Every finding on record at Hayward Gardens Post Acute

Based on interview and record review, the facility did not ensure that Resident 79's binding arbitration agreement was explained to and signed by Resident 79's designated representative.This deficient practice has the potential to result in residents and/or resident representatives not being aware and/or fully understanding the implications of arbitration agreements.Finding:During a record review of Resident 79's admission Record (AR), the AR indicated, Resident 79's diagnoses included a history of transient ischemic attack (TIA, a brief interruption of blood flow to the brain causing temporary stroke like symptoms and is considered a warning sign for possible future stroke), heart failure and weakness. During a record review of Resident 79's admission Record (AR), the AR indicated that Resident 79's healthcare decision maker was his daughter.During a record review of Resident 79's Arbitration Agreement, on 05/05/2026 at 4:33 PM, the signatory on the document indicated Resident 79's signature and not Resident 79's daughter.During an interview on 05/05/2026, at 3:50 PM, with Resident 79's daughter (healthcare decision maker), Resident 79's daughter stated that Resident 79's arbitration agreement was not discussed with her.During an interview on 05/07/2026 at 09:35 AM, with the admission Coordinator (AC) 1, AC 1 explained how she determines whether a resident or representative understands the arbitration agreement. AC 1 stated that if the resident or representative does not understand arbitration, she provides an explanation. AC 1 stated that some individuals sign and others decline.During record review on 05/05/2026, the facility's policy and procedure (P&P), titled, Binding Arbitration Agreements, revision dated, November 2023, the P&P indicated, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Policy Interpretation and Implementation. 5. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. 6. The terms and conditions of a binding arbitration are explained to the resident (or representative) in a form and manner that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning. 7. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. a. A signature alone is not sufficient acknowledgment of the understanding. b. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgment documented by the staff member who explains the agreement.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program when:Certified Nursing Assistant (CNA) 4 handled contaminated linen from Resident 33, who is on contact precautions for MRSA, without wearing the required PPE. The contaminated linen was not bagged prior to being placed in the laundry hamper.CNA 1 handled Resident 29's soiled linens and garbage disposal bag without gloves worn and did not perform hand hygiene. Two lighters were found stored in an opened full box of Tegaderm dressings in the medication storage room (Tegaderm is a thin, see through plastic dressing used to cover wounds, scrapes and surgical incisions. It acts as a protective, germ-proof barrier that keeps dirt out of the skin).License Vocational Nurse (LVN) 1 did not perform hand hygiene before preparing and giving medications to Resident 37.These failures placed the residents at increased risk of healthcare-associated infections. 1.During an observation on 5/4/26, at 9:49 a.m., Certified Nursing Assistant (CNA 4) came out of Resident 33's room. CNA 4 had slightly yellow-stained towels and bed sheets in her bare hands, while contaminated linen touched CNA 4's arm and the sleeve of her uniform. While standing outside of Resident 33's room, CNA 4 waited for another staff to push the barrel (laundry hamper) towards her and dropped the contaminated linen directly into the hamper, without bagging them. During an interview on 5/4/26, at 9:57 a.m., CNA 4 stated that she needed to wear PPE (Personal Protective Equipment, gear worn to lessen exposure from germs or infection) when handling dirty laundry, and not doing so increased the risk of spreading germs and infection to other residents. During a review of Resident 33's physician order, dated 4/24/26, under Order Summary indicated, Resident 33 was on contact precautions (safety measure to wear gloves and gown when in contact with an infected resident, surfaces or equipment) related to MRSA (methicillin-resistant staphylococcus aureus, bacteria that does not respond to antibiotics). During an interview om 5/4/26, at 2:44 p.m., laundry personnel (LP) stated contaminated laundry for Resident 33 should be bagged into a red/yellow plastic bag before placing it directly inside the barrel for laundry personnel to be able to tell to handle those contaminated linens with more caution. During an interview on 5/6/26, at 9:23 a.m., Director of Nursing (DON) stated that full gown, gloves, mask are needed to be worn when caring and handling contaminated linen of a resident on contact precautions because of risk of spreading infection causing fever, abnormal laboratory blood results, and change in level of consciousness (a person is less awake, aware or responsive than normal). During a review of the facility's Policy and Procedure (P&P) titled, Isolation – Categories of Transmission-Based Precautions, dated September 2022, the P&P indicated, Contact Precautions . Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. During a review of the facility's P&P titled, Laundry and bedding, soiled, reviewed January 2026, the P&P indicated, contaminated laundry is bagged or contained at the point of collection. 2. During an observation on 05/04/26, at 9:45 AM, Resident 29's door had an Enhanced Barrier Precaution (EBP) sign posted, which required staff to don appropriate personal protective equipment (PPE) and perform hand hygiene upon entry and exit. CNA 1 entered Resident 29's room without disposable gloves worn. CNA 1 removed Resident 29's soiled linens and discarded the garbage disposal bag in the disposable bin. CNA 1 then exited Resident 29's room and proceeded to the clean linen room and retrieved clean linens. CNA 1 did not perform hand hygiene. CNA 1 returned to Resident 29's room and replaced the Resident 29's bed linens. During an interview on 05/04/26 at 10:25 AM with CNA 1, when asked whether staff must perform hand hygiene when entering and exiting resident rooms, including rooms with EBP signs posted on the door, CNA 1 acknowledged they are required to do hand hygiene and stated, I am sorry ma'am, I did not do hand hygiene. During record review of the facility's policy and procedure (P&P), titled, Handwashing/Hand Hygiene, revision dated October 2024, the P&P indicated, that hand hygiene is required. Immediately before touching a resident. Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device). After contact with blood, body fluids, or contaminated surfaces. After touching a resident. After touching the resident's environment . Before moving from work on a soiled body site to a clean body site on the same resident. Immediately after glove removal. The P&P further indicated that single use disposable gloves must be worn.Before performing aseptic procedures . When anticipating contact with blood or body fluids. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 3. During the medication storage room observation on 5/4/26, at 2:00 p.m., with the Infection Preventionist (IP), two lighters were found stored in an opened full box of Tegaderm dressings in the medication storage room. The IP stated that the lighters should not be stored with Tegaderm dressings, as the dressings were used for resident wounds. IP further stated the risks involved were contamination (making something dirty due to addition of germs) and the spread of infection. During an interview on 5/6/26, at 10:25 a.m., with Director of Nursing (DON), The DON stated that lighters and Tegaderm should not be stored together because Tegaderm was used for wound care and keeping them together posed a risk of infection. Review of the facility's policy and procedure (P&P) titled, Monitoring Compliance with Infection Control, revised August 2019, the P&P indicated, Policy statement: Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices. 4. During the medication pass observation on 5/5/26, at 8:14 a.m., Licensed Vocational Nurse (LVN) 1 did not sanitize his hands before preparing Resident 37's medications. Immediately following preparation, LVN 1 gave the medication to Resident 37 without sanitizing his hands in between. During an interview on 5/5/26, at 8:35 a.m., with LVN 1, LVN 1 stated he should have sanitized his hands before preparing and giving medications to Resident 37 and stated the risk of not performing proper hand hygiene was spread of infection. During an interview on 5/6/26, at 10:25 a.m., with the DON, the DON stated that medication nurses must perform hand hygiene both before handling and administering medications. The DON noted that improper hand hygiene posed a risk for the spread of infection. During an interview on 5/7/26, at 9:38 a.m., with the IP, the IP stated that medication nurses should perform hand hygiene before handling medications and before giving medications and stated the risk of not doing proper hand hygiene was spread of infection. Review of the facility's policy and procedure (P&P) titled, Handwashing/ Hand Hygiene, revised October 2024, the P&P indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1. All personnel are trained and regularly in-serviced (employee education or training) on the importance of hand hygiene in preventing the transmission of healthcare associated infections 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interview, and record review, the facility failed to ensure staff protected dignity and maintained personal privacy for one of one resident (Resident 29) during preparation and transport for a scheduled shower. This failure resulted in Resident 29 being exposed and insufficiently covered while being moved through the hallway, creating risk for embarrassment, loss of dignity, and violation of personal privacy.Findings:During a record review of Resident 29's admission Record (AR)printed on 5/07/26, the AR indicated, Resident 29 was admitted to the facility on [DATE]. The AR indicated Resident 29 was a [AGE] year-old female with diagnosis of limitations of activities due to cerebral aneurysm (also called a brain aneurysm, is a weak, bulging area in the wall of a blood vessel in the brain. If the blood vessel ruptures, it can leak blood into the area around the brain. This type of bleeding is life-threatening and requires emergency medical treatment), cognitive communication deficit (trouble with the thinking parts of communication) and weakness.During a record review of Resident 29's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 4/22/26, the MDS indicated, Resident 29's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was four (4) out of fifteen (15), indicating cognitive (mental) impairment.During an observation on 05/04/26 at 9:45 AM, Certified Nursing Assistant (CNA) 1 was preparing Resident 29 in Room A for a scheduled shower. Resident 29 was observed seated on a white plastic shower chair with her backside uncovered and fully exposed. Resident 29 was covered with small hand towels: one was draped across the upper chest , one over the abdomen, and one from the hips to mid-thigh. During and observation on 05/04/26 at 09:50 AM, CNA 1 wheeled Resident 29 from Room A to the shower room while the Resident 29's upper back, buttocks and lower back were exposed. During an interview on 05/04/26 at 10:25 AM, CNA 1 was informed that the Resident 29 was observed with her backside exposed and covered only with hand towels. CNA 1 responded, yes ma'am, I know I'm sorry. CNA 1 acknowledged that he should have provided fuller coverage for the resident and that transporting the resident in the condition observed was not in accordance with facility expectations.During a record review of the facility's written policy and procedure (P&P) titled Dignity, revised 1/2026, the P&P indicated, staff to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment process.

Based on observation, interview and record review, the facility failed to provide respiratory care to one of 20 sampled residents when Resident 38's order for incentive spirometer (a handheld, plastic device used after surgery or illness to help exercise the lungs, encourage deep breathing, and prevent lung complications like pneumonia or lung infection) was not followed.This failure had the potential to result in Resident 38 experiencing respiratory distress and a decline in health status.During a review of Resident 38's admission record indicated the resident was admitted on [DATE] with diagnoses that included bronchiectasis and respiratory failure [bronchiectasis is a long-term lung condition where the airways (the tubes that move air in and out of your lungs) become permanently widened, scarred, and inflamed; respiratory failure is a life-threatening condition where the lungs cannot get enough oxygen into the blood or cannot remove enough carbon dioxide (waste gas) from the body].During a review of Physician's Orders, dated 5/7/26, the Physician Orders indicated an active order of Incentive spirometer at least 10 times every hour while awake, with a start date of 4/17/26.During a concurrent observation and interview with Registered Nurse (RN) 1 on 5/7/26, at 8:45 a.m., in Resident 38's room, there was no IS found at the resident's bedside table and drawers. The RN acknowledged failing to offer the IS to the resident during her shift on 5/6/26. RN 1 stated that the purpose of the IS was to strengthen the resident's lungs.During a concurrent interview and record review on 5/7/26, at 10:04 a.m., with Registered Nurse Supervisor (RN-S), Resident 38's physician orders, dated 5/7/26, and Medication Administration Record (MAR), dated May 2026 were reviewed. The MAR did not indicate the nurses were offering the IS to Resident 38. RN-S stated nurses should follow the physician orders to provide and to offer the resident an IS and stated the IS was intended to expand Resident 38's lungs and to prevent further respiratory issues.During a review of the facility's policy and procedure (P&P) titled, Respiratory Care Services, revised January 2026, indicated, .Incentive spirometer: Residents shall use an incentive spirometer only when clinically appropriate and ordered by the physician/provider or recommended as part of the resident's respiratory or post-surgical plan of care. Staff shall educate, cue and monitor residents for correct use and tolerance. Procedure: Staff shall: 1. Verify the order, including frequency, duration.8. Document use, tolerance, resident response, education, refusals, and any concerns.

