/91 g protein, 834 ml water) ON at 1200 noon. Off at 0800. Order status indicated active start date 6/5/26. During a review of Resident 1's OSR, dated 7/10/26, the OSR indicated, Enteral Feed Orders.two times a day related to Gastrostomy status, Dysphagia, G -tube: FWF at 30 ml/hour x 20 hours on at 1200 noon and off at 0800. Order status indicated active start date 5/29/26. During an observation on 7/10/26 at 7:40 a.m., in Resident 1's room. Resident 1 was again observed lying in bed with continuous tube feeding [brand name] 1.5 being administered via G-tube, infusing at 50 ml/hr. The pump's cumulative volume displayed indicated 8,871 ml of enteral feed formula (specialized liquid food designed for individuals to receive proper nutrition delivered directly into the stomach through the G-tube) had been infused. The bottle enteral formula had a total of 400 ml remaining. During a concurrent observation and interview on 7/10/26 at 9:45 a.m. with LVN 1, in Resident 1's room, LVN 1 was observed handling Resident 1's [brand name] feeding. LVN 1 confirmed feeding bag contained approximately 400 ml of enteral formula labeled 7/9/26 at 12:00 p.m. LVN 1 stated the date and time indicated when the feeding started. LVN 1 stated the enteral feeding pump displayed an infusion rate of 50 ml/hour and a cumulative infused volume of 8,873 ml. LVN 1 stated I might as well throw it out because I have to restart another one at 12:00 p.m. During a concurrent interview and record review on 7/10/26 at 9:55 a.m. with LVN 1, Resident 1's ORS and Medication Administration Record (MAR) dated 5/26-7/26 were reviewed. The ORS indicated [brand name] 1.5 was supposed to infuse at 55 ml/hr for 20 hours (provides 1100 ml volume .) LVN 1 acknowledged the infusion rate on Resident 1's pump was set at 50 ml/hour and not the appropriate 55 ml/hr. LVN 1 stated he administered medication through the G-tube and flushed the tube with approximately 10 to 15 ml of water between medications. LVN 1 stated the orders indicated .flush with 5 ml water in between medications. LVN 1 stated he flushes before and after feeding and meals 30 ml of water. Resident 1's OSR and MAR dated 7/10/26 was reviewed, the OSR indicated FWF 30 ml/hr x 20hours. and MAR indicated completed. LVN 1 stated I don't know what FWF stands for I would have to ask, I just check the box saying I did it. LVN 1 stated nursing staff relied on the cumulative volume displayed on the feeding pump to determine how much formula had been infused. LVN 1 stated the cumulative volume was not reset. LVN 1 stated Resident 1 did not receive the entire bottle of [brand name] formula feeding and LVN 1 could not determine how much enteral nutrition Resident 1 had received during the ordered feeding cycle. LVN 1 acknowledged using 10 to 15 ml of water between medications was not following the physician's orders. LVN 1 confirmed Resident 1 should have been receiving 55 ml/hr of [brand name] feeding formula since 6/5/26 and was not. During a review of Resident 2's AR, dated 7/10/26, the AR indicated, Resident 2 was admitted on [DATE] with a diagnosis of Anoxic Brain damage (happens when the brain is completely deprived of oxygen, causing brain cells to die), gastrostomy (G-tube- a feeding tube inserted directly into the stomach through the abdominal wall), and persistent vegetative state (severe disturbance of consciousness where the person maintains a sleep-wake cycle but has no conscious awareness of self or the environment). During a review of Resident 2's MDS assessment, dated 6/8/26, the MDS assessment indicated, Resident 2's BIMS assessment score was NA out of 15 which indicated Resident 2 was unable to complete the assessment. Resident 2 was dependent on staff for all activities of daily living and with personal hygiene. During a review of Resident 2's OSR dated 7/10/26, the OSR indicated, Eternal Feed Orders.[brand name] 1.5 kcl at 40ml/hour x20 hours, providing 800 ml/1200 kcal start at 1200 noon until total amount of feeding completed), order status indicated active, start date 4/3/26. During a review of Resident 2's OSR, dated 7/10/26, the OSR indicated, Enteral Feed Order.FWF Free water fluid at 60 ml/hour x 20 hours, proving 1200 ml/day (on at 1200 noon until total amount of FWF completed, order status indicated active, start date 4/3/26. During a concurrent observation and interview on 7/10/26 at 8:25 a.m., with Registered Nurse (RN) 1 in Resident 2's room, Resident 2 was observed lying in bed receiving enteral feeding [brand name] via G-tube connected to an enteral feeding pump. The feeding pump displayed [brand name] 1.5 infusing at 40 ml/hr with a cumulative infused volume of 5,135 ml. A free water flush bag was connected to the pump and displayed 60 ml per hour with a cumulative infusion volume of 7,740 ml. The feeding [brand name] was labeled 7/10/24 at 2:45 a.m. The bottle of formula [brand name] had a remaining volume of 1,000 ml. RN 1 stated it was time to discontinue the G-tube feeding because at 8:00 a.m. all the residents who have G-tube feeding stop at 8 am. The RN stated it was the practice of the facility to infuse for 20 hours and rest for 4 hours. During a concurrent observation and interview on 7/10/26 at 9:00 am in Resident 2's room, with RN 1, RN 1 was observed stopping the infusion of the pump. RN 1 stated it is the facilities practices to flush the G-tube with 30 ml of water after G-tube feeding was completed. The RN identified the G-tube was clogged. RN 1 attempted to restore patency by flushing the tube with 30 ml of water: however, the water did not infuse after approximately 10 minutes. RN 1 discounted the 30 ml of water and made a second attempt and repeated the process. RN 1's attempts to unclog the G-tube lasted approximately 20 minutes. RN 1 discontinued attempts to unclog the G-tube and contacted Resident 2's hospice provider for further guidance. RN 1 stated it is facility practice to inform the DON if the G-tub is clogged and after orders are obtained to send the resident out to the hospital and have it replaced. RN 1 stated hospice staff instructed RN 1 to administer carbonated soda into the G-tube to restore patency. During a concurrent interview and record review on 7/10/26 at 11:38 a.m. with RN 1, Resident 2's Physician orders, ORS, and MAR were reviewed. The physician orders indicated [name brand] 1.5 was to be infused at 40 ml/hour for 20 hours providing 800 ml daily (on at 12 noon until total amount of feeding completed). Residence 2's MAR, dated 7/2026 indicated enteral nutrition [name brand] 1.5 was infused indicating Resident 2 received 800ml. RN 1 acknowledged the total volume displayed on the pump was not routinely reset and was discontinued at 9:00 a.m. and RN 1 could not determine whether Resident 2 had received the physician ordered amount of enteral nutrition. RN 1 further acknowledged Resident 2's MAR documented the enteral nutrition [brand name] as administered, however she could not verify the documentation was accurate because the accumulative volume displayed on the internal feeding pump had not been cleared. RN 1 stated Resident 2 remained at risk for malnutrition, dehydration, and further health decline if physician-orders were not consistently administered. During an interview on 7/10/26 at 11:55 a.m. with the Director of Nursing (DON), DON stated nursing staff relied on the cumulative volume displayed on the enteral nutrition administered. The DON stated nursing staff were expected to clear the cumulative volume displayed on the enteral feeding pump following completion of each feeding cycle; however, DON stated nursing staff were not routinely doing so. The DON acknowledged that when the cumulative volume was not cleared, nursing staff could not accurately determine whether residents received the physician-ordered amount of enteral feeding. The DON stated nursing staff documented administration of enteral feedings on the MAR and did not routinely document intake and output unless specifically ordered by the physician. When asked how nursing staff verified residents received the proper amount of enteral nutrition when intake and output was not documented and the cumulative volume displayed on the enteral feeding pump was not reset, the DON stated staff relied on the MAR documentation. The DON acknowledged that if nursing staff did not follow the physician's orders, the MAR documentation would not accurately reflect the enteral feeding administered. The DON initially stated she did not know the abbreviation FWF referred to free water flushes. After reviewing the physician's orders, the DON acknowledged FWF referred to free water flushes and stated nursing staff should understand physician orders before documenting administration. The DON stated documenting administration of physician orders that nursing staff did not understand would constitute false documentation. The DON stated adequate enteral nutrition and proper flushing of the G-tube were important to prevent tube clogging, maintain adequate nutrition status, and promote wound healing. During a telephone interview on 7/10/26 at 5:00 p.m., with the Registered Dietitian (RD), the RD stated she started working with the facility in April 2026. The RD stated the previous RD was only available through telehealth (the use of digital information and communication technologies such as computers, smartphones, and video conferencing to access healthcare services remotely). The RD stated she goes physically into the facility to talk with the residents and look at the residents, as that was an important part of gathering information about the residents' nutritional needs. RD stated she communicates nutritional recommendations through Nutrition/Dietary Notes, verbal communication with nursing staff, and physician order recommendations. The RD stated nursing staff are responsible for implementing physician and dietitian recommendations and accurately documenting administration of the enteral nutrition. The RD stated she verifies implementation of her recommendations by reviewing the MAR and relies on the accuracy of the MAR and trusts nursing documentation when determining whether her nutritional recommendations have been implemented. The RD stated she identified significant weight loss for Resident one and recommended increasing the eternal feeding. After being informed that Resident one feeding pump was infused at 50ml/hr instead of the physicians order rate of 55 ml/hr and the cumulative volume displayed on the pump was not routinely reset the RD stated Resident one had not been receiving the prescribed amount of eternal nutrition.The RD stated proper maintenance of G-tubes, including administration of ordered free water flushes and flushing before and after medications, is essential to prevent tube occlusion. After being informed Resident 2's G-tube became clogged during observation and the ordered enteral feeding and free water flushes could not be administered, the RD stated it was reasonable to conclude Resident 2 did not receive the physician-ordered amount of enteral nutrition and hydration. The RD stated it is nursing's responsibility to ensure residents receive prescribed enteral nutrition and hydration. The RD stated inaccurate nursing documentation could result in inappropriate nutritional recommendations because she depends on accurate documented intake when evaluating residents. The RD stated increasing enteral nutrition based on inaccurate documentation could result in feeding intolerance, vomiting, or other adverse outcomes. The RD further stated failure to receive prescribed enteral nutrition may contribute to malnutrition, dehydration, delayed wound healing, continued weight loss, further decline in resident condition and possible death. During a review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, dated 9/2017, the P&P indicated, Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Cause Identification: .2. For individuals with recent or rapid weight gain or loss [for example, more than a pound a day], the staff will review for possible fluid and electrolyte imbalance as a cause. Treatment/Management: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Monitoring: 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting. During a review of the facility's P&P titled, Administering Medications, dated 12/2012, the P&P indicated, Policy Statement: Medications shall be administered in a safe and timely manner as prescribed.administered in accordance with the orders, including any required time frame.The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving.given at a time other than scheduled time, the individual administering the medication shall initial the MAR space provided for that drug and dose. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation: .2. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment and is consistent with current standards of practice. 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian.11. The Nurses confirm that orders for enteral nutrition are complete. Complete orders include: a. The enteral nutrition product.d. administration method (continuous, bolus, intermittent); e. Volume and rate of administration; f. The volume and rate goals and recommendations.g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume). During a professional reference review from Journal of Parental and Enteral Nutrition, titled, ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, volume 41, number 1, dated 1/15/17, the professional reference review indicated, Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors.Section 1. Assessment and Recommendations: .b. Physical exam includes GI function assessment and existing access devices as well as nutrition focused physical findings. Physical exam. Along with weight status, nutrition-focused physical exam findings should include assessment of skin integrity, fluid accumulation or deficit, muscle and fat loss, and functional status. Handgrip strength is a predictive indicator of postoperative complications, hospital length of stay and read mission, and physical status. Physical therapists may offer a valuable assessment of physical function. Muscle function correlates well and reacts quickly to changes in nutrition status. In pediatric patients, developmental status and risk of aspiration with oral intake should be evaluated. d. Administration method and rate. i. Document the method of administration (continuous, bolus, intermittent feedings). ii. Clearly define the volume and/or rate of EN administration for each method of administration. Section 6. The administration of EN therapy is a step in the process with significant potential for error. Errors can stem from incomplete evaluation of a patient's tolerance for enteral feeding that increases the risk for aspiration or GI complications. Enteral misconnections, poor positioning, pump misadventures, and contamination can all lead to less than optimal patient outcomes . During a professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC4951873/pdf/616.pdf, titled, Enteral tube feeding, dated 12/10/2010, the professional reference review indicated, .Indications for enteral feeding. Impaired swallowing, Altered level of consciousness making oral feeding impossible, Dysphagia. Delivery of enteral feed: Feed can be administered as a bolus or continuously. Continuous feeding is usually over 16-18 hours, while bolus feed are typically 100-500 ml of feed over 15-60 minutes at 3-6 hours interval. Other complications associated with enteral feeding: In addition to complications associated with the tubes and their insertion, enteral feeding can also cause GI (Gastrointestinal - stomach and intestines) problems such as diarrhea, nausea and vomiting, reflux, and metabolic abnormalities such as refeeding syndrome and various electrolyte disturbances.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of three sampled residents (Resident 1) when Resident 1 required enteral feeding (EF- a method of supplying nutrition directly into the stomach or intestines through a flexible tube) diet and the facility failed to administer physician-ordered enteral nutrition (often called tube feeding essential liquid nutrition) and free water flushes (a specific volume of water administered to a person receiving tube feeding (enteral nutrition) through( gastrostomy tube) G-tube) in accordance with physician orders, facility policies and procedures, and professional standards of practice. This failure resulted in Resident 1 not consistently receiving physician-ordered enteral nutrition and hydration and had the potential to contribute to malnutrition, dehydration, delayed wound healing, continued weight loss, and further decline in Resident 1's overall health status.Findings: During a concurrent observation and interview on 7/7/26 at 8:35 a.m., in Resident 1's room, Resident 1 was observed lying in bed with continuous tube feeding (TF) [brand name] 1.5 being administered via G-tube, connected to a feeding pump infusing (the continues introduction of fluids, medication, or nutrients directly into the body) at 50 ml/hr. (milliliters per hour-unit of measurement). Resident 1 was nonverbal (unable to speak) and limited moved to upper and lower extremities (limbs of the body such as the arms and legs) due to contractures. During a review of Resident 1's admission Record, (AR-a document with personal identifiable and medical information), dated 7/7/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), quadriplegia (refers to the partial or total loss of sensory and motor function in both arms, legs, and torso), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joint to shorten and become very stiff), dysphagia (difficulty swallowing), sepsis (is a life threatening reaction to an infection), and gastrostomy (G-tube- a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) assessment, dated 6/29/26, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMs- assessment of cognitive status for memory and judgment assessment) assessment score indicated NA (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 1 was unable to complete the assessment. During a review of Resident 1's MDS, dated 5/22/26, Section GG (Functional Abilities) indicated Resident 1 was dependent (helper does all of the effort and the resident does none of the effort) for activities of daily living. The MDS further indicated some activities were not attempted due to Resident 1's medical conditions. During a review of Resident 1's MDS, dated 5/22/26, Section K (Swallowing/Nutritional Status) indicated Resident 1 weighted 141pounds and experienced significant weight loss, indicating a weight loss of 5% or more in the last month or 10% or more in the last six months. The MDS further indicated Resident 1 received nutrition through a feeding tube. During a review of Resident 1's Weight Summary, dated 7/7/26 the weight summary indicated: .3/6/26 168.0 lbs. (pounds measurement of weight) .4/6/26 168.0 lbs.5/20/26 136.6 lbs.5/28/26 141.5 lbs.6/3/26 133.8 lbs. 6/9/26 135.2 lbs.6/16/26 133.4 lbs.6/23/26 137.2 lbs.6/29/26 135.6 lbs.7/6/26 136.4 lbs.7/7/26 135.6 lbs. Weight Summary indicated 4/6/26 to 5/20/26 Resident 1 had a 31.4-pound weight loss which is 18% severe weight loss in a six-week period. From 5/28/26 to 6/3/26 Resident 1 had a 7.7-pound weight loss which is 5.4% severe weight loss in a one-week period. During a review of Resident 1's Order Summary Report (OSR), dated 4/2/26 to 4/16/26 Resident 1's OSR indicated, one time a day. G-tube order [brand name] 1.2 kcal at 50 ml/hour x 20 hours, providing 1000 ml/1200 kcal (ON at 1200 noon until total amount of feeding completed). During a review of Resident 1's OSR dated, 4/16/26 to 5/29/26 the OSR indicated: one time a day. G-tube order [brand name] 1.5 kcal at 40 ml/hour x 20 hours (provides 1200 kcal/66 g protein, 607 ml water) .ON at 1200 noon until total amount of feeding completed. During a review of Resident 1's OSR dated 5/30/26 to 6/4/26, the OSR indicated, two times a day. G-Tube: [brand] 1.5 kcal at 20 ml/hour x 20 hours (provides 1000 ml volume, 1500 kcal/82 g protein). ON at 1200 noon. Off at 0800 During a review of Resident 1's OSR dated 6/4/26 to 6/4/26, the OSR indicated, two times a day. G-Tube: [brand name] 1.5 kcal at 50ml/hour x 20 hours (provides 1000 ml volume, 1500 kcal/82 g protein). ON at 1200 noon. Off at 0800 During a review of Resident 1's OSR dated 6/4/26, the OSR indicated, two times a day.) G-Tube:[brand name] 1.5 kcal at 55ml/hour x 20 hours (provides 1100 ml volume, 1650 kcal/91 g protein, 834 ml water) ON at 1200 noon. Off at 0800. During a concurrent interview and Record review on 7/7/26 at 10:00 a.m. with Licensed Vocational Nurse (LVN) 3 and the Assistant Director of Nursing (ADON), Resident 1's Electronic Medical Record, dated 7/7/26 was reviewed. The ADON stated LVN 3 was new to the facility, and she would help review the records. LVN 3 confirmed Resident 3 had a significant wight loss from 4/6/26 to 5/20/26 indicating Resident 1 had lost 30 lbs. in a six-week period. LVN 3 stated the was no Change in Condition (CIC) documentation. The ADON stated it was determined the discrepancy was the fault of the scale that was used indicating the scale needed to be calibrated and has since been corrected. LVN 3 stated there was IDT note dated 5/22/26 indicating Resident 1 was sent to the hospital Resident 1 was unresponsive. LVN 3 confirmed Resident 1 weighted 136.6 lbs. leaving the facility. LVN 3 stated on 5/28/26 Resident 1 returned from the hospital back to the facility and weighted 141.5 lbs. indicating a weight gain. Resident 1's Hospital Discharge Summary only indicated Resident 1's medication and not the summary of the five-day hospital admission. The ADON stated that was the only documentation the facility was able to provide. ADON was unable to explain the reason for Resident 1's hospital transfer. LVN3 started on 6/3/26 Resident 1 weighed 133.8 lbs. and confirmed that was a weight loss of 8 lbs. in one week. Nutrition Dietary Note (NDN) dated 6/4/26 indicated the Registered Dietitian (RD) indicated on 5/29/26 she had made a recommendation on 5/29/26 to increase Resident 1's G-Tube feeding but per the ADON nursing inadvertently entered the order incorrectly. During the interview the ADON stated that nurse no longer works here. The ADON stated the order had been corrected since and the current order was correct. LVN 3 stated Resident 1 had wounds to his bilateral heels and developed a new unstageable pressure wound to the right elbow. LVN 3 stated proper nutrition was an important part of wound healing process. During a review of Resident 1's Nutritional Assessment, dated 5/29/26, the document indicated, .current TF (tube feeding) plus liquid protein plus water flush orders provide 22 kcal/kg.see recommendations.nutritional needs based on current weight of 141.5 pounds calories 1463-1756 kcal fluid: 1605-1925 ml fluid.Nutritional risk related to resident is at risk for weight loss, malnutrition, dehydration r/t diagnosis quadriplegia, DM, intracranial injury, dysphagia.Nutritional Interventions indicated.1.5 at 50 ml/hr x20 hrs/day (provides 1000ml volume 1500 kcal/82 g protein). Free water flush at 30 ml/hr x 20 hr/day Nursing to specify start/stop time in orders. During a review of Resident 1's IDT Note, dated 6/4/26, the IDT note indicated, .discussed residents weight loss.recommendations to start [brand name] 1.5 @ 55 ml/hr x 20 hrs/day (provides 1100 ml volume,.) free water flush of 30 ml/hr x 20hrs.blood sugar readings reviewed no new orders received to change or adjust diabetic medications at this time.). During a separate observation on 7/10/26 at 7:40 a.m., in Resident 1's room. Resident 1 was observed lying in bed with continuous tube feeding [brand name] 1.5 being administered via G-tube, infusing at 50 ml/hr., The pump's cumulative volume displayed indicated 8,871 ml of enteral feed formula (specialized liquid food designed for individuals to receive proper nutrition delivered directly into the stomach through the G-tube) had been infused. The bottle enteral formula had a total of 400 ml remaining. During a concurrent observation and interview on 7/10/26 at 9:45 a.m. with LVN 1, in Resident 1's room, LVN 1 was observed handling Resident 1's [brand name] feeding. LVN 1 confirmed feeding bag contained approximately 400 ml of enteral formula labeled 7/9/26 at 12:00 p.m. LVN 1 stated the date and time indicated when the feeding started. LVN 1 stated the enteral feeding pump displayed an infusion rate of 50 ml/hour and a cumulative infused volume of 8,873 ml. LVN 1 stated I might as well throw it out because I have to restart another one at 12:00 p.m. During a concurrent interview and record review on 7/10/26 at 9:55 a.m. with LVN 1, Resident 1's ORS and Medication Administration Record (MAR) dated 5/26-7/26 were reviewed. The ORS indicated [brand name] 1.5 was to infuse at 55 ml/hr for 20 hours (provides 1100 ml volume .) LVN 1 acknowledged the infusion rate on Resident 1's pump remained set at 50 ml/hour. LVN 1 indicated Resident 1 did not receive the intended nutritional amount. LVN 1 acknowledged Physician order was not carried out as prescribed. LVN 1 stated he administered medication through the G-tube and flushed (essential maintenance routine to keep the tube clear and prevents clogging in the tube by pushing water through the tube using a syringe) the tube with approximately 10 to 15 ml of water between medications. LVN 1 stated the orders indicated .flush with 5 ml water in between medications. LVN 1 stated he flushes before and after feeding and meals 30 ml of water. Resident 1's OSR and MAR dated 7/10/26 was reviewed, the OSR indicated 'FWF' 30 ml/hr x 20hours. and MAR indicated completed. LVN 1 stated I don't know what 'FWF' stands for I would have to ask, I just check the box saying I did it. LVN 1 stated nursing staff relied on the cumulative volume of displayed on the feeding pump to determine how much formula had been infused. LVN 1 stated the cumulative volume was not reset, and Resident 1 did not receive the entire bottle of [brand name] formula feeding it could not be determined how much enteral nutrition Resident 1 had received during the ordered feed cycle. LVN 1 acknowledged using 10 to 15 ml of water between medications was not following the physician's orders. LVN 1 confirmed Resident 1 should have been receiving 55ml of [brand name] feeding formula since 6/5/26. LVN 1 further indicated proper nutrition for Resident 1 was important for wound healing, and not receiving the adequate amount of nutrition could deal healing, weight loss, and lead to other complications. LVN 1 confirmed Resident 1 had a history of his G-tube getting clogged, and stated water flushes are important for hydration and helped provide proper maintenance keeping the tube from getting clogged due to the nutritional formula and medication administration. During an interview on 7/10/26 at 11:55 a.m. with the Director of Nursing (DON), DON stated nursing staff relied on the cumulative volume displayed on the enteral nutrition administered. The DON stated nursing staff were expected to clear the cumulative volume displayed on the enteral feeding pump following completion of each feeding cycle; however, nursing staff were not routinely doing so. The DON acknowledged that when the cumulative volume was not cleared, nursing staff could not accurately determine whether residents received the physician-ordered amount of enteral feeding. The DON stated nursing staff documented administration of enteral feedings on the MAR and did not routinely document intake and output unless specifically ordered by the physician. When asked how nursing staff verified residents received the proper amount of enteral nutrition when intake and output was not documented and the cumulative volume displayed on the enteral feeding pump was not reset, the DON stated staff relied on the MAR documentation. The DON acknowledged that if nursing staff did not follow the physician's orders, the MAR documentation would not accurately reflect the enteral feeding administered. The DON initially stated she did not know the abbreviation FWF referred to free water flushes. After reviewing the physician's orders, the DON acknowledged FWF referred to free water flushes and stated nursing staff should understand physician orders before documenting administration. The DON stated documenting administration of physician orders that nursing staff did not understand would constitute false documentation. The DON stated adequate enteral nutrition and proper flushing of the G-tube were important to prevent tube clogging, maintain adequate nutrition status, and promote wound healing. During a telephone interview on 7/10/26 at 5:00 p.m., with the Registered Dietitian (RD), the RD stated she started working with the facility in April 2026. The RD stated the previous RD was only available through telehealth (the use of digital information and communication technologies such as computers, smartphones, and video conferencing to access healthcare services remotely). The RD stated she goes physically into the facility to talk with the residents and look at the residents, as that was an important part of gathering information about the resident's nutritional needs. RD stated she communicates nutritional recommendations through Nutrition/Dietary Notes, verbal communication with nursing staff, and physician order recommendations. The RD stated nursing staff are responsible for implementing physician and dietitian recommendations and accurately documenting administration of the enteral nutrition. The RD stated she verifies implementation of her recommendations by reviewing the MAR and relies on the accuracy the MAR and trusts nursing documentation when determining whether her nutritional recommendations have been implemented. The RD stated she identified significant weight loss for Resident 1 and recommended increasing Resident 1' enteral feeding pump was observed infusing at 50 ml/hr despite physician orders for 55 ml/hr and the cumulative volume displayed on the enteral feeding pump was not routinely reset, the RD stated Resident 1 had not been receiving the prescribed amount of enteral nutrition. The RD stated proper maintenance of G-tubes, including administration of ordered free water flushes and flushing before and after medications, is essential to prevent tube occlusion. After being informed Resident 2's G-tube became clogged during observation and the ordered enteral feeding and free water flushes could not be administered, the RD stated it was reasonable to conclude Resident 2 did not receive the physician-ordered amount of enteral nutrition and hydration. The RD stated it is nursing's responsibility to ensure residents receive prescribed enteral nutrition and hydration. The RD stated inaccurate nursing documentation could result in inappropriate nutritional recommendations because she depends on documented intake when evaluating residents. The RD stated increasing enteral nutrition based on inaccurate documentation could result in feeding intolerance, vomiting, or other adverse outcomes. The RD further stated failure to receive prescribed enteral nutrition may contribute to malnutrition, dehydration, delayed wound healing, continued weight loss, further decline in resident condition and possible death. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 3/2022, the P&P indicated, Policy Statement: Resident weights are monitored for undesirable and unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 3. Any weight change of 5 % or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 5. The threshold for significant unplanned and undesired wight loss will be based on the following criteria [where percentage of body weight loss = (usual wight - actual weight)/(usual weight) x 100]: a. 1 month - 5 % weight loss is significant; greater than 5 % weight loss is significant; greater than 5 % is severe. b. 3 months - 7.5 % weight loss is significant; greater than 7.5 % is severe. c. 6 months - 10 % weight loss is significant; greater than 10 % is severe. Evaluation: . The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, wight loss or increasing the weight loss. Interventions: .2. Interventions for undesired weight gain consider resident preferences and right. A weight loss regimen will not be initiated for a cognitively capable resident without his/her approval and involvement. During a review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, dated 9/2017, the P&P indicated, Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Cause Identification: .2. For individuals with recent or rapid weight gain or loss [for example, more than a pound a day], the staff will review for possible fluid and electrolyte imbalance as a cause. Treatment/Management: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Monitoring: 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting. During a review of the facility's P&P titled, Administering Medications, dated 12/2012, the P&P indicated, Policy Statement: Medications shall be administered in a safe and timely manner as prescribed.administered in accordance with the orders, including any required time frame.The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving.given at a time other than scheduled time, the individual administering the medication shall initial the MAR space provided for that drug and dose. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation: .2. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment and is consistent with current standards of practice. 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian.11. The Nurses confirm that orders for enteral nutrition are complete. Complete orders include: a. The enteral nutrition product.d. administration method (continuous, bolus, intermittent); e. Volume and rate of administration; f. The volume and rate goals and recommendations.g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume). During a professional reference review from Journal of Parental and Enteral Nutrition, titled, ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, volume 41, number 1, dated 1/15/17, the professional reference review indicated, Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors.Section 1. Assessment and Recommendations: .b. Physical exam includes GI function assessment and existing access devices as well as nutrition focused physical findings. Physical exam. Along with weight status, nutrition-focused physical exam findings should include assessment of skin integrity, fluid accumulation or deficit, muscle and fat loss, and functional status. Handgrip strength is a predictive indicator of postoperative complications, hospital length of stay and read mission, and physical status. Physical therapists may offer a valuable assessment of physical function. Muscle function correlates well and reacts quickly to changes in nutrition status. In pediatric patients, developmental status and risk of aspiration with oral intake should be evaluated. d. Administration method and rate. i. Document the method of administration (continuous, bolus, intermittent feedings). ii. Clearly define the volume and/or rate of EN administration for each method of administration. Section 6. The administration of EN therapy is a step in the process with significant potential for error. Errors can stem from incomplete evaluation of a patient's tolerance for enteral feeding that increases the risk for aspiration or GI complications. Enteral misconnections, poor positioning, pump misadventures, and contamination can all lead to less-than-optimal patientDuring a professional reference review from American Academy of Family Physician Journal volume 65, number 4, dated 2/15/02, indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death. Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year .

Based on observation, interview and record review, the facility failed to implement infection prevention and control practices for two of three sampled residents (Resident 1 and Resident 2) requiring Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of infection). Nursing staff failed to utilize required personal protective equipment (PPE) while providing feeding tube care and skin assessment, in accordance with the facility EBPs policy. The facility's failure to implement proper infection prevention and control practices created a potential risk for the spread of infectious germs and bacteria. Consequently, the residents were exposed to an increased likelihood of the spread of harmful infections, which could be transferred from one resident's environment to another. This elevated risk could contribute to the decline of their overall health and safety. Findings: During a review of Resident 1's admission Record, (AR-a document with personal identifiable and medical information), dated 7/7/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), quadriplegia (refers to the partial or total loss of sensory and motor function in both arms, legs, and torso), sepsis (is a life threatening reaction to an infection), and gastrostomy (G-tube- a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) assessment, dated 6/29/26, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMs- assessment of cognitive status for memory and judgment assessment) assessment score was NA out of 15 which indicated Resident 1 was unable to complete the assessment. Resident 1 was dependent (helper does all the effort) on daily living and with personal hygiene (habits to maintain cleanliness such as bathing, dressing and toileting). During a review of Resident 1's Order Summary Report, dated 7/7/26, the Order Summary Report indicated, Resident 1 had a gastrostomy tube (a feeding tube inserted directly into the stomach though the abdominal wall). During a review of Resident 2's AR, dated 7/10/26, the AR indicated, Resident 2 was admitted on [DATE] with a diagnosis of Anoxic Brain damage (happens when the brain is completely deprived of oxygen, causing brain cells to die), gastrostomy (G-tube- a feeding tube inserted directly into the stomach through the abdominal wall), and persistent vegetative state (severe disturbance of consciousness where the person maintains a sleep-wake cycle but has no conscious awareness of self or the environment). During a review of Resident 2's MDS assessment, dated 6/8/26, the MDS assessment indicated, Resident 2's BIMS assessment score was NA out of 15 which indicated Resident 2 was unable to complete the assessment. Resident 2 was dependent on daily living and with personal hygiene. During a review of Resident 2's Order Summary Report, dated 7/10/26, the Order Summary Report indicated, Resident 2 had a gastrostomy tube. During an observation on 7/10/26 at 8:35 a.m., in Resident 1's room, the doorway was observed with a sign that stated EBP and PPE, as well as a smile face sticker displayed on the residence nameplate outside the room identifying Resident 1 as requiring EBP. Licensed vocational nurse (LVN) 1 entered Resident 1's room without first wearing the proper PPE and actively touched and handled Resident 1's G tube gauze dressing and wound dressing while performing an assessment. LVN 1 was observed to only be wearing gloves without the required gown.During an observation on 7/10/26 at 9:00 a.m., in Resident 2's room, the doorway was observed with a sign that stated EBP and PPE, as well as a smile face sticker displayed on Resident 2's nameplate outside the room identifying Resident 2 as requiring PPE. Registered Nurse (RN) 1 was observed to provide direct care by assessing the skin and providing feeding tube care by flushing (essential maintenance routine to keep the tube clear and prevents clogging in the tube by pushing water through the tube using a syringe) Resident 2's G tube without wearing the required PPE. During an interview on 7/10/26 at 11:50 a.m. with the Director of Nursing (DON), the DON stated residents with wounds and or G-tubes require EBP. The DON stated EBP included EBP signage and PPE at the entrance of the door. The DON stated gowns and gloves are required when staff provided direct care to an EBP resident. The DON stated nursing staff received education regarding EBP and were expected to follow the facility's policy by wearing the appropriate personal protective equipment when providing care to residents requiring EBP. During an interview on 7/10/26 at 12:45 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated he started working with the facility approximately three weeks ago, the end of June 2026. CNA 1 stated the smiley face stickers posted outside the resident's room identified residents requiring EBP. CNA 1 stated staff were expected to wear PPE which included gown and gloves before providing care involving resident contact. CNA 1 stated it was important to help prevent the risk of spreading infection to other residents who are at a high risk of infection. CNA 1 identified Resident 1 as a resident on EBP because of his wounds to both of his heels, right elbow and having a G-tube. During an interview on 7/10/26 at 12:54 p.m., with CNA 2, CNA 2 stated the smiley face stickers were used to identify residents requiring EBP and stated staff were required to wear PPE which included gloves and a gown when providing resident care. CNA 2 stated Resident 2 was assigned to her care and identified Resident 2 requiring EBP due to her G-tube, CNA 2 further indicated when providing care such as changing or bathing Resident 2 PPE is required. CNA 2 stated EPB was important for residents to reduce the chance of infections. During a review of the facility's document titled, In-Service Meeting, 3/20/26, the In-Service topic was Enteral Feedings. The Brief Summary indicated Discussed Enteral Feedings (also known as G-tube feeding) preventing contamination, preventing infections, proper positioning in bed, proper technique, hand washing, use of PPE, indicated RN 1 was in attendance. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 12/2014, the P&P indicated, .are implemented to reduce the transmission of multidrug-resistant organisms during high-contact resident care activities. 7 EBP employ targeted gown and gloves used in addition to standard precaution during high contact resident care activities.b. personal protective equipment (PPE) is changed before caring for another resident.8. examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . i. device care or use (central line, urinary catheter, feeding tube.) and j. wound care (any skin opening requiring a dressing. During a professional reference review from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in the Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, the professional reference review from CDC indicated, .Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and gloves used during high contact resident care activities.EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following.Wounds or indwelling medical devices, regardless of MDRO colonization status.Infection or colonization with an MDRO.examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing.transferring.providing hygiene.device care or use: central line, urinary catheter, feeding tube.wound care.

