Every finding on record at Grossmont Post Acute Care

Based on observation, interview and record review, the facility failed to ensure a peripherally inserted central catheter (PICC, a long, thin and flexible tube [catheter] that is inserted into a vein in the upper arm for medication administration) was measured weekly for one of two residents reviewed (Resident 1).This failure resulted in Resident 1 returning to the hospital with chest pain, removal of the PICC, and replacement with another catheter to complete medication administration. Findings:A consumer complaint was filed with the California Department of Public Health regarding Resident 1's catheter. The complaint alleged the catheter had moved out of the original position and posed a risk to Resident 1's health.According to an undated Face Sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses to include an infection in the bone.An interview was conducted with Licensed Nurse (LN) 1 on 5/14/26 at 2:30 P.M. LN 1 stated a PICC line was for intravenous (IV, within a vein) medications, and only a Registered Nurse (RN) could administer those to residents. LN 1 stated her role was to monitor the PICC line site on the resident's arm for any signs and symptoms of infection or swelling, and if they observed any of those, they would inform the RN. LN 1 stated other than monitoring the site, the RNs would manage the PICC line. An interview was conducted with RN 1 on 5/14/26 at 2:40 P.M. RN 1 stated she was responsible for administering medications through the PICC line for all residents. RN 1 stated when administering medications, she looked for bleeding, redness or swelling, which could mean the IV was not positioned correctly. RN 1 stated a clear dressing (a protective device to hold the IV in place and prevent bacteria from getting into the vein) which covered the IV was changed every Sunday. RN 1 stated when the dressing was changed, the RN measured the arm circumference and the length of the catheter. RN 1 stated both of those measurements were important to ensure the resident did not have an infection from the catheter, and to ensure the catheter was always in the same position in the vein. RN 1 stated she did not work Sundays, so she did not routinely change the dressings for residents with PICC lines. An interview and record review was conducted with RN 2 on 5/14/26 at 3:15 P.M. RN 2 stated she did work on Sundays, and she was familiar with the process for changing the dressings on PICC lines. RN 2 was able to describe the process, and stated measurements of arm circumference and catheter length were important to ensure the resident was receiving the medication safely. RN 2 stated the PICC line dressing kit used to change the dressing on Sundays included a measuring tape. RN 2 reviewed Resident 1's IV Medication Administration Record (MAR), and stated, There are no measurements. The RN should have documented the catheter length and the arm circumference so they could compare those values to the previous week. If there wasn't a place in the IV MAR, the RN could have written a progress note, but I don't see one.A record review was conducted.A physician's order, dated 4/13/26, indicated Resident 1 was to receive an antibiotic twice daily for a bone infection. A physician's order, dated 4/13/26, indicated the RN was to change the dressing and securement device (a clip to hold the PICC line in place) every Sunday, and to measure the catheter length and the arm circumference in centimeters after each dressing change. The IV MARs for April and May 2026 were reviewed. No measurements of catheter length or arm circumference were identified. According to the MAR, the PICC line dressing was changed on 4/19/26, 4/26/26, and 5/3/26. An interview and concurrent record review of Resident 1's IV orders and MAR was conducted with the Director of Nursing (DON) on 5/14/26 at 4:30 P.M. The DON stated it was the responsibility of the RN who admitted the resident to obtain the measurements from the hospital when a resident was admitted to the facility. The DON stated if the measurements were not available, the RN should measure on the day the resident arrived so the facility would have a baseline to compare to the Sunday measurements. The DON reviewed Resident 1's record and stated there was no measurements on admission, or from the Sunday dressing changes. Per the DON, this could cause a complication such as an infection, and the RN would be unable to compare to previous measurements to ensure the catheter was still in place. The DON stated the RN should have documented the measurements, but did not. Per the facility policy, updated January 2021 and titled PICC Dressing Change, .The PICC catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection. Documentation: Document date and time of procedure, site assessment, length of external catheter.

Based on interview and record review, the facility failed to obtain a chest x-ray (an image of the chest that shows lung problems) as ordered for one of two sampled residents (1). As a result, there was an increased risk of Resident 1 to receive a delay in care or incorrect treatment. Findings: Per the facility's Face Sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (a lung disease which causes difficulty breathing), heart failure, bronchitis (lung infection), emphysema (a long disease which causes difficulty breathing), solitary pulmonary nodule (a growth in a lung), and discharged to an acute care hospital on 1/25/26. Per the facility's Progress Notes, on 1/24/26 at 8:34 A.M., Resident 1 had a Change in Condition involving shortness of breath (the feeling of not getting enough air), and Medical Doctor (MD) 3 ordered a chest x-ray for Resident 1. Per the facility's Order Summary Report, dated 1/25/26, there was an order for a chest xray on 1/25/26. There were no orders for a chest xray entered on 1/24/26. Per the facility's Progress Notes, on 1/25/26 at 11:57 P.M., Resident 1 was sent to an acute care hospital for multiple episodes of vomiting with shortness of breath. On review of the progress notes. On 2/10/26 at 11:10 A.M., a telephone interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated, MD 3 gave Licensed Nurse (LN) 2 a verbal order on the morning of 1/24/26 for Resident 1 to have a chest x-ray, but due to a miscommunication LN 2 did not enter the order into the medical record, and did not notify the mobile radiology service (company who provides x-rays) until the following morning on 1/25/26. The ADON stated that the chest x-ray should have been completed on the same day that it was ordered, and LN 2 should have notified the mobile radiology service at the time MD 3 gave her the verbal order. The ADON further stated, that when the chest x-ray order was entered on the morning of 1/25/26 it was entered as a STAT order (to happen immediately), and that the chest x-ray should have been completed within six hours of entering the order as STAT. The ADON further stated, that when Resident 1 left the faciity on 1/25/26 at 10:20 P.M., (more than 36 hours after the chest x-ray was verbally ordered, and more than 11 hours after it was entered as a STAT order) that the chest x-ray had not been completed for Resident 1. Per the facility's policy, titled Diagnostic Test Results Notification, revised April 2025, It is the policy of this facility to obtain laboratory and radiology services when ordered