Based on interview and record review, the facility failed to ensure foley catheter (a thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) care, monitoring and assessment were documented within the electronic health record (EHR) for one of seven sampled residents (Resident 72). This failure caused a lack of information to facilitate communication among the interdisciplinary team (IDT-a collaborative group of healthcare professionals from diverse specialties who work together to manage complex resident care) and to provide resident-centered care for Resident 72. During record review of admission record, printed on 5/7/26, Resident 72 was admitted on [DATE].During record review of Resident 72's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/23/26, indicated Resident 72's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 15 out of 15, and indicated Resident 72's cognition was intact. MDS Functional Abilities section indicated Resident 72 was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) in toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). MDS Bowel and Bladder section indicated Resident 72 had a foley catheter. During record review of Resident 72's Order Summary Report indicated, check and empty drainage bag every shift and as needed.During a review of Resident 72's Bladder Care Plan, initiated 4/21/26, indicated external catheter: provide catheter care and empty catheter every shift and as needed .record output of foley catheter.During a review of Resident 72's Medication Administration Record (MAR), initiated 5/6/26, the MAR indicated, check and empty drainage bag every shift and as needed.monitor fluid output every shift.check and empty drainage bag every shift and as needed when half full. During an interview on 05/06/2026, at 2:14 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated Resident 72 could not get out of bed and preferred bed baths. CNA 4 stated Resident 72 was incontinent to stool with foley catheter and wore a brief. CNA 4 stated they completed catheter care daily in the morning and afternoon. CNA 4 stated they documented catheter output in the EHR as Resident 72 typically had a large output. CNA 4 stated it was important to document catheter care and urine output because it was done.During a concurrent interview and record review on 5/7/26, at 9:46 a.m., with Director of Staff Development (DSD), the intake-output MAR and bladder incontinence task record were reviewed. The intake-output MAR indicated no foley output for April or May, and the bladder incontinence task record indicated a total of 1600ml of urine output since admission. DSD stated there was no documentation of foley catheter care since admission. DSD also stated foley catheter care and urine output should be documented in EHR daily by CNA and/or Registered Nurse (RN).During a concurrent interview and record review on 05/07/2026, at 10:12 a.m., with the Registered Nurse Supervisor (RN-S), the intake-output MAR and bladder incontinence task record were reviewed. The RN-S stated accurate documentation of foley care and urine output was very important because that was how the foley catheter was monitored and how the staff were able to report to physician any changes or abnormalities. RN-S stated there was no foley care documentation for April or May and insufficient foley output documentation for April and May 2026.During a review of the facility's policy and procedure (P&P) titled, Catheter care, Urinary, dated August 2022, the P&P indicated, nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use.the following information should be recorded in the residents medical record, the date and time catheter care was given, the name and title of the individual giving catheter care, all assessment data obtained when giving catheter care, character of urine such as color and odor, any problems noted at catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain, any problems or complaints made by the resident related to the procedure, how the resident tolerated the procedure.During a review of the facility's P&P titled, Charting and Documentation, undated, the P&P indicated, all observations, medication administered, services performed, etc., must be documented in the residents clinical record.

Based on observation, interview and record review, the facility failed to ensure a qualified and competent director of nursing had oversight of the facility when Assistant Director of Nursing (ADON), who did not have a Registered Nursing license, assumed the director of nursing duties and during the survey, assigned Registered Nurse Supervisor/Director of Nursing (RNS)/[DON], who was not trained nor competent in the role, as director of nursing. The facility was previously cited for assigning ADON as the director of nursing and did not follow their plan of correction which was submitted to the state agency on 12/12/2024.This failure resulted unqualified nursing leadership for 15 months which resulted in nursing staff failing to follow provide adequate mental health services to Resident 1 after Resident 1's suicide attempt (see F tag 742).During a record review of facility statement of deficiencies document titled, Department of Health and Human Services Centers for Medicare and Medicaid Services Statement of Deficiencies and Plan of Corrections, dated 12/12/2024, the document indicated ADON was assigned the facility Director of Nursing for seven months. The document indicated the facility would hire a registered nurse for the Director of Nursing position.During a record review of facility roster titled, [Facility] Employee Roster Report, dated 11/20/24, the roster indicated ADON was listed as the Director of Nursing and RNS/[DON] was listed RN (AM Supervisor).During record review of state registered nursing board records, on 8/4/25, the records did not indicate ADON had a Registered Nurse license.During a concurrent observation and interview on 8/6/25, at 9:21 a.m. with Operations Assistant (OA), OA greeted surveyors at the facility entrance and introduced ADON as the Director of Nursing, OA went to summon ADON for the entrance conference and then corrected themselves and stated ADON was not the Director of Nursing.During a concurrent observation, interview and record review on 8/6/25, at 11:30 a.m. with RNS[DON], Resident 1's nursing progress note titled, [Facility] Progress Notes *NEW*, dated 5/3/25, was reviewed. RNS[DON] stated they entered a progress note indicating they found Resident 1 with wiring around their neck attempting to strangle himself. The progress note indicated it was signed RNS[DON] - RN Supervisor [e-SIGNED]. When RNS[DON] was asked if they had notified the Director of Nursing about the incident, RNS[DON] replied not because RNS[DON] had been the Director of Nursing for the past two years. RNS/[DON] was wearing a badge indicating they were the RN supervisor and did not wear anything else that identified them as the Director of Nursing. RNS/[DON] stated they had assigned ADON all the DON duties because RNS/[DON] typically spent their time at the front nurses station.During an interview on 8/6/25, at 12:12 p.m. with pharmacist consultant (PC), PC stated they had been the pharmacist consultant with the facility for two years and stated RNS/[DON] was not the Director of Nursing.During an interview on 8/6/25, at 12:25 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated ADON was the Director of Nursing.During an interview on 8/6/25, at 12:51 p.m. with occupational therapist assistant (OTA), OTA stated ADON was the facility Director of Nursing.During an interview on 8/6/25, at 12:56 p.m. with admission manager (AM), AM stated ADON and Director of Staff Development reviewed potential residents to determine if they were appropriate for the facility. AM did not specifically state ADON was the Director of Nursing. AM stated they would text the Director of Nursing if AM had questions about the medical appropriateness of potential residents. Once a resident has been approved for admission, their information is populated in the electronic medical record (EMR). AM stated RNS/[DON] was a Nurse Supervisor and would be able to see the EMR information after a resident was accepted.During a record review of facility staff sign in sheet titled, Nursing Staffing Assignment and Sign-in Sheet, dated 1/17/25, 3/28/25, 5/3/25 and 7/4/25 and facility staff ratio sheet [Facility] Estimated Daily DHPPD, dated 1/17/25, 3/28/25, 5/3/25 and 7/4/25, the staff sign-in sheet indicated RNS/[DON] had signed as the Nursing Supervisor for all four dates. The sign-in sheets dated 1/17/25, 5/3/25 and 7/4/25 indicated ADON was listed as the Director of Nursing. The sign in sheet, dated 3/28/25, indicated ADON and RNS/[DON] were the Director of Nursing with RNS/[DON]'s name was handwritten on the sheet compared to typed names for other staff. The facility staff ratio sheets dated 1/17/25 and 3/28/25, indicated there was both a Supervisor nurse (RN) and DON working on those dates. The facility staff ratio sheets dated 5/3/25 and 7/4/25, indicated a Supervisor nurse (RN) working, but no DON was working on those dates.During a concurrent interview and record review on 8/6/25, at 2:11 p.m. with OA, RNS/[DON]'s human resources (HR) file titled View Worker [RNS/[DON]], dated 8/6/25, was reviewed. OA stated this was the current HR file for RNS/[DON] The HR file indicated ADON was the manager of RNS/[DON] and did not indicate RNS/[DON] was the facility Director of Nursing. The file indicated a management structure listing ADON as the facility's Director of Nursing throughout the file.During an observation on 8/6/25, at 2:13 p.m., RNS/[DON] was in the Director of Nursing's office, during a general review of Resident 1's medical record, RNS/[DON] did not know how to view or print copies of Resident 1's past progress notes and care plans. RNS/[DON] needed to ask for assistance to find the information.During an interview on 8/6/25, at 2:49 p.m., with RNS/[DON], an inquiry was made into RNS/[DON]'s function as the Director of Nursing. RNS/[DON] was unable to answer questions about the facility process of creating a quality assurance performance improvement (QAPI) plan and did not know of any current QAPI projects. RNS/[DON] was unable to describe what a QAPI plan was. RNS/[DON] was unable to describe AM's process for screening resident's appropriateness for the facility, and stated they only learned about resident after their records appear on the electronic medical record.During a phone interview on 8/6/26, at 7:44 p.m. ADON was on the phone with RNS/[DON] coaching RNS/[DON] to remain calm. ADON stated RNS/[DON] recalled having an interdisciplinary team (IDT) meeting regarding Resident 1's suicide attempt but did not write down or recall the exact date and did not recall details about the meeting. RNS/[DON] stated the IDT meeting might have been on 5/5/25 or 5/6/25 with Medical Doctor 1(MD1).During a phone interview on 8/6/26 at 7:46 p.m. with MD 1 and with ADON in the room, MD 1 stated there was no IDT meeting during week following Resident 1's suicide attempt.During a record review of facility Quality Assurance and Performance improvement (QAPI) meeting sign in sheet titled, Weekly IDT Meeting Sign Sheet Topic: QUAPI [DATE], dated 3/11/25 and Weekly IDT Meeting Sign Sheet Topic: QAPI May, dated 6/10/25, the QAPI sign in sheets indicated RNS/[DON] was not present for both meeting. Both sheets indicated ADON was present for the QAPI meeting.During record review of facility policy and procedure (P&P) titled, Quality Assurance and Performance Improvement Program - Governance and Leadership, dated 3/2020, the P&P indicated the QAPI committee include the director of nursing services.During a record review of ADON's HR file titled, ADON: ADON, dated 8/6/25, the file indicated ADON was hired as Asst. Director of Nursing (RN)-S. The HR file indicated ADON had received discretionary monthly payments titled, DON monthly bonus from 11/2024 to 7/2025.During a phone interview on 8/11/25, at 8/11/25, at 1:49 p.m. with Administrator (ADM), the ADM stated they had hired and trained RNS/[DON] as the Director of Nursing on 12/24 but did not have any supporting documentation.During a record review of an email sent by ADM, dated 8/12/25, the email indicated they did not have records of RNS/[DON]'s training or job description as the DON and would be backdating documents when RNS/[DON] returned from vacation.During a phone interview on 8/21/25 at 11:11 a.m. with the Ombudsman (OM), the OM stated the ADON had introduced themselves as the DON and did not recall RNS/[DON] as the DON.

Based on observation, interview, and record review, the facility failed to ensure, for residents 1-11, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (data match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs (Narcotic Take Back Log). The facility did not have complete records. The facility did not have accurate records.These failures resulted in the potential for undetected loss and diversion (theft). During an interview, on 8/7/25 at 9:20 a.m., Medical Record Director (MRD) was asked to describe the scheduled medication accountably (records of narcotic use) procedure. Her description included pharmacy Shipping Manifests and CDRs were scanned (electronic copies). The scanned copies were retained. The scanning process started on 3/23.During a concurrent observation and interview, on 8/7/25 at 10:20 a.m., at a medication cart (stores medication), Licensed Vocational Nurse (LVN 1) was asked to describe the schedule medication accountability procedure. Continuing the interview at 10:30 a.m., his description included receiving the scheduled medication and signing the Shipping Manifest. He then placed the scheduled medication into the medication cart. He filed the CDR at the cart. His description included handing remaining discontinued scheduled medication to the Director of Nursing (DON). LVN 1 and the DON counted the remaining medication. Both signed the CDR documenting the transfer of the medication to the DON. During an interview, on 8/7/25 at 11 a.m., ADON was asked to describe the scheduled medication accountability procedure. Her description included the unit nurse handed the remaining medication and the CDR to the DON. The amount transferred was documented in the Narcotic Take Back Book. The nurse and the DON signed the Narcotic Take Back Book documenting the amount transferred. The DON and the pharmacist destroyed the medication. The DON and the pharmacist signed the Narcotic Take Back Book to verify the amount destroyed. The CDR was filed in medical recordsDuring a concurrent interview and document review, on 8/7/25 at 12:35 a.m., ADON identified the Shipping Manifests, CDR, and Narcotic Take Back Log (Narcotic Take Back Book). The documents were from 1/1/24-3/31/24. During a concurrent interview and record review, on 8/8/25 at 9:55 a.m., ADON identified CDR 6510061 Resident 1 Hydrocodone (narcotic pain reliever)/APAP (acetaminophen, non-narcotic pain reliever) 5/325 mg (milligram) Tablet (on two prescription cards, CDRs with the same number). ADON acknowledged the CDRs had a space for Signature of Nurse Receiving Medication, Date and No. of Doses Received. ADON acknowledged both cards did not document the nurse signed, dated, and the doses received. During a concurrent interview and record review, on 8/8/25 at 12:45 a.m., ADON identified the Narcotic Take Back Log. The log required licensed nurse giving back or LN giving Nurse and Accepting RN to be completed for each line item (resident prescription). Inspection of the log entries on page 6 through page 22, showed 21 line items where one nurse signed as both licensed nurse giving back/LN giving Nurse and Accepting RN. Five instances are listed below.6234192 Resident 2 Hydromorphone (narcotic pain reliever) 2 mg tablet #556173765 Resident 3 Oxycodone (narcotic pain reliever) 10 mg #26120466 Resident 4 Hydrocodone/APAP 5/325 mg #95969962 Resident 5 Hydrocodone/APAP 5/325 mg #545673957 Resident 6 Hydrocodone/APAP 5/325 mg #5In addition, 79 line items were incomplete due to missing the LN giving signature. Five instances are listed below.6206149 Resident 7 Morphine (narcotic pain reliever) Sulf ER 15 mg tab #46264040 Resident 8 Oxycodone 5 mg T #546213128 Resident 9 Oxycodone 5 mg T #566130195 Resident 10 Oxycodone/APAP 10/325 mg #155621896 Resident 11 Hydrocodone/APAP 5/325 mg #13ADON acknowledged the above line items were missing the required signatures. The total number of all line items on pages 6-22 were 137. An administrative record review, of the policy for Controlled Substances (November 2022), showed Dispensing and Reconciling Controlled Substances, showed Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage.An administrative record review, of the policy for Controlled Substances (November 2022), showed Dispensing and Reconciling Controlled Substances, 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. An administrative record review, of the policy for Discarding and Destroying Medications (November 2022), showed References, OBRA Regulatory Reference Numbers, S483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.

