Every finding on record at Hillcrest Heights Healthcare Center

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a high risk elopement resident (1) from leaving the facility unnoticed. In addition, the facility failed to ensure transfer safety coordination was in place when the facility did not ensure the front entrance was secured and monitored in a manner that prevented the resident from leaving the facility unnoticed.As a result, Resident 1 eloped from the facility and required evaluation and observation in the emergency department (ED) after testing positive for methamphetamine (a highly addictive stimulant drug). The facility's failure to ensure safety coordination of transfer and monitoring resulted in Resident 1 not entering the facility and remained unattended in the community until located by emergency medical services. Resident 1 was admitted to the facility on [DATE] with diagnoses including vascular dementia (memory loss due to poor circulation to the brain) and psychoactive substance abuse (misuse of mind-altering drugs) per the facility admission record. A review of Resident 1's admission elopement assessment dated [DATE] indicated Resident 1 was categorized as a high risk for elopement. The assessment indicated that Resident 1 was ambulatory and had exit seeking behaviors with expressions of wanting to go home. A review of Resident 1's nursing note, dated 10/31/25 at 11:04 A.M., indicated at 10:30 A.M. the medication nurse reported Resident 1 was nowhere to be found, and the resident's roommate reported Resident 1 had verbalized she wanted to go to the welfare office. During an observation of the entrance to the facility on [DATE] at 1:20 P.M., the facility's wooden entry gate was open and the front door, equipped with a keypad lock, was unlocked and could be opened without entering a code. No alarm sounded when the door was opened.During an interview on 11/13/25 at 1:30 P.M., Resident 1 stated she left the faciity on [DATE] without telling anyone because she did not like living there. Resident 1 stated she walked out through the front door, which she reported was always open and that she could get freely in and out of. Resident 1 stated she did not tell anyone she left, and no one tried to stop her from leaving. Resident 1 stated she left to go to the welfare office to ask about finding another place to live. During an observation and interview with the Maintenance Director (MD) on 11/13/25 at 1:50 P.M., the emergency exit doors closest to Resident 1's room were inspected. The left door of the emergency double doors was not fully shut in alignment with the right door. The MD stated the emergency exit door should have been fully closed for the safety of all clients to ensure the alarm was fully activated. The MD acknowledged if the door was not fully shut the facility could not ensure the alarm was functioning properly. The MD stated the main front entrance was not set up to alarm on opening and was kept unlocked during the day because the facility receptionist is stationed at the front desk to monitor who is entering and exiting. During an interview and record review on 11/13/25 at 2:30 P.M., receptionist (RCPT) 1 stated she worked Monday through Friday from 12:00 PM to 5:00 P.M. and was not working at the time Resident 1 eloped on 10/31/25. RCPT 1 stated receptionists are responsible for monitoring the front doors while stationed at the front desk. RCPT 1 stated residents at risk for elopement have their information and picture placed in the elopement binder kept at the front desk. The elopement binder was reviewed, and Resident 1 was listed in the binder as high risk for elopement. RCPT 1 stated if she saw a high-risk elopement resident listed in the binder attempting to leave, she would try to stop the resident and notify the director of nursing (DON) or charge nurse. During an interview on 11/13/25 at 2:47 P.M., licensed nurse (LN) 1 stated she last saw Resident 1 around 8:00 A.M. on 10/31/25. LN 1 stated she was not aware that Resident 1 was assessed as high risk for elopement.During an interview with certified nursing assistant (CNA) 1 on 11/13/25 at 3 P.M., CNA 1 stated he saw Resident 1 in the dining room around 8:30 A.M. on 10/31/25. CNA 1 was not aware Client 1 was classified as high risk for elopement. A review of Resident 1's nursing note dated 11/1/25 at 5:30 P.M., indicated the hospital [name] notified the facility that Resident 1 was in the emergency department following the resident's elopement of the facility on 10/31/25.A review of hospital ED provider notes dated 11/1/25-11/2/25, indicated, Resident 1 tested positive for methamphetamine intoxication. The notes indicated Resident 1 was a current resident at the facility and discharge and transportation would be arranged with the facility following overnight for observation in the ED. A review of Resident 1's nursing note dated 11/2/25 at 5:45 A.M., indicated that the hospital registered nurse notified licensed nurse (LN) 2 that Resident 1 would be returning to the facility by taxicab. LN 2's note indicated, .staff will be looking out for her transportation and will meet her in the parking lot and bring her inside.A review of nursing notes dated 11/2/25 at 6:45 A.M., indicated that during morning huddle, staff prepared for Resident 1's return. The note indicated an unnamed certified nursing assistant reported seeing Resident 1 .walking on 6th Street toward the park. The note indicated LN 2 called the hospital and was informed the resident was no longer in the hospital and had been transported by taxi to the facility. During an interview on 11/17/25 at 2:02 P.M., the case manager for risk management (CMRM) at [name of hospital] stated the hospital discharged Resident 1 by taxicab at 5:48 A.M. on 11/2/25 after confirming facility readmission with LN 2. The CMRM stated the taxi company confirmed Resident 1 was dropped off in front of the facility, and the hospital later received a call from the facility stating Resident 1 had not entered the building. The CMRM stated the hospital nursing notes did not indicate the facility notified the hospital the Resident 1 needed supervised medical transportation due to elopement risk. During an observation on 11/25/25 at 10:50 A.M., upon entrance to the facility with the DON, the front door was noted to be unlocked and unalarmed. The reception desk was unstaffed, and no staff were present in the lobby area monitoring the entrance. During an interview on 11/25/25 at 11:00 A.M., receptionist (RCPT) 2 stated she was not working when Resident 1 eloped from the facility on 10/31/25. RCPT 2 stated Resident 1 had tried to leave the facility before eloping on 10/31/25 but had been stopped by staff in the parking lot. RCPT 2 stated she was unsure if Resident 1 wore a wandergaurd (bracelet that alarms when resident leaves facility). RCPT 2 stated monitoring the front door was part of the receptionist's job duties. RCPT 2 stated the front doors were unlocked and unalarmed during the day while a receptionist was present at the front desk. RCPT 2 acknowledge she had left the reception desk unattended today. RCPT 2 stated she left the reception desk occasionally to go to the bathroom or deliver a package. RCPT 2 stated that leaving the reception desk unattended presented a safety issue for residents at risk for elopement. During an interview on 11/25/25 at 11:16 A.M., LN 2 confirmed she received the discharge report at 5:45 A.M. on 11/2/25 and was informed Resident 1 would arrive at the facility around 6:15 A.M. LN 2 stated she did not confirm the transportation type or what company the hospital had booked to transport Resident 1 back to the facility. LN 2 stated she did not wait outside to meet Resident 1 but monitored the parking lot cameras from the nursing station. LN 2 stated she later learned staff had seen Resident 1 walking near the park. LN 2 stated she should have confirmed the hospital obtained supervised medical transportation for Resident 1's transfer back to the facility. LN 2 stated the facility did not have a procedure for ensuring safe transportation for residents returning from the hospital.During an interview and concurrent record review on 11/25/25 at 11:35 A.M. the director of nursing (DON) acknowledged Resident 1 was assessed as high risk for elopement on the initial admission elopement assessment, dated 9/5/25. The DON stated residents at high risk for elopement have their pictures and information placed in the elopement binder at the front desk. The DON stated Resident 1 did not have a wandergaurd bracelet on prior to the first elopement. The DON stated the receptionist on duty is expected to review the binder regularly to know who is at risk for elopement. The DON confirmed the front doors are unlocked during the day and the receptionist is expected to monitor the entrance. The DON stated the facility's usual practice was for the hospital case manager to communicate with the facility marketer regarding transportation, but in this case the nurse handled the transition of care. The DON stated the facility did not have a policy, procedure or system for confirming the type of transportation arranged or whether the resident would be supervised during the transition. The DON stated she did not believe the facility should be responsible for confirming the type of discharge transportation from the hospital for their residents. The DON stated she did not believe the facility could have done anything differently to prevent Resident 1 from not arriving to the facility safely or leaving again following the first hospital discharge.During an interview on 11/25/25 at 12:00 P.M., the administrator (Admin) acknowledged Resident 1 was assessed as high risk for elopement and left the facility unnoticed on 10/31/25. The Admin stated she did not believe the facility was responsible for confirming or ensuring safe transportation following Resident 1's hospital discharge. The Admin stated the facility did not do anything wrong and there was nothing else we could have done to ensure Resident 1's safe transition from the hospital to the facility upon acceptance of readmission to the facility. A review of the facility's elopement policy indicated no procedures addressing verification of safe or supervised transportation for residents identified at risk for elopement returning from the hospital.

Based on interview and record review, the facility failed to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1). This failure placed Resident 1 at risk for an unsafe discharge and rehospitalization. Findings: During a record review on 5/23/25, Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included infective endocarditis (an infection of the heart), abnormalities of gait and mobility, and need for assistance with personal care. During a record review on 5/2325, Resident 1's Minimum Data Set (MDS-an assessment tool) dated 4/2/25 indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 1 had intact cognition (pertaining to memory, judgement and reasoning ability). On 5/23/25 at 10:24 A.M., an interview was conducted with Resident 1 in his room. Resident 1 stated on 5/20/25, he was informed by facility staff that he needed to discharge from the facility. Resident 1 stated, They told me this place was for older people .that my insurance stopped paying or something .that I don't need to be here anymore because I'm high functioning . Resident 1 stated he was not high functioning because he still needed assistance with ADL's (Activities of Daily Living- dressing, transferring, bathing, and toileting). Resident 1 stated on 5/21/25, he was discharged to [Sober Living Facility]. Once he arrived at [Sober Living Facility], .staff [at Sober living facility] said they weren't equipped for me. Resident 1 stated he was incontinent of bladder and bowel, and there was no staff available who was able to provide incontinent care. Resident 1 stated on 5/21/25, staff at [Sober living facility] called 911 and had him transferred to the hospital, because he felt out of breath. Resident 1 stated he was transferred back from the hospital back to [Skilled Nursing Facility] later that day. Resident 1 stated one of the ladies [from the skilled nursing facility] promised me that [Sober Living Facility] had caregivers there, but they did not. It's a sober living mental health place, not a caregiving place .they couldn't help me to the bathroom, or change me, or anything . On 5/23/25 at 10:54 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was familiar with Resident 1 and had provided care for him in the past. CNA 1 stated Resident 1 was always incontinent and He never uses the bathroom. I've never seen him walk . CNA 1 stated Resident 1 required assistance with showering and transferring from bed to wheelchair. On 5/23/25 at 11:10 A.M., an interview was conducted with CNA 2. CNA 2 stated she had provided care for Resident 1 in the past. CNA 2 stated Resident 1, never went to the toilet himself. He would urinate and have bowel movements in his brief, and I always had to change him . CNA 1 stated Resident 1 needed assistance with dressing, showering, and transfers. CNA 1 stated, He gets tired and gets out of breath easily, so he isn't able to help much . On 5/23/25 at 1:26 P.M., an interview was conducted with the Social Services Director (SSD). The SSD stated prior to discharging on 5/21/25, Resident 1 voiced concerns regarding [Sober living facility]. The SSD stated, His concern was there wasn't going to be someone to assist him to and from the wheelchair, or to the toilet. The SSD stated the Case Manager spoke with Resident 1 and assured Resident 1 that [Sober living facility] had caregivers who could help him with ADL's. The SSD stated, If someone is incontinent, they shouldn't go there . On 5/27/25 at 11:16 A.M., a telephone interview was conducted with [Sober living facility representative-REP 1]. REP 1 stated [Sober living facility] was provided housing for residents for 90 days. REP 1 stated, We do not offer any type of medical or physical assistance .ADL's (Activities of Daily Living) must be independently done by the resident . REP 1 stated, .our facility got information that [Resident 1] was independent and could manage all his ADL's. On the paperwork it was specified that he can walk without assistance. It was to my surprise that when he arrived [to Sober living facility] we saw the resident needed assistance . REP 1 stated she was not aware that Resident 1 was incontinent and needed assistance with ADL's. REP 1 stated, We would not have accepted the resident because we would not have been able to meet his needs physically or medically . A review of Resident 1's MDS dated [DATE] indicated Resident 1 was able to perform ADL's at the following levels: Oral hygiene: partial/moderate assistance Toileting hygiene: substantial/maximal assistance Upper body dressing: partial/moderate assistance Lower body dressing: substantial/maximal assistance Putting on/taking off footwear: substantial/maximal assistance Personal hygiene: substantial/maximal assistance The MDS dated [DATE] also indicated Resident 1 was frequently incontinent of urine and bowel. On 6/6/25, an interview was conducted with the Director of Nursing (DON). The DON stated the facility was responsible for ensuring Resident 1 was discharged to a facility that was able to meet his needs. The DON stated, .[Resident 1] should not have been discharged to [Sober Living Facility] because they could not take care of him. They would not have been able to provide his care needs . The DON stated it was her expectation that residents were discharged to the appropriate facilities to avoid rehospitalizations and readmissions. During a record review on 6/6/25, the facility policy titled Discharge Summary and Plan dated 12/2016 indicated, The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident .and will include: The degree of caregiver/support person availability, capacity and capability to perform required care .What factors may make the resident vulnerable to preventable readmission; and .how those factors will be addressed .