Based on interview and record review, the facility failed to ensure necessary care monitoring, and interdisciplinary (IDT) coordination to prevent respiratory depression (hypoxia and loss of consciousness) and excessive sedation, when administrating multiple central nervous system (CNS) depressant medications (mirtazapine a medication for depression/mood, oxycodone a strong pain-relieving medicine, and alprazolam a medication for anxiety) for one of three sampled residents (Resident 1).This had the potential for Resident 1 to experience a significant decline in respiratory status from hypoxia.Findings:A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing) and was transferred to a higher level of care on 3/18/23 related to lethargy (drowsiness) and respiratory distress (shortness of breath [SOB], low oxygen levels (below 90%), use of accessory muscles (using muscles in your neck, chest, and stomach to help you breathe). On 10/15/25 a review of Resident 1's clinical chart was conducted: Resident 1's care plan for anxiety (excessive worry, fear and nervousness) medication .Xanax [brand name of Alprazolam] . with a black box warning (the strongest warning the U.S. FDA can issue for a prescription drug, alerting healthcare providers and patients to the risk of serious or life-threatening adverse reactions) initiated 3/9/23, indicated, .Concomitant [simultaneous or successive use of two or more drugs] use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. Per the Acute Hospital Records dated 3/7/23, indicated .chronic hypoxic (low oxygen) respiratory failure with COPD, on 3 to 4 L of home oxygen.A review of the admission assessment dated , 3/8/23 titled, admission Drug Regimen Review indicated, Possible drug interaction(s) or duplicate therapy was identified after pharmacy orders are entered in the system. was answered No. The New admission Medication Regimen Review medication regimen review (MRR-pharmacy review recommendations) dated, 3/8/25 indicated, .Recommendations.Drug interactions.MD Notified No. A review of the Progress note Medication Regimen Review dated, 3/9/2023 at 17:05 (5:05 P.M.) indicated, .Received new admission MRR from [facility Pharmacy Vender Name] with recommendations from pharmacist to monitor for CNS depression due to alprazolam, mirtazapine, and oxycodone pain medication that can cause CNS depression]. Review of the Change in Condition [COC] notes was conducted. The COC note dated, 3/13/2023 21:22 (9:22 P.M.) indicated, Other change in condition positive covid [COVID- a highly contagious virus that infects the respiratory system to cause SOB, respiratory distress and death] .The COC note dated 3/14/23 17:00 (5 P.M), indicated, .At approximately 1700 the patient had hypoxia and an O2 saturation of 54%.There was no documented evidence of physician's notification regarding MRR Pharmacy recommendations with Resident 1's medications (Alprazolam, Mirtazapine, and Oxycodone) for clarification, parameters, and/or monitoring of CNS depression. In addition, there was no interdisciplinary team (IDT) documented to address Resident 1's change of condition. A review of the Medication Administration Record (MAR) dated, 3/17/23 indicated, .ALPRAZolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth as needed for ANXIETY BID [twice daily] . was given to Resident 1 at 2011(8:11 P.M.).oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 2 tablet mouth every 4 hours as needed for SEVERE PAIN. was given to Resident 1 at 2128 (9:28 PM). A review of the COC note dated 3/17/2023 10:30 (P.M.), indicated, .Shortness of breath Other change in condition HYPOXIA/LETHARGY.02 [oxygen] 73 % .Date and time of clinician notification:03/17/2023 10:50 PM.The COC note dated 3/18/2023 00:30 (12:30 A.M.), indicated, .Pt noted to be lethargic and still having increased SOB, O2 sat is 70% on 3L/min via NC, condition rapidly declined, use of accessory muscle with breathing. Pt [patient] repositioned on. High Fowler's (a position in which the individual lies on their back with the head of bed elevated at 30-45 degrees), O2 sat ranging from 96-97% on non-rebreather mask @ 8L/min at around 2330. MD notified, advised to call 911. On 10/25/25, a record review was conducted on Resident 1's clinical chart. Resident 1's post respiratory vital signs (oxygen levels and respirations) after medications (alprazolam, oxycodone and mirtazapine) were administered indicated:- 3/13/23 all three medications given, alprazolam 0.25 milligrams (mg) given at 2300 (11 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2111 (9:11 P.M.) No respirations, or oxygen levels was taken after alprazolam within one hour of administration.- 3/14/23 all three medications given, alprazolam 0.25 mg given at 2024 (8:24 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2123 (9:23 P.M.). No respirations, or oxygen levels was taken after alprazolam within one hour of administration.- 3/15/23 all three medications given, alprazolam 0.25 mg given at 2055 (8:55 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2239 (10:39 P.M.). No respirations, or oxygen levels were taken after each medication within one hour of administration for two medications (alprazolam and mirtazapine).-3/16/23 all three medications given, alprazolam 0.25 mg given at 2014 (8:14 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg given at 2150 (9:50 P.M.). No respirations, or oxygen levels were taken after each medication (mirtazapine and oxycodone) within one hour of administration for all three medications.- 3/17/23 all three medications given, alprazolam 0.25 mg given at 2011 (8:11 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.), and oxycodone 20 mg given at 2128 (9:28 P.M.). No respirations, or oxygen levels were taken after each medication (alprazolam, mirtazapine, and oxycodone) within one hour of administration. On 10/15/25 at 11:45 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 was not on Hospice. The ADON stated while in the facility Resident 1 continued with rehab services for occupational therapy (OT) and physical therapy (PT). The ADON stated Resident 1 had malignant rectal cancer (harmful tumor of the rectum) and was treated with radiation/chemo and immunotherapy. On 10/16/25 at 11:05 A.M., an interview and record review were conducted with LN 1. LN 1 stated she was a nurse supervisor that reviews the MRR. LN 1 stated Resident 1 had an MRR dated 3/8/23 to monitor CNS depression because Resident 1 was on medications (Alprazolam, Mirtazapine and oxycodone) that can cause CNS depression to include respiratory distress. LN 1 stated CNS depression on the MRR was vague and was not clarified with the Pharmacist nor physician notified of recommendation as to what should be monitored when all three meds were given because taking three medications (Alprazolam, Mirtazapine and oxycodone), knowing Resident 1's history of respiratory disease and COVID would enhance the incidence of Respiratory depression. On 10/16/25 at 12:28 P.M., an interview and record review were conducted with ADON. The ADON stated they did not have a written policy and procedure for monitoring facility residents who was on several sedating medications. ADON agreed the care plan was not updated to address CNS depression as recommended per the MRR. The ADON stated the MRR recommendation for CNS depression monitoring was vague and should have been clarified with Resident 1's physician because monitoring for Resident 1's respiratory status should have included the respiratory rate, and oxygen saturation levels. On 10/20/25 at 10:15 A.M., an interview and record review were conducted with the Pharmacist (Pharm). The Pharm stated Resident 1 was receiving meds for COPD and given her history, Resident 1 had medications for depression (Mirtazapine) to control her depression. The Pharm stated she would not recommend stopping Mirtazapine for depression management but would have questioned the Alprazolam and the Oxycodone which were two medications that were short-acting medications (fast onset works within 20-30 minutes to work) that could cause a higher risk for CNS depression. The Pharm stated it would be best for a different class of anti-anxiety medication from a different class that did not interact with opiate medication to minimize the CNS depression. The Pharm stated Resident 1's history of COPD and COVID monitoring for respiratory distress would need to be assessed more often before and after administration of combined medications of Oxycodone and Xanax. On 10/20/25 at 2:14 P.M, an interview was conducted with the Medical Director (MD). The MD stated the combination (oxycodone, mirtazapine, and alprazolam) could cause central nervous system (CNS) depression and respiratory distress. The MD stated if there were any signs of CNS depression during a COC while on narcotic (drugs that are controlled because of their potential for abuse) medications (oxycodone and alprazolam) the nursing staff should notify the assigned physician, and if unable to get a hold of the assigned physician, to notify him. The MD stated, in general if there is CNS depression not responding (not talking, not responding to pain) then Narcan would be recommended but if a resident (any residents) was with it (alert and able to respond), then oxygen administration would be recommended. The MD stated it was professional standards of practice to monitor before and after vital signs (blood pressure, heart rate, respiration rate, and oxygen levels) during medication administration. The MD stated vital signs should be monitored after each medication within one hour of administration. On 10/20/25 at 3:06 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MRR recommendations from the Pharm was vague and was not specific to what needed to be monitored for CNS depression when taking the medications (Alprazolam, Mirtazapine, and Oxycodone). The DON stated it was important when giving medications to have clear instructions to follow as part of Resident 1's specific plan of care to monitor for CNS depression to include lethargy, increased sedation and vital signs before and after administration according to professional standards of practice of high-risk (addictive/life-threating) medications such as Oxycodone and Xanax. According to the Centers for Disease Control and Prevention (CDC), 11/28/22 SUDORS Manual Version 6.3 at https://www.cdc.gov/overdose-prevention/media/pdfs/2025/02/SUDORS_Coding_Manual_OD2A_v6.3b_Feb2025.pdf .Since opioids [ a controlled medication class such as Oxycodone] can cause respiratory depression, having a pulmonary (lung) condition such as COPD can put someone at risk for opioid-involved overdose . A review of the facility's policy and procedure titled, Significant Change in Condition, Monitoring for (Undated), indicated .The IDT shall collaborate with the Attending Physician, Resident, and/or Resident Representative to review risk indicators and the plan of care as well as document this collaboration in the EMR [electronic medical record] in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT .

Based on record review the facility did not develop a care plan for a pacemaker (implanted device that regulates your heartbeat) for one of 18 sampled residents (34). As a result, the facility staff would not know if the pacemaker was malfunctioning. Finding: Resident 34 was admitted to the facility on [DATE], with diagnosis including atrial flutter, (abnormal heart rhythm where the heart's upper chambers (atria) beat too quickly), and a pacemaker. Resident 34's clinical record was reviewed on 6/20/25. There was no care plan or any documentation referring to Resident 34's pacemaker settings. The only information found related to the pacemaker was a History and Physical dated 5/11/25, that included permanent pacer model l310 .implanted 9/11/18. There was no information to indicate when Resident 34 was to have the pacemaker evaluated with an appointment with cardiology and no documentation of the pacemakers settings.

2. Resident 1 was admitted to the facility on [DATE], with diagnosis including bone cancer, per the admission Record. A review of Resident 1's clinical record using the Electronic Medical record system on 6/18/25 could not locate a POLST. On 6/19/25 at 8:49 A.M., the Medical Records Director found the physical POLST. The POLST was signed and dated by the MD, but the Signature of Patient or Legally Recognized Decision maker had the printed name of Resident 1's grandson. In the area for his signature was the word verbal with a date of 4/4/25. There was no signature of the person getting a verbal consent and no indication that they had attempted to get a signature from anyone since that date. A review of the facility's policy and procedure titled ADVANCED DIRECTIVE undated, indicated, .Social Services offers the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to accept refused medical or surgical treatment and the right to formulate Advance directives .Document in the resident health record that the resident and/or resident representative have been offered with written information regarding advance directives . Based on observation, interview, and record review, the facility failed to provide and document information about advance directives (AD-legal document that records your wishes for medical care) and sign a Physician Ordered Life Sustaining Treatment (POLST) for two of 18 residents (Resident 281 and Resident 1). These deficient practices placed Resident 281 and Resident 1 at risk for not having their treatment preferences known or honored during a medical emergency. Findings: 1. A review of Resident 281's admission Record indicated Resident 281 was admitted to the facility on [DATE] with diagnoses which included a history of atherosclerotic heart disease (thickening or hardening of the arteries). A record review of Resident 281's minimum data set (MDS- a federally mandated resident assessment tool) dated 6/3/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 281 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/18/25 at 11:53 A.M., a record review was conducted on Resident 281's Social Assessment Evaluation dated 6/17/25. Resident 281's Social Assessment Evaluation indicated, .She has not yet completed a DPOAHC (durable power of attorney for health care: a document that allows you to appoint someone to make medical decisions) . There was no information that a written form was given to Resident 281's right to formulate an AD and/or no AD in Resident 281's clinical chart was available. On 6/18/25 at 2:39 P.M., an interview was conducted with Resident 281, in Resident 281's room. Resident 281 stated she had previously made an AD prior to coming to the facility and that her husband had her AD at home. Resident 281 stated the AD she completed was for medical decisions she wanted in an event she was unable to make health care decisions. Resident 281 stated she did not remember receiving or given written information regarding an AD since she had one available at home. On 6/19/25 at 8:57 A.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD stated, I write vaguely for all the residents I ask regarding an AD because they either want help, don't want it or refuse but I should make it clear that information had been given. The SSD stated Resident 281's Social Evaluation assessment dated [DATE] was unclear if written information regarding an AD was given. The SSD stated that residents who have an AD should have a copy of their AD in their chart because it was their right to receive care according to their AD. On 6/20/25 at 10:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 281's AD evaluation should be clear in documentation if written information was given and should not be worded the same for all residents being evaluated for an AD. The DON stated it was her expectations that residents who have an AD be readily available to provide care according to their preferences and for residents to be given written information on their right to formulate an AD.