Based on observation, interview and record review, the facility failed to provide adequate and timely mental health services for one of four sampled residents (Resident 1) who attempted suicide by strangulation when facility:1. allowed Resident 1 access to the same ligature implement used in their suicide attempt for more than three months and, 2. did not provide Resident 1 with adequate follow up care when the Assistant Director of Nursing, who had been acting as director of nursing, provider and police were not informed of Resident 1's suicide attempt.This failure resulted in Resident 1's continued thoughts of suicide without appropriate care or follow up interventions for more than three months.A review of Resident 1's admission record indicated Resident 1 was admitted for hemiplegia (loss of muscle function on one side of the body) and hemiparesis (relatively mild loss of strength in the arm, leg and sometimes face on one side of the body) following cerebral infarction (death of an area of brain tissue when there, low back pain, weakness, and history of falling.During a record review of Resident 1's progress notes titled, [Facility] Progress Notes *NEW*, dated 8/6/25, Resident 1's progress note dated 5/2/25, at 9:24 p.m., was reviewed. The progress note indicated Licensed Vocational Nurse 1 (LVN 1) documented Resident 1's Change in Condition which indicated at 5/2/25, at 9:20 p.m., Resident 1 was yelling 'I want to kill myself' over and over. Resident 1 cannot be distracted from his suicidal ideation. MD notified.During a concurrent interview and record review on 8/7/25, at 2:30 p.m., with Operations Manager (OM), the police call report titled City of [City] Emergency Communications Center Call for Service Detail Report - CFS 1005, dated 5/2/25, at 9:39 p.m., was reviewed. OM stated the record was the only police record for the month of May. The report indicated Resident 1 was threatening to hurt himself.upset that mother passed away recently.yelling can hear him in the background. The report indicated [City] officers were in the facility on 5/2/25, at 10:14 p.m., and spoke to [Resident 1]. He wanted to hurt himself due to the fact of him having back pain.During a concurrent interview and record review on 8/6/25, at 11:30 a.m., with Registered Nurse Supervisor/Director of Nursing (RNS/[DON]), Resident 1's progress note titled, [Facility] Progress Notes *NEW*, dated 8/6/25, was reviewed, the note indicated on 5/3/25, at 6:20 a.m., RNS/[DON] found out patient succeeded to pull circadia (a electronic medical device attached to the wall used to monitor resident breathing and activity) wiring.and tried to strangle himself by using the wire to entangle to his neck. RNS/[DON] stated they were rounding and found Resident 1 with a cable around their neck. RNS/[DON] stated Resident 1 had suicidal ideation the previous day. After removing the cable around Resident 1's neck, they asked two certified nursing assistants to move Resident 1 out of the room. After a review of the progress note, RNS/[DON] stated they could not recall if the police or provider was called. RNS/[DON] stated they did not call the Director of Nursing because they stated, I was the Director of Nursing. RNS/[DON] stated the progress note they wrote did not indicate the police or provider were contacted. RNS/[DON] was unable to find documentation the circadia wire was removed from the room. RNS/[DON] stated there was an order for suicide monitoring.During a record review of Resident 1's physician order set titled [Facility] Order Review Report, Dated 8/6/26, the order set indicated Resident 1 had an order to monitor every shift for suicidal ideation: Repeatedly expressing desire to kill himself. The order set did not indicate any orders to remove strangulation implements from his vicinity. The order set also indicated two psych consults on 6/3/25 and 7/30/25. During a record review of Resident 1's psychology note titled [Contractor] Psychology Initial Evaluation Note], dated 6/12/25 and 6/16/25, both notes did not indicate any specific evaluation or treatment of the 5/3/25 suicide attempt.During a concurrent observation and interview of Resident 1's room, on 8/6/25, at 11:02 a.m., Resident 1 was in their room in bed with the covers over them. A bedside table was in front of them with a call bell next to the bed. Next to Resident 1's bed was the circadia device with wiring attached to the wall. Resident 1 stated they recalled a recent suicide ideation and attempt. When asked about the suicide attempt, Resident 1 began to cry inconsolably. Resident 1 was unable to answer questions verbally because of the crying and could only shake their head or nod due to the crying. Resident 1 nodded their head when asked if they used anything in the room for the suicide attempt and nodded when the surveyor pointed to the circadia device in the room. When asked if they still had thoughts of suicide, Resident 1 nodded and began to cry more intensely and was visibly shaking. Resident 1 continued to cry for 10 minutes with surveyor in the room. After Resident 1 stopped crying, Resident 1 stated they were not sent out for further evaluation, and the facility did not provide any follow up to the suicide attempt. Resident 1 stated they still wanted to get help and talk about the suicide attempt.During a concurrent interview and record review on 8/6/25, at 1:00 p.m., RNS/[DON] stated they were the Director of Nursing. RNS/[DON] stated Resident 1's medical record did not have a care plan, change in condition documentation, interdisciplinary team (IDT) meeting or specific interventions ordered to address the 5/3/25 suicide ideation. RNS/[DON] stated as Director of Nursing, they expected staff to follow policy and procedure for suicide attempts.During an interview on 8/6/25, at 3:00 p.m., with Medical Doctor (MD 1), MD stated they were notified of Resident 1's suicidal ideation twice during Resident 1's admission, once on 5/2/25 and once in June, but did not recall being informed of the suicide attempt. MD 1 stated they received one notification in May 2025 and one notification in June 2025. MD 1 stated they were not part of any IDT meeting regarding Resident 1's suicide attempt but expected staff to remove the strangulation implement and for Resident 1 to have a psychiatric consult.During an interview and record review on 8/6/25, at 7:30 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. the ADON stated they were not previously informed of Resident 1's suicide attempt, did not have an IDT meeting about Resident 1's suicide attempt and did not have a care plan regarding Resident 1's suicide attempt.During an interview on 10/30/25, at 11:45 a.m. with Medical Consultant (MC), MC stated suicide attempts were psychiatric emergencies similar to a heart attack and would expect staff to provide immediate treatment and evaluation. Evaluation would include the provider and law enforcement to determine if there is danger to the resident.During a review of facility policy and procedure (P&P) titled, Response to Attempted Suicide and Suicide Attempts in Progress, dated 1/2025, the P&P indicated in response to suicide attempts staff must respond promptly, follow established procedures, and notify appropriate personnel, including the resident's physician, legal representative.and emergency service. The P&P further indicated in response to a suicide attempt in progress staff dial 911 immediately and notify them of a psychiatric emergency in progress.notify the charge nurse and/or the Director of Nursing (DON) at once.arrange for a psychiatric or psychological evaluation as soon as possible.follow provider recommendations for treatment or transfer to a psychiatric facility.update the resident's care plan to reflect suicide risk and prevention measures. Include behavioral management strategies and therapeutic interventions.Conduct a debriefing session with all staff involved.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of care when:Facility did not monitor Resident 1's rash on bilateral breast fold for increased spread or signs of infection according to care plan.Facility did not promptly notify Resident 1's representative that Resident 1 had rash in multiple areas, bilateral breast fold. These failures caused Resident 1 to not receive appropriate care and services to meet needs and the potential to prevent Resident 1's emotional distress and Resident 1's representative their right to be informed. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 6/5/25, the MDS indicated Resident 1 had no skin problems but was at risk of developing pressure ulcers/injuries. Resident 1 was confined to bed and diagnoses included End-Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids).During an interview on 7/28/25, at 11:10 a.m., with Resident 1's Family Member/representative (FM1), FM1 stated the facility did not notify FM1 of changes in Resident 1's skin condition. FM1 stated the facility did not inform FM1 that Resident 1 had a wound under her breast. FM1 stated that when Resident 1 was transferred to the hospital, FM1 stated the Emergency Department (ED) nurse informed FM1 that Resident 1 had a wound under her breast that was septic.During a review of Resident 1's change of condition note, dated 4/24/2025, the change of condition note indicated Resident 1 had rashes in multiple areas and Resident 1 had stated the rash was spreading. The change of condition note also indicated Resident 1's representative was not notified.During a review of Resident 1's care plan, initiated 4/24/25, the care plan indicated Resident 1 had a rash on the right flank and between stomach folds; interventions included to monitor Resident 1's rash for increased spread or signs of infection.During a review of Resident 1's Treatment Administration Record (TAR), dated 4/1/25 to 4/30/25, and 5/1/25 to 5/31/25, the TARs indicated Resident 1's rash was not monitored for increase spread or signs of infection and skin conditions were also not monitored.During a review of Resident 1's ED notes, dated 6/16/25, the ED notes indicated Resident 1 had rashes noted to bilateral breast folds, more so on the left breast fold. During a concurrent interview and record review on 9/23/25, at 11:15 a.m., with the Assistant Director of Nursing (ADON), Resident 1's change of condition note and care plan, dated 4/24/25, and Resident 1's TARs dated 4/1/25 to 4/30/25, and 5/1/25 to 5/31/25 were reviewed. The change of condition note indicated Resident 1's representative was not notified of rash to breast. TARs indicated Resident 1's rash noted to bilateral breast fold were not monitored according to the care plan. ADON stated Resident 1's representative (FM1) was not notified of Resident 1's rash to bilateral breast fold and Resident 1's rash was not monitored.During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on observation, interview and record review, the facility failed to conduct an accurate assessment of one resident's functional capacity when Resident 42's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) was coded incorrectly for dental condition. This failure had the potential to cause health decline, and to inhibit or delay proper care planning and treatment. Findings: During a record review of Admission Record, printed December 5, 2024, Resident 42 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), Aphasia (a brain disorder that affects how you speak and understand language) following Cerebral Infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), and Hemiplegia (paralysis or weakness of one side of the body). During a concurrent observation and interview on 12/2/24, at 2:57 p.m., Resident 42 began to talk but had to remove her upper and lower dentures from her mouth to speak effectively. Resident 42 stated her dentures were loose, and even after applying denture cream, the plates would stay in place for only five minutes or so. Resident 42 also stated she had to remove her teeth to eat meals effectively. Resident 42 stated this made her feel uncomfortable and she wished that something could be done to improve this situation. During a record review of Resident 42's MDS Section C (Assessment of Cognitive Status), dated 11/4/24, Resident 42's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) showed a score of 14, which indicated normal cognitive function. During a record review of MDS Section L (Assessment of Oral/Dental Status), dated 11/4/24, the coding indicated no oral/dental problems were present for Resident 42. During an interview on 12/5/24, at 1:30 p.m., with the Minimum Data Set Nurse Coordinator (MDSC), the MDSC stated if the MDS assessment is not completed correctly, the resident may not receive appropriate care planning and treatment. During an interview on 12/5/24, at 1:15 p.m., with the Social Services Director (SSD), the SSD stated Resident 42 had financial concerns affecting her dental care, but other arrangements for reduced-price dental care were possible to obtain for her. During a record review of policy and procedure (P&P) titled, Resident Assessments, dated 2001, the P&P indicated, the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.

Based on interview and record review, the facility failed to refer one resident with a serious mental disorder for level II Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1. all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2. be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3. receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR S483.100-138) screening when Resident 57's Level 1 PASARR did not accurately show the resident's diagnosed psychiatric condition. This failure had the potential for the resident to receive inappropriate or ineffective care, treatment, or services. Findings: During a record review of Resident 57's Admission Record, printed 12/5/24, the Admission Record indicated that Resident 57 was admitted to the facility on [DATE] with diagnoses including paraplegia (the loss of muscle function in the lower part of the body including both legs), generalized muscle weakness, bipolar disorder (a mental condition in which a person has wide or extreme swings in their mood. Periods of feeling sad and depressed may alternate with periods of intense excitement and activity or being cross or irritable), and personal history of other mental and behavioral issues. During a record review of Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), Section C, dated 11/14/24, the MDS indicated that the resident Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15, indicating normal, intact cognitive function. During a record review of MDS, Section I, dated 11/14/24, the MDS was coded to indicate Resident 57 had bipolar disorder. During a record review of Department of Health Care Services (DHCS) Preadmission Screening and Resident Review (PASSR) Level 1 Screening, dated 11/8/24, PASSR Level 1 indicated Resident 57 did not have a serious mental illness. During a record review of facility policy and procedure (P&P) titled, Admission Criteria, dated 2001, the P&P indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASSAR) process .the disciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. Regarding residents that receive a positive level I PASSAR, and a subsequent level II PASSAR screening, the facility would be provided with notification of any specialized or rehabilitative services available, and whether placement in the facility is appropriate. During an interview on 12/5/24, at 12:15 p.m., with the Administrator (ADM) and Director of Nursing (DON), the DON stated if a newly admitted resident's Level 1 PASSAR did not correctly identify a diagnosed psychiatric condition, this information would be captured and corrected by the Minimum Data Set Nurse Coordinator(MDSC) during the initial 14 day MDS assessment. At that time, the PASSAR process would restart, leading to a positive level I and a subsequent level II. During an interview 12/5/24, at 1:30 p.m., with the MDSC, the MDSC stated an inaccurate PASSAR screening could result in the resident failing to receive all available services for psychiatric or developmental problems.

