Every finding on record at Imperial Manor

Based on interview and record review, the facility staff failed to limit Resident 25's as needed psychotropic medication to 14 days and did not re-evaluate the resident for appropriateness of the medication Hydroxyzine (used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg (milligram). This failure had the potential for an increased risk of adverse effects related to prolonged use of antipsychotics [a class of prescription medications primarily used to manage symptoms of psychosis, such as hallucinations (seeing or hearing things that aren't there) and delusions (false, fixed beliefs)]. Per the facility admission record, Resident 25 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a complex chronic brain disorder that alters how a person perceives reality). On 5/13/26, a record review of Resident 25's physician orders was conducted. Resident 25's physician orders indicated on 1/26/26, Hydroxyzine 25mg every 12 hours as needed for paranoid schizophrenia was ordered without a length of therapy and re-evaluation order. On 5/14/26, a concurrent interview and record review was conducted with the director of nursing (DON). A record review of the current physician's order for Resident 25's Hydroxyzine order was not re-evaluated every 14 days as required. The DON stated it was her responsibility that all residents using PRN antipsychotic medications are re-evaluated after 14 days of use. The facility policy titled Medication Utilization and Prescribing, dated April 2018, indicated that the physician and staff will evaluate the rationale for existing medications that .are being used intermittently on a PRN basis.

Based on interview and record review, the facility staff failed to complete a medication regiment review (MRR -a systematic check of all the medications and supplements you take, conducted by a pharmacist or doctor with the goal of promoting positive outcomes and minimizing adverse. consequences associated with medication) for one of six sampled residents (25). This failure had the potential for a medication error for Resident 25's nicotine patch (a medicated adhesive bandage worn on the skin to help people quit smoking or vaping). Per the facility admission record, Resident 25 was admitted to the facility on [DATE] with diagnoses that included tobacco use. Per Resident 25's physician orders, on 9/30/25, an order for Nicotine Transdermal Patch 24 hour (a medicated adhesive bandage worn on the skin to help people quit smoking or vaping) - Apply 1 patch transdermally one time a day smoking cessation and remove per schedule. On 5/13/26, a record review of Resident 25's MRR was conducted. An MRR dated 4/5/26 indicated that Resident 25's Nicotine patch order is missing dose e.g. 21 or 14 or 7mg/24 hours and missing the length of therapy. The physician signed and dated the MRR on 4/6/26. Another MRR dated 5/6/26 was reviewed for the same Nicotine patch order and indicated that Resident 25's Nicotine patch order is missing dose e.g. 21 or 14 or 7mg/24 hours and missing the length of therapy. On 5/14/26, a concurrent interview and record review was conducted with the director of nursing (DON). A record review of the current physician's order for Resident 25's nicotine patch indicated that the MRR was not completed. The DON agreed that the Nicotine patch order was missing the dosage. The DON stated that it was her responsibility that MRRs are completed. A review of the facility policy titled Medication Utilization and Prescribing, dated April 2018, indicated that .The physician and staff will identify significant factors that may affect medication effectiveness and medication-related problems .