Based on observation, interviews, and record reviews, the facility failed to follow physician-ordered oxygen therapy and ensure safe care practices for one of 18 sampled residents (Resident 286). This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care due to staff performing duties they were not trained or authorized to do. Cross-Reference F726 Findings: According to the National Institutes of Health (2018) .Long-term oxygen therapy (LTOT) has beneficial effects on survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia [low oxygen] at rest . A review of Resident 286's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses which included a history of chronic (6 months or more of an illness) respiratory distress (difficulty breathing or unable to breathe properly) with hypoxia (low oxygen). A record review of Resident 286's minimum data set (MDS- a federally mandated resident assessment tool) dated 6/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 286 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/17/25 at 11:43 A.M., an observation and interview was conducted with Resident 286 and Resident 286's daughter, in Resident 286's room. Resident 286 was in her bed in an upright position on oxygen wearing a nasal cannula (oxygen therapy through the nose) tube. Resident 286's daughter stated that the night before a CAN removed Resident 286's oxygen then walked her to the bathroom and sat her (Resident 286) on the toilet without oxygen. Resident 286's daughter stated she slept overnight when Resident 286 informed her of this incident. Resident 286 (while taking deep breaths in-between words) stated I did not have my oxygen while I was walking to the bathroom. The CAN removed it but I need my oxygen, cause it's hard to breathe. It should have been on. I had to yell out until the med [medication] nurse came. On 6/19/25 at 8:07 A.M., a clinical chart review on Resident 286's Physician's (MD) Orders, progress notes, and care plan was conducted. Resident 286's MD order's indicated: - Orders for Oxygen 5L/min [liters]/ [per] min [minute] NC with Exertion 2L NC at rest. Start date 5/27/25 dc 6/16/25. New orders on 6/16/25 indicated Oxygen 4LPM via NC Continuously, 5L/min NC with exertion [activity] every shift. - Resident 286's progress noted on 6/16/25 indicated, .Pt [patient] was assisted by the CAN using a walker and sat in the restroom without oxygen for approximately 5 mins, while CAN was getting the portable 02 tank with wheels. Patient called writer and was upset that she was transferred to the restroom and left without oxygen . - Resident 286's Care Plan initiated 6/5/25 indicated, .risk for altered respiratory status/Difficulty breathing r/t Emphysema [long term condition that causes shortness of breath] .Interventions .Provide oxygen as ordered . On 6/19/25 at 10:40 A.M., an interview was conducted with CAN 1. CAN 1 stated Resident 286 was the only resident that had continuous oxygen assigned in her area. CAN 1 stated to transfer Resident 286 from the bed to the bathroom she would switch over the concentrator [oxygen device that supplies oxygen not connected to the wall] and switch to portable oxygen and then would transfer them that way [remove the end of oxygen tubing that is connected to oxygen concentrator then connect to portable oxygen]. Usually, I would just turn the knob [oxygen level dial] on and set to the level of the setting and would switch it on. CAN 1 stated upon transfer back to bed that she would switch the tubing back on the concentrator and turn the oxygen back up to their (facility residents) settings. On 6/19/25 at 10:52 A.M., an interview and record review was conducted with Licensed Nurse 2. LN 2 stated CNAs should not be adjusting oxygen settings and should notify LNs when oxygen needs to be switched from a concentrator to a portable oxygen tank. LN 2 stated Resident 286 was being transferred by a CAN per the progress noted on 6/16/25 and assisting Resident 286 to ambulate to the bathroom. LN 2 stated ambulating would be considered exertion and should have been on continuous oxygen per MD orders. LN 2 stated she [Resident 286] could have respiratory failure from lack of oxygen. LN 2 further stated Resident 286 had COPD that could lead to exacerbation (worsening) of respiratory distress. On 6/20/25 at 7:59 A.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that CAN's are not to touch the oxygen settings. The DSD stated she held an in-service on oxygen use to CAN's on 6/18/25. The course content indicated: .CNAs are not to use oxygen .It is not in your scope of practice .If asked CNAs can not turn on oxygen . The DSD further stated that she just tells the CNAs not to touch oxygen and gets checked off for their skills checklist. The DSD stated that prior to this lesson plan on 6/18/25 the CNAs just get told not to touch the oxygen with a return demonstration of not touching oxygen. The DSD stated the only rationale with the lesson plan is that it's not in their scope of practice. The DSD stated that the lesson plan does not address the importance of use and why it should be treated as a medication. The DSD stated that it lacked instructions to notify the LN, and the safety risks associated with oxygen use. The DSD stated it was important to explain this further to the CAN's because the facility serves a population of residents with respiratory disorders who need oxygen to provide safe care to prevent respiratory distress. The DSD stated Resident 286 should have had her oxygen on and safely managed appropriately according to MD orders and that this was not practiced according to professional standards of practice to prevent respiratory distress. On 6/20/25 at 9:47 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the CAN should have called the nurse to help transition Resident 286 from an oxygen concentrator to a portable oxygen prior to getting resident up from bed to ambulate (on excretion) to the bathroom because Resident 286 was on continuous oxygen orders. The DON stated this was not practiced according to professional standards of practice of the MD orders and care plan to provide the treatment and care for the safety of oxygen use. The DON stated this could lead to further respiratory distress (hypoxia and SOB) for Resident 286 because she was on continuous oxygen. A review of the facility's policy and procedure titled OXYGEN, USE of undated, did not indicate oxygen use administration safety.

Based on observation, interview and record review, the facility failed to label (name, date, time, and dose) an intravenous fluid (IVF: hydration therapy given through the vein) therapy and discarding the IVF according to their policies and procedures for one of 18 sampled residents (Resident 275). In addition, the IVF bag and tubing was moved in next to a different resident's bedside and was left uncapped (open to infection). This deficient practice placed all residents receiving IVF and/or IV medications at risk for infection, medication errors, and unsafe care due to improper handling and storage of IVF. Findings: On 6/17/25 at 8:26 A.M., an observation and interview was conducted in Resident 275's room. Resident 275's roommate (Resident 285) stated Resident 275 was still in the dining room being assisted for breakfast. An IVF fluid (without remaining fluid) was hanging on an IV pole that was unlabeled with an uncapped IV tubing in Resident 275's room. A review of Resident 275's admission Record indicated Resident 275 was admitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (stroke). A record review of Resident 275's minimum data set (MDS- a federally mandated resident assessment tool) dated 6/5/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 0 points out of 15 possible points which indicated Resident 275 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/19/25 at 10:09 A.M., an observation, interview and record review was conducted with LN 2, in Resident 275's room. LN 2 was shown pictures of the IVF and tubing in Resident 275's room and she confirmed that was Resident 275's room. LN 2 stated she was unable to find IVF physician's orders for Resident 275. On 6/19/25 at 10:35 A.M., an observation, interview and record review was conducted with LN 1, in Resident 275's room. LN 1 was shown pictures of the IVF and tubing in Resident 275's room and observed the same rainbow flag and bedside dresser next to the IVF hanging on the IV pole. LN 1 stated the IVF bag and tubing was unlabeled and uncapped. LN 1 stated that the IVF should be labeled according to the five rights of medications (right resident, right order, right route, right dosage and right time). LN 1 stated the IV tubing should also be labeled to know when it was used and know when to replace the tubing and capped to protect from cross-contamination. LN 1 stated he was unsure who the IVF was really for and stated since the IVF was used (no fluids remaining in bag) it should have been discarded properly. LN 1 stated that the unlabeled IVF and tubing was unsafe due to possible contamination and could lead to accidentally being used. On 6/19/25 at 10:44 A.M., an interview and record review was conducted with LN 2. LN 2 stated that the IVF had belonged to her roommate (Resident 285). LN 2 stated Resident 285's order on 6/11/25, indicated: - .IVF D5W [Dextrose 5% in water used for hydration therapy] x [times] 500 ml [milliliters] . LN 2 further stated the IVF found in Resident 275's room should have been properly discarded immediately after the IVF was administered. LN 2 stated this had the potential for misuse and infection control issues because it was not discarded properly and was uncapped. LN 2 stated this was probably placed there by the housekeeper because it was unlabeled. On 6/20/25 at 10:08 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the IVF bag and tubing should have been discarded after it was administered and IV pole removed from room. The DON stated her expectations was for IVF/IV medications to be labeled properly to prevent medication errors and for staff to discard IV supplies properly. The DON stated this could be unsafe or misused and a possible infection control issue. A review of the facility's policy and procedure ADMINISTRATION of PARENTERAL MEDICATION undated 5/2002, indicated, .Bag must be used or discarded after 24 hours .