Based on observation, interview and record review, the facility failed to meet professional standards of practice according to the facility's policies and procedures (P&P) titled, Weight Assessment and Intervention, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, Change in a Resident's Condition or Status, Care Planning - Interdisciplinary Team, Administering Medication, and Enteral Nutrition, for four of eight sampled residents (Resident 1, 6, 7, and 8) when Resident 1, 6, 7, and 8 had unplanned weight loss from 4/20/26 to 5/25/26 and:The facility did not accurately obtain the weights of Resident 1, 6, 7 and 8 from 4/20/26 to 5/25/26.The facility did not complete a CIC (Change in Condition-a tool for staff to communicate important information with the resident's Responsible Party [RP-a person designated to make medical decisions for the resident] and Medical Doctor [MD] when there is change in the resident's health status) form and notify the RP and MD of the documented weight loss for Resident 1, 6, 7 and 8.The facility did not conduct an IDT (Interdisciplinary Team-a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) meeting to discuss the cause of the documented weight loss and develop a care plan to address the weight loss for Resident 1, 6, 7 and 8.The 4/2026 and 5/2026 Medication Administration Record (MAR) did not indicate when the administration of Resident 1 and 7's TF (Tube Feeding-the delivery of liquid nutrients, fluids, and medications directly into the stomach or intestines through a flexible tube) was turned off as ordered by the MD and as recommended by the Registered Dietitian (RD). These failures resulted in a documented and not validated unplanned weight loss for Resident 1, 6, 7, and 8 and had the potential to lead to malnutrition and health deterioration.Findings: During a concurrent observation and interview on 5/26/26 at 2:15 p.m. with Resident 1 in Resident 1's room, Resident 1 was in bed with TF [brand name] 1.5 connected to Resident 1's gastrostomy (an artificial opening into the stomach through the abdominal wall used for feeding and administering medication) infusing (the continuous introduction of fluids, medications, or nutrients directly into the body) at 40 ml/hr (milliliters per hour-unit of measurement). Resident 1 was nonverbal (unable to speak) and could only move his right arm. During a concurrent observation and interview on 5/6/26 at 2:20 p.m. with Resident 8 in Resident 8's room, Resident 8 was sitting on the side of the bed. Resident 8 was Spanish speaking only. Resident 8 stated he was unable to walk and used a wheelchair for mobility (to get from one place to another). During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other patient information), dated 5/27/26, the AR indicated Resident 1 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Hemiplegia (a medical condition characterized by paralysis of one side of the body) affecting right dominant side, Convulsions (sudden, involuntary, and violent contractions of the muscles that cause the body to shake uncontrollably), Dysphagia (difficulty swallowing), Gastrostomy, and Injury at C4 level (the fourth bone in the neck). During a review of Resident 1's Minimum Data Set (MDS-process for clinical assessment of all residents of long term care nursing facilities), dated 4/1/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS-an assessment of a resident's ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 0 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent (helper does all the effort) with transfer from bed to chair and dependent with dressing and personal hygiene (habits to maintain cleanliness such as bathing and toileting). During a review of Resident 6's AR, dated 5/27/26, the AR indicated Resident 6 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Hemiplegia, Hemiparesis, Unspecified Psychosis (a clinical classification used when a patient experiences a disconnect from reality but the symptoms do not fit the criteria for a specific disorder, and drug use or physical illness have been ruled out), Dysphagia, and Gastrostomy. During a review of Resident 6's MDS, dated 4/9/26, the MDS indicated, Resident 6's BIMS score was 0. The MDS indicated Resident 6 was dependent with transfer from bed to chair and dependent with dressing and personal hygiene. During a review of Resident 7's AR, dated 5/27/26, the AR indicated Resident 7 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Convulsions, Gastrostomy, Extrapyramidal and Movement Disorder (a physical condition causing involuntary movements, muscle rigidity, and changes in posture or motor control), and Rhabdomyolysis (a serious and potentially life-threatening medical condition where damaged skeletal muscle tissue breaks down rapidly).During a review of Resident 7's MDS, dated 4/17/26, the MDS indicated, Resident 7's BIMS score was 0. The MDS indicated Resident 7 was dependent with transfer from bed to chair and dependent with dressing and personal hygiene. During a review of Resident 8's AR, dated 5/28/26, the AR indicated Resident 8 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Nontraumatic Intracerebral Hemorrhage (bleeding directly into the brain tissue not caused by injury), Hemiplegia and Hemiparesis (a medical condition characterized by weakness on one side of the body). During a review of Resident 8's MDS, dated 3/9/26, the MDS indicated, Resident 8's BIMS score was 11. The MDS indicated Resident 8 required supervision (verbal cues and/or touching, steadying and/or contact guard assistance provided as resident completes activity) with transfer from bed to chair and with dressing and personal hygiene. During a concurrent interview and record review on 5/26/26 at 12:54 p.m. with the Director of Nursing (DON), the Weekly Weight (WW), dated 4/20/26 to 5/25/26 was reviewed. The WW indicated Resident 1 weighed 141 lbs (pounds-unit of measurement) on 4/27/26, 96 lbs on 5/4/26, 96 lbs on 5/18/26, and 99.2 lbs on 5/18/26. The DON stated Resident 1 was weighed with a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) with a scale attached. The WW indicated Resident 6 weighed 120 lbs on 4/20/26, 120 lbs on 4/27/26, 122.1 lbs on 5/4/26, 122.1 lbs on 5/11/26, 103.8 lbs on 5/18/26, and 104.2 lbs on 5/25/26. The DON stated Resident 6 was weighed with a Hoyer lift. The WW indicated Resident 7 weighed 101.2 lbs on 4/20/25, 99.2 lbs on 4/27/26, 100.2 lbs on 5/4/26, 101 lbs on 5/11/26, and 97 lbs on 5/18/26. The DON stated Resident 7 was weighed with a Hoyer lift. The WW indicated Resident 8 weighed 220.1 lbs on 4/20/25, 221.4 lbs on 4/27/26, 209.2 lbs on 5/4/26, 223 lbs on 5/11/26, 209 lbs on 5/18/26, and 210.2 on 5/25/26. The DON stated Resident 8 was weighed with a standing scale. The DON stated Resident 1, 6, 7, and 8 were on weekly weight monitor because they had significant weight loss. The DON stated the RD was concerned that Resident 1, 6, 7 and 8's weight may not be accurate, and when the DON investigated the concern, the DON learned that the Restorative Nursing Assistants (RNAs) were not consistently weighing the residents with the same device each time, the RNAs were not weighing the residents consistently at the same time each time and the RNAs were not ensuring the residents were wearing the same clothes each time. The DON stated the facility had a Hoyer lift with a scale to weigh the residents and a standing scale to weigh the residents. The DON stated the Hoyer lift was calibrated (to adjust, evaluate, or mark a measuring device to ensure accuracy and precision) on 4/30/26. During a concurrent interview and record review on 5/26/26 at 1:30 p.m. with the DON, the invoice (cost for services provided) from [name of company], dated 4/30/26 was reviewed. The invoice indicated, Calibrate (2) Hoyer lifts + (1) wheelchair. (1) Health floor scale tested good. (1) Hoyer lift scale tested good. Other Hoyer lift did not have a scale on it. The DON stated the facility was unable to determine if Resident 1, 6, 7 and 8's weights were obtained correctly and accurately and an inservice (training and education) was provided to the RNAs to obtain weights consistently to ensure accuracy. During an interview on 5/26/26 at 1:55 p.m. with the RD, the RD stated she started working with the facility in April of 2026. The RD stated the previous RD was only available through telehealth (the use of digital information and communication technologies such as computers, smartphones, and video conferencing to access healthcare services remotely). The RD stated observing the resident and talking to the resident in person was an important part of ensuring accurate nutritional assessments (the gathering of information) and recommendations. The RD stated the RNA weighed the residents and licensed staff entered the weights into the resident's electronic medical record (EMR). The RD stated, Ideally, residents should be weighed wearing the same clothes each time, should be weighed at same time of day each time and with the same device each time to obtain accurate weights. During an interview on 5/26/26 at 2:25 p.m. with RNA 2, RNA 2 stated her duty was to weigh the residents. RNA 2 stated all the residents were weighed monthly and some were weighed weekly. RNA 2 stated residents with weight loss were weighed weekly. RNA 2 stated the facility had two devices for weighing the residents. One was the Hoyer lift with a scale on it and the other was a standing scale. RNA 2 stated a resident may stand on the scale to be weighed or be in a wheelchair to be weighed. RNA 2 stated a resident may switch from the Hoyer lift to the standing scale to be weighed if the resident was able to stand. During an interview on 5/26/26 at 2:30 p.m. with RNA 3, RNA 3 stated her duty was to weigh the residents monthly and weekly. RNA 3 stated the residents were weighed throughout the day before and after meals. RNA 3 stated she did not know wearing different clothes and being weighed at different times of the day would affect the accuracy of the weights. RNA 3 stated the DON recently provided an in-service on obtaining accurate weights. RNA 3 stated they were required to weigh the residents using the same device each time to ensure accuracy. During an interview on 5/26/26 at 2:51 p.m. with the DON, the DON stated the previous RD decreased Resident 1's TF because Resident 1 was gaining weight. On 5/6/26, Resident 1 had a 45 lbs weight loss. The DON stated there was no Nursing note or MD note regarding Resident 1's weight loss on 5/6/26. The DON stated the current RD noted on 5/6/26 that the RD confirmed with the Assistant Director of Nursing (ADON) that Resident 1's weight loss was accurate. The DON stated there was no IDT note for the weight loss either. The DON stated an IDT meeting for the weight lost was also not conducted and there was no note when the MD was notified of the weight loss. The DON stated unplanned weight lost was considered a change in condition and the MD and the RP were required to be notified. The DON stated the Registered Nurse (RN) Supervisor and the ADON were required to complete a CIC to notify Resident 1's MD and RP and that it was not done. During a concurrent observation and interview on 5/27/26 at 9:44 a.m. with Certified Nursing Assistant (CNA) 8, Registered Nurse (RN) 3 and the Registered Dietitian (RD) in Resident 1's room, CNA 8 and RN 3 assisted Resident 1 on to the Hoyer lift to be weighed. When Resident 1's gown was lifted for observation, Resident 1's rib cages and knee caps were visible. Resident 1 appeared to be thin with no body fat. The scale indicated Resident 1 was 91.8 lbs. The RD stated 91.8 lbs was consistent with Resident 1's appearance. During a concurrent interview and record review on 5/27/26 at 10:00 a.m. with the RD, Resident 1's [name of laboratory provider], dated 4/9/25 was reviewed. The RD stated Resident 1's Electrolytes (essential minerals such sodium, potassium, and calcium in the body to maintain adequate hydration), TSH (Thyroid Stimulating Hormone - hormone that regulates the body's metabolism), and Pre-Albumin (a protein produced by the liver that is used to evaluate the nutritional status and track the effectiveness of tube feeding) were within normal limits. The RD stated Resident 1 was [AGE] years old with a history a quadriplegia (the partial or total paralysis of all four limbs and torso), injury to the head at the C4 level and convulsions (sudden, rapid, and uncontrollable involuntary muscle contractions that cause violent shaking or jerking of the body). The RD stated Resident 1 was not on diuretics (medications that promote the increase production of urine), had no edema (swelling), no nausea or diarrhea to explain the rapid weight loss. The RD stated a 45 lbs weight loss in one week was severe (a loss of more than 5 % [percent-unit of measurement] body weight in one month, 7.5 % in three months and 10 % in six months) and considered a change in condition. The RD stated the ADON confirmed that Resident 1's weight was 96 lbs on 5/6/26 and the ADON was instructed to notify Resident 1's MD. During an interview on 5/27/26 at 10:15 a.m. with the ADON, the ADON stated she confirmed with the RD that Resident 1 was 96 lbs on 5/6/26. The ADON stated Resident 1's RP and MD were not notified of the weight loss on 5/6/26. The ADON stated the IDT did not conduct a meeting for the weight loss neither nor was a CIC form completed. The ADON stated it was her responsibility to complete the CIC form, notify Resident 1's RP and MD of the weight loss and conduct an IDT meeting and she did not do that. During a concurrent interview and record review on 5/27/26 at 10:30 a.m. with the RD, Resident 1's Nutrition/Dietary Note (NDN), dated 3/22/26 was reviewed. The RD stated on 3/22/26 the previous RD decreased Resident 1's TF [brand name] 1.5 to 35 ml/hr for weight gain. The NDN indicated Resident 1 was 155.6 lbs on 3/6/26, 155 lbs on 12/10/25, 150 lbs on 9/3/25. with a weight gain of 5.6 lbs (3.7 %) in six months. The RD stated the 3/22/26 recommendation was based on 17 kcal/kg (kilocalories per kilogram - unit of measurement) with BMI (Body Mass Index-a screening tool that uses height and weight to estimate body fat) of 29.4. The RD stated Resident 1's 91.8 lbs was the accurate weight and the previous RD based the nutritional recommendation for being overweight at 155 lbs. The RD stated Resident 1 was underweight and was not getting enough nutrient from the TF. The RD stated Resident 1 required 35-40 kcal/kg. The RD stated 35-40 kcal/kg was the underweight recommendation. The RD stated at 91 lbs, Resident 1 will need TF at 60 ml/hr for 20 hours. The RD stated it will provide 1800 calories (units of energy used to measure the amount of potential energy stored in food and beverages) and 70 g (grams - unit of measurement) of protein (an essential nutrient for building and repairing tissues, supporting immune function, and regulating hormones). The RD stated 912 ml of water from the TF formula and water flush at 50 ml/hr for 20 hours will provide 1,912 ml of total water. The RD stated Resident 1's TF will need to be gradually increased to avoid adverse effects (an unwanted, undesirable, and potentially harmful response to a treatment or medication). During a concurrent interview and record review at 5/27/26 at 10:45 a.m. with the RD, Resident 1's Order Summary Report (OSR), dated 4/24/26, was reviewed. The OSR indicated, Enteral Feed Order. [brand name] 1.5 kcal at 40 ml/hour x (for) 20 hours, providing 800 ml/1200 kcal, 51 g Protein, 608 water (ON at 1200 noon until total amount of feeding completed). The RD stated, On at 1200 noon until total amount of feeding completed, was vague and needed clarification. The RD stated it was standard practice to administer TF for 20 hours per day (24 hours) with the remaining four hours to allow for bowel rest, medication administration, and time for ADLs (Activities of Daily Living such as bathing, showering, and hygiene). During a review of Resident 1's MAR, dated 4/1/26 - 4/30/26, the MAR indicated, [brand name] 1.5 kcal at 35 ml/hour x 20 hours, providing 700 ml/1050 kcal (ON at 1200 noon until total amount of feeding completed). The MAR indicated there was no off time (the time TF should be turned off). During a review of Resident 1's MAR, dated 5/1/26 - 5/31/26, the MAR indicated, [brand name] 1.5 kcal at 40 ml/hour x 20 hours, providing 800 ml/1200 kcal, 51 g Protein, 608 water (ON at 1200 noon until total amount of feeding completed). The MAR indicated there was no off time (the time TF should be turned off).During a review of Resident 7,'s MAR, dated 4/1/26 - 4/30/26, the MAR indicated, [brand name] 1.5 kcal at 55 ml/hour x 20 hours (1100 ml/1650 kcal). ON at 12:00 PM until total amount of feeding completed). The MAR indicated there was no off time (the time TF should be turned off). During a review of Resident 7,'s MAR, dated 5/1/26 - 5/31/26, the MAR indicated, [brand name] 1.5 kcal at 50 ml/hour x 20 hrs/day (Provides 1500 kcal, 64 g Protein, 760 ml water). ON at 12:00 PM until total amount of feeding completed). The MAR indicated there was no off time (the time TF should be turned off). During a concurrent observation and interview on 5/27/26 at 11:09 a.m. with RN 1 in Resident 1's room, Resident 1's TF was observed. RN 1 stated she was assigned to Resident 1. RN 1 stated Resident 1's TF was [brand name] 1.5 at 40 ml/hr x 20 hours. The TF was observed to be disconnected from Resident 1 and the TF pump (a medical device used to deliver fluids such as medications, nutrients, and blood into the body) was turned off. RN 1 stated all TF pumps were turned off at 8:00 a.m. and will be turned back on at 12:00 p.m. RN 1 stated the TF pumps were turned off at 8:00 a.m. to administer medication and to allow the stomach to rest. When RN 1 was asked to provide documentation of when the TF pump was turned off, RN 1 stated there was no documentation in the MAR to indicate the TF pump was turned off. RN 1 stated it was standard practice to accurately document the administration of the TF according to the RD's recommendations and MD's orders. During an interview on 5/27/26 at 11:56 a.m. with LVN 1, LVN 1 stated she was assigned to Resident 1 on 5/4/26. LVN 1 stated the DON or the ADON enters the residents' weight in the EMR. LVN 1 stated no one informed her Resident 1 had weight loss. LVN 1 stated she became aware of Resident 1's weight loss when she saw Resident 1 was on alert charting (targeted, short-term documentation triggered by a change in a patient's condition) in the EMR. LVN 1 stated she did not complete a CIC or notify Resident 1's RP and MD of the weight loss on 5/4/26. LVN 1 stated the ADON or the DON may have completed the CIC for Resident 1 on 5/4/26 and notified Resident 1's RP and MD but she was uncertain (not sure). LVN 1 stated the residents' weights were managed by the ADON, DON and RN Supervisor and when there was a weight change, the resident was put on alert charting. LVN 1 stated weight changes were considered a CIC and a CIC form should be completed to notify the Resident's RP and MD. LVN 1 stated Resident 1 was on TF at 40 ml/hr. LVN 1 stated the TF pump should be turned off 8:00 a.m. and restarted at 12:00 p.m. LVN 1 stated the MAR should indicate when the TF was turned off and when it was turned on to indicate the RD's recommendation and MD orders were followed correctly. LVN 1 stated complete and accurate documentation of medication administration was standard practice. During an interview on 5/27/26 at 12:14 p.m. with the ADON, the ADON stated when there was a change in condition (CIC-a change in a resident's health care status), the facility was required to notify the resident's Responsible Party (RP-the person designated to make medical decisions for the resident), MD and complete a CIC form (a tool for staff to communicate important information with the resident's RP and MD). The ADON stated it was standard practice to notify the RP, MD, conduct an Interdisciplinary Team (IDT-a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff). meeting and develop a care plan for the resident when there was a CIC. The ADON stated a 45 lbs weight loss in one week was considered a CIC. The ADON stated inaccurate weights, incomplete and inaccurate documentation of medication administration, not completing a CIC form, not notifying the RP and MD, not conducting an IDT meeting, and not developing a care plan when there was a condition was unacceptable. During an interview on 5/27/26 at 12:20 p.m. with the Administrator (ADM), the ADM stated the DON or the ADON should have informed the Charge Nurse (CN) when there was a CIC so the CN could have assessed Resident 1, 6, 7 and 8 immediately. The ADM stated an IDT meeting should be conducted for Resident 1, 6, 7 and 8 and it was not. The ADM stated a 45 lbs weight loss in one week was considered a CIC. The ADM stated the purpose of conducting an IDT meeting when there was significant weight loss was to investigate the root cause of the weight loss and develop a care plan to address the weight loss. The ADM stated inaccurate weights, incomplete and inaccurate documentation of medication administration, not completing a CIC form, not notifying the RP and MD, not conducting an IDT meeting, and not developing a care plan when there was a change in condition was unacceptable. During an interview on 5/27/26 at 3:31 p.m. with the MD, the MD stated he was informed of Resident 1's weight loss one to two weeks ago. The MD stated a loss of 45 lbs in one week was impossible and stated the weight must be inaccurate. The MD stated he saw Resident 1 beginning of May 2026 and there was no change during the assessment compared to Resident 1's current status and Resident 1 was stable. The MD stated 91 lbs was more accurate for Resident 1 and not 141 lbs, but 91 lbs was considered underweight and he would refer Resident 1 to the RD for nutritional consultation. The MD stated it was standard of practice to notify the MD when there was a CIC, follow the RD's recommendation, and administer TF as ordered. The MD stated documentation should be complete and accurate to reflect the care provided. During a review of the facility's P&P titled, Weight Assessment and Intervention, dated 3/2022, the P&P indicated, Policy Statement: Resident weights are monitored for undesirable and unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 3. Any weight change of 5 % or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 5. The threshold for significant unplanned and undesired wight loss will be based on the following criteria [where percentage of body weight loss = (usual wight - actual weight)/(usual weight) x 100]: a. 1 month - 5 % weight loss is significant; greater than 5 % weight loss is significant; greater than 5 % is severe. b. 3 months - 7.5 % weight loss is significant; greater than 7.5 % is severe. c. 6 months - 10 % weight loss is significant; greater than 10 % is severe. Evaluation: . The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, wight loss or increasing the weight loss. Interventions: .2. Interventions for undesired weight gain consider resident preferences and right. A weight loss regimen will not be initiated for a cognitively capable resident without his/her approval and involvement. During a review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, dated 9/2017, the P&P indicated, Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Cause Identification: .2. For individuals with recent or rapid weight gain or loss [for example, more than a pound a day], the staff will review for possible fluid and electrolyte imbalance as a cause. Treatment/Management: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Monitoring: 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 5/2017, the P&P indicated, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical condition and/or status. Policy Interpretation and Implementation: .3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form (CIC form). During a review of the facility's P&P titled, Care Planning - Interdisciplinary Team, dated 9/2013, the P&P indicated, Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation: .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident. During a review of the facility's P&P titled, Administering Medications, dated 12/2012, the P&P indicated, Policy Statement: Medications shall be administered in a safe and timely manner as prescribed. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation: .2. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice. 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. During a professional reference review from Journal of Parental and Enteral Nutrition, titled, ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, volume 41, number 1, dated 1/15/17, the professional reference review indicated, Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors.Section 1. Assessment and Recommendations: .b. Physical exam includes GI function assessment and existing access devices as well as nutrition focused physical findings. Physical exam. Along with weight status, nutrition-focused physical exam findings should include assessment of skin integrity, fluid accumulation or deficit, muscle and fat loss, and functional status. Handgrip strength is a predictive indicator of postoperative complications, hospital length of stay and read mission, and physical status. Physical therapists may offer a valuable assessment of physical function. Muscle function correlates well and reacts quickly to changes in nutrition status. In pediatric patients, developmental status and risk of aspiration with oral intake should be evaluated. d. Administration method and rate. i. Document the method of administration (continuous, bolus, intermittent feedings). ii. Clearly define the volume and/or rate of EN administration for each method of administration. Section 6. The administration of EN therapy is a step in the process with significant potential for error. Errors can stem from incomplete evaluation of a patient's tolerance for enteral feeding that increases the risk for aspiration or GI complications. Enteral misconnections, poor positioning, pump misadventures, and contamination can all lead to less than optimal patient outcomes . During a professional reference review from American Academy of Family Physician Journal, titled, Evaluating and Treating Unintentional Weight Loss in the Elderly, volume 65, number 4, dated 2/15/2002, the professional reference review indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death. Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year . During a professional reference review retrieved from https://aspenjournals.onlinelibrary.[NAME].com/doi/abs/10.1177/0884533611405794 titled, Enteral Nutrition for Older Adults in Nursing Facilities, dated 5/16/11, the professional reference review indicated, Older adults who reside in nursing facilities tend to be frail and to have multiple comorbidities, increased risk of unintended weight loss, and protein energy malnutrition. Approximately 5.8% of nursing facility residents in the United States receive enteral feedings. The prevalence is higher for residents with cognitive impairment, ranging from 18% to 34%. In cognitively impaired residents, the majority of tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources and high postinsertion mortality rates within 60 days of insertion. Nursing facilities must abide by state and federal regulations and undergo stringent survey evaluation while balancing complex decisions related to initial placement of feeding tubes. Informed choice, resident-centered care decisions, and the role of advanced directives are essential in the decision-making process. In nursing facilities, it is often the registered dietitian who alerts the healthcare team to determine whether a feeding tube is appropriate. Once a tube is placed, healthcare practitioners must make careful decisions related to ordering, administering, and monitoring enteral nutrition (EN) delivery; adequacy of nutritional content; tolerance to feedings; monitoring for potential complications; and the possibility of return to oral feeding or, conversely, the decision to discontinue feedings. Further evidence-based research is neede

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for four of eight sampled residents (Resident 1, 6, 7 and 8) when Resident 1, 6, and 7 required enteral feeding (a method of supplying nutrition directly into the stomach or intestines through a flexible tube) and Resident 8 required regular, mechanical soft texture (a texture-modified eating plan for individuals with difficulty chewing or swallowing), regular consistency (thin liquids such as water) diet and staff did not administer nutrition in accordance with policies and procedures and professional standards of practice. This failure resulted in a documented unplanned weight loss of 45 pounds (lbs-unit of measurement) for Resident 1 from 4/27/26 to 5/4/26, a documented 18.3 lbs weight loss for Resident 6 from 5/11/26 to 5/18/26, documented 4 lbs weight loss from 5/11/26 to 5/18/26 for Resident 7, and documented 12 lbs weight loss from 4/27/26 to 5/4/26 for Resident 8.Findings:During a concurrent interview and record review on 5/26/26 at 12:54 p.m. with the Director of Nursing (DON), the Weekly Weight (WW), dated 4/20/26 to 5/25/26 was reviewed. The WW indicated Resident 1 weighed 141 lbs on 4/27/26, 96 lbs on 5/4/26, 96 lbs on 5/18/26, and 99.2 lbs on 5/18/26. The DON stated Resident 1 was weighed with a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) with a scale attached. The WW indicated Resident 6 weighed 120 lbs on 4/20/26, 120 lbs on 4/27/26, 122.1 lbs on 5/4/26, 122.1 lbs on 5/11/26, 103.8 lbs on 5/18/26, and 104.2 lbs on 5/25/26. The DON stated Resident 6 was weighed with a Hoyer lift. The WW indicated Resident 7 weighed 101.2 lbs on 4/20/25, 99.2 lbs on 4/27/26, 100.2 lbs on 5/4/26, 101 lbs on 5/11/26, and 97 lbs on 5/18/26. The DON stated Resident 7 was weighed with a Hoyer lift. The WW indicated Resident 8 weighed 220.1 lbs on 4/20/25, 221.4 lbs on 4/27/26, 209.2 lbs on 5/4/26, 223 lbs on 5/11/26, 209 lbs on 5/18/26, and 210.2 lbs on 5/25/26. The DON stated Resident 8 was weighed with a standing scale. The DON stated Resident 1, 6, 7, and 8 were on weekly weight monitor because they had significant weight loss (a loss of 5 % [percent-unit of measurement] body weight in one month, 7.5 % in three months and 10 % in six months). During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other patient information), dated 5/27/26, the AR indicated Resident 1 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Hemiplegia (a medical condition characterized by paralysis of one side of the body) affecting right dominant side, Convulsions (sudden, involuntary, and violent contractions of the muscles that cause the body to shake uncontrollably), Dysphagia (difficulty swallowing), Gastrostomy, and Injury at C4 level (the fourth bone in the neck). During a review of Resident 1's Minimum Data Set (MDS-process for clinical assessment of all residents of long term care nursing facilities), dated 4/1/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS-an assessment of a resident's ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 0 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent (helper does all the effort) with transfer from bed to chair and dependent with personal hygiene (habits to maintain cleanliness such as bathing, dressing and toileting). The MDS indicated Resident 1 was 156 lbs and was not on a physician-prescribed weight gain or loss regimen.During an interview on 5/26/26 at 1:55 p.m. with the Registered Dietitian (RD), the RD stated she started working with the facility in April of 2026. The RD stated the previous RD was only available through telehealth (the use of digital information and communication technologies such as computers, smartphones, and video conferencing to access healthcare services remotely). The RD stated observing the resident and talking to the resident in person was an important aspect of ensuring accurate nutritional assessments (the gathering of information) and recommendations. The RD stated Resident 1 weighed 141 lbs on 4/29/26 and 96 lbs on 5/6/26. The RD stated a loss of 45 lbs in one week was severe weight loss (a loss of more than 5 % body weight in one month, 7.5 % in three months and 10 % in six months). The RD stated the Assistant Director of Nursing (ADON) confirmed Resident was 96 lbs on 5/6/26. The RD stated she instructed the ADON to notify Resident 1's Medical Doctor (MD) immediately. During a concurrent observation and interview on 5/27/26 at 9:44 a.m. with Certified Nursing Assistant (CNA) 8, Registered Nurse (RN) 3 and the RD in Resident 1's room, Resident 1 was in bed with Tube Feeding (TF) [brand name] 1.5 connected to Resident 1's gastrostomy (an artificial opening into the stomach through the abdominal wall used for feeding and administering medication) infusing (the continuous introduction of fluids, medications, or nutrients directly into the body) at 40 ml/hr (milliliters per hour-unit of measurement). Resident 1 was nonverbal (unable to speak) and immobile (unable to get from one place to another). CNA 8 and RN 3 assisted Resident 1 on to the Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) to be weighed. When Resident 1's gown was lifted for observation, Resident 1's rib cages and knee caps were visible. Resident 1 appeared to be thin with no body fat. The scale indicated Resident 1 was 91.8 lbs. The RD stated 91.8 lbs was consistent with Resident 1's appearance. During a concurrent interview and record review on 5/27/26 at 10:30 a.m. with the RD, Resident 1's Nutrition/Dietary Note (NDN), dated 3/22/26 was reviewed. The NDN indicated Resident 1 was 61 inches tall, 155.6 lbs on 3/6/26, 155 lbs on 2/5/26, 151 lbs on 12/10/25, 150 lbs on 9/3/25, gain 4.6 lbs (3 %) in three months, gain 5.6 lbs (3.7 %) in six months. The NDN indicated Resident 1's BMI (Body Mass Index-a screening tool that uses height and weight to estimate body fat; 18.5 is considered underweight, 18.5-24.9 is considered healthy weight, 25.0-29.9 is considered overweight, and 30.0 or higher is considered Obesity) was 29.4 indicating Resident 1 was overweight. The RD stated on 3/22/26 the previous RD decreased Resident 1's TF [brand name] 1.5 to 35 ml/hr for weight gain. The RD stated the 3/22/26 recommendation was based on 17 kcal/kg (kilocalories per kilogram-unit of measurement). The RD stated Resident 1's weight of 91.8 lbs on 5/27/26 was the accurate weight and the previous RD based the nutritional recommendation for being overweight at 155 lbs. The RD stated Resident 1 was underweight and was not getting enough nutrients from the TF. The RD stated 35-40 kcal/kg was the underweight recommendation. The RD stated at 91 lbs, Resident 1 will need TF at 60 ml/hr for 20 hours. The RD stated it will provide 1800 calories (units of energy used to measure the amount of potential energy stored in food and beverages) and 70 g (grams-unit of measurement) of protein (an essential nutrient for building and repairing tissues, supporting immune function, and regulating hormones). The RD stated 912 ml of water from the TF formula and water flush at 50 ml/hr for 20 hours will provide 1,912 ml of total water. The RD stated Resident 1's TF will need to be gradually increased to avoid adverse effects (an unwanted, undesirable, and potentially harmful response to a treatment or medication). During a record review of Resident 1's NDN, dated 4/29/26, the NDN indicated, On 4/25/26, TF rate was increased from 35 to 40 ml/hour per RD recommendation. BMI continues overweight and current weight remains within desired body weight range of 140 # (pounds) +- 5 #. RD recommends to continue TF as ordered; RD will monitor weekly weights and adjust plan of care as needed. During a record review of Resident 1's NDN, dated 4/24/26, the NDN indicated, Resident returned back from [name of acute care hospital] with replaced G-tube [gastrointestinal tube] on 4/21/26. Presents with significant weight loss of 12 #/7.7 % x 1 month, possibly in part d/t RD's recommendation on 3/22/26 to decrease tube feeding from [brand name] 1.5 40 ml/hr to 35 ml/hr. Weight loss was intentional and desired and resident is now within desired body wight range of 140+/- 5 #. RD recommends weight maintenance with no significant changes. During a review of Resident 6's AR, dated 5/27/26, the AR indicated Resident 6 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Hemiplegia, Hemiparesis, Unspecified Psychosis (a clinical classification used when a patient experiences a disconnect from reality but the symptoms do not fit the criteria for a specific disorder, and drug use or physical illness have been ruled out), Dysphagia, and Gastrostomy. During a review of Resident 6's MDS, dated 4/9/26, the MDS indicated, Resident 6's BIMS score was 0. The MDS indicated Resident 6 was dependent with transfer from bed to chair and dependent with personal hygiene. The MDS indicated Resident 6 was 106 lbs and was not on a physician-prescribed weight gain or loss regimen. During a concurrent interview and record review on 5/27/26 at 11:31 a.m. with the RD, Resident 6's NDN, dated 5/20/26 was reviewed. The NDN indicated Resident 6 was on TF [brand name] 1.5 at 237 ml every 4 hours (2133 kcal, 91 g protein, 1080 ml free water). Free water flush 90 ml water before and 90 ml water after each bolus (a single, concentrated mass of a substance) feeding (2160 ml water total). The RD stated Resident 6 presented with a severe weight loss of 18.3 lbs between 5/11/26 and 5/19/26 (14.9 % weight loss) possibly due to an error on the scale or the Hoyer lift being recalibrated recently. The RD stated on 5/20/26 the nursing staff re-weighed Resident 6 and he was 105.6 lbs. similar to the weight on 5/19/26 of 103.8 lbs. The RD stated Resident 6's ideal body weight (IDBW) was 106 lbs and his usual body weight was 120-130 lbs. During a record review of Resident 6's NDN, dated 4/29/26, the NDN indicated, RD Consult: TF Review. Diet: NPO (nothing by mouth), TF: [brand name] 1.5 237 ml 5xday via bolus (6 AM, 10 AM, 2 PM, 6 PM, 10 PM) (1185 ml/1778 kcal, 76 g protein, 901 ml water) with free water flush 100 ml water before and 100 ml water after each bolus feeding (T [total]: 1901 ml). Assessment: On 4/26/26, RD recommended to add an additional bolus feeding of [brand name] 1.5 120 ml at 12 AM (120 ml/180 kcal, 8 g protein, 91 ml water) with 50 ml free water flush before/after each bolus feeding (100 ml). However, RN Supervisor consulted RD on 4/29/26, asking if the tube feeding order could be changed so that all boluses are 237 ml. [brand name] 1.5 237 ml 6x/day would add 255 kcal/16 g protein, providing a daily total of 2133 kcal, 91 g protein, which would be in excess of estimated nutritional needs (39 kcal/kg, 1.7 g/kg protein, 39 ml/kg fluid) but may be appropriate given recent weight loss. Intervention: 1. D/c (discontinue current TF order. 2. Start [brand name] 1.5 235 ml q (every) 4 hours (provides 2133 kcal, 91 g protein, 1080 ml free water). 3. Start free water flush 90 ml water before and 90 ml water after each bolus feeding (2160 ml water total). 4. Continue weekly weight monitoring. During a record review of Resident 6's NDN, dated 4/26/26, the NDN indicated, Weight Review. Diet: NPO (nothing by mouth), TF: [brand name] 1.5 237 ml 5xday via bolus (6 AM, 10 AM, 2 PM, 6 PM, 10 PM) (1185 ml/1778 kcal, 76 g protein, 901 ml water) with free water flush 100 ml water before and 100 ml water after each bolus feeding (T [total]: 1901 ml). Patient with significant weight loss x 49 days. Unavoidable weight loss s/p recent hospitalization for hematuria [the presence of red blood cells in the urine]. TF was changed on 3/22/26 as per TD d/u progressive weight gain. TF provides 33 kcal/kg/d, 1.39 g protein kg/d, 35 ml fluid/kg/d. Tolerating TF without N/V/D [nausea, vomiting, diarrhea] or residuals. Recommend: 1. Add additional bolus of feeding of [brand name] 1.5 120 ml at 12 a.m. [120 ml/180 kcal, 8 g protein, 91 ml water] with 50 ml free water flush before/after each bolus feeding [100 ml]. 2. Weekly weights x 4 weeks. During a record review of Resident 6's NDN, dated 4/24/26, the NDN indicated, TF Review. Diet: NPO (nothing by mouth), TF: [brand name] 1.5 237 ml 5xday via bolus (6 AM, 10 AM, 2 PM, 6 PM, 10 PM) (1185 ml/1778 kcal, 76 g protein, 901 ml water) with free water flush 100 ml water before and 100 ml water after each bolus feeding (T [total]: 1901 ml). No weight available as patient was transferred to hospital on 4/6/26 d/t hematuria. Patient came back with a diagnosis of UTI (urinary tract infection) and was treated with ATB (antibiotics). TF was changed on 3/23/26 as per RD recs (recommendation) d/t progressive weight gain. Tolerating TF without N/V/D or residuals. Recommend f/u (follow up) on weight. During a review of Resident 7's AR, dated 5/27/26, the AR indicated Resident 7 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Convulsions, Gastrostomy, Extrapyramidal and Movement Disorder (a physical condition causing involuntary movements, muscle rigidity, and changes in posture or motor control), and Rhabdomyolysis (a serious and potentially life-threatening medical condition where damaged skeletal muscle tissue breaks down rapidly). During a review of Resident 7's MDS, dated 4/17/26, the MDS indicated, Resident 7's BIMS score was 0. The MDS indicated Resident 7 was dependent with transfer from bed to chair and dependent with personal hygiene. The MDS indicated Resident 7 was 106 lbs and was not on a physician-prescribed weight gain or loss regimen. During a concurrent interview and record review on 5/27/26 at 11:40 a.m. with the RD, Resident 7's NDN, dated 5/20/26 was reviewed. The NDN indicated Resident 7 was 66 inches tall, 97 lbs on 5/19/26, 99.2 lbs on 4/29/26, 101.2 lbs on 4/23/26, 105.6 lbs on 4/14/26, 117 lbs on 3/15/26, 116 lbs on 2/5/26, 119 lbs on 1/6/26, and 116 lbs on 12/1/25. The NDN indicated Resident 7 had a BMI of 15.7. The NDN indicated Resident 7 was on TF [brand name] 1.5 at 65 ml/hr x 20 hours (1300 ml, 1050 kcal, 83 g protein, 988 ml water) FWF (Free water flush): 55 ml/hr x 20 hours (2097 ml total water). The RD stated Resident 7 had a 15 lbs weight loss in 3 months (12.9 % weight loss indicating severe weight loss) and 26 lbs in six months (19.2 % weight loss indicating severe weight loss). During a record review of Resident 7's NDN, dated 4/26/26, the NDN indicated Resident 7 was on TF [brand name] 1.5 at 65 ml/hr x 20 hours (1300 ml/1950 kcal, 83 g protein, 988 ml water) with free water flush of 55 ml/hr x 20 hours (total from formula and flush of 2088 ml). The NDN indicated, Trigger for significant weight loss x 9 days/x 40 days/x 3 months/x 6 months. Unavoidable weight loss s/p [status post] acute encephalopathy [sudden, temporary brain dysfunction], s/p CRF [chronic renal function- the progressive and irreversible decline of the kidneys' ability to filter blood, remove waste products, and maintain fluid and chemical balances in the body], s/p sepsis/infection [the body's extreme, life-threatening reaction to an infection], COPD [chronic obstructive pulmonary disease- . It is a progressive, long-term lung disease that makes it hard to breathe by restricting airflow into and out of the lungs]. TF provides approximately 42 kcal/kg/d, 1.8 g protein/kg/d, 45 ml fluid/kg/d. Tolerating TF without N/V/D or residuals. TF was increased on 4/23/26. During a review of Resident 8's AR, dated 5/28/26, the AR indicated Resident 8 was a [AGE] year old male resident admitted on [DATE] with a diagnosis of Nontraumatic Intracerebral Hemorrhage (bleeding directly into the brain tissue not caused by injury), Hemiplegia and Hemiparesis (a medical condition characterized by weakness on one side of the body). During a review of Resident 8's MDS, dated 3/9/26, the MDS indicated, Resident 8's BIMS score was 11. The MDS indicated Resident 8 required supervision (verbal cues and/or touching, steadying and/or contact guard assistance provided as resident completes activity) with transfer from bed to chair and with personal hygiene. The MDS indicated Resident 8 was 228 lbs and was not on a physician-prescribed weight gain or loss regimen. During a record review of Resident 8's NDN, dated 5/20/26, the indicated Resident 8 was on a regular diet, mechanical soft texture, regular consistency. The NDN indicated, PO (by mouth) intake remains 75-100 % at every meal in the last 14 days. The NDN indicated, Resident report that he has noticed that he has lost weight in his legs and would not like to lose any more weight. During a record review of Resident 8's NDN, dated 4/11/26, the NDN indicated, indicated Resident 8 was on a regular diet, mechanical soft texture, thin liquids and consumed 76-100 %. The NDN indicated, Noted patient is on Metformin (a medication used to treat and lower and blood sugar levels) for DM (Diabetes Mellitus), which can contribute to the weight loss. Patient is also on a diuretic (medication that help the body eliminate excess salt and water through increased urination) for HTN (hypertension-high blood pressure). Weight loss is desirable/beneficial to decrease risks of morbid/mortality associated with elevated BMI. Weekly weight were ordered. During an interview on 5/27/26 at 12:14 p.m. with the ADON, the ADON stated when there was a change in condition (CIC-a change in a resident's health care status), the facility was required to notify the resident's Responsible Party (RP-the person designated to make medical decisions for the resident), MD and complete a CIC form (a tool for staff to communicate important information with the resident's RP and MD). The ADON stated it was standard practice to notify the RP, MD, conduct an Interdisciplinary Team (IDT-a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff). meeting and develop a care plan for the resident when there was a CIC. The ADON stated a 45 lbs weight loss in one week was considered a CIC. The ADON stated inaccurate weights, incomplete and inaccurate documentation of medication administration, not completing a CIC form, not notifying the RP and MD, not conducting an IDT meeting, and not developing a care plan when there was a condition was unacceptable. During an interview on 5/27/26 at 12:20 p.m. with the Administrator (ADM), the ADM stated the DON or the ADON should have informed the Charge Nurse (CN) when there was a CIC so the CN could have assessed Resident 1, 6, 7 and 8 immediately. The ADM stated an IDT meeting should be conducted for Resident 1, 6, 7 and 8 and it was not. The ADM stated a 45 lbs weight loss in one week was considered a CIC. The ADM stated the purpose of conducting an IDT meeting when there was significant weight loss was to investigate the root cause of the weight loss and develop a care plan to address the weight loss. The ADM stated inaccurate weights, incomplete and inaccurate documentation of medication administration, not completing a CIC form, not notifying the RP and MD, not conducting an IDT meeting, and not developing a care plan when there was a change in condition was unacceptable. During an interview on 5/27/26 at 3:31 p.m. with the MD, the MD stated he was informed of Resident 1's weight loss one to two weeks ago. The MD stated a loss of 45 lbs in one week was impossible and stated the weight must be inaccurate. The MD stated he saw Resident 1 at the beginning of May 2026 and there was no change during the assessment compared to Resident 1's current status and Resident 1 was stable. The MD stated 91 lbs was more accurate for Resident 1 and not 141 lbs, but 91 lbs was considered underweight and he would refer Resident 1 to the RD for nutritional consultation. The MD stated it was standard of practice to notify the MD when there was a CIC, follow the RD's recommendation, and administer TF as ordered. The MD stated documentation should be complete and accurate to reflect the care provided. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 3/2022, the P&P indicated, Policy Statement: Resident weights are monitored for undesirable and unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 3. Any weight change of 5 % or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 5. The threshold for significant unplanned and undesired wight loss will be based on the following criteria [where percentage of body weight loss = (usual wight - actual weight)/(usual weight) x 100]: a. 1 month - 5 % weight loss is significant; greater than 5 % weight loss is significant; greater than 5 % is severe. b. 3 months - 7.5 % weight loss is significant; greater than 7.5 % is severe. c. 6 months - 10 % weight loss is significant; greater than 10 % is severe. Evaluation: . The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, wight loss or increasing the weight loss. Interventions: .2. Interventions for undesired weight gain consider resident preferences and right. A weight loss regimen will not be initiated for a cognitively capable resident without his/her approval and involvement. During a review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight - Clinical Protocol, dated 9/2017, the P&P indicated, Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Cause Identification: .2. For individuals with recent or rapid weight gain or loss [for example, more than a pound a day], the staff will review for possible fluid and electrolyte imbalance as a cause. Treatment/Management: 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Monitoring: 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting. During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation: .2. The reaccommodation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice. 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. During a professional reference review from Journal of Parental and Enteral Nutrition, titled, ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, volume 41, number 1, dated 1/15/17, the professional reference review indicated, Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors.Section 1. Assessment and Recommendations: .b. Physical exam includes GI function assessment and existing access devices as well as nutrition focused physical findings. Physical exam. Along with weight status, nutrition-focused physical exam findings should include assessment of skin integrity, fluid accumulation or deficit, muscle and fat loss, and functional status. Handgrip strength is a predictive indicator of postoperative complications, hospital length of stay and read mission, and physical status. Physical therapists may offer a valuable assessment of physical function. Muscle function correlates well and reacts quickly to changes in nutrition status. In pediatric patients, developmental status and risk of aspiration with oral intake should be evaluated. d. Administration method and rate. i. Document the method of administration (continuous, bolus, intermittent feedings). ii. Clearly define the volume and/or rate of EN administration for each method of administration. Section 6. The administration of EN therapy is a step in the process with significant potential for error. Errors can stem from incomplete evaluation of a patient's tolerance for enteral feeding that increases the risk for aspiration or GI complications. Enteral misconnections, poor positioning, pump misadventures, and contamination can all lead to less than optimal patient outcomes . During a professional reference review from American Academy of Family Physician Journal volume 65, number 4, dated 2/15/02, indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death. Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year . During a professional reference review from Journal of Nutritional Disorders & Therapy, titled, Nutritional Dietary Recommendations for Acute Ischemic Stroke and their Outcomes, volume 13, issue 3, dated 6/29/23, the professional reference review indicated, Nutritional intake is a key component of stroke care that can influence the recovery and outcome of acute ischemic stroke patients. An early screening and assessment of dysphagia and nutritional status is recommended for all stroke patients. Adequate hydration energy protein micronutrients fatty acids intake should be ensured while avoiding foods that can increase the risk of recurrent stroke or aspiration pneumonia. Dietary modifications may be needed depending on the patient's comorbidities swallowing ability preferences needs. A multidisciplinary approach involves physicians, nurse, dietitian speech-language pathologists pharmacists caregivers is essential for providing optimal nutritional care for stroke patients. Ensure adequate energy and protein intake to prevent or treat malnutrition, which is common in stroke patients and can impair recovery and increase mortality. The recommended energy intake ranges from 25 to 35 kcal/kg/day, and the recommended protein intake ranges from 1.2 to 1.5 g/kg/day. Provide oral nutritional supplements or enteral nutrition (tube feeding) if oral intake is insufficient or unsafe due to dysphagia or reduced appetite. Enteral nutrition should be initiated within 24 to 48 hours after stroke onset if oral intake is less than 50% of the estimated needs. Monitor fluid and electrolyte balance to prevent dehydration or overhydration, which can worsen cerebral edema or increase blood pressure. The recommended fluid intake ranges from 30 to 40 ml/kg/day, depending on the patient's condition and urine output.