Based on an interview and record review, the facility failed to (1) Notify the physician of the change of condition [rashes on the head] and monitor skin changes for one of three sampled residents (Resident 3) and (2) Thoroughly assess and document Resident 3's condition following an unwitnessed fall. As a result, Resident 3 experienced delayed care, and the medical record did not accurately reflect the resident's condition, potentially impacting their health and safety. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses that included hypertension (abnormal blood pressure), per the Admission Record. A review of Resident 3's medical record was conducted. Per the Shower Sheet, dated 1/25/25, Licensed Nurse (LN) 2 documented Resident 2 had rashes on top of the head and above the forehead. There was no documented evidence that the physician was notified of the rashes or monitoring. Per the Progress Notes, dated 1/26/25 at 12:48 P.M., LN 2 documented that Resident 3 reported falling over a month ago and hitting her head. Resident 3 also stated she had a wound on top of the head. LN 2 further documented that Resident 3 had no change in level of consciousness, and no signs or symptoms of bleeding were noted. However, there was no documented evidence of the wound description, including its appearance or size, before the hospital transfer. A further review of Resident 3's medical record was conducted. There was no fall incident documented. LN 2 was not available for an interview. Per the hospital report, titled General Medicine History and Physical, dated 1/26/25, Resident 3 went to the emergency department with purulent (pus) drainage from the a wound on the scalp. On 5/21/25 at 1:15 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated any change of condition [such as fall, rashes or wound] should have been reported to the physicians and documented. The ADON further stated the LNs should have document detailed observations of the wound. Per the facility's policy and procedure, revised 5/2017, titled Change in Resident's Condition or Status, .Our facility should promptly notify .attending physician .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .

Based on observation, interview, and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure increased the risk that the residents' wishes would not be honored. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included aftercare following surgery, per the Admission Record. On 5/8/25, a review of Resident 1's medical record was conducted. Resident 1 was discharged from the facility on 4/18/25. There was no evidence that a discharge care plan was developed. On 5/8/25 at 11 A.M., an interview was conducted with the Social Service Director (SSD). The SSD stated that a care plan should have been done on admission. Resident 1 did not have a discharge care plan and the facility should have ensured the resident was discharged according to the plan. On 5/08/25 at 12:55 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the discharge care plan should have been developed to meet residents' needs. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body), per the Admission Record. On 5/8/25 at 12:35 P.M., Resident 2 was observed sitting on the transport wheelchair. Resident 2 stated that he was discharged today at 2 P.M. and did not know where he was going. On 5/8/25, a review of Resident 2's medical record was conducted. There was no evidence that a discharge care plan was developed. On 5/8/25 at 1:15 P.M., an interview was conducted with the SSD. SSD stated that Resident 2 did not have a discharge care plan and should have had one in place. Per the facility's policy and procedure, reviewed 1/2023, titled Care Plans - Baseline, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within fourty-eight (48) hours of admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment . Per the facility's policy and procedure, reviewed 1/2023, titled Care Plans, Comprehensive Person-Centered, .A comprehensive. person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on interview and record review, the facility failed to develop an effective discharge plan that ensured residents' discharge goals were identified and addressed for one of three sampled residents (Resident 2). As a result, Resident 2 felt rushed, unheard, and unprepared to transition to the next care setting, which affected the continuity of care. (Cross-reference: F-655, Baseline Care Plans) Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body), per the Admission Record. A record review of the facility's census and list of residents scheduled for discharge was conducted. The facility indicated that Resident 2 will be discharged today [5/8/25]. On 5/8/25 at 12:35 P.M., Resident 2 was observed holding a cell phone and sitting on the transport wheelchair. Resident 2 stated that yesterday [5/7/25], he was told by the Social Service Director (SSD) that he would be discharged today [5/8/25}. Resident 2 stated he indicated his concerns [like finance and wheelchair], and the SSD did not seem to want to listen to him. Resident 2 stated that the SSD appears to have decided that he will leave, regardless of the circumstances. Resident 2 further stated that he did not know where he was going and was told that transportation would pick him up by 2 P.M. on 5/8/25. Resident 2 further said he tried to call his family members to let them know. On 5/8/25 at 12:44 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that the process for discharging a resident involved the licensed nurse (LN) informing them of who would be discharged at the beginning of their shift so that they could prepare the resident's belongings. CNA 1 stated the LN did not inform her of Resident 2's discharge today and received the information through Resident 1. CNA 1 stated that Resident 2 was upset, looking for his belongings, and she was doing her best to gather them all. On 5/8/25 at 12:55 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated the SSD would provide them with a copy of the resident's name and the day of discharge. LN 1 stated Resident 2 was not scheduled to be discharged today. However, when LN 1 reviewed Resident 2's medical record, the SSD documented that Resident 2 would be discharged today with transport scheduled. In addition, Resident 2 did not have a care plan or a physician's order for discharge. On 5/8/25 at 1:15 P.M., an interview was conducted with the SSD. The SSD stated that Resident 2 had agreed to leave on that day, and she found a placement for him. The SSD denied having knowledge of Resident 2's concerns. The SSD stated she should have created a discharge care plan for Resident 2 and ensured the resident's preference was considered for placement. On 5/8/25 at 1:30 P.M., an interview with the Administrator (ADM) was conducted. The ADM stated that a care plan should have been created to ensure residents' needs were prepared before discharge. Per the facility's policy and procedure, dated 12/2016, titled Transfer or Discharge, Preparing a Resident for, .Resident will be prepared in advance for discharge .A post-discharge plan is developed for each resident prior to his or her transfer or discharge .

Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and failed to accurately and timely administer resident medications, when: 1. The Controlled Drug Records (accountability records) for four out of seven randomly selected residents (Residents 91, 86, 81, and 11) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability of controlled medications and the potential for accidental duplicate medication administration; and 2. The pharmacy did not provide Resident 30's Creon (brand name for pancrelipase, a medication for the pancreas) for 13 days. This failure could result in ineffective management of Resident 30's pancreatic insufficiency (inability to properly digest food due to pancreas dysfunction); and 3. Nursing staff failed to administer one medication as ordered by the prescriber for one out of seven residents (Resident 3). This failure resulted in Resident 3 receiving a dose of metformin (a medication for diabetes) without food which could cause side effects such as diarrhea and upset stomach. Findings: 1a. Resident 91 had a physician order, dated 11/24/24, for oxycodone (a controlled narcotic medication for pain) 10 milligrams (mg), one tablet by mouth every four hours as needed for severe pain. During a concurrent interview and record review on 1/7/25 at 10:24 A.M. with licensed nurse (LN) 1, Resident 91's oxycodone 10 mg Controlled Drug Record (CDR) and December 2024 MAR were reviewed. LN 1 confirmed the CDR indicated the nursing staff signed out one tablet on the following date and time but did not document the administration on the MAR (total of one dose): - 12/7/24 at 12 A.M. 1b. Resident 86 had a physician order, dated 10/12/24, for hydrocodone with acetaminophen (a controlled narcotic medication for pain, generic for Norco) 10-325 mg, one tablet by mouth every four hours as needed for moderate to severe pain. During a concurrent interview and record review on 1/7/25 at 10:24 A.M. with LN 1, Resident 86's Norco 10-325 mg CDR and January 2025 MAR were reviewed. LN 1 confirmed the CDR indicated the nursing staff signed out one tablet on the following date and time but did not document the administration on the MAR (total of one dose): - 1/3/25 at 2:30 P.M. 1c. Resident 81 had a physician order, dated 7/29/24, for oxycodone 5 mg, one tablet by mouth every six hours as needed for severe pain. During a concurrent interview and record review on 1/7/25 at 11:19 A.M. with LN 2, Resident 81's oxycodone 5 mg CDR and January 2025 MAR were reviewed. LN 2 confirmed the CDR indicated the nursing staff signed out one tablet on the following date and time but did not document the administration on the MAR (total of one dose): - 1/2/25 at 9 A.M. 1d. Resident 11 had a physician order, dated 7/4/24, for Norco 5-325 mg, one tablet by mouth every six hours as needed for moderate and severe pain. During a concurrent interview and record review on 1/7/25 at 11:19 A.M. with LN 2, Resident 11's Norco 5-325 mg CDR and January 2025 MAR were reviewed. LN 2 confirmed the CDR indicated the nursing staff signed out one tablet on the following date and time but did not document the administration on the MAR (total of one dose): - 1/3/25 at 8:30 A.M. During a concurrent interview and record review on 1/7/25 at 1:37 P.M. with the Assistant Director of Nursing (ADON), the Controlled Drug Records and MARs for Residents 91, 86, 81, and 11 were reviewed. ADON acknowledged the following controlled medications were unaccounted for: - Resident 91: one tablet of oxycodone 10 mg - Resident 86: one tablet of Norco 10-325 mg - Resident 81: one tablet of oxycodone 5 mg - Resident 11: one tablet of Norco 5-325 mg The ADON stated the nursing staff need to document the administration of pain medications in the MAR. During an interview on 1/9/25 at 9:27 A.M., the DON verified she was aware of the discrepancies in the controlled drug medical records for Residents 91, 86, 81, and 11. The DON stated the expectation is that every time the nurse administers a narcotic medication, the nurse documents the administration in the CDR and the MAR. The DON stated documentation in the MAR is important as proof that the resident received the medication. The DON also stated a concern of inaccurate MAR documentation is accidental duplicate administration of narcotic pain medications. A review of the facility's policy and procedure titled, Preparation and General Guidelines IIA5: Controlled Medication, dated April 2008, indicated: .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): .Date and time of administration .Amount administered .Initials of the nurse administering the dose on the MAR after the medication is administered . 2. During an interview on 1/7/25 at 11:40 A.M., Resident 30 stated she had been discharged from the hospital two weeks ago with a new medication to take with meals for her pancreas. Resident 30 stated someone at the facility told her that her insurance would not cover the pancreas medicine and she could not afford to pay for the medication herself. Resident 30 verified she had not received this medication since her re-admission to the facility on [DATE]. Resident 30 had a physician order, dated 12/24/24, for Creon 24,000-76,000 units, Give 2 capsule by mouth with meals for PANCREATIC INSUFFICIENCY. During a telephone interview on 1/7/25 at 3:24 P.M., the Consultant Pharmacist (CP) stated the pharmacy delivered Resident 30's Creon to the facility on [DATE] at 7:04 P.M. During a follow up telephone interview on 1/7/25 at 3:41 P.M., CP verified this was the first delivery of Creon for Resident 30. During a telephone interview on 1/8/25 at 12:48 P.M., Pharmacist 1 (PH 1) stated the pharmacy received orders for Resident 30's Creon on 12/24/24. PH 1 stated the first time the pharmacy filled and delivered Resident 30's Creon was on 1/6/25. PH 1 stated the pharmacy notified the facility that the medication was not covered by insurance and requested a signature on the authorization form, Urgent Notice of Non-Covered/High-Cost Drug, to dispense. PH 1 then stated the pharmacy received the signed authorization form to deliver the medication on 1/5/25. PH 1 verified Resident 30 did not receive Creon from the pharmacy from 12/24/24 until 1/6/25. PH 1 stated the facility has discretion to sign the authorization form. PH 1 stated there is no alternative medication for Creon. During an interview on 1/8/25 at 3:21 P.M., the DON stated Resident 30 received the first Creon dose on 1/7/25 because the first Creon delivery was on 1/6/25. The DON verified Resident 30 did not receive any doses between 12/24/24 and 1/7/25. The DON stated the facility noticed Resident 30's Creon was missing on 1/5/25 and contacted the pharmacy to follow up on the delay. The DON stated she submitted the signed authorization form after talking to the pharmacy on 1/5/25. The DON stated the insurance issue for Creon was identified by the facility on 1/5/25. The DON also stated when resident medications are missing, the nurse should follow up with the pharmacy. The DON stated Resident 30 was supposed to start Creon on 12/25/24 at the facility. During an interview on 1/9/25 at 8:12 A.M., the DON stated she was investigating whether any facility staff had contacted the pharmacy between 12/25/24 and 1/5/25 to follow up on the Creon. The DON did not provide evidence of facility contacting the pharmacy prior to 1/5/25 to the surveyor. A review of the signed authorization form Urgent Notice of Non-Covered/High-Cost Drug, signed and dated 1/5/25 by the DON for Resident 30, indicated: .Option 1: Pay for current medication as per below .Drug Name and Strength: Creon . and .Option 3 - No Covered Alternative (if this option is checked by pharmacy, Facility staff must select option 1 and sign below) . A review of the Consolidated Delivery Sheets, dated 1/6/25 at 12:52 P.M., indicated delivery confirmation of 100 capsules of Creon for Resident 30 to the facility. A review of the Creon Administration Notes for Resident 30, dated 12/24/24 to 1/9/25, indicated: - 12/25/24 at 9:55 A.M.awaiting for delivery . - 12/25/24 at 1:26 P.M.not covered with insurance awaiting for dlivery [sic] . - 12/26/24 at 7:48 A.M.awaiting delivery from pharmacy . - 12/26/24 at 12:31 P.M.f/u with pharmacy . - 12/26/24 at 4:45 P.M.med unavailable. pharmacy notified . - 12/27/24 at 9:46 A.M.Awaiting pharmacy to delivery . - 12/27/24 at 2:45 P.M.No med awaiting for pharmacy to dliver [sic] . - 12/29/24 at 8:36 A.M.Med unavailable, waiting for pharmacy delivery. Will administer when arrived . - 12/29/24 at 11:44 A.M.Med unavailable, waiting for pharmacy delivery. Will administer when arrived. MD aware . - 12/30/24 at 9:15 A.M.Med unavailable, waiting for pharmacy delivery. Will administer when arrived. MD (medical doctor) aware . - 12/30/24 at 11:39 A.M.Med unavailable, waiting for pharmacy delivery. Will administer when arrived. MD aware . - 1/1/25 at 8:07 A.M.not covered by insurance . - 1/1/25 at 4:22 P.M.no meds available. pharmacy notified . A review of the facility's policy and procedures titled Medication Ordering and Receiving from Pharmacy IC3: Ordering and Receiving Medications from the Dispensing Pharmacy, dated January 2022, indicated: .Medications and related products are received from the dispensing pharmacy on a timely basis . and .New medications .are ordered as follows: If needed before next regular delivery, inform pharmacy of the need for prompt delivery . and .New Admission/Re-admission Orders .Facility .indicates whether a new supply of medication is needed from the pharmacy . and .A licensed nurse .Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor .Assures medications are incorporated into the resident's specific allocation prior to the next medication pass . A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Creon, dated 2/6/12, retrieved from DailyMed, indicated: .CREON is indicated for the treatment of .pancreatic insufficiency in adult and pediatric patients . 3. During a concurrent medication pass observation and interview on 1/6/25 at 11:34 A.M., LN 3 was observed preparing and administering one medication to Resident 3. There was no meal tray observed in Resident 3's room during the medication pass observation. LN 3 stated lunch starts at noon and had not started yet. During an interview on 1/6/25 at 11:56 A.M., Resident 3 stated he had not had his lunch yet. Resident 3 had a physician order, dated 9/20/24, for metformin (a medication to treat diabetes) 500 mg, Give 1 tablet by mouth two times a day for DM [diabetes] Give with meals. Breakfast and lunch only. The orders indicated to hold if the resident refuses to eat or has PO [by mouth] intake under 50%. During an interview on 1/9/25 at 9:29 A.M., the DON stated the expectation when orders indicate to give medication with food is for the nurse to give the medication with a meal or a snack. The DON agreed the expectation is for the medication nurse to follow the prescriber's orders. A review of the Prescribing Information for metformin tablets, dated 9/6/12, retrieved from DailyMed indicated: .Metformin .should be given in divided doses with meals .to reduce gastrointestinal side effects, and .Common side effects .include diarrhea, nausea, and upset stomach .Taking your medicine with meals can help reduce these side effects . A review of the facility's policy and procedures titled Administering Medications, dated December 2012, indicated: .Medication must be administered in accordance with the orders, including any required time frame . and .Medication must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on interview and record review, the facility failed to ensure one of one resident (Resident 30) was free of a significant medication error when the facility did not give Creon (brand name for pancrelipase, a medication for the pancreas) to Resident 30 for 13 days. This failure resulted in Resident 30 having digestive symptoms and had the potential for worsening of her medical conditions. Findings: During an interview on 1/7/25 at 11:40 A.M., Resident 30 stated she had been discharged from the hospital two weeks ago with a new medication to take with meals for her pancreas. Resident 30 stated the hospital told her that her pancreas is failing and she needs to take a pancreas medication with breakfast, lunch, dinner, and snacks. Resident 30 verified she had not received her pancreas medication since her re-admission to the facility on [DATE]. Resident 30 stated since her re-admission, she noticed her stool had a worsened slimy film (also known as oily stool) than in the hospital. While rubbing her upper abdomen, Resident 30 also stated she noticed more pancreas pain since her return to the facility. Resident 30 stated that on 1/6/25, she had an episode of sudden onset nausea and vomited dark coffee colored liquid into a trash can while with facility staff. Resident 30 also stated she had a bowel movement while vomiting. When she checked afterwards, she noted a bright orange oily glob in her undergarments. Resident 30 stated she was embarrassed by this incident and did not tell facility staff about the orange glob. Resident 30 stated she was scared to walk around in case she had another accident with her bowels. Resident 30 stated she wanted to continue taking the pancreas medication from the hospital. A review of Resident 30's medical record indicated a physician order, dated 12/24/24, for Creon 24,000-76,000 units, Give 2 capsule by mouth with meals for PANCREATIC INSUFFICIENCY (inability to properly digest food due to pancreas dysfunction). Resident 30 had an additional physician order, dated 12/24/24, for Creon 24,000-76,000 units, Give 1 capsule by mouth as needed for PANCREATIC INSUFFICIENCY WITH SNACKS PRN (as needed). During a telephone interview on 1/7/25 at 3:41 P.M., the Consultant Pharmacist (CP) verified the pharmacy first delivered Resident 30's Creon to the facility on [DATE] at 7:04 P.M. The CP stated she did not think the facility would go this long without giving the resident this medication. The CP stated if the resident is not getting the medication, the facility staff need to inform the physician. The CP stated Creon is an enzyme medication. The CP also stated every medication is important and given to residents to improve quality of life. The CP stated if the resident is not getting Creon, the concerns are digestive issues, including poor absorption of nutrients, bloating, and discomfort. When informed Resident 30 reported episodes of oily stool, the CP stated there can be different type of stool if the resident does not get the enzyme medication to break down food. During an interview on 1/8/25 at 11:19 A.M., Resident 30 stated she received the first dose of Creon on 1/7/25. Resident 30 reported continued abdominal pain and oily stool. Resident 30 stated she feels better now that she is getting the medication. During a telephone interview on 1/8/25 at 12:48 P.M., Pharmacist 1 (PH 1) stated the pharmacy received orders for Resident 30's Creon on 12/24/24. PH 1 stated the first time the pharmacy filled and delivered Resident 30's Creon was on 1/6/25. PH 1 stated the pharmacy received signed authorization from the facility to deliver the Creon on 1/5/25. During a telephone interview on 1/8/25 at 1:10 P.M., Pharmacist 2 (PH 2) stated 100 capsules of Creon should last 13 days for Resident 30 based on the physician's orders. PH 2 stated he calculated a 13 day supply for Resident 30 assuming she ate three meals and one or two snacks per day. When PH2 was asked the risks of Resident 30 not receiving Creon doses for multiple days, PH 2 stated Resident 30 would not be able to digest food properly and there is a risk of inadequate nutrition. PH 2 stated nausea and differences in bowel movements would be effects of missing doses of Creon. During an interview on 1/8/25 at 3:21 P.M., the Director of Nursing (DON) verified Resident 30 had active orders for Creon with meals and snacks for pancreatic insufficiency. The DON stated Resident 30 received the first dose of Creon on 1/7/25. The DON stated the facility noticed the missed Creon doses on 1/5/25 and notified the physician. The DON stated Resident 30 was supposed to start Creon on 12/25/24 at the facility. During an interview on 1/8/25 at 4:42 P.M., the Medical Director (MD 1) verified he was first informed of the missing doses of Creon on 1/5/25. MD 1 stated if a resident misses one day of medication, the physician needs to be informed. MD 1 stated oily stool could be caused by poor absorption due to the pancreas and means the dietary fat was not broken down. MD 1 verified pancreatic insufficiency is a long-term condition. During an interview on 1/9/25 at 9:06 A.M., Resident 30 stated she has pain in her stomach radiating to her lower back and the pain is an eight out of 10. During an interview on 1/9/25 at 9:29 A.M., the DON stated the expectation when orders indicate to give medication with food is for the nurse to give the medication with a meal or a snack. The DON agreed the expectation is for the medication nurse to follow the prescriber's orders. During a telephone interview on 1/9/25 at 9:54 A.M., Physician 2 (MD 2) stated he ordered Resident 30 to continue the Creon from the hospital. MD 2 stated he was informed a couple days ago about the facility not giving Creon to Resident 30. MD 2 stated resident could have flank pain, vomiting, and loss of appetite due to not getting the medication. When informed of interview with Resident 30 regarding her pain in stomach and lower back, MD 2 stated the pain is concerning for the pancreas and he was not aware. When informed of interviews with Resident 30 reporting oily stools, nausea, and vomiting, MD 2 stated he was not aware of these symptoms. MD 2 stated the presence of pain, nausea, and oily stools could be related to Resident 30 not getting the Creon. MD 2 stated these symptoms are the reason Resident 30 needs Creon. During an interview on 1/9/25 at 10:44 A.M, Resident 30 stated her pain in her lower back is an eight out of 10. Resident 30 stated she informed MD 1 of her pain before the interview. Resident 30 stated the hospital said her pancreas is failing and she wants to take care of herself. A review of the Nurses Notes for Resident 30, dated 1/5/25 at 6:51 P.M., indicated .Resident noted to have missed 3 or more doses of medication Creon .MD/NP (nurse practitioner) aware. Will contact pharmacy for eta (estimated time of arrival) of medication . A review of the Nurses Notes for Resident 30, dated 1/7/25 at 8:26 P.M., indicated .Resident c/o (complained of) abdominal discomfort. Assessment shows hardening of abdomen, loose stool .MD/NP notified . A review of Resident 30's December 2024 MAR for Creon two capsules with meals, dated 12/25/24 to 12/31/24, indicated: - 14 out of 21 entries marked 9=Other/See Progress Notes - Two of 21 entries marked 14 = Will administer when available. MD notified - Five of 21 entries incorrectly marked as administered (cross reference F842). A review of Resident 30's January 2025 MAR for Creon two capsules with meals, dated 1/1/25 to 1/9/25, indicated: - 14 of 26 entries marked 8 = Medication Not Available .Notify MD . - Four of 26 entries incorrectly marked as administered (cross reference F842) - Six of 26 entries marked as administered. A review of Resident 30's Nutrition Documentation for meal intake, dated 12/26/24 to 1/8/25, indicated Resident 30 ate three meals every day. A review of Resident 30's December 2024 MAR for Creon one capsule as needed with snacks, dated 12/24/24 to 12/31/24, indicated zero administration entries. A review of Resident 30's January 2025 MAR for Creon one capsule as needed with snacks, dated 1/1/25 to 1/8/25, indicated zero administration entries. A review of Resident 30's Nutrition Documentation for HS (bedtime) Snacks, dated 12/24/24 to 1/6/25, indicated Resident 30 ate a bedtime snack on 11 of 14 days. A review of Resident 30's care plans, dated 1/5/25, indicated .Resident missed 3 or more doses of medication Creon . and .Notify MD/NP of missed doses of medication . A review of the facility's policy and procedures titled Administering Medications, dated December 2012, indicated: .Medication must be administered in accordance with the orders, including any required time frame . and .Medication must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . A review of the facility's policy and procedures titled Adverse Consequences and Medication Errors, dated April 2014, indicated: .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders . and .Examples of medication errors include .Omission - a drug is ordered but not administered .