Based on observation, interview, and record review, the facility failed to ensure one out of five sampled residents (Resident 38) received the necessary services to maintain good grooming, and personal hygiene when Resident 38's shower schedule was not consistently followed and reason for refusals were not documented and acted upon. This failure resulted in Resident 38 having unmet physical, physiological, and psychological needs. Findings: A review of Resident 38's face sheet indicated Resident 38 was admitted with diagnoses that included end stage kidney disease, dependence on kidney dialysis, diabetes, and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/24/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicated no cognitive impairment. The MDS also indicated, Resident 1 required partial/moderate assistance from staff for shower/bathe self. During a review of the shower schedule for Resident 38, the shower schedule indicated Resident 38 was to receive a shower every Monday and Friday. During a review of Resident 38's care plan, initiated 8/13/24, the care plan for activities of daily living (ADL)intervention/tasks indicated .Bathing assistance: Resident requires assistance of staff/others to wash and dry hair, trunk/extremities during scheduled bath days 2X/week and as needed . The care plan, initiated on 2/21/24 indicated, .Bathing/Showering: Avoid scrubbing & pat dry sensitive skin . During a concurrent observation and interview on 12/3/24, at 8:55 a.m., with Resident 38 in the lobby, Resident 38 sat in a wheelchair, waiting for transportation to an appointment. Resident had her head covered with a shawl. Resident 38 stated the facility had scheduled her showers on Monday and Friday, which were on her dialysis days. Resident 38 stated her dialysis days were Monday, Wednesday, and Friday - 10 a.m. was dialysis, breakfast was 7:30 a.m. and she was picked up at 9 a.m. She came back at 4 p.m. from dialysis. Resident 38 stated she had not had a shower for several weeks and no bed baths were given. During an interview on 12/4/24, at 12:30 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated showers were scheduled to be given to residents twice a week. CNA 1 showed the showers/bath daily schedule in a binder in the front station desk. CNA 1 stated staff currently charted on the shower and bed bath sheet noted as 'weekly body checklist' and placed the sheet in the Acting Director of Nursing (ADON) box on ADON's door. During a concurrent interview and record review on 12/4/24, at 2:15 p.m., with Registered Nurse Supervisor (RNS) 1 and Medical Records Director (MRD), RNS 1 stated the CNAs documented on the weekly body checklist sheets and the checklist would indicate if a Resident had a bed bath or a shower. She stated the CNAs gave the checklists to the ADON who reviewed the sheets and gave them to the MRD to upload into the computer. The MRD provided four 'weekly body checklist' sheets each for October and November, for Resident 38. MRD stated she could not find any more checklists in the computer. A review of two of the four sheets for October, dated 10/18/24, indicated, Resident refused shower before dialysis, and dated 10/ 21/24, indicated, Resident refused. The checklists did not include reasons documented for Resident 38's refusals. A review of the November sheets indicated for dates 11/9/24, 11/22/24, 11/25/24, and 11/29/24, Resident 38 received bed baths, and there was no documentation for showers provided. RNS 1 stated Resident 38 left the facility for dialysis on Monday, Wednesday, and Friday. RNS 1 stated Resident 38 was usually very tired in the evening upon return from dialysis and refused showers then. RNS 1 stated if a resident refused a shower, the CNA should inform the charge nurse or supervisor, and then document the refusal in the progress note and inform the family. During an interview on 12/4/24, at 4:05 p.m., CNA 1 stated when a Resident refused a shower or bed bath, the CNA should notify the nurse. During an observation and interview on 12/5/24, at 9:35 a.m., with Resident 38, Resident was lying in her bed, alert, and waiting for assistance for bed bath. There was a cup of mouth rinse for brushed teeth on her overhead table. Resident stated she asked the receptionist a few weeks ago if they could change her showers to days that are not dialysis days. Resident 38 stated the receptionist reported it to RNS 2, but RNS 2 stated the days cannot be changed because they are always set. During an interview on 12/5/24, at 10:58 a.m., with the ADON, the ADON stated showers were scheduled for 2 times a week, and residents could ask for more if needed. The ADON stated there was no schedule for bed baths. The ADON stated refusals were documented in the shower sheet, and she stated Resident 38 had refusals of showers but was unable to state the reason for Resident 38's refusals of showers/bed baths. The ADON stated shower schedules should be able to be changed to accommodate the residents' preferences. The ADON stated the resident had the right to have showers and could get showers whenever they needed it. During a review of the bathing record, Task: Bathing 30 days look back for November, presented by the ADON on 12/5/24, at 11:30 a.m., the record from 11/6/24 through 12/1/24 indicated Resident 38 refused showers on 11/8/24 (scheduled shower day as well as dialysis day), 11/11/24 (scheduled shower day as well as dialysis day), and 11/16/24 (non-scheduled day for shower) without documented reasons for the shower refusals. The bathing record indicated no documentation of Resident 38 receiving a bed bath on 11/8/24 or 11/11/24 when Resident 38 refused a shower. The bathing record, Task: Bathing for the month of October 2024 was not provided. The documentation for Resident 38's refusal for showers/bed bath was not provided. During an interview on 12/5/24, at 12:38 p.m., with RNS 2, RNS 2 stated Resident 38 refused showers because Resident 38 did not want to be in a hurry to get ready for dialysis after breakfast. RNS 2 stated residents could reschedule the shower, but it would be difficult to switch the scheduled shower days as RNS 2 would have to switch the shower days with another resident. During a review of the facility's policy and procedure (P&P) titled, Bath, Shower/Tub dated [DATE], and P&P titled Bath, Bed dated March 2021 indicated, The purpose of this procedure is to promote cleanliness, provide comfort and to observe the condition of the resident's skin . If the resident refused the shower/bed bath, document the reason(s) why and the intervention taken . Report other information in accordance with facility policy and professional standards of practice. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated March 2018, the P&P indicated, interventions .in accordance with the resident's needs, preferences, stated goals .response to interventions will be monitored, evaluated and revised as appropriate.

Based on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) was a registered nurse (RN) for seven months. This failure resulted in an unqualified nurse being designated the DON and had the potential for inadequate supervision and management of the facility residents and nursing staff. Findings: During a concurrent observation and interview on 11/25/24, at 10:04 a.m., with the DON, the DON was wearing a badge indicating they were the Director of Nursing. The DON stated they had been the DON since 3/2024 as the acting DON. The DON stated they had just finished school to be a RN and was waiting to take the National Clinical Licensure Examination (NCLEX, an examination to become a RN) to be a RN. During a concurrent phone interview and record review on 11/25/24, at 11:15 a.m., with the Administrator (Admin), the facility ' s job description for the DON was reviewed. The Admin stated the job description indicated the DON is a registered nurse who oversees and supervises the care of all residents .minimum requirements to perform this position include: .must be in good standing with the State Board of Nursing and maintain all required continuing education/licensing requirements at all times. The Admin stated the DON had been in the position for more than six months and was an Licensed Vocational Nurse (LVN). The Admin stated the DON working as acting DON would have to meet the same requirements but was required to delegate RN duties to RNs on staff. During a concurrent interview and record review on 11/25/24, at 11:40 a.m., with the DON, the DON ' s licensed vocational nurse credentials titled, Board of Vocational Nursing and Psychiatric Technicians, dated 11/25/24, was reviewed. The DON stated they were an LVN and that was their current license. During a record review of the facility staff roster, dated 11/20/24, the staff roster indicated the DON as the DON. The staff roster did not indicate an acting DON position. During a record review of the facility daily staffing sheet titled, Estimated daily NHPPD, dated 11/21/24, the staffing sheet indicated there was one DON on duty. The daily staffing sheet did not indicate an acting DON position.

Based on observation, interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) brief was changed with two people helping to turn Resident 1 in the bed. This failure resulted in Resident 1 falling off the bed and suffering a right femur fracture (broken right upper leg bone). Findings: During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool used to plan care for the resident), dated, 1/4/2022, MDS indicated two people were required to move Resident 1 to and from lying position, to turn side to side, and to position body in the bed. During a concurrent observation and interview on 4/12/2023, at 10:37 a.m. in Resident 1 ' s room with Certified Nursing Assistant (CNA) 1, CNA 1 stated, CNA 1 was changing Resident 1 ' s brief on 3/21/2022, when Resident 1 fell off the bed. CNA 1 stated, Resident 1 was in her bed with side rails up at the head of the bed only. CNA 1 stated, CNA 1 was standing on one side of the bed. CNA 1 stated, she assisted Resident 1 to roll up on her side, while Resident 1 was holding the side rail with her hand, resulting in Resident 1 facing the siderail with her back facing CNA 1. CNA 1 stated, Resident 1 let go of the side rail, slid off the bed on the side opposite where CNA 1 was standing, and fell on to the floor. CNA 1 stated, CNA 1 was changing Resident 1 ' s brief by herself 1 demonstrated how CNA 1 stood on one side of the bed and turned Resident 1 up onto her side, while Resident 1 held the side rail. CNA 1 stated Resident 1 ' s legs started sliding off the bed when Resident 1 let go of the side rail. CNA 1 stated, CNA 1 grabbed Resident 1, but was unable to prevent her sliding off the bed onto the floor. CNA 1 stated, CNA 1 was regularly assigned to Resident 1 and had always changed Resident 1 ' s brief by herself. CNA 1 stated, Resident 1 was sleepier than usual that day. CNA 1 stated, CNA 1 told the charge nurse Resident 1 was sleepier than usual that day. During an interview on 4/12/2023, at 10:55 a.m., with Registered Nurse (RN) 1, RN 1 stated, RN 1 assessed Resident 1 after she fell on [DATE], and found Resident 1 to be alert, oriented and in no pain. RN 1 stated, RN 1 worked day shift the day Resident 1 fell . RN 1 stated, RN 1 told the evening shift staff that Resident 1 had fallen. During an interview by telephone on 4/25/2023, at 2:27 p.m., with LVN 1, LVN 1 stated, she cared for Resident1 on the evening shift on 3/12/2022. LVN 1 stated, LVN 1 had been informed by the day shift nurse that Resident 1 had fallen out of bed earlier that day. LVN 1 stated, LVN 1 observed Resident 1 ' s level of alertness was down. LVN 1 stated, 911 was called and Resident 1 was sent out to the acute care hospital. During a review of Resident 1 ' s Progress Notes (NP), dated 3/21/22, at 9:45 p.m., the PN indicated, Resident 1 was unable to answer simple questions and therefore, was transferred to the acute care hospital. During a review of Resident 1 ' s History and Physical (H & P) from the acute care hospital, dated 3/22/2022, the H & P indicated, Resident 1 came from skilled nursing facility after a witnessed fall on 3/21/2022, at 2:00 p.m. H & P indicated, Resident 1 was in septic shock, had an abnormal urinalysis (test of urine), and was very sleepy. H & P indicated Resident 1 was admitted to the hospital. During a review of Resident 1 ' s Orthopaedic Consultation Note, from the acute care hospital, undated, indicated Resident 1 had a fall on 3/21/2023, at Resident 1 ' s care facility, complained of right hip pain two days later and was found to have a right proximal femur fracture. During an interview on 5/15/2023, at 3:14 p.m., with RN 1, RN 1 stated, CNA 1 had been regularly assigned to Resident 1. During a concurrent interview and record review on 5/15/2023, at 2:58 p.m., with the Assistant Director of Nursing (ADON), ADON stated, ADON reviewed the MDS, dated , 1/4/2022. ADON stated, the MDS indicated, Resident 1 required a two person assist when being moved in the bed, such as when Resident 1 was turned. ADON stated, Resident 1 required a two person assist when staff changed Resident 1 ' s brief, because Resident 1 had to be turned up on her side to change the brief.