2. Resident 2 was admitted to the facility was readmitted on [DATE] with diagnoses to include paranoid schizophrenia (subtype of schizophrenia, a mental illness with persistent paranoid delusions), muscle spasm and dementia (memory loss) per the undated facility admission Record. A review of Resident 2's swallow evaluation dated 9/14/23 indicated Resident 2 had history of dysphagia (difficulty in swallowing) and examination performed was modified swallow impression positive laryngeal penetration. A review of Resident 2's weight records was conducted. The weight record indicated monthly weights from August 2024 to March 2025: 7/14/24 114.1 pounds (lbs.) 8/15/24 110.9 lbs. 9/12/24 108.3 lbs. 10/11/24 108 lbs. 11/12/24 105.8 lbs. 12/16/24 108 lbs. 2/14/25 108 lbs. 3/14/25 108 lbs. On 4/8/25 at 8:20 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 2's meal intake had been 75 to 100% lately. CNA 1 stated sometimes Resident 2's intake was 50%. On 4/8/25 at 10:26 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 2 was losing weight. CNA 2 stated when she started working in the facility, Resident 2 could eat by himself but now he needed assistance with eating. On 4/8/25 at 2:27 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 2 needed assistance with eating since 2023. LN 1 stated he was not aware that Resident 2 had poor meal intake. LN 1 stated CNAs were responsible of letting LNs know when residents had poor meal intake. On 4/9/25 at 3 P.M, an interview and joint record review were conducted with the Director of Nursing (DON). The DON stated Resident 2's weight loss was not significant. The DON acknowledged Resident 2 experienced weight loss from July through November 2024. The DON reviewed Resident 2's medical record. The DON stated she could not find documentation to show that Resident 2's weight loss was identified, discuss and addressed. On 4/9/25 at 5:16 P.M., an interview and record review were conducted with the DON and the Registered Dietician (RD). The RD stated Resident 2 should have been placed on weekly weights. The DON acknowledged Resident 2's weight loss should have been identified and discussed in the IDT (Interdisciplinary team - group of professionals from different fields who collaborate to achieve a common goal) meeting to address the resident's weight loss. The DON stated the Resident 2's physician should have been notified. A review of the facility policy title Weight Assessment and Intervention, revised March 2022 was conducted. The policy indicated .Resident weights are monitored for undesirable or unintended weight loss or gain .Evaluation .2. The physician and the multidisciplinary team identify conditions . that may be causing weight loss . Based on observations, interview, and record reviews, the facility failed to implement a comprehensive systemic approach, to ensure nutritional status were maintained for two of two sampled residents (Resident 12 and Resident 2) when: 1. Resident 12's unplanned significant weight loss (loss of body weight greater than 5% in a month) was not identified and addressed. 2. Resident 2's unplanned weight loss was not identified and addressed. As a result, the facility's system was not effective at identifying and addressing progressive weight loss. The staff were not consistent in identifying unplanned weight loss and significant weight loss. The interdisciplinary team (IDT - a group of professionals from different disciplines who collaborate to treat a patient's needs) did not developed a plan to monitor and address the residents' weight loss. The above cited systems failures had the potential to negatively impact and compromise the medical status of the residents. Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality. (American Family Physician, July 2021/Volume 104, Number 1) Findings: 1. According to the admission Record, Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic disorder (occurs when abnormal chemical reactions in your body disrupt this process), iron deficiency (a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues), paraplegia (loss of motor and/or sensory function in the lower part of the body, including the legs and lower abdomen), and gastrostomy status (an opening (gastrostomy) into the stomach, typically for feeding or draining purposes). During a review of the Minimum Data Set (MDS-an assessment tool), the MDS indicated, Resident 12 had a BIMS (Brief Interview for Mental Status - a tool to test cognition) score of 9 which meant a score between 8 and 12 indicated moderate to mild mental impairment. On 4/7/25 at 12:23 P.M., an observation was conducted during lunch. Resident 12 was observed in the dining room. Certified Nursing Assistant (CNA) 1 was feeding Resident 12. CNA 1 was observed holding a spoon of pureed food up to Resident 12's mouth. Resident 12 had her lips tightly closed shut, and she tilted her chin away from the spoon. On 4/8/25 at 7:13 A.M., a concurrent observation and interview was conducted in the dining room during breakfast with Licensed Vocational Nurse Student (LVNS) 1. Residents were observed walking out of the dining room. Resident 12 was sitting in a wheelchair, at a dining room table during breakfast, without a breakfast tray. LVNS 1 stated Resident 12 refused to eat breakfast, and her tray was taken away. LVNS 1 stated, .they're looking for something else to give her for breakfast . LVNS 1 stated Resident 12 has been refusing to eat meals and, .we give her [a supplemental drink] as alternative . On 4/09/25 at 3:00 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 12 had been refusing to eat during meals. CNA 2 stated she noticed Resident 12 was losing weight. CNA 2 stated, .Before when I would change her [briefs], it would be more difficult to put [the brief] around her .I think she uses the green [brief] which is size 2x. Now, the brief fits looser, we don't struggle as much to put it on her. That's how I could tell that she lost weight . During a review of Resident 12's Electronic Health Record, titled, the Weight Summary for August 2024 through March 2025 indicated: 8/15/24-190.4 pounds 9/12/24-182 pounds 10/11/24-173 pounds 11/22/24-171.7 pounds 12/12/24- 168 pounds 1/15/25- refused to be weighed 2/12/25-164 pounds 3/14/25-157 pounds Resident 12 experienced a 25-pound weight loss (13.7%) in six months, from 9/24 to 3/25. During a telephone interview with the Registered Dietitian (RD) on 04/08/25 02:19 P.M., the RD stated she was aware that Resident 12 had lost 7 pounds from 2/25 to 3/25. The RD stated the weight loss was unplanned and considered a significant weight loss. The RD stated in her opinion Resident 12's weight loss was not concerning because staff had reported that Resident 12 .had been eating good . and because Resident 12 was still in the obese category based on her height and weight. The RD stated, I feel like I'm more concerned [about weight loss] with someone who is not eating . The RD stated on 3/26/25 she wrote a progress note on 3/26/25, but did not do a comprehensive nutritional assessment for Resident 12. The RD stated comprehensive nutritional assessments were only done annually for all residents, regardless of any significant weight changes. During a review of Resident 12's Progress Notes, a note titled Weight Change Note dated 3/26/25 indicated, Weight loss of 7 lbs (pounds) in the past 1 month reported to RD. Resident 12 was reported to be eating well. Good appetite and good p.o. (oral) intake. BMI (Body Mass Index - a widely used measure that estimates body fat based on height and weight) of 30. No diet changes recommended at this time. Continue monitoring daily p.o. intake and monthly weights. Notify RD of significant changes . During a review of Resident 12's Weight Summary dated, 4/10/25 at 8:58 A.M., Resident 12's weight was recorded as 147.4 pounds, which indicated a weight loss of 10 pounds (6%, which is a significant weight loss) since 3/14/25. On 4/10/25 at 11:09 A.M., a follow up interview was conducted with the RD. The RD stated she wrote a progress note on 4/9/25 with interventions to address Resident 12's weight loss. The RD stated, .the interventions listed in the progress note was what I should have done to prevent even more weight loss from happening . On 4/10/25 at 8:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that a comprehensive nutritional assessment was done when a resident has significant weight loss. The DON stated, A comprehensive assessment should have been done, with interventions . The DON stated the resident was, .at risk of losing body mass, muscle mass, and losing function . During a review of the facility policy titled Nutrition revised 10/17 indicated, . 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .and as indicated by a change in condition that places the resident at risk for impaired nutrition . During a review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol revised 9/2012, the document indicated, The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications .

Based on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours per day, for three months, October 1 to December 31, 2024. This failure had the potential for advanced care activities, that needed an RN, to not be provided to the residents due to the unavailable RN. Findings: During the initial tour of the facility on 4/07/2025 at 9 A.M., the only RN at the facility was the Director of Nursing (DON). A review of the facility's PBJ (payroll-based journal) Staffing Data Report, [NAME] Report 1705D (a report that can help Skilled Nursing Facilities identify areas for improvement in care and operations) of fiscal year 2025 Quarter 1, indicated the facility was triggered for no RN hours, which meant four or more days within the quarter with no RN hours. The Report indicated the following dates with no RN hours: - 10/1,10/2,10/3, 10/4,10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/17, 10/18, 10/19, 10/20, 10/21, 10/22, 10/23, 10/24, 10/25, 10/26, 10/27, 10/28, 10/29, 10/30, and 10/31/24. - 11/1, 11/2, 11/3 (SU), 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29, and 11/30/24. - 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, and 12/31/24. On 4/7/24 at 9:07 A.M., an interview was conducted with the Facility Assistant (FA). The FA stated the Director of Nursing (DON) was the only RN in the building. The FA stated the DON was not included in the schedule because the DON came to the facility on an as needed basis only. On 4/8/25 at 2:27 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated the DON was the only RN working in the facility. LN 1 stated the DON came to facility approximately twice times a week. On 4/9/25 at 11:17 A.M., an interview was conducted with the DON. The DON stated she was the only RN working in the facility. The DON stated she came to the facility to fill in for call offs or last-minute call in sick. The DON acknowledged there should be an RN for 8 consecutive hours in a 24-hour shift. On 4/10/25 at 8:17 A.M., an interview and joint record review of the facility's Direct Care Service Hours Per Patient Day (DHPPD- staffing requirement reporting) was conducted with the FA. The FA stated from January of 2025 to current, there was no RN scheduled to work at the facility. According to the DHPPD report for March 17 to 31, 2025, there were no RNs projected to work, and there were no RNs who actually worked on March 17 to 31, 2025. The FA stated the DON was the only RN in the facility. Th FA acknow;edged there was no consistent RN for eight (8) consecutive hours per day for seven (7) days. A review of the facility's policy titled Staffing, Sufficient and Competent Nursing, revised in August 2022, was conducted. The policy indicated .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident .

Based on observation, interview, and record review the facility failed to ensure scales were calibrated per manufacturer's instructions. This failure had the potential for inaccurate weights to be obtained. Findings: During an observation and interview on 4/9/25 at 9:22 A.M., the Maintenance Worker (MW) stated the maintenance department was responsible for calibrating (the process of checking a measuring instrument to see if it is accurate) scales used to weigh residents. The MW stated the facility used two different scales: a standing scale for residents who were able to stand, and a scale to weigh residents while they are sitting in the wheelchair. The MW stated to calibrate the standing scale, he will press the tare button to zero out the scale. The MW stated once the scale reads 0.0, the scale is calibrated. The MW stated he did not use any handheld weights, .I put a person on the scale, not weights . to ensure the machine was calibrated. On 4/9/25 at 10:02 A.M., an interview was conducted with the Maintenance Supervisor (MS). The MS stated to calibrate the standing scale and the wheelchair scale, he uses two five-pound hand weights. The MS stated to calibrate the wheelchair machine, he will zero it out . then place a five-pound weight on the machine. The MS stated if the machine reads five pounds, then it is calibrated. A review of the manufacturer's instructions for the standing scale titled, Medical Scale-Calibration Manual, indicated, .Calibration of the scale is performed using certified weights. 50/100/200/400 lbs [pounds] are employed as the calibration standards . A review of the manufacturer's instructions for the wheelchair scale titled, Weighing Indicator User Manual indicated, .The indicator is calibrated by the following procedures .The minimum test weight that can be used is 1% of the full-scale capacity . On 4/10/25 at 8:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for maintenance to calibrate the scales according to the manufacturer's instructions. The DON stated, We should know how to calibrate the scales. The scales should be accurate because we want to obtain the residents' accurate weight. It can deter, or give false impressions of the [resident's] weight and therefore affect the patient's plan of care . During a review of the facility's policy titled Scale Use Policy, the policy indicated, .all residents will be weighted .using calibrated and facility-approved scales, following standard procedures to ensure accuracy, safety, and dignity .

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent when two out of 31 medications were administered incorrectly. The facility's error rate was 6.45%. These failures had the potential to negatively affect the residents' health and safety. Findings: 1. On 4/9/25 at 8 A.M., a medication administration observation was conducted with licensed nurse (LN) 1. LN 1 prepared and administered three medications to Resident 27. One of the medication LN 1 administered to Resident 27 was Benztropine mesylate (a medication for [Parkinson's disease] a progressive disease of the nervous system affecting movement) 1 milligram (mg). A review of Resident 27's physician order was conducted. The physician order, dated 8/15/23, indicated an order to give Resident 27 .Benztropine Mesylate Oral Tablet 2 MG (Beztropine Mesylate) Give 1 mg by mouth one time a day . On 4/9/25 at 10:31 A.M., an interview and joint record review of Resident 27's physician order were conducted with LN 1. LN 1 stated the physician order was written as Benztropine mesylate 2 mg and give 1mg by mouth one time a day. LN 1 stated the pharmacy dispensed a blister pack of Benztropine mesylate in 20 mg tablet. LN 1 acknowledged that the order for Benztropine was unclear and should have been clarified with Resident 27's physician. On 4/9/25 at 4:54 P.M., an interview and joint record review were conducted with the Director of Nursing (DON). The DON stated Resident 27's Benztropine order should have been clarified with the resident's physician. 2. On 4/9/25 at 8:44 A.M., a medication administration observation was conducted with licensed nurse (LN) 1. LN 1 prepared and administered six medications to Resident 26. One of the medication LN 1 administered to Resident 26 was Olanzapine (a medication for [schizophrenia] mental illness characterized by disturbance in thought) 20 milligrams (mg). A review of Resident 26's physician order was conducted. The physician order, dated 8/20/24, indicated an order to give Resident 26 .OLANzapine Oral Tablet 10 MG (Olanzapine) .Give 10 mg by mouth one time a day . and .OLANzapine Oral Tablet 20 MG (Olanzapine) . Give 20 mg by mouth at bedtime . A review of Resident 26's Olanzapine blister pack label indicated . Olanzapine 20 mg TAB . TAKE 1 TABLET BY MOUTH IN THE MORNING & BEDTIME . On 4/9/25 at 4:55 P.M., an interview and joint record review were conducted with the Director of Nursing (DON). The DON stated according to the physician order, Resident 26 should have been given Olanzapine 10 mg in the morning. The DON stated Resident 26's physician order for Olanzapine was 10 mg for morning but pharmacy dispensed 20 mg for both morning and bedtime. The DON stated the medication was not administered in accordance with the physician order. A review of the facility's policy and procedure titled Administering Medications, revised in April 2019, was conducted. The policy indicated, .4. Medications are administered in accordance with prescriber orders .10. The individual administering the medication checks the label THREE (3) times to verify the .right dosage .before giving the medication .

Based on observation, interview, and facility document review, the facility failed to ensure pureed food was prepared in a consistency that met the needs for two of two sampled residents sampled residents (12, 13). This failure placed the residents at risk for choking and/or aspiration (inhaling food into the lungs). Findings: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic disorder (occurs when abnormal chemical reactions in your body disrupt this process), iron deficiency (a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues), paraplegia (loss of motor and/or sensory function in the lower part of the body, including the legs and lower abdomen), and gastrostomy status (an opening (gastrostomy) into the stomach, typically for feeding or draining purposes). A review of the of the facility document titled, Nutrition Quarterly Review assessment written by the dietary services supervisor (DDS) indicated, the Resident 12 was on a puree diet due to chewing problems. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included underweight. During an observation of pureed foods preparation with [NAME] 1 and [NAME] 2 on 4/7/25 at 11:16 A.M., [NAME] 1 was preparing brussel sprouts in a pureed form. [NAME] 1 placed 2 4-ounce scoops of cooked brussel sprouts into a blender, with 1 ½ 4-ounce scoops of broth into the blender. After blending the brussel sprouts and the broth, [NAME] 1 placed a scoop of the blended brussel sprouts onto two plates, covered the plates, and then placed them on two trays. The blended brussel sprouts had pea sized chunks and was not smooth in appearance. On 4/7/25 at 11:25 A.M., an interview was conducted with [NAME] 2. [NAME] 2 stated the blended brussel sprouts, .needs more broth and more time in the blender . [NAME] 2 stated it was important to make the food smooth per recipe, .if they have a problem chewing the meat, it needs to not have chunks, we need to follow the recipe . During a record review, the recipe for Brussel Sprouts indicated, .PUREE DIET: Process each serving, gradually adding 2-4 tbsp [tablespoons] of vegetable or chicken stock until smooth and mixture meets the Spoon Tilt Test standard. Food should be smooth with no lumps .Pureed vegetables should have a smooth texture, no lumps, and hold shape on a spoon . During a record review of the policy titled, Pureed dated July 2019, the document indicated, PUREED .This modification is designed for people who have severe chewing and/or swallowing problems. Properly pureed foods elimitate the chewing phase .Puree all foods to a smooth, lump-free .consistency .Always refer to the recipe and spreadsheet for directions .