Based on interview and record review, the facility failed to ensure medical records were accurate and concise for two of two residents (Residents 30 and 71), reviewed for medical records accuracy when: 1. Resident 30's medication administration records (MARs) for Creon (brand name for pancrelipase, a medication for the pancreas) incorrectly indicated nine doses were administered between 12/25/24 - 1/9/25, when the medication was not administered and was unavailable; and 2. Resident 71's Dialysis Communication Form, post assessment listed a graft, (an internal surgically created connection between an artery and a vein that allows for hemodialysis treatment), instead of a Perma-cath, (a central line inserted into a main vein). These failures had the potential to result in inaccurate documentation of the resident's medical history and response to care. Findings: 1. During an interview on 1/7/25 at 11:40 A.M., Resident 30 stated she had been discharged from the hospital two weeks ago with a new medication to take with meals for her pancreas. Resident 30 verified she had not received this medication since her re-admission to the facility on [DATE]. Resident 30 had a physician order, dated 12/24/24, for Creon 24,000-76,000 units, Give 2 capsule by mouth with meals for PANCREATIC INSUFFICIENCY. During a concurrent observation and interview on 1/7/25 at 10:50 A.M. at Medication Cart #4 with licensed nurse (LN) 4, a sealed bottle of Creon 24,000-76,000 units was noted in the top drawer. The Creon bottle was labeled for Resident 30 and indicated a pharmacy fill date of 1/6/25. LN 4 stated Resident 30 will start this medication the following day. During an interview on 1/8/25 at 11:40 A.M., Resident 30 stated she got her first dose of Creon with lunch on 1/7/25. Resident 30 stated she only got one dose of Creon on 1/7/25. A review of Resident 30's January 2025 MAR indicated Resident 30 received a Creon dose on 1/7/25 at 8 A.M., before the observation of the sealed Creon bottle on 1/7/25 at 10:50 A.M. During a concurrent interview and record review on 1/8/25 at 3:21 P.M. with the Director of Nursing (DON), Resident 30's December 2024 and January 2025 MARs were reviewed. The December 2024 MAR indicated Resident 30 received a Creon dose on the following dates and times: - 12/25/24 at 5 P.M. - 12/28/24 at 5 P.M. - 12/29/24 at 5 P.M. - 12/30/24 at 5 P.M. - 12/31/24 at 5 P.M. The January 2025 MAR indicated Resident 30 received a dose on the following dates and times: - 1/3/25 at 5 P.M. - 1/4/25 at 5 P.M. The DON stated Resident 30 received the first dose of Creon on 1/7/25. The DON verified Resident 30 did not receive the doses above as documented in the MAR. During an interview on 1/9/25 at 9:27 A.M., the DON stated documentation in the MAR is important as proof that medication was administered to the resident. During a concurrent observation, interview, and record review on 1/9/25 at 1:13 P.M. at Medication Cart #4 with LN 5, LN 5 did a physical count of Resident 30's Creon capsules. LN 5 counted 88 capsules of Creon remaining in the bottle. LN 5 verified the sealed bottle contained 100 capsules. LN 5 verified the January 2025 MAR for Resident 30's Creon indicated a total of 16 Creon capsules had been administered to Resident 30 since 1/7/25 at 8:09 A.M. LN 5 stated the Creon bottle should have 84 capsules remaining based on the entries in the January 2025 MAR. A review of the facility's policy and procedure titled, Charting and Documentation, dated July 2017, indicated: .All services provided to the resident .shall be documented in the resident's medical record .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . and .Documentation in the medical record will be objective .complete, and accurate . 39220 2. Resident 71 was admitted to the facility on [DATE], with diagnoses which included dependence on renal dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly), per the facility's Face Sheet. An observation and interview was conducted with Resident 71 on 1/7/25 at 2:21 P.M. Resident 71 was sitting up in bed, eating lunch. Resident 71 stated she just got back from a dialysis treatment and showed me her Perma-cath (a central line covered with a gauze), located on her upper right chest wall. Resident 71 stated she goes to dialysis three times a week, on Tuesday, Thursday, and Saturday early in the morning. Resident 71's clinical record was reviewed on 1/07/25: According to the physician orders, dated 10/22/24, monitor vital signs pre and post dialysis and right chest Perma-cath (a central line for blood access) for signs and symptoms of bleeding, swelling, redness and pain. According to the care plan, titled Right upper chest Perma cath, undated, interventions listed included: Monitor for signs and symptoms of bleeding, swelling, redness, and pain. Notify medical doctor if observed. The facility's Dialysis Communication book (a form that communicates to dialysis team of resident's vital signs and Perma-cath site, dialysis documentation of what occurred while at dialysis, and a post assessment, once resident returns to the facility of vital signs and Perma-cath site) from 12/3/24 through 1/7/25 was reviewed. Of the 16 communication forms completed during that time frame, five forms were inaccurate. The five forms (dated 12/3/24, 12/27/24, 12/19/24, 12/23/24, and 1/2/25) listed on the post assessment, that Resident 71 had a graft site (an internal surgically created connection between an artery and a vein that allows for hemodialysis treatment), instead of a Perma-cath. An interview and record review was conducted with the Director of Staff Development (DSD) on 1/8/25 at 10:45 A.M. The DSD stated dialysis grafts can only be assessed by checking the bruit (listening) and checking the thrill (feeling) the site, since the graft is internal. The DSD stated Perma-caths were assessed visually by checking for bleeding and signs of infection. The DSD stated she had been at the facility for four months and had not provided any in-services or education to Licensed nurses regarding the dialysis access sites. An interview and record review was conducted with Licensed Nurse 7 (LN 7) on 1/8/25 at 10:53 A.M., regarding post dialysis assessments. LN 7 stated with Perma-caths there is no bruit and thrill, those can only be assessed on dialysis grafts. LN 7 was asked to review the post dialysis form she completed on 12/19/24. LN 7 stated she documented there was a dialysis graft with a bruit and thrill and did not document the resident had a Perma-cath instead. LN 7 stated she knows the difference between the two and she made an error. LN 7 stated it was important to document accurately, so everyone reviewing the record knew what was going on with the resident. An interview and record review was conducted with LN 8 on 1/08/25 at 11:11 A.M. regarding post dialysis assessments. LN 8 stated it was very important to conduct post dialysis assessments to identify potential problems or complications. LN 8 reviewed a post dialysis assessment she completed on 12/23/24. LN 8 stated she documented Resident 71 had a bruit and thrill, which was inaccurate because the resident actually had a Perma-cath. An interview and record review was conducted with the Director of Nursing on 1/8/25 at 11:14 A.M., of Resident 71's Dialysis Communication Forms. The DON stated post dialysis assessments were important to identify early signs of bleeding, infection, or complications. The DON stated she recently presented dialysis training to the nurses, during their annual skills assessment. The DON reviewed Resident 71's five Dialysis Communication Forms, indicating a graft was present. The DON stated the documentation was not accurate and could cause confusion to the reader. According to the facility's policy, titled Dialysis Communication Form, undated, .9. Licensed Nurse will evaluate the resident's condition including but not limited to vital signs, dialysis access site .and skin condition upon return .and will document on the post-dialysis assessment (bottom part) communication form . According to the facility's policy, titled Charting and Documentation, dated July 2017, .7. Documentation of procedures and treatment will include care specific details, including: a. The date and time the procedure/=treatment was provided .d. How the resident tolerated the procedure/treatment .

Based on observation, interview, and record review, the facility failed to honor resident food preferences listed on their resident's meal tickets, for five of 88 residents (Residents 1, 11, 49, 75, 151), reviewed for Resident Accommodations. This failure had the potential for resident's wishes, likes, and dislikes to be ignored. Findings: A lunch tray line observation was conducted in the kitchen on 1/8/25 at 12:10 P.M. The lunch meal consisted of oven crisp fish, sweet potato fries or brown rice, seasoned carrots, wheat roll, and cranberry crunch bar for dessert. 1. On 1/8/25 at 12:24 P.M., the lunch tray for Resident 1 was viewed and compared to the meal ticket. On the plate was fish, sweet potato fries, carrots, and a wheat roll. Listed on the meal tickets was a dislike for fish. The dislike was pointed out to staff after the plate had been covered and was getting ready to load on the metal wheeled food cart. The fish was removed by the cook and a cooked hamburger patty was place instead of the fish. An interview was conducted with Resident 1 on 1/9/25 at 9:08 A.M., in her room. Resident 1 stated she was told by someone she had been losing weight. Resident 1 stated she did not like some of the food. Resident 1 stated if fish was served to her, she would not eat it. 2. On 1/8/25 at 12:48 P.M., the lunch tray for Resident 11 was viewed and compared to the meal ticket. On the plate was a small piece of fish, sweet potato fries, carrots, and a wheat roll. Listed on the meal ticket was a preference listed as Portion: Double meat, fish, eggs. The preference portion was pointed out to the staff, after the plate had been covered and was getting ready to load on the metal wheeled food cart. The plate was given back to the cook, who added another portion of fish. An interview was conducted with Resident 11 on 1/9/25 at 9:11 A.M., in her room. Resident 11 was sitting up in bed, with her breakfast tray covered and untouched on the bedside table. Resident 11 stated she was in pain and did not feel like eating. Resident 11 stated she was aware she was losing weight and was trying not to. Resident 11 stated she liked to have extra meat, fish or eggs on her plate, because it was usually the only thing she ate. 3. On 1/8/25 at 1:07 P.M., the lunch tray for Resident 75 was viewed and compared to the meal ticket. A like was listed on the meal ticket as soup, with a dislike of Tomato soup. A covered bowl of tomato soup had been added to the tray, with a package of crackers on top. After the plate had been covered and the tray was getting ready to be added to the metal wheeled food cart, the dislike of tomato soup was pointed out to Kitchen Aide 1 (KA 1). KA 1 removed the soup bowl. On 1/9/25 at 9:20 A.M., an interview was conducted with Resident 75, in her room. Resident 75 stated she loved soup, but she hated tomato soup specifically. Resident 75 stated she would not get upset if it was given to her, she just would not eat it. 4. On 1/8/25 at 1:14 P.M., the lunch tray for Resident 151 was viewed and compared to the meal ticket. The meal ticket listed the diet as Vegetarian, Fortified. The plate was viewed which consisted of a cooked meat patty. The cook was questioned if the patty on the plate was meat or vegetarian. The cook stated he ran out of cooked veggie patty and gave no explanation of the reason meat was served in its place. The cook immediately began to cook a veggie patty, which was later plated. On 1/9/25 at 9:24 A.M., an interview was conducted with Resident 151 in her room. Resident 151 stated she had been a vegetarian since 4 years of age. Resident 151 stated if meat was served to her, she would be able to immediately tell. Resident 151 stated she just would not eat it (meat), and it would not upset her. 5. On 1/8/24 at 1:19 P.M. the lunch tray for Resident 49 was viewed and compared to the meal ticket. Served on the tray was a homemade cranberry bar dessert. On the meal ticket, listed a dislike of cranberry sauce. After the plate had been covered and the tray was getting ready to be added to the metal wheel cart, KA 1 was notified of the dislike. The dessert was removed, and vanilla ice cream was added in its place. On 1/9/25 at 9:29 A.M., an interview was conducted with Resident 49, as he laid in bed. Resident 49 stated, No, I don't like cranberry sauce or anything related to cranberries. Resident 49 stated if it was served to him, he just would not eat it. An interview was conducted with the Food Nutrition Service Manager (FNS) on 1/8/24 1:50 P.M. The FNS stated she expected all preferences to be honored and respected. An interview was conducted with the Registered Dietician (RD) on 1/8/25 at 4:05 P.M. The RD stated all resident food preferences should be honored, because it was a resident's right. The RD stated she expected all kitchen staff to review the meal cards and compare them to the plated meal during service. According to the facility's policy, title Food Preferences, dated 2023, Resident food preferences will be adhered to within reason .Procedure: Food preferences will be obtained as soon as possible through the initial resident screen. This screening must be completed within 7 days of admission by the Food Nutrition Services Director .

Based on observation, interview, and record review, the facility failed to ensure resident safety for one of three residents (Resident 50), identified as requiring a smoking apron while smoking, when reviewed for accidents. This failure had the potential for Resident 50's clothing to catch fire when smoking. Findings: Resident 50 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's Admission Record. An observation was conducted of Resident 50 on 1/6/25 at 10:10 A.M. Resident 50 was sitting outside in the smoking area with four other resident's, including a smoking monitor (a person who supervises smoking residents and hands-out smoking material). Resident 50 was wearing a protective smoking apron and holding a cigarette in his right hand. An observation was conducted of Resident 50 on 1/7/24 at 8:10 A.M. Resident 50 was outside smoking with three other residents and a smoking monitor was present. Resident 50 was not wearing a protective smoking apron and was holding a lit cigarette in his right hand. An interview was conducted with the Smoking Monitor (SM 1) on 1/7/25 at 8:11 A.M. SM 1 stated there was only one resident who required a protective apron while smoking which was identified as Resident 1. Resident 50's clinical record was reviewed On 1/7/25: According to the annual Minimum Data Set (a clinical assessment tool), dated 10/25/24, Resident 50 had a cognitive score of 5, indicting severe impaired cognition. The Health Condition section indicated Resident 50 was not a user of tobacco products. According to the facility's Smoking Safety Evaluation, dated 10/21/24, Resident 50 was identified as a smoker, who consumed 2-5 cigarette a day. Resident 50 was required to wear a smoking apron for protection and staff were required to extinguish the resident's cigarette. According to the care plan, titled Resident at risk for smoking related injury, revised 12/11/24, interventions included; Supervise resident per Smoking Assessment. A follow-up interview was conducted with SM 1 on 1/7/25 at 2:45 P.M. SM 1 stated his supervisor had communicated to him that Resident 50 needed a smoking apron. SM 1 stated Resident 50 was upset with him one day about wearing the apron, so SM 1 stopped putting the apron on Resident 50. SM 1 stated Resident 50 could be harmed when not wearing the apron, because his clothing could catch on fire. SM 1 stated he knew he should have put the apron on Resident 50. SM 1 stated there were three residents who required smoking aprons and Resident 50 was one of them. An interview was conducted with Licensed Nurse 6 (LN 6) on 1/7/25 at 2:50 P.M. LN 1 stated Smoking Assessments were completed by Licensed Nurses. LN 1 stated if LNs determined a smoking apron was required for safety reasons, then the resident should always wear an apron while smoking. LN 6 stated if a required smoking apron was not put on, the resident could be at risk of burns if their clothing caught fire. LN 6 stated their job was to keep the residents safe. An interview was conducted with the Director of Nursing (DON) on 1/7/25 at 2:56 P.M. The DON stated if the Smoking Assessment indicated a protective apron was required, then she expected staff to ensure the apron was in place when the resident was smoking. According to the facility's policy, titled Safe Smoking-Resident, dated August 2022, .2. Resident's will be assessed by the IDT (Interdisciplinary Team) .The assessment is to determine if the Resident is ale to smoke safely and not harm themselves . 3. As identified by the Safe Smoking Assessment', Residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied/unsupervised .