Based on observation, interviews and review of facility documents, the facility failed to ensure:1. The Certified Dietary Manager (CDM) met state requirements, California Code of Regulations (CCR), Health and Safety Code 1265.4 when the CDM did not complete the six hours of in-service training on the CCR, Dietetic Services Requirements of Title 22 and;2. The CDM received frequently scheduled consultation from the Registered Dietitian (RD). These failures had the potential to result in insufficient oversight and consultation with the CDM of food and nutrition services that resulted in a lack of the RD identifying system issues regarding hair restraint availability and use, prevention of wet stacking (when dishes/pans are stacked together while they are still damp, trapping moisture between surfaces and preventing air circulation and proper drying), and lack of food safety for dates and labeling of food items for the health and safety of the 61 residents admitted to the facility.Findings:1. During a review of the California Health and Safety Code 1265.4, indicated seven qualification pathways of the full-time position responsible for the day-to-day operation of dietetic services. Pathway four indicated the supervisor is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.During a review of the CDM personnel file, indicated a credential verification dated 11/4/25 that he is a certified dietary manager through 8/31/26.During an interview on 3/18/26 at 4:44 p.m. with the Certified Dietary Manager (CDM), the CDM stated he had been employed at the facility as the CDM since October 2025 and was not aware of the CCR additional six-hour requirement for CDM's in skilled nursing facilities (SNF). The CDM stated he worked for a hospital prior to this job and the hospital he worked for never mentioned any additional requirements. The CDM stated he would look into completing those requirements as soon as possible.During an interview on 3/19/26 at 11:15 a.m. with the Registered Dietitian Consultant (RDC), the RDC stated her expectation was the CDM follow state mandates for certifications/trainings for the position he is in and completed whatever requirements were necessary for that particular certification.During an interview on 3/20/26 at 8:55 a.m. with the Administrator (ADM), the ADM stated it was her expectation that the CDM met all credentials prior to employment to ensure the staff being hired was qualified to perform their job duties according to regulations. The ADM stated verifying credentials and certifications according to state regulations, it was important to ensure staff being hired were qualified for the position they were being hired. The ADM stated if the CDM did not have the appropriate certifications for his job title, then facility Policies and Procedures (P&P) were not followed.During a review of the facility's policy and procedure (P&P) titled, Dietary Services, (undated), the P&P indicated, .The facility shall provide organized, safe, and sanitary dietary services under the direction of a qualified Dietary Manager.Purpose To ensure.Compliance with Title 22 and survey requirements.Qualifications of Dietary Manager.Dietary Manager must meet one of the following: Certified Dietary Manager (CDM) with approved training.Required Title 22 in-service training (minimum 6 hours) before assuming duties.2. A series of observations on 3/17/26 between 8:41 a.m. and 9:25 a.m. identified a dietary aid working in the kitchen did not have a hair net on, a wet quarter pan was stacked on top of another quarter pan, and ground beef was thawing in the refrigerator with no pull/thaw date on it (the date marked on a food item when it is removed from the freezer to thaw), and no use by date. (Cross Reference F812.)During an interview on 3/18/26 at 4:44 p.m. with the CDM, the CDM stated the RDC checked in with him periodically to see how things were going in the kitchen. The CDM stated if he had any questions relating to residents or kitchen concerns, he reached out to the RDC via telephone or email.During an interview on 3/19/26 at 11:00 a.m. with the RDC, the RDC stated she had been the RDC for the facility since the end of October 2025 and was located out of Los Angeles, California. The RDC stated she worked remotely and did not come physically into the facility. The RDC stated her duties included new resident/readmit assessments, significant weight changes, wounds, residents on dialysis and tube feeder assessments. The RDC stated she assessed patients via review of the medical record once or twice a week remotely. The RDC stated her and the other RDC that she worked with were in contact with the CDM via telephone conferences. The RDC stated the CDM was responsible for the day-to-day kitchen operations at the facility and the CDM was aware he could reach out at any time regarding resident concerns, menus, kitchen questions etc. During an interview on 3/19/26 at 3:21 p.m. with the RDC, the RDC stated her conversations with the CDM were not a scheduled consultation that was set weekly on a certain date and time but instead were based on the CDM's questions and RDC questions she had for him. The RDC stated consultations were provided on a weekly basis with the CDM and more often if needed. The RDC stated she did not keep documentation of the consultations, and conversations were done via a telephone call and were sometimes put in the RDC note on the resident record for all team members to see in Point Click Care (PCC-a computer charting system) if it was applicable depending on the resident concern or issue. The RDC stated she did not write down every single item discussed with the CDM and if it was a kitchen or nutrition related issue, conversations would be done through email as well. The RDC stated she does not keep a log or documentation on consultations provided and consultations were done either through phone or email.During an interview on 3/19/26 at 3:26 p.m. with the RDC, the RDC stated she relied strictly on the CDM to communicate and report any kitchen issues/concerns with food services to her because the CDM was the one at the facility full time. The RDC stated if the CDM had any questions, The CDM had both RDC's contact numbers and could call them at any time.During an interview on 3/20/26 at 11:03 a.m. with the ADM, the ADM stated she was aware the RDC was supposed to be visiting every week and knows this from working at her previous building. The ADM stated at her previous building, the RD would come in person to assess new admits, and then came on a regular basis every month and while they were in the facility, the RD would observe the kitchen tray line (meal service), do sanitation audits, review weights etc. and the ADM would get a copy of the evaluation/report including wt. loss recommendations etc. The ADM stated she had been actively looking for a RD that could come to the facility in person and stated she had not had any luck finding an in-person RD company that is willing to come to the facility. The ADM stated it was important for the RDC to be present at the facility to guide the staff and CDM with the functions of the kitchen and stated that having a RD present would be beneficial because it was a second person aside from the CDM looking at the kitchen service and giving recommendations. The ADM stated audits were important in order to provide a better food service and quality to the patient. ADM stated the current situation at the facility of RD's not coming in person to the facility, was making her uncomfortable with all the issues going on in the kitchen. The ADM stated having an RD present at the facility would be beneficial in providing a better kitchen service to the residents.During a review of the facility document titled, Registered Dietitian Job Description- Skilled Nursing Facility (SNF), (undated), the Registered Dietitian Job Description indicated, The Registered Dietitian (RD) is responsible for assessing, planning.care for residents in accordance with federal, state (e.g., Title 22).and facility regulations.Regulatory Compliance Ensure compliance with CMS, Title 22, and state regulations Maintain accurate and timely documentation participate in audits and survey readiness. Food Service Oversight.monitor kitchen sanitation and safety.Monitoring & Education.Educate residents, families, and staff.During a review of the consultation agreement for dietetic consultation services document titled, SCM Nutrition and Diet Inc. [Name of RDC], MS RD., Consultant Dietitian, dated October 22, 2025, the consultation agreement for dietetic consultation services document indicated, .Facility provides skilled nursing and/or long-term care services and wishes to engage Consultant to provide dietary services to residents of the Facility in accordance with the provisions of this Agreement and applicable state and federal laws.DUTIES AND OBLIGATIONS OF CONSULTANT.Evaluate sanitation, safety, and food handling practices and meal service regulations in food service department.During a review of the facility business correspondences (the written or digital communications exchanged by a facility or organization to manage its operations, maintain relationships, and document activities) completed by RDCs dated 11/7/25 through 3/17/26, showed RDC recommendations for clinical nutrition and did not show any evaluation of food services. There was no documentation provided to show the RDC provided frequently scheduled consultation to the CDM. During a review of the facility's policy and procedure (P&P) titled, Dietitian, dated November 2022, the P&P indicated, .If a dietitian is not employed full time.a director of food and nutrition services will be designated. This individual will.receive frequently scheduled consultations from a qualified dietitian .Our facility's dietitian is responsible for.food preparation, service and storage.

Based on interviews and observations during the survey period from 3/17/26 through 3/20/26, the facility failed to ensure eight of eight sampled bedrooms, accommodated no more than four residents each.This failure had the potential for residents to not have reasonable privacy or adequate space.Throughout the survey period from 3/17/2026 through 3/20/2026, eight rooms in Building Two had more than four residents in each bedroom. The variations were in accordance to residents particular care needs and comfort. Wheelchairs and toilet facilities were accessible to residents. A reasonable amount of privacy was provided and adequate closet and storage space were available. There was sufficient space for residents to ambulate and staff to provide care to residents. Nursing care of the residents was not impacted. During Survey observations and residents and staff interviews, there was reasonable amount of privacy provided, storage closet was adequate and storage space was available. Wheelchairs and toilet facilities were accesible to residents. There was sufficient space for residents and staff to provide resident care. Nursing care of residents was not impacted.Building Room# # of Beds2 201 82 202 82 203 82 204 82 205 82 206 82 207 82 208 8Recommend waiver continue in effect._______________________________________Health Facilities Evaluator Supervisor Signature &DateRequest waiver continue in effect._____________________________________Administrator Signature & Date

The facility failed to follow its own policy and procedure to complete quarterly smoking assessments when three out of four sampled residents (Residents' 41, 52 and 54) quarterly assessments were not completed on time. These failures had the potential for Residents' 41, 52 and 54 to experience accident related to smoking like burn.Findings:During a review of resident 41's admission Record (AR-a document containing resident profile information), dated 3/20/26, the AR indicated resident 41 was admitted to the facility on [DATE] with diagnoses which included pulmonary embolism, depression (serious, long-lasting mood disorder), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and anxiety (body's natural reaction to stress, acting as a feeling of fear, dread, or uneasiness about future threats or unknown). During a review of Resident 41's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 41's Brief Interview for Mental Status ([NAME]-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale, 0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) indicating Resident 41 had no cognitive deficit. During a concurrent observation and interview on 3/17/26 at 9:41 a.m. during initial tour in Resident 41's room, Resident 41 was observed sitting up in wheelchair at bedside watching TV. Resident 41 stated he is a smoker and goes outside after each meal to smoke. Resident 41 stated facility staff go outside with the smokers to ensure they are safe.During a review of Resident 52's AR dated 3/20/26, the admission Record, indicated Resident 52 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizures During a review of Resident 52's MDS assessment dated [DATE], indicated Resident 52's BIMS assessment score was 13 out of 15 indicating resident 52 had no cognitive deficit.During a concurrent observation and interview on 3/17/26 at 9:55 a.m. during the initial tour in the hallway outside of Resident 52's room, Resident 52 was observed sitting up in his wheelchair. Resident 52 stated he had been in the facility for almost two years and was just outside smoking. Resident 52 stated he was allowed to smoke three times a day after meals. During a review of Resident 54's admission Record, dated 3/20/26, the AR indicated Resident 54 was admitted to the facility on [DATE] with diagnoses which included anxiety, depression, and pain. During a review of Resident 54's MDS assessment dated [DATE], indicated Resident 54's BIMS assessment score was 14 out of 15 indicating resident 54 had no cognitive deficit.During a concurrent interview and record review on 3/19/26 at 10:55 a.m. with Registered Nurse (RN) 1, RN 1 reviewed clinical records of Residents' 41, 52 and 54. RN 1 stated Resident 41 was admitted to the facility on [DATE] and his smoking assessment was completed on 10/31/25 and 3/17/26. RN 1 stated Resident 52 was admitted to the facility on [DATE] and his smoking assessments were completed on 10/31/25 and 3/17/26. RN 1 stated Resident 54 was admitted to the facility on [DATE] and his smoking assessments were completed on 10/27/25 and 3/17/26. RN 1 stated she was not sure how often smoking assessments were completed because she had not completed one. RN 1 stated it was important to complete smoking assessment to ensure residents are safe to smoke.During a concurrent interview and record review on 3/19/26 at 2:56 pm. With Minimum Data Set Nurse (MDSN), MDSN stated smoking assessments are completed initially on admission and quarterly. The MDSN stated she was responsible in completing smoking assessments. The MDSN stated facility was not a smoking facility but in October 2025 facility started to allow residents to smoke and the social service person completed the initial smoking assessments. The MDSN stated smoking assessment was to be completed quarterly but Residents' 41, 52 and 54 was not completed until 3/17/26, stated It was supposed to be completed sooner. The MDSN stated smoking assessment was important to ensure residents are safe to smoke.During an interview on 3/20/26 at 2:25 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the multidisciplinary team (MDT- experts from different fields work collaborate to provide comprehensive care) to ensure smoking assessments were completed quarterly. The DON stated there should have been another smoking assessment completed for Residents' 41, 52 and 54 after their initial assessments after the facility decided to allow residents to smoke. During an interview on 3/20/26 at 3:28 p.m. with the Administrator (ADM), the ADM stated she completed Residents' 41, 52 and 54's initial smoking assessment when she was the Social Service Director. The ADM stated, Smoking assessment should be completed quarterly to ensure residents are still safe to smoke. During a review of facility's policy and procedure (P&P) titled, Smoking Policy-Residents, dated 10/23, the P&P indicated, .Resident smoking status is evaluated upon admission.A resident's ability to smoke safely is re-evaluated quarterly, upon significant change [(physical or cognitive)] and as determined by staff. The facility may impose smoking restriction on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for four of eight sampled residents (Resident 5, Resident 6, Resident 11 and Resident 40) when:1. The facility did not follow their Policy and Procedure (P&P) for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) by placing EBP signage inside the room on the wall and EBP containers were below the EBP signage inside the room.2. Personal Protective Equipment (PPE) was not worn during care for Resident 11, Resident 40 and Resident 5. 3. The gastrostomy tube (G-tube- a surgical opening made through the abdominal wall into the stomach to insert a feeding tube for long-term nutritional support tube) for Resident 11 and Resident 40 had dried residue on the G-tube's medication and feeding port (the opening or access point on the outside of a feeding tube that allows formula, water, and medication to be delivered directly into the stomach).4. The connector end of the feeding bag tubing for Resident 40 did not have a tube cover cap, was left open to air and the exposed feeding bag tubing connector was available for use by Registered Nurse (RN) 4 to Resident 40's feeding port during enteral feeding (tube feeding- is a method of delivering liquid nutrients directly into the stomach or small intestine via a tube).5. Resident 6's yank [NAME] suction catheter (YSC-a rigid, oral suction instrument used to clear blood, saliva, and secretions from a patient's mouth and throat, primarily to prevent aspiration) was not dated to indicate the YSC's first use date, the YSC had yellow substance inside and at the tip of the YSC and the storage package had some dried yellow/brown substance.6. Resident 6's oxygen (O2- a colorless, odorless and tasteless gas essential for life) tubing was not labeled to indicate the O2 tubing's first use date.7. During an observation of medication administration on 3/18/26 at 4:00p.m., Registered Nurse (RN) 3 obtained blood pressure (a measurement that showed how hard the blood was pushing against the wall of the blood vessels when the heart pumped and when it rested) readings from Resident 26, 14 and 34 using the same blood pressure cuff without cleaning or disinfecting (the process of cleaning something to kill germs and make it safe to use) the equipment between residents. These failure had the potential to result in cross contamination (when germs were spread from one person, surface or object to another, which could make someone sick) and the transmission of infectious organisms (tiny living things, like germs or viruses that could enter the body and cause illness) between residents, placing residents at risk of infectionFindings: 1. During an observation on 3/17/2026 at 10:02 a.m. in Resident 11's room, there was EBP signage inside the room on the wall and EBP containers were below the EBP signage inside the room. During an observation on 3/17/26 at 10:10 a.m. during in Resident 5's room and Resident 40's room, there was EBP signage inside the room on the wall and EBP containers were below the EBP signage inside the room. During an interview on 3/18/26 at 3:37 p.m. with RN 4, RN 4 stated EBP is used when residents have communicable disease. RN 4 stated she wears PPE when caring for residents with G-tubes, catheter, and dialysis port. RN 4 stated this was important because there was an opening in the residents' body, and the PPE protected the residents from cross contamination. During a concurrent interview and record review on 3/20/26 at 8:50 a.m. with the Infection Preventionist (IP), the facility's P&P titled, Enhanced Barrier Precautions, dated 8/2022, and a picture of the EBP signage and EBP containers in Resident 5 and Resident 11's rooms were reviewed. The P&P indicated, .Policy Statement- Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.Policy Interpretation and Implementation.5. EBPs are indicated . for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms. 12. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. The IP stated the EBP signage was placed on the inside of residents' room by the door, and there was a 3-drawer container underneath the signage where the PPE equipment was stored. After a review of the P&P, the IP stated the facility did not have the EBP containers outside the residents' room. The IP stated it made more sense for the signage to be outside the room, along with the PPE to ensure family and staff were aware residents were on precaution. During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, and the picture of the EBP signage and EBP containers in Resident 5 and Resident 11's rooms were reviewed. The DON stated the EBP containers should be outside the residents' room. The DON stated the facility did not follow the EBP policy. During a concurrent interview and record review on 3/20/26 at 11:56 a.m. with the Administrator (ADM), the picture of the EBP signage and EBP containers in Resident 5 and Resident 11's rooms were reviewed. The ADM stated the EBP containers should be outside the residents' room. The ADM stated the EBP policy was not followed. During a review of Centers for Disease Control and Prevention (CDC)'s website, Professional Reference titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, (found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) the reference indicated, .Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 2. During an observation on 3/17/26 at 9:20 a.m. with Resident 11 in Resident 11's room, there was an EBP signage inside the room on the wall. The EBP signage indicated . Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. device care or use: central line, ., feeding tube. Resident 11 was lying in bed with eyes opened, unable to communicate. Resident 11 had a G-tube with feeding pump by the bedside. During an observation on 3/17/26 at 12:22 p.m. in Resident 11's room, RN 3 was observed in Resident 11's room with gloves on and no gown worn, administering medication through Resident 11's G-tube. During a review of Resident 11's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/18/26, the AR indicated, Resident 11, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . hemiplegia (form of paralysis that causes severe or complete loss of muscle function, weakness, or stiffness on only one side of the body), quadriplegia (paralysis affecting all four limbs- both arms and both legs- and usually the torso, caused by damage to the spinal cord in the neck), gastrostomy status, dysphagia (difficulty or discomfort in swallowing), gastrostomy infection, gastrointestinal hemorrhage (bleeding that occurs anywhere along the digestive tract- from the esophagus down to the rectum) . During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 12/29/25, the MDS section C1000 indicated, Resident 11's Staff Assessment for Mental Status- Cognitive skills for daily decision-making score was 3 (0. Independent- decision consistent/ reasonable, 1. modified independence- some difficulty in new situations only, 2. moderately impaired- decisions poor; cues/ supervision required, 3. severely impaired- never/ rarely made decisions). The score indicated Resident 11 was severely impaired During a review of Resident 11's Order Summary Report (OSR), the OSR indicated .Enteral Feed two times a day related to gastrostomy status .dysphagia, . G-tube: [named brand] feeding formula 1.5 kcal (kilocalorie- a unit of energy used to measure the amount of energy provided by food and drinks) at 40 mL (milliliter- unit of measure)/hour x 20 hours, providing 800 ml/1200kcal . order start date 1/21/26. During a review of Resident 11's Care Plan (CP), the CP indicated .Resident 11 is on Enhanced Barrier Precaution due to G-tube placement with interventions . Staff to use appropriate PPE equipment prior to providing direct care and/or handling resident's body fluids .start date 9/12/24. During an interview on 3/18/26 at 1:55 p.m. with RN 3, RN 3 stated EBP meant facility staff wear the PPE whenever care is provided for residents with G-tube, catheter care (thin, flexible, or rigid tube inserted into the body to drain fluids (like urine), inject fluids (like medicine), or keep passageways open), bedside dressing. RN 3 stated it is used to protect staff and the residents. When asked if she used the PPE when administering enteral feeding, RN 3 stated she did not use the PPE, RN 3 stated she was expected to use the PPE always when caring for residents with G-tube. RN 3 stated it was important to use the PPE to prevent infection from staff to residents. During an interview on 3/18/26 at 2:38 p.m. with CNA 8, CNA 8 stated EBP was used whenever any resident had a port, catheter or G-tube. CNA 8 stated the expectation was that staff should wear the gown and have all material to be used ready before resident care. CNA 8 stated this was important because if the staff was sick, the staff did not get the residents sick and if the residents were sick, the staff did not get sick. During an interview on 3/20/26 at 8:50 a.m. with the IP, the IP stated the expectation from the Licensed Nurse (LN)s was to wear the gown for G-tube feeding, to protect Resident 11. During an interview on 3/20/26 at 10:56 a.m. with the DON, the DON stated she expected RN 3 to use PPE during when handling Resident 11 feeding tube to prevent infection. During a concurrent observation and interview on 3/19/26 at 11:43 a.m. with RN 2 in Resident 40's room, RN 2 was observed operating the feeding tube on Resident 40. RN 2 did not wear a PPE gown. RN 2 stated there was no need for LNs to wear a PPE gown when handling a feeding tube. RN 2 stated feeding tube was not included in the list of devices that required EBP usage when residents are on EBP. During a review of Resident 40's AR, dated 3/20/26, the AR indicated, Resident 40, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . Anoxic brain damage (a type of injury caused by a total lack of oxygen reaching the brain, leading to brain cell death within minutes), systemic inflammatory response syndrome (SIRS- a widespread, intense inflammatory reaction throughout the body, acting as a warning sign of severe stress, infection, or trauma), bacteremia (the presence of viable bacteria in the bloodstream), dysphagia, gastrostomy status . During a review of Resident 40's MDS, dated [DATE], the MDS section C was not completed. During a review of Resident 40's OSR, the OSR indicated .G-tube: NPO (nothing by mouth) . order start date 1/21/26. During a review of the facility's EBP signage, the EBP signage indicated . Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. device care or use: central line, ., feeding tube. During an interview on 3/20/26 at 8:34 a.m. with RN 2, RN 2 stated EBP was used for residents that had wound dressing, dialysis residents, and feeding tubes. RN 2 stated she should have worn a gown on 3/19/26 when she attended to Resident 40 during initiation of feeding through the feeding tube. During an observation on 3/20/26 at 8:25 a.m. with RN 2 and CNA 12 in Resident 5's room, RN 2 was observed performing a wound dressing treatment while CNA 12 assisted by holding Resident 5's Right leg. RN 2 had gown, mask and gloves on. CNA 12 had gloves on but did not wear a gown. RN 2 applied the treatment as ordered to Resident 5's fifth toe on the right foot. During a review of Resident 5's AR, dated 3/20/26, the AR indicated, Resident 5, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . pressure ulcer of sacral region (a localized injury to the skin and underlying tissue, typically over the tailbone (sacrum), caused by prolonged pressure, friction, or shear), urinary tract infection (an infection caused by bacteria entering the urinary system, commonly affecting the bladder), pressure induced deep tissue damage of left heel . During a review of Resident 5's MDS, dated [DATE], the MDS section C1000 indicated, Resident 5's Staff Assessment for Mental Status- Cognitive skills for daily decision-making score was 3. The score indicated Resident 5 was severely impaired During a review of Resident 5's OSR, the OSR indicated .Wound Treatment (Deep Tissue Pressure Injury on Right fifth toe) . order start date 3/18/26. During a review of Resident 5's CP, the CP indicated .Resident 5 was on Enhanced Barrier Precaution . with interventions . Wear PPEs during high contact activities/care to reduce the transmission of infection. During an interview on 3/18/26 at 3:37 p.m. with RN 4, RN 4 stated Resident 5 had a pressure ulcer on the fifth toe on the right foot. RN 4 stated the LNs were responsible for cleaning the PU site During an interview on 3/20/26 at 8:34 a.m. with RN 2 outside Resident 5's room, RN 2 stated EBP was used for residents that had wound dressing, dialysis residents, and feeding tubes. RN 2 validated CNA 12 did not wear a gown during the wound treatment for Resident 5. RN 2 stated CNA 12 should have worn a gown to ensure there was precaution for herself and Resident 5. RN 2 stated the failure could bring about cross contamination, because CNA 12 was caring for so many residents. During an interview on 3/20/26 at 8:36 a.m. with CNA 12, CNA 12 stated EBP was used for any resident that had a catheter, colostomy bag (a lightweight, waterproof pouch worn over a surgically created opening in the abdomen), wound care. CNA 12 stated herself and RN 2 completed the wound treatment on Resident 5's right foot. CNA 12 stated, since she was involved in the wound care process, she should have worn a gown. CNA 12 stated it was important to avoid anything coming in contact with staff and the wound. CNA 12 stated the failure could have led to the spread of infection. During an interview on 3/20/26 at 8:50 a.m. with the IP, the IP stated the use of the EBP was for any resident with device in them, wounds, foley catheter, dialysis resident, residents with G-tube. The IP stated the expectation was for CNA 12 to wear a gown to keep Resident 5 safe, and to prevent infection spreading to other residents. During an interview on 3/20/26 at 10:56 a.m. with the DON, the DON stated she expected CNA 12 and RN 4 to wear PPE during wound treatment for Resident 5. During a review of the facility's P&P titled, Dressing, Dry/Clean dated 2001, the P&P indicated, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings.Equipment and Supplies.5. Personal protective equipment (e.g., gowns, gloves, masks.) . During a review of the facility's P&P titled, Enhanced Barrier Precaution dated 08/2022, the P&P indicated, Purpose: Enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. Policy interpretation and implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gowns and gloves used during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include.g. device care or use (.feeding tube, .) . h. wound care (any skin opening requiring a dressing) .5. EBPs are indicated .for residents with wounds and/ or indwelling medical devices regardless of MDRO colonization. 9. Staff are trained to care for residents on EBPs. 3. During an observation on 3/17/26 at 12:22 p.m. in Resident 11's room, RN 3 was observed administering medication through Resident 11's G-tube. The G-tube port was observed to have brown substance at around the opening of the medication and feeding port. During an observation on 3/17/26 at 12:35 p.m. in Resident 40's room, RN 4 was observed during enteral feeding for Resident 40. Resident 40's G-tube port was observed to have brown /black substance at around the opening of the medication and feeding port. During a concurrent interview and record review on 3/20/26 at 8:50 a.m. with the IP, the picture of Resident 11 and Resident 40's the G-tube's medication and feeding ports were reviewed. The IP stated Resident 11's G-tube port looked like dark substance or dried formula. The IP stated Resident 40's G-tube tubing looked good but the G-tube ports did not. The IP stated the substances could be really dried formula. The IP stated the G-tube port should not look that way. The IP stated the expectation from LNs would be to keep the ports clean and when there was so much build up then the G-tube should be replaced. During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the DON, the picture of Resident 11 and Resident 40's the G-tube's medication and feeding ports were reviewed. The DON stated the substance inside the G-tube ports for Resident 11 and Resident 40 were residuals. The DON stated the LNs were not flushing the G-tube properly. The [NAME] stated the LNs were not properly cleaning the port before and after feeding. The DON stated if the tube was not clean or the residuals could no longer come off, then the G-tube needed to be changed. The DON stated the expectation from the LNs was they flush the tube and clean the residuals. The DON stated the failure had the potential to cause gastrointestinal infection (GI- an infection/inflammation of the stomach and intestines caused by viruses, bacteria, or parasites) for the residents. During a concurrent interview and record review on 3/20/26 at 11:56 a.m. with the ADM, the picture of Resident 11 and Resident 40's the G-tube's medication and feeding ports were reviewed. The ADM stated the G-tube port was dirty. The ADM stated the G-tube port was not cleaned properly 4. During an observation on 3/17/26 at 10:56 a.m. during the initial tour in Resident 40's room, Resident 40 was in bed sleeping and there was a feeding pump with feeding formula set up. The connector end of the feeding bag tubing for Resident 40 did not have a tube cover cap and was left open to air. The inside of the feeding bag tubing was observed to be clogged with dried formula build up and around the tip of the connector end of the feeding bag tubing had dried formula build up. During a concurrent observation and interview on 3/17/26 at 12:35 p.m. in Resident 40's room, RN 4 was observed during enteral feeding for Resident 40. RN 4 was observed taking the exposed connector end of the feeding bag tubing that had dried formula buildup at the tip and was clogged on the inside of the feeding bag tubing for Resident 40's G-tube feeding port. RN 4 was asked if the tip of feeding tube should be opened and attached to Resident 40. RN 4 stated the tip of the feeding bag tubing should have been covered with a cap. RN 4 was observed cleaning around the end of feeding bag tubing and inside the feeding bag tubing with the hand glove she had removed. RN 4 stated I used the inside of the gloves to clean the tip of the tube. When asked if that was the correct process, RN 4 stated it should not be like that, I would use a gauze with normal saline. When asked if using the gauze with normal saline would remove the dried formula content partially obstructing the inside of the feeding bag tubing, RN 4 stated after cleaning with the gauze and normal saline, the tube would still have dried formula. During an interview on 3/18/26 at 3:37 p.m. with RN 4, RN 4 stated there was dried formula on the inside of the feeding bag tubing for Resident 40. RN 4 stated she should have inspected the feeding bag tubing before connecting it to Resident 40, and since the cap of the tubing was not there, she should have changed the whole feeding tube set. RN 4 stated attaching the feeding tube to Resident 40 was passing bacteria to the resident due to the tip of the feeding tube been opened to air for over 4 hours. RN 4 stated the last enteral feeding for Resident 40 was completed at 8 a.m. and the feeding was re-started at 12 p.m. RN 4 stated Resident 40 could have gotten GI infections due to this failure. During an observation on 3/18/26 at 8:02 a.m. in Resident 40's room, Resident 40 was in bed sleeping and the feeding bag tubing was observed to be on the floor. During a review of Resident 40's AR, dated 3/20/26, the AR indicated, Resident 40, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . Anoxic brain damage, systemic inflammatory response syndrome, bacteremia, dysphagia, gastrostomy status . During a review of Resident 40's OSR, the OSR indicated .G-tube: NPO (nothing by mouth) . order start date 1/21/26. During a concurrent interview and record review on 3/20/26 at 8:50 a.m. with the IP, the picture of Resident 40's feeding bag tubing that had no cover cap and the picture of the feeding bag tubing lying on the floor were reviewed. The IP stated there was no cover cap at the end of the feeding bag tubing. The IP stated there should have been a cover cap, because without the cover cap, the feeding bag tubing was exposed, and anything could crawl up the inside of the feeding bag tubing. The IP stated if feeding bag tubing is not connected Resident 40, there should be a cap on the tip of the tubing. The IP stated the failure could lead to an infection, make the Resident 40 very sick and Resident 40 could end up in the hospital. The IP stated there was dried formula inside the tubing. The IP stated RN 4 using the inside of the glove to clean the tubing was wrong because the gloves were already contaminated with the RN 4's hand. The IP stated when RN 4 realized she did not cap the end of the tubing; she should have changed out the whole set to prevent any kind of infection to Resident 40. The IP stated the capped tubing lying on the floor should be on the pole. During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the DON, the picture of Resident 40's feeding bag tubing that had no cover cap and the picture of the feeding bag tubing lying on the floor were reviewed. The DON stated if feeding bag tubing is not connected to the resident it should be covered with a cap. The DON stated the tube should not be hanging or lying on the floor. The DON stated the whole tubing kit needed to be changed. During a concurrent interview and record review on 3/20/26 at 11:56 a.m. with the ADM, the pictures of Resident 40's feeding bag tubing that had no cover cap and the clogged inside of the feeding bag tubing were reviewed. The ADM stated Resident 40 would not be getting sufficient formula since the tubing was occluded. The ADM stated there should have been a cap on the tubing. 5. During an observation on 3/17/26 at 11:19 a.m. in Resident 6's room during the initial tour, Resident 6 was not in his room, the YSC was noted to have no label indicating the date Resident 6 started the use of the YSC. During a concurrent observation and interview on 3/17/26 at 12:09 p.m. with Resident 6 in his room, Resident 6 was sitting in a wheelchair, the YSC tip and inside were noted to have yellow substances and the inside of the storage package had some dried yellow/brown substance. Resident 6 stated the YSC was to help suck the extra saliva in his mouth. Resident 6 stated when there is a buildup of saliva in my mouth, I choke on it. Resident 6 stated the last time he used the YSC to suction was the day before which indicated 3/16/26. During a review of Resident 6's AR, dated 5/8/25, the AR indicated, Resident 6, was admitted to the facility on [DATE] from nursing home and had diagnoses that included . cerebral infarction (brain tissue death caused by a lack of blood supply), chronic obstructive pulmonary disease (COPD- is a progressive, long-term lung disease that makes it hard to breathe), dysphagia following cerebral infraction, Methicillin-resistant Staphylococcus aureus infections (MRSA-a type of staph bacteria resistant to many common antibiotics, causing serious, hard-to-treat infections) . During a review of Resident 6's MDS, dated [DATE], the MDS section C indicated Resident 6 had a had 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 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview. The BIMS score indicated Resident 6 was cognitively intact. During a review of Resident 6's OSR, the OSR indicated .May use oral suctioning PRN for increased sections. order start date 6/19/25. During a concurrent interview and record review on 3/18/26 at 2:38 p.m. with CNA 8, the picture of Resident 6's YSC was reviewed. CNA 8 stated Resident 6 used the YSC for both his nose and his mouth. CNA 8 stated the YSC did not have a label. CNA 8 stated the YSC should have a label and should be changed every week. CNA 8 stated the Respiratory Therapist (RT) was responsible for changing the YSC. CNA 8 stated the date label should be on the YSC tubing. CNA 8 stated it was important, so that LNs know when to change the YSC, there should be no cross contamination, and it prevented Resident 6 from getting sick. CNA 8 stated the inside of the YSC had probably phlegm (thick, sticky mucus produced in the lungs and throat, usually during illness) from inside the Resident 6's nose or mucous. CNA stated the package where the YSC was stored had dead skin and it was contaminated. CNA stated this could lead to a respiratory infection for Resident 6. During a concurrent observation, interview and record review on 3/18/26 at 2:55 p.m. with the RT, Resident 6's YSC was observed in Resident 6's room and Resident 6's OSR were reviewed. The RT stated the YSC should be changed weekly or as needed (PRN). The RT stated this was important for infection control purposes. The RT stated the facility staff want to prevent possible diseases entering Resident 6's lungs that could lead to pneumonia. The RT stated there should be 2 YSC for Resident 6, one for the mouth and one for the nose. The RT stated the label could be placed on the YSC itself or the manufacturer's package. The RT stated the manufacturer's package was what was used as storage for the YSC. The RT stated both the RT and the LNs were responsible for changing the YSC. During the observation in Resident 6's room, the Oral suction device, canister and tubing were observed. The RT stated there was hardened mucous in the YSC. The RT stated there was accumulated dust or old fluid from the secretion in the storage package. The RT stated there was no label on the tubing, device or the canister. The RT stated the YSC should have been labeled. The RT stated this was important, so the LN and RT know when to change the YSC and for infection prevention. The RT stated the whole process on the YSC was not properly implemented. The RT stated the substance in the YSC could lead to respiratory infection. During a concurrent interview and record review on 3/20/26 at 8:50 a.m. with the IP, the picture of Resident 6's YSC was reviewed. The IP stated disgusting material was inside the YSC. The IP stated the inside of the package had collected dust which should not be there. The IP stated her expectation was that the YSC should be cleaned and changed as needed. The IP stated this failure could lead to oral infection for Resident 6, and the infection could get to Resident 6's GI and Resident could have major issues. During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the DON, the picture of Resident 6's YSC was reviewed. The DON stated the YSC was dirty. The DON stated the YSC should be changed every 24 hours. The DON stated Resident 6 could develop infection. 6. During an observation on 3/17/26 at 10:13 a.m. with Resident 8 during the initial tour, Resident 8 was in bed sleeping and a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nose, connected to a working oxygen concentrator (device that produces oxygen for breathing). The middle part of the O2 tubing was in a bag dated 2/7/26, and the O2 tubing itself has no date label indicating the date Resident 8 started the use of the O2 tubing. During a concurrent interview and record review on 3/18/26 at 1:55 p.m. with RN 3, the picture of Resident 8's O2 tubing was reviewed. RN 3 stated there was no label close to the connector or on any part of the O2 tubing. RN 3 stated the storage bag was dated 2/7/26. RN 3 stated the date on the bag was for the nebulizer set and Resident 8 uses the nebulizer every morning. RN 3 stated whenever the O2 tubing is changed, it should be labeled with the date. RN 3 stated the label was expected to be attached close to the connector. During a concurrent interview and record review on 3/18/26 at 2:38 p.m. with CNA 8, t