Based on observation, document review, and interviews, the facility failed to comprehensively assess and implement nutritional interventions for one resident (Resident 59), who lost a total of 39.6 pounds over a period of 28 weeks. The facility failed to follow the weight loss policy and procedure including providing recommended nutritional interventions, having interdisciplinary committee meetings to provide an analysis of identified weight loss, and calculating adequate estimated nutritional needs by the registered dietitian. This failure had the potential to result in unintended weight loss which is strongly correlated with increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death) in the older adult for one resident (Resident 59) out of a facility census of 65. Findings: Review of a Practice Paper published by 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]. (American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). Involuntary weight loss can lead to muscle wasting depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) A publication titled Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated the Registered Dietitian (RD) 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). According to international research the prevalence of malnutrition (lack of proper nutrition) is higher in older adults with PI. Decreased intake of calories (a unit of energy), protein, vitamins, and minerals is commonly seen in individuals with malnutrition, which is often associated with undernutrition. This results in unplanned and undesired weight loss, protein-calorie malnutrition, decreased BMI (Body Mass Index, a weight to height ratio), reduced muscle mass, and dehydration, all of which are linked to PIs (Pressure Injuries, injury to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure injuries which are classified as unstageable when the wound is covered by a layer of dead tissue referred to as slough or eschar. Unstageable PIs are a stage 3 or 4 when revealed because slough/eschar does not form on stage 1 and 2 ulcers. The term PI and pressure ulcer are often used interchangeably). Unplanned or involuntary weight loss is considered a major risk factor for both malnutrition and PI development. The EPUAP (European Pressure Ulcer Advisory Panel)/NPIAP (National Pressure Injury Advisory Panel)/PPPIA CPG (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines) recommendation is to provide 30-35 kcal per kg (kilocalorie and kilogram - metric units of measure) of body weight per day for adults with PI who are malnourished or at risk for malnutrition. The recommendation for protein is 1.25 to 1.5 g (gram a metric unit of weight) per kg or body weight per day (Munoz N, Posthauer M E, Cereda E, Schols J, Haesler E. (2020). The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Advances in Skin and Wound Care Journal, March 2020, 123-136.) The Centers for Medicare-Medicaid Services, State Operations Manual (SOM) revised 2/3/23 provides these parameters for significant/severe weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of facility the Policy and Procedure titled Weight Assessment and Intervention dated 2001 and revised March 2022, showed residents weights are monitored for undesirable or unintended weight loss. Residents are weighed at intervals established by the interdisciplinary team (IDT) and recorded in the individual's medical record. If the weight change is desirable, this is documented. For the evaluation, undesirable weight change is evaluated by the treatment team to assess if the criteria for significant weight change is met. This evaluation includes: an evaluation of the resident's target weight range, and evaluation of the resident's calorie, protein, and other nutrient needs which are compared with the resident's current intake, an evaluation of the relationship between the resident's current medical condition and recent weight change, and an evaluation of whether and to what extent weight stabilization or improvement can be anticipated. The evaluation also includes the physician and IDT to identify conditions and medications that may be causing weight loss or increasing the risk of weight loss. Review of the facility protocol titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol dated 2001 and revised September 2017, showed staff will report to the physician significant weight gains or losses. Review of the facility Policy and Procedure titled Nutrition assessment dated 2001 and revised October 2017, showed the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutrition assessment will be conducted by IDT and shall identify things including but not limited to, usual body weight, fluid and nutrient loss that may increase nutritional requirements. The dietitian is to complete an estimate of calorie, protein, nutrient and fluid needs, whether the resident's current intake is adequate to meet his/her nutritional needs. Review of the facility policy and procedure titled Food and Nutrition Services dated 2001, showed each resident is provided with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs. The multidisciplinary team staff, including nursing staff, the attending physician, and the dietitian will assess each resident's nutritional needs. Resident 59 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses including but not limited to unspecified protein-calorie malnutrition, an unstageable pressure ulcer of the left heel, a non-pressure chronic ulcer of the other part of left foot with unspecified severity, and congestive heart failure (CHF, a chronic condition in which the heart does not pump blood as well as it should). Admission diet order was a cardiac (low-fat low cholesterol), 2-gram, pureed diet. Review of the Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set dated 2/20/23 and 5/19/23 showed Resident 59 had a BIMS score (Brief Interview for Mental Status, a structured evaluation aimed at evaluating aspects of the cognition in elderly patients. A BIMS of 0-7 indicates severe cognitive impact) of 1 and 4 respectively. The MDS dated [DATE] showed Resident 59 currently had one unstageable pressure ulcer which was present since admission. The MDS dated [DATE] showed Resident 59 currently had state 4 pressure ulcer present since admission. Review of the document titled Weights and Vitals Summary from 11/19/2022 to 6/1/2023 for Resident 59, showed the following: 11/19/2022 165.6 pounds (lbs); 12/3/2022 154 lbs - a decrease of 11.6 lbs or 7% in 2 weeks; 1/3/2023 137.6 lbs - a decrease of an additional 16.4 lbs or 10.6% in one month and a total loss of 28 lbs or 16% in 2 months both of which are considered severe. 2/1/2023 130.4 lbs - a further decrease of 7 lbs or 5% in 1 month; a total loss of 23.6 lbs in 2 months or 15%; a total loss of 35 lbs or 21.5% in 3 months - all of which are considered severe. 5/1/23 129.2 lbs - a decrease of 24.8 lbs or 16% in 5 months which is considered severe. 6/1/23 126 lbs - a decrease of 28 lbs in 6 months or 18%, and overall weight loss of 39 lbs or 23% in 6-1/2 both of which are considered severe. Review of the document titled Nutritional Breakdown dated Spring 2023 and provided by the facility as the nutitional analyisis of the current menu, showed the combination Lowfat/Cholesterol, 2-gram sodium diet provided between 1850-2100 kcals per day. Percentage of intake calculations of the Lowfat/Cholesterol, 2-gram sodium diet show this diet would provide the following kcals on a daily basis: 0%-25% = 0-525 kcals 26%-50% = [PHONE NUMBER] kcals 51%-75% = [PHONE NUMBER] kcals 76%-100% = 1406-2100 kcals The facility's Documentation Survey Report v2 from 11/20/22-3/31/23 for Resident 59 were reviewed. Calculation of the facility's documented meal intakes show: The average meal intake for 30 documented meals (one refusal was not included) from 11/20/22-11/30/22 was 18%, this equates to an average daily intake of 333-378 kcals. The average meal intake for 86 documented meals from 12/1/22 -12/31/22 was 15% (this calculation does not include 3 meal refusals), this equates to an average daily intake of 278-315 kcals. The average meal intake for 82 documented meals from 1/1-1/31/23 was 14% this equates to an average daily intake of 259-294 kcals. The average meal intake for 77 documented meals from 2/1/23 - 2/28/23, was 35% which equates to an average daily caloric intake of 648-735 kcals. There was no documentation of meal intake on this form from 3/1/23-3/26/23. The average meal intake for 15 documented meals from 3/27-3/3 was 71%, this equates to an average daily intake of 1314-1491 kcals. A Nutrition Admission Note completed by Registered Dietitian (RD) 3 on 12/6/22 (2-1/2 weeks after admission) showed Resident 59 was on a low fat, low cholesterol, 2-gram sodium, pureed diet. RD3 noted current body weight as 154 lbs and admission weight as 165.6 lbs. She showed this was an 11.6 lb weight loss which was a 7% decrease since admission. RD3 documented there was an unstageable pressure injury at left heel and wounds present since admission. RD 3 estimated Resident 59's energy needs as 1400 - 1750 kcal (kilocalories). Additionally, RD3 noted Resident 59's meal intake was documented as 0-75% (the time frame was not included in the note). RD3 noted the weight loss was likely due to poor intake, Lasix (a medication that can reduce fluid retention which is known as a diuretic), and wounds. RD3 recommend Sugar Free Health Shake three times a day (TID) and Pro-Stat (a protein supplement) 30 ml twice a day (BID) for weight stabilization and wound healing (In an interview on 6/9/23 at 2:14 p.m., DSD stated no nutrition supplements except for Pros-tat/Proheal (a protein supplement) were ordered for Resident 59 while Resident 59 was at the facility.) The Nutrition Admission Noted written by RD3 on 12/6/22 shows she did not use current standard recommendations for calculating estimated energy needs and protein needs for wound healing. RD3 showed she used 20-25 kcals/kg (kilogram) for energy needs and 1.0 - 1.2 gm/kg for protein needs in her Nutrition Admission Note dated 12/26/22. Using the current recommended standards of 30-35 kcals/kg (energy needs for PI), Resident 59's energy needs are estimated as 2100-2450 kcals per day. A calculation of Resident 59's documented meal intake using the facility's Documentation Survey Report v2 from 11/20/22-12/5/22 includes 42 documented meals (did not include 2 refusals) and reveals Resident 59's had an average intake was 15% which equates to an intake of 278-315 kcals per day. The Pro-Stat adds an additional 200 calories per day. The calculation of estimated needs using the current recommended standard energy needs (30-35 kcals/kg/day for PI), compared to Resident 59's calculated estimated intake shows Resident 59's intake was significantly less than estimated needs. In addition, the comparison of RD3's estimation of needs for resident 59 (calculated in her 12/26/22 Nutrition Admission Note as 1400-1750 kcals/kg/day), also shows Resident 59's intake was significantly less than the needs calculated by RD3. A follow up RD progress note titled Weight Change Note dated 2/3/2023 (2 months after the last RD note tiled Nutrition Admission Note dated 12/6/22), completed by RD2 showed Resident 59 was on a low-fat low cholesterol, 2-gram sodium, pureed diet. RD2 documented resident 59 was not receiving supplements at this time. The assessment showed Resident 59 had a significant weight loss. RD2 failed to recognize the weight loss since admission as severe and noted Resident 59 had significant weight loss related to poor intake. RD2 maintained Resident 59's energy needs as 1400-1750 using 20 -25 kcal/kg/day. RD 2 recommended health shakes TID, (In an interview on 6/9/23 at 2:14 p.m., DSD stated no nutrition supplements except for Pros-tat/Proheal were ordered for Resident 59 while the Resident was at the facility). RD2 also recommended a swallow evaluation and one to one feeding assistance. There were no other nutrition interventions to support increased caloric intake. A follow up RD progress note titled RD note re: need RD eval dated 2/17/2023 completed by RD2 showed resident current intake by mouth is about 68% average in the past week. RD2 recommended to add a health shake (sugar free) TID with meals for weight maintenance and to prevent further weight loss. A calculation of Resident 59's documented meal intake using the facility's Documentation Survey Report v2 from 2/10/23-2/16/23 (the 7 days prior to RD2's note on 2/17/23) includes 18 documented meals and reveals Resident 59 had an average intake of 42% which equates to an intake of 777-882 kcals per day. An average intake of 68% (which RD2 showed for Resident 59 in her note on 2/17/23), equates to an intake of 1258-1428 kcals per day. A calorie intake of 1258-1428 barely meets the low end of RD3's estimated needs for Resident 59 of 1400-1750 kcals per day based on 20-25 kcal/kg/day (from RD2's note on 2/3/23). There was no follow up or assessment by an RD until 5/26/23 (over 3 months after the last RD note). Review of the Nutritional Risk Review (Quarterly) dated 5/26/23 and signed by RD1, showed Resident 59 was on a low-fat low cholesterol, 2-gram sodium diet, soft and bite size texture. The document also showed, Resident 59 was not receiving nutritional supplements/nourishment. RD 1 showed the percent meal intake was 75-100% (no time frame indicated). RD1 documented Resident 59 had a Stage 4 pressure injury on the left heel. RD1 documented Resident 59 had increased nutrition needs related to wound healing and had significant weight loss of 24.8 lbs in six months. Caloric interventions recommended by RD1 included diet liberalization and adding health shakes TID. There was no documentation of estimated nutritional needs. Resident 59's Nutrition Care Plan initiated on 12/1/2022 and last updated on 5/26/23 showed two significant rather than severe, weight losses of 16.1% on 5/1 and 20.3% on 4/1. Also mentioned was a Stage 4 pressure injury on left heel and significant weight loss. The Interventions which supported increased caloric intake included Recommend adding health shakes TID which was added to the care plant on 5/26/23. Review of the Order Summary Report dated 6/9/23, showed a physician order for Soft and Bite Sized texture, No added salt diet was ordered for Resident 59 on 6/6/23. A dining observation and interview with Certified Nursing Aide (CNA) 2 on 6/8/23 at 12:03 p.m., showed a lunch tray was delivered to Resident 59 in her room. The tray tag showed Resident 59 was on a Soft and Bite-Sized NAS (no added salt) diet. According to the menu, gravy was missing on the rice, there was no pureed bread with margarine, and no milk. CNA 2 stated resident 59 ate solid foods okay and really liked her fluids. Resident 59 sat upright in bed and fed herself. She consumed 100% of the fluids on her tray and approximately 80% of her solid food. The menu spreadsheet titled Noon Meal Therapeutic Spreadsheets dated Week 2 Thursday Cycle 2 2023, showed a soft bite-sized diet included but not limited to rice with gravy, pureed bread with margarine, and 8 ounces of whole milk. In an interview on 6/8/23 at 10:44 AM, Registered Nurse (RN) 1 indicated RD recommendations were placed in a binder for nursing staff to act upon. In a phone interview on 6/8/23 at 3:25 p.m., RD 1 said if milk or a comparable substitute was not provided on a regular basis, then residents would not receive enough protein or calories according to the planned menu. RD1 stated she typed recommendations and handed a copy to nursing staff. She said these typed recommendations went into a binder kept by nursing staff. RD1 stated nursing staff called the Medical Doctor to approve or not approve a recommendation. In an interview on 6/9/23 at 9:02 a.m., RD1 stated she was aware that Resident 59 was losing weight and had a recent significant weight loss over three months RD 1 stated she wanted to focus on Resident 59's wound before addressing the weight loss. RD 1 stated she did not use severe weight loss parameters and still documented significant weight loss even if the weight loss was severe. She said she was aware Resident 59 was not receiving health shakes and would check her next monthly weight before recommending a supplement to address the Resident's weight loss. RD1 stated she did not calculate Resident 59's calorie or protein needs on her quarterly assessment because calculating needs for a quarterly assessment was not required. RD1 stated Resident 59 should have been weighed weekly. RD1 confirmed it was not appropriate for Resident 59 to only be weighed one time per month when Resident 59 exhibited continual weight losses. RD1 confirmed Resident 59 was continuing to lose weight and stated, but not as much. When RD 1 was asked if weight loss was beneficial when a wound was healing, RD 1 stated no. In an interview on 6/9/23 at 9:02 a.m., RD1 stated she did not talk to the resident's doctor about weight loss for Resident 59. RD1 said she was responsible for the nutrition care plan for the residents at the facility. She stated there was not a care plan for planned weight loss for Resident 59. RD1 stated when assessing resident weight loss, she assessed if the resident met nutritional needs. She stated interventions included therapeutic diets and additional snacks. She stated if the snacks she recommended did not help, then she changed the intervention. RD1 said she should have recommended weekly weights to assess Resident 59's weight on June 6, 2023. RD1 stated IDT meetings were conducted every Tuesday and the team included herself and the Assistant Director of Nursing (ADON). She said in the meetings she talked about resident weight loss and her recommendations. RD1 stated there was not an IDT meeting done for Resident 59. Review of the undated, untitled document RD1 provided as a reference to show estimated nutritional needs for a variety of medical diagnoses, showed for pressure ulcers at stages 2-5, the estimated energy needs were 30-35 kcals/kg/day. In an interview on 6/9/23 at 12:07 p.m., Licensed Vocational Nurse 6 (LVN 6) stated she started treating Resident 59's Stage 4 pressure ulcer wound about 2 months ago LVN 6 stated she has not seen any signs of edema or fluid retention. In an interview on 6/9/23 at 12:58 p.m., the Director of Staff Development (DSD) stated she was also the acting Assistant Director of Nursing (ADON) since there was not a current ADON or DON (Director of Nursing). She stated when a resident had a significant weight loss, the weight assessment and intervention policy should be followed. She stated this included notification to the physician and family member, and a meeting with IDT to come up with a plan of treatment to promote weight stabilization or weight gain. In a phone interview on 6/9/23 at 1:50 p.m., Nurse Practitioner 1 (NP1) stated she was familiar with Resident 59. She stated Resident 59 was ordered diuretics for CHF. She stated Resident 59's CHF was stable and did not see any problems. NP1 stated there would be initial fluid loss with a diuretic, however she would not expect to see continuous severe weight loss over months. She stated weight stabilization and wound healing was desired. NP1 stated the resident needed enough protein and calories to heal the wound and stabilize weight. She stated with severe weight loss, the resident would benefit from calorie supplements. In an interview on 6/9/23 at 2:14 p.m., the DSD stated the weight assessment and intervention policy would be followed if a resident had a severe weight loss. She stated this would require a nutritional assessment by the RD to calculate the resident's nutritional needs. DSD stated no nutrition supplements except for Pros-tat/Proheal were ordered for Resident 59 while Resident 59 was at the facility. The DSD also said the physician and family were not notified for Resident 59's severe weight loss and there were no documentation of IDT meetings for Resident 59 while the resident was at the facility.