Based on interview and record review, the facility failed to identify weight loss trends in their Quality Assurance Performance Improvement (QAPI- a plan developed by the facility with the goal of improving conditions in the facility) as an area of improvement that required an action plan. As a result, the facility did not provide a systemic approach in adressing Resident 12 and Resident 2's weight loss. (Refer to F-692) Findings: During a interview and record review with the Director of Nursing (DON) on 4/10/25 at 2:05 P.M., the DON stated the issues that were discussed during the monthly QAPI meetings were elopement prevention and resident to resident altercations. The DON stated the weight losses should have been identified by the facility, and discussed in the monthly QAPI meetings. The DON stated, Yes, the weight losses should have been identified before [the recertification suvey] .it's part of patient care. Monitoring weight was part of patient care and should have been part of QAPI because it would sound an alarm . During a review of the facility's undated policy titled, QAPI Policy and Procedure, the policy indicated, the purpose of QAPI was, to monitor, evaluate, and improve the quality of resident care and services provided at [Facility's Name] . In addition, the policy indicated the objective of QAPI included to, .Engage staff at all levels in identifying and solving quality concerns .

Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed required annual specialized training related to infection control. This deficient practice had the potential to affect the facility's ability to maintain a safe environment and to prevent and manage transmission of diseases and infections. Findings: During an interview with the IP on 4//25 at 7:45 A.M., the IP stated he had been the IP at the facility, for about a year . The IP further stated he is scheduled to pass medications for 36 hours a week and dedicated approximately 2-4 hours weekly as an IP. A review of the IP's training certificates indicated, the IP completed a course titled, Infection Control and Prevention on 12/13/24 for 4 credit hours. In addition, the IP completed a course titled Hand Hygiene For Healthcare Online Course on 1/2/24 and a Personal Protective Equipment Online Course on 1/2/24. The courses had no listed CEU's (Continuing Education Units- a measure in ongoing education programs) or credit hours. During a concurrent interview and record review with the Director of Nursing (DON) on 4/10/25 at 10:38 AM., the Job Description for the facility's Infection Preventionist indicated, Specific Requirements .Must possess a current, unencumbered, active license to practice as a Registered Nurse in this state. The DON acknowledged the IP was a Licensed Vocational Nurse and not a Registered Nurse. During a record review of the Job Description for the facility's Infection Preventionist dated 2001, the Job Description indicated, Working Conditions .Attends and participates in continuing education programs .

Based on observation, interview and record review, the facility failed to follow their own infection prevention and control program for two of two sampled residents (5, 12) when: 1. Resident 5's uncovered urinary bag touched the floor on multiple occasions for one of 12 residents (Resident 5). 2. The Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs, an infection control intervention using protective gown and gloves) was not implemented for Resident 12. These failures could potentially contribute to Resident 5 acquiring a urinary tract infection. Also, failure to implement the CDC guidelines had the potential to result in the spread of Multiple Drug Resistant Organisms (MDROs, microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) throughout the facility. Findings: 1. Resident 5 was admitted to the facility on [DATE] with diagnose that included benign prostate hyperplasia with lower urinary symptoms (BPH -noncancer causing prostate enlargement) according to the undated facility admission record. A review of Resident 5's Minimum Data Set (MDS- a standardized, federally mandated assessment tool used in nursing homes) Section C, dated 1/31/25, was conducted. The document indicated Resident 5 had a Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify cognitive [thinking process] impairment of resident) score of 00 which indicated severe mental impairment. On 4/7/25 at 8:49 A.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered and was touching the floor. On 4/7/25 at 12:29 P.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered and was touching the floor. On 4/8/25 at 7:30 A.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered and was touching the floor. On 4/8/25 at 8:37 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 5's urinary bag and tubing should not be touching the floor. On 4/8/25 at 10:16 A.M, an interview was conducted with CNA 2. CNA 2 stated Resident 5's urinary bag and tubing was not supposed to be on the floor. CNA 2 stated the floor was contaminated and infection might go to Resident 5's urinary bag. CNA 2 stated Resident 5's urinary bag and tubing should be above the ground. On 4/9/25 at 2:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 5's urinary bag and tubing should not touch the floor because of possibility of reintroducing the bacteria back to the urinary tract causing infection. A review of the facility's policy titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, revised September 2017 was conducted. The policy indicated .Steps in procedure . 6 .c .Do not place the drainage bag on the floor . 2. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic disorder (occurs when abnormal chemical reactions in your body disrupt this process), iron deficiency (a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues), paraplegia (loss of motor and/or sensory function in the lower part of the body, including the legs and lower abdomen), and gastrostomy status (an opening (gastrostomy) into the stomach, typically for feeding or draining purposes). On 4/7/25 at 7:30 A.M., observations were conducted of the nursing unit. Residents 12 was identified with indwelling medical devices (a medical device inserted into the body and left in place for a period of time, either for treatment or to allow access for various procedures). There was no signage posted for EBP, or PPE available for staff use observed outside the residents' bedrooms. During an interview on 4/8/25 at 7:45 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the residents with indwelling medical devices were not placed on EBP. The IP stated he did not know what Enhanced Barrier Precautions were or what the precaution entailed. On 4/9/25 at 11:03 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated she did not know what Enhanced Barrier Precautions were, and that the facility had not implemented EBP for any residents with indwelling medical devices. During a review of the All Facilities Letter (AFL- a memorandum issued by the California Department of Public Health), dated 6/13/2024, the memo indicated skilled nursing facilities should implement EBP per Centers for Disease Control (CDC) guidance, as part of infection control for skilled nursing facilities. A review of the facility's policy titled Infection Prevention and Control Program, revised October 2018, indicated, The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures .outbreak management, prevention of infection .policies and procedures reflect the current infection prevention and control standards of practice . During a review of the Quality, Safety and Oversight (QSO- a memorandum issued by the Centers for Medicare & Medicaid Services) 24-08-NH the memorandum indicated, EBP are indicated for residents with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples include .urinary catheters, feeding tubes .EBP should be used for any residents who meet .the criteria, wherever they reside in the facility .