Based on interview and record review, the facility did not ensure completion of a performance review/evaluation of nurse's aides were competed at least every 12 months for two of three Certified Nurse Assistant (CNA 8 and CNA 9) when the CNAs personnel files review did not have annual performance evaluations since their Date of Hire (DOH).This failure had the potential to negatively affect the competency of the CNAs and the quality of care provided to the facility residents. Findings:During a concurrent interview and record review on 3/19/2026 at 1:57 p.m., with the Director of Staff Development (DSD), CNA 8, CNA 9, and CNA 10's personnel files were reviewed. The personnel file for CNA 8 indicated CNA 8's DOH was 12/9/24, and there was no performance evaluation completed in CNA 8's file. The personnel file for CNA 9 indicated CNA 9's DOH was 6/6/23, and there was no performance evaluation completed in CNA 9's file since DOH. The DSD stated she was responsible for ensuring the performance review of the CNAs were completed. The DSD stated the sampled CNAs did not have performance evaluations completed annually. The DSD stated this was important because it helped ensure staff were able to provide quality care for residents.During an interview on 03/20/2026 at 10:56 a.m. with the Director Of Nurses (DON), the DON stated the performance review/evaluation determines if a staff is able to do the job the right way. The DON stated evaluations should be done 3 months after hire, after one year, and yearly for staff that are still employed longer than one year. The DON stated the expectation from the DSD was there should have been performance evaluation every year. The DON stated this was important because it would determine if the staff were performing poorly or improving. The DON stated if the staff were consistently performing poorly, the staff would need to be let go.During a review of the facility's Policy and Procedure (P&P) titled, Hiring Policy & Procedure, undated, the P&P indicated, .Policy- The facility shall implement a standardized hiring process to ensure all employees are: Qualified, competent and legally eligible for employment; Properly screened . oriented and trained prior to resident care. Purpose- To ensure: Safe and competent staffing, protection of resident health and safety, compliance with state regulatory and survey standards, proper documentation for survey readiness.Responsibility- Administrator: Final hiring approval and compliance oversight, Human Resources (HR): Manage hiring process and documentation, Department Heads: Conduct interviews and competency validation, DON (Director of Nursing): Verify clinical staff qualifications. 5. Procedure.5.9 Personnel File Requirement . Each employee file must include .Performance evaluations.During a review of the facility's P&P titled, Performance Evaluations, dated 09/2020, the P&P indicated, .Policy Statement- The job performance of each employee shall be reviewed and evaluated at least annually. Policy Interpretation and Implementation1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.4. Performance evaluations will be completed by the employee' department directors and supervisors.5. The written performance evaluations will contain the director's and /or supervisor's remarks and suggestions, any actions that should be taken (e.g. further training, etc.), and goals.9. The completed performance evaluation will be. placed in the employee's personnel record.

Based on observation, interview and record review the facility failed to ensure staff provided care in a manner that maintained resident dignity during mealtime assistance for one of four sampled residents (Resident 1)This failure to ensure staff assisted residents at eye level, rather than standing over residents during feeding, had the potential to cause Resident 1 to feel intimidated, uncomfortable and experience a loss of dignity during care.Findings:During an observation on 3/17/26 at 11:59 a.m. Certified Nursing Assistant (CNA) 6 was observed standing over Resident 1 while assisting with feeding at the bedside. Resident 1 was positioned in bed with the head of the bed elevated. CNA 6 remained standing directly over Resident 1 throughout the feeding assistance.During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included cerebral infarction (occurred when blood could not reach part of the brain. Without blood, that part of the brain did not get oxygen [a gas people breathed to stay alive and give the body energy] and became damaged. This could cause problems like weakness, trouble talking or moving), dementia (a condition that affected the brain and caused problems with memory, thinking and daily activities), depression (a condition that caused a person to feel very sad, lose interest in things and have trouble with daily life), and bipolar (a condition that caused a person to have extreme mood changes, including very high moods and very low moods).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was incomplete indicating Resident 1 was severely cognitively impaired and BIMs score could not be completed.During an interview on 3/19/26 at 9:29 a.m. with CNA 6, CNA 6 stated when preparing to feed a resident, she would obtain the meal tray and position the resident for feeding with the head of the bed elevated. CNA 6 stated Resident 1 could be pushy at times and may attempt to fight, and therefore she preferred to remain standing while feeding him. CNA 6 further stated staff were typically expected to sit next to the resident during feeding to promote a homelike environment.During an interview on 3/20/26 at 9:25 a.m. with the Director of Staff Development (DSD), the DSD stated the CNA should sit next to the resident and offer food from the tray. The DSD stated the CNA should be at eye level and in close proximity to the resident during feeding. The DSD further stated it would be inappropriate for staff to stand over a resident during feeding, as this could be intimidating and make the resident uncomfortable, impacting the resident's dignity.During an interview on 3/20/26 at 11:56 a.m. with the Director of Nursing (DON), the DON stated it was not the facility's expectation for CNA's to stand over residents during feeding. The DON stated CNA's should be seated in a chair and positioned at eye level with the resident during feeding. The DON further stated this was a dignity issue and it was not appropriate for residents to have staff standing over them during mealtimes.During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated 2017, the P&P indicated, resident's who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals.During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 2009, the P&P indicated, residents shall be treated with dignity and respect at all times.treated with dignity and respect means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview and record review, the facility failed to ensure physician (MD) notification of elevated blood glucose (the amount of sugar in the blood that the body used for energy) levels per facility procedure for one of four sampled residents (Resident 33). When Resident 33 had seven blood glucose readings from 3/1/26 through 3/18/26 that were greater than 350 milligrams per deciliter (mg/dL a unit of measurement. Blood glucose normal range is 80 to 130 before meals). This failure resulted in Resident 33's blood glucose levels to go unmonitored and delayed adjustment of the treatment regimen and had the potential to result in adverse outcomes including significantly elevated blood sugars, dehydration (when the body did not have enough water to stay healthy and work the way it should), infection and hospitalization. Findings:During an observation on 3/17/26 at 11:27 a.m., Resident 33 was observed in her room eating lunch while watching television. Registered Nurse (RN) 4 entered the room to perform a blood glucose check and administer lispro-a fast-acting type of insulin used to lower blood sugar levels, usually given around mealtimes) insulin 12 units as ordered. The blood glucose result was obtained and measured at 223mg/dL. Resident 33 appeared alert and oriented and did not exhibit signs of distress or concern. During the observation, Resident 33 stated it's been higher. During a review of Resident 33's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 33 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes. During a review of Resident 33's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 33 had no cognitive impairment. During an interview on 3/18/26 at 2:15 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 described Resident 33 as an easy-going resident who was alert and preferred to do things independently. CNA 7 stated Resident 33 was diabetic, and staff were expected to notify the nurse when meal trays were delivered so insulin could be administered as ordered. During a concurrent interview and review of Resident 33's electronic health record on 3/19/26 at 10:37 a.m. with RNS, Resident 33 was described as alert and oriented and able to communicate her needs. Review of the medication orders indicated Resident 33 was prescribed brand name long acting (a long-acting type of insulin that worked slowly over the day to help keep blood glucose levels steady) in the evening and short acting insulin. The order for short acting insulin included instructions to hold the medication if the blood glucose level was less than 100 mg/dL. There were no additional blood glucose level parameters in Resident 33's medical record. RNS stated it was important to have MD notification parameters to determine when blood glucose levels were outside an acceptable range and whether medication adjustments were needed. RNS stated the facility followed a standard blood glucose range for diabetic residents and indicated nurses should know when to notify the MD. During the interview, RNS initiated entry of an order in Resident 33's chart to notify the MD if blood glucose levels were below 60 mg/dL or above 350 mg/dL. Review of Resident 33's blood glucose records for the month of March indicated blood glucose readings greater than 350 mg/dL on 3/5/26 (402 at breakfast and dinner), 3/8/26 (379 at dinner), 3/13/26 (366 at lunch), 3/14/26 (400 at dinner) and 3/16/26 (390 at breakfast and 393 at lunch). RNS stated the MD should have been notified of Resident 33's elevated glucose on 3/5/26, 3/8/26, 3/13/26, 3/14/26, and 3/16/26. There was no documentation that Resident 33's MD had been notified. During an interview on 3/20/26 at 11:56 a.m. with the Director of Nurses (DON), the DON stated nursing staff were expected to obtain blood glucose readings, follow ordered parameters and administer insulin according to a sliding scale. The DON stated elevated blood glucose readings exceeding parameters required attention. The DON stated residents on insulin should have parameters in the medical record indicating when to notify the MD. The DON stated nurses should notify the MD when blood glucose readings were consistently elevated and multiple readings above 350mg/dL, a blood glucose greater than 350 mg/L would be considered a change in condition. The DON stated her expectation was for nursing staff to contact the MD to obtain appropriate blood glucose parameters for residents. The DON stated when Resident 33's blood glucose was elevated nurses should have completed a change in condition assessment. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, the P&P indicated, the nurse will notify the resident's attending physician or physician on call when there has been a (an): e. need to alter the resident's medical treatment significantly. i. specific instruction to notify the physician of changes in the resident's condition.except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.During a review of the facility's policy and procedure (P&P) titled, Diabetes-Clinical Protocol, dated 2001, the P&P indicated, the physician will follow up on any acute episodes associated with a significant sustained change in blood sugars.the physician will order desired parameters for monitoring and reporting information related to blood sugar management. a the staff will incorporate such parameters into the medication administration record and care plan.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated, documentation of procedures and treatments will include care-specific details, including f. notification of family, physician or other staff, if indicated.During a review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, dated 2001, the P&P indicated, reports promptly to the supervisor and the attending physician.reports other information in accordance with facility policy and professional standards of practice.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS- MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of four sampled residents (Residents' 9 and 52) when:1.Resident 9's surgery was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 9's surgical care needs to not be treated properly. 2.Resident 52's dental health was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 52's dental health problems to go untreated due to inaccurate assessments of missing and broken natural teeth.Findings:1.During a concurrent observation and interview on 3/17/26 at 9:48 a.m. during initial tour in Resident 9's room, Resident was lying in bed and watching a show on his electronic device. Certified Nurse Assistant (CNA) 11 was standing at bedside and trying to communicate with Resident 9 using gestures. CNA 11 stated Resident 9 did not speak and only communicated using signs, gestures and pointing at things. During a review of Resident 9's admission Record (AR- a document containing resident profile information), dated 3/19/26, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included paraplegia (loss of movement or sensation in the lower half of the body), chronic tubulo-interstitial nephritis (long-term kidney disease characterized by lasting inflammation and scarring in the spaces between the kidney) and infection and inflammatory reaction due to nephrostomy catheter (small, flexible tube inserted through the back into the kidney to drain urine directly into an external bag).During a review of Resident 9's Care Plan (personalized, written guide outlining a person's health needs, goals, and the specialized daily support required to manage their well-being) dated 3/2/26, the Care Plan indicated, Focus: Resident has infection to right quad (abdominal quadrants) laparoscopic (keyhole surgery- minimally invasive technique where doctors operate through 1-3 tiny incisions in the belly using a camera) site due to kidney removal (3/2/26).During an interview on 3/18/26 at 4:07 p.m. with CNA 3, CNA 3 stated she was familiar with Resident 9's care. CNA 3 stated Resident 9 had multiple wounds, three or four small openings on his abdominal area. CNA 3 stated the nurse changed the dressings every day. CNA 3 stated Resident 9 did not talk and communicated only by gestures and pointing at things. During a concurrent interview and record review on 3/20/26 at 8:51 a.m. with Minimum Data Set Nurse (MDSN), MDSN reviewed Resident 9's quarterly MDS assessment dated [DATE] section M (Surgical Conditions), MDSN stated Resident 9's surgical wound was not coded in the MDS assessment. MSDN stated she should have coded as yes because Resident 9 had a surgical wound and daily treatment was still being provided. 2.During a concurrent observation and interview on 3/17/26 at 9:55 a.m. during initial tour in the hallway outside of Resident 52's room, Resident 52 was sitting up in his wheelchair. Resident 52 stated he had been in the facility for almost two years. Resident 52 had broken and missing natural teeth to the top and bottom gums. Resident 52 stated he was seen by a dentist recently who was in the facility but did not remember the exact date. Resident 52 stated he did not have any mouth pain but would like to get his teeth fixed. During a review of Resident 52's AR dated 3/20/26, the admission Record, indicated Resident 52 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizures. During a concurrent interview and record review on 3/20/26 at 8:39 a.m. with Infection Preventionist (IP), the IP stated she covered as the MDS nurse but not sure of the exact dates. The IP reviewed Resident 52's annual MDS assessment dated [DATE] that she had completed. The IP stated MDS assessment section L (Oral/Dental Status) was not coded correctly because Resident 52 has broken natural teeth. The IP stated she should have placed a check mark on Section L0200D (obvious or likely cavity or broken natural teeth) but she did not. During an interview on 3/20/26 at 2:29 p.m. with the Director of Nursing (DON), the DON stated her expectation was for each person completing a section in the MDS assessment to accurately reflect resident assessed status.During an interview on 3/20/26 at 3:20 p.m. with the Administrator (ADM), the ADM stated, I trust the MDS nurse to make sure the assessments are accurate. The ADM stated each person completing a section in the MDS assessment was responsible in making sure their assessments reflected the condition of each resident.During a review of facility document titled, MDS Coordinator Job Description, undated, the Job description indicated, .Responsible for the initiation and completion of all MDSs on time. Responsible for assisting with all parts of the MDS. Responsible for insuring that the MDS reflect a true picture of the resident. During a review of facility policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 11/19, the P&P indicated, .Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of the assessment. The information captured on the assessment reflects the status of the resident. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident.During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated. Coding Instructions. Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen. Definitions .Surgical Wounds any healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites.

Based on observation, interview, and record review, the facility failed to complete a level 1 Preadmission Screening and Resident Review (PASARR-federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for one of three sampled residents (Resident 36). This failure had the potential for Resident 36 not to receive the appropriate services related to her diagnoses.Findings:During a record review of Resident 36's admission Record (AR-a document containing resident profile information), dated 3/19/26, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses which included palliative care (a type of medical care that helps people who have serious illness feel better; it focuses on relieving symptoms like pain, stress, and other problems, rather than trying to cure the illness), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbance in thoughts).During a review of Resident 36's Order Summary Report (OSR- a breakdown of all orders placed within the specified time period), dated 3/19/26, the OSR indicated, .Resident admitted to [name of hospice agency] Hospice on 02/26/26 under Primary diagnosis of Alzheimer's Dementia (a disease characterized by a progressive decline in mental abilities) .During a concurrent observation and interview on 3/17/26 at 9:34 a.m. during the initial tour in Resident 36' room, Resident 36 was observed sitting at the edge of his bed watching TV and calling for assistance and was assisted by a certified nursing assistant. Resident appeared restless and not able to answer questions appropriately.During a concurrent interview and record review on 3/19/26 at 8:56 a.m. with Minimum Data Set Nurse (MDSN), the MDSN stated she started doing PASARR assessments January 2026. The MDSN stated for new admissions PASARR are completed at the acute hospital and sent to the facility. The MDSN stated she completes a new PASARR assessment for significant changes like admitted or discharged from hospice care. Resident 36 clinical record was reviewed and MDSN stated Resident 36 was admitted to hospice care on 2/26/26. MDSN stated she did not find a PASARR level 1 completed when Resident 36 was admitted under hospice care. MDSN stated, I should have completed a PASARR level 1 assessment when Resident 36 was admitted under hospice care. MDSN stated PASARR was important to see whether residents needed specialized care. During an interview on 3/20/26 at 2:46 p.m. with the Director of Nursing (DON), the DON stated MDSN was responsible for creating PASARR assessments for significant changes. The DON stated there should have been a new level 1 PASARR assessment completed when Resident 36 was admitted under hospice care. The DON stated PASARR was important to get payment or reimbursement for the care provided to residents. During a record review of the MDS Coordinator's job description undated, the job description indicated, .Responsible for the initiation and completion of all MDSs on time. Responsible for assisting with all parts of the MDS. Meeting with staff and residents to gather information that may have changed. During a record review of the Job Description Director of Nursing, undated, the job description indicated, .Assumes ultimate responsibility for planning, directing, implementing, and evaluating care for all facility residents.During a review of facility's policy and procedure (P&P) titled, Admissions-From Other Healthcare Facilities, revision date 3/17, the P&P indicated, .The following information will be provided to the facility prior to or upon the resident's admission: .PASARR (as appropriate) . During a review of professional reference from the California Department of Health Care Services (DHCS), (a government agency that provides healthcare services to low-income and disabled Californians) titled, Preadmission Screening and Resident Review (n.d.), the PASARR Policy Manual indicated, facilities must ensure that PASARR evaluations are updated when clinically indicated, including after significant changes in condition.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of four sampled residents (Resident 9 and Resident 36) when Resident 9 and Resident 36 did not have care plans for the use of antibiotics (medication used to treat infections caused by bacteria).These failures placed Resident 9 and Resident 36 at a potential risks for harm by not identifying and monitoring for side effects of medications. Findings: During a concurrent observation and interview on 3/17/26 at 9:48 a.m. during initial tour in Resident 9's room, Resident was lying in bed and watching a show on his electronic device. Certified Nurse Assistant (CNA) 11 was standing at bedside and trying to communicate with Resident 9 using gestures. CNA 11 stated Resident 9 did not speak and only communicated using signs, gestures and pointing at things. During a review of Resident 9's admission Record (AR- a document containing resident profile information), dated 3/19/26, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included paraplegia (loss of movement or sensation in the lower half of the body), chronic tubulo-interstitial nephritis (long-term kidney disease characterized by lasting inflammation and scarring in the spaces between the kidney) and infection and inflammatory reaction due to nephrostomy catheter (small, flexible tube inserted through the back into the kidney to drain urine directly into an external bag).During a record review of Resident 36's AR dated 3/19/26, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses which included palliative care (a type of medical care that helps people who have serious illness feel better; it focuses on relieving symptoms like pain, stress, and other problems, rather than trying to cure the illness), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbance in thoughts).During a concurrent observation and interview on 3/17/26 at 9:34 a.m. during the initial tour in Resident 36' room, Resident 36 was observed sitting at the edge of his bed watching TV and calling for assistance and was assisted by a certified nursing assistant. Resident appeared restless and not able to answer questions appropriately.During an interview on 3/19/26 at 9:18 a.m. with Registered Nurse (RN) 1, RN 1 stated licensed nurses are responsible in initiating a care plan when receiving new medication order including antibiotics. RN 1 stated care plan was important to direct nursing staff to care for resident needs.During a concurrent interview and record review on 3/19/26 at 9:59 a.m. with Licensed Vocational Nurse/Assistant Director of Nursing (LVN/ADON), LVN/ADON reviewed Resident 9's clinical record and stated there was an order of antibiotic on 3/2/26 but there was no care plan. LVN/ADON stated there should have been a care plan initiated as soon as Resident 9 started the antibiotic. LVN/ADON stated care plan was important to direct staff how to care for residents. LVN/ADON stated it was the responsibility of licensed nurses to create a care plan as soon as they received new medication order.During a concurrent interview and record review on 3/19/26 at 3:15 p.m. with Minimum Data Set Nurse (MDSN), MDSN reviewed Resident 9's clinical record and stated Resident 9 had an order of antibiotic on 3/2/26. MDSN stated she did not find a care plan for the antibiotic and there should have been one. MDSN reviewed Resident 36's clinical record and stated Resident 36 was ordered antibiotic on 3/13/26. MDSN stated she did not find a care plan for the antibiotic order. The MDSN stated licensed nurse receiving the medication order was responsible in initiating a care plan. MDSN stated the Infection Preventionist (IP) was to make sure there was a care plan initiated and created a care plan if there was none. MDSN stated care plan was important to direct staff to care for residents.During an interview on 3/20/26 at 9:40 a.m. with the IP, the IP stated licensed nurses receiving antibiotic orders were responsible in creating a care plan. The IP stated she reviewed Resident 9 and Resident 36's antibiotic orders but did not remember if she reviewed the care plans. The IP stated, As the IP it was my responsibility to ensure they had care plans.During an interview on 3/20/26 at 2:12 p.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to create a care plan as soon as a new order was received. The DON stated the multidisciplinary team (MDT-coordinated team of specialists collaborating to treat a patient's physical, mental, and social needs, rather than just their symptoms, ensuring holistic care) should have made sure all care plans were reviewed and created care plans if missing. The DON stated care plans directs staff on how to care for residents.During a review of facility policy and procedure (P&P) titles, Care Plans, Comprehensive Person-Centered, revised date 12/16, the P&P indicated, . The Interdisciplinary team (IDT-group of experts from different fields who work closely together to solve complex problems, such as comprehensive patient care), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will: Include measurable objectives and timeframes; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure the care plans (CP) were reviewed and revised for two of eight sampled residents (Resident 6 and Resident 11) when:1. Resident 6 had yankAuer suction catheter (YSC-a rigid, oral suction instrument used to clear blood, saliva, and secretions from a patient's mouth and throat, primarily to prevent aspiration) that he uses for his mouth and nose, and the CP was indicated for oral (relating to the mouth) suctioning use only.2. Resident 11's CP did have interventions reflective of their physician order dated 1/21/26.These failures had the potential for Resident 6 and Resident 11's needs to not be met.Findings:1. During an observation on 3/17/26 at 11:19 a.m. in Resident 6's room during the initial tour, Resident 6 was not in his room, the YSC was noted to be on Resident 6's dresserDuring a concurrent observation and interview on 3/17/26 at 12:09 p.m. with Resident 6 in his room, Resident 6 was sitting in a wheelchair. Resident 6 stated the YSC was to help suck the extra saliva in his mouth. Resident 6 stated when there is a buildup of saliva in my mouth, I choke on it. Resident 6 stated the last time he used the YSC to suction was the day before which indicated 3/16/26.During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/25, the AR indicated, Resident 6, was admitted to the facility on [DATE] from nursing home and had diagnoses that included . cerebral infarction (brain tissue death caused by a lack of blood supply), chronic obstructive pulmonary disease (COPD- is a progressive, long-term lung disease that makes it hard to breathe), dysphagia following cerebral infraction, Methicillin-resistant Staphylococcus aureus infections (MRSA-a type of staph bacteria resistant to many common antibiotics, causing serious, hard-to-treat infections) .During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 3/1/26, the MDS section C indicated Resident 6 had 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 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview. The BIMS score indicated Resident 6 was cognitively intact.During a review of Resident 6's Order Summary Report (OSR- indicates the physician order), the OSR indicated .May use oral suctioning PRN for increased sections. order start date 6/19/25.During a review of Resident 6's CP, the CP indicated .Interventions. May use oral suctioning PRN for increased sections.During a concurrent interview and record review on 3/18/26 at 2:24 p.m. with RN 4, Resident 6's YSC order dated 6/19/25 was reviewed. The order indicated .May use oral suctioning PRN for increased sections. RN 4 stated she was unsure if the YSC was for the nose or mouth because the Respiratory Therapist said it was for Resident 6's nose.During an interview on 3/18/26 at 2:38 p.m. with CNA 8. CNA 8 stated Resident 6 used the YSC for both his nose and his mouth.During a concurrent interview and record review on 3/18/26 at 2:55 p.m. with the RT, Resident 6's YSC order was reviewed. The RT stated Resident 6 had a lot of secretion in his mouth and had runny nose. The RT stated Resident 6 used the YSC for his mouth and nose. The RT stated there should be 2 YSC for Resident 6, one for the mouth and one for the nose.During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the DON, Resident 6's CP was reviewed. The DON stated Resident 6 used the YSC for his nose and mouth and the CP did not reflect that. The DON stated the CP should have been revised to reflect the YSC could be used for both the nose and the mouth.2. During an observation on 3/17/26 at 9:20 a.m. with Resident 11 during the initial tour in Resident 11's room, Resident 11 was lying in bed with eyes opened, unable to communicate. Resident 11 had a gastrostomy tube (G-tube- a surgical opening made through the abdominal wall into the stomach to insert a feeding tube for long-term nutritional support tube) with feeding pump by the bedside.During a review of Resident 11's AR, dated 3/18/26, the AR indicated, Resident 11, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . hemiplegia (form of paralysis that causes severe or complete loss of muscle function, weakness, or stiffness on only one side of the body), quadriplegia (paralysis affecting all four limbs- both arms and both legs- and usually the torso, caused by damage to the spinal cord in the neck), gastrostomy status, dysphagia (difficulty or discomfort in swallowing), gastrostomy infection, gastrointestinal hemorrhage (bleeding that occurs anywhere along the digestive tract- from the esophagus down to the rectum) .During a review of Resident 11's MDS dated 12/29/25, the MDS section C1000 indicated, Resident 11's Staff Assessment for Mental Status- Cognitive skills for daily decision-making score was 3 (0. Independent- decision consistent/ reasonable, 1. modified independence- some difficulty in new situations only, 2. moderately impaired- decisions poor; cues/ supervision required, 3. severely impaired- never/ rarely made decisions). The score indicated Resident 11 was severely impairedDuring a review of Resident 11's OSR, the OSR indicated .Enteral Feed two times a day related to gastrostomy status .dysphagia, . G-tube: [named brand] feeding formula 1.5 kcal (kilocalorie- a unit of energy used to measure the amount of energy provided by food and drinks) at 40 mL (milliliter- unit of measure)/hour x 20 hours, providing 800 ml/1200kcal . order start date 1/21/26.During a review of Resident 11's CP, the CP indicated . Interventions. [named brand feeding formula] 1.5 VIA GTUBE PUMP @ at 70 mL (milliliter- unit of measure)/hour x 20 hours (provides 1400 ml total, 2100kcal, . dated 10/27/2023, revision on 10/11/2024.During a concurrent interview and record review on 3/19/26 at 1:27 p.m. with the Minimum Data Set Nurse (MDSN), Resident 11's CP dated 10/26/23 and OSR dated 1/21/26 were reviewed. The CP indicated . [brand name feeding formula] 1.5 via G tube pump @ 70ml/hour. The OSR indicated . the active order was 40ml/hour. The MDSN stated CP was completed by the MDSN, admission Nurses, and Floor Nurses. The MDSN stated she was responsible for updating the CP. The MDSN stated CP are revised when an intervention needs to be updated. The MDSN stated [brand name feeding formula] 1.5 via G tube pump @ 70ml/hour. should no longer be an intervention and the CP needed to be updated. The MDSN stated the intervention should have been updated when Resident 11's order was changed on 1/21/26. The MDSN stated the CP was the plan of care for the residents. The MDSN stated this could cause confusion because the order was updated on 1/21/26 and the intervention was not. The MDSN stated the LNs would question the order and there could be confusion over which order was correct.During a concurrent interview and record review on 3/20/26 at 10:56 a.m. with the DON, Resident 11's CP dated 10/26/23 and OSR dated 1/21/26 were reviewed. The DON stated the CP was reflecting dates 2023/ 2024, and .70ml/hour. The DON stated the active order stated .40ml/hour. The DON stated it was important that the CP was revised because the CP should be reflective of the care provided for Resident 11.During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated 4/2009, the P&P indicated, Policy Statement- Care plans shall incorporate goals and objectives that lead to the residents' highest obtainable level of independence. Policy interpretation and implementation- 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the residents clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. 4. Goals and objectives as entered on the resident care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and or revised. d. at least quarterly .During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/ the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on observation, interview, and record review, the facility failed to ensure1. Two of four Registered Nurses (RN 2 and RN 4) were competent in the enteral feeding (tube feeding- is a method of delivering liquid nutrients directly into the stomach or small intestine via a tube) process when providing care to Resident 40 during enteral feeding.2. The Licensed Nurse (LN)s Competency/ Skills checklist (CSC) (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed upon hire for one of six staff members (RN 4).These failures had the potential for the facility to not be able to assess the skills necessary to provide nursing services such as enteral feeding and thus placed the Resident 40 at riskFindings:1. During an observation on 3/17/26 at 10:56 a.m. in Resident 40's room, Resident 40 was in bed sleeping and there was a feeding pump with feeding formula set up. The connector end of the feeding bag tubing for Resident 40 did not have a tube cover cap and was left open to air. The inside of the feeding bag tubing was observed to be clogged with dried formula build up and around the tip of the connector end of the feeding bag tubing had dried formula build up.During a concurrent observation and interview on 3/17/26 at 12:35 p.m. in Resident 40's room, Registered Nurse (RN) 4 was observed taking the exposed connector end of the feeding bag tubing that had dried formula buildup at the tip and was clogged to connect it to Resident 40's gastrostomy tube (G-tube or PEG tube- a surgical opening made through the abdominal wall into the stomach to insert a feeding tube for long-term nutritional support tube) feeding port. RN 4 was asked if the tip of the feeding tube should be opened and attached to Resident 40. RN 4 stated the tip of the feeding bag tubing should have been covered with a cap. RN 4 was observed cleaning around the end of the feeding bag tubing and inside the feeding bag tubing with the hand glove she had removed. When asked the process, RN 4 stated I use the inside of the gloves to clean the tip of the tube. When asked if that was the correct process, RN 4 stated it should not be like that, I would use a gauze with normal saline. When asked if using the gauze with normal saline would remove the dried formula, RN 4 stated after cleaning with the gauze and normal saline, the tube would still have dried formula.During a concurrent observation and interview on 3/19/26 at 11:43 a.m. with Registered Nurse (RN) 2 in Resident 40's room, Enhanced Barrier Precautions (EBP) RN 2 was observed operating the feeding tube on Resident 40. RN 2 did not wear a Personal Protective Equipment (PPE) gown. RN 2 stated there was no need for RNs to wear a PPE gown when handling a feeding tube. RN 2 stated feeding tubes were not included in the list of devices that required Enhanced Barrier Precautions (EBP) usage when residents are placed on EBP.During an interview on 3/18/26 at 3:37 p.m. with RN 4, RN 4 stated she had no training on feeding tube. RN 4 stated she had only one day of orientation when she was hired, and she started working with residents. RN 4 stated there was no skills or competency training, demonstration or evaluation on feeding tube training. RN 4 stated there was dried formula on the inside of the feeding bag tubing for Resident 40. RN 4 stated she should have inspected the feeding bag tubing before connecting it to Resident 40.During an interview on 3/20/26 at 8:50 a.m. with the Infection Preventionist (IP), The IP stated RN 4 was not competent, and the expectation was that RN 4 should have changed the whole tubing kit. The IP stated competency needed to be addressed. The IP stated she was unaware if there was a competency or skill check for staff's competency when providing care for residents using a feeding tube. The IP stated RNs should be skilled and checked for competency before the attempt to do it.2. During a concurrent interview and record review on 3/19/2026 at 1:57 p.m., with the Director of Staff Development (DSD), the DSD stated RN 4 had orientation training on 1/14/26 and RN 4's Competency/ Skills checklist (CSC) was done with the DON.During a concurrent interview and record review on 03/19/2026 at 4:45 p.m. with the DON, RN 3 and RN 4's CSC were reviewed, the CSC indicated RN 3 completed the CSC on 7/16/25 and there was no CSC for RN 4. The DON stated she did not complete RN 4's CSC. The DON stated RN 4 started working in the facility in January 2026. The DON stated the CSC is completed after 3 months of staff employment. The DON stated the CSC should have been completed after orientation and there should have been a repeated evaluation after 3 months.During a concurrent interview and record review on 03/20/2026 at 10:56 a.m. with the DON, the feeding tube pictures were reviewed and the observation of RN 4 during the tube feeding session was discussed. The feeding tube pictures indicated the feeding tube was clogged. The DON stated RN 4 needed more skill testing. The DON stated RN 4 was not competent in enteral feeding. The DON stated she expected RN 4 to know what she was doing because she had previously worked in the facility. When asked if that was sufficient training for RN 4, the DON stated there was a need to ensure that RNs were shown the process and there was a repeat demonstration to ensure the RNs know what they were doing.During a concurrent interview and record review on 03/20/2026 at 11:56 a.m. with the Administrator (ADM), the observation of RN 4 during the tube feeding session was discussed. The ADM stated the expectation was that competency testing and training should be completed upon hire. The ADM stated, I see a hole there, a very big one. The ADM stated Resident 40 would not be getting sufficient feeding since the tubing was occluded. The ADM stated there should have been a cap on the tubing. The ADM stated the RN 4 needed training. The ADM stated RN 4 should have had a skills checkoff before she went on the cart by herself. The ADM stated the expectation from the DON, is that LNs should have passed their competencies and skill checks should have been completed. The ADM stated proper training, and frequent rounds should be done to ensure compliance. The ADM stated this was important because lives are involved, the LNs should know what they are doing because there are lives depending on them.During a review of the facility's Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 04/2025, the P&P indicated, .Policy Statement- The Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and implementation.Competent staff: 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3. Licensed staff must demonstrate the skills and techniques necessary to care for resident needs including. i. nursing skills consistent with scope of practice.5. Competency requirements and training for nursing staff are established and monitored by nursing leadership.During a review of the facility's P&P titled, Hiring Policy & Procedure, undated, the P&P indicated, .Policy- The facility shall implement a standardized hiring process to ensure all employees are: Qualified, competent and legally eligible for employment; Properly screened . oriented and trained prior to resident care. Purpose- To ensure: Safe and competent staffing, protection of resident health and safety, compliance with state regulatory and survey standards, proper documentation for survey readiness.Responsibility- Administrator: Final hiring approval and compliance oversight, Human Resources (HR): Manage hiring process and documentation, Department Heads: Conduct interviews and competency validation, DON (Director of Nursing): Verify clinical staff qualifications. 5. Procedure.5.5 Pre employment screening (mandatory).5.8 Competency Validation: department head validates skills competency, clinical staff must demonstrate - safe patient care skills, equipment usage, documentation practices.