Based on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of full-time, competent oversight of food and nutrition staff placed 61 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in death and/or nutritional related medical complications. Findings: 1. There was no full-time, qualified oversight of the Food and Nutrition Services Department. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). Review of the job description titled Dietary Services Director signed by the Dietary Manager (DM) on 2/1/23, showed a qualification required was to possess a valid and current certification as required by state law. Review of the document titled Certificate of Completion with an issue date of 5/12/23, showed DM completed a training course for the Food Manager Certification (a certified food manager has successfully passed and accredited food safety exam that does not require classroom hours or necessarily involve a training program . In an interview on 6/5/23 at 9:50 a.m., DM stated she was the fulltime Dietary Manager. She stated she used to be the Social Worker and she was asked to be the Dietary Manager. In an interview on 6/5/23 at 11:58 a.m., Registered Dietitian 1 (RD1) stated she worked at the facility part time. RD1 stated she was usually at the facility one day a week. In an interview on 6/7/23 at 9:44 a.m., the Administrator (Admin) confirmed DM was not qualified for the Dietary Services Director position per the California Code, Health, and Safety Code - HSC S 1265.4 and the certificate provided for DM did not qualify her. He stated he did not look into the certificate to make sure it qualified DM for the position. 2. There was no full-time, competent oversight of the Food and Nutrition Services Department. Review of the job description titled Dietary Services Director signed by DM on 2/1/23, showed duties and responsibilities of a Dietary Services Director for Food and Nutrition Services, included but were not limited to: ensures adequate stock is always on hand and purchases or oversees the purchase of food, supplies and equipment as required to meet needs; develops and utilizes comprehensive inventory control procedures; assures menus are served and filled in accordance with established policies and procedures; assists with developing methods for determining quality and quantity of food served; monitors food temperatures and quality at point of service on the dining room and resident rooms; checks food production and food service to assure proper safety and sanitation procedures and precautions are maintained at all times; training competent department personnel. The job description also showed the knowledge and qualifications required included but were not limited to: knowledge of dietary procedures, regulations and guidelines pertaining to long term care. Review of the job description titled Registered Dietitian signed by RD1 on 3/27/23, showed RD1 was responsible for monitoring food services operations to ensure conformance to nutritional, safety, sanitation and quality standards and regulations; and monitor food control systems such as food temperatures, portion control, preparation methods, and presentation of food in order to ensure food is prepared and presented in an acceptable manner. A. Review of the policy and procedure titled Food Preparation and Service dated 2001, showed potentially hazardous foods (also referred to as Time/Temperature Control for Safety foods, which are foods that can grow harmful bacteria or toxins when they are not stored at safe temperatures) include meat products. Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit (F) to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours. According to the 2022 Federal Food Code, the person in charge is to ensure that employees are using proper methods to rapidly cool Time Temperature Control for Safety (TCS) 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. An observation during the initial kitchen tour on 6/5/23, at 10:40 a.m., showed a reach-in refrigerator number 1 that stored food. Inside the refrigerator was sliced beef in a metal container covered with foil with a handwritten label showing prepared 6/4/23, use by 6/7/23; cooked green beans in a metal container covered with foil with a handwritten label showing prepared 6/4/23, use by 6/7/23; and sliced/diced chicken in a metal container covered with foil with a handwritten label showing prepared 6/4/23, use by 6/7/23. During an interview on 6/5/23, at 12:18 p.m., with the Cook 1, (C1) stated the food stored in refrigerator 1, including the beef dated 6/4/23, use-by 6/7/23, diced/sliced chicken dated 6/4/23 use-by 6/7/23, and green beans dated 6/4/23 use-by 6/7/23 were leftovers from the last night's meal. C1 stated these leftovers would be served as substitute for the residents' dinner tonight. C1 said there were residents who did not like fish, so these leftover items can be used as an alternate for their dinner tonight. During an interview on 6/6/23, at 10:05 a.m., DM stated she was not sure if there was a cooldown log. DM stated staff typically do not save leftovers. She said if leftovers were used, then there would need to be documentation for cooldown. She stated she did not know the cooldown process off the top of her head since the kitchen staff did not do cooldown and she would have to look it up. During an interview on 6/6/23, at 10:30 a.m., Cook 2 (C2) stated the kitchen had no food cooldown documentation. During an interview on 6/8/23, at 3:25 p.m., RD 1 stated DM told her the kitchen did not save leftovers from previous night to use for the following day. RD1 stated the kitchen was not supposed to provide leftover food. B. Review of the facility's policy and procedure titled, Substitutions dated 2007, showed the Food Service Manager, in conjunction with the Dietitian, may make food substitutions as appropriate or necessary. The Food Services Shift Supervisor on duty will make food substitutions only when unavoidable. In addition, substitutions are noted on the menu and filed. Notations of substitutions must include the reason for the substitution. Review of the policy and procedure titled Menus dated 2001, showed menus are developed and prepared following established national guidelines for nutritional adequacy. Deviations from the posted menu are recorded. On 6/5/23 at 11:53 a.m., observation and interviews showed garlic bread was not served when it was on the menu for lunch that day, a resident who had gluten allergy documented on his tray card did not receive pasta on his lunch tray, and milk was not provided to the majority of residents when it was on the menu. A substitute was not provided for any of these items (Cross-reference F803, F806). Another observation of trayline on 6/5/23 at 12:19 p.m., showed a fruit tart was served instead of strawberry chiffon. C1 stated strawberry chiffon did not come in the food delivery. Review of the Therapeutic Spreadsheets dated Monday Cycle 2 2023 showed for lunch on 6/5/23, strawberry chiffon was on the menu for all diets except liquid, vegan, and vegetarian diets. During an interview on 6/5/23, at 12:20 p.m., DM stated she did not know there was no garlic bread to serve for lunch. She stated normally something similar was substituted but there was only regular bread and that bread had to be to be rationed for sandwiches. She stated she ordered pre-made garlic bread. In addition, DM confirmed she was aware that residents were not getting milk for lunch. RD1 stated she was not aware residents did not receive milk for lunch and stated they should get milk because it was on the menu. In an interview on 6/6/23 at 9:35 a.m., DM confirmed a substitute was not provided for milk on the lunch trays and she did not really communicate with RD1 about substitutions. During an interview and document review on 6/7/23, at 10:39 a.m., food delivery invoices were reviewed with DM. DM confirmed she was responsible for ordering food for the menu. DM said if garlic bread was ordered, it would be on the June 2 invoice. DM confirmed garlic bread and strawberry chiffon were not ordered to serve for lunch on 6/5/23. She stated fruit pie was ordered instead of strawberry chiffon the vendor did not have pre-made strawberry chiffon. DM stated technically the cooks should follow recipes but sometimes making food from scratch was not within the facility's budget and she ordered a substitute pre-made item. DM said did not consult the RD1 when she ordered a pre-made item as a substitute for a recipe made item. A dining observation and review of the Therapeutic Spreadsheets dated week 2 Friday Cycle 2 2023, on 6/9/23 at 12:43 p.m., showed chicken with gravy was the entree served on Resident 59's lunch tray. The tray tag for resident 59 indicated she was on a soft and bite sized, no added salt diet. The spreadsheet showed the entree for the soft/bite size diet was a baked fish fillet with sauce. In an interview on 6/9/23 at 12:56 p.m., C1 and C2 stated chicken was served because there was no fish available to prepare. In an interview on 6/9/23 at 1:10 p.m., DM stated she was not aware there was no fish available. C. According to the 2022 Federal Food Code Annex, cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. During the initial tour of the kitchen which started on 6/5/23 at 9:21 a.m., observations showed there were multiple areas in the kitchen that were not clean including equipment, utensil, and food storage areas, and the floor and ceiling around a reach-in freezer (Cross-reference F812). It was also determined through interviews from 6/5/23 to 6/9/23 with the DM and the House Keeping Account Manager (HAC), that DM expected kitchen staff to clean their own areas and all kitchen staff were responsible for cleaning shared areas. However, there was not a cleaning schedule for staff to follow. In addition, even though the DM stated housekeeping staff deep cleaned the kitchen on a monthly basis, it was determined that housekeeping staff did not deep clean the kitchen on a regular basis and did not have a schedule for deep cleaning the kitchen. (Cross-reference F812). D. During the recertification survey from 6/5/23 to 6/9/23 it was determined that there was a shortage of serving utensils to serve the appropriate serving sizes indicated on the menu (Cross-reference F803) and equipment such as cutting boards and pans were not being replaced when they were in poor condition (Cross-reference F812). In an interview on 6/6/23 at 9:35 a.m., DM stated she was responsible for ordering serving utensils such as scoops for trayline and cutting boards. She stated she was not aware there was a shortage of serving equipment for trayline. E. According to the 2022 Federal Food Code, the person in charge shall demonstrate knowledge by explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of equipment. The person in charge is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution chemical concentration. During the recertification survey from 6/5/23-6/9/23, it was determined that kitchen staff were not competent regarding using test strips to test the sanitizer strength of the sanitizing solution used to sanitize food contact surfaces (Cross-reference F802). In addition, DM was not competent regarding the procedures for ensuring adequate sanitizer strength when she provided the incorrect test strips to staff to test the sanitizer (Cross-reference F802). On 6/6/23 at 10:48 a.m., an observation and interview DM dipped the quaternary ammonium (quat) test strip into a quat sanitizer solution to test the strength of the solution. She dipped the test strip in and out of the solution quickly. The test strip turned a very dark green. DM stated the solution was too strong when she compared the test strip color to the color chart inside the test strip container. DM stated dark green showed the solution strength was about 500 parts per million (ppm) and thought it should be 150-200 ppm. When DM was asked how long the test strip should be held in the solution, she stated the last consultant told her to dip the test strip in and out. The surveyor showed DM the manufacturer's instructions located inside the test strip container and DM confirmed the instructions to hold the test strip in the solution for 10 seconds. DM stated when solution was too strong, staff had to dump sanitizer out and refill the solution. When DM was asked how how changing the solution decreased the strength of the solution, she stated she had to ask the diet aide since the diet aide normally filled the sanitizing buckets. During an observation and interview on 06/06/23, at 12:58 p.m., DM tested a sanitizer solution again after it was determined Dietary Aide 1 (DA1) was not competent testing the sanitizer solution. Again, the test strip turned a very dark green. DM stated more water needed to be added to the sanitizer solution. The sanitizer solution came out of a tube connected to a box attached to the wall. The box was connected to the water supply and a container containing quat sanitizer. DM was asked if the solution should be mixed automatically without the need to manually add water. DM stated she did not know. F. According to the Federal Food Code 2022, the person in charge shall demonstrate knowledge by explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of equipment. The person in charge shall ensure that employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of exposure time for chemical sanitizing. During the recertification survey from 6/5/23-6/9/23, it was determined that kitchen staff were not competent regarding manual warewashing (Cross-reference F802). Additionally, in an observation and concurrent interview with C2 and DM on 6/6/23 10:30 a.m., when C2 described the manual dishwashing process, she did not know how long to immerse items in the sanitizer solution. DM also did not know how long items had to be immersed in the sanitizer solution using the manual warewashing process. It was noted there were no directions posted in the manual dishwashing area for staff to refer to in the case they had to revert to manual warewashing. G. According to the 2022 Federal Food Code, the person in charge shall ensure that persons unnecessary to the food establishment operation are not allowed in the food preparation, food storage, or warewashing areas. Brief visits and tours may be authorized by the person in charge if steps are taken to ensure that exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles are protected from contamination. A concurrent observation and interview, on 06/06/23 at 9:35 a.m., showed Activity Assistant (AS) inside kitchen unattended and walking out of the dry food storeroom. She stated she was getting drinks and snacks for a resident coffee social. AS stated she entered the kitchen regularly to get drinks and coffee for resident activities. During an interview on 6/6/23 at 1:07 p.m., with DM, she stated it was ok for AS to go inside the kitchen to get what she needed for the resident coffee social. H. During the initial tour on 6/5/23 at 10:50 a.m., an observation showed an opened milk container stored in reach-in refrigerator number 2. There was no date on the milk to show when it was opened. During an interview on 6/8/23 at 12:03 p.m., DM stated all food had to be dated to use-by or discard within three days after opening. She stated milk was different, after milk was opened the expiration date on the milk was used as the use-by or discard date. DM stated there was not a list to show long food can be stored after opening the food package or container. Review of the document titled Use by Dates - Refrigerator Items dated 3/2/2020 and provided by DM after she stated there was no list, Items in their original container that has been opened need a Use By Date. showed milk should be used by 7 days after opening or by the expiration date of the milk, whichever comes first.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. a staff did not know how to read a freezer thermometer correctly; 2. staff did not know how to test the food-contact surface sanitizer correctly; 3. staff did not know how to sanitize juice machine according to posted cleaning instructions; and 4. a staff did not label a chemical containing container. These failures had the potential to result in the kitchen not being maintained in a safe and sanitary manner leading contamination of food and utensils, and/or reduced quality of food for 61 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 6/6/23, at 9:55 a.m., Cook 2 (C2) stated she was responsible for documenting freezer temperatures when she arrived for her shift in the morning. She stated she used the internal thermometer in the reach-in freezer to determine the temperature. Stated the freezer temperature had to be at least negative one. C2 demonstrated how she read the thermometer and showed she looked at the bottom line which had a C at the beginning of the line. She said the thermometer had to read one line less than zero which she said was negative one. On the same thermometer was a line of numbers with an F at the beginning of the line. During a concurrent observation and interview on 6/6/23, at 9:56 a.m., the Dietary Manager (DM) looked at same thermometer and stated the bottom line with a C showed degrees Celsius ( C) and the top line with an F showed degrees Fahrenheit ( F). She stated the line C2 looked at was the Celsius line. DM stated what C2 referred to as negative 1 on the Celsius line was 26 F. DM stated C2 did not read the thermometer correctly. Review of the Freezer Temperature Log dated 5/23 and June 2023 and a concurrent interview with DM on 6/6/23 at 9:55 a.m., showed the temperature was logged twice a day. There were 67 temperatures recorded for May and June combined and every temperature recorded was negative one. DM confirmed C2 was one of the staff documenting freezer temperatures in the logbook. Review of the job description titled Cook and signed by C2 on 5/2/22, showed one duty and responsibility was to document freezer/refrigerator temperatures. Review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage dated 2022, showed functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food nutrition services manager or designee. 2. During a concurrent observation and interview 6/6/23 at 10:48 a.m., C2 described how to wash dishes manually using the 2-compartment sink. C2 stated the first sink was for washing the dishes, the second sink was for rinsing the dishes, and the sanitizing step was done in a refuse container designated for the purpose of sanitizing dishes. C2 stated she did not know how long to immerse the dishes in the sanitizer. DM stated all staff would wash dishes manually if the dish machine was broken. She stated the cook would wash her dishes and the diet aides would wash their dishes. In an interview on 6/6/23 at 1:35 p.m., with Dietary Aide (DA) 1 and DA2, DA1 stood by the 2-compartment sink and described how to wash dishes using the sink. DA1 stated sink one was for washing with soap, sink 2 for rinsing with water and a little bleach, and the designated refuse container was for sanitizing with the sanitizer that came out of tube at the sink (which was quaternary ammonia sanitizer). She confirmed she would use bleach and water for rinsing in the second sink and stated she would test the bleach/water solution with a chlorine test strip test strip to make sure it had the right strength. DA2 stated he agreed with the steps DA1 described for manual dishwashing. Review of the facility's policy and procedure (P&P) titled, Sanitation dated 2022, manual washing and sanitizing is a three-step process for washing, rinsing and sanitizing. The procedures showed the first sink is for washing, the second sink is for rinsing with hot water to remove soap residue, and the third sink is for sanitizing with hot water or a chemical sanitizing solution such as a quat (quaternary ammonium) solution. According to the 2022 Federal Food Code, when manually warewashing, contact times shall be consistent with those on EPA registered label use instructions. For sanitizers other than chlorine, the contact time is at least 30 seconds. 5. During concurrent observation and interview on 6/6/23 at 10:48 a.m., C2 stated she tested red buckets filled with a sanitizer solution, used to clean food contact surfaces, every morning and 2-3 hours later throughout the day. She demonstrated how she tested the sanitizer solution. C2 used a chlorine test strip from a container labeled [brand name] Chlorine Test Paper to test the solution a red bucket. C2 stated she filled the red bucket with the solution about an hour ago. She dipped the test strip in and out quickly and the test strip did not change color. C2 stated the result was too light and did the test with second chlorine test strip, then a third chlorine test strip. C2 then stated she was using the wrong type of test strips. C2 went to DM and DM gave C2 a container of chlorine test strips. C2 tested the sanitizer again and the strip color did not change. The surveyor asked C2 what type of sanitizer she used to fill the red bucket. C2 showed she filled the bucket with a solution from a tube that was connected to a container of quat sanitizer and water. The surveyor asked C2 if there were any other type of test strips to test quat sanitizer. C2 showed where the test strips were located on a shelf near the dish machine. She picked out a container of test strips labeled QT-40 [brand name] (used to test quat sanitizer solution), and stated she never used the quat strips to test the sanitizer in the red buckets. During a concurrent observation and interview with DA1 and DM on 06/06/23, at 12:53 p.m., DA1 stated she was responsible for filling and checking the sanitizer in the red buckets in the dish machine area. She tested the solution in a red bucket with a quat test strip and the strip did not change color. DA1 stated it was not strong enough and probably mixed too much water into the solution because the test strip was too light. DA1 said the quat test strip should show 200 ppm (parts per million). In comparison to the color chart inside the test strip container, the test strip would turn yellow if at 200 ppm. DA1 refilled the red bucket with sanitizer from a tube above the two compartment sink then added water to the bucket. The solution became very foamy with at least 4 inches of foam on top of the solution. DA1 dipped a test strip into the foam and the strip did not reach the solution. The test strip turned a very dark green color. DA1 stated the result was 400 ppm when she compared the color to the chart inside the test strip container. She said the solution was too strong. DA1 tested again and dipped the strip into the foam for 5 seconds. Result was colored dark green again. DM confirmed DA1 dipped the test strip into the foam and not into the solution. Review of the manufacturer's directions located inside the test strip container used by DA1, titled QT-40[name brand] showed to dip paper in quat solution NOT FOAM SURFACE for 10 seconds . Review of the policy and procedure titled Sanitization dated 2001, showed all equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Service area wiping cloths are placed in a chemical sanitizing solution of appropriate concentration. 6. During a concurrent observation and interview on 6/7/23 at 10:58 a.m., DA1 stated she was responsible for cleaning the juice machine every day and demonstrated how. She removed the nozzle from the juice gun and placed it in a container of hot water. Then she ran the tray though the dish machine. She then put it all back together. She stated that was all she did when she cleaned the juice machine in the morning. DA1 said the evening person cleaned the juice machine too and soaked the juice gun and nozzle overnight. During an interview and observation on 6/7/23 at 1:40 p.m., with DA1 and DA2, DA2 stated he cleaned the juice machine every evening. He explained how he cleaned the machine and stated he took apart the juice gun by removing nozzle. Then he filled a container with hot water and soaked the nozzle and the gun in the water overnight. He stated morning dietary staff put the juice gun back together. DM1 stated she soaked the nozzle again in hot water before she put it back together each morning. She stated she did not use sanitizer on the gun or the nozzle. She stated she only used sanitizer to wipe the juice machine hoses and the outside surface of the juice machine. Review of the undated beverage equipment cleaning instructions attached to the front of the juice machine indicated, Daily care and cleaning: 1. Detach the black nozzle from the dispensing gun. Twist counterclockwise and gently pull down. 2a. Soak the nozzle and dispensing gun in lukewarm water for 10 to 15 minutes. Do not use bleach or abrasive cleaners. 2b. Refill container with cleaner water, add sanitizer and soak for an additional 10 minutes. 3. Dry and reconnect nozzle to bar gun. 4. Wipe clean dispensing gun hose and drip tray with warm soapy cloth. During an interview on 6/7/23 at 1:50 p.m., DM acknowledged staff were not following cleaning instructions posted on the juice machine. 4. During an observation and interview on 6/7/23 at 1:40 p.m., with DA1, stated she used water and bleach to clean the outside of the juice machine. She provided a spray bottle container half filled with a clear liquid. The container had a label showing [name brand] multi-surface cleaner degreaser. DA1 stated spray bottle did not contain degreaser. She stated she mixed water and a little bleach and put it in the degreaser spray bottle. Review of the policy and procedure titled Hazard Labeling dated 2001, showed workplace labeling for hazardous chemicals not shipped directly from a manufacturer for distributor shall include either the product identifier, signal work, hazard statement, pictogram, precautionary statements, and information about the chemical manufacturer; or the product identifier, a method for conveying general information about the hazards of the chemical, and other information available to employees that provides specific information about the physical or health hazards of the chemical.

Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Milk was not provided as shown on the lunch menu for 55; 2. Incorrect servings of food were served to10 residents who received a pureed, minced and moist, or a mechanical soft diet. These failures had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents. Findings: Review of the policy and procedure titled Menus dated 2001, showed menus are developed following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. 1. Review of the Week 2 Therapeutic Spreadsheets dated Monday Cycle 2 2023, showed milk was listed for all diets on the lunch menu for all diets except clear liquid and renal diets. On 6/5/23 in an interview with Diet Aide 1 (DA1), the Dietary Manager (DM), and Registered Dietitian 1 (RD1) and an observation of trayline food service that started at 11:53 a.m., showed milk was not placed on the lunch trays. DA1 stated only two residents received milk on their tray because they requested it for their coffee, but no other residents received milk. DM confirmed residents did not receive milk on their tray. She stated all of the residents except for a couple did not want milk at lunch. She confirmed it was not shown residents did not like milk for lunch on the tray tickets. RD1 stated residents should receive milk for lunch because it was on the menu. She stated if a resident did not want milk for lunch, it should be stated on the meal ticket. The tray tickets showed 55 residents were on diets that allowed milk for lunch that day and did not show preferences for no milk. In an interview on 6/6/23 at 9:35 a.m., DM stated when milk was on the menu for lunch and was not provided to the residents. She also stated a substitute for milk was not provided. DM stated she did not have documentation to show residents did not like milk for lunch. On 6/8/23 starting at 12:54 p.m., three residents who were able to recall if they received milk for lunch were interviewed about their milk preferences. Resident 19 stated he did not receive milk for lunch, and he liked milk for lunch. Review of the tray tag for Resident 19, showed he was on an easy to chew, no added salt diet. There was no indication on his tray ticket that he could not have milk or disliked milk for lunch. Review of the MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.2 dated 4/24/2023, showed Resident 19 had a BIMS score (Brief Interview for Mental Status, a structured evaluation aimed at evaluating aspects of the cognition in elderly patients. A BIMS of 0-7 indicates severe cognitive impact) of 15. In an interview on 6/8/23 at 12:56 p.m., Resident 287 stated she did not receive milk for lunch, and she liked milk for lunch. Review of the tray tag for Resident 287 showed she was on a Regular diet. There was no indication on his tray ticket that he could not have milk or disliked milk for lunch. Review of the MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.2 dated 4/24/2023, showed Resident 287 did not have a BIMS score calculated yet because the MDS was not complete. On 6/8/23 at 1 p.m., an observation and interview with Resident 12, showed Resident 12 sat in the dining room eating his lunch. Resident 12 did not have milk on his tray. When Resident 12 was asked if he liked milk, he stated yes and he would love milk for lunch. Review of the tray tag for Resident 12 showed he was on a no added salt, regular diet. There was no indication on his tray ticket that he could not have milk or disliked milk for lunch. Review of the MDS 3.0 Nursing Home Comprehensive (NC) Version 1.17.2 dated 3/10/2023, showed Resident 12 had a BIMS score of 13. In an interview on 6/8/23 at 3:30 p.m., RD1 stated if residents did not want milk when it was on the menu, the residents should be provided with an appropriate substitute such as another dairy product. If a resident did not want dairy, a non-dairy substitute would be recommended. She stated if residents did not get what was listed on the menu on a regular basis, they residents would not receive enough protein and/or calories. 2. Review of the Therapeutic Spreadsheets dated Monday Cycle 2 2023, showed pureed diets received a number 6 scoop (4.5 ounces) of pureed chicken parmesan, and a number 8 scoop (3.7 ounces) of angel hair pasta. Mechanical soft diets received 4 ounces of ground parmesan chicken. On 6/5/23 an observation of trayline food service that started at 11: 53 a.m., and concurrent interviews with Cook 1 (C1) and RD1, C2 used a number 10 scoop (2.75 ounces) to serve one scoop of pureed chicken, a number 10 scoop to serve one scoop of pureed pasta, a number 10 scoop to serve one scoop of mechanical soft chicken. C2 stated there was only number 8 scoop available to use in the kitchen. RD 1 verified the portions served were incorrect. She stated pureed pasta should be served with a number 8 scoop, pureed chicken should be served with a number 6 scoop, and the serving for mechanical soft chicken should be 4 ounces, or a number 8 scoop.