Based on observation, interview, and record review, the facility failed to accurately assess and code one of three residents (Resident 50) on their annual Minimum Data Set (MDS-a clinical assessment tool which is a Federal requirement to be submitted to Centers for Medicare and Medical Services {CMS}) who was identified as a smoker, when reviewed for Comprehensive Assessments. This failure had the potential for CMS to be unaware of Resident 50's current health status. Findings: Resident 50 was admitted to the facility on ,d+[DATE]//23, with diagnoses which included dementia (progressive memory loss), per the facility's Admission Record. An observation was conducted of Resident 50 on 1/6/25 at 10:10 A.M. Resident 50 was sitting outside in the smoking area with four other residents and a smoking monitor (a person who supervises smoking residents and hands-out smoking material). Resident 50 was wearing a protective smoking apron and holding a cigarette in his right hand. An observation was conducted of Resident 50 on 1/7/24 at 8:10 A.M. Resident 50 was outside smoking with three other residents and a smoking monitor was present. Resident 50 was not wearing a protective smoking apron and was holding a lit cigarette in his right hand. Resident 50's clinical record was reviewed On 1/7/25: According to the annual Minimum Data Set (a clinical assessment tool), dated 10/25/24, Resident 50 had a cognitive score of 5, which indicated severe impaired cognition. The Health Condition section indicated Resident 50 was not a user of tobacco products. According to the facility's Smoking Safety Evaluation, dated 10/21/24, Resident 50 was identified as a smoker, who consumed 2-5 cigarette a day. Resident 50 was required to wear a smoking apron for protection and staff were required to extinguish the resident's cigarette. According to the care plan, titled Resident at risk for smoking related injury, revised 12/11/24, interventions included: Supervise resident per Smoking Assessment. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 1/7/25 at 3:01 P.M., of Resident 50's annual MDS dated [DATE]. The MDSN stated when Resident assessments were completed for MDS, he reviewed the physician orders, nursing notes, assessments, and care plans first. The MDSN stated if a resident was identified as a smoker, it would be listed in Section J, Health Condition in MDS. The MDSN reviewed Resident 50's annual MDS, dated [DATE], and stated Resident 50 was listed as a non-smoker, which was incorrect. The MDSN stated he missed it, and the annual MDS was incorrect. The MDSN stated the harm to the inaccurate MDS assessment was CMS was not informed of the resident's smoking status. An interview was conducted with the Director of Nursing (DON) on 1/8/245 at 4:30 P.M., The DON stated she expected the MDS's to be accurate, so CMS had an accurate picture of what was currently going on with the resident. According to the Resident Assessment Instrument (RAI-a tool used by the MDSNs to code and submit accurate MDS data) dated October 2019, .Section J1300, Health-related Quality of Life: The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed .

Based on observation, interview, and record review, the facility failed to follow the posted menu. In addition, two of 88 residents (Resident 32 and 86) did not receive a fortified (foods with nutrients added to them), meal as ordered, when reviewed for nutritional needs. This failure had the potential for residents' nutritional needs to not be met. Findings: A lunch tray line observation was conducted in the kitchen on 1/8/25 at 12:10 P.M. The lunch meal consisted of oven crisp fish, sweet potato fries or brown rice, seasoned carrots, wheat roll, and cranberry crunch bar for dessert. 1. An observation was conducted on 1/8/25 at 1:23 P.M., during lunch tray line service in the kitchen. Some lunch trays contained white rice, in lieu of the sweet potato fries. The posted daily menu listed brown rice or sweet potato fries as being served with the fish. The cook was questioned about the white rice and went to view the posted menu. The cook stated It does indeed say brown rice. The cook stated, I did not look at it closely and made white rice instead. The cook stated the Registered Dietician was unaware white rice was made, instead of brown rice. An interview was conducted with the Food Nutrition Service (FNS) manager on 1/8/25 at 1:50 P.M. The FNS stated when white rice was served instead of brown rice the cook was not following the menu. An interview was conducted with the Registered Dietician (RD) on 1/8/25 at 4:05 P.M. The RD stated brown rice contains more fiber and nutrients then white rice. The RD stated she should have been notified the posted menu was not being followed, to ensure residents were getting all their nutrients. According to the facility's policy, titled Meal Planning, dated 2023, .3. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet .Only the Facility Registered Dietician or FNS Director can make permanent changes. The FNS Director is to receive the Facility Registered Dietician's approval for any permanent changes .Menu changes should also be noted on the menus on the consumers board and any other menus which may be posted . 2a. Resident 32 was admitted to the facility on [DATE], with diagnoses which include moderate protein-calorie malnutrition per the facility's Admission Record. An observation of the lunch tray line was conducted on 1/8/25 at 12:20 P.M. Resident 32's meal was compared to the plate prepared. The meal ticket listed fortified ground consistency with double meat, fish, eggs. The plate contained fish, carrots, and white rice. No fortified additive was noted. The cook was asked what fortified additive was being used. The cook stated, melted butter on the vegetables and rice, if indicated The cook stated, I forgot to add the melted butter to Resident 32's meal. The plate was returned to the cook prior to putting on the food cart, and additional butter was added. 2b. Resident 86 was admitted to the facility on [DATE], with diagnoses which included displaced fracture of the right lower leg, per the facility's Admission Record An observation of Resident 86's lunch tray was compared to his meal ticket on 1/8/25 at 1:37 P.M., during tray line. Resident 69's meal ticket read, Fortified regular consistency. The plate contained fish, carrots, sweet potato fries, and dessert. No additional butter was added to the carrots. The plate was covered and getting ready to place on the food cart for delivery. The meal ticket was pointed out to staff that no fortified additive was present. The cook added butter to the carrots without commenting. An interview was conducted with the Food Nutrition Service Manager (FNS) on 1/8/25 at 1:50 P.M. The FNS stated fortified foods were required for residents experiencing weight loss. The FNS stated if the fortified additive were not added, they were not meeting the resident's nutritional needs. An interview was conducted with the Registered Dietitian (RD) on 1/8/24 at 4: 05 P.M. The RD stated fortified additives were important to provide residents experiencing weight loss with additional calories. The RD stated if the residents were not getting their fortified additives, it could be contributing to their weight loss. According to the facility's policy, titled Fortification of Foods: Increasing Calories and/or Protein in the Diet, dated 2023, .Identification of residents in need of fortification will be done by the facility's Registered Dietician or the FNS Director. The physician will then order a Fortified Diet.Calories and/or protein will be added to selected food .FNS staff will be familiar with the fortification process for each item chosen to be used at the facility .