Based on observation, interviews, and record reviews, the facility failed to ensure that certified nursing assistants (CNA) followed safe and appropriate procedures when providing oxygen administration to one of 18 sampled residents (Resident 286). This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care and potential harm due to nursing staff performing tasks they were not trained or allowed to do. Cross-Reference F684 Findings: A review of Resident 286's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses which included a history of chronic (6 months or more of an illness) respiratory distress (difficulty breathing or unable to breathe properly) with hypoxia (low oxygen). A record review of Resident 286's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 286 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/17/25 at 11:43 A.M., an observation and interview was conducted with Resident 286 and Resident 286's daughter, in Resident 286's room. Resident 286 was in her bed in an upright position on oxygen wearing a nasal cannula (NC- oxygen therapy through the nose) tube. Resident 286's daughter stated that the night before a CNA removed Resident 286's oxygen then walked her to the bathroom and sat her (Resident 286) on the toilet without oxygen. Resident 286's daughter stated she slept overnight when Resident 286 informed her of this incident. Resident 286 (while taking deep breaths in-between words) stated I did not have my oxygen while I was walking to the bathroom. The CNA removed it but I need my oxygen, cause it's hard to breathe. It should have been on. I had to yell out until the med [medication] nurse came. On 6/19/25 at 8:07 A.M., a clinical chart review on Resident 286's Physician's (MD) Orders, progress notes, and care plan was conducted. Resident 286's MD orders indicated: - Orders for Oxygen 5L/min [liters]/ [per] min [minute] NC with Exertion [activity] 2L NC at rest. Start date 5/27/25 dc [discontinued] 6/16/25. A new order for oxygen dated 6/16/25 indicated Orders for Oxygen 4LPM via NC Continuously, 5L/min NC with exertion every shift. - Resident 286's progress noted on 6/16/25 indicated, .Pt [patient] was assisted by the CNA using a walker and sat in the restroom without oxygen for approximately 5 mins, while CNA was getting the portable 02 tank with wheels. Patient called writer and was upset that she was transferred to the restroom and left without oxygen . - Resident 286's Care Plan initiated 6/5/25 indicated, .risk for altered respiratory status/Difficulty breathing r/t [related to] Emphysema [long term condition that causes shortness of breath] .Interventions .Provide oxygen as ordered . On 6/19/25 at 10:40 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 286 was the only resident that had continuous oxygen assigned in her area. CNA 1 stated to transfer Resident 286 from the bed to the bathroom she would switch over the concentrator [oxygen device that supplies oxygen not connected to the wall] and switch to portable oxygen and then would transfer them that way [remove the end of oxygen tubing that is connected to oxygen concentrator then connect to portable oxygen]. Usually, I would just turn the knob [oxygen level dial] on and set to the level of the setting and would switch it on. CNA 1 stated upon transfer back to bed that she would switch the tubing back on the concentrator and turn the oxygen back up to their (facility residents) settings. On 6/20/25 at 7:59 A.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that CNA's are not to touch the oxygen settings. The DSD stated she held an in-service on oxygen use to CNA's on 6/18/25. The course content indicated: .CNAs are not to use oxygen .It is not in your scope of practice .If asked CNAs can not turn on oxygen . The DSD further stated that she just tells the CNAs not to touch oxygen and gets checked off for their skills checklist. The DSD stated that prior to this lesson plan on 6/18/25 the CNAs just get told not to touch the oxygen with a return demonstration of not touching oxygen. The DSD stated the only rationale with the lesson plan is that it's not in their scope of practice. The DSD stated that the lesson plan does not address the importance of use and why it should be treated as a medication. The DSD stated that it lacked instructions to notify the Licensed Nurse (LN), and the safety risks associated with oxygen use. The DSD stated it was important to explain this further to the CNA's because the facility serves a population of residents with respiratory disorders who need oxygen to provide safe care to prevent respiratory distress. The DSD stated Resident 286 should have had her oxygen on and safely managed appropriately according to MD orders and that this was not practiced according to professional standards of practice to prevent respiratory distress. On 6/20/25 at 9:47 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations for in-service lesson plans with oxygen safety should indicate the importance of oxygen use for safety and explain why CNAs are not allowed to touch settings and administer oxygen. The DON stated CNAs need to understand why they should not be touching oxygen because of the population of the facility serves to provide the necessary care for residents with pulmonary and respiratory disorders. A review of the facility's Job Description titled, CERTIFIED NURSING ASSITANT dated 12/17/21 did not indicate essential functions for safety with oxygen use.