Based on observation, interview and record review, the facility failed to provide care that promoted dignity and respect for one of 12 residents (Resident 5) reviewed for resident rights, when Resident 5's urinary catheter bag (tube inserted to drain urine) was not covered. As a result, Resident 5's urinary bag was visible to anybody passing by. Findings: Resident 5 was admitted to the facility on [DATE] with diagnose that included benign prostate hyperplasia with lower urinary symptoms (BPH -noncancer causing prostate enlargement) according to undated the facility admission record. A review of Resident 5's Minimum Data Set (MDS- a standardized, federally mandated assessment tool used in nursing homes) Section C, dated 1/31/25, was conducted. The document indicated Resident 5 had a Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify cognitive [thinking process] impairment of resident) score of 00 which indicated severe mental impairment. On 4/7/25 at 8:49 A.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered, while other residents were present in the dining room. On 4/7/25 at 12:29 P.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered, while other residents were present in the dining room. On 4/8/25 at 7:30 A.M., an observation was conducted of Resident 5. Resident 5 sat in a wheelchair in the dining room with his urinary bag uncovered, while other residents were present in the dining room. On 4/8/25 at 8:42 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she did not know she had to cover Resident 5's urinary bag. CNA 1 acknowledged that leaving the resident's urinary bag uncovered did not promote the resident's dignity and could result in the resident feeling embarrassed. On 4/8/25 at 10:20 A.M, an interview was conducted with CNA 2. CNA 2 stated Resident 5's urinary bag should be covered to promote the resident's dignity. On 4/9/25 at 2:45 P.M. an interview and record review were conducted with the Director of Nursing (DON). The DON stated Resident 5's urinary bag should be covered with to promote Resident 5's dignity. A review of the facility's policy and procedure titled Resident Rights, dated February 2021, was conducted. The policy indicated, .Employees shall treat all residents with kindness, respect and dignity .1 These rights include the resident's rights to: a. a dignified existence . A review of the facility's policy and procedure titled Dignity, revised in February 2021, was conducted. The policy indicated, .1. Residents are treated with dignity and respect at all times .

Based on observation and record review, the facility failed to ensure that 1 of 9 resident rooms (room [ROOM NUMBER]) accommodated 4 or less residents. Findings: During the initial facility tour on 4/7/25 at 9 A.M., room [ROOM NUMBER] was observed to have 6 resident beds in the room. During a review of the facility's Analysis of Accommodations (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the document indicated room [ROOM NUMBER] had 6 residents housed in the room. There were no quality of care or quality of life issues identified during the survey for the six residents that resided in room [ROOM NUMBER]. A contuinance of a waiver allowing the six-bed room was therefore recommended.

Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in rooms 1, 2, 3, 6, 7 and 8. Findings: An observation of resident rooms was conducted from 4/7/25 through 4/10/25 during the annual recertification survey. A review of the facility's Analysis of Accommodations indicated there were 6 of 9 resident rooms that did not meet the minimum room size requirement, as follows: 1. room [ROOM NUMBER], with 3-resident occupancy, 72 square feet per resident totaling 216 square feet. 2. room [ROOM NUMBER], with 3-resident occupancy, 74 square feet per resident totaling 222 feet. 3. room [ROOM NUMBER], with 3-resident occupancy, 72 square feet per resident totaling 216 square feet. 4. room [ROOM NUMBER] with 3-resident occupancy, 70 square feet per resident totaling 210 square feet. 5. room [ROOM NUMBER] with 3-resident occupancy, 73.66 square feet per resident totaling 221 square feet. 6. room [ROOM NUMBER], 4-resident occupancy, 70.75 square feet per resident totaling 283 square feet. The variations in room size requirements did not adversely affect the resident's health, safety, quality of care, or quality of life during the survey. A continuance of the room size waiver for all affected rooms were recommended.