Based on observation, interview and record review, the facility failed to ensure residents were served palatable food when food was bland and at a low temperature. This deficient practice placed the residents at risk of decreased nutrient intake leading to weight loss and/or nutritional medical complications for 61 residents who received food from the kitchen. Findings: During observation on 6/5/23 at 1:10 p.m., a meal delivery cart holding resident trays and two test trays left the kitchen. During an observation and interview with Dietary Manager (DM) on 6/5/23 at 1:16 p.m., a regular and puree texture meal was sampled immediately following the delivery of the last resident tray. The regular tray contained chicken parmesan with marinara sauce and pasta. The puree tray contained pureed chicken parmesan and pureed zucchini. Temperatures of the food were measured with the surveyor's calibrated thermometer. The pureed chicken was 113 Fahrenheit ( F), and the pureed zucchini was 104.9 F. The regular chicken parmesan was dry and regular pasta was very bland and dry. The pureed chicken felt barely warm in the mouth and the pureed zucchini felt barely warm in the mouth and tasted bland. DM stated pureed food was just warm and not hot enough to serve to the residents. DM also stated the pureed zucchini and regular pasta tasted bland and chicken parmesan patty was dry. Review of the policy and procedure titled Food and Nutrition Services dated 2001, showed each resident is provided with a palatable diet.

Based on observation, interview, and record review the facility failed to provide: 1. an alternate for gluten (a protein found in wheat, barley, and rye) containing food for one resident (Resident 288) who had a documented gluten allergy and a diagnosis of ulcerative colitis (a condition in which the lining of the large intestine (colon) and rectum become inflamed). 2. an alternate for garlic bread at a lunch meal for 61 residents who received food from the kitchen. This deficient practice had the potential to result in decreased nutrient intake leading to weight loss and/or nutrient related medical complications. Findings: Review of the facility's policy and procedure (P&P) titled, Menus, dated October 2017, showed if a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. 1. Review of the Admission Record showed Resident 288 was admitted on [DATE] with a primary diagnosis of ulcerative colitis. On 6/5/23 in an interview with Cook 1 (C1) and Cook 2 (C2) and concurrent observation of trayline food service that started at 11:53 a.m., C2 prepared a lunch tray for Resident 288. The tray ticket on the tray showed Resident 288 had a gluten allergy. C2 eliminated the pasta from Resident 288's tray and did not provide a substitute for the pasta. C1 stated the resident could not have starch. A review of the facility's Week 2 Therapeutic Spreadsheets, dated Monday Cycle 2 2023, indicated gluten-free was not on the therapeutic diet spreadsheet to show what to provide to a resident with a gluten allergy. During an interview on 6/6/23, at 10:48 a.m., with the Dietary Manager (DM), the DM stated she was aware that one resident was had a gluten allergy. DM acknowledged the facility did not have a menu for gluten free diet. During an interview on 6/8/23, at 3:25 p.m., with the Registered Dietitian (RD) 1, RD1 stated, Resident 288 had a diagnosis of ulcerative colitis so the resident's need for gluten-free food was therapeutic and should have a gluten-free diet. RD1 stated there should be an alternative list (a substitute from the same food group) but did not know if there was an alternate list for gluten-free foods. During an interview on 6/8/23, at 5:05 p.m., with the Cook 1 (C1), C1 stated there was no alternative list for gluten free diet. 2. Review of the facility's Week 2 Therapeutic Spreadsheets, dated Monday Cycle 2 2023, showed garlic bread was on the menu for every diet (except for clear and full liquid) on the spreadsheet On 6/5/23 an observation of trayline food service that started at 11:53 a.m., showed garlic bread was not served to any resident. During an interview on 6/5/23, at 12:19 a.m., with the C2, C2 stated garlic bread was not available and there no substitute is provided. During an interview on 6/5/23, at 12:20 p.m., DM the facility used pre-made garlic bread and if garlic bread was not available, they could substitute regular bread, but they had to ration the bread for sandwiches.

Based on observation, interviews, and record review, the facility failed to provide one person limited assistance during meals as specified in the latest nursing assessment of [DATE], in the plan of care and according to the recommendations by the speech therapist, for one (Resident 1) of three sampled residents. Resident 1 had a history of [REDACTED]. As a result of this failure, Resident 1 aspirated had a respiratory arrest and died later that day in the hospital. Findings: During a phone interview on [DATE] at 1:30 p.m., Resident 1's relative stated that Resident 1 required individual assistance with eating as she pocketed food (kept food in the cheek pocket after swallowing) and needed to be slowed down. The relative stated that he visited Resident 1 every evening to assist with dinner. Resident 1 had her meals in the 'assisted dining room' and doesn't speak English. In 2013, she had aspiration pneumonia (due to inhaled food) and that's when a diet consistency of pureed foods and thickened liquids was started. The relative stated, I got a call from the director of nurses (DON) that she (Resident 1) choked and 911 was called. The ER (emergency room ) doctor told me he found food in her lungs. Review of the medical record showed that Resident 1 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. (COPD is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing.) The MDS (minimum data set, complete resident assessment), dated [DATE], showed that Resident 1 required limited assistance of one staff for eating; (Limited assistance was defined in the MDS as Resident is highly involved in the activity and staff provide guided maneuvering of limbs or other non- weight- bearing assistance). The brief interview for mental status (BIMS) could not be conducted as resident rarely/ never understands. Review of the computerized and untitled care plan, with a revision date of [DATE], showed the following Focus or identified problem for Resident 1: The resident had an ADL (activities of daily living) self- care performance deficit related to dementia, impaired balance, late effects of CVA (stroke), activity intolerance, limited mobility, and confusion. One of the interventions listed, and initiated on [DATE], for the ADL deficit was: EATING: The resident requires assistance to eat (Specify- hand over hand, reminding, prompting, cueing, assistance). There was no change to this instruction since [DATE]. Another Focus listed on the computerized care plan showed, that Resident 1 had speech therapy for swallowing related to oral consistency- initiated [DATE] and resolved [DATE]. The intervention listed and dated [DATE] was: Ongoing Assessment of Swallow Efficiency . there was no resolution date. Continued review of the untitled care plan showed another Focus: The resident is at nutritional risk due to chewing and swallowing deficit, nectar thick liquids, [DIAGNOSES REDACTED]. The intervention showed, Assist resident with meals as needed. During interview and concurrent record review on [DATE] at 12:30 p.m., the director of nurses (DON) confirmed that Resident 1 was last evaluated by a speech therapist on [DATE]. This report showed a Discharge Status and Recommendation: Swallow strategies/ Positions -To facilitate safety and efficiency, it is recommended that the patient use the following: general swallow techniques/ precautions and guided bolus/ utensil placement and upright posture during meals (These may include preferable food consistencies, changes in the position of the head while eating and drinking, and maneuvers that may help keep the airway closed during swallowing.) .Feeding assistance at all meals. Supervision of Oral intake- Close supervision. During further interview the DON stated Resident 1 .feeds herself after set- up . During an interview on [DATE] at 2:10 p.m., CNA 1 stated, Last Friday at 12:45 p.m., we passed the trays. She (Resident 1) sits alone and eats independently. One of the tables was unsteady and the RNA (restorative nursing assistant) was fixing it. Resident 1 was hitting the table and I told CNA 2 she needs attention. CNA 2 went to her and her lips were blue. CNA 2 and LVN 1 did the Heimlich and RNA swept her mouth. We called a code blue. (The Heimlich Maneuver is a first aid procedure used to treat upper airway obstruction by standing behind a person and using hands to exert pressure on the bottom of the diaphragm in an effort to dislodge and expel food stuck in the trachea.) During interview on [DATE] at 2:15 p.m., CNA 2 indicated that no one assisted Resident 1 with her meal prior to the choking incident. CNA 2 stated, During lunch, we were still passing trays. She (Resident 1) likes to eat right away. She likes to feed herself. We assisted her by encouraging her. RNA was trying to fix the wobbly table next to her. I was helping with the table .Resident 1 was coughing and her color was changing and she was trying to reach RNA and hitting the table. I yelled for help and everyone came. The above staff interviewed, the DON and CNA 1 and 2, described that Resident 1 ate meals independently contrary to directions in Resident 1's nursing assessment, the care plan, and the speech therapist's recommendations that Resident 1 required supervision and one person feeding assistance at all meals. During interview on [DATE] at 1:50 p.m., LVN 1 (licensed vocational nurse) stated, I was giving meds to a resident in the dining room and, as I turned, I saw three CNA's with Resident 1, asking for help, saying, 'She's choking.' She was trying to speak but couldn't .Her color changed and I knew she was lacking oxygen. We lowered her to the floor. RN 1 brought the suction machine. We tried to suction; the material (suctioned) looked like mashed potatoes. During interview on [DATE] at 2:30 p.m., RN 1 (registered nurse) stated, I heard a commotion and they were wanting help. I saw them doing the Heimlich while Resident 1 was sitting in a chair. I saw her gasp for air and she was having difficulty breathing and trying to talk but no words came out. Her color changed and she passed out. We saw she was not breathing. During interview on [DATE] at 2:45 p.m., RN 2 stated, I was in the front station and was called to the big dining room. I saw the staff was with Resident 1, doing Heimlich. I got suction and oxygen and RN 1 and DON were there. Resident 1 looked like she can't breathe. I called 911 and said that she was eating, we think she aspirated, and CPR was in progress. Review of Resident 1's ER discharge summary showed, Date of Admission: [DATE]. Date of Expiration: [DATE]. Final Diagnosis: [REDACTED]. The Hospital Course: This [AGE] year old patient who has a history of severe dementia that has been progressive and has resulted in multiple aspiration events .Had a major aspiration event and presented after having a cardiac arrest which was induced by the respiratory arrest. The patient was found to have .a major amount of aspirate in her airway. The patient's chest x-ray demonstrated bilateral infiltrates (Pulmonary infiltrates may be caused by cardiac failure, adult [DIAGNOSES REDACTED] (ARDS), blood clot in the pulmonary veins, hemorrhage in the lungs and inhaled food particles.)