Based on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards and residents received adequate supervision to prevent accidents for one of five residents (Resident 1) when, nursing staff were aware of Resident 1's behavior to self-propel in a wheelchair equipped with foot pedals and did not adequately supervise Resident 1 while propelling in a wheelchair. Staff did not assess the safety of the wheelchair for Resident 1's physical size and abilities. Resident 1 was not assessed and fitted for a wheelchair for personal use and instead Resident 1 used wheelchairs available for general use in the facility. Staff did not identify declining mobility in Resident 1's upper and lower extremities as identified in the Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, judgment and physical function).These failures resulted in Resident 1 experiencing an unwitnessed avoidable accident on 8/17/25 where an internal investigation determined Resident 1's legs became entangled in the wheelchair while Resident 1 was self-propelling. The unwitnessed avoidable accident resulted in pain and tenderness to Resident 1's right lower leg and was sent to the local acute care hospital for evaluation which required hospitalized from [DATE] to 8/21/25. Resident 1 was diagnosed with acute (sudden and unexpected) right tibial (the larger of the two bones in the lower leg) fracture (a break or discontinuity in a bone) with only minimal displacement (broken bone fragments move out of alignment) and proximal (closer to the point of attachment or origin) fibular (thinner, outer bone of the lower leg) fracture. As a result of Resident 1's accident and injury he has pain, does not have the capability to self-propel and is isolated to his room.Findings:During an interview on 8/27/25 at 1:35 p.m. with Registered Nurse (RN) 1, RN 1 stated she was notified that Resident 1 had pain to the right lower leg and did not want to move his leg by the Certified Nursing Assistant (CNA) 1 on 8/18/25 around 11:00 a.m. RN 1 stated she went to Resident 1's room and did a physical assessment which included palpation (medical examination technique that involves using the hands to assess the body to detect abnormalities such as; tenderness/pain, temperature, size and shape, etc.) to the right lower leg. RN 1 stated Resident 1 had severe pain in the right lower leg when it was palpated and grimaced when palpated. RN 1 stated, Resident 1 does not complain about pain, and this complaint was unusual and new for him. RN 1 stated there was no physical deformity (a condition in which something is distorted from the usual or typical shape), no swelling or bruising, just pain. RN 1 stated she reported the condition of Resident 1 to the Director of Nursing (DON), offered pain medication to Resident 1 and notified the physician of Resident 1's condition.During a concurrent interview and record review on 8/27/25, at 1:45 p.m. with RN1, Resident 1's Situation, Background, Assessment, and Recommendation Communication Form (SBAR-a standardized communication tool used to convey patient status updates when a change occurs from baseline), dated 8/18/25 was reviewed. The SBAR indicated, .Situation.Resident has severed pain 9/10 (Pain scale from 0 to 10 with 0 representing pain free and 10 representing unspeakable bedridden pain) in the right lower limb.decreased mobility.2. Functional Status Evaluation (compared to baseline; check all changes that you observe) Decreased mobility, Other (describe).severe pain on the [right] lower extremity (the body parts farthest from the center of the body).9. Pain Evaluation.Does the resident have pain: yes (describe below), is the pain new: yes. Description/location of pain: Right lower leg pain, Intensity of Pain (rate on scale of 1-10, with 10 being the highest): 9.Appearance, CNA notified [charge nurse] regarding resident has severe pain in right lower limb. There is no swelling or redness, he claim[ed] it happened yesterday evening like he twisted his leg while propelling his wheelchair. He denied he had a fall. RN 1 stated CNA 1 informed her that Resident 1 was having pain in his right lower leg and RN 1 completed an assessment and did not find any deformity of the leg. RN 1 stated she administered acetaminophen (a drug used to relieve mild or chronic pain), informed the Medical Doctor (MD) and received an order for an in-house X-ray (a medical imaging tool used for diagnosing various conditions including bone fractures). RN 1 stated after Resident 1 twisted his legs while propelling his wheelchair on 8/17/25 she believes Resident 1 is sad because Resident 1 cannot roll around to different areas in the facility using a wheelchair anymore and he just lays in his bed and does not get up.During a review of Resident 1's Medication Administration Record (MAR), dated 8/25, the MAR indicated, .[acetaminophen] tablet.Give 325 mg (milligrams-unit of measure) by mouth every 8 hours as needed for mild pain. The MAR indicated medication was administered 8/18/25 at 10:58 a.m. and 8/19/25 at 8:13 a.m. both were after Resident 1 twisted his legs while propelling his wheelchair on 8/17/25 while awaiting in-house imaging results. No documentation of the pain level was indicated in Resident 1's MAR.During a review of the facility's Radiology Report (RR) for Resident 1, dated 8/19/25 the RR indicated, .Results: Proximal tibia/fibula fractures with mild displacement. Mild soft tissue swelling (condition that occurs when fluids accumulate in the damaged tissues) Conclusion: Acute appearing proximal tibia/fibula fractures as noted.During a record review of the general acute care hospital's (GACH) Discharge Summary (DS-a medical document that provides a comprehensive overview of a patient's hospital stay) for Resident 1, dated 8/21/25, the DS indicated, Resident 1 was admitted to the GACH on 8/19/25 and discharged on 8/21/25. Resident 1's admission diagnosis was closed fracture (break in a bone that does not penetrate the skin) of the right tibia and fibula (two bones in the lower leg). The DS indicated, .Consults: Orders place this encounter: [inpatient] consult to [company name] Orthopedic Surgery (medical specialty focused on the surgical and non-surgical treatment of the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves).Procedure (during this hospitalization): No surgery found. [X-ray] Tibia Fibula Right.Impression: Tibial and fibular fracture, [Computed Tomography] (medical imaging technique that uses X-rays to create detailed cross-sectional images of the body's internal structures, such as organs, bones, and blood vessels) Knee Right [without] Contrast (a special dye that is used to enhance the visibility of certain structures in the body during a CT scan).Impression: 1. Acute right tibial metaphyseal (the wider, growing part of a long bone) fracture with only minimal displacement. 2. Proximal fibular fracture.Received [acetaminophen], fentanyl (a synthetic opioid that is used to treat severe pain), ibuprofen (over the counter non-steroidal anti-inflammatory drug used to relieve pain), [ondansetron] (used to prevent nausea and vomiting).Assessment And Plan: [company name] Ortho consulted-non operative [management], orthopedics to sign off, ok for discharge from orthopedic perspective.pain control.Non-Weight bearing (medical instruction to avoid placing any weight on a specific body part, typically a limb) [right lower extremity], [physical therapy] [evaluation].return to clinic in 2 weeks.During a concurrent observation and interview on 8/27/25, at 11:00 a.m. with Resident 1 and Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed lying in bed looking out the window. Resident 1 was observed to have a cast on his right leg extending from his right foot to his mid-thigh. Resident 1's right leg was extended straight and immobile due to the cast. When asked about his legs, Resident 1 stated while using a facility wheelchair on 8/17/25 he tried to turn the wheelchair, and both legs got caught under the wheelchair. Resident 1 stated the wheelchair had foot pedals (footplates-where the user of the wheelchair rests their feet on a flat surface) and he uses the foot pedals sometimes. Resident 1 stated he did not fall, and he did not inform staff of the injury due to not being in pain at the time of the incident but had pain the following morning on 8/18/25. Resident 1 stated he has been using a wheelchair for a long time, even before he got to the current facility. Resident 1 appeared sad, talked in a low voice and responded to interview questions in short sentences even when asked to expand.During a concurrent observation and interview on 9/3/25 at 1:30 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed, looking out the window with both legs extended straight with a cast to his right leg extending from his foot to his mid-thigh rendering his leg immobile. Resident 1 stated he was not in pain at the moment. Resident 1 stated that he was sad he cannot use the wheelchair due to twisting his legs while propelling his wheelchair on 8/17/25. Resident 1 stated he likes to go to the activities room and self-propel himself in the facility and now, he just lies in his bed.During an interview on 8/27/25 at 11:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with the needs of Resident 1 and had cared for him in the past. CNA 1 stated before the accident and injury when Resident 1 twisted his legs while propelling his wheelchair on 8/17/25, she had observed Resident 1 propelling himself in a wheelchair that had foot pedals around the facility. CNA 1 stated she was unsure if the wheelchair was safe for use that Resident 1 used to self-propel himself. CNA 1 stated she noticed a difference in Resident 1's mood and level of activity after the accident and injury and that he seemed quieter now and doesn't get up and go to the activities room like before.During an interview on 8/27/25 at 12:00 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she is currently assigned to Resident 1. CNA stated she knew Resident 1 has broken bones in his right leg through CNA-to-CNA handoff report (the formal transfer of patient care responsibility and relevant information ensuring the continuity and safety of patient care during a transition, such as a shift change). CNA 2 stated before the accident and injury on 8/17/25 when Resident 1 twisted his legs while propelling in the wheelchair, she observed Resident 1 propelling himself around the facility in the wheelchair using his arms and feet. CNA 2 stated Resident 1 sometimes used the foot pedals to rest his feet on. CNA 2 stated Resident 1 requires assistance with transfers from the wheelchair to bed and vice versa and Resident 1 required a mechanical lift (device that uses a sling to help a caregiver safely lift and transfer a person between surfaces like beds, chairs, and wheelchairs) before and after the accident. CNA 2 stated she has not been informed of Resident 1's needs specific to assistive equipment like wheelchairs for mode of transportation. CNA 2 stated Resident 1 has always used a wheelchair, so staff just put him in it when he wanted. CNA 2 stated she does not know if the wheelchair was safe for Resident 1 to use or if he had ever been assessed for safety when using it. CNA 2 stated Resident 1 would comply if there were any safety concerns while propelling himself in the facility. CNA 2 stated Resident 1 seems sad after the accident and injury on 8/17/25 when Resident 1 twisted his legs while propelling his wheelchair. CNA 2 stated Resident 1 just looks out the window and has not gotten up to go to activities room which he liked to do before the accident and injury.During an interview on 8/28/25 at 9:15 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated before Resident 1's accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, she observed Resident 1's feet dragging on the floor while he used his hands to propel himself. CNA 3 stated Resident 1 had been doing this as long as she can remember. CNA 3 stated it was not communicated to her if a safety assessment for use of a facility wheelchair had been completed for Resident 1 and she was not told which wheelchair was safe to use for Resident 1. CNA 3 stated Resident 1 appears sad since the accident and injury because Resident 1 smiles less than he did before the injury and accident.During an interview on 9/3/25 at 1:50 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she is currently assigned to Resident 1, and she noticed a difference in Resident 1's mood and activity level after the accident and injury and that he doesn't seem as bright and isn't getting up and going to the activities room or to the dining room. CNA 4 states she thinks Resident 1 is in pain because sometimes she sees Resident 1 grimace in pain when repositioning himself. CNA 4 stated before the injury and accident, only one of Resident 1's feet were functional, so he used the opposite foot and both hands to propel himself in the wheelchair around the facility. CNA 4 stated Resident 1 would comply if there were any safety concerns while propelling. CNA 4 stated before the injury and accident to Resident 1, she was not informed if Resident 1 had been cleared to use a wheelchair or if the wheelchair was safe for him to use.During an interview on 9/3/25 at 2:00 p.m. with the Activities Director (AD), the AD stated before the accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, Resident 1 used to hang out in the activities room all day. The AD stated but since the accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, the AD hasn't seen Resident 1 in the activities room. The AD stated Resident 1 seems more down and a little more quiet when she visits with him in his room since he cannot get up in the wheelchair since the accident and injury.During an interview on 8/27/25 at 3:30 p.m. with the Director of Nursing (DON), the DON stated an internal investigation was completed regarding the injury to Resident 1. The DON stated she was informed on 8/18/25 that Resident 1 had pain to his right lower leg and not wanting to get out of bed. The DON stated the physician was notified right away, medications were administered and an order for in-house X-ray was received with the results coming in the following day on 8/19/25. The DON stated the resident refused to go to the hospital on 8/18/25, pending results of the X-Ray. After the results of the X-Ray, Resident 1 was agreeable to be sent to the hospital. The DON stated Resident 1 was interviewed two different times by different staff members on two different days and Resident 1 responded the same way both times, that he had twisted his leg on his wheelchair the day prior 8/17/25. He said he didn't tell anyone because he was feeling OK. The DON stated she interviewed the night nurse on 8/17/25 and Resident 1 did not complain of pain or mention his legs getting caught in the wheelchair. The DON stated she also interviewed the CNA's Resident 1 had on 8/17/25, day before the incident on 8/18/25. The DON stated the interviews with the CNA's did not report Resident 1 complaining of pain or his legs getting caught in the wheelchair. The DON stated this was an unusual occurrence and was investigated thoroughly.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, and judgment) and physical function) Assessment, dated 8/8/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 7, (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment (a significant decline in mental functions like memory, thinking, and judgment, making it impossible for an individual to live independently and requiring significant assistance with daily tasks and self-care).During a review of Resident 1's admission Record (AR-document containing resident demographic information and medical diagnosis), dated 8/27/25, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but was not limited to .ABNORMAL POSTURE (a deviation from the normal upright position of the body).OTHER MUSCLE SPASM (involuntary and forceful contractions of muscles).OTHER SPECIFIED ARTHRITIS, OTHER SITE (a group of conditions that cause inflammation and pain in the joints where the specific type of arthritis is known, but the affected joint location is not specified, or the arthritis affects multiple sites).OTHER ALZHEIMER'S DISEASE (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). There was no documentation indicating Resident 1 used a wheelchair from the AR.During a concurrent interview and record review on 9/5/25 at 9:25 a.m. with the Minimum Data Set Coordinator (MDSC-person who evaluates the process of patients in long-term care facilities, where they're responsible for up-to-date assessments of the patient and oversee the interdisciplinary assessment for all nursing home patients), Resident 1's Transfer/Discharge Report (TDR-a document that health care providers complete when a patient/resident is moved from one level of care to another, or is leaving a healthcare facility to go home or to another setting for continued services), dated 4/27/22, was reviewed. The TDR stated, .Ambulation [the act of moving about freely, can be done with or without assistance from assistive devices like canes, walkers, and wheelchairs]: Bedfast (confined to bed, or bedridden)/ [wheelchair]. The MDSC stated she was not in the current position at that time of the admission of Resident 1. The MDSC stated it looks like the facility just allowed Resident 1 to use wheelchairs because the TDR indicated the need for a wheelchair for mobility. The MDSC stated the facility also continued to use a mechanical lift (a medical device that helps safely transfer patients with no/limited mobility between surfaces like a bed, chair, or toilet) for transfers without knowing what Resident 1 could or could not do. The MDSC stated the facility should have done a physical therapy (type of medical treatment to improve movement and function) referral for an assessment at the time of admission and did not. The MDSC stated the facility continued with what the TDR indicated as far as the wheelchair for mobility mechanical lift and did not assess into if Resident 1 could walk or not at the time. The MDSC stated the only way to determine if Resident 1 could walk was to do a physical therapy referral for an assessment and it was not completed at that time or since admission.During a concurrent interview and record review on 9/5/25 at 9:50 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS was reviewed, dated 5/9/22, 8/9/22, 11/9/23, and 8/8/25. The MDS dated [DATE] indicated, .Section G-Functional Status.Surface-to-surface transfer (transfer between bed and chair or wheelchair) 2: Not steady, only able to stabilize with staff assistance. Functional Limitation in Range of Motion (the full movement available at a joint, determined by the joint's condition and the flexibility of surrounding muscles and connective tissues). Upper extremity (shoulder, elbow, wrist, hand): 0-no impairment, Lower extremity (hip, knee, ankle, foot): 0-no impairment.Functional Rehabilitation Protentional, Resident believes he or she is capable of increased independence in at least some ADL (Activities of Daily Living like bathing, eating and dressing): yes. Direct care staff believe resident is capable of increased independence in at least some ADL's: yes. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 1-impairment on one side, Lower extremity: 0-No impairment.Mobility Devices: C-Wheelchair. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 1-Impairment on one side, Lower extremity: 2-Impairment on both sides.Mobility Devices: C-Wheelchair. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 2-Impairment on both sides, Lower extremity: 2-Impairment on both sides.Mobility Devices: C-Wheelchair. The MDSC stated there was a change in functional status for Resident 1 and he was admitted to current facility with no impairment in his upper extremity on 5/9/22 to an impairment to both upper and lower extremities on both sides on 8/8/25. The MDSC stated it appears if Resident 1 is declining and that is a reason to inform the physician and to do a physical therapy referral for assessment and neither of those things were done at the time of the MDS assessment or since then. The MDSC stated a physical therapy referral should have been completed to see what he was capable of doing regarding his range of motion and strength and if he was able to use the wheelchair safely. The MDSC stated no documentation could be provided indicating physician was notified and no documentation for a physical therapy referral could be provided. During a concurrent interview and record review on 8/27/25 at 12:15 p.m. with the Rehabilitation Coordinator (RC), Resident 1's Electronic Chart (EC-a digital version of a patient's medical information, encompassing their comprehensive health history, including medications, diagnoses, test results, and treatment plans). The RC confirmed Resident 1 had not had any referrals to physical therapy for consultation and/or assessment. The RC stated physical therapy cannot evaluate a resident unless there is a referral for physical therapy. The RC stated that any resident can have a wheelchair, but to have a custom wheelchair (personalized mobility device by taking detailed individual measurements and preferences to meet the unique medical, physical, and psychosocial needs of the user, that generic wheelchairs cannot provide), they would need a Medical Doctors (MD) order, which is preceded by a referral for consultation and assessment from physical therapy. The RC stated the physical therapy staff must do a complete assessment and evaluation of a resident for the resident to get a custom wheelchair. The RC stated the physical therapy staff do not give out wheelchairs to just any resident. The RC confirmed Resident 1 used a wheelchair in the facility and did not have a wheelchair assigned to him by physical therapy staff.During a concurrent interview and record review on 9/3/25 at 3:15 p.m. with the Physical Therapist (PT), the PT verified Resident 1 never had a physical therapy evaluation from his admission to the facility on 5/9/22 to present day. The PT stated that she does not know if it is safe or appropriate for Resident 1 to be using a wheelchair. The PT stated the only way to know if a resident is safe to use any Durable Medical Equipment (DME-reusable medical devices, equipment, and supplies prescribed by a healthcare provider for a resident to manage a medical condition or disability. Examples include walkers, wheelchairs, hospital beds, and crutches) is to do an evaluation to determine strength, range of motion, and potential for improvement. The PT confirmed Resident 1 did not have an evaluation by physical therapy.During a concurrent interview and record review on 8/27/25 at 2:58 p.m. with the Assistant Director of Nursing (ADON), Resident 1's EC, undated was reviewed. The ADON confirmed Resident 1 had an accident with an injury on 8/17/25 that resulted in 2 broken bones in the lower right leg to Resident 1. The ADON confirmed there was not a physical therapy referral in the E-Chart for Resident 1. The ADON also confirmed there was no wheelchair component to the Care Plan (a dynamic, patient-centered document to outline their specific health needs, goals, preferences, and the necessary treatments, services, and support to achieve them) for Resident 1. The ADON stated there is no way of knowing if Resident 1 is safe or capable of using a wheelchair since there was no physical therapy assessment. The ADON stated Resident 1 seems sadder to me because before the accident and injury, he would wheel himself around the facility and now he just lays in his bed and doesn't get up.During a concurrent interview and record review on 8/27/25, at 1:30 p.m. with Registered Nurse (RN) 1, Resident 1's Care Plan (CP-a personalized, detailed document created to outline the specific medical, physical, and psychosocial needs of an individual receiving care by comprehensive assessments and includes identified risks, goals, treatments, and preferences to ensure the resident receives consistent, individualized, high-quality care to achieve their highest practicable well-being), dated August 2025, was reviewed. The CP did not have a component for the use of a wheelchair for Resident 1. RN 1 stated if Resident 1 was using a wheelchair, he should have a CP. RN 1 stated she did not know if Resident 1 needed the wheelchair for ambulation due to disability and does not know if the wheelchair is appropriate for the resident. RN 1 stated she did not know if the resident was assessed by physical therapy for safety or appropriateness of wheelchair use.During a concurrent interview and review on 8/27/25 at 3:10 p.m. with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, dated February 2021 was reviewed. The P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents.1. Certain devices and equipment that assist with resident mobility, safety and independence are provided. c. mobility devices (wheelchairs).3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' care plan. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition-the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit-the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight. The ADON stated the facility did not follow the P&P and did not make sure Resident 1 was safe with his wheelchair.During a review of the facility's document titled, MDS Coordinator Job Description, dated 2/19/25, the MDS Coordinator Job Description indicated, .Job Responsibilities: .Responsible for insuring that the MDS reflect a true picture of the resident.Meeting with staff and residents to gather any information that may have changed on the MDS.During a review of the facility's document titled, RN (Registered Nurse) Charge Nurse, dated 1/23/25, the RN Charge Nurse indicated, . Job Summary: The charge nurse is to ensure that effective, efficient and comprehensive resident care is provided.Job Responsibilities: . 5. Is responsible for maintaining an acceptable standard of nursing practice. 6. Is responsible for accurate observations, evaluations, and multi-system assessment of residents in an accurate and timely manner. 9. Is responsible for supervising the CNA's (Certified Nursing Assistant) during the care they provide to residents-ensuring resident safety. 11. Is responsible for correlating resident care with other departments. 15. Is responsible for. care planning as needed.During a review of the facility's document titled, Assistant Director of Nursing Job Description, dated 7/12/24, the Assistant Director of Nursing Job Description indicated, .The primary purpose of the job position is to assist.in managing overall operation of the Nursing Services Department in accordance with current Federal, State and local.regulations that govern this facility.to ensure that the highest degree of quality care is maintained at all times.Essential Job Functions:. Monitor unit activities, communicate policies.Conduct regular rounds to monitor resident activity and ensure resident quality care. Assess residents' physical and psychosocial status. Monitor care activities and documentation to ensure the delivery of nursing care according to the physician's orders, care plans and established standards and facility policies.Plan, organize and direct.effective administration of nursing unit and patient care given based on the establish goals and objectives, standards, policies and procedures of this facility. Regularly inspect the facility and nursing practices for compliance with federal, state and local standards and regulations. Assure residents of.safe environment. Assist in development of Patient Care Plans for individual residents including rehabilitative and restorative activities. Assist in.scheduling of rounds to see all residents.During a review of the facility's policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, dated July 2017, the P&P indicated, .All hazardous areas, devices and equipment in the facility will be identified and address appropriately to ensure resident safety and mitigate accident hazards to the extent possible.1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed. Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. b. Devices and equipment that are improperly used. Assessment and Analysis of Hazards: 1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. 3. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments. 4. Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident. 5. Improper or inappropriate use of equipment and devices will be identified as part of the hazard assessment and analysis.During a review of the facility's policy and procedure (P&P) titled Assistive Devices and Equipment, dated February 2021, the P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents.1. Certain devices and equipment that assist with resident mobility, safety and independence are provided. c. mobility devices (wheelchairs).3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' care plan. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition-the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit-the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight.During a review of a professional reference titled, Topics in geriatric rehabilitation, dated 2015, retrieved from https://doi.org/10.1097/TGR.0000000000000042, indicated, .e

Based on observation, interview and record review, the facility failed to ensure licensed nurse (LN) staff followed Podiatrist 1 ' s (P, a podiatrist is a medical specialist who treats conditions related to foot, ankle, and lower leg) instructions to check Residents 5 and 6 ' s feet daily, apply lotion daily, and elevate their feet to reduce edema (swelling). From 6/14/22 to 11/1/22 (five months), LN staff did not assess foot and toenail care and Certified Nursing Assistants (CNAs) did not provide daily foot and toenail care in accordance with P1 ' s instructions. The Director of Nursing (DON) did not provide clinical oversight to ensure the instructions provided by P 1 were fully implemented. These failures resulted in Residents 5 and 6 to have toenails that measured one to one and a half centimeters long (cm, a unit of measurement), jagged, thick and discolored yellow and brown- color toenails and scaly and discolored skin between the toes. Residents 5 and 6 has serious potential for avoidable pain and fungal infection as a result of not providing foot care. The serious potential risk for Residents 5 and 6 included complications such as loss of limb/foot amputation from underlying diseases such as diabetes (high blood sugar level in the blood), or even death. Because of the actual harm of avoidable pain and fungal infection and the serious potential harm of complications related to underlying disease such as diabetes to Residents 5 and 6, caused by facility ' s failures to assess, monitor, report, and provide prompt and appropriate foot care and treatment, an Immediate Jeopardy (IJ) (a situation in which facility non-compliance has placed the health and safety of residents or patients in its care at risk for serious injury, harm, impairment, or death; and involves immediate action to remove the threat of harm or potential harm), with a scope and severity of K, under 42 CFR S483.25 (B)(2) - F687, was called on 11/3/22, at 4:20 p.m., with the Interim Director of Nursing (IDON), Medical Record Director (MRD), and Director of Staff Development (DSD). The facility was provided with the IJ template which listed the identified regulatory non-compliance, the potential or actual outcomes of the non-compliance, and the requirement for the facility to develop, implement, and submit a Plan of Removal (POR, a plan consisting of interventions or action items that must be immediately implemented by the facility to correct and remove the IJ situation). The facility submitted an acceptable IJ POR (Version 3) on 11/4/22, which addressed the actions needed to remove the IJ situation. The IJ POR included but is not limited to the following: 1) Residents 5 and 6 were assessed by the IDON and immediately referred to Podiatry provider for podiatry consult, Residents 5 and 6 were started on antifungal medication, 2) Residents 5 and 6 were treated onsite at the facility by P1 on 11/4/22, 3) All residents were checked by the IDON for any issue and there were no toe nail issues found, 4) On 11/9/22, P1 will be at the facility to examine/treat other residents, 5) Immediately reinforced daily skin checks and foot check to be done by CNAs and identify any changes, and reported to the charge nurse and SSD (Social Services Director) for immediate intervention, 6) Skin checks and foot checks will be performed daily by the LNs, and any identified issues will be reported to SSD for podiatry referral, 7) Podiatry referrals will be discussed for any podiatry issues/resident toe nail issues during the daily morning meeting to ensure that all departments are aware of the resident ' s podiatry needs, and 8) follow up by SSD who will report any podiatry issue to the QA (Quality Assurance) meeting. On 11/5/ 22, the components of the IJ POR - Version 3, were validated through observations, interviews, and record review. The facility was determined to have implemented its POR. The IJ for Foot Care - 483.25 (B) (2) - F687 was removed onsite, on 11/5/22 at 4:48 p.m., with the IDON and DSD. Findings: 1. During a review of Resident 5 ' s ADMISSION RECORD, undated, indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage (a brain injury caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide (colorless and odorless gaseous waste product made by the body), Peripheral Vascular Disease (PVD, a condition where there is reduced circulation of blood to a body part, including the legs or feet), and persistent vegetative state (person is awake but does not show conscious awareness, nor is able to respond to what is happening around them). During a review of Resident 5 ' s Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs), dated 8/19/22, Section C for BIMS (Brief Interview for Mental Status), indicated, Resident 5's BIMS was not scored due to diagnoses of persistent vegetative state. Section G for functional status indicated, Resident 5 required extensive assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. Section G, for functional status indicated, Resident 5 was totally dependent on one- person physical assist to maintain basic personal hygiene such as combing hair, brushing teeth, washing hands, and incontinent care. During a concurrent observation and interview on 11/2/22 at 11:20 a.m., with the MRD, inside Resident 5 ' s bedroom, Resident 5 was observed lying in bed with eyes open. Resident 5 was observed to be non-verbal with her hands curled into a fist. Resident 5 was observed with no handrolls on both hands. The MRD stated, Resident 5 should always have a handroll on each hand due to contractures (a permanent tightening of the muscles, tendons, skin, and tissues that causes the joints to shorten and become stiff, and limits flexibility and joint movement). During a concurrent observation and interview, on 11/2/22 at 11:25 a.m., with the MRD, at Resident 5 ' s bedside, Resident 5 was observed with soft heel-protectors on her left and right feet. Resident 5 was observed with bilateral feet contractures and the dorsal (top) part of both feet were puffy. Resident 5 ' s left and right feet was observed with toenails that were approximately 1.5 cm long, thick, and yellow and brown in color. Resident 5 ' s skin between the toes were dry, scaly, and brown in color. The MRD stated, Resident (name) toes/ toenails look bad. During an interview on 11/2/22 at 12:04 p.m., with the Social Services Director (SSD), in the DON ' s office, SSD stated, she had not been made aware Resident 5 had issues with her feet/toes/toenails. SSD stated the certified nursing assistants (CNAs) should be reporting problems with the resident ' s feet, toes and toenails to the licensed vocational nurses (LVN). SSD stated, The CNAs are the ones providing daily care to the residents . If the CNAs reported these to me, I would tell the LVN who should first assess the resident then call his/her primary care physician (PCP, a doctor who provides (and acts as the first contact) and coordinate healthcare services for residents) . If a podiatry or dental referral is needed, then I follow through. SSD stated she could not recall the last time she had referred Resident 5 or any resident to the Podiatrist. SSD stated, I cannot remember .it ' s been a while. During an interview, on 11/2/22 at 12:24 p.m., with the IDON, the IDON stated, he was made aware of the condition of Resident 5 ' s feet and toenails by the MRD. IDON stated, P1 (non-contractual independent provider) would be at the facility on 11/4/22, to treat Resident 5 and Resident 6. The IDON stated, P1 was not a contracted service. The IDON stated the first line of monitoring and reporting of foot issues are the CNAs. The IDON stated the root cause of the lack of foot care was due to the LNs ' failure to assess, document, inform the Medical Doctor (MD), and report the foot condition to the DON, and the lack of clinical oversight from past DONs employed by the facility between 11/12/21 to 10/29/22. During an interview, on 11/3/22 at 11:52 a.m., with facility CNA 1, in the hallway, CNA 1 stated, This is my third week here . When asked to describe the standard of practice specific to foot/nail care, CNA 1 stated, I would look at the resident ' s skin during showers, if there ' s anything wrong, I report up, document it in the PCC (Point Click Care [electronic charting]) under Comments and notify the charge nurse (LVN). CNA 1 stated, she had cared for Resident 5, but did not check her feet or toenails. CNA1 stated, . I think the LVNs should do that . During an interview, on 11/4/22 at 10:30 a.m., with facility CNA 2, at the nurses ' station, CNA 2 stated she was assigned to Resident 5 on 11/2/22 and saw the condition of Resident 5 ' s toes. CNA 2 stated, I saw her feet were very swollen (puffy) and her toenails were long and looked infected . But I did not report it to the LN . I was very busy . we were short-staffed, I did not have time to clean Resident 5 ' s feet . the California Department of Public Health (CDPH) surveyor saw the resident ' s feet . Suddenly, the IDON was looking at the residents ' feet. During an interview, on 11/4/22 at 10:45 a.m., with registry LVN 1, at the nurses ' station, LVN 1 stated, I come to this facility on a regular basis . I am here to pass medications and this place is always short-staffed. I get very busy with medication pass, let alone check the resident ' s skin . I don ' t have time to do skin checks . I don ' t look at their toenails, that ' s the CNAs job. LVN 1 stated, No one had been providing oversight/supervision to the CNAs and LNs . No one! They don ' t have a DON . The facility is on autopilot . No one is watching the shop . During a review of Resident 5 ' s Order Summary Report (OSR), dated 11/2022 the OSR indicated Order date: 2/27/19 - Podiatry care q (every) 61 days (2 months) and PRN (as needed) for treatment of hypertrophied toenails and/or other foot problems. During a review of Resident 5 ' s Podiatry report dated 6/13/22, and signed by P1 on 7/13/22, indicated SUBJECTIVE: (Resident 5 ' s name) has painful toenails that feel better when treated . OBJECTIVE/LOWER EXTREMITY EXAM: VASCULAR (relating to the vessels that carry blood or other fluids in a person ' s body): Pedal (top of the foot) pulses non-palpable, plus one (slight) pitting (indentation or pit is left on the skin when sustained pressure is applied over a swollen area of the body) edema (swelling) noted to lower extremities . Nails 1 & 5 both feet are thickened, discolored, elongated with debris and are painful with palpation (use of hands over a body part to feel the size, shape, firmness, or location of an object, mass, growth, or body part) . Nails 2, 3, & 4 on both feet are elongated and painful on palpation . ASSESSMENT: Diagnosis: 1) Nail dystrophy (cracked nails), 2) PVD, 3) Pain in right foot, 4) Pain in left foot, 5) Xerosis cutis (abnormally dry skin), 6) Tinea unguium (nail fungus). PLAN: Care plan: Discussed findings and treatment options with staff . Instructed staff to check feet daily . Debrided (damaged nails were removed using a podiatry grade nail grinder and nail clippers) nails x (times) 4 in length and thickness, trimmed dystrophic nails (nails that are deformed, thickened, or discolored due to infection or injury) x 6 in length and thickness . provided education to staff on foot care. Apply lotion daily, elevate feet to reduce edema .Next treatment planned in 9-10 weeks. During a review of Resident 5 ' s electronic health records (eHR, electronic documentation), for entries between 6/13/22 and 11/2/22, there was no Change in Condition (CIC) assessment completed by LNs regarding Resident 5 ' s swollen feet and fungal nails, no Interdisciplinary team (IDT, a group of professionals who meet and discuss resident concerns, care issues, and resolutions) discussion/monitoring of Resident 5 ' s swollen feet and fungal nails, in accordance with standards of practice and/or facility policies and procedures (P/P) pertinent to resident CIC, no LN Progress Notes pertaining to implementation of P1 ' s foot care recommendations on 6/13/22, no Plan of Care interventions developed and implemented to ensure Resident 5 received daily foot care and monitoring and ensure debrided toenails done on 6/13/22, would heal and not get infected. During a review of Resident 5 ' s eHR, for entries between 6/13/22 and 11/2/22, there were no reports of subsequent podiatry visits as ordered by the PCP and as recommended by P 1 on his last visit on 6/13/22. During a review of Resident 5 ' s eHR, for entries between 11/2/22 to 11/7/22, there was no CIC assessment and no IDT discussion and monitoring, and no long-term plan to check, assess, and monitor Resident 5 ' s feet/toes post-debridement on 11/4/22. During an interview on 11/4/22 at 2:00 p.m., with the MRD, regarding clinical documentations and the lack thereof, MRD stated there she was unable to find CIC, IDT notes, and LN progress notes pertaining to the condition of Resident 5 ' s toes from 6/13/22 to 11/4/22. MRD commented, I was taught in nursing school, if it is not documented, it did not happen. During a phone interview on 11/4/22 at 2:30 p.m., with the previous administrator (ADM) 1, ADM 1 stated, she was employed at the facility on 7/18/22 and had resigned on 10/31/22. ADM 1 stated, there was a Pending service agreement with a podiatry group based out of town, that was made on 10/7/22. ADM 1 stated, the podiatry group had not entered into an agreement with the facility and had not signed the contract. ADM 1 stated, Truth be told, the podiatrist had not treated any of the residents at the facility since July 2022. 2. During a review of Resident 6 ' s ADMISSION RECORD, undated, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis from the neck down, including the trunk, legs and arms), Type 1 Diabetes (a chronic (long-term) condition in which the pancreas produces little or no insulin), and contractures (a permanent tightening of the muscles, tendons, skin, and tissues that causes the joints to shorten and become stiff, and limits flexibility and joint movement of hands and feet. During a review of Resident 6 ' s Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs) dated 7/20/22, Section C for BIMS (Brief Interview for Mental Status), indicated Resident 6's BIMS was not scored. Section G, for functional status indicated, Resident 6 was totally dependent on one- person physical assist to maintain basic personal hygiene such as combing hair, brushing teeth, washing hands, and incontinent care. During a concurrent observation and interview, on 11/2/22 at 11:30 a.m., with the MRD, inside Resident 6 ' s bedroom Resident 6 was observed lying in bed with eyes open and with his hands curled into a fist. Resident 6 was non-verbal. Resident 6 was observed without handrolls on both hands. During a concurrent observation and interview, on 11/2/22 at 11:35 a.m., with the MRD, at Resident 6 ' s bedside, Resident 6 was observed with soft heel-protectors on both feet. Resident 6 ' s feet was observed to have contractures, and the dorsal (top) part of both feet were puffy. Resident 6 ' s right and left feet was observed with long (approximately 1.5 cm long), thick, elongated, and yellow and brown color toenails. The skin between the toes were dry, scaly, and brownish in color. The MRD stated, [Resident 6] toes/ toenails look really bad. During an interview, on 11/2/22 at 12:04 p.m., with the Social Services Director (SSD), SSD stated, she had not been made aware Resident 6 had issues with his feet/toes/toenails. SSD stated, the CNAs should be reporting problems with the resident ' s feet /toes/toenails to the LVNs (licensed vocational nurses). SSD stated, The CNAs are the ones providing daily care to the residents . If the CNAs reported these to me, I would tell the LVN who should first assess the resident then call his/her PCP . If a podiatry or dental referral is needed, then I follow through. SSD stated she could not recall the last time she had referred Resident 6 or any resident to the Podiatrist. SSD stated, I cannot remember .it ' s been a while. During an interview, on 11/2/22 at 12:24 p.m., with the IDON, the IDON stated, he was made aware of the condition of Resident 5 ' s feet and toenails by the MRD. IDON stated, P1 (non-contractual independent provider) would be at the facility on 11/4/22, to treat Resident 5 and Resident 6. The IDON stated, P1 was not a contracted service. The IDON stated the first line of monitoring and reporting of foot issues are the CNAs. The IDON stated the root cause of the lack of foot care was due to the LNs ' failure to assess, document, inform the MD, and report the foot condition to the DON, and the lack of clinical oversight from past DONs employed by the facility between 11/12/21 to 10/29/22. During an interview, on 11/3/22 at 11:52 a.m., with facility CNA 1, in the hallway, CNA 1 stated, This is my third week here . When asked to describe the standard of practice specific to foot/nail care, CNA 1 stated, I would look at the resident ' s skin during showers, if there ' s anything wrong, I report up, document it in the PCC (Point Click Care [electronic charting]) under Comments and notify the charge nurse (LVN). CNA 1 stated she had not cared for Resident 6 and had not seen his toenails. CNA 1 stated she only heard Resident 6 ' s toes looked bad. During an interview, on 11/4/22 at 10:45 a.m., with registry LVN 1, at the nurses ' station, LVN 1 stated, I come to this facility on a regular basis . I am here to pass medications and this place is always short-staffed. I get very busy with medication pass, let alone check the resident ' s skin . I don ' t have time to do skin checks . I don ' t look at their toenails, that ' s the CNAs job. LVN 1 stated, No one had been providing oversight/supervision to the CNAs and LNs . No one! They don ' t have a DON . The facility is on autopilot . No one is watching the shop . During a review of Resident 6 ' s Order Summary Report (OSR), dated 11/2022, the OSR indicated Order date: 11/19/07 - Podiatry care q (every) 61 days (2 months) and PRN (as needed) for treatment of hypertrophied toenails and/or other foot problems. During a review of Resident 6 ' s Podiatry report dated 6/13/22, and signed by P1 on 7/13/22, indicated SUBJECTIVE: (Resident 6 ' s name) has painful toenails that feel better when treated . OBJECTIVE/LOWER EXTREMITY EXAM: VASCULAR (Pedal (top of the foot) pulses non-palpable, mild edema noted to lower extremities . Nails 1, 4 & 5 both feet are thickened, discolored, elongated with debris and are painful with palpation . Nails 2, 3, right and 1-5 are elongated and painful on palpation . ASSESSMENT: Diagnosis: 1) Type 2 diabetes, 2) Tinea unguium (nail fungus), 3) PVD, 4) Pain in right foot, 5) Pain in left foot . PLAN: Care plan: Discussed findings and treatment options with staff . Instructed staff to check feet daily . Debrided nails x (times) 3 in length and thickness, trimmed dystrophic nails (nails that are deformed, thickened, or discolored due to infection or injury) x 7 in length and thickness . provided education to staff on foot care. Apply lotion daily, elevate feet to reduce edema .Next treatment planned in 9-10 weeks. During a review of Resident 6 ' s electronic health records (eHR, electronic documentation), for entries between 6/13/22 and 11/2/22, there was no Change in Condition (CIC) assessment completed by LNs regarding Resident 6 ' s swollen feet and fungal nails, no Interdisciplinary team (IDT, a group of professionals who meet and discuss resident concerns, care issues, and resolutions) discussion/monitoring of Resident 6 ' s swollen feet and fungal nails, in accordance with standards of practice and/or facility policies and procedures (P/P) pertinent to resident CIC, no LN Progress Notes pertaining to implementation of P1 ' s foot care recommendations on 6/13/22, no Plan of Care interventions developed and implemented to ensure Resident 6 received daily foot care and monitoring and ensure debrided toenails done on 6/13/22, would heal and not get infected. During a review of Resident 6 ' s eHR, for entries between 6/13/22 and 11/2/22, there were no reports of subsequent podiatry visits as ordered by the PCP and as recommended by P 1 on his last visit on 6/13/22. During a review of Resident 6 ' s eHR, for entries between 11/2/22 to 11/7/22, there was no CIC assessment and no IDT discussion and monitoring, and no long-term plan to check, assess, and monitor Resident 5 ' s feet/toes post-debridement on 11/4/22. During an interview on 11/4/22 at 2:00 p.m., with the MRD, regarding clinical documentations and the lack thereof, MRD stated there she was unable to find CIC, IDT notes, and LN progress notes pertaining to the condition of Resident 6 ' s toes from 6/13/22 to 11/4/22. MRD commented, I was taught in nursing school, if it is not documented, it did not happen. During a phone interview, on 11/4/22 at 2:30 p.m., with the past administrator (ADM) 1, ADM 1 stated, she was employed at the facility on 7/18/22 and had resigned on 10/31/22. ADM 1 stated, there was a Pending service agreement ' with a podiatry group based out of town, that was made on 10/18/22. ADM 1 stated the podiatry group had not entered into an agreement with the facility and had not signed the contract. ADM 1 stated, Truth be told, the podiatrist had not treated any of the residents at the facility since July 2022. During a review of the facility ' s P/P titled, Care of Fingernails/Toenails, dated 2/2018, and reviewed and approved by the Quality Assurance (QA) Committee on 7/29/22, indicated Purpose: To clean the nailbed, keep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming . Proper nail care can aid in the prevention of skin problems around the nail bed . trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin .Watch for and report any changes in the color of the skin around the nail bed, signs for poor circulation, cracking of the skin around the toes, any swelling .report to the nurse if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease .do not trim nails of diabetic residents or residents with circulatory impairment . During a review of the facility ' s P/P titled, Change in a Resident ' s Condition or Status, dated 5/2017, and reviewed and approved by the Quality Assurance (QA) Committee on 7/29/22, indicated The nurse will notify the resident ' s attending physician when there has been a change in .d) significant change in the resident ' s . physical condition . Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the care providers . A significant change of condition is a major decline . in the resident ' s status that a) Will not normally resolve itself without intervention by staff or by implementing standard disease - related clinical intervention . During a review of Centers for Disease Control and Prevention (CDC, a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability), at https://www.cdc.gov/fungal/nail-infections.html, dated 9/13/22, indicated Tinea unguium is a type of fungal infection which the fungus infects the fingernails and, more commonly, the toenails. It ' s more common in men, older adults, and people who have diabetes, peripheral vascular disease, or another health problem that weakens the immune system. Bacterial infection can occur on top of a fungal nail infection and cause serious illness. It can spread from one nail to another. The infected nail may become brittle, thick, hard, discolored (yellow to brown), irregular in shape, and have crumbling white or colored material under it. If left untreated, the fungus may spread to the nail bed, which is the skin under the nail. Treatments include good hygiene, keeping the feet clean, and dry, keeping the nails trimmed and short, and taking antifungal products, which may kill the fungus and ease symptoms. The nail may be surgically removed, with high chance the fungus will return. Fungal nail infections can be difficult to cure, and treatment is most successful when started early. Fungal nail infections typically don ' t go away on their own and the best treatment is usually prescription antifungal pills. In severe cases, a healthcare professional (podiatrist) might remove the nail completely. It can take several months to a year for the infection to go away. During a review of professional reference regarding Director of Nursing oversight and the ability of nursing staff to adhere to patient safety and quality of care, at https://www.ncbi.nlm.nih.gov/pmc/articles, dated 3/19/2020, indicated The World Health Organization defines patient safety as the absence of preventable harm to patients and prevention of unnecessary harm by healthcare professionals. Patient harm during the provision of healthcare is recognized as one of the top 10 causes of disability and death in the world. Patient-safety principles are methods for achieving a reliable healthcare system that minimizes the incidence rate and impact of adverse events and maximizes recovery from such incidents. These principles can be categorized as risk management . infection control, patient education and participation in own care, prevention of pressure ulcers, nutrition improvement, leadership, teamwork, knowledge development, feeling of responsibility and accountability, and reporting practice errors . The nurses ' role is to preserve patient safety and prevent harm during the provision of care in both short-term and long-term care settings. Nurses are expected to adhere to organizational strategies for identifying harms and risks through assessing the patient, planning for care, monitoring and surveillance activities, double-checking, offering assistance, and communicating with other healthcare providers. In addition to clear policies, leadership, research driven safety initiatives, training of healthcare staff, and patient participation, nurses ' adherence to the principles of patient safety is required for the success of interventions aimed at the prevention of practice errors and to achieve sustainable and safer healthcare systems and quality of life for patients/residents . Systemic factors influencing nurses ' adherence to and compliance with patient-safety principles are as follows: the organizational patient-safety climate, workload, time pressure, encouragement by leaders and colleagues, staff competencies, provision of education for the improvement of knowledge and skills, policies and procedures, and also communication between healthcare staff and patients,. In addition, personal motivation, resistance to change, feelings of autonomy, attitude toward innovation, and empowerment are personal factors that impact on the nurses ' adherence to patient-safety principles. During a review of professional reference relatedto the value of Podiatry services in the elderly, at https://mercedesmedicalcenters.com/en/importance-of-podiatry-in-the-elderly/, dated 9/11/19, indicated Podiatry is the health profession that is responsible for everything related to the feet, including research, prevention, and treatment. The elderly is a population group with a high prevalence of foot-related disorders. Periodic reviews by a podiatrist are essential to improve the quality of life of the elderly. From the advice in choosing the right footwear for each situation, to the treatment of ulcers, through the removal of calluses (corn), as well as an adequate cut of the nails. Podiatry is especially important for people with diabetes. Podiatry becomes vitally important in those who have diabetes, so it is essential to pay special attention to the feet when one has this disease. It is essential to treat the problems of the feet in the case of those who have diabetes, because, although foot care is always key to the health of any person, it is known that people with diabetes are at higher risk rates to develop certain problems. Recent studies show, for example, that up to 34% of these people can develop foot ulcers. During a review of professional reference related to the value of supporting ADLs for residents who are fully dependent on staff for care, at https://www.ncbi.nlm.nih.gov/books/, dated 7/22/19, indicated, The ability to perform activities of daily living (ADLs) results in the dependence on other individuals and/or mechanical devices. Chronic illnesses in elderly progress over time, resulting in a physical decline that may lead to a loss of ability to perform ADLs. The inability of staff to support and accomplish essential activities of daily living for those who are totally dependent on staff for care may lead to unsafe conditions and poor quality of life. The basic ADL include Personal hygiene: The ability to bathe and groom oneself and maintain dental hygiene, nail, and hair care.