Based on interview and record review the facility failed to implement its abuse reporting policy when it had knowledge of an allegation of genital exposure by Resident 3 to Resident 4 and did not report it to the State Agency (SA). This failure resulted in continued proximity of Resident 4 to Resident 3 who was the alleged aggressor, and prevented investigation by the SA. Resident 3 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder bipolar type (a mental illness that can affect your thoughts, mood and behavior) and schizophrenia (a mental disorder characterized by disruptions in thought processes). Resident 4 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a pattern of behavior where a person feels distrustful of others and behaves accordingly) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness). On 7/16/24 at 12:20 P.M. an interview was conducted with Resident 4 who stated, (Resident 3) exposed his genitals to me and the staff aren ' t doing anything about it. On 7/16/24 at 12:39 P.M. an interview was conducted with the Director of Nursing (DON) who stated, (Resident 3) doesn ' t have any history of hypersexualization (a person ' s inability to control their sexual behavior and impulses). On 7/19/24 a review of Resident 3 ' s Imperial County Behavioral Health Services psychiatric note dated 5/22/24 indicated Resident 3 had history of hypersexual - stuck tongue out at female staff twice. On 7/22/24 at 10:37 A.M. a follow up telephone interview and concurrent record review was conducted with the DON who stated, I didn ' t see this in the record before now. On 7/19/24 a review of Resident 3 ' s Communication note dated 7/8/24 at 8:13 A.M. indicated, Female resident (Resident 4) pointed to male resident (Resident 3) claiming he exposed himself to her in the lunchroom near lunch hour. On 7/19/24 a review of Resident 4 ' s Communication Note dated 7/11/24 at 8:36 A.M. indicated, Writer check in with both the resident and fell ow female resident (Resident 4) on claim made by (resident 4) on 7/8/24 about the resident exposing himself to her. On 7/19/24 at 2:14 P.M. a follow up telephone interview was conducted with the Social Worker (SW) who stated, I didn ' t report what (Resident 4) said because I wasn ' t here when it happened. On 7/16/24 at 12:39 P.M. an interview was conducted with the DON who stated, It was not reported to the SA. A review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 indicated, All reports of resident abuse . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. A review of the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 indicated, Protect residents from any further harm during investigation.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to Centers for Medicare & Medicaid Services (CMS) for one of four fiscal quarters (1st quarter of 2023 [10/01/23 to 12/31/23]). This failure resulted in lack of reporting of facility's direct care staffing as required by CMS. Findings: During a concurrent interview on 4/15/24 at 10:40 A.M. and 4/17/24 at 9:47 A.M. with the Director of Nursing (DON) and Facility Manager (FM), the Payroll -Based Journal Staffing Data Report (PBJ) for 1st quarter of 2023 (10/1/23 to 12/31/23) was reviewed.The DON and FM verified by stating the report indicated the 1st quarter was triggered because the facility did not submit the direct care staffing information data. The DON stated they did not submit PBJ because the facility residents were all with Medicaid insurance and this PBJ was only applicable for residents with Medicare insurance. FM stated we had not set up for PBJ submission because it was for Medicare and our facility had residents with Medicaid insurance. FM stated it was important to report the actual hours to make sure the facility was properly staffed for resident care. A review of the facility's [NAME] Report for Quarter 1 2024 October 1 to December 31, 2023 indicated the following Metric was Failed to Submit Data for the Quarter which resulted as triggered which by definition meant no data submitted for Quarter. A review of the CMS Electronic Staffing Data Submission Payroll-Based Journal; Long-Term Care Facility Policy Manual, version 2.6 , date June 2022 indicated .1.2 Submission Timeliness and Accuracy .Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate .Submissions must be received by the end of the 45th calendar day 911:59 pm Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food items were not properly labeled with the expiration or use by date, 2. Oven exhaust fan and the air vent were not kept cleaned; and, 3. Kitchen staff did not calibrate the food thermometer correctly. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread forborne illnesses. Findings: 1. On 4/15/24 at 9:54 A.M., an observation in the kitchen was conducted. The refrigerator labeled as refrigerator # (number sign) 1, contained the following food items: - a plastic bag of cilantro with preparation (prep) date on 4/10/24, no use by date. - a plastic bag of cut cabbage leaves with brownish core and leaves, and carrots with prep date on 4/9/24, no use by date. - a plastic bag of grated parmesan cheese with date opened on 3/21/24, no use by date. - a plastic bag of tortilla with opened date on 4/9/24, no use by date. - a plastic bag of Monterey cheese with opened date on 4/10/24, no use by date. - a bag of bagel with opened date on 3/26/24, no use by date. - a bag of cocoa with prep date on 11/28/23, no use by date. On 4/15/24 at 9:59 A.M., an observation in the dry food storage room was conducted. There was a rack that contained dry foods in plastic bins. The plastic bins contained the following dry foods with no use by date or expiration date: - Gelatino - prep date 10/31/23, no expiration date. - Marshmallow - prep date 10/24/23, no expiration date. On 4/15/24 at 10:56 A.M., a joint observation of the kitchen and an interview with the cook (Ck) and interpreted by the Facility Manager (FM) was conducted. Per the Ck, the policy was for the kitchen staff to indicate the use by date or the expiration date of the opened food items. Per the Ck, once the kitchen staff indicated the opened or the prep date of the food items, the kitchen staff knew when to discard them though there was no use by date or expiration date. Per the Ck, the policy was for the kitchen staff to write the expiration date of the food items that were not in their original boxes like the gelatin and the marshmallows. Per the Ck, some food items like the cheese should be discarded after seven days and with the bread and the bagel, the Ck stated the kitchen staff based it on the look of the bread and did not use them if it did not look or smell good. On 4/17/24 at 9:47 A.M., an interview with the Certified Dietary Manager (CDM) was conducted. The CDM stated the policy was for the kitchen staff to properly label the food items when they were opened and when was the expiration date or the use by date. On 4/18/24 at 10:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectations was for the kitchen staff to label all food including fresh foods at the time of opening and indicate the expiration or used by date to prevent foodborne illness for the residents. A review of the facility's policy titled Food Service Policy dated 12/10/2010 was conducted. The policy indicated, .It is the policy of this facility to provide a means for the safe storage of refrigerated items that have been opened and may not be in their original container . 2. On 4/17/24 at 10:22 A.M., an observation and an interview with the Certified Dietary Manager (CDM) was conducted. There was dust and lint in the oven exhaust fan and in the air vent. The CDM stated the expectation was for the staff to maintain the cleanliness of the exhaust fan and the air vent in the kitchen for infection control because it could cause food related illness. On 4/18/24 at 10:43 A.M., an interview with the DON was conducted. The DON stated the oven exhaust fan and the air vent in the kitchen should be maintained clean to ensure there was no dust particles and microbes that goes into the residents' food that could potentially cause harm to the residents when ingested. A review of the facility's undated policy titled, Sanitation and Maintenance was conducted. The policy indicated, Policy: All kitchen and food storage areas will be maintained and sanitized according to state and federal regulations in order to assure sanitary conditions for food preparation and service .The Food Service Supervisors (FSS) is responsible for monitoring and maintaining department sanitation . 3. On 4/17/24 at 10:43 A.M., an observation of the Ck calibrating the food thermometer and an interview with the Ck and the CDM was conducted. The Ck placed some ice into a cup and added some water. The Ck immersed the food thermometer into the cup and let the thermometer rest with the tip of the thermometer touching the base of the cup. The CDM stated the tip should not be touching the base of the cup to get an accurate reading to ensure the temperature of the food was safe for the residents. On 4/18/24 at 10:43 A.M., an interview with the DON was conducted. The DON stated the kitchen staff should know how to calibrate the food thermometer to keep the food safe at a temperature that it should prevent foodborne illness. A review of the facility's policy titled, Calibrating Your Bi-Metal Stemmed Thermometer dated 12/10/2010 was conducted. The policy indicated, .The best method for calibrating the accuracy of this type of thermometer is the ice point procedure. 1. Fill an insulated container such as Styrofoam cup or thermos with crushed ice and water. The consistency of the solution must be a slurry to be at 32 degrees Fahrenheit (F). 2 When the slurry has stabilized .immerse the thermometer into the contents. Make sure the stem of the thermometer is away from the bottom and sides of the container .

Based on interview and record review, the facility failed to follow infection control practices when the facility did not do water testing for germs. This failure had the potential to spread germs and placed residents at risk for infections. Findings: On 4/17/24 at 11:40 A.M., an observation and interview was conducted with the DON and Maintenance Personnel (MP) during a facility tour. MP stated there was no water testing done to check water level for germs and elements including Legionella (germs in water). The DON stated there was no illnesses noted with residents in the facility related to water-borne infections. There was no documented evidence provided by the facility to ensure water was being tested .