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of two residents (Resident 1). This failure had the potential to cause psychosocial harm because Resident 1 was unable to understand instructions and explanations of treatments and care that was being given by the facility staff. Findings: On 11/7/24 at 10:30 A.M. Resident 1 was interviewed with the assistance of a translator, (Resident 1 communicates primarily in Spanish). Resident 1 stated she had used the call light to ask for assistance when using a beside commode. Resident 1 stated she was unable to communicate in English with CNA 1, who had answered her call light to provide assistance. Resident 1 explained she was not able to use her hands to care for herself and was not able to communicate this in English to CNA 1. Resident 1 stated CNA 1 did not seem to understand her and started to shake the bedside commode and continued to give directions to Resident 1 in English. Resident 1 stated she was unsure about CNA 1's instructions. Certified Nursing Assistant 2 was interviewed on 11/7/2024 at 11:57 A.M. CNA 2 stated the facility's procedure for a resident who speaks another language would be to utilize the language line. CNA 2 stated a miscommunication could lead to not knowing a resident's needs or resident pain issues. CNA 2 stated, the facility would not be providing quality care if there was a miscommunication due to a language barrier. LN 1 (Licensed Nurse 1) was interviewed on 11/7/2024 at 12:05 P.M. LN 1 stated, the facility's policy was to use the language line. LN 1 stated I speak Spanish, so I would not use the language line for Spanish. LN 1 also stated if the language line is not used, there could have been miscommunication or assumptions about care related to Resident 1. LN 1 stated, quality of care could not be provided with poor communication. LN 1 stated Resident 1's anxiety could have increased with poor communication. The Director of Nursing (DON) was interviewed on 11/7/24 at 12:12 P.M. The DON stated when the language is Spanish, the staff could have utilized a Spanish speaking co-worker, a communication board, an on-line translator, or the staff could have used the language line. The DON stated to not receive instructions or care in the language Resident 1 understands could make Resident 1 uncomfortable and anxious. A concurrent interview and record review with the Director of Nursing (DON) on 11/7/2024 at 1:08 P.M was conducted. Per Resident 1's admission Minimum Data Set (MDS, a standardized tool to identify a resident's health needs and strengths to develop an individualized care plan) indicated that Resident 1's primary language was Spanish and that Resident 1 desired to have a translator when instructions were given, or when care was provided. The DON stated the MDS assessment triggered the need to create a communication care plan. The DON continued to state, the resident care plans were created by the MDS nurse and there should have been a care plan for communication and the need for a translator for Resident 1. Resident 1's active care plans were reviewed and there were no care plans for a Spanish language speaker. The DON stated, There is no care plan because it was probably missed. The DON stated, if a care plan had been in place there would have been better communication, understanding, and quality of care. Record Review of the facility's policy titled Care Plans, Comprehensive-Person Centered revised December 2016, the policy indicated .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of missing money for one of three residents (Resident 1) reviewed for Resident Rights under Grievances. As a result, Resident 1 ' s grievance was not promptly resolved and there was limited documentation to prove a thoughtful, meaningful investigation was conducted. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness on one side of the body) following cerebral infarct (stroke) affecting the left non-dominant side, per the facility ' s Admission Record. An observation and interview was conducted with Resident 1 on 10/16/24 at 11:50 A.M., within the resident ' s room. Resident 1 was dressed, groomed, and sitting in a self-propelling wheelchair. Also observed in his room was a walker with an adjustable seat, next to the bed. Resident 1 stated about two months ago, he realized he would need to sell his truck, since he could no longer afford the registration and insurance. Resident 1 stated he asked a family friend (FF) to sell the truck for him, since the friend owned an automotive business. Resident 1 stated the FF sold the truck and brought him $2500.00 in cash. Resident 1 could not remember what day the money was brought to him, but remembered it was sometime in August 2024. Resident 1 stated after he received the money for his truck, he asked the Social Service Director to take him to the bank, so he could open a savings account. Resident 1 stated the SSD told him they did not do things like that, but she would see what she could do to help him. Resident 1 stated the last time he saw his money was on Friday evening 8/16/24 around 10 P.M., as he was preparing for bed. Resident 1 stated he placed the $100.00 bills in a small Q-tip box and placed the Q-tip box inside the toe of his tennis shoe. Resident 1 stated he placed his wallet on top of the Q-tip box and then shoved his two socks up against them, to keep them in the toe of his shoe. Resident 1 continued, stating the next morning, an unknown certified nurse ' s assistant (CNA) was helping him get dressed. Resident 1 stated when he removed his socks, the wallet, and the Q-tip box from his shoe, he realized th Q-tip box had less bills inside. Resident 1 stated there was only one $100.00 bill left and someone had taken $2400.00, possibly while he had been sleeping. Resident 1 pointed to his seated walker and said he had placed his tennis shoes on top of the walker seat and did not hear anyone come into his room that night. Resident 1 stated all the staff knew he was selling his truck, because he talked about it constantly, telling them he did not want to sell it, but he had to. Resident 1 stated only two staff knew about the money, because he had told them about it. Resident 1 stated he never showed anyone the money and he did not tell anyone where he was hiding it. Resident 1 named the two staff members as Licensed Nurse 1 (LN 1) and a Certified Nurse ' s Assistant 1 (CNA 1), who both worked on the evening shift (3 P.M. through 11:30 P.M). Resident 1 continued, stating on the morning of 8/17/24 he immediately went to the charge nurse on the day shift (7 A.M. through 3:30 P.M.), saying he thought the charge nurse that day was LN 2, who he told about the missing money. Resident 1 stated he explained to LN 2 how he got the money. Resident 1 provided LN 2 his FF phone number, who LN 2 called to verify the money was given to Resident 1. Resident 1 stated he called the police department and filed a report that same Saturday. Resident 1 stated on Monday, 8/19/24, he filed a Grievance with the Social Service Director (SSD) and he spoke with the Administrator (ADM). Resident 1 stated the ADM informed him they would investigate it and get back to him. Resident 1 stated just recently, the ADM told him they would not be replacing the money, because no one saw the money and he should have given it to an LN to lock up, for safekeeping. Resident 1 stated he was informed if he had turned it over to an LN, they would have added the money to his inventory sheet, and there would have been a record, so the facility would have had to reimburse him. Resident 1 ' s clinical record was reviewed on 10/16/24: According to the quarterly Minimum Data Set (a clinical assessment tool), Resident 1 had a cognitive score of 15, indicating cognition was intact. According to the Functional Abilities, Resident 1 used a walker and a wheelchair, and required set-up assistance only. There was no documented evidence by any LN that the money had been reported missing on 8/17/24 or 8/18/24, and there was no documented evidence the FF had been contacted. According to the SSD note dated 8/19/24 at 3:11 P.M., Resident came to SS (social services) office regarding missing money $2400 that he got from selling his truck. Per resident he put his money in a Q-tip case with his wallet on top in his show with his socks jammed inside the show. Resident stated he last saw his money on Friday night after he counted the money and put it back into his shoe on top of his rollator walker. Administrator, case manager and SS went through all of resident ' s ' belongings again to make sure, SS also explained to resident the importance of money, valuable to inform department heads for safekeeping or [NAME] open up a trust account, resident agreeable. The next documentation regarding the missing money was on 9/9/24 at 11:12 A.M. by the SSD, SS met with resident following up with the missing money, per resident stated that he is doing well, but a little upset he didn ' t let the facility know that he was selling his truck and not letting the facility know he had that much money with him. Resident stated that he has the police report number in his e-mail, when he has access, he will provide number. The next and last documentation was on 9/18/24 at 5:01 P.M., by the Administrator, Resident came to office to discuss alleged missing $2400. Writer and DON (Director of Nursing) made follow up call to SDPD regarding resident ' s concern. Dispatcher stated that a report was made in August case # (case number) also verbalized that anything less than 10k (thousand) they will only conduct phone report. Dispatcher asked if there was any updated information Resident was re-educated on informing staff if he has money. Re-educated on resident trust and safe keeping of cash. The facility ' s Inventory of Personal Effects for Resident 1 was reviewed. The inventory list contained personal items, dated 6/12/23, with no additional items added after admitted [DATE]. An interview was conducted with the FF on 10/16/24 at 12:22 P.M. The FF stated he has known Resident 1 and his family for over [AGE] years. The FF stated Resident 1 asked him to sell his truck, which he did for $3000.00. The FF stated resident 1 instructed him to keep $200 for selling it and to keep another $200 to buy his staff lunch as a thank you. The FF stated he brought Resident 1 a total of $2600.00 in a bank envelope, all in $100 dollar bills. The FF stated he could not remember what day he brought the envelope with the money, but believed it was on a Tuesday. The FF stated he received a call from the facility and described the caller as a male nurse. FF stated the phone call from the facility occurred 1-2 days after the money was delivered to the resident. The facility nurse asked FF if he sold Resident 1 ' s truck and how much money the resident was given. The FF stated he answered all the staff member ' s questions and did not think any more about it. An interview was conducted with the SSD on 10/16/24 at 12:54 P.M. The SSD stated Resident 1 never asked her to take him to the bank to open an account. The SSD stated she knew Resident 1 would need a valid identification card to open an account, and currently the resident had no valid Identification. The SSD stated she had offered to assist the resident with obtaining a valid Identification card when he was ready, and he agreed. The SSD stated she learned of Resident 1 ' s missing money over the weekend, when she got a call from the staff. The SSD continued, stating when she returned to work on Monday, she searched the residence ' s room and assisted him with filing a grievance, The SSD stated the resident informed her that he had also filed a police report and he was instructed to give her the police report number, so she could follow up on the facility ' s investigation. The SSD stated she discussed the incident with the Administrator, and both were surprised he had been holding that amount of money. The SSD stated once the grievance was filed, the ADM took over the investigation. The SSD provided a copy of Resident 1 ' s grievance that was filed on 8/19/24. A review of the grievance indicated it was filed on 8/19/24 at 2 P.M. with an alleged occurrence date of 8/17/24 at 8 A.M. and a handwritten explanation of how and where the money was stored. There was no documented evidence of a written resolution to the grievance. An interview was conducted with LN 2 on 10/16/24 at 1:11 P.M. LN 2 stated he was not the nurse working on the morning of 8/17/24, and he did not call Resident 1 ' s friend to verify the selling of his truck or the money . LN 2 stated he learned of the allegation during stand-up, (when staff meet to discuss resident events or conditions over the last 24 hours) after the incident occurred. LN 2 stated his only involvement was asking Resident 1 if he was okay. LN 2 stated if Resident 1 reported the missing money to a nurse, the nurse should have documented the day and time it was reported, if the resident ' s room was searched, and who was notified or contacted. An interview was conducted with the ADM on 10/16/24 at 1:40 P.M. The ADM stated Resident 1 comes and talks to her several times a day, and he never mentioned to her that he was selling his truck or that he sold it and had money from the sell. The ADM stated when she returned to work on Monday 8/19/24, she talked with staff and could not find anyone who knew about the money or the selling of Resident 1 ' s truck. The ADM stated she interviewed two staff members, LN 1 and CNA 2, who denied seeing or taking any money. The ADM stated she did not interview any other staff members and she did not take any written statements. The ADM stated she did not contact the family friend to inquire on the selling of Resident 1 ' s truck. The ADM stated she could have performed a more thorough investigation and documented things better. The ADM stated the alleged missing money was not reportable because no one saw the money, no one witnessed the money, and the resident originally said he never told anyone about the money, so the allegation could not be substantiated. An interview was conducted with the Business Office Manager (BOM) on 10/16/24 at 2:26 P.M. The BOM stated if valuables were received after hours, she expected residents to inform the charge nurse, who would then lock the valuables in the medication cart until Monday morning, so the BOM could take over. The BOM stated in the facility ' Admission packet, all residents were provided with instructions about safeguarding valuables by locking them up in the business office safe or a personal lock box could be provided. Staff should always update the resident ' s inventory sheet with the valuables when they get turned over for safekeeping. A follow-up interview was conducted with the SSD on 10/17/24 at 12:42 P.M. The SSD could not recall which nurse called her at home on 8/17/24, but reviewed her personal cell phone log. The ADM stated the call came in to her on 8/17/24 at 10:29 A.M. The SSD was shown a list of the staffing for the day shift on 8/17/24, and stated it was the charge nurse LN 3, who called her. The SSD stated if LN 3 was informed that day of loss by the resident, there should be a nurses note. The SSD stated she was unaware Resident 1 had the money or where he got it from, and the whole story did not make sense. The SSD stated she provided the ADM with Resident 1 ' s grievance on Monday 8/19/24, because the grievance investigation was the ADM responsibility. The SSD stated Resident 1 had complained before about missing items from his room, such as a pen and other small things like that. An interview was conducted with LN 3 on 10/17/24 at 1:05 P.M. LN 3 stated he had been working on 8/17/24 when Resident 1 came to him and reported money was missing. LN 3 stated it was around 10 A.M. when the resident reported the missing money, and he was unsure of what he should do, so he informed LN 4 who was the MOD (Manager of the Day). LN 3 stated he and the MOD searched Resident 1 ' s room and then the MOD contacted the ADM via phone. LN 3 stated he was provided Resident 1 ' s friend ' s phone number from the resident, so he called the friend. The FF told LN 3 that he had sold Resident 1 ' s truck and brought the resident the money around 6 P.M. LN 3 recalled Resident 1 also speaking with the SSD over the phone. LN 3 stated he did not document the reported loss or who he contacted in the nurse ' s notes, but maybe he should have. LN 3 stated he had never been in this situation before, and no one told him to document it. An interview was conducted with the MOD, (LN 4) on 10/17/24 at 1:14 P.M. LN 4 stated he was contacted by LN 3 around 10 A.M. on 8/16/24, after Resident 1 reported money missing from his room. LN 4 did not know if the incident was reportable, so he contacted the ADM to explain the situation. The ADM informed him the resident was responsible for informing staff, so the money could be safeguarded. LN 4 stated he checked with staff, and no one was aware Resident 1 had that kind of money in his room. LN 4 stated he and LN 3 searched the resident ' s room and could not find the money. LN 4 stated he had no other involvement after he informed the ADM. A follow up interview was conducted with the ADM on 10/17/24 at 1:32 P.M. The ADM stated she should have conducted a better investigation and attached documentation of the investigation to the grievance. The ADM stated she also interviewed Resident 1 ' s roommate, but did not originally document the roommate ' s response. The ADM stated she should have provided a written response or resolution to the grievance. According to the facility ' s policy, titled Grievances/Complaints, Filing, dated April 2017, .3. All grievances, complaints or recommendation stemming from resident . Actions on such issues will be responded to in writing, including a rationale for the response 12. The resident or person filing the grievance Will be informed (verbally and in writing) of the findings of the investigation and the actions taken to be corrected any identified problems .

Based on observation, interview, and record review, the facility failed to update the care plan for one of three residents (Resident 1) reviewed for falls. As a result, Resident 1 had the potential to have further incidences of falls and/or injuries. Findings: A record review conducted on 9/23/24 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included repeated falls, dementia (a condition that causes forgetfulness, confusion and memory loss), and polyneuropathy (a disease which causes weakness, numbness and pain). A review of the Progress Note dated 8/23/24 at 10 A.M. indicated Resident 1 had an unwitnessed fall on 8/22/24. A review Resident 1 ' s Progress Note dated 8/29/24 at 10:10 A.M. indicated Resident 1 had an unwitnessed fall on 8/27/24. On 9/23/24 at 12:55 P.M., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the Interdisciplinary Team (IDT) determined the root cause of the fall on 8/22/24 was .dementia .Our main cause [of the fall] was dementia. The resident does not remember what they were doing . The ADON stated staff was in-serviced on falls, but there was no other intervention implemented. On 9/23/24 at 1:33 P.M. An interview was conducted with The Director of Nursing (DON). The DON stated the IDT did not determine the root cause for Resident 1 ' s falls on 8/22/24 and 8/29/24. The DON also stated Resident 1 ' s care plans did not address any new interventions to prevent future falls. The DON stated, We should have at least done labs .and had a more patient centered care plan, and tried to find a more established root cause . The DON stated not updating Resident 1 ' s care plan placed Resident 1 at risk for continued falls. A review of the facility policy titled Falls- Clinical Protocol, revised 3/18, indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable .if the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident ' s falling .and also reconsider the current interventions .

Based on observation, interview and record review, the facility failed to notify residents and/or the resident representatives when their care plans and physician ' s orders were updated to reflect exposure to Legionella bacteria (bacteria causing a serious lung disease) for three of three sampled residents (Resident 1, Resident 2 and Resident 3). As a result, residents and/or the resident representatives were not aware of the risks involved in being exposed to Legionella bacteria. In addition, the residents and/or the resident representatives were not involved in their plan of care. Findings: On 2/6/24, an unannounced onsite visit at the facility was conducted related to a reported facility ' s water testing positive for Legionella bacteria. During an interview and joint observation on 2/6/24, at 9:06 A.M. with the Assistant Director of Nursing (ADON), a sink at the nurse ' s station had a sign posted which indicated the sink was out of order. According to the ADON, the water from the sink tested positive for Legionella. The ADON stated residents and/or families have not been notified. Resident 1 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) according to the facility ' s Admission Record. Resident 2 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) according to the facility ' s Admission Record. Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) according to the facility ' s Admission Record. A review of the facility ' s water test result titled, Legionella Test Results Summary Log, dated 2/2/24 was conducted. The test result indicated, .Legionella Non-pneumophilia was detected at 6cfu/ml (colony forming unit per milliliter-the amount of bacteria) at the nurse ' s station in the hot water . During an interview and concurrent record review on 2/6/24, at 9:44 A.M. with LN 1, LN 1 stated physician ' s orders were obtained for all residents to be monitored for signs and symptoms of legionnaires ' disease. LN 1 stated care plans were also developed for all residents based on the physicians ' orders. LN 1 showed physician ' s orders and care plans for sampled Residents 1, 2 and 3 which indicated, .Legionella Disease S/S (signs and symptoms) MONITORING .every shift for 14 days . Resident 1, 2 and 3 ' s care plans indicated, At Risk for Altered Respiratory Status/Difficulty breathing R/T (related to) Potential Exposure to Legionella Bacteria . The Director of Nursing (DON) was interviewed on 2/6/24, at 10:50 A.M. The DON stated residents and families were not notified of the positive Legionella bacteria in the water. The DON stated it was her expectation for nurses to follow physician ' s orders and develop a care plan. The DON further stated residents did not need to be informed of physician ' s orders unless residents had a change in condition, but residents should be part of their care planning to know their plan of care. During review of the facility ' s policy and procedure (P&P) titled, Resident Rights Guidelines for All Nursing Procedures, revised October 2010, the P&P indicated .Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including .Resident notification of rights, services, and health/medical condition .Resident/Family participation in care planning .