Based on observation, interview, and record review, the facility failed to document: 1. The disposition of a discharged resident from the facility for one of three residents (Resident 73), reviewed for closed records; and 2. Every two hours, the lint removal in the dryer's maintenance log within the facility's laundry room, reviewed for infection control. These failures resulted Resident 73's location not being known to the reader after discharge and laundry staff being unable to verify when the dryer lint was last removed. Findings: Resident 73 was admitted to the facility on [DATE], with diagnoses which included posthemorrhagic anemia, (a sudden blood loss which leads to low red blood cell count), according to the facility's admission Record. According to the physician's order, dated 3/11/25, .Admit to (name of agency) Hospice (end of life care), for end stage cardiac (heart) disease . According to the nursing progress notes, dated 3/22/25 at 8:29 A.M., Licensed Nurse 11 (LN 11) documented Resident 73, passed away at 1:35 A.M. Hospice notified and arrived at facility at 2:28 A.M., called medical doctor, family, and mortuary. There was no documentation of when Resident 73 left the facility or what mortuary he was transported to. There was no documented evidence of a mortuary receipt being prepared by the facility. An interview and record review was conducted with LN 12 on 6/19/25 at 1:32 P.M. LN 12 stated he performed discharges. LN 12 stated when residents were discharged , the nurse was required to document what time the resident left the facility, who with, and how, such as private vehicle, ambulance etc. LN 12 reviewed Resident 73's nursing progress notes dated 3/22/25, and stated there was no disposition of when or where the resident was discharged to. LN 12 stated it was important to document the resident's discharge because it was a nursing requirement and showed a continuum care. A hard copy medical record review was conducted on 6/19/25, in the Medical Records Department. According to the Hospice file, (name of mortuary, located in Westminster, CA.) was notified by the hospice nurse on 3/22/25 at 3:55 A.M. An interview and record review was conducted with the Director of Nursing on 6/19/25 at 1: 38 P.M. The DON stated all LN's needed to document in the nursing progress note of when a resident left the facility and with whom. The DON stated documentation of discharge dispositions was a nursing requirement and showed consistency in care. The DON reviewed Resident 73's electronic record and could find no documentation of where the resident was sent or at what time the resident left. The DON reviewed the hard copy medical record, and stated she could not locate the facility's receipt for mortuary pick-up. According to the facility's policy, titled Charting and Documentation, undated, The resident's clinical record is a concise account of treatment .8. Continuous nurse's notes are required on all residents . 2. On 6/18/25 at 9:53 P.M., an observation was conducted of the facility's laundry room as part of the Infection Control task. Present were laundry aide 1 (LA 1) and Laundry Supervisor (LS), for assistance with interpretation. An observation and record review was conducted on 6/18/25 at 10 A.M. with LA and LS, in the drying area. The room contained two industrial dryers. The dryer's maintenance binder was reviewed, titled LINT CLEANING LOG. Entries for 6/17/25 and 6/18/25 at 7 A.M., 9 A.M. and 11 A.M., were blank and not initialed as being completed. Listed on the bottom of the lint cleaning log was, Manufacture Requirements: Lint should be removed from the lint screen after every load or after every two hours of operation . Dryer #2 contained dried chuks, (a thick absorbent bed pad) sitting inside the machine. The lint screen on Dryer #2 was removed by LS for inspection. A moderate amount of lint was present on dryer #2's lint screen with a thicker accumulation on the edges of the screen. LS stated it did not look like the screen had been cleaned at 9 A.M. An observation was conducted of dryer #1, which had a thin coat of lint on the screen. An interview with LA with LS interrupting was conducted. LA stated if the dryer screens were not cleaned every two hours, linens would take longer to dry and the dryer unit would not get as hot as possible. LA stated she usually runs the dryers at the same time and cleans the screens. LA stated Dryer #2, needed to dry some more, because the thick chuks were not dry yet, so the lint screen was not cleaned. LA stated the log entries were not completed as they should have been. An interview and record review was conducted with the LS on 6/18/25 at 10:20 A.M. The LS stated if staff removed the dryer lint, he expected them to document it so they could get credit. The LS stated if it was not documented, it was not done. The LS provided a photocopy of an in-service with laundry staff, titled Proper Documentation/Logging Work, dated 5/21/25. LA was listed as attending the in-service. An interview was conducted with the Infection Control Nurse (ICN) on 6/18/25 at 11:35 A.M. The ICN stated if lint screens were not cleaned every two hours, the linens would not get as hot as possible, which helped with destroying bacteria. The ICN stated lint removal needed to be documented in the maintenance book as removed every two hours, in order to meet the standard of practice for infection control. An interview was conducted with the Director of Nursing (DON) on 6/19/25 at 9:55 A.M. The DON stated she expected dryer lint traps to be cleaned every two hours, which was important for fast drying to prevent hazards, such as fires. The DON stated she also expects staff to routinely documents the lint cleaning in the dryers' maintenance log. The facility was unable to locate a policy related to lint trap removal for the dryers.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1), who was cognitively impaired and dependent on staff for care, was free from abuse when certified nursing assistant (CNA) 2 called the resident an ass then smacked the side of his head with an open hand while telling the resident, That's for hitting me last week. As a result, Resident 1 became agitated and attempted to hit staff back. In addition, Resident 1 had seemed guarded following the incident, per staff interview. This deficient practice had the potential to cause Resident 1 to experience fear, humiliation, and emotional distress. Findings: A review of Resident 1's Admission Record, dated 7/26/24, indicated the resident was admitted to the facility on [DATE] with diagnoses to include Parkinsonism (condition characterized by balance issues and tremors), unspecified psychosis (thoughts not based in reality), and dementia (condition characterized by impaired memory and judgement) with behavioral disturbance. A review of Resident 1's annual History and Physical, dated 4/10/24 indicated, the resident, Does not have the capacity to understand and make decisions. On 7/26/24, the California Department of Public Health (CDPH, state agency that licenses and certifies skilled nursing facilities) received a SOC 341 report (document used to report suspected abuse) dated 7/26/24, from the facility. The facility's SOC 341 document indicated, the facility was reporting an incident of suspected physical abuse perpetuated by CNA 2 against Resident 1 and that the incident had been witnessed by a student certified nursing assistant (SCNA). On 7/30/24 at 10:29 A.M., a telephone interview was conducted with SCNA. SCNA stated on 7/26/24 she went to help CNA 2 and CNA 3 give Resident 1 a shower. SCNA stated she, along with CNA 2 and CNA 3, were inside the shower room with Resident 1. SCNA stated they transferred Resident 1 from his wheelchair into the shower chair. SCNA stated Resident 1 was calm and cooperative at that time. SCNA stated CNA 2 was not talking nicely about the resident and had told her Resident 1 always fights and tries to hit staff and, He's an ass. SCNA stated CNA 2 then smacked Resident 1 with an open hand on the side of his head while stating, That's for hitting me last week. SCNA stated Resident 1 became agitated, had an angry expression on his face, and raised both hands in a motion to hit CNA 3 who stood directly in front of him. SCNA stated CNA 2 had been standing off to the side and was not standing in the resident's line of sight. SCNA stated CNA 2 left the shower room and that she remained behind with CNA 3 to help shower the resident. SCNA stated CNA 3 had to calm Resident 1 back down by rubbing his back. SCNA stated, It didn't feel right . [CNA 2] wasn't treating [Resident 1] like a human . SCNA stated what she saw was abusive. SCNA stated Resident 1, Seemed too confused to report such an incident himself. SCNA stated she reported the incident immediately to her CNA instructor. On 8/1/24 at 9:55 A.M., an onsite visit and interview with the administrator (ADM) was conducted to investigate the facility reported allegation of abuse. The ADM stated she had finished her investigation of the 7/26/24 incident with Resident 1 and CNA 2 and provided a copy of the results of the investigation. The ADM stated she had substantiated SCNA's report of the incident, and that CNA 2 had acted inappropriately. The ADM stated CNA 2 had been terminated and that CNA 3 had also been terminated for failing to come forward about what occurred with Resident 1 on 7/26/24. The ADM stated CNA 2 had been hit by Resident 1 a couple of weeks ago and a facility incident report for work-related injuries was filed. A review of the facility's document titled [facility name] Confidential Abuse Investigation dated 7/30/24, and completed by the director of staff development (DSD) and ADM, indicated, .Interviews .[SCNA] was advised [by CNA 2] to be careful as [Resident 1] tends to be combative and hit staff during care . [CNA 2] tapped the side of [Resident 1's] head and said, ' That's for punching me.' . [CNA 2] denied tapping [Resident 1] on the head or making the comment .Findings: Although [CNA 2's] alleged actions likely stemmed from immaturity without intent to harm, the action is demeaning towards an elderly resident who lacks the capacity to make decisions and is not representative of [Facility]. [CNA 2's] employment with [facility] has been terminated. In addition, after much thought and consideration, decision was made to terminate [CNA 3] as well On 8/1/24 at 10:43 A.M., a telephone call was placed to CNA 3. CNA 3 did not respond or return the phone call. On 8/1/24 at 11:40 A.M., a joint interview and record review was conducted with the DSD. The DSD stated she conducted the facility's abuse prevention and dementia training. The DSD provided CNA 2 and CNA 3's training records for review and stated they were both trained on abuse prevention and dementia care. The DSD stated her staff training had included scenarios of joking around or horseplay and tapping or smacking a resident as not acceptable or appropriate behavior and such things were considered abuse. The DSD stated based on the abuse training provided by the facility, CNA 2 would have known her behavior was wrong. The DSD stated she interviewed CNA 3 about what had happened during Resident 1's shower and CNA 3 had put her head down and claimed to have not seen or heard anything on 7/26/24 during Resident 1's shower. The DSD stated this was not believable and, There's no way she didn't hear or see what happened. The DSD stated CNA 3's employment had been terminated because she would not tell the truth about what had happened. The DSD stated CNA 2 and CNA 3 were, Really good friends. The DSD reviewed the facility document titled Employee Incident Report dated 7/8/24, for CNA 2, which indicated, .I [CNA 2] was taking [Resident 1's] brief off. While I was bent over [Resident 1] closed fisted, punched me in my face right side under eye The document listed CNA 3 and CNA 4 as a witness to the incident. The DSD further stated the SCNA started clinical training at the facility on 7/23/24 and would not have had knowledge of CNA 2 being hit by Resident 1 on 7/8/24 unless that was indeed what CNA 2 had said in the shower room on 7/26/24. On 8/1/24 at 12:14 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 was very confused and would sometimes try to hit or kick when he was touched during care. CNA 4 stated she had not been hit by the resident because she dodged it, or would attempt care later if the resident was agitated. CNA 4 stated she did not take Resident 1's behavior personally, because he did not understand what he was doing. CNA 4 stated on 7/8/24, she was helping CNA 2 and CNA 3 with Resident 1 when she heard a smack sound and CNA 2 said, My eye. CNA 4 stated she did not see the physical contact but that CNA 2's eye had a red mark and CNA 2 had to put ice on it. CNA 4 further stated discussing a resident's behavior, even if they were confused, should be done privately and not in front of the resident. CNA 4 stated it was never okay to use improper language with a resident or to smack a resident's head. CNA 4 stated she received abuse prevention training at the facility and according to her training, calling a resident an ass and smacking them on the head would be considered physical and verbal abuse. CNA 4 stated a cognitively intact person would feel bad about being treated like that. On 8/1/24 at 12:46 P.M., an interview was conducted with CNA 5. CNA 5 stated she knew Resident 1 well and had provided care to him since his admission to the facility. CNA 5 stated she heard Resident 1 would hit staff, but she had not seen or experienced that from the resident. CNA 5 stated Resident 1 had memory issues and was confused. The reported incident on 7/26/24 was discussed with CNA 5. CNA 5 stated she believed in the moment things were taking place, Resident 1 would have been able to understand that he was being discussed and was called an ass. CNA 5 stated Resident 1 would probably get agitated in that situation and start mumbling. CNA 5 stated Resident 1 was a military veteran and if he was smacked on the head, he could get triggered and would probably try to defend himself. CNA 5 became tearful and stated she was upset to have heard what had been reported to have happened to Resident 1 on 7/26/24 during care. CNA 5 stated when she worked on 7/29/24, after having had time off, Resident 1 seemed, Guarded, hesitant to accept care, and more agitated than usual. CNA 5 further stated she had not been aware of the report that Resident 1 had been called an ass and smacked on the head a few days prior to returning to work. CNA 5 stated she had not understood at that time why Resident 1 had acted different on her first day back to work. CNA 5 wiped the tears from her eyes and stated, This is abuse, picking on someone who can't defend themselves or report what happened. CNA 5 stated as a reasonable person, if she experienced what Resident 1 had, she would feel upset and want to defend herself, too. On 8/1/24 at 12:37 P.M., an observation was conducted of Resident 1 while inside the resident's room. Resident 1 was in bed with the blanket pulled up to his chin. Resident 1 had his eyes closed and did not respond to interview attempt. Resident did not have any observable facial/head injuries. On 8/1/24 at 1:19 P.M., an interview was conducted with licensed nurse (LN) 6. LN 6 stated Resident 1 was severely cognitively impaired and depended on staff to provide care. LN 6 stated Resident 1 could not walk and that it took two to three staff to safely move him between locations. LN 6 stated she heard Resident 1 could hit staff, but she had not seen it or experienced it herself. LN 6 stated she was off on 7/26/24. What was reported to have occurred on 7/26/24 between Resident 1 and CNA 2, was discussed with LN 6. LN 6 stated it was unacceptable to discuss a resident's behavior in front of the resident, even if they were confused. LN 6 stated the facility had provided training related to abuse. LN 6 stated based on her facility training, being called an ass and smacked on the head was physical and emotional abuse. LN 6 further stated it was abuse even if the resident was confused, not hit hard, or the staff thought it was a joke. LN 6 stated Resident 1 was vulnerable and was not capable of telling anyone what had occurred on 7/26/24. LN 6 stated if what happened to Resident 1 had happened to her, she would feel, Hurt, upset, and emotionally distressed. On 8/1/24 at 2:05 P.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated Resident 1 was cognitively impaired, had poor recall, and responded in a non-verbal way with mumbling that could not be understood. The ADON stated she was aware of the reported incident on 7/26/24 with CNA 2 and Resident 1. The ADON stated she had received facility training related to abuse. The ADON stated based on her training, what had occurred to Resident 1 was abuse. The ADON stated it was still considered abuse even though Resident 1 was confused and had memory issues. The ADON stated if it had happened to her, I'd feel bad. On 8/1/24 at 2:45 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated she helped CNA 3 transfer Resident 1 from his wheelchair into the shower chair while in the shower room on 7/26/24. CNA 2 stated she had been assigned two student CNAs to follow her that day and she had not worked with them before. CNA 2 stated she had asked one of them if she wanted to observe the resident's shower care. CNA 2 stated Resident 1 had been agitated, grabbed onto the shower handrail, and would not let go, and had been trying to bite CNA 3. CNA 2 stated she told the student that Resident 1 was combative and to watch out because he hits. CNA 2 stated that was all that she said about Resident 1. CNA 2 was asked if the resident's behavior should have been discussed in front of the resident. CNA 2 stated, It should be done privately but [Resident 1's] AOx1 [only had awareness to self] and can't understand so I thought it was a good time to tell her [SCNA]. CNA 2 stated she pushed Resident 1's shoulders back when he tried to bite CNA 3 but did not touch the resident anywhere else. CNA 2 denied smacking Resident 1's head or calling the resident an ass. CNA 2 was asked how the student CNA would have known that she had been hit by Resident 1 previously. CNA 2 stated, Oh, well, I told her that he [Resident 1] punched me then, too. On 8/2/24 at 1:15 P.M., an interview was conducted with the administrator (ADM). The director of nursing was also present. The ADM was asked if what happened to Resident 1 on 7/26/24 was abuse. The ADM stated the incident on 7/26/24 between Resident 1 and CNA 2 was an inappropriate interaction that she attributed to CNA 2's age and immaturity. The ADM stated the incident was substantiated and CNA 2 and CNA 3's employment had been terminated as a result. A review of the facility's policy titled Abuse: Prevention of and Prohibition Against, dated 11/2017, indicated, It is the policy of this facility that each resident has the right to be free from abuse . exploitation and mistreatment The policy defined abuse as .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation . Mistreatment means inappropriate treatment . of a resident . Physical abuse includes but is not limited to hitting, slapping . Verbal abuse includes the use of oral .language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability

Based on interview and record review, the facility failed to implement one resident's (Resident 1) written care plans related to behavior as evidenced by angry outbursts after the resident hit a staff member during care. As a result of this deficient practice, Resident 1's behavior was not documented in the resident's clinical record and it was not reported to the physician as indicated in the resident's written care plans. This had the potential for the resident's behavior to go unmanaged. Findings: A review of Resident 1's Admission Record, dated 7/26/24, indicated the resident was admitted to the facility on [DATE] with diagnoses to include Parkinsonism (condition characterized by balance issues and tremors), unspecified psychosis (thoughts not based in reality), and dementia (condition characterized by impaired memory and judgement) with behavioral disturbance. A review of Resident 1's written behavior care plan for angry outbursts and the potential to physically harm self and staff, dated 4/27/22, indicated, .Interventions .Monitor/document/report to MD [medical doctor] of danger to self and others A review of Resident 1's written care plan for the use of a psychotropic medication (drugs used to control thoughts, behavior and/or mood) for behavior management of Parkinson's Disease related psychosis as evidenced by angry outbursts dated 2/8/22, indicated, .Interventions . Monitor/record occurrence of for targeted behavioral symptoms and document A review of the facility document titled Employee Incident Report dated 7/8/24, for certified nursing assistant (CNA) 2, indicated, .Time of incident 12:55 P.M.I [CNA 2] was taking [Resident 1's] brief off. While I was bent over [Resident 1] closed fisted, punched me in my face right side under eye The document listed CNA 4 as a witness to the incident. On 8/1/24 at 12:14 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 was very confused and would sometimes try to hit or kick when he was touched during care. CNA 4 stated she had not been hit by the resident because she dodged it, or would attempt care later if the resident was agitated. CNA 4 stated she did not take Resident 1's behavior personally, because he did not understand what he was doing. CNA 4 stated on 7/8/24, she was helping CNA 2 and CNA 3 with Resident 1 when she heard a smack sound and CNA 2 said, my eye. CNA 4 stated she did not see the physical contact but that CNA 2's eye had a red mark and CNA 2 had to put ice on it. A review of Resident 1's medication administration record (MAR) for July 2024, indicated the resident was being monitored every shift for number of episodes of target behavior angry outbursts. The MAR indicated Resident 1 had zero angry outbursts during all three shifts on 7/8/24. On 8/1/24 at 1:19 P.M., a joint interview and record review was conducted with licensed nurse (LN) 6. LN 6 reviewed the Employee Incident Report dated 7/8/24, for CNA 2, and stated Resident 1 punching CNA 2's face was considered an angry outburst. LN 6 reviewed Resident 1's July 2024 MAR and stated 7/8/24 should not have been documented as zero episodes. LN 6 reviewed Resident 1's two written care plans (dated 2/8/22 and 4/27/22) related to angry outbursts and stated the care plans were not implemented. LN 6 reviewed Resident 1's clinical record and stated the resident's angry outburst was not recorded and the MD was not called. LN 6 stated Resident 1's MD should have been called as the MD may have wanted further treatment or to evaluate the resident. LN 6 stated Resident 1's written care plans should have been implemented as it was important to make sure care goals were achieved. LN 6 further stated documenting the episodes of angry outbursts was important to make sure Resident 1's psychotropic medication was addressing his target behavior. On 8/1/24 at 2:05 P.M., a joint interview and record review was conducted with the assistant director of nursing (ADON). The ADON stated on 7/8/24, when Resident 1 hit CNA 2's face, that was considered an angry outburst and harm to staff. The ADON reviewed Resident 1's clinical record and stated Resident 1's angry outburst should have been documented and the resident's MD should have been notified of the behavior. The ADON stated Resident 1's MAR for 7/8/24 should not be recorded as zero episodes of the target behavior. The ADON stated Resident 1's behavior care plans related to angry outbursts should have been implemented. The ADON stated either Resident 1's MAR was inaccurate on 7/8/24, or the resident's LN was not made aware of the behavior and should have been notified. The ADON stated the LN had to be aware of the resident's behavior to implement the care plans. On 8/1/24 at 2:45 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated Resident 1 had hit her eye on 7/8/24 and that she reported it to the resident's LN. CNA 2 stated she could not recall the LN's name. On 8/1/24 at 3:58 P.M., a joint interview and record review was conducted with LN 7. LN 7 reviewed Resident 1's MAR for 7/8/24 monitoring episodes of target behavior angry outbursts and stated she had documented zero episodes. LN 7 reviewed the Employee Incident Report dated 7/8/24, for CNA 2. LN 7 stated she was working and providing care to Resident 1 on 7/8/24 when the incident took place at 12:55 P.M. LN 7 stated no one had notified her that this had happened, and she was completely unaware Resident 1 had hit CNA 2. LN 7 stated she should have been informed right away and that she would have called the MD and documented the incident. LN 7 reviewed Resident 1's two written care plans related to angry outbursts (dated 2/8/22 and 4/27/22) and stated these care plans were not implemented and they should have been. A review of the facility's undated policy titled Care Planning/Care Conference did not provide guidance related to care plan implementation.

Based on interviews and record reviews, the facility failed to follow their own policy when Resident 1 was transferred from bed to wheelchair without the use of a gait belt (assistance safety device). This failure resulted in Resident 1 ' s injury of chipped fracture to his right tibia (shin bone). Findings. A review of the Facility ' s undated Admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses that included Repeated Falls, Cognitive Communication Deficit and Retention of Urine Unspecified. An interview on 4/23/24 at 10:55 A.M., with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was supposed to be watching lights and provide assistance to residents when needed. CNA 1 stated if a resident wants to be left alone, CNA 1 will leave them alone but would be watching from a distance. A phone interview on 4/29/24 at 4:13 P.M., with CNA 2 was conducted. CNA 2 stated, she worked with Resident 1 that night of 3/15/24. CNA 2 stated at around 5:45 A.M., she asked Resident 1 if he wanted to go to the bathroom and Resident 1 agreed. CNA 2 transferred Resident 1 from the bed to his wheelchair with the use of a [NAME] steady (manual lift). After being transferred, Resident 1 slid from the wheelchair while being assisted by CNA 2 to the floor. CNA 2 stated she did not have a gait belt on him since he required minimal (the assisting person or device are required to perform 25 % of the work or a mobility task) assistance. CNA 2 acknowledged she should always have her gait belt with her to use with Resident 1 ' s transfers. An interview on 4/23/24 at 11:20 A.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated Resident 1 required moderate (the assisting person or device are required to perform 50% of the work or mobility task) assistance with transfers as assessed by the Physical Therapist. The ADON stated the staff needs to always have the gait belt with them during transfers and ambulating residents in the facility. A phone interview on 4/29/2024 at 4:34 P.M., with the Director of Nursing (DON) was conducted. The DON stated the staff should always have their gait belts in their possession. The DON stated Resident 1 was a partial 1 per rehab assessment, and Resident 1 required moderate assistance with transfers and ambulation. A phone interview with family member (FM)1 on 4/24/24 at 9:04 A.M., was conducted. FM1 stated, the Administrator (ADM) told and confirmed that her husband did not have a gait belt on him when he fell and that he was assisted to the floor when he slid from his wheelchair. FM1 stated the facility stated it was a witnessed fall. FM1 stated her husband had a history of falls and had injured his right leg previously and then again at the facility as a result of the fall. A record review of Resident 1 ' s MDS (minimum data set- tool assessment ) dated, 3/8/24 indicated, Resident 1 ' s cognition was severely impaired or a score of 5 (0-7 indicated severe cognitive impairment; 8-12 indicated moderate cognitive impairment; 13-15 indicated cognition is intact). A record review of the Physical Therapy Treatment Encounter notes dated, 3/13/2024 indicated, Resident 1 required moderate assistance of 1 person during sit to stand and transfers from chair/bed and to chair transfers and uses a front wheel walker as an assistive device. A record review of the Emergency Department visit at the Acute Hospital on 3/15/24 indicated, final result impression of the x-rays of Resident 1 ' s tibia and fibula (calf bone) indicated Non-displaced acute medial tibial plateau fracture with associated A record review of the Facility ' s undated Gait Belt Policy indicated .#3 cnas/nas are required to have always assigned gait belt in their possession . #4 gait belts should be used when transferring and ambulating residents if and indicated .

Based on observation, interview and record review, the facility failed to ensure kitchen staff received the competencies and training needed to perform their job duties when: 1. A Cook could describe the cool down process for cooked foods, and 2. A Diet Aide could not describe the correct temperatures of the three-compartment sink for manual dish washing These failures placed residents at risk of cross contamination and acquiring food-borne illnesses. Findings: 1. During an interview on 7/24/23 at 9:40 A.M. with Cook (CK 1) and the Director of Dietary (DD), CK 1 stated there was no cool down process for foods, but only for meats. CK 1 stated if they cooled meats to serve later, they would cool it for a couple of hours, label it, date it then place it in the refrigerator. CK 1 further stated it had been a while since he received training on the cool down process. The DD acknowledged CK 1 did not correctly verbalize the cool down process for cooked foods. According to the 2022 Federal FDA Food Code, section 3-501.14 titled Cooling, .Time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms the Food Code provision for cooling provides for cooling from 135 F to 41 F or 45 F in 6 hours, with cooling from 135 F to 70 F in 2 hours. The 6-hour cooling parameter, with an initial 2-hour rapid cool, allows for greater flexibility in meeting the Code. The initial 2-hour cool is a critical element of this cooling process . 2. During the kitchen observation on 7/24/23, at 4:20 P.M., Diet Aide (DA) 2 was interviewed. A Certified Nurse Assistant (CNA) 22 translated in Spanish the responses of DA 2 regarding the manual three compartment sink temperatures. DA 2 stated if the dishwasher was broken, a manual wash would be done at the three-compartment sink. DA 2 stated she would check the water temperature with the thermometer and the sink water temperatures should be 120 degrees Fahrenheit (F) in all three sinks. DA 2 was not able to verbalize the entire process for the 3 compartment sink manual dishwashing. DA 2 stated she was trained by another Diet Aide on the process. During an interview on 7/26/23, at 10:44 A.M. with the Registered Dietitian (RD), the RD stated she took over employee monitoring to improve on their tasks. The RD stated the dietary staff were informed of identified concerns in the kitchen for training but there was no in-service record pertaining to manual dishwashing or the cool down process. According to the 2022 Federal Food Code section 4-603.16, titled Rinsing Procedures, .(A) Use of a distinct, separate water rinse after washing and before sanitizing if using: A 3-compartment sink .A 3-step washing, rinsing, and sanitizing procedure in a warewashing system . According to the 2022 Federal Food Code section 4-501.19, titled Manual Warewashing Equipment, Wash Solution Temperature, The wash solution temperature required in the Code is essential for removing organic matter . According to the 2022 Federal Food Code section 4-501.111, titled Manual Warewashing Equipment, Hot Water 2Sanitization Temperatures, If the temperature during the hot water sanitizing step is less than 171 Fahrenheit (F), sanitization will not be achieved. As a result, pathogenic organisms may survive and be subsequently transferred from utensils to food. The facility's policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023 was reviewed. The P&P indicated supplies needed and five steps to complete a manual dishwashing procedure.