Based on interview and record review, the facility failed to ensure 2 of 2 sampled residents (8, 24) had end of life wishes or a POLST (physician orders for life sustaining treatment) completely signed by the RP(responsible party) and physician respectively in their record. As a result there was a potential to not have their life end of life wishes honored. Findings: 1.On 4/17/24 at 9 A.M., an interview and record review was conducted with the DON. The DON stated Resident 8's POLST was the physician order for life sustaining treatment. The DON stated Resident 8's POLST was a legal document, which meant a major decision for sustaining life for Resident 8. The DON stated Resident 8's POLST should be reviewed, agreed upon by both parties, and signed to include the title or relationship to Resident 8. The DON further stated, Resident 8 's POLST was not valid without the signature. A review of Resident 8's medical record indicated Resident 8 was on a public conservatorship from 1/17/24 to 1/17/25. A review of Resident 8's POLST (Physician Orders for Life-Sustaining Treatment) indicated it was signed by the physician on 5/14/19. The section for Patient or Legally Recognized Decisionmaker had a box for Signature (required) and Relationship (write self if patient) which was left blank and was not completed. 2. On 4/18/24 at 11:23 A.M, an interview and record review were conducted with the DON. The DON stated Resident 24's POLST should have been signed by the physician because POLST was an order and needed a physician signature. A review of Resident 24's POLST (Physician Orders for Life-Sustaining Treatment) indicated the section for Signature of Physician/Nurse Practitioner/Physician Assistant (Physician/NP/PA) had the physician's name but there was no signature and date. Per the facility policy entitled Palliative/End-of-Life Care-Clinical Protocol, revised date March 2018 indicated, 1. Upon admission, the attending physician will help identify the prognosis for each resident .2. The physician and staff will identify individuals who desire or are likely candidates for palliative car .3. The physician will review the resident's decision-making capacity and support the resident's participation in the care plan to the extent possible .

Based on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 12 sampled residents (Resident 5). This was when Resident 5 had developed stage III pressure ulcer (full thickness tissue injury, open wound that goes deeper into the tissue beneath) of her coccyx (tailbone). This failure had the potential to result in Resident 5 to be unable to achieve or maintain optimal status of health, function, and quality of life. Findings: Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia (the loss of cognitive function like thinking, remembering, and reasoning to such an extent that interferes with a person's daily life and activities), per the facility's Admission Record. A review of Resident 5's MDS dated [DATE], indicated her cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score was three, which indicated the resident's cognition was severely impaired. The MDS for skin conditions indicated Resident 5 had no skin conditions but was prone to developing skin damage. A review of Resident 5's physician's order dated 3/18/24, indicated there was an antibiotic (anti-infective) ointment order for Resident 5's pressure ulcer stage III of her tailbone which was completed on 4/9/24. A review of the facility's matrix (is used to identify pertinent care categories like pressure ulcer) dated 4/15/24 did not indicate Resident 5 had stage III pressure ulcer of her tailbone. A review of Resident 5's MDS for significant change in status assessment was conducted. There was no SCSA MDS for Resident 5's stage III pressure ulcer of the coccyx. During an observation and interview of Resident 5 in her room on 4/15/24 at 11:28 A.M., Resident 5 laid in bed, with her eyes closed and yelled out when her name was called. Resident 5 did not respond to questions. During an interview with Certified Nursing Assistant (CNA) 1 on 4/16/24 at 3:02 P.M., CNA 1 stated Resident 5 was alert, yelled out when she did not want to get up in bed. CNA 1 stated Resident 5 required assistance from her bed to her wheelchair but was able to wheel herself to the hallway. CNA 1 stated Resident 5 had strong hands but had no mobility on her legs. CNA 1 stated Resident 5 had a wound on her tailbone, and the Licensed Nurses (LNs) put some ointment and that the wound had gotten better. During a concurrent observation of Resident 5 and LN 2 performing wound treatment on Resident 5 on 4/18/24 at 9:17 A.M., LN 2 cleansed Resident 5's tailbone with normal saline (solution) and put some cream on Resident 5's pressure ulcer. During an interview with LN 2 on 4/18/24 at 9:18 A.M., LN 2 stated Resident 5's pressure ulcer had improved from a size of 2 centimeter (cm) by 2 cm to a scrape like and clean edges wound. During a joint review of Resident 5's clinical record and an interview with the Director of Staff Development (DSD) on 4/17/24 at 8:54 A.M., the DSD stated Resident 5's pressure ulcer had been treated with antibiotic ointment and the open area had closed. The DSD stated Resident 5's pressure ulcer stage III was identified on 3/16/24 and was not coded in MDS. The DSD stated the LNs who identified the change in Resident 5's skin condition should have triggered a situational alert to trigger the MDS tool. The DSD stated it was important to code Resident 5's changed in skin condition in MDS to communicate with the nursing staff what was the status of the resident and was a part of the resident's medical history. The DSD stated a comprehensive assessment was conducted to aid in developing a care plan for the residents. During an interview with the Director of Nursing (DON) on 4/18/24 at 10:43 A.M., the DON stated Resident 5's pressure ulcer was recent. The DON stated Resident 5's pressure ulcer was not coded in the MDS tool. The DON stated the LNs should be coding the resident's MDS as mandated. A review of the facility's policy titled, Comprehensive Assessment, revised October 2023 was conducted. The policy indicated, Comprehensive MDS assessments are conducted to assist in developing person-centered care plan .7. Significant Change in Status Assessment (SCSA) - the SCSA is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team - group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) has determined that a resident meets the significant change guidelines for either major improvement .8. A significant change is a major decline or improvement in a resident's status .