Based on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. The Cook (CK) 1 did not perform hand hygiene consistently during food preparation, 2. The Dietary Aide (DA) crossed over from dirty station to clean station while working in the dishwashing station, and 3. Cook (CK) 1 and the Dietary Assistant Manager (DAM) were unable to verbalize the cool down process. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne pathogens to come in contact with the residents' food and may cause food borne illness to the residents. The facility's census was 91. Findings: 1. On 1/30/24 at 10:19 A.M., an observation and an interview of CK 1 was conducted. CK 1 put on a pair of gloves, did not perform hand hygiene. CK 1 put two ladle full of hot butter to the milk, added some water, then poured the mixture into the mixer. CK 1 stated he was preparing for mashed potato. CK 1 added parsley flakes, garlic powder and one and a half carton of complete mash potation into the mixer. CK 1 removed his gloves, opened the trash lid with bare hands and discarded the gloves. CK 1 then took a glove from the box, put it on his right hand, took out the mixer from its stand, and mix the mashed potato, holding the rim of the mixer with bare left hand. CK 1 then removed his glove from his right hand, opened the trash lid with bare hand and discarded the glove. CK 1 put on a new pair of gloves, separated the mashed potato into small and large metal trays, removed his gloves touching the lid of the trash bin, put on new pair of gloves, mixed the mashed potato in the metal trays before putting them away in the oven. CK 1 did not perform hand hygiene in between tasks. On 1/30/24 at 10:33 A.M., an observation and an interview of CK 1 preparing roast beef was conducted. CK 1 stated he will prepare for pureed roast beef. CK 1 poured gravy into the roast beef and placed them in the blender until the meat was pureed. CK 1 placed the pureed meat into the oven. CK 1 removed his gloves, threw them into the trash bin touching the lid of the bin, then put on a new pair of gloves. CK 1 took a small metal tray and stated he will make the ground meat. CK 1 completed the task without performing hand hygiene in between tasks. CK 1 stated he forgot to wash his hands during food preparation. CK 1 stated he should have washed his hands to prevent food contamination. On 2/1/24 at 12:02 P.M., a telephone interview was conducted with the Registered Dietician, with the presence of the Administrator (ADM) and the Dietetic Services Supervisor (DSS). The RD stated the expectation was the kitchen staff should be aware of handling food properly to prevent cross contamination and for them to wash hands between tasks to prevent foodborne pathogens. The facility's policy titled Food Preparation, dated 2023 was reviewed. The policy did not indicate infection control measures during food preparation. 2. On 1/30/24 at 10:07 A.M., an observation of Dietary Aide (DA) 1 was conducted in the dishwashing station. DA 1 was scraping foods from the plate, poured out water and juice from the cups, placed the plates and cups in a separate bin, loaded the bin over to the dishwashing machine, then he transferred over to the clean station to pick up the washed plates and cups from the dishwashing machine. DA 1 was observed crossing back to the dirty station and loaded another bin of plates and cups, then crossed over to the clean station to remove the washed plates and cups from the dishwashing machine. DA 1 did not perform hand hygiene and used the same gloves he used for loading the dirty plates and cups. DA1 used the same gloves to pick up the clean plates and cups from the dishwashing machine. On 1/30/24 at 11:10 A.M., an interview with DA 1 was conducted. DA 1 stated he scraped the food from the plates and utensils, placed them in bin then load them in the dishwashing machine. DA 1 stated he did the task by himself and crossed over from dirty station to clean station. DA 1 stated there should be two people assigned to the dishwashing station to prevent cross contamination. On 1/30/24 at 11:14 A.M., an interview with the DSS was conducted. The DSS stated there should be two staff assigned in the dishwashing station, one in the dirty station and the other one in the clean station to prevent cross contamination. On 2/1/24 at 12:02 P.M., a telephone interview was conducted with the RD, with the ADM and the DSS. The RD stated the expectation was for the dietary staff to separate dirty and clean area to prevent cross contamination. 3. During an interview with CK 1 on 1/30/24 at 10:47 A.M., CK 1 stated the cool down process was for left over foods. CK 1 stated the cool down process was to bring down the temperature to 90 degrees Fahrenheit for four hours until the temperature reached 40 degrees Fahrenheit. CK 1 stated the facility used ice bath to cool down foods. CK 1 stated if the food did not meet the cool down, CK 1 stated reheat the food at 175 degrees Fahrenheit for 30 seconds then follow the same process for total of four hours, then if it did not meet again, CK 1 stated food may be discarded. During an interview with the DAM on 1/30/24 at 10:49 A.M., the DAM stated the cool down process of food was to bring down the food temperature at 140 degrees Fahrenheit for two hours then let it cool until it reached 41 degrees Fahrenheit for a total of four hours. The DAM stated it was important to follow the cool down process because bacteria may grow and could affect the residents' health. During an interview with the DSS on 1/30/24 at 11 A.M., the DSS stated the importance of cooling down was for infection control to prevent growth of bacteria and prevent contamination. During a telephone interview with the RD with the ADM, and the DSS on 2/1/24 at 12:02 P.M., the RD stated the expectation was for the kitchen staff to be aware on the cool down process. The RD stated an in-service will be provided to the kitchen staff because the staff were not aware of the food cool down process. A review of the facility's policy titled, Cooling and Reheating of Potentially Hazardous Or Time/ Temperature Control For Safety Food, dated 2023, indicated, Cooked Potentially Hazardous Food .shall be cooled and reheated in a method to ensure food safety .The method is: Cool cooked food from 140 degree Fahrenheit to 70 degree Fahrenheit within two hours, then cool from 70 degree Fahrenheit to 41 degree Fahrenheit or less in an additional four hours for a total cooling time of six hours .

Based on interview, and record review, the facility failed to ensure a resident's right to be free from abuse when Resident 17 wandered into Resident 78's room. As a result, Resident 78 was punched on the right upper chest by Resident 17. FINDINGS: Resident 78 was admitted to the facility on [DATE]. The resident's diagnoses included but is not limited to chronic pain, falls and depression. A review of Resident 78's Minimum Data Set (MDS- an assessment tool), dated 12/26/23, indicated Resident 78's mental cognition, to understand and make herself understood. A review of Resident 78's History and Physical (H and P - a physician's assessment and examination of the resident), dated 12/22/23, indicated the resident has the capacity to understand and make her own decisions. Resident 17 was originally admitted to the facility on [DATE] with a recent re-admitted [DATE]. Resident 17's diagnoses include but is not limited to dementia (impaired ability to remember, think, or make decisions), falls and generalized anxiety disorder. A review of Resident 17's MDS, dated [DATE], indicated his mental cognition is severely impaired. A review of Resident 17's H and P, dated 1/10/23, indicated that Resident 17 can make needs known but not make medical decisions. On 1/31/24, at 10:20 A.M., during the facility's annual recertification survey, a Facility Reported Incident (FRI) was initiated by the survey team. FRI # 882588 was initiated with the Director of Nursing (DON). On 1/31/24, at 10:50 A.M., an interview was conducted with Resident 78 in her room. Resident 78 stated she heard a man's voice in the middle of the night around 1 A.M. Resident 78 stated she got into her wheelchair to check and saw that Resident 17 was inside her room. Resident 78 stated when she opened the door and when she asked Resident 17 to leave, he got angry and punched her on the right side of her upper chest near her neck. Resident 17 stated that Certified Nursing Assistant (CNA) 25 came to the room and took Resident 17 to his own room. Resident 78 then reported the incident to Licensed Nurse (LN) 26. Resident 78 stated she has told the staff that Resident 17 had come into her room on several different occasions and feels the staff has not done anything. Resident 78 stated that she is aware Resident 17 has mental issues but stated I do not feel safe or comfortable because he can come in my room, and he is not in his right mind. On 1/31/24, at 11:10 A.M., an interview was conducted with Resident 2, Resident 78's roommate. Resident 2 stated that Resident 17 has come into her room several times and can be verbally aggressive. Resident 2 stated she has witnessed Resident 17 go into her room and other people's rooms. On 1/31/24, at 11:21 A.M., an interview was conducted with CNA 21. CNA 21 stated that he knows Resident 17 very well. CNA 21 stated he knew about Resident 17 going into other resident's rooms. CNA 21 stated that Resident 17 has a history of verbal and physical aggression. CNA 21 stated that Resident 17 is not very easy to redirect and can be easily agitated. On 1/31/24, at 11:35 A.M., an interview was conducted with LN 22. LN 22 stated that he has witnessed Resident 17 many times go into staff rooms and into resident rooms. LN 22 stated he has witnessed Resident 17 to be verbally aggressive with staff and residents but only physically aggressive with staff. LN 22 states the staff monitor for Resident 17's aggressive behaviors because of his history and stated that we should be monitoring the resident more because of the incident that happened. On 1/31/24, at 11:46 A.M., an interview was conducted with LN 23. LN 23 stated that Resident 17 has a history of going into other people's rooms. LN 23 states that Resident 17 has a bad temper and has witnessed his aggressiveness. LN 23 stated he stands back when redirecting the resident because he is known to take swings with his hands towards other people. LN 23 stated that the staff should increase the monitoring of the resident to protect the other residents. On 1/31/24, at 4:25 P.M., an interview was conducted with CNA 24. CNA 24 stated he had witnessed Resident 17's verbal and physical aggressive behavior. CNA 24 stated that Resident 17 must be watched constantly if he is up in the wheelchair to make sure he does not enter other people's rooms. On 2/1/24, at 9:33 A.M., a phone interview was conducted with CNA 25. CNA 25 stated that she has known Resident 17 since he was first admitted to the facility. CNA 25 stated she was the CNA in charge of Resident 17 on 1/31/24 when the incident happened. CNA 25 stated she remembered Resident 78 shouting get him out of here! CNA 25 stated she heard a thud, and she quickly went into the room where she heard the shouting. CNA 25 stated she saw both residents in front of the doorway and brought Resident 17 to his room. CNA 25 stated she had seen Resident 17 go into other people's rooms many times. CNA 17 stated that Resident 17 goes into Resident 78's room a lot because it used to be his room. CNA 25 stated that Resident 17 should be monitored more closely when he is in a wheelchair. On 2/1/24, at 11:15 A.M., a concurrent interview and record review was conducted with LN 22. A review of Resident 17's medical record by LN 22 revealed there was not an assessment or care plan done for Resident's 17's known behavior of going into other resident's rooms. Further review of the medical record indicated that the known behavior was not addressed prior to the incident. LN 22 agreed that if the known behavior of Resident 17 going into other people's rooms would have been addressed, the chances of the incident could have been decreased. On 2/1/24, at 1:37 P.M., a concurrent interview and record review was conducted with The Director of Nursing (DON). The DON stated she was not aware of Resident 17's behavior of wandering into other rooms. The DON stated that if she had been notified by staff, she would have done an assessment and care plan for the resident going into other resident and staff rooms. The DON agreed that this behavior should have been assessed and implemented as part of his plan of care. A review of the facility policy titled Abuse Reporting and Investigation, dated 1/10/24, indicated that it is the facility's policy to keep residents safe and prevent from future or recurrent potential abuse .to ensure resident's safety and well-being .once admitted to the facility.

Based on observation, interview, and record review, the facility failed to provide a clean fan for Resident (5) to use. In addition, the facility failed to provide a homelike environment for one of two sampled residents (5) reviewed for homelike environment whose room had bubbling in the ceiling surface. As a result, Resident 5 did not feel comfortable with using a dirty fan or looking at a ceiling in need of repair. Findings: During a review of Resident 5's Admission Record dated 8/20/18, the Admission Record indicated Resident 5 was admitted to the facility from another nursing facility with diagnoses which included lung disease. During a review of Resident 5's history and physical (H&P) dated 11/19/19, the H&P indicated Resident 5 had the capacity to understand and make decisions. a. During an observation and interview with Resident 5 in her room on 1/29/24 at 10:16 A.M., Resident 5 was lying in bed, watching a movie. A standing fan was turned on with lint and brown substance (dust) in the fan blades and the blade guard. Resident 5 stated, Yes, I saw that, it was gross. No one comes and clean them. During a joint observation and interview with Licensed Nurse (LN) 1 on 1/29/24 at 10:30 A.M., LN 1 stated the housekeeping staff were responsible for cleaning the fans for the residents. LN 1 stated the standing fan was dusty and needed some cleaning. LN 1 stated the fan should have been kept clean for infection control purposes and to prevent Resident 5 from developing allergies because the fan blades circulated the dust and dirt into the air. LN 1 stated he would have the housekeeping clean the standing fan for Resident 5. During an interview with housekeeping staff (HSK) 1 on 1/31/24 at 9:01 A.M., HSK 1 stated housekeeping staff were responsible for cleaning the fans for the residents. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 2/1/24 at 9:22 A.M., the DON stated fans used for residents should have been kept clean to prevent respiratory issues. b. During an observation and interview with Resident 5 in her room on 1/29/24 at 10:16 A.M., Resident 5 was lying in bed, watching a movie. There was a bubbling or blistering on the ceiling near the electrical connection of the television in Resident 5's room. Resident 5 stated the ceiling had leaked when it rained hard last week. During a joint observation and interview with the maintenance director (MT) on 1/30/24 at 2:45 P.M., MT stated he was aware of the bubbles in the ceiling of Resident 5's room. MT further stated the ceiling needed to be fixed. During an interview with the Administrator (ADM) on 2/1/24 at 11:55 A.M., the ADM stated she did not notice the bubbling on the ceiling surface until it was pointed out by the maintenance director. The ADM stated the expectation was to provide the residents with a homelike environment. During a review of the facility's policy titled Homelike Environment, revised February 2021, the policy indicated, Residents are provided with a safe, clean, comfortable and homelike environment .