Based on interview and record review, the facility failed to ensure licensed nurses followed professional standards of nursing practice for two of two residents (Resident 7 and 15) when: 1. Licensed nurses did not assess, recognize, and act on the clinical changes to Resident 7 to provide a higher level of care. Resident 7 was admitted with known insulin (a medication used to control blood sugar) dependent diabetes mellitus (body ' s inability to produce insulin), known history of diabetic ketoacidosis (DKA - serious life-threatening complication of diabetes that can lead to death) and experienced episodes of vomiting, refusing fluids and meals, refused medications, insulin was not administered as ordered for high blood sugar, high blood sugars were not rechecked after readings of 388 mg/dl (milligrams per deciliter [a unit of measure]), and the change of condition and clinical decline were not communicated to the physician. Licensed nurses did not communicate the clinical decline to Medical Doctor (MD) or to the administrator. Licensed nurses did not develop and implement a person-centered comprehensive care plan for the diagnosis of DKA. Competencies for change of condition was not done with licensed nurses upon hire. Pharmacy recommendations regarding Resident 7 ' s insulin medication was not communicated to the MD. MD ' s order for laboratory (lab-facility that performs blood test) draw hemoglobin A1c (tests average level of blood sugar over 2-to-3-month period) was not carried out on ,d+[DATE]. The facility was without a Director of Nurses or designee to coordinate the quality of care and ensure resident safety. These failures resulted in no assessment to address Resident 7 ' s change of condition to prevent life -threatening illness and the need to notify the physician to implement interventions to prevent serious harm, or death. Resident 7 was found unresponsive and died at the facility on [DATE]. 2. Resident 15's physician orders for Insulin was not carried out when the insulin order was not administered. Licensed Nurses (LN) did not call the MD to advise per MD's orders for blood sugar less than 60 or greater than 400. Resident 15 ' s blood sugar was 410mg/dl on [DATE], 500mg/dl on [DATE], 466mg/dl on [DATE], and 436mg/dl on [DATE], the MD was not notified as prescribed by the physician. This failure increased the potential for Resident 15 to experience fluctuations with blood sugar levels and could potentially result in complications such as confusion, coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period), headache and increased hunger. Because of the systemic failure to provide clinical oversight and safe care to residents and the serious actual harm to Resident 7 and the serious potential harm to Resident 15 an Immediate Jeopardy (IJ, a situation in which non-compliance with one or more regulatory requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on [DATE] at 4:25 p.m. at a scope and severity of K (Pattern-more than a very limited number of residents), under Code of Federal Regulations (CFR) 483.25 (F684) with the Interim Director of Nursing (IDON), Director of Staff Development (DSD), and Medical Records Director (MRD). The facility was provided the IJ template which indicated the need to submit an acceptable written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility submitted a Plan of Removal (POR) to address the IJ situation. The IJ POR included: 1) Certified Nursing Assistants (CNA) and Licensed Vocational Nurses (LVN) were in-serviced regarding identification of symptoms related to high/low blood sugars, change of condition, prevention, management, and reporting of any change of condition. 2) Director of Nurse (DON) and Licensed Nurses immediately assessed residents with diagnosis of diabetes for any change in condition or symptoms related to diabetes. 3)IDON and DSD reviewed competencies with all licensed nurses and reviewed facility policies regarding changes in condition, assessment, emergency care, and MD (Medical Doctor) notification.4) IDON collected data to start a root cause analysis of the residents with diabetes and on insulin medication to ensure that the facility maintains and follows the policy and procedure on changes in condition reporting, monitoring, and physician notification. 5) Facility provided outside services for CPR (Cardiopulmonary resuscitation [emergency lifesaving procedure performed when the heart stops beating]) and AED (Automated external defibrillator [medical device used to shock the heart]) training for all staff. 6) The facility will review and revise, if needed, the policy and procedure for diabetes management on [DATE]. 7) The Medical Director was notified of the survey findings. The IJ Plan of Removal was accepted on [DATE] at 11:15 a.m. While onsite, the surveyor validated the POR implementation action items through observations, interviews, record reviews and confirmed that all POR action interventions to address the IJ situation were fully implemented. The IJ was removed on [DATE] at 4:48 p.m., with the IDON and DSD. Findings: 1.During a review of Resident 7's Face Sheet (FS- a document containing resident profile information), dated [DATE], the FS indicated, Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus with Ketoacidosis and long-term use of insulin. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment were reviewed. MDS dated [DATE], indicated Resident 7 ' s Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 (,d+[DATE] indicated severe cognitive impairment - [memory loss, poor decision making-skills], ,d+[DATE] moderate cognitive impairment, and (,d+[DATE]) cognitively intact). During a review of Resident 7 ' s General Acute Care Hospital (GACH) Discharge Summary (DS), dated [DATE], the DS indicated, Resident 7 was discharged with a diagnosis of diabetic ketoacidosis (DKA). The DS indicated Resident 7 ' s chief complaint on [DATE] at the time Resident 7 was transferred to the GACH was decreased intake of food, medication, and vomiting. The DS indicated, patient was also hospitalized in ,d+[DATE] and ,d+[DATE] for DKA as well, presumably due to inadequate insulin regimen. Resident 7 was discharged to the skilled nursing facility on [DATE] with resolved hyperglycemia (high blood sugar). During a review of Resident 7 ' s Progress Note (PN) dated [DATE], the PN indicated, pt [patient] BS [blood sugar] has been running high [500mg/dl] .I asked CNA if he [meaning Resident 7] was acting as he usually does, she stated no, he usually eats dinner and he did not eat, I called 911 and 911 is taking him to [hospital name] in Fresno . During a review of Resident 7 ' s GACH Discharge Summary (DS), dated [DATE], the DS indicated, Resident 7 ' s chief complaint on [DATE] was decreased mouth intake, altered mental status and high blood sugar. Resident 7 was admitted with a diagnosis of DKA, his blood sugar was 1454 mg/dl (normal range ,d+[DATE] mg/dL). Resident 7 was discharged to the skilled nursing facility on [DATE] with a diagnosis of diabetic ketoacidosis (DKA). During a concurrent interview and record review on [DATE], at 10:30 a.m., with LVN 1, Resident 7 ' s Medication Administration Record (MAR), dated ,d+[DATE] was reviewed. The MAR indicated, on [DATE], for the 5:30 p.m. administration time, there was no licensed staff initials in the box for Resident 7 ' s (brand name [insulin lispro-medication used to control blood sugar]) sliding scale (insulin dose varies based on blood sugar level), to demonstrate the medication was administered. LVN 1 stated her initials on the MAR were [initials] and that there was no documentation on the MAR dated [DATE]-[DATE] that indicated Resident 7 received the insulin on [DATE] at 5:30 p.m. and his blood sugar was not rechecked. LVN 1 stated, she had been an LVN for [AGE] years working in multiple different healthcare setting and stated if it was not documented it is not done. LVN 1 stated, on [DATE] she worked AM shift 6:30 a.m. to 2:30 p.m. and was asked to stay four extra hours. LVN 1 stated Resident 7 ' s blood sugar was 388 mg/dl at 7:30 a.m. and 11:30 a.m. during her shift. LVN 1 stated, she did not recheck Resident 7 ' s scheduled 5:30p.m. blood sugar and did not administer his insulin but she should have. LVN 1 stated, on [DATE] CNA 2 and CNA 6 informed her that Resident 7 had vomited. LVN 1 stated, on [DATE] she observed resident self-induced vomiting and that Resident 7 vomited on the bed twice and described the appearance as dark brown, pasty texture, and approximately half a cup in size. LVN 1 stated, she did not document the vomiting in the progress note and did not initiate a change of condition but should have. LVN 1 stated, CNA 2 had informed her that Resident 7 ' s behavior was not his norm. LVN 1 stated, on [DATE] Resident 7 was uncomfortable, restless, refusing his meal and refusing his medications. LVN 1 stated, Resident 7 refused all his medications by keeping his mouth shut but could not refuse insulin because that was injected in his arm which he couldn ' t refuse. LVN 1 stated, she coded the MAR with the number 9 which indicated see progress note resident refused. LVN 1 stated, she should have called the physician for the change of condition but did not. LVN 1 stated, in addition to calling the physician she should have informed the DON but there was no DON at the time. LVN 1 stated, she had previous experience working in hospice (end of life care) and she felt as though Resident 7 was ready to pass away. During an interview on [DATE], at 11:17 a.m., with CNA (5), CNA 5 stated, she had been working at the facility for more than a month. CNA 5 stated, she was familiar with Resident 7 and was working morning shift on [DATE]. CNA 5 stated, Resident 7 would normally drink a lot of water, on [DATE] she offered him water and he refused. CNA 5 stated, she offered Resident 7 breakfast and lunch and he refused the tray and did not want feeding assistance. CNA 5 stated, on [DATE] she observed Resident 7 placing his fingers in his mouth to self-induce vomiting and was uncomfortable moving his body forward and swinging his right hand. CNA 5 stated, she was not a nurse but felt Resident 7 was declining. CNA 5 stated, she felt something was wrong and informed LVN 1 that Resident 7 ' s behavior was unusual. During a review of Resident 7 's Progress Note (PN), dated [DATE], the PN indicated, .Orders-Administration Note .refused [medications] x3 [times three] risks and benefits explained During a review of Resident 7 ' s Medication Administration Record (MAR), dated ,d+[DATE], the MAR indicated .insulin lispro inject as per sliding scale: if ,d+[DATE] = 0 units XXX,d+[DATE]= 2 units; ,d+[DATE]=4 unit; ,d+[DATE]=6 units; ,d+[DATE]=8 units; ,d+[DATE]=10 units; ,d+[DATE]=12 units; .subcutaneously [injection beneath the skin] before meals XXX[DATE] . 0730 .BS[blood sugar] 388 .10units .1130 .BS 388 .10 units .1730 [5:30p.m.] BS [left blank no entry] . [LVN ' s initials and amount of insulin given left blank no entry] . During an interview on [DATE], at 10:54 a.m., with CNA 2, CNA 2 stated, she worked on [DATE] a.m. shift and was assigned to care for Resident 7. CNA 2 stated, she observed Resident 7 vomit before breakfast and before lunch. CNA 2 stated, she observed Resident 7 place his fingers in his mouth to self-induce vomiting which was not his norm. CNA 2 stated, Resident 7 would normally eat his food but refused his meals. CNA 2 stated, Resident 7 appeared uncomfortable by constant movement and would take off his blanket. CNA 2 stated, she informed both LVN 1 and CNA 6 regarding Resident 7 ' s changes because she felt something was wrong. During a review of Resident 7's physicians Order Summary Report (OSR), dated [DATE], the OSR indicated, .Insulin .Inject as per sliding scale .Below 60mg/dl [milligrams per deciliter (a unit of measure)], Notify MD .If Blood Sugar Is Above 400mg/dl .Notify MD .before meals related to .diabetes . During a concurrent interview and record review on [DATE], at 1:03 p.m., with Medical Record Director (MRD), Resident 7 ' s MAR ' s dated ,d+[DATE] - ,d+[DATE] was reviewed. The MAR indicated, the following dates Insulin was not administered, and Blood Sugar was above 400mg/dl and the physician was not notified per physician order. The MRD stated, she had worked at the facility for three years and was familiar with navigating the online chart and validated the following entries: [DATE] at 5:30 p.m. BS (Blood Sugar) 450mg/dl [DATE] 5:30 p.m. MRD stated, no licensed staff initials in the box demonstrated the medication was administered [DATE] at 7:30a.m. BS 500mg/dl and 11:30 a.m. BS 408mg/dl [DATE] at 11:30 a.m. MRD stated, no licensed staff initials in the box demonstrated the medication was administered [DATE] at 9:00p.m. MRD stated, no licensed staff initials in the box demonstrated the medication was administered [DATE] at 6:00p.m. BS 485mg/dl MRD reviewed Resident 7's progress notes for blood sugars over 400 on [DATE], [DATE],[DATE] and stated, that there were no progress notes indicating that the MD was notified when the blood sugars were above 400. MRD stated, there were no progress notes on the dates listed above indicating on the reason BS was not taken and the insulin was not given. During a concurrent interview and record review on [DATE], at 4:24 p.m., with IDON, Resident 7 ' s Order Summary Report (OSR), dated [DATE] was reviewed. The OSR indicated, .Hemoglobin A1C every 3 months (Jun, Sep, Dec, Mar) . IDON stated, the lab draw for ,d+[DATE] was not done, he had called the lab company which informed him that lab draw was not done. IDON stated, although Resident 7 was sent to the hospital on [DATE] and returned [DATE] the admitting nurse should have confirmed the order with the MD and scheduled the lab draw but didn ' t. IDON stated, the lab draw was an MD order and MD orders should be followed. IDON stated, with Resident 7 ' s history of high BS the lab draw was critical to obtain. During a telephone interview on [DATE], at 4:38 p.m., with CNA 6, CNA 6 stated, she worked on [DATE] and was assigned to Resident 7 on PM shift. CNA 6 stated, during change of shift CNA 2 had informed her to keep a close watch for Resident 7 as he did not eat, vomited, and would place his fingers in his mouth to self-induce vomiting. CNA 6 stated, Resident 7 vomited two times during her shift, the vomit was watery, cup sized and brown in color. CNA 6 stated, Resident 7 refused his dinner and did not drink water when offered. CNA 6 stated, she cleaned Resident 7 and informed LVN 1 that he had vomited. CNA 6 stated, she stayed overtime and worked the night shift, at approximately 4:30 a.m. on [DATE] she was changing the water pitcher when she checked on Resident 7, his eyes were closed and appeared lifeless. CNA 6 stated, she informed DSD of Residents 7 ' s changes at approx. 4:30 a.m. During a telephone interview on [DATE], at 5:10 p.m., with CNA 7, CNA 7 stated, she was working on [DATE] PM and night shift. CNA 7 stated, she was unable to recall the change of shift report she received for Resident 7. CNA 7 stated, CNA 6 was in the room changing water pitchers when she noticed Resident 7 unresponsive. CNA 7 stated, during the night shift she had observed Resident 7 taking off his gown and appeared restless. During an interview on [DATE], at 10:46 a.m., with IDON, IDON stated, from [DATE] to [DATE] and from [DATE] to [DATE], the facility did not have a DON. During an interview on [DATE], at 11:45 a.m., with IDON, IDON was requested to provide LVN 2 ' s phone number because she was the PM nurse on [DATE] where Resident 7 refused his medications, and the MD was not notified. IDON was asked two times and IDON did not provide the phone number to LVN 2. IDON stated, LVN 2 was from a registry and was unable to locate a phone number. During an interview, on [DATE] at 10:45 a.m., with LVN 1, at the nurses ' station, LVN 1 stated, I come to this facility on a regular basis . I am here to pass medications and this place is always short-staffed. I get very busy with medication pass. LVN 1 stated, No one had been providing oversight/supervision to the CNAs and LNs . No one! They don ' t have a DON . The facility is on autopilot . No one is watching the shop . During a concurrent interview and record review on [DATE], at 1:45 p.m., with MRD, Resident 7 ' s MAR dated ,d+[DATE] was reviewed. The MAR indicated, on [DATE] the following medications were refused: 8:00a.m. Aspirin (preventative medication) 81 MG (milligram- unit of measure) 8:00a.m. calcium citrate (calcium medication) 950 MG 8:00a.m. Zinc Sulfate (medication to prevent low level of zinc) 220MG 8:00a.m. Amlodipine (medication to control blood pressure) 10mg 8:00a.m. clopidogrel (blood thinner) 75MG 9:00a.m. and 9:00p.m. levetiracetam (Anticonvulsant) 500MG 8:00a.m. and 8:00p.m. Magnesium Gluconate (medication used to treat low magnesium) 27MG 8:00a.m. and 8:00p.m. metoprolol (treats high blood pressure) 25MG 8:00a.m. and 8:00p.m. Senna Tablet (used for constipation) 8.6 MG 8:00a.m. and 8:00p.m. ascorbic acid (vitamin C) 500MG 8:00p.m. melatonin (sleeping medication) 3MG 8:00p.m. multivitamin 8:00p.m. Simvastatin (high cholesterol medication) 20MG 9:00p.m. mirtazapine (Antidepressant) 15MG MRD stated, the box for staff initials on [DATE] were coded as a 9 during LVN 1 ' s shift indicating see progress note which indicated resident refused and during LVN 2 ' s shift on [DATE], medications were coded as 2 indicating drug refused. MRD reviewed the progress notes and stated there was no progress note indicating change of condition, physician notification or assessment done on [DATE]. MRD stated, the only note on [DATE] was documented by LVN 1 that Resident 7 had refused his medications and that the risks and benefits were explained. During a concurrent interview and record review on [DATE], at 2:29 p.m., with LVN 1, the facility Policy and Procedure (P&P) titled Change in a Resident ' s Condition or Status dated ,d+[DATE] was reviewed. The P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition .The nurse will notify the resident ' s Attending Physician or physician on call when there has been a(an): .significant change in the resident ' s physical/emotional/mental condition .refusal of treatment or medications two (2) or more consecutive times .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR [situation, background, assessment, recommendation]Communication form .The nurse will record in the resident ' s medical record information relative to the changes in the resident ' s medical/metal condition or status . LVN 1 stated the facility policy was not followed. LVN 1 stated per the facility policy the physician should have been called because Resident 7 refused medications two consecutive times. LVN 1 stated Resident 7 ' s significant change in his physical condition should have been reported to the physician but was not. During an interview on [DATE], at 3:36 p.m., with Registered Nurse (RN) 3, RN 3 stated, she was the nurse who admitted Resident 7 when he returned from the hospital on [DATE]. RN 3 stated, she was aware of Resident 7 Diagnosis of DKA and that his BS ran high. RN 3 stated, she should have placed Residents 7 ' s name in the lab book located in the nursing station to ensure his lab was drawn but did not. RN 3 stated, the purpose of the A1C lab draw was to measure a 3-month BS levels for the MD to determine if diabetes was well controlled or if new interventions were needed. During an interview on [DATE], at 9:19 a.m., with MRD, MRD was asked to provide LVN 1 ' s employee file to include all in-service trainings. MRD stated, she was unable to locate the LVN 1 ' s employee file. During a concurrent interview and record review on [DATE], at 9:21 a.m., with DSD, Resident 7 ' s PN dated [DATE] was reviewed. The PN indicated, [DATE] 07:10 .Change in Conditions .unresponsiveness . 1738 [5:38p.m.] Resident expired at approx. 0445 .Approx [approximately] 02:25 CNA was doing rounds - resident had his head covered with his blanket - CNA removed blanket to see resident; resident pulled blanket back over his head Approx 0300 CNA was doing walking rounds and noticed that resident had removed his gown; therefore CNA placed new gown on resident Approx 0430 CNA was passing out water and noticed that resident had a blank stare therefore CNA went to get the Charge nurse Approx 0430 RN assessed resident (no noted vital signs), sent for crash cart [equipment used in emergency] and started compression; AMBU [handheld device used to deliver air during emergency] bag was used by LVN Approx ,d+[DATE] LVN phoned EMT Approx 0448 EMT arrived Approx 0500 Family notified, MD notified Approx 0500 EMT [emergency medical technician] phoned coroner Approx 0719 Coroner arrived and departed at 0749 . DSD stated, she worked from 11p.m. to 7:00 a.m. on [DATE] ,she was the nurse assigned to care for Resident 7. DSD stated, she did not complete her documentation for the change of condition because she got busy and returned to the facility to complete her documentation. DSD stated, she did not review Resident 7 chart before starting her shift but should have because she was unaware of Resident 7 ' s refusal of his medications and not receiving his scheduled dose of insulin. DSD stated, if she had reviewed Resident 7 ' s chart she would have seen that Resident 7 ' s blood sugar was 388 two consecutive times and no BG recheck was done. DSD stated, Resident 7s refusal of medication, vomiting, missed dose of insulin should have been reported to the physician but was not. DSD stated, the nurse should have completed a change in condition and notified the physician. DSD stated, there were two opportunities to call the physician when Resident 7 had a change in condition and had refused his medications two consecutive times, but the physician was not called. During a concurrent interview and record review on [DATE], at 9:33 a.m., with DSD, Resident 7 ' s Care Plan (CP) dated [DATE] was reviewed. The CP indicated, .The resident has Diabetes Mellitus .Administer medications as per MD orders. Monitor/document for side effects and effectiveness .Dietary consult for nutritional regimen and ongoing monitoring .Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen . DSD stated, there was no intervention revised since [DATE] related to diabetes. DSD stated, the there was no care plan developed for the diagnosis of DKA, the two hospital visits on [DATE] and [DATE] related to DKA should have triggered the development of a care plan or a revision to the diabetes care plan. DSD stated, the importance of the care plan was to alert staff of Resident 7 ' s high risk of DKA, interventions to follow, and alert the staff on guidance regarding Resident 7 ' s care. DSD stated, it was the IDT (Interdisciplinary Team) responsibility to update and revise the care plan, the IDT consisted of the Administrator, Director of Nursing, Dietary, Activities, Registered Dietitian, and Social Services. During a concurrent interview and record review on [DATE], at 9:40 a.m., with DSD, the Department Specific Orientation (Skills Check-off) (DSO) undated was reviewed. The DSO indicated, . Licensed Nurses Orientation . Instructions: nurse that is providing the orientation to the nursing department will be responsible to initial in the column on the right side after completion of specific area will sign on the back page when the Department specific orientation is completed. Associate Name: [DSD ' s name] Title: DSD . Notification of Change in Resident Status .Medical Record Policy .Nursing Policy .Change of Condition Policy . Reporting .Monitoring of Nursing Documentation .Medication and Treatment Records .Competency -[skills check-off] .Change in Resident Status .Notification of Physician .Notification of Director of Nurses or Nursing Supervisor . DSD stated, she had been working at the facility approximately two months and had signed and printed her name on the DSO skills check off form. DSD stated, the form was blank because when she was hired there was no DON to complete her onboarding competency, skills check off, and training. DSD stated, if there was a DON, it would be the DON ' s responsibility to complete skills check off and in-service training. DSD stated, LVN 1 ' s employee file was not located. DSD stated, LVN 1 was from registry (third party to work at a nursing care institution) and no orientation or skills check off was done at the facility for LVN 1. During a telephone interview on [DATE], at 10:23 a.m., with Pharmacy Consultant (PC), PC stated, he would send his recommendations via email to the DON and ADON. PC stated, the facility was aware and had access to a system where they could log into and retrieve his recommendations as well. PC stated, he made the recommendation on [DATE] regarding Resident 7 insulin sliding scale and sent it to [Assistant Director of Nursing Licensed Vocational Nurse] (ADON/LVN). PC stated, his recommendation was to discontinue sliding scale insulin because Resident 7 needed a better insulin regimen instead of sliding scale which was chasing high number. During an interview on [DATE], at 11:58 a.m., with LVN 3, LVN 3 stated it was her first day at the facility and that she was from an agency. LVN 3 stated, when she started her first day, she got report from the previous nurse regarding the patients but had not received any in-service training, competency or skills check. During a concurrent interview and record review on [DATE], at 1:45 p.m., with MRD, Resident 7 ' s pharmacy recommendation titled Note to Attending Physician/Prescriber ([NAME]) dated [DATE] was reviewed. The [NAME] indicated, .Resident has an order for Insulin [brand name] sliding scale .Sliding scale insulin has been shown to produce more episodes of hyperglycemia [high blood sugar] and hypoglycemia [low blood sugar] (since it is based on ' catching up ' with current blood glucose readings). Also, the State Operations Manual views long term use of sliding scale as inadequate glycemic control. Please re-evaluate the diabetic regimen in an effort to reduce/eliminate the use of sliding scale insulin . Physician/Prescribers Response .Signature : [no signature on line] Date: [no date documented] . MRD stated, it was the previous ADON/LVN duty to notify and fax pharmacy recommendations to the MD. MRD stated, the [NAME] was not signed or dated by MD and if MD had seen the pharmacy recommendation there would be a MD signature, date, and a note if he agreed or disagreed with the recommendation from the pharmacy. During an interview on [DATE], at 2:13 p.m., with IDON, IDON stated, physician orders should be followed, and the physician should be notified if an order was not carried out. IDON stated it was his expectation for LVN ' s to notify the physician and document the intervention and communication with the physician. IDON stated, it was his expectation for licensed nurses to promptly address change of condition and document in the residents record. During an interview on [DATE], at 2:28 p.m., with IDON, IDON stated, care plans should be updated quarterly and as needed. IDON stated, there was no IDT revisions done for Resident 7 ' s care plan. IDON stated, the purpose of the care plan was to guide staff on the residents needs, to include interventions, and expectations when providing care. IDON stated, when Resident 7 was readmitted there should have been an IDT meeting but was not done. During a telephone interview on [DATE], at 2:45 p.m., with Medical Doctor (MD) 1, MD 1 stated, his practice for corresponding to pharmacy recommendations were to sign, date, and document if he would like to change or continue the pharmacy recommendations. MD 1 stated, he does not recall the facility sending him pharmacy recommendation for Resident 7 on [DATE]. MD 1 stated, my orders for Resident 7 indicated to call him when Resident 7 ' s BS was above 400 and expected the nurses to call him and document the conversation in a progress note. MD 1 stated, if the nurses did not document that they notified him then it was not done. During a concurrent interview and record review on [DATE], at 10:15 a.m., with DSD, the facility Policy and Procedure (P&P) titled Competency of Nursing Staff dated ,d+[DATE] was reviewed. The P&P indicated, In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: .participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .The staff development and training program . is designed to train nursing staff to deliver individualized, safe, quality of care and services for the residents . Competency in skills and techniques necessary to care for the residents ' needs includes but is not limited to .Basic nursing skills .Medication management .Identification of changes in condition . Facility and resident-specific competency evaluations will be conducted upon hire, annually, and as deemed necessary based on the facility assessment .Competency demonstrations will be evaluated based on the staff member ' s ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge . DSD stated, the facility Competency policy was not followed, staff should be competent to ensure safe care. DSD stated, her competency and LVN 1 ' s should have been done upon hire. During an interview on [DATE], at 11:46 a.m., with IDON, IDON stated, the DON and DSD should be involved in hiring and training staff. IDON stated, the expectation was to ensure staff were competent to perform their duties without issues or challenges and that competency should be provided and performed. During a review of Resident 7 's Ambulance Report (AR), dated [DATE], the AR indicated, .Call Recvd: 04:36 a.m Enroute: 04:37 a.m. On Scene: 04:44 a.m. Pt[patient] Contact: 04:46a.m.64 y/o [year old], apneic [stop breathing], and pulseless. Per staff, the Pt was given a gown at approximately 0230 and last seen around the 0300 hour. At 0430 CPR [cardiopulmonary resuscitation] was initiated by staff when they realized Pt was nonresponsive. Pt was moved to the floor by Cal Fire Unit where Pt was then pronounced dead at 0448 . 2.During a review of Resident 15's Face Sheet(FS), dated [DATE], the FS indicated, Resident 15 was readmitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus. During a review of Resident 15's Minimum Data Set, dated dated [DATE], indicated Resident 15 ' s Brief Interview for Mental Status BIMS score was 6 out of 15 indicating Resident 15 had severe cognitive impairment. During a review of Resident 15's Order Summary Report (OSR), dated ,d+[DATE], the OSR indicated, .Insulin .Inject as per sliding scale .Below 70mg/dl [milligrams per deciliter (a unit of measure)], Notify MD .If Blood S [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for two of four sampled residents (Resident 2 and Resident 6) when: 1. Resident 2 experienced a severe weight loss (weight loss greater than 5% in one month) of 12.6 pounds (lbs., unit of measurement for weight) (10.6%), from 118.0 lbs. on 9/7/22 to 105.4 lbs. on 10/29/22. Resident 2 had a history of unplanned weight loss and there was no Registered Dietitian (RD) to evaluate the resident ' s nutritional status and risks from 9/1/22 to 10/31/22; and collaborate with the Interdisciplinary Team (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address the resident ' s physical, mental, and psychosocial needs) in implementing effective and resident-specific interventions to prevent further weight loss. 2. Resident 6 experienced a nine lbs. (6.6 %) weight loss in 54 days. Resident 6 has Type 1 Diabetes (a chronic [long-term] condition in which the pancreas produces little or no insulin) and history of weight loss and skin breakdown, and there was no Registered Dietitian (RD) to evaluate Resident 6 ' s nutritional status and risks from 9/1/22 to 10/31/22 ; and no collaboration with IDT in developing and implementing effective and resident-specific interventions to prevent further weight loss. As a result of these failures, Residents 2 and 6 ' s overall health and safety had been compromised and could lead to further medical complications, including but not limited to dehydration, malnutrition (a condition that develops when the body is deprived of vitamins and minerals and other nutrients it needs to maintain healthy tissues and organ function), loss of muscle mass with decreased mobility, and skin breakdown. Because of the unintended and severe weight loss for Residents 2 and 6, the facility ' s lack of systemic approach that would ensure effective monitoring and systems to maintain acceptable parameters of nutritional status was in place, and the lack of RD and Director of Nursing (DON) clinical and nutritional oversight, an Immediate Jeopardy (IJ) (a situation in which facility non-compliance has placed the health and safety of residents or patients in its care at risk for serious injury, harm, impairment, or death; and involves immediate action to remove the threat of harm or potential harm), with a scope and severity of K, under 42 Code of Federal Regulations (CFR) S483.25 Nutrition/Hydration Status Maintenance (F692), was called on 11/3/22, at 4:09 p.m., with the Interim Director of Nursing (IDON), Medical Record Director (MRD), and Director of Staff Development (DSD). The facility was provided with the IJ template which listed the identified regulatory non-compliance, the potential or actual outcomes of the non- compliance, and the requirement for the facility to develop, implement, and submit a Plan of Removal (POR, a plan consisting of interventions or action items that must be immediately implemented by the facility to correct and remove the IJ situation). The facility submitted an acceptable IJ POR (Version 3) on 11/4/22, which addressed the actions needed to remove the IJ situation. The IJ POR included but is not limited to the following: 1) Residents were immediately referred to RD for nutritional assessment and intervention, 2) All residents were weighed for the month of November 2022, 3) RD came to the building and evaluated and assessed monthly weights and weight variance(difference) and will initiate nutritional assessments on residents with weight changes, 4) A different scale was used to re-weigh residents to compare and identify discrepancies in scale, which will be added as part of the RCA (root cause analysis). Those identified with significant weight changes will be reviewed with IDT weight variance, 5) Immediately re-implemented monthly weight variance meetings for all significant weight changes to allow IDT to identify any weight changes and implement nursing and dietary interventions, 6) DON, RD, and MDS will review all monthly weights for any significant changes for immediate interventions, 7) Care plans will be reviewed and updated during weight variance meetings for any changes, 8) Nursing staff will perform monthly weights and all weight changes will be reviewed and discussed during the weight variance meetings with DON, RD, and dietary supervisor, 9) All significant weight changes will be reported to resident ' s primary physician, 10) Effective 11/4/2022, residents that will be put on weekly weights will be reviewed by the DON, RD, and dietary supervisor for interventions during the IDT weight meeting, 11) On 11/3/2022, DSD initiated education/in-service with CNAs ' and licensed nurses regarding identification of weight loss/gain, prevention, management and reporting and weight changes or changes in resident PO intake. Staffs who were in-serviced were able to perform return demonstration via verbalization and communication of understanding of items in serviced, 12) DSD will include training of weight variance and identification of weight changes during new hire orientation, 13) DON provided in- service to CNAs regarding weight changes, reporting, monitoring, and interventions. Topics included identifying resident appearance for any weight changes, amount of food intake, any refusal of meals, offering of substitutes and discussing with charge nurse and dietary supervisor. Staff was able to confirm and verify understanding of in-serviced topic by verbalization and question and answers. DON and DSD will provide ongoing education on all staff by 11/10/2022 to ensure 100% compliance, 14) The QA committee will meet to review facility policy and procedure for weighing and measuring the residents ' significant weight loss/weight gain. Any changes in the facility policy will be documented and updated with approval of facility Medical Director, 15) DON started to collect data for the root cause analysis (RCA) on residents with weight changes and lack of interventions and facility will implement results of RCA and will review with the QA committee monthly, 16) DON started and will implement review of the facility ' s policies and procedures, 17) Medical Director was notified of the IJ concerns and guidance was provided and, 18) Medical director and QA committee team members will review facility ' s systems and RCA of weight and nutritional noncompliance. On 11/5/22, the components of the IJ POR - (CFR) S483.25 Nutrition/Hydration Status Maintenance (F692), Version 3, were validated through observations, interviews, and record review. The facility was determined to have implemented its POR. The IJ was removed onsite, on 11/5/22 at 4:48 p.m., with the IDON and DSD in attendance. Findings: 1. During a review of Resident 2 ' s ADMISSION RECORD, undated, the ADMISSION RECORD indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes (an impairment of the body to regulate and use sugar), nutritional anemia (anemia is a condition that develops when the body does not produce enough healthy red blood cells. Nutritional anemia is caused by inadequate intake of food rich in iron and vitamins), anorexia (lack or loss of appetite for food), dementia (condition that affects one ' s ability to remember, think, or make decisions that interferes with doing everyday activities), oral phase dysphagia (difficulty in swallowing due to problems using the mouth, lips, and tongue to control food or liquid), and muscle weakness. During a review of Resident 2 ' s Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs) dated 8/19/22, Section C for BIMS (Brief Interview for Mental Status), indicated, Resident 2's BIMS score was zero of 15, which indicated Resident 2 had cognitive impairment (no recall or memory and inability or difficulty in making decisions that affect everyday life). Section G for functional status, indicated Resident 2 fed herself independently but required one staff assistance to set-up her meals. Resident 2 required extensive one-staff assistance for transfers, toileting, hygiene, bathing/showers, repositioning, and dressing. During a review of Resident 2 ' s Order Summary Report (OSR) dated 11/2/22, indicated Diet: Mechanical Soft Texture, Regular Consistency - scoop plate with all meals to assist with eating . Med Plus (supplement) 4 ounces (unit of fluid measurement) two times a day . FBS (Fasting Blood Sugar, is the sugar level in the blood after an overnight of not eating) level in the morning every Monday, Wednesday, and Friday . QuikPen insulin glargine (pen that delivers the precise dialed dose of insulin once a day to manage blood sugar levels in patients with diabetes) 30 units subcutaneously (injected beneath the skin) once a day at bedtime . During an observation, on 10/26/22 at 1:15 p.m., in Resident 2 ' s room, Resident 2 was observed lying in bed with her eyes open. An uncovered food plate with uneaten food items (country style baked chicken, barley pilaf, glazed beets, and orange tapioca) was on top of the bedside table on the right side of Resident 2 ' s bed. Certified Nursing Assistant (CNA) 1 came into the room, picked up Resident 2 ' s tray and placed it inside the food cart that would be going back to the kitchen for dishwashing. During an interview, on 10/26/22 at 1:18 p.m., with CNA 1, CNA 1 stated, Resident 2 could feed herself independently, if her tray was set-up for her. CNA 1 stated, Resident 2 had poor appetite and often refused to eat. CNA 1 stated, She ate zero % of her lunch today . (Resident 2) had been losing weight. During an interview on 10/28/22 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had noticed Resident 2 had been losing weight. LVN 1 stated, She (Resident 2) eats between 10% to 25% of her meals and would often refuse to eat. I guess the weight loss is an expected outcome because she has diabetes. LVN 1 stated, I have no idea how much she weighs this month because weights are taken every first week of each month, on the weekends. LVN 1 stated, that because she is a registry nurse, it would take a while for her to learn each resident ' s medical condition and specific needs. LVN 1 stated, she did not know how to calculate the percentage of weight loss/gain and did not know the difference between significant and severe weight loss or gain. LVN 1 stated, That ' s for the RD to do. During an interview on 10/28/22 at 3:04 p.m., with Administrator (ADM) 1, ADM 1 stated, she had concerns about resident weight loss since 7/2022. ADM 1 stated, the residents ' monthly weights for October 2022 had not yet been taken because the Restorative Nursing Assistant (RNA, a healthcare worker who has acquired knowledge, skills, and techniques to work alongside rehabilitation staff caring for residents/patients with limited mobility and capacity for self-care), who took the residents ' monthly weights was reassigned to patient care due to short staffing. During an interview on 10/28/22 at 3:10 p.m., with ADM 1, ADM 1 stated, the facility did not have a contract or service agreement with a registered dietitian (RD) since 9/1/22. ADM 1 stated, As of today, 10/28/22, we don ' t have a contract or service agreement with a RD. ADM 1 stated that because there was no RD onboard, there had been no Nutritional Risk Assessments (NRA) done to identify those residents with significant or severe weight variances and implement resident- specific interventions to prevent further weight loss for these residents. ADM 1 stated that the standards of practice to have weekly IDT weight variance meetings to discuss unplanned weight loss/gain, conduct nutritional risk assessment, and develop and implement resident-specific care plan had not occurred since 7/2022. ADM 1 stated, We also don ' t have a director of nursing (DON) to provide clinical oversight and monitoring, since 10/16/22 . I won ' t be surprised if we find more residents who have unplanned weight loss. During a concurrent record review and interview, on 10/28/22 at 3:40 p.m., with ADM 1, Resident 2's Weights and Vitals Summary (WVS), indicated, from 1/4/22 to 9/7/22, Resident 2 weighed between 117-119 lbs. ADM 1 stated, We don ' t have an RNA today so I will have Resident 2 weighed tomorrow, 10/29/22. During a concurrent record review and interview, on 10/28/22 at 3:45 p.m., with ADM 1, Resident 2 ' s NUTRITIONAL ASSESSMENT, dated 3/28/22.ADM 1 stated this was the last nutritional assessment done by RD 1 for Resident 2 before she resigned from the facility in August 12, 2022. During a concurrent record review and interview, on 10/28/22 at 3:50 p.m., with ADM 1, Resident 2 ' s Nutrition Dietary Note - Quarterly, 6/17/22, and completed by dietary supervisor (DS) 2, indicated Meal intake varies 25-100% of meals .eats meals in the room .Labs: low hgb (hemoglobin, carries oxygen throughout the body) . high glucose .) ADM 1 validated the last dietary note done by DS 2 for Resident 2 was 6/17/22. During a concurrent review and interview, on 10/31/22 at 4:00 p.m., with Medical Record Director (MRD), Resident 2 ' s WVS was reviewed. The WVS indicated, on 10/29/22 at 5:42 p.m., Resident 2 ' s weight was 105.4 lbs. Resident 2 ' s WVS indicated, a weight loss of 12.6 pounds (10.6%), from 118.0 lbs. on 9/7/22 to 105.4 lbs. on 10/29/22. MRD stated she had reached out to the IDON and informed him of Resident 2 ' s weight loss. During a review of Resident 2 ' s WVS, dated 9/7/22 to 10/29/2022, indicated the following weights: 10/29/22 at 5:42 p.m.: 105.4 lbs. 9/7/22: 118 lbs. During a review of Resident 2 ' s care plan titled, NUTRITIONAL STATUS, dated 3/15/22 and 7/3/22, indicated Resident 2 was at risk for weight loss due to dementia, leaves 25% or more of uneaten food, anorexia, history of weight loss, diabetes, unable to state food preferences. Goal: Goal weight 115 - 120 lbs. Resident will have no significant weight changes through next review date of 10/15/22 . Interventions: Provide assistance with meals as needed, provide supplement as ordered, do not serve food the resident does not like, weigh resident per facility protocol, monitor meals and snacks. During a concurrent review and interview, on 11/5/22 at 4:00 p.m., with RD 2, onsite at the facility, RD 2 stated she evaluated Resident 2 ' s nutritional status on 11/4/22, and determined Resident 2 ' s weight loss of 12.6 pounds (10.6%), from 118.0 lbs. on 9/7/22 to 105.4 lbs. on 10/29/22 was severe (based on the criteria where a 5% weight loss in one month is significant and greater than 5% is severe; a 7.5% weight loss in 3 months is significant and greater than 7.5% is severe; and a 10% weight loss in 6 months is significant and greater than 10% is severe). RD 2 stated, Resident 2 ' s unplanned severe weight loss required immediate additional nutritional interventions such as monitoring weekly weights for one month, diet change to fortified (adding nutrients to food to improve nutrition and health) diet and adding nutritional supplement three times a day. RD 2 stated, Resident 2 had been identified as at high risk for weight loss due to her diagnoses od Type 2 diabetes and should have been monitored closely. During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, undated, indicated The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data (weights) and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition . During a review of the facility policy and procedure (P&P) titled, Care plans, Comprehensive Person-Centered dated 12/2016, 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 Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Incorporate problem areas .Incorporate risk factors associated with identified problems .The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident ' s condition; .When the resident has been readmitted from a hospital stay . During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association) . During a review of professional reference titled, Involuntary Weight Loss can lead to Muscle Wasting . Depression and an increased rate of Disease Complications (www.aafp.org/afp American Family Physician), dated 2/15/02, indicated, . One study showed that nursing home patients had a significantly higher mortality (death) rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost five percent of their body weight in one month were found to be four times more likely to die within one year . During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . During a review of professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated 2007-2009, indicated, . The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) . 2. During a review of Resident 6 ' s ADMISSION RECORD, undated, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses including quadriplegia (paralysis from the neck down, including the trunk, legs and arms), Type 1 Diabetes (a chronic [long-term] condition in which the pancreas produces little or no insulin), and gastrostomy tube (GT, a tube which is surgically inserted through the abdomen and into the stomach to deliver nutrition or medication to a person who is unable to swallow or take food or fluids by mouth). During a review of Resident 6 ' s Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs) dated 7/20/22, Section C for BIMS (Brief Interview for Mental Status), indicated Resident 6's BIMS was not scored. Section G, for functional status indicated, Resident 6 was totally dependent on staff to receive nourishment via (by way of) tube feeding. During an observation, on 11/2/22 at 11:30 a.m., with the MRD in attendance, inside Resident 6 ' s bedroom, Resident 6 was observed lying in bed with eyes open and with his hands curled into a fist. Resident 6 was non-verbal. Resident 6 was observed with a GT. A feeding bag labeled [Brand Name] was infusing per pump. During a review of Resident 6 ' s Order Summary Report (OSR) dated 11/2022, indicated an order date of 9/1/22, for [Brand Name] (Nutritional Supplements), 65 milliliters (ml, a unit of liquid measurement) per hour for 20 hours (total of 1300 mls - 1400 calories) with 78 grams of protein. The OSR included an order date of 6/11/22, for Trulicity Solution Pen-injector 3 mg/0.5 ml, subcutaneously (injected beneath the skin), one time a day on Mondays related to Type 1 Diabetes. During a review and interview, on 11/2/22 at 3:00 p.m., with the MRD, the facility ' s Monthly Weight Report, dated 1/2022 to 11/2022, indicated Resident 6 ' s weight had not been obtained for the month of October 2022. MRD stated, The RNAs are working on it . During a review and interview, on 11/3/22 at 4:30 p.m., with the IDON, MRD, and Director of Staff Development (DSD), the facility ' s Monthly Weight Report, dated 1/2022 to 11/2022, indicated Resident 6 ' s weight on 11/3/22 was 130.8 lbs. The IDON stated, We need to re-weigh Resident 6 . the weight loss seems too big .we will use a different scale. During a review of facility document titled, RESIDENTS TO WEIGH AND REWEIGH, dated 11/4/22, indicated Resident 6 was re-weighed on 11/4/22, with a weight of 137.0 pounds. During a review of Resident 6 ' s Weights and Vital Summary, dated 6/4/22 to 11/5/22, indicated the following weights for Resident 6: 11/5/22: 137 lbs. 10/10/22: No weight taken on 10/10/22 9/9/22: 146 lbs. 8/9/22: 145 lbs. 7/4/22: 142 lbs. 6/4/22: 142 lbs. During a concurrent review and interview, on 11/5/22 at 4:00 p.m., with the IDON, Resident 6 ' s care plan titled, NUTRITIONAL STATUS, dated 2/12/21, indicated At risk for weight loss/gain due feeding status, quadriplegia, Type 1 Diabetes. Goal . maintain weight at 145 pounds every month . will not show any signs and symptoms of malnutrition . Will have no significant weight changes through next review date . Interventions: GT feedings, monitor weight monthly . notify MD (physician) and RD of significant weight loss or gain . The IDON stated, This care plan was not followed as it pertains monitoring the resident ' s monthly weight. During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, undated, indicated The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data (weights) and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition . During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association) . During a review of professional reference titled, Involuntary Weight Loss can lead to Muscle Wasting . Depression and an increased rate of Disease Complications (www.aafp.org/afp American Family Physician), dated 2/15/02, indicated, . One study showed that nursing home patients had a significantly higher mortality (death) rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost five percent of their body weight in one month were found to be four times more likely to die within one year . During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . During a review of professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated 2007-2009, indicated, . The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) .