Based on observation, interview and record reviews, the facility failed to develop a person-centered care plan for a resident (5) at risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), and for a resident (19) involved in a resident-to-resident altercation for two of 12 sampled residents reviewed for care plans. These failures had the potential of Resident 5 and Resident 19 to not receive the care and services needed to preserve optimal health status and prevent further decline. Findings: 1. Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia (the loss of cognitive function like thinking, remembering, and reasoning to such an extent that interferes with a person's daily life and activities), per the facility's Admission Record. A review of Resident 5's MDS dated [DATE], indicated her cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score was three, which indicated the resident's cognition was severely impaired. The MDS for skin conditions indicated Resident 5 had no skin conditions but was prone to developing skin damage. A review of Resident 5's physician's order dated 3/18/24, indicated there was an antibiotic (anti-infective) ointment order for Resident 5's pressure ulcer of her tailbone which was completed on 4/9/24. During an observation and interview of Resident 5 in her room on 4/15/24 at 11:28 A.M., Resident 5 laid in bed, with her eyes closed and yelled out when her name was called. Resident 5 did not respond to questions. During a joint review of Resident 5's clinical record and an interview with the Director of Staff Development (DSD) on 4/17/24 at 8:54 A.M., the DSD stated Resident 5's pressure ulcer was identified on 3/16/24. The DSD stated the LNs who identified the change in Resident 5's skin condition should have triggered a situational alert to trigger the system for the LNs to develop a care plan. The DSD stated a care plan should have been developed because it directed what kind of care was provided to the resident. During an interview with the Director of Nursing (DON) on 4/18/24 at 10:43 A.M., the DON stated Resident 5's pressure ulcer was recent. The DON stated a care plan should have been developed related to Resident 5's pressure ulcer because it was a way of implementing the treatment of care and a way of measuring if the targeted treatment goal was achieved. A review of the facility's policy titled, Goals and Objectives, Care Plans revised April 2009 was conducted. The policy indicated, .Care plan goals and objectives are defined as the desired outcome for a specific problem .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 2. Resident 19 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), per the facility's Admission Record. A review of Resident 19's history and physical dated 9/25/23 indicated Resident 19 was alert and oriented. During an interview with Resident 19 in the hallway on 4/15/24 at 4:10 P.M., Resident 19 stated her roommate hit her in the left side of her face while she was sleeping in her bed. Resident 19 stated, Now they are moving me to another room. I don't know why I am transferred. During an interview with Certified Nursing Assistant (CNA) 2 on 4/16/24 at 11:49 A.M., CNA 2 stated Resident 19 had an altercation with another resident on 4/15/24. CNA 2 stated there was no behavioral monitoring on Resident 19. During an interview with the Social Worker (SW) on 4/17/24 at 4:01 P.M., the SW stated Resident 19 had an altercation with her roommate. The SW stated she did not develop a care plan for Resident 19 after the altercation. The SW stated there was no care plan in Resident 19's clinical record. The SW stated a care plan should have been developed to know the plan for the residents' care like monitoring them after an altercation. During an interview with the Director of Nursing (DON) on 4/18/24 at 10:43 A.M., the DON stated a care plan should have been developed after an altercation between Resident 19 and her roommate because a care plan was a way of monitoring the care of the resident and to monitor them to prevent further incidents. A review of the facility's policy titled, Goals and Objectives, Care Plans revised April 2009 was conducted. The policy indicated, Care plan shall incorporate goals and objectives that lead to the highest obtainable level of independence .3. Care plan goals and objectives are derived from information .in the resident's .assessment and: a. are resident oriented; b. are behaviorally stated, c. are measurable .

Based on observation, interview and record review, the facility failed to follow the prescribed diet orders and ensure 1 of 3 sampled residents (1) received a chopped diet (cut ,d+[DATE] inch or smaller). As a result, Resident 1 choked and died after consuming a sandwich that was not cut as ordered. Findings: According to the facility's Admission Record, Resident 1 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Intake Information sheet dated [DATE], Resident 1 was given a sandwich to eat by staff at the facility. While eating the sandwich, Resident 1 choked and died . According to the Glossary of Cooking Terms related to Texture Modified Diets dated ,d+[DATE], a chopped diet .bite size ,d+[DATE] inch or smaller . On [DATE], a review was conducted of Resident 1's current physician orders, dated [DATE]. The orders indicated, Diet: Chopped diet (7am/noon/5pm), large (large portions), chopped portions. A review was conducted of Resident 1's care plan, titled Risk for Aspiration (breathing in food/saliva), dated [DATE]. Resident 1's aspiration risk care plan indicated, Resident to be monitored for aspiration s/s (signs and symptoms) due to hurried food/meal intake. Among the interventions listed: 1. Resident to maintain mech (mechanically) soft chopped large portion [diet] .5. Encourage resident to eat small amounts slowly . A review was conducted of Resident 1's undated tray ticket (card made for each individual resident, indicating dietary orders, preferences, and allergies). Resident 1's tray ticket read, Diet: Mech (mechanically) soft chopped, large portion. On [DATE] at 10:35 A.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 1 was ordered a chopped diet because he had no teeth. The DON stated Resident 1 was known by staff to eat fast. The DON stated Resident 1 was a long-time resident of the facility. On [DATE] at 11:13 A.M., an interview was conducted with kitchen worker (KW) 1. KW 1 stated residents with chopped diet orders needed food cut into very small pieces. KW 1 stated if a resident had chopped diet orders and was served a sandwich, it was necessary to cut the sandwich into little pieces. KW 1 stated she always chopped up the entire sandwich for Resident 1 when sandwiches were served at mealtime. On [DATE] at 11:22 A.M., an interview was conducted with the dietary supervisor (DS). The DS stated residents with chopped diets required small pieces of soft foods. The DS stated the reason for a chopped diet was to prevent choking in residents with alterations (difficulty) in chewing or swallowing. The DS stated residents with chopped diet orders should have their sandwiches cut into small pieces. The DS stated according to his tray ticket, Resident 1 had orders for a chopped diet. On [DATE] at 11:55 A.M., an interview was conducted with LN 1. LN 1 stated she was the licensed nurse on duty the night Resident 1 choked. LN 1 stated Resident 1 approached the nurse's station at approximately 8:40 P.M. and made hand gestures that he was hungry. She stated she offered Resident 1 a cheese sandwich. LN 1 stated CNA 1 accompanied Resident 1 back to his room, where he went to eat the sandwich. LN 1 stated a few minutes later, Resident 1 came running toward the nurse's station looking anxious and making signs he was choking. She stated she attempted to perform the [MEDICATION(S)] maneuver. LN 1 stated Resident 1 turned blue, passed out, and was moved to the floor. LN 1 stated 911 was called and Resident 1 had no pulse, no breathing or lung sounds. LN 1 stated she began to perform CPR (cardiopulmonary resuscitation-a lifesaving technique used when someone's heartbeat has stopped). LN 1 stated a small chunk of the sandwich came out of Resident 1's airway, but he did not start breathing. She stated when the paramedics arrived, they assumed care of Resident 1 and took him to the hospital. LN 1 stated the hospital later called and informed her Resident 1 had died . During the same interview, LN 1 stated a chopped diet was ordered for Resident 1 and that sandwiches should have been given to him in pieces, but she did not check to see if the sandwich was chopped according to physician orders. LN 1 stated she believed CNA 1 knew to cut up Resident 1's sandwich. On [DATE] at 2:40 P.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 was not on a modified diet (modified texture) but was known for being a fast eater and sometimes did not chew his food. CNA 1 stated that at approximately 8:30 P.M. on [DATE], she and LN 1 reviewed what Resident 1 had eaten that day and noticed according to records, he had not eaten dinner. CNA 1 stated she was instructed by LN 1 to wake Resident 1 at approximately 8:30 at night and offer him a sandwich. CNA 1 stated she had never been told to wake a resident up for a snack before and did not think Resident 1 was hungry if he was sleeping. CNA 1 stated she felt she was required to do what LN 1 told her to do. CNA 1 stated she woke Resident 1 up and gave him half of