Based on observation, interview and record review, the facility failed to notify the physician regarding a significant weight loss for one of two sampled residents reviewed for nutrition. (Resident 69) This deficient practice had the potential to delay necessary care and services to prevent Resident 69 to have further weight loss. Findings: Resident 69 was readmitted to the facility on [DATE] with diagnoses including chronic kidney disease according to the facility's Admission Record. During an observation on 1/30/24, at 8:32 A.M., Resident 69 was in bed with unfinished food on her breakfast tray. Resident 69 stated she did not feel well and covered herself with a blanket. During an interview on 1/30/24, at 3:41 P.M. with Certified Nurse Assistant (CNA) 31, CNA 31 stated Resident 69 was independent with eating, but only ate less than 50% of her meals. CNA 31 stated Resident 69's family brought in bottles of a nutritional supplement and water. On 1/31/24 at 8:30 A.M., Resident 69 was observed in bed with a full breakfast tray untouched. During the interview, Resident 69 stated she did not like the cream of wheat, apple juice and the milk. Resident 69 stated she will drink the nutritional supplement [NAME] eat the vanilla pudding later. A concurrent record review on 1/31/24, at 11:32 A.M. was conducted with Licensed Nurse (LN) 33. LN 33 reviewed Resident 69's meal intake and stated Resident 69 ate 0-25% of her breakfast and 25-50% for lunch and dinner. LN 33 then reviewed Resident 69's weight record. Resident 69's weight record indicated: 10/2/23 110 lb (pounds), 11/7/23 111.5 lb, 12/3/23 111 lb, and 101 lb on 1/1/24. LN 33 stated Resident 69 had a 10 pound weight loss. LN 33 reviewed the progress notes and stated there was no documentation of physician notification regarding the weight loss. LN 33 further stated there was no change of condition form completed for Resident 69. LN 33 reviewed the Registered Dietician's (RD) note dated 1/4/24 and the RD's note indicated Resident 69 had a significant weight change in one month, three months and six months. LN 33 stated it was important to notify Resident 69's physician because it was an unusual occurrence and contributing factors needed to be assessed. LN 33 further stated the physician can provide orders such as lab draw, medication, or other referrals. During an interview on 2/1/24, at 12:02 P.M., with the Assistant Director of Nursing (ADON), the ADON confirmed the RD's progress note regarding Resident 69's significant weight loss. The ADON stated a list of residents who had significant weight loss was provided to the nursing staff to notify the physician, but Resident 69's weight loss was missed. An interview on 2/1/24, at 3:12 P.M with the Director of Nurses (DON) was conducted. The DON stated it was important to notify the physician regarding weight loss to address the resident's clinical issues. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 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 .)

Based on observations, interviews, and record reviews the facility failed to ensure the facility provided a safe, comfortable, and homelike environment when it did not ensure temperatures were within the required temperature range of 71 degrees - 81 degrees Fahrenheit (F) during an excessive heat wave [MEDICATION(S)] more than 7 days. The facility also failed to repair or replace inoperable roof mounted Air Conditioning (AC) units. As a result, 41 of 42 resident rooms (Rooms 20, 21 ,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 40, 41, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62) were more than 81 F, and 13 of the 42 rooms (Rooms 20, 21, 23, 25, 26, 29, 56, 57, 58, 59, 60, 61, 62) were between 90 F - 99 F. This had the potential to put residents at risk for heat exposure, dehydration, and possible death. Findings: On 9/1/22, the California Department of Public Health (CDPH) issued AFL (All Facilities Letter) 22-18 alerting all healthcare facilities of a Level II Extreme Heat Alert to have contingency plans in place to deal with the loss of air conditioning and take measures to ensure patients and residents are free of adverse conditions that may cause heat related health complications. On 9/4/22, the Department received a complaint regarding very high temperatures in the building hallways and resident rooms. An unannounced on-site visit was conducted on 9/4/22. Upon arrival at the facility on 9/4/22 at 4:22 PM, the afternoon sun was hitting the west facing rooms, and the building lobby was observed to be hot and humid. A tour of the facility was conducted. There were eight (8) large portable 1-ton AC units in the resident hallways blowing cold air, and several residents were sitting near the AC units. There were also large box fans located throughout the facility to distribute the air from the chillers towards the 42 resident rooms. The resident census was 83. On 9/4/22 at 4:40 PM, Resident 4 stated it had been hot and uncomfortable for several days, and .no one seemed to be doing anything about it. Resident 4 was observed to have a damp towel draped around his neck. Resident 4 stated, I wrap ice in the towel and put it around my neck. It is helping me. I have to take care of myself. On 9/4/22 at 4:45 PM , a concurrent facility tour and interview was conducted of all resident rooms with the Maintenance Supervisor (MS). The MS measured the temperature of the 42 resident rooms utilizing the facility laser temperature gun. The MS stated three (3) of the four (4) Roof Mounted Air Conditioning units were not working, and the facility was not able to provide enough cold air to resident rooms. He further stated he was unsure how long the units had been broken. He stated he was hired in July 2022, and they were not working then. During the tour, the MS also stated there were not enough portable fans for each resident, there was a total of 32 portable fans in use. It was observed that portable fans were not available for use by every resident. In some rooms there was 1 portable fan being shared for 2-3 residents. The MS stated he thought the acceptable maximum temperature was 86 F, and stated he was not sure what the required temperature range was supposed to be. Temperature checks revealed 41 out of 42 resident rooms had temperatures above (>) 81 degrees F. Thirteen (13) of the 40 rooms (Rooms 20, 21, 23, 25, 26, 29, 56, 57 58, 59, 60, 61, 62) measured 90 - 99 degrees F. The four hallway thermostats read more than 81 F [90, 83, 83, 83]. The dining room temperature measured 86 F. The temperature in the main lobby measured 95 F. On 9/4/22 at 5 PM, Resident 9 was interviewed. Resident 9 stated his fan didn't help. The sliding door in the room was observed to be open, with warm outside air coming in. Resident 9 stated it would be better with the door closed. On 9/4/22 at 5:05 PM, Resident 8 was interviewed. Resident 8 stated her fan didn't work well, and she was very uncomfortable. It has been very hot! On 9/4/22 at 5:50 PM, an interview and record review were conducted with the Director of Nurses (DON), the MS, and the Director of Staff Development (DSD). The daily facility temperature logs were reviewed. There were no temperatures recorded for 9/3/22 or 9/4/22. The MS stated he was off those days, and his assistant would have been the person to take the temperatures and record them, however he had just quit without any notice. The MS stated no one was identified to fill in for him over the weekend. The MS provided a copy of the policy & procedure entitled Quality of Life - Homelike Environment, revised May 2017. Per the policy, .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: . h. Comfortable and safe temperatures (71 F - 81 F) . The MS stated he was not clear about the temperature requirements until he reviewed the policy, .just now. The DON stated she was newly hired and had only been the DON for approximately 4 weeks. She stated the Administrator had been on vacation since 8/30/22. The DON also stated she was scheduled to be off for the weekend but had just arrived after being notified of the situation. The DON stated she had just reviewed the policy & procedure provided by the MS, and stated she was not aware to the temperature range until she had just reviewed the policy. On 9/4/22 at 6:30 PM, an Immediate Jeopardy to resident health and safety related to dangerously high internal temperatures was called with the Administrator (via telephone), the DON, MS, and the DSD. The facility was requested to provide a plan of action to remove the immediacy. On 9/4/22 at 9 PM, the facility presented the plan of action which included: - Resident sliding doors and windows identified as open were closed by staff to help regulate the temperature. - Facility was purchasing more fans and portable AC units to be installed in resident rooms and the dining area. The facility corporation had purchased 25 fans which were scheduled to be delivered that evening and purchased 2 additional portable chillers scheduled to arrive the following morning. - The MS contacted their HVAC (Heating, Ventilation, Air Conditioning) vendor to check on rental of additional units, but none were available. In addition, the MS contacted 3 additional rental vendors for availability. -Residents to be offered to temporarily move to the dining area or rehab gym for a cooler and acceptable temperature range. Residents who refused to move would be monitored for any changes in condition. All resident's vital signs were checked and monitored every 4 hours. -The MS and designee would routinely check resident rooms to ensure the rooms were within a comfortable and safe temperature every 4 hours. -The DSD provided in-services to the Licensed Nurses (LN) and Certified Nursing Assistants (CNA) to ensure all residents were offered fluids every 2 hours while awake, vital signs were to be monitored every 4 hours. Any resident with a change of condition would be reported to the resident's MD (doctor) / NP (Nurse Practitioner) for any orders. -The Facility would be assigning 1-2 extra CNAs to check resident vital signs every 4 hours, offer fluids, and to check resident room temperature every 4 hours. On 9/4/22 at 9:08 PM, the Plan of Action was accepted, however the Immediate Jeopardy was not removed as temperatures were not back within the acceptable range for all resident rooms and building areas. The temperature checks taken at 8 PM revealed 6 rooms (Rooms 52, 53, 57, 58, 60, 61) out of 42 rooms with temperatures measuring between 84.1 F - 91.1 F. On 9/5/22 at 7:10 AM, an unannounced on-site visit was conducted. A tour of the facility was conducted with Operational Resource (OR)1. The facility was notably cooler than the day before. On 9/5/22 at 7:30 AM, Resident 31 was observed to have a fan at the bedside. On 9/5/22 at 7:35 AM, Resident 9 was observed to have a fan at the bedside. On 9/5/22 at 7:40 AM, Resident 75 was interviewed. Resident 75 stated, the room temperature was .not much better. The resident was observed to have a fan at the bedside. On 9/5/22 at 9:45 AM, the temperature rounds logs were reviewed. The log for 9/5/22 at 12 AM, revealed 32 rooms (Rooms 21, 23, 25, 26, 28, 29, 30, 34, 35, 37, 38, 39, 41, 43, 44, 45, 46, 47, 48, 49, 50, 51, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62) out of 42 rooms remained >81 F. The highest temperature was documented as 88 F. The log for 9/5/22 at 4 AM, revealed 7 rooms (41, 46, 47, 48, 49, 54, 57) out of 42 rooms remained >81 F. The highest temperature was documented as 84 F. The log for 9/5/22 at 8 AM, revealed 2 rooms (Rooms 46, 55) out of 42 rooms remained >81 F. The highest temperature was documented as 82 F. The 4 hallway thermostats read 81 F, 81 F, 78 F, 81 F. On 9/5/22 at 11:20 AM, Operational Resource (OR) 1 stated 2 additional 1-ton AC units would arrive in approximately 2 hours and 1 would be placed in each resident hallway. A 5-ton AC unit had been rented and arrived on site only to discover it was the wrong unit. It had to be returned in exchange for the correct unit which was to arrive later in the day. On 9/5/22 at 1 PM, the temperature logs for the 12 PM rounds were provided for review. Staff had documented 25 rooms (Rooms 20, 21, 24, 25, 26, 28, 29, 30, 36, 37, 38, 39, 41, 44, 45, 46, 48, 49, 50, 51, 52, 54, 56, 57, 59) out of 42 rooms remained >81 F. The highest temperature documented was 84 F. On 9/5/22 at 5:15 PM, Resident 54 was interviewed. Resident 54 stated, It's hot, but give the coolers (AC) to someone else who needs it more. I can wheel myself around to cooler areas. Resident 54's room temperature measured 84.9 F. On 9/6/22 at 5 PM, the facility provided the temperature logs for review. Record review of the temperature logs for 9/6/22 at 8 AM, 12 PM, and 4 PM revealed all 42 rooms were between 71 F and 81 F. On 9/6/22 at 5:45 PM, the Immediate Jeopardy was removed on site at the facility with OR 1, OR 3, the DON, the MS, and the Clinical Nurse Consultant.