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: 1. A tray with fourteen small glasses of milk and four glasses of juice each dated 7/14/23, were on the shelf for use in the walk-in refrigerator. 2. The kitchen's clean dish storage area had dirty serving utensils and food items stored on them. 3. The ceiling vent was full of grayish-black dust. 4. The facility did not use a cool down process for ambient temperature prepared foods. 5. An ice cream freezer door gasket had dark brown and black stains and was not clean. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. During an initial kitchen tour on 7/24/23 at 8:50 A.M. conducted with the facility's Director of Dietary (DD) and Lead Cook (LCK), inside the walk-in refrigerator there was a tray with twelve small 4 ounce glasses of milk covered with plastic wrap on top and other beverages next to them. The milk and other beverages were dated 7/18/23. The DD acknowledged all the cups of milk and beverages were outdated and should have been discarded. The facility's policy and procedure (P&P) titled, Refrigerator and Freezer, dated 2023, the P&P indicated, .3. Check all foods at least weekly, being mindful of expiration and use by dates. 2. During the kitchen tour on 7/24/23 at 8:50 A.M., the clean area with containers filled with serving utensils was observed with a water bottle, Starbucks coffee cup and a cleaning spray on the counter. A serving scoop inside the clean container was observed to have a small brown debris. Diet Aide 2 (DA 2) stated both the water bottle and coffee belonged to her and should have been stored outside of the kitchen, not in the clean area. Another clean area at the bottom of the microwave counter were clean, small plastic glasses inside a container. A dirty tray was observed on top of the container. DA 2 confirmed that the tray was dirty. During an interview on 7/24/23, at 8:50 A.M. with the DD, the DD stated it was everyone's responsibility to check the clean area. Beside the microwave a beverage/juice machine dispenser was observed. The DD stated the aides cleaned the nozzles of the dispenser daily. The DD further stated there was no cleaning log for the nozzles. According to the FDA Food Code, 1022 4-601.11, .it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas . 3. During the initial kitchen tour on 7/24/23, at 10:16 A.M. with the RD and the DD, the ceiling vent above the steam table was observed with full of grayish-black dust. The RD and the DD stated the ceiling vent should be clean. The Director of Maintenance (DM) was interviewed on 7/26/23, at 3:41 P.M. The DM stated there was no maintenance repair request or binder for the kitchen maintenance issues and there was no facility policy maintenance service. The DM further stated the ceiling vent should have been cleaned. According to the Federal FDA Food Code 2022, section 6-501.12, titled Cleaning, Frequency and Restrictions, .(A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . During a review of the facility's P&P titled, Hoods, Filters, and Vents dated 2023, the P&P indicated, Vents must be free of dust and dirt . 4. During an interview on 7/24/23 at 9:20 A.M. with Cook 1 (CK 1) regarding the cool down process of food, CK 1 stated meats were the only foods needing cool down for a couple of hours, then date and label it. A follow up interview and concurrent record review was conducted with the LCK. The LCK stated they did not need to conduct any cool down process because food was served right out of the oven. The LCK presented a cool down log dated 2022. The LCK was not able to provide cool down process for the tuna salad in the walk-in refrigerator. During an interview on 7/24/23, at 4:03 P.M. with Cook 2 (CK 2) about cool down of ambient temperature foods, CK 2 stated he did not write the temps on a log when preparing tuna salad. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, the P&P indicated, .Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. 5. During a concurrent observation and interview were conducted on 7/24/23 at 12:00 P.M. with the DD, a freezer outside the kitchen was observed during the kitchen tour. The freezer was against a short brick wall under the sun. Inside the freezer were cups of ice cream which were not frozen. In addition, the ice cream freezer door gasket was observed with dark brown and black stains and was not clean. According to the DD, the freezer was kept outside because there was not enough voltage inside the kitchen. During a dining room observation on 7/24/23, at 1:00 P.M., one resident was observed with a sherbet ice cream on the tray which was almost melted. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .7. The goal is to serve cold food cold . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams .

Based on observations, interviews, and record reviews the facility failed to ensure effective dietetic systems related to food and nutrition services were executed according to facility policy and standards of practice when: 1. A resident's (Resident 6), nutrition care plan was not carried out, and experienced unintentional weight loss. 2. Kitchen staff were not trained in day-to-day food safety and sanitation practices. 3. Residents' meals were not served at palatable temperatures according to policy. 4. Expired foods, dirty dishes, and dirty equipment were found in the kitchen. 5. Kitchen equipment was not maintained for proper operation. These deficient practices led to a resident to experience unintentional weight loss, and exposed 81 residents to unsafe and unsanitary food practices, which may have further compromised their nutrition status. Cross reference F656, F692, F802, F804, F812, and F908 Findings: According to the Federal FDA Food Code section ,d+[DATE].11, titled Person in Charge (PIC), .The PERSON IN CHARGE shall ensure that .(H) EMPLOYEES are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within 4 hours, through daily oversight of the employees routine monitoring of FOOD temperatures during cooling; .the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment . 1. During a record review of Resident 6's care plan, dated [DATE] indicated, snacks, and an intervention dated [DATE] indicated, RD to meet with resident weekly+to update food preferences, offer alternatives, encourage greater intakes. The care plan further indicated an intervention dated [DATE], RD will check with resident 1x daily . During a record review of Resident 6's weight history on [DATE], the weight record in the electronic medical record indicated: 202 lb on [DATE], 200.6 lb on [DATE], 188.5 lb on [DATE], 175 lb on [DATE], and 172.4 lb on [DATE]. A record review on [DATE], at 11:26 A.M. of the facility's Nutrition Assessment, signed [DATE], indicated, Despite poor po intakes resident accepts boost plus at times, will recommend adding this routinely bid to lunch and dinner meals. In addition, Resident 6's physician's order dated [DATE] indicated, Boost plus with meals BID, and on [DATE] the physician's order indicated, Boost bid with meals. During a concurrent interview and record review on [DATE], at 9:31A.M., with the Registered Dietitian (RD), the RD stated she did not specify which meal Resident 6 was to receive the boost and was unsure which meal tray it was sent to. The RD further acknowledged there was no record of the amount of boost Resident 6 consumed daily. The RD stated it was important to know how much boost was consumed to competently calculate calories for the resident. During an interview and concurrent record review on [DATE], at 10:44 A.M., with the Registered Dietitian (RD), the RD stated she checked in with the resident but there was no documentation regarding Resident 6's intake of snacks or the supplement. The RD further stated there was no RD coverage on the weekends and therefore Resident 6 will not be checked daily according to the care plan. The RD acknowledged she could not verify whether the nutrition care plan interventions for Resident 6 were consistently implemented, but they should have been carried out as documented. The RD further stated Resident's 6 weight loss was unintentional. 2. During the kitchen observation and interview on [DATE] at 4:20 P.M. with a Diet Aide (DA) 2, a Certified Nurse Assistant (CNA) 22 translated in Spanish the responses of DA 2 about the manual three compartment sink. DA 2 stated if the dishwasher was broken, a manual wash would be done at the three-compartment sink. DA 2 stated she would check the water temperature with the thermometer and the sink water temperatures should be 120 degrees Fahrenheit (F) in all three sinks. DA 2 was not able to verbalize the entire process for the 3 compartment sink manual dishwashing. DA 2 stated she was trained by another Diet Aide on the process. During an interview on [DATE], at 10:44 A.M. with the Registered Dietitian (RD), the RD stated she took over employee monitoring to improve their tasks. The RD stated the dietary staff were informed of and trained on identified concerns in the kitchen but there was no in-service record pertaining to manual dishwashing or the cool down process. The facility's policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023 was reviewed. The P&P indicated supplies needed and five steps to complete a manual dishwashing procedure. 3. During a breakfast meal test tray process on [DATE] at 7:40 A.M., the DD and the Consultant Dietary Manager (CDM) took temperatures and tasted a regular diet meal tray and pureed diet meal tray for acceptable temperature and palatability. The test tray for regular and pureed meals included a Spanish egg omelet with salsa on top, a carton of milk, cranberry juice and wheat toast. The temperature for the eggs in the regular tray was 142 F. The puree eggs temperature was 119 F. The DD acknowledged the regular omelent eggs temperature and puree omelet temperature, then stated they could be warmer. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .3. The food will be served on trayline at the recommended temperature .Meat 160 F-170 F .Scrambled eggs 150 F-170 . 4. During a concurrent observation and interview of kitchen conducted on [DATE] at 12:00 P.M. with the DD, an outside freezer was observed with cases of ice cream cups. The freezer was against a short brick wall under the sun. The ice cream cups were not frozen and soft. The freezer door inner gasket was observed with dark brown and black stains and was not clean. According to the DD, the freezer was kept outside because there was not enough voltage inside the kitchen. During a dining room lunch observation on [DATE], at 1:00 P.M., one resident was observed with a sherbet ice cream on the tray which was almost 100 percent melted. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, .7. The goal is to serve cold food cold . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams . 5. During the initial kitchen tour on [DATE] at 10:16 A.M. with the Registered Dietitian (RD) and the Dietary of Dietary (DD), a cord connected to the tray line steam table was observed hanging out of the socket. The RD and the DD stated the cord should not be exposed because it may cause damage and it was a safety risk. There was a large air vent with black and gray dirt and lint contaminants observed blowing air directly above a clean dish drying rack. The RD and DD further acknowledged the dirty vent above the clean dish rack and stated it should be clean. During an interview with the Facility Administrator (ADMIN) on [DATE] at 2:54 P.M regarding kitchen operations, the ADMIN stated it was her expectation that the DD train and educate the kitchen staff on correct kitchen operations, updated the staff with current changes in duties, and took input from the RD and the residents when needed to improve the department operations. According to the 2022 Federal FDA Food Code, section ,d+[DATE].11, titled Good Repair and Proper Adjustment, Proper maintenance of equipment .helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures .

Based on observations, interviews and record reviews, the facility failed to ensure the nutrition care plan was implemented for one of 18 residents reviewed for care plans. (Resident 6) This failure resulted in Resident 6 not receiving foods listed in the care plan, which may have led to the resident's continued gradual weight loss. Cross reference F692, F800 Findings: Resident 6 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Oropharyngeal Phase (swallowing problem occurring in the mouth and/or throat) according to the Admission Record. A review of Resident 6's Minimum Data Set (MDS-tool that measures health status), dated 6/10/23 indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. During a dining room observation on 7/24/23 at 1:00 P.M., Resident 6 was having lunch. Resident 6 was observed eating the soup and stated he did not want the rest of the meal. Resident 6 requested a strawberry yogurt from staff. An interview was conducted on 7/25/23, at 10:31 A.M., with Certified Nurse Assistant (CNA) 22. CNA 22 stated she had not seen any snacks provided to residents. During an interview on 7/25/23, at 10:46 A.M., with Resident 6, Resident 6 stated he had lost 30 lb (pounds) since he had been ill and lost 10 lb in the facility. Resident 6 stated snacks have not been offered and food preferences have not been updated. Resident 6 further stated no menu or alternates have been provided to him. There was no menu or snack list observed in Resident 6's room. A review of Resident 6's care plan, dated 6/28/23 indicated, snacks and an intervention dated 7/19/23 indicated, RD to meet with resident weekly+to update food preferences, offer alternatives, encourage greater intakes. The care plan further indicated an intervention dated 7/25/23, RD will check with resident 1x daily . During an interview and concurrent record review on 7/26/23, at 10:44 A.M., with the Registered Dietitian (RD), the RD stated she checked in with the resident but there was no documentation regarding Resident 6's intake of snacks or the supplement. The RD further stated there was no RD coverage on the weekends and therefore Resident 6 will not be checked daily according to the care plan. The RD acknowledged she could not verify whether the nutrition care plan interventions for Resident 6 were consistently implemented, but they should have been carried out as documented. During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2023, the P&P indicated, .A care plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal .The facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions .

Based on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment tool) was accurately coded for one of 18 residents (Resident 59) reviewed for accurate MDS. This failure had the potential for Resident 59 to receive inappropriate care due to inaccurate diagnosis. Findings: A review of Resident 59's Admission Record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses to include Benign Prostatic Hypertrophy (BPH, also called enlarged prostate). During a reconciliation of Resident 59' medication administration record and Resident 59's physician order on 7/26/23 at 9:53 A.M., Resident 59 was diagnosed with BPH. Resident 59's hospital records prior to admission to the facility did not indicate diagnosis of BPH. During a concurrent interview and record review on 7/26/23 at 10:50 A.M., with the minimum data set nurse (MDSN), the MDSN reviewed Resident 59's MDS dated [DATE] section I-1400. The MDSN stated Resident 59 was coded incorrectly with a diagnosis of BPH. The MDSN stated I'm not sure why she has BPH, she is a female. We should re-assure that the diagnosis is really there but this one was really an error. We will modify MDS due to coding error. I will modify today. During an interview on 7/27/23 at 2:20 P.M., with the Director of Nursing (DON), the DON stated the MDSN should have coded Resident 59 with correct diagnosis because she did not have a prostate. A record review of the facility's undated policy titled Resident Assessment, Accuracy of Assessments, indicated, It is the policy of this facility to ensure that the assessment accurately reflect the resident's status .

Based on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when: 1. A Certified Nursing Assistant (CNA 3) did not disinfect the vital signs machine between each resident use. 2. The Business Office Manager (BOM) did not perform hand hygiene when delivering meal trays to the residents. This failure had the potential to spread infections between residents. Findings: 1. On 7/25/23 at 2:58 P.M.,an observation was conducted with CNA 3. CNA 3 went to residents' room and took the vital signs of the two residents. CNA 3 then exited the first room and went to another resident's room without sanitizing the vital sign machine. On 7/25/23 at 3:01 P.M., an interview was conducted with CNA 3. CNA 3 stated she had nine residents and had already took their vital signs. CNA 3 stated the process was the vital sign machine should be sanitized between each resident use. CNA 3 stated she did not wipe the vital sign machine after taking each resident's vital signs. CNA 3 stated she should have sanitized after each use to prevent infection and transmission of disease. On 7/27/23 at 9:37 A.M., an interview was conducted with the Infection Preventionist. The IP stated the expectation was for the staff to sanitize the critical items like the vital sign machine to prevent transmission of infection. On 7/27/23 at 2:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was the staff should have sanitized the vital sign machine in between resident use to prevent transmission of infection. A review of the facility's undated Infection Control policy, indicated, It is the policy of this facility to provide supplies and equipment that are adequately cleaned and disinfected .1. Supplies and equipment will be cleaned immediately after use . 46982 Findings: 2. A Meal Tray delivery was observed on 7/24/23 at 12:40 PM. The Business Office Manger (BOM) was seen delivering a meal tray to a room, returning to the cart, retrieving another tray, and delivering to the other resident in the room. Hand Hygiene (HH- the process of rubbing the hands with Alcohol Based Sanitizing Liquid until dry) was not observed. The BOM returned to the cart, retrieved another tray, and delivered to another resident room. The BOM then performed HH. The BOM retrieved a meal tray from the cart and handed the tray to staff wearing gown, gloves, N95 mask, and face shield, in the doorway of a room. No HH was performed. The BOM then returned to the cart, retrieved a meal tray and handed the meal tray to staff, similarly garbed, in the doorway of another room. No HH was performed. The BOM returned to the cart, retrieved and handed a meal tray to staff in the doorway of the same room. No HH was performed. The BOM returned to the meal cart, retrieved a tray, and handed it to the staff in the doorway of the same room. No HH was performed. The BOM selected another tray from the cart and handed it to staff in the doorway of the room. No HH was performed. The BOM selected another meal tray from the cart and handed it to staff in the doorway of the room. The BOM then performed HH and left the area. On 7/24/23 at 12:49 P.M., The DSD was interviewed. The DSD stated the importance of hand hygiene between delivery of meals to residents was to minimize the risk of infection from one resident, or from high touch surfaces to another resident. The DSD stated the residents are at high risk for infection due to their physical conditions, and staff need to perform adequate infection control practices. The DSD agreed that HH should have been done between meal tray delivery by the BOM.

Based on Interview and Record Review, the facility failed to accurately record medications given for one of one resident reviewed for IV medication administration. This failure had the potential for harm, leading to missed or additional medication being given. Findings: The Admission Summary for Resident 217 indicated that the Resident was admitted on [DATE], with health problems that included: urinary tract infection (UTI). The Physician admitting orders included: Zosyn (an antibiotic) 3.375 grams , via IV (given through a soft flexible tube inserted in a vein), four times a day for nephrolithiasis (kidney stones) with UTI until 7/29/23. The physician order included administration times of 1 A.M., 7 A.M., 1 P.M. and 7 P.M. On 7/26/23, at 11:19 A.M. a concurrent record review and interview was held with the Director of Staff Development (DSD), the Director of Nursing (DON) and the Infection Preventionist Nurse (IP). The e-MAR (the electronic health record for Medication Administration Record) was reviewed, and out of 42 opportunities for Zosyn administration, (the RN administering the medication signs that it was given) there were 10 missed opportunities when the RN did not record the administration of the IV antibiotic. The IP and DON stated that inaccurate documentation could lead to inadequate or overdosing of a medication, harming the patient. The DON stated that education will be completed with all RN staff administering IV medications, and that the problem has been added to QAPI.

Based on observation, interview and record review, the facility failed to ensure adequate nutrition was provided for one of two sampled residents with severe weight loss in less than one month. (Resident 6) This failure had the potential to result in Resident 6's further unintentional and unplanned weight loss. Cross reference F656, F800 Findings: 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, . 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 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 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) . Resident 6 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Oropharyngeal Phase (swallowing problem occurring in the mouth and/or throat) according to the Admission Record. A review of Resident 6's Minimum Data Set (MDS-tool that measures health status), dated 6/10/23 indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. During an interview on 7/25/23, at 10:46 A.M., with Resident 6, Resident 6 stated he had lost 30 lb (pounds) since he had been ill and lost 10 lb in the facility. Resident 6 stated snacks have not been offered and food preferences have not been updated. Resident 6 was observed with boost (a nutritional supplement) at the bedside. Resident 6 stated he received Boost every three days and will request for boost daily from staff. During a review of Resident 6's weight history on 7/26/23, the weight record in the electronic medical record indicated: 202 lb on 6/28/23 200.6 lb on 7/1/23 188.5 lb on 7/8/23 175 lb on 7/15/23 172.4 lb on 7/23/23 During a record review on 7/25/23 of the facility's Nutrition Assessment signed by the RD on 7/6/23, the assessment indicated Despite poor po intakes resident accepts boost plus at times, will recommend adding this routinely bid to lunch and dinner meals. In addition, Resident 6's physician's order dated 7/7/23 indicated, Boost plus with meals BID, and on 7/14/23 the physician's order indicated, Boost bid with meals. During a concurrent interview and record review on 7/26/23, at 9:31A.M., with the Registered Dietitian (RD), the RD stated she did not specify which meal Resident 6 was to receive the boost and was unsure which meal tray it was sent to. The RD further acknowledged there was no record of the amount of boost Resident 6 consumed daily. The RD stated it was important to know how much boost was consumed to competently calculate calories for the resident. The RD further stated Resident's 6 weight loss was unintentional. During an interview of the facility's Medical Director (MD) on 7/27/23 at 11:08 A.M., the MD stated all efforts to improve nutrition should be documented. The MD further stated if interventions were carried out as written as an order and care plan, interventions should make a positive difference in a resident's weight status. During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2023, the P&P indicated, .The facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions .Calculate energy, protein, and fluid needs using perimeters as in the initial assessment.