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on employment screening when nine of 10 current employees (housekeeping [HKA], janitorial [JAN], maintenance supervisor [MS], two dietary aides [DA 1 and DA 2], nursing assistant [NA], two certified nursing assistants [CNA 1 and CNA 3], and a Licensed Vocational Nurse [LVN 1] hired between the first week of April 2022 through 7/13/22 were permitted to work in the facility without first conducting criminal background screening and failed to check the CNA registry. Facility staff were aware the contract ended with the vendor used to conduct background checks and no new vendor was contracted. These failures placed all 62 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,29, 20, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, and 62) in the facility at risk for abuse, neglect, serious injury, harm, impairment, death and resident exploitation. Because of the potential serious harm to residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 20, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, and 62 related to possible abuse, neglect and resident exploitation by not conducting criminal background checks on employees, an Immediate Jeopardy (IJ) situation (a situation that involves immediate action to remove the threat of harm or potential harm) was called with a scope and severity L under 42 CFR S483.12(b)(1), F607 on 7/13/22 at 3:31 p.m. with the Facility Administrator (ADM), Director of Nurses (DON), Business Office Manager (BOM), Registered Nurse Care Manager (RN CM).The facility was provided the CMS IJ template which indicated the need to submit an acceptable written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility submitted an acceptable IJ Plan of Removal on 7/14/22 at 2:14 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: (1) all ten employees that were identified as not having background screening as per the facility's policy and procedures were entered into the [TRADE NAME] background check verification system; (2) All nine employees that were identified as not having background screenings were taken off of the work schedule until background checks had been completed and reviewed by the BOM; (3) DON, Dietary Manager and housekeeping supervisor made arrangements to cover the shifts of the ten employees removed from the work schedule; and (4) an in-service on the policy and procedures on the hiring and background screening process was conducted for the BOM and department heads of the facility. The components of the IJ Plan of Removal were validated through observations, interviews, and record review. The IJ was removed on 7/14/22 at 3:07 p.m. with the ADM, DON, and BOM. Findings: The Department received an online anonymous complaint alleging . an employee who works in housekeeping, we heard he's a felon . During a concurrent interview and record review on 7/13/22, at 11:36 a.m., with the ADM, the facility documents titled Exclusions Search Results: Individuals (ESRI), (HKA), dated May 11, 2022, ESRI, (JAN), (DA 1), (DA 2), dated May 3, 2022, ESRI, (MS), dated May 23, 2022, ESRI, (LVN 1), dated June 22, 2022, ESRI, (CNA 1), dated May 4, 2022, ESRI, (CNA 3), dated May 3, , ESRI, (NA), dated June 22, 2022, were reviewed. The ADM stated since she had been here, the owners of the facility used the Office of Inspector General list search (https://exclusion.oig.hhs.gov/Searchresults.aspx) to conduct the background screening. The webpage defines the database: This webpage provides information about OIG's exclusion authority and activities. OIG has the authority to exclude individuals and entities from federally funded health care programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud. Those that are excluded can receive no payment from Federal healthcare programs for any items or services they furnish, order, or prescribe. This includes those that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan). None of the reviewed documents indicated any of the ten employees were excluded from a federally funded health care program. She stated the website does not perform a background check and does not screen for criminal behavior. The ADM stated this search was not appropriate for conducting background screenings on potential employees. The ADM stated she discussed the concern with the RN Case Manager (RN CM), the individual in charge of obtaining the contract for the agency to perform background checks. The ADM stated she needed to have appropriate background screening conducted but was told the contract had not been finalized. During a concurrent interview and record review on 7/13/22, at 1:44 p.m., with the ADM, the facility's P&P titled, Background Screening Investigations, dated December 2006, was reviewed. The P&P indicated, 1. The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on persons making application for employment with this facility. Such investigation will be initiated within two days of employment or offer of employment. 2. For any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be conducted to determine if any findings of abuse, neglect, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM stated step 1 is not being done for employees at this time and step 2 is not being done with CNAs. During a concurrent interview and record review on 7/13/22, at 2:20 p.m., with the RN CM, the documents titled [Facility Name and Limited Liability Company (LLC) Number]: Welcome to the [TRADE NAME] Employee Screen Services! 5 messages, dated April 25, 2022, and [Facility Name LLC:] [TRADE NAME] Employee Screening Services Action Required 1 message, dated May 19, 2022, were reviewed. The RN CM stated he negotiates and completes the contracts for the facility. He stated the first week of April 2022, the contract for background screenings was terminated. He stated he attempted to start on a new contract but the new contract for services was started on July 11, 2022. He stated no background screenings occurred from the first week of April 2022 until July 11, 2022, for potential employees. The RN CM stated he took over the background screenings at this time using the Office of Inspector General list search as he pursued another contract. He stated he would provide the ADM the search results. He stated background screenings should occur before employees work for the facility. He stated there could be a potential of hiring an employee with a criminal history and a history of abuse. He stated potentially all the residents in the building could be harmed by abuse. During an interview on 7/13/22, at 2:30 p.m., with the ADM, the ADM stated staff (HKA, JAN, DA 1, DA 2, MS, CNA 1, CNA 3, NA and LVN 1) have not had background screening investigations should not be working until the background screens are completed and reviewed. She stated by allowing employees to work who have not completed the process, residents could potentially be exposed to employees with a history of abuse/exploitation and residents could be harmed. She stated this would include every resident in the building. During an interview on 7/13/22, at 2:50 p.m., with the MS, the MS stated he was hired 5/23/22. The MS stated he was working and performed tasks in the facility. The MS stated he normally works eight hours, Monday to Friday and is on call for the facility if they need him for maintenance issues. The MS stated he filled out the form to consent for a background screening on the job application. He did not know if the background screening was conducted. He stated as the maintenance supervisor, he has access to every part of the facility and to all areas where residents are located. During a review of MS ' s employee file, the document titled, [Facility Name, LLC]-Employment application (SRFEA), dated 5/23/22 was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked 'no' and added 'never'] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. MS ' s background screening was not completed by the facility. During an interview on 7/13/22, at 2:38 p.m., the JAN stated he was hired 5/3/22. He stated he filled out the form to consent for a background screening on the job application. He did not know if the background screening was conducted. He stated he is responsible to clean the resident rooms and the common areas of the facility. During a review of JAN's employee file, the document titled, SRFEA, dated 5/2/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. JAN ' s background screening was not completed by the facility. During an interview on 7/13/22, at 2:38 p.m., with DA 1, DA 1 stated she was hired 5/3/22. DA 1 stated she filled out the form to consent for a background screening on the job application. She did not know if the background screening was conducted. During a review of DA 1 ' s employee file, the document titled, SRFEA, dated 5/2/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. DA 1 ' s background screening was not completed by the facility. During review of the facility document titled, ORIGINAL Schedule .July 2022, the ORIGINAL Schedule .July 2022 indicated DA 1 worked 7/1, 7/5, 7/6, 7/7, 7/8, 7/9/ 7/10, 7/11, and 7/13. During a review of HKA's employee file, the document titled SRFEA, dated 5/10/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked yes] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. HKA ' s background screening was not completed by the facility. During a review of DA 2's employee file, the document titled, SRFEA, dated 6/13/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. DA 2 ' s background screening was not completed by the facility. During review of the facility document titled, ORIGINAL Schedule, dated July 2022, the ORIGINAL Schedule indicated DA 2 worked 7/1, 7/2, 7/3, 7/4, 7/11, and 7/12. During a review of NA ' s employee file, the document titled SRFEA, dated 6/13/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. The NA ' s background screening was not completed by the facility. During a review of CNA 1's employee file, the document titled SRFEA, dated 4/26/22, was reviewed. The SRFEA is missing page 2, asking the about whether the employee has been convicted of a felony. SFREA indicated .APPLICANTS STATEMENT I hereby grant [Facility Name] permission to contact all persons and employers listed. I give permission for the [Facility Name] to do a criminal conviction investigation check on me. All direct care staff (those not licensed under Title 8 of the Education Law or under Article 28 - D of the Public Health Law) who apply for employment with [Facility Name] are required to have a background check. CNA 1 ' s background screening was not completed by the facility. During review of the facility's document UNTITLED [Schedule], dated June 2022, the UNTITLED [Schedule] indicated CNA 1 worked 6/1, 6/2, 6/7, 6/8.6/9, 6/12, 6/13, 6/14, 6/15, 6/16, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/26, 6/27, 6/28, 6/29, and 6/30. During review of the facility's document UNTITLED [Schedule], dated July 2022, the UNTITLED [Schedule] indicated CNA 1 worked 7/3, 7/4, 7/5, 7/6.7/9, 7/10, 7/11, and 7/12. During a review of CNA 3's employee file, the document titled SRFEA, dated 4/8/22, was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] CNA 3 ' s background screening was not completed by the facility. During review of the facility's document UNTITLED [Schedule], dated May 2022, the UNTITLED [Schedule] indicated CNA 3 worked 5/3, 5/3, 5/5, 5/6, 5/7, 5/10, 5/11, 5/12, 5/13, 5/15, 5/16, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, 5/26, 5/27 and 5/28. During review of the facility's document UNTITLED [Schedule], dated June 2022, the UNTITLED [Schedule] indicated CNA 3 worked 6/5, 6/6, 6/11, 6/12. 6/23, 6/24, 6/29, and 6/30. During review of the facility's document UNTITLED [Schedule], dated July 2022, the UNTITLED [Schedule] indicated CNA 3 worked 7/4, 7/5, 7/10, and 7/11. During a review of LVN 1's employee file, the document titled, SRFEA, dated 6/13/22 was reviewed. The SRFEA indicated .Have you been convicted of a felony within the last ten years? .sic [marked no] . LVN 1 ' s background screening was not completed by the facility. During a review of the facility's document License Nurse Schedule, dated July 2022, the License Nurse Schedule indicated LVN 1 worked on 7/1, 7/4, 7/5, 7/6, 7/7, 7/8, 7/11 and 7/12. During a review of the professional reference, the Society for Human Resource Management published guidelines https://www.shrm.org/resourcesandtools/tools-and-samples/toolkits/pages/conductingbackgroundinvestigations.aspx titled Conducting Background Investigations and Reference Checks dated 7/20/2022, the professional reference indicated, . A background investigation generally involves determining whether an applicant may be unqualified for a position due to a record of criminal conviction, motor vehicle violations, poor credit history, or misrepresentation regarding education or work history. A reference check generally involves contacting applicants' former employers, supervisors, co-workers and educators to verify previous employment and to obtain information about the individual's knowledge, skills, abilities and character . SAFETY .A major reason to conduct background and reference checks is to avoid harm or legal liability of various types to the employer or to others. This includes harm to: Other employees by sexual harassment or workplace violence. The organization's customers by, for example, sexual assault on business premises .

Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable and homelike environment for 30 of 54 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 29, 32, 37, 41, 43, 52, and 54) when the temperature levels in seven resident rooms in Building (BLDG) 1, including the resident television room, main halls, nursing station, resident medication room and nutrition room, exceeded 81 degrees Fahrenheit (F- unit of temperature) (comfortable and safe temperature is 71 to 81 degrees F) on 7/1/21 at 3:55 p.m. and continued to climb to 90 degrees F by 6:15 p.m. In BLDG 2, the medication room temperature exceeded 81 degrees F and reached 88.2 degrees F. The facility staff had previous knowledge of the non-functioning cooling system and did not implement effective interventions to address the unsafe and uncomfortable temperatures in BLDG 1 and BLDG 2 and of the facility. These failures placed residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) in BLDG 1 at risk for dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), heat related illnesses, reduced their ability to participate in their normal activities to preserve their highest practical physical, mental, and psychosocial well-being and resulted in unsafe storage of medications in BLDG 1 and BLDG 2 for residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 29, 32, 37, 41, 43, 52, and 54). Because of the potential serious harm to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19 related to excessive heat and heat related illnesses such as heat exhaustion (condition whose symptoms may include heavy sweating and a rapid pulse, a result of your body overheating), dehydration, heat stroke (a condition caused by your body overheating) and the failure to maintain safe and comfortable ambient (the surrounding area or environment) temperatures in the facility, an Immediate Jeopardy (IJ) situation (a situation that involves immediate action to remove the threat of harm or potential harm) was called with a scope and severity K under 42 CFR §483.10(i)(6), F584 on 7/1/21 at 7:28 p.m. with the Facility Chief Executive Officer (CEO) and Director of Nurses (DON). The facility was provided the IJ template which indicated the need to submit an acceptable written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility submitted an acceptable IJ Plan of Removal (Version 4) on 7/6/21 at 6:32 a.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1. Immediate assessment of all residents, including their hydration status, vital signs (heart rate, temperature, respiration rate, blood pressure), implementation of cooling measures, provision of lightweight clothing, additional fans, hydration stations (a designated area strategically placed to promote and provide fluids for hydration) and extra fluids if not contraindicated. 2. Development of a monitoring tool to assess and document room temperatures to ensure the ambient temperatures were safe, comfortable, and within the acceptable ranges (71 degrees F to 81 degrees F). 3. Immediate training and in-service of all staff for awareness of safe and comfortable ambient temperature levels and signs and symptoms of heat stroke, heat exhaustion, and dehydration. 4. Immediate implementation of scheduled rounds (act of visiting each of several people or places) to monitor residents and medications in the affected areas with corresponding documentation. 5. Inspection and maintenance of the facility's chiller/cooling systems by a reputable vendor to ensure the systems were properly functioning and able to maintain safe and comfortable ambient temperatures. The components of the IJ Plan of Removal were validated through observations, interviews, and record review. The IJ was removed on 7/7/21 at 12:50 p.m. with the Facility Administrator (ADM), CEO, DON, Assistant Director Of Nurses (ADON), Minimum Data Set (MDS) Coordinator, Dietary Manager (DM), Infection Preventionist (IP), Maintenance Supervisor (MS), Activities Director (AD), Medical Records (MR), and Social Service Director (SS). Findings: During an interview on 7/1/21, at 1:30 p.m., with the Ombudsman (OM- an appointed official that advocates for residents and investigates complaints) assigned to the facility, the OM stated she received two anonymous complaints regarding excessive heat in the facility in June 2021. The OM stated on 6/23/21, she entered the facility to start her investigation. During a concurrent observation and interview on 7/1/21 at 1:45 p.m., with the CEO, at the facility's entrance in BLDG 2 and visitor COVID-19 (an infectious respiratory disease) screening area, the ambient temperature at the entrance was hot and humid. The CEO acknowledged the interior building's hot temperature and stated the facility's air conditioning system broke down in May 2021 and the facility awaited delivery of a compressor (mechanical component of the air conditioning system) to complete the repair of one of the units. The CEO acknowledged the air conditioning unit was still broken and was in need of the compressor. The CEO stated the broken air conditioning unit affected the front portion of BLDG 2, which included her office, central supply, the nursing station, medication room, and kitchen. The CEO stated the resident rooms were not affected in BLDG 2. The CEO stated when the air conditioning system broke in May 2021, staff were assigned to check temperatures however stated no system was in place to measure and document the temperatures. During a review of [heating and plumbing vendor] invoice number 5, dated 5/9/21, the invoice indicated, Customer complained ac [air conditioner] not working . on unit 1 (small package unit) found burnt out compressor/ with bad valves system is obsolete Bid to replace . On unit 2 . found 2 bad compressors/ with high amp draw and mechanical issues . Also found missing components system is obsolete Bid to replace . During an interview on 7/1/21, at 2:15 p.m., with Resident 20, in BLDG 2's television room, Resident 20 stated BLDG 2, . Was very hot a couple of weeks ago . they [facility administration] had to move residents around . Resident 20 stated the temperatures in BLDG 2 had since improved but BLDG 1 remained hot. Resident 20 stated, .Ask the people over there [BLDG 1] . they come over here [BLDG 2] to cool off . many of them say it's too hot over there [BLDG 1]. During a review of Resident 20's Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs), dated 5/12/21, the MDS assessment indicated, Resident 20 was cognitively intact with a Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During an interview on 7/1/21, at 2:25 p.m., with the MS, the MS stated BLDG 2's heating, ventilation, and air conditioning units (HVAC) broke down in May 2021. The MS stated the administrative offices and nurse's station located in the front part of BLDG 2 were still affected. The MS stated BLDG 2 had nine HVACs located on BLDG 2's roof and BLDG 1 had two chiller (component of the heating, ventilation and air conditioning system that uses water or refrigerant to cool air) systems located near the nurse's station. The MS stated the air conditioning units and chiller systems were old, required frequent repairs, and ambient temperatures were difficult to regulate. The MS stated he was unsure of the make and model of each unit since the units were installed over [AGE] years ago and the product manuals were missing. The MS stated he did not have a routine scheduled maintenance program for the air conditioning units in either building. The MS stated, I just call [vendor] when something breaks down. The MS stated he was not professionally trained nor certified to do the scheduled maintenance on the air conditioning units and chiller systems and was not aware of any industry standard. The MS stated he changed filters, . When I have a chance. The MS stated a nurse reported ambient temperatures in the BLDG 1's medication room registered high last week, and he was called. The MS stated the temperature issue resolved after he removed a pre-cut piece of cardboard from the ventilation system that was used to cover the vent. The MS stated he did not know when the cardboard was placed but thought it was used to prevent air from circulating through the vent. The MS stated he notified the CEO and the DON of BLDG 1's elevated temperatures in the medication room and nurse's station the day it happened. The MS stated elevated temperatures were not documented. During a concurrent observation and interview on 7/1/21, at 3:15 p.m., with the CEO, in BLDG 2's nurse's station and medication room, the ambient room temperature was collected using a infrared temperature gun (tool that can measure temperatures of an object from a distance and with no contact necessary). The nurse's station temperature ranged between 85.4 degrees F and 88.2 degrees F. The medication room ranged between 86.9 degrees F and 88 degrees F. The digital thermometer on the medication refrigerator door indicated the ambient room temperature of the medication room was 85.6 degrees F. Five bottles unknown volume of liquid anticonvulsant medication (medicine used to treat and/ or prevent seizures [characterized by abnormal nerve cell activity in the brain]), two boxes of bronchodilator medication (medicine to alleviate difficult breathing), 12 bottles unknown volume of liquid [MEDICATION(S)] (stool softener), and five bottles of nutritional supplements sat on the medication room shelves. The CEO stated the stored medications were back up seizures medications, breathing treatments, and laxatives for the residents in BLDG 2. The CEO acknowledged the room was hot. The CEO stated staff had not reported elevated temperatures in the medication room and referred to the medication temperature log binder in the medication room. The temperature log was dated 1/1/21 through 6/30/21. Temperatures documented on the temperature log ranged between 66 degrees F and 78 degrees F. The CEO confirmed one air conditioning unit in BLDG 2 was non-functional and awaited repairs and acknowledged there were disparities (differences) between the logs and current temperature readings. During an interview on 7/1/21, at 3:20 p.m., with Licensed Nurse (LN) 2, LN 2 stated temperature checks in the medication room were done usually in the morning after clinical tasks were completed. LN 2 stated the external digital temperature gauge on the refrigerator door was used to read the temperatures. LN 2 stated the nurse's station and medication room was hot for several weeks. During a telephone interview on 7/1/21, at 3:45 p.m., with the facility's pharmacy consultant (PhC), the PhC stated industry standard was to store over the counter medications in temperatures less than 77 degrees F. The PhC stated occasional spikes in temperature up to 86 degrees F was acceptable provided the medications were not stored above 86 degrees F for prolonged periods of time exceeding 48 to 72 hours. The PhC stated medications stored over the counter should not experience frequent temperature fluctuations. The PhC stated regardless of industry standards, instructions found on medication product labels should be followed to ensure medication safety for the residents. During a professional reference review of Lexicomp (professionally recognized evidence-based online drug referential manual), last updated 7/15/21, the directions for the anticonvulsant indicated, .category . Anticonvulsant . Storage and Stability . Store at 25°C (77°F); excursions (deviation) permitted to 15°C to 30°C (59°F to 86°F) . During a review of the [MEDICATION(S)]'s product label insert, undated, the directions for storage indicated, . Store at controlled room temperature . 68 degrees F to 77 degrees F . During a professional reference review of Lexicomp, last updated 7/14/21, directions for the bronchodilator nebulizing (liquid converted to spray) solution indicated, uses .Storage and Stability . Nebulization solution: Store at 2°C to 25°C (36°F to 77°F) . During a review of Resident 22's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 7/1/21, the AR indicated, Diagnosis information . Asthma (a breathing condition marked by spasms in the lungs, causing difficulty in breathing) . unspecified convulsions (abnormal, involuntary contraction of the muscles typically seen with certain [CONDITION(S)] disorders) . During a review of Resident 23's AR, dated 7/1/21, the AR indicated, Diagnosis information . Shortness of breath . Chronic obstructive pulmonary disorder ([CONDITION(S)]- a long- [MEDICATION(S)] inflammation in the lungs that blocks airflow) . Wheezing (whistling sound made airways are tightened, blocked, or inflamed) . During a review of Resident 24's AR, dated 7/1/21, the AR indicated, Diagnosis information . unspecified convulsions . constipation (difficulty emptying bowels) . During a review of Resident 25's AR, dated 7/1/21, the AR indicated, Diagnosis information . constipation . unspecified convulsions . During a review of Resident 29's AR, dated 7/1/21, the AR indicated, Diagnosis information . [CONDITION(S)] (neurological disorder characterized by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) . constipation . During a review of Resident 32's AR, dated 7/1/21, the AR indicated, Diagnosis information . constipation . unspecified convulsions . During a review of Resident 37's AR, dated 7/1/21, the AR indicated, Diagnosis information . [CONDITION(S)] . shortness of breath . During a review of Resident 41's AR, dated 7/1/21, the AR indicated, Diagnosis information . unspecified convulsions . During a review of Resident 43's AR, dated 7/1/21, the AR indicated, Diagnosis information . Chronic respiratory failure (narrow and damaged airways in the lungs) .[CONDITION(S)] .constipation .shortness of breath . During a review of Resident 52's AR, dated 7/1/21, the AR indicated, Diagnosis information . constipation . unspecified convulsions . During a review of Resident 54's AR, dated 7/1/21, the AR indicated, Diagnosis information . unspecified convulsions . During a concurrent observation and interview on 7/1/21, at 3:55 p.m., with the MS, in BLDG 1, the MS provided a tour of BLDG 1. The ambient room temperatures in resident care areas were collected using an industrial infrared temperature gun. Notable in BLDG 1 were the long hall and the resident television/ activities room which immediately felt hot and humid upon entry. The wall thermostat (mechanical device for regulating temperature) located in BLDG 1's long hall indicated the ambient temperature in the hall was 82.6 degrees F. The MS stated he was unsure if the thermostat provided accurate readings, however he has had to install portable air conditioning window units in some of the resident rooms due to poor air circulation and temperature regulation in the building. The MS stated staff told residents to keep their blinds closed to help manage the heat. The ambient temperature in the long hall and television room registered between 84.2 to 85.4 degrees F on the industrial infrared temperature gun. The resident television and activity's room was void of residents. The room was hot and lacked a hydration station. During an observation on 7/1/21, at 3:57 p.m., in Resident 8's room, Resident 8's room door was closed. Upon entry, Resident 8 was found sitting shirtless at the side of the bed with the window blinds shut. Resident 8 declined interview at this time. Resident 8's skin was pink and moist. A standing floor fan located near the wall was off. The ambient temperature in the room registered 83.9 degrees F on the industrial infrared temperature gun. During a review of Resident 8's MDS assessment, dated 5/28/21, the MDS assessment indicated, Resident 8 had severe cognitive impairment with a BIMS score of 2. During an observation on 7/1/21, at 3:58 p.m., in Resident 19's room, Resident 19's door was closed. Upon entry, Resident 19 was found sitting at the edge of the bed with the window blinds shut. Resident 19 declined an interview at this time. An oscillating tower fan (distributes airflow over a wider area) located near the wall was on. Resident 19's skin was moist and the hair on his head appeared greasy. The ambient temperature in the room registered 84.2 degrees F on the industrial infrared temperature gun. During a review of Resident 19's MDS assessment, dated 4/23/21, the MDS assessment indicated, Resident 19 had severe cognitive impairment with a BIMS score of 6. During a concurrent observation and interview on 7/1/21, at 3:59 p.m., with Resident 1, in Resident 1's room, Resident 1 laid in bed covered with a bed sheet. Resident 1's skin was pink and moist, lips chapped. The oscillating fan on the bedside table was on and faced Resident 1. Resident 1 stated, Sometimes the heat is unbearable. Resident 1 stated he notified the DON his room was hot and was provided the fan on the bedside table. Resident 1 stated, Okay with the fan, but it's still hot. The ambient temperature collected via the infrared gun registered at 85.8 degrees F. During a review of Resident 1's MDS assessment, dated 4/27/21, the MDS assessment indicated, Resident 1 was cognitively intact with a BIMS score of 14. During an observation on 7/1/21, at 4:05 p.m., in BLDG 1, the ambient temperature in Resident 3, Resident 4, and Resident 18's room ranged between 81.1 degrees F and 84.5 degrees, depending on the area within the room. During a review of Resident 3's AR, dated 7/1/21, the AR indicated, Diagnosis information . Type 2 Diabetes (DM- a chronic disease resulting in elevated blood sugar levels in the body that can cause serious health complications) . Paranoid [CONDITION(S)] (mental disorder) . Essential Hypertension ([CONDITION(S)]- high blood pressure) . Major Depressive Disorder (mood disorder causing sadness) . During a review of Resident 4's AR, date 7/1/21, the AR indicated, Diagnosis information . Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should) . [CONDITION(S)] (a condition in which the blood doesn't have enough healthy red blood cells.) . Anxiety (persistent worry or fear) . [CONDITION(S)] (irregular heart rate) . [CONDITION(S)] . Dysphagia (difficulty swallowing) . Major Depressive Disorder . During a review of Resident 18's AR, date 7/1/21, the AR indicated, Diagnosis information . Cerebral infarction (disruption of blood flow in the brain) . DM . [CONDITION(S)] (abnormal nerve cell activity in the brain) . [CONDITION(S)] . Dysphagia . Chronic (longstanding) Respiratory (breathing) Failure . Anxiety . During an observation on 7/1/21, at 4:06 p.m., in BLDG 1, the ambient temperature in Resident 2, Resident 5, Resident 15, Resident 16, and Resident 17's room ranged between 80 degrees F and 81.9 degrees F, depending on the area within the room. During a review of Resident 2's AR, date 7/1/21, the AR indicated, Diagnosis information . Cerebral infarction . [CONDITION(S)] . [CONDITION(S)] (high fat in blood) . Cerebral [CONDITION(S)] (swelling in the brain) . During a review of Resident 5's AR, date 7/1/21, the AR indicated, Diagnosis information . Cerebral infarction . Major Depressive Disorder . [CONDITION(S)] . [CONDITION(S)] . [CONDITION(S)] . Anxiety . During a review of Resident 15's AR, date 7/1/21, the AR indicated, Diagnosis information . [CONDITION(S)] . DM . [CONDITION(S)] (underactive [CONDITION(S)]- a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature) . [CONDITION(S)] . During a review of Resident 16's AR, date 7/1/21, the AR indicated, Diagnosis information . [CONDITION(S)] disease (disorder of the central nervous system) . Dementia (loss of memory, language, problem-solving and other thinking abilities . Alzheimer's disease (disorder that causes the brain to shrink and brain cells to die) . [CONDITION(S)] (loss of muscle function in part of the body) . [CONDITION(S)] . [CONDITION(S)] disease . Major Depressive disorder . Idiopathic [CONDITION(S)] (nerve damage) . During a review of Resident 17's AR, date 7/1/21, the AR indicated, Diagnosis information . Dementia . [CONDITION(S)] . Obstructive [CONDITION(S)] (excessive fluid in the brain) . unspecified convulsions (uncontrollable muscle contractions) . During an observation on 7/1/21, at 4:07 p.m., in BLDG 1, the ambient temperature in Resident 6, Resident 10, Resident 11, Resident 13, and Resident 14's room ranged between 79.9 degrees F and 82.4 degrees F, depending on the area within the room. During a review of Resident 6's AR, date 7/1/21, the AR indicated, Diagnosis information . Quadriplegic (loss of muscle function in both arms and legs) . Type 1 DM (body produces little or no insulin) . Dysphagia . [CONDITION(S)] . convulsions . During a review of Resident 10's AR, date 7/1/21, the AR indicated, Diagnosis information . Injury to head . Dysphagia . [CONDITION(S)] . disturbances of salivary (saliva) secretions . During a review of Resident 11's AR, date 7/1/21, the AR indicated, Diagnosis information . Nontraumatic [CONDITION(S)] (bleed in the brain) . Major depressive disorder . [CONDITION(S)] . DM . [CONDITION(S)] . During a review of Resident 13's AR, date 7/1/21, the AR indicated, Diagnosis information . Nontraumatic [CONDITION(S)] . Anarthria (inability to articulate words) . [CONDITION(S)] . [CONDITION(S)] . DM . Anxiety . [CONDITION(S)] . Dysphagia . During a review of Resident 14's AR, date 7/1/21, the AR indicated, Diagnosis information . DM . [CONDITION(S)] . [CONDITION(S)] . [CONDITION(S)] disorder (mental illness) . During an observation on 7/1/21, at 4:08 p.m., in BLDG 1, the ambient temperature in Resident 7, Resident 9, and Resident 12's room ranged between 80 degrees F and 81.4 degrees F, depending on the area within the room. During a review of Resident 7's AR, date 7/1/21, the AR indicated, Diagnosis information .Asthma (chronic lung disease that causes swelling in the breathing passages) . intracranial (brain) injury . Anxiety . [CONDITION(S)] . Dysphagia . During a review of Resident 9's AR, date 7/1/21, the AR indicated, Diagnosis information . Congestive heart failure . chronic obstructive pulmonary disease ([CONDITION(S)]- lung disease where the small airways in the lungs are damaged, making it harder for air to get in and out) . Asthma . [CONDITION(S)] . Neuralgia (damaged nerves) . During a review of Resident 12's AR, date 7/1/21, the AR indicated, Diagnosis information .DM . Major Depressive Disorder . [CONDITION(S)] (drop in blood pressure when moving from the lying/ sitting position) . During an interview on 7/1/21, at 4:10 p.m., with LN 1, LN 1 stated the elevated temperatures in BLDG 1 was typically hot, like today. LN 1 stated BLDG 1's air conditioning system stopped working on several occasions which made the room temperatures hotter. During a review of [name of weather service] forecast for 7/1/21 indicated outside temperatures in [area of the facility] reached a high of 100 degrees F on 7/1/21. During a review of [name of weather service] forecast for 6/1/21 to 6/30/21 outside temperatures in [area of the facility] averaged 97 degrees F with temperatures exceeding 100 degrees F on 6/1/21, 6/2/21, 6/3/21, 6/4/21, 6/17/21, 6/18/21, 6/19/21, 6/20/21, 6/21/21, 6/26/21, 6/27/21, 6/28/21, 6/29/21, and 6/30/21. The highest temperatures recorded were on 6/18/21 and 6/19/21 when outside temperatures reached 111 degrees F. During an interview on 7/1/21, at 4:15 p.m., with Resident 12, Resident 12 stated he lived in the facility for many years and every summer was the same: hot inside and the air conditioning did not work. Resident 12 stated residents assigned to BLDG 1 watched television in BLDG 2 to avoid the heat and muggy air in BLDG 1. Resident 12 stated BLDG 1's ventilation system had not worked properly for years. During a review of Resident 12's AR, undated, Resident 12's AR indicated, . Orig. [original] Admin. [admission] Date 3/5/14 . During a review of Resident 12's MDS assessment, dated 5/17/21, the MDS assessment indicated, Resident 12 was cognitively intact with a BIMS score of 15. During a concurrent observation, interview, and record review on 7/1/21, at 4:30 p.m., in BLDG 1's medication room, with the ADON and LN 1, the ADON accessed BLDG 1's medication room. The external digital thermostat on the medication refrigerator indicated the medication and nutrition room's temperature was 90 degrees F. The digital thermostat also indicated the temperature inside the medication refrigerator was 50.4 degrees F. The ambient temperature was then taken in various parts of the medication room with the industrial infrared temperature gun. Temperatures ranged between 86.4 degrees F and 91.8 degrees F. The ADON stated the ambient temperature in the medication room and in the refrigerator were too hot then opened the refrigerator used to store medications. There were two unused boxes of slow release auto-injectable (prefilled device used to self-inject the medication) insulin (medicine to control blood sugar) pens, one tray filled with opened and unopened multidose vials of long- acting ([MEDICATION(S)]) insulin (100 units / [per] milliliter (ml- unit of measure), and one tray filled with opened and unopened multidose vials of fast-acting insulin (100 units/ml). The temperature in the refrigerator registered 54.1 degrees F with the infrared temperature gun. The ADON stated current temperatures in the refrigerator were not acceptable and the efficacy of the medications inside the refrigerator may be compromised if the medications were not removed. The temperature logs for the medication and room and refrigerator were reviewed. The medication room temperature log was dated 1/1/2021 to 6/30/2021 and documented temperature readings recorded during the morning and night shifts for the previous six months. April, May, and June had missing data for the morning and night shifts. Notable was the month of June with 39 of 60 spaces left blank. The refrigerator log was also dated 1/1/2021 to 6/30/2021 and documented temperature readings recorded during the morning and night shifts for the previous six months. The refrigerator log had missing data for the morning and night shifts in January, February, March, April, May, and June. Again, notable was the month of June with 38 of 60 spaces left blank. The ADON stated staff were required to document the temperatures on the facility's temperature log to ensure medications were properly stored. The ADON stated the logs were tools used to validate the medication room and refrigerator temperatures were checked daily. The ADON stated since the logs were not complete, she could not confirm the temperatures were checked nor validate medication storage areas maintained acceptable temperatures to ensure proper and safe storage. LN 1 stated she had not noticed the temperatures were not documented until review of the logs. LN 1 stated the refrigerator was used to store insulins prescribed to the residents in BLDG 1 diagnosed with Diabetes. LN 1 stated it was unsafe to use insulin that was not stored as directed because it could potentially compromise the insulin or make it ineffective. LN 1 stated several residents in BLDG 1 received insulin injections [for Diabetes]. The ADON stated staff did not check and document the ambient temperature today because there was no log for the month of July. During a review of Lexicomp, last updated 7/2/21, directions for the slow release auto-injectable insulin indicated, .Storage/ Stability . store under refrigeration at 2°Celsius (C- unit of temperature) to 8°C (36°F to 46°F) . During a review of Lexicomp, last updated 6/24/21, directions for the long- acting insulin indicated, .Storage/ Stability . Store unopened vials and prefilled pens refrigerated at 2°C to 8°C (36°F to 46°F) . Once punctured (in use), store vials refrigerated or at room temperature less than (<) 30°C (<86°F) and use within 28 days . During a review of Lexicomp, last updated 6/29/21, directions for the fast- acting insulin indicated, .Storage/ Stability . unopened vials, cartridges, and prefilled pens may be stored under refrigeration between 2°C and 8°C (36°F to 46°F) . Once punctured (in use), vials may be stored under refrigeration or at room temperature <30°C (<86°F) . During a review of an article from the U.S. (United States) Food and Drug Administration (FDA- government agency that regulates certain foods, drugs, cosmetics, and medical supplies) titled, Information Regarding Insulin Storage and Switching Between Products in an Emergency, dated 9/19/17, the article indicated, . Insulin loses effectiveness when exposed to extreme temperatures. The longer exposed to extreme temperatures, the less effective the insulin becomes. This can result in loss of blood glucose control over time . keep insulin as cool as possible . During a review of the facility's resident Matrix (used to identify resident care categories), undated, the Matrix indicated five of the 19 residents (Resident 1, Resident 3, Resident 11, Resident 18, and Resident 19) received insulin injections. During an observation on 7/1/21, at 6:15 pm, BLDG 2 and BLDG 1 were toured to collect the ambient room temperatures in resident care areas using an industrial infrared temperature gun. In BLDG 2, the occupied rooms in BLDG 2 (rooms 201, 204, 205, 206, and 207) had ambient room temperatures between 74.4 degrees F and 79.9 degrees F. The ambient room temperature of the nurse's station ranged between 85.6 degrees F and 88.9 degrees F. The temperature of the medication room ranged between 88 degrees F and 90.1 degrees F. During an observation on 7/1/21, at 6:20 pm, in BLDG 1, the ambient room temperature of the long hall and resident television and activities room ranged between 84.4 degrees F and 88.1 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:22 pm, in BLDG 1, the ambient temperature of Resident 1's room ranged between 86.8 degrees F and 88.9 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:24 pm, in BLDG 1, the ambient temperature of Resident 19's room ranged between 84 degrees F and 84.2 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:25 pm, in BLDG 1, the ambient temperature of Resident 8's room ranged between 84 degrees F and 88.1 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:26 pm, in BLDG 1, the ambient temperature of Resident 3, Resident 4, and Resident 18's room ranged between 83.4 degrees F and 86.5 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:27 pm, in BLDG 1, the ambient temperature of Resident 2, Resident 5, Resident 15, Resident 16 and Resident 17's room ranged between 81 degrees F and 83.4 degrees F, depending on the area within the room. During an observation on 7/1/21, at 6:28 pm, in BLDG 1, the ambient temperature of Resident 6, Resident 10, Resident 11, Resident 13, and Resident 14,'s room ranged between 82.8 degrees F and 83.9 degrees F, depending on the area within the room. Duri[TRUNCATED]

Based on observation, interview, and administrative document review, the facility failed to maintain an effective pest control program when rodent and widespread cockroach activity was observed throughout the kitchen, food storage and food preparation area as well as 26 resident rooms, 2 storage rooms, and other areas occupied and/or used by residents. This failure resulted in an unsanitary environment throughout the facility including the kitchen food preparation area and had the potential to cross contaminate and transmit infection to 67 residents facility residents. Because of the serious potential risk of cross contamination of infectious disease due to widespread infestation of cockroaches in all areas of the facility, an Immediate Jeopardy (IJ) situation was called with the Director of Nursing (DON) on 8/3/16 at 5:43 p.m. The facility submitted an acceptable Plan of Action to address the IJ situation and implemented steps to address the immediacy. The immediacy was removed on 8/8/16 at 2:45 p.m. Findings: On 8/2/16 at 10:30 a.m., a Resident Council meeting was conducted. By a show of hands, 11 of 12 residents, (Residents 18, 20, 22, 23, 24, 35, 67, 75, 76, 77 and 78), stated they had seen all sizes of cockroaches, every day, and especially at night. On 8/3/16 at 8 a.m., during a concurrent observation and interview with in Building 2, Room 206, Licensed Nurse (LN) 3 stated the one inch bug observed crawling under the bedside nightstand closest to the doorway entrance was a cockroach. A dozen or more live cockroaches, ranging in size from approximately one quarter (1/4) inch to one inch scattered when the nightstand next to bed 2 in room 206 was moved and repositioned. Live cockroaches, too many to count, scattered in all directions across a boom box (portable radio), and five dead cockroaches were under the boom box on the bedside table. LN 3 demonstrated reluctance to lift the boom box and stated, Cockroaches are repulsive. On 8/3/16 at 8:30 a.m., during a concurrent observation and interview in room 207, adjacent to bed 2, multiple live cockroaches scattered quickly when the nightstand was moved. LN 3 stated she counted at least seven, confirmed the sightings at multiple bedsides. She further stated she had seen cockroaches crawling across the floor of the nurses' station located across from the kitchen since June 2014. On 8/3/16 at 8:50 a.m., concurrent observation and staff interviews were conducted on the women's side of Building 2. In room 203, under the nightstands, adjacent to beds 1, 4, 5 and 7, dead and live cockroaches were observed. Certified Nursing Assistant (CNA) 4 stated the bugs observed were cockroaches and she had seen more cockroach activity in the last year. On 8/3/16 at 9 a.m., during a concurrent observation and interview in room 202, under the nightstands, next to beds 1, 2, ,3 and 4, dead and live cockroaches were observed in numbers too large to count. CNA 5 stated, All those bugs are roaches. We see them everywhere, every day. They have been bad for the last year, but they have always been here . They're even in the employee break room in the refrigerator. CNA 5 stated, This room is pretty bad, and indicated room 202. On 8/3/16 at 9:15 a.m., in room 201, under the nightstands beside bed 3 and bed 8, dead and live cockroaches were observed. At bed 8, there were more than 20, too many to count. CNA 6 stated, We see them every day. There is a whole village of cockroaches. We see them on the curtains, the walls, the floors and in the shower rooms . I even saw one on a CNA one time. They are on the milk trays and food carts. I don't lean against the wall because I am afraid they will get on me. It effects how we take care of residents because we don't want to touch anything, and the residents don't like the roaches. On 8/3/16 at 9:25 a.m., during a concurrent observation and interview in room 204, under the nightstands beside bed 4 and 5, live cockroaches were observed. CNA 7 stated, Those are roaches . I've seen them in all the rooms . and on the milk carts and meal carts. On 8/3/16 at 9:45 a.m., in the room where residents make telephone calls, dead cockroaches were observed. CNA 8 said, Those are cockroaches, it's been awhile since they sprayed. On 8/3/16 at 9:55 a.m., during an interview, Cook 1 stated, I saw some (cockroaches) when I walked in this morning, about 5:07 a.m. I am always the first one here. They were on the walls and on the steam cart. I guess when I turn the light on they just come out. I don't know where they come from; where they are hiding. Cook 1 stated he told his supervisor, the Dietary Service Supervisor (DSS) this morning that he saw the bugs. Cook 1 stated the cockroach problem was not getting worse; it had been about the same for the last year or two. On 8/3/16 at 10:23 a.m., concurrent observation and interview with the DSS was conducted in the kitchen. A small insect was observed running across the pantry (dry storage) floor. The DSS stated, It looks like a baby cockroach. They have been seen on the kitchen floor and on the kitchen counter tops. The DSS stated the pest control company had not sprayed since 3/16. On 8/3/16 at 10:30 a.m., the DSS picked up a dead cricket under the pantry rack, against the wall. The DSS stated, We don't want them (bugs) in the food. They will contaminate it (the food). On 8/3/16 at 10:35 a.m., during concurrent observations and staff interviews in Building 1, room 104, under the nightstands, between bed 2 and 3, approximately 16 live cockroaches of varying size were observed. CNA 1 and CNA 8 stated the insects were cockroaches. In room 102, 103, and 107, CNA 1 and CNA 8 stated there were too many to count. Cockroaches were also observed in rooms 108, 111, and 112. CNA 1 stated she killed the cockroaches when she saw them, but she didn't tell anyone. CNA 8 stated, .Just bugs and ants and roaches. I haven't seen them this bad before. CNA 8 stated she had seen more cockroach activity in the last couple of months. Further tour of the facility revealed cockroach activity was also observed in shower rooms, the boiler room and the utility room. CNA 8 confirmed these sightings. On 8/3/16 at 11:35 a.m., during an interview in room 207, Resident 78 from the Resident Council meeting, stated he had seen lots of cockroaches. Resident 24, also from the Council meeting, stated, I see them (cockroaches) every day, on the floor, three to four at a time, for the last 2 to 3 months. On 8/3/16 at 11:45 a.m., during an interview in room 203, Resident 35 from the group council meeting stated she had seen cockroaches on the curtain, behind her Christmas stocking hanging on the wall, and on the floor. Resident 35 stated she usually saw one of them at a time, for the last couple years. Resident 35 stated, It's been a little bit worse recently, for the last month and a half. On 8/3/16 at 3:15 p.m., during observation and concurrent interview in the kitchen, the DSS presented a laminated kitchen cleaning assignment document. The DSS stated staff were assigned the tasks but staff did not sign off tasks they were assigned to. The DSS stated she could not provide documentation that routine cleaning in the kitchen had been done. On 8/3/16 at 3:30 p.m., during an interview, the DON stated the Contracted Registered Dietician (CRD) provided clinical oversight only, and kitchen oversight was not included. The DON stated she was not aware the kitchen cleaning assignment was laminated and there was no oversight or documentation of cleaning. On 8/3/16 at 4:45 p.m., during a concurrent observation and interview with the DSS, a cockroach was crawling inside a drawer located under the juice dispenser. Cook 2 stated when a crawling insect was pointed out, it's a cockroach. An opened drawer contained a variety of cooking utensils the utensils were lifted, multiple small live and dead cockroaches were seen and verified by the Dietary Service Supervisor (DSS) and Cook 2. Review of the document Effective Management of Cockroach Infestations published (undated) by the County of Los Angeles Department of Public Health Vector Management Program and obtained from the CDPH Infection Control Consultant on 8/3/16 indicated under the heading: Problems Associated with Cockroaches . Cockroaches may become pests in . virtually any structure that has food preparation or storage areas. They contaminate food and eating utensils . When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning (Salmonella spp. and Shigella spp.) if they enter into structures. German cockroaches are believed to be capable of transmitting disease-causing organisms such as Staphylococcus spp., Streptococcus spp. [MEDICAL CONDITION] virus, and coliform bacteria. They also have been implicated in the spread of [MEDICATION NAME] and dysentery. Indoor infestations of cockroaches are an important source of allergens and risk for asthma among some populations. The levels of cockroaches and allergens have been directly related to cockroach density, housing disrepair, and sanitary conditions . Under the heading Management, the document indicated .You must first determine where the roaches re located. The more hiding places you locate and manage, the more successful your control program will be .Reduction of both food and water sources, as well as all hiding places is essential .The most effective method of managing an established cockroach infestation is by applying an integrated approach that utilizes several different strategies. Under Use the IPM (Integrated Pest Management) Approach the document indicated .IPM is the most effective means of controlling a cockroach infestations and preventing its reoccurrence . All aspects of the situation must be evaluated: reduce food and water sources; eliminate hiding places; consider using baits; avoid sprays if possible; use traps to monitor the population . Under the heading Sanitation the document indicated . Important sanitation measures include the following: store food in inset-proof containers such as glass jars or resealable plastic container; keep garbage and trash in containers with tight-fitting lids and use liners to keep interior of cans clean; [MEDICAL CONDITION] away from doorways; remove trash, newspapers, magazines, piles of paper bags, rags, boxes, and other items that provide hiding places and harborage; eliminate plumbing leaks and correct other sources of the free moisture, increase ventilation where condensation is a problem; vacuum cracks and crevices to remove food and debris; be sure surfaces where food or beverages have been spilled are cleaned up immediately . On 8/4/16 at 8:40 a.m., during a telephone interview with the facility's pest control and extermination company Operations Manager (Op Man), the facility's pest control program and current cockroach problem was discussed. The Op Man stated, The facility is behind on it's service. They had an overdue balance for three months, and after three months we suspended the service. We sent letters and made calls, the collections department was notified and we sent invoices . Bi monthly service had been recommended due to an increase in cockroach activity, but instead of increasing the frequency of service, all service was suspended in June, after three months of non-payment. The pest company report of service dated 5/5/16 was reviewed. The document titled Detailed Service Report indicated under the heading Area Inspections the Interior patient rooms were treated and had the following comment .Treated interior patient rooms building 2 rooms 201 and 202 spike in German roach activity in patient room due not being serviced account on hold . On 8/3/16 at 5:35 p.m., the DON was interviewed to discuss concerns related to the widespread observation of live cockroaches, their presence in the facility kitchen, and the lack of pest control prevention services, which resulted in the widespread infestation. Due to the serious potential for harm related to the cockroaches' potential to spread infection to a vulnerable population, an Immediate Jeopardy (IJ) was called on 8/3/16 at 5:43 p.m., in the DON's presence. The facility was notified of the requirement to submit a written Plan of Action to address and lift the IJ. The team emphasized the need for the facility to come up with a system-wide strategy to ensure: · the safety of food service · to identify and correct interior and exterior environmental risks · to consult with pest control experts and follow their suggestions for sanitation and eradication · to identify and remove food sources · to develop and implement work aides for complete and consistent surveillance, cleaning, and reporting · to educate staff and residents to impress the importance and gain cooperation to reduce food sources, increase surveillance, boost awareness and encourage cockroach activity reporting · to assign administrative oversight for the dietary and environmental services departments On 8/10/16 at 10:30 a.m., until 1:15 p.m., the County Health Department Environmental specialist (CHDES) inspected the kitchen. The CHDES stated he rated the cockroach problem at a seven on a zero to ten scale, with zero being no bugs, and ten being so bad they fall on your head. The CHDES stated the best case scenario the problem could be eradicated in two months. On 8/10/16 at 5:05 p.m., the IJ was lifted when the plan of action contained a comprehensive sweep by the pest control company to eradicate the presence of the cockroaches, and for the staff to effectively clean and sanitize all resident contact areas. The DON and the Administrator were present when the IJ was lifted and the Plan of Action accepted.

Based on staff interview and administrative document review, the facility failed to safeguard, manage and account for the personal funds of 57 of 57 Residents with trust accounts (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, and 57) when: The Owner/Administrator withdrew $20,000.00 from one of two Resident Trust Accounts (Trust Account 1) and deposited this amount into his personal/business account for the purpose of paying personal and business accounts. This failure resulted in the unauthorized use of resident funds, not notifying the affected residents of the withdrawal and the inability to account for the amount for each resident affected for this withdrawal. This failure resulted in the potential harm of residents' not having access to their personal funds and possible psychological and emotional distress from the unauthorized access. Findings: On 12/30/15 at 10:00 a.m., during an interview, the Owner/Administrator (O/AD) stated he had a bank account in place for the residents' trust account. The O/AD stated to his knowledge, 44 residents were on the account. The O/AD stated the facility kept records (ledger) of the amount of money each resident had in his/her account and each resident received a monthly statement of their account balance from the facility. The AD stated that he could not provide bank statements for the residents trust account. He stated they were not available at the facility and could not access the bank records. During clinical record review a document (resembling a spread sheet)untitled, and undated included names of the month of the year with Resident names listed. Next to the names was listed a dollar amount under each month. There were 57 residents listed. A document not titled and not dated, hand-typed, indicated each month of the year, and revealed a dollar amount next to each resident name. At the bottom of the page the document indicated, Total of all resident trust funds. The following indicated the dollar amount for each month: January $12,686.20 ; February $12,452.16; March $13,726.23; April $16, 905.96; May $18,454.79; June 17,290.93; July $14,487.52; August $13,926.76; September $14,955.93; October-$15,056.64; November $14,069.67; December $16,161.03. The document titled, .Your combined statement from the bank with the account number representing Trust Account #1 indicated monthly totals as follows: January 2015 $16,981.81; February 2015 $14,281.71; March 2015 $18.041.17; April 2015 $22,872.80; May 2015 $25,694.05; June 2015 $3,541.12; July 2015 $977.67; August 2015 $4,707.37; September 2015 $2,603.03; October 2015 $6,545.66; November $8,614.90; December 2015 $9,645.98. The following represents the difference indicated between the facility resident trust account #1 statement and the monthly bank statements for 2015: January $4,295.61; February $1,829.55; March $4,314.94; April $5,966.84; May $7,239.26; June $13,749.81; July $13,509.85 (bank total less than facility total); August $9,219.39 (bank total less than facility total); September 12, 392.90 (bank total less than facility total); October $8,510.98 (bank total less than facility total); November $5,454.77; (bank total less than facility total); and December $ 6,515.05 (bank total less than facility total). The total descrepancy of missing funds in Resident Trust Account #1 for 2015=$43,602.94 which did not include the months the bank had a higher amount than the facility. The total difference was a deficit of $6206.93 out of the resident trust fund. Bank statements reviewed indicated, Resident Trust Account #1. There was an account summary listed which included beginning balance amounts, deposits and other credits, withdrawals and other debits, checks, service fees and an ending balance for June 1, 2015. There were no resident names listed on the document. There were copies of individual checks made out to Sunnyside Convalescent Hospital, or to Cash. Review of the document titled, .Your Business Advantage Checking dated June 1, 2015 indicated the beginning balance on June 1, 2015 was 25, 694.05. Withdrawals and other debits was $20,000 for 6/24/15. On 12/30/15 at 10:45 a.m., during an interview, the Office Assistant (OA) stated to her knowledge 44 residents had a trust account. The OA stated the residents came to the office to ask for money when they needed it to purchase sodas and other small items. The OA stated she was authorized to give residents their money when requested. On 12/30/15 at 11:45 a.m., during an interview, the O/AD stated he was unable to provide bank statements. The O/AD stated he telephoned the bank to ask for bank statements and was informed that it would take three business days to have access to the statements. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated when the resident monies arrived he made a deposit into the account at the bank. He stated the residents did not have individual accounts, he made the deposit in one general trust account. The O/AD stated he provided residents with a monthly statement that reflected the amount of money that should be in their account, not the actual balance on the account. The O/AD stated that the resident's trust fund money was his regular bank account because he needed the money to pay the bills, meet payroll and keep the facility open. The O/AD stated the residents were not aware he took money from their trust accounts. The O/AD stated he borrowed $20,000.00 on 6/24/15, and had not returned the money to the resident's trust account. The O/AD stated he does not know when or how he will return the money owed to the resident trust account. Review of document titled, Deposits 1/1/15 to 12/31/15 Sunnyside Convalescent Hostital indicated various dollar amounts deposited. At the bottom of the page, the document indicated. Transfer to Account #7217 $20,000. On 3/9/16 at 1:30 p.m., during an interview, the OA stated she provided the residents with monthly trust account statements. The OA stated the facility did not have a business manager. The OA stated the monthly statements given to the residents or their responsible party (RP) was what should have been in their account, not the actual amount of their account. On 3/9/16 at 1:45 p.m., during an interview, the O/AD stated he did not have a process for handling of resident trust accounts and could not produce a policy or procedure On 5/18/16 at 9:30 a.m., during an interview, Resident 7 stated she received a monthly statement from the facility. On 5/18/16 at 9:50 a.m., during an interview, Resident 16 stated she had never received a statement from the facility regarding the trust account. On 5/18/16 at 9:50 a.m., during a phone interview, the Responsible Party for Resident 25 stated she never got a statement on the trust account from the facility. On 5/18/16 at 1:45 p.m., during an interview, Resident 55 stated he never got a statement from the facility and never got any money. Resident 55 stated he could use some money to buy snacks.

Based on staff and vendor interview, and administrative document review, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the Owner/Administrator (O/AD) misused and withdrew greater than $20,000.00 from one of two trust accounts for 57 of 57 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, and 57) when: without prior authorization or resident knowledge. The O/AD deposited the resident trust monies into his personal account. This failure resulted in the loss of the right to be free from misappropriation of resident funds and potential harm from financial loss and a breach of trust which could cause psychological and emotional distress. Findings: On 3/9/16 at 10:25 a.m., during a phone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities)stated she had terminated her position due to payroll problems. LVN 1 stated residents had complained they could not get information on their financial accounts. LVN 1 stated the business office was always closed. On 3/9/16 at 1:15 p.m., the O/AD stated he borrowed $20,000.00 on 6/24/16, and had not returned the money to the resident's trust account. The O/AD stated he does not know when or how he will return the money owed to the resident trust account. The O/AD was unable to provide itemized receipts for any resident money spent. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of residents trust account. The O/AD stated when resident checks arrived he made a deposit in the residents trust account. The O/AD stated he did not have a process on how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he makes a withdrawal where there are funds available. On 3/9/16 at 1:35 p.m., the O/AD stated the residents received monthly statements from the facility regarding the balance of funds in their account. The O/AD stated the residents do not have individual bank accounts. The O/AD stated he transferred money from the residents trust account on 6/24/15 to his account. The O/AD stated the money was used to pay bills, meet payroll, keep the facility open and pay the suppliers. The O/AD stated he owed the suppliers money. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they are or how much owed to them. The O/AD stated, all I know is that I owe all the suppliers money. The O/AD stated he borrowed $20,000.00 on 6/24/15 and did not re-deposit the money into the residents trust account. The O/AD stated he had no definite plans to pay the money back into the resident trust account. The O/AD stated he did not get the resident's permission or authorization to withdraw money from the resident trust account. The O/AD stated he has no money and residents are not aware that he transferred money from their trust account to his account. The O/AD stated the trust account resident's monthly statements did not reflect the real balance on their account, and stated, I give them statements with what money should be in the account not what is really in the account . Review of the document titled, .Your Business Advantage Checking dated June 1, 2015 indicated the beginning balance on June 1, 2015 was 25, 694.05. Withdrawals and other debits was $20,000. Review of document titled, Deposits 1/1/15 to 12/31/15 Sunnyside Convalescent Hostital indicated various dollar amounts deposited. At the bottom of the page, the document indicated. Transfer to Account #7217 $20,000. The document titled, .Your combined statement from the bank with the account number representing Trust Account #1 indicated monthly totals as follows: January 2015 $16,981.81; February 2015 $14,281.71; March 2015 $18.041.17; April 2015 $22,872.80; May 2015 $25,694.05; June 2015 $3,541.12; July 2015 $977.67; August 2015 $4,707.37; September 2015 $2,603.03; October 2015 $6,545.66; November $8,614.90; December 2015 $9,645.98. The following represents the difference indicated between the facility resident trust account #1 statement and the monthly bank statements for 2015: January $4,295.61; February $1,829.55; March $4,314.94; April $5,966.84; May $7,239.26; June $13,749.81; July $13,509.85 (bank total less than facility total); August $9,219.39 (bank total less than facility total); September 12, 392.90 (bank total less than facility total); October $8,510.98 (bank total less than facility total); November $5,454.77; (bank total less than facility total); and December $ 6,515.05 (bank total less than facility total). The total descrepancy of missing funds in Resident Trust Account #1 for 2015=$43,602.94 which did not include the months the bank had a higher amount than the facility. The total difference documented was a deficit of $6206.93 out of the resident trust fund. The .(name of bank) Your Business Advantage Checking with a 12 digit account number dated 8/1/15 Resident Trust Account #1 indicated a service fee of $35.00 for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from a savings account into the trust account was made in the amount of 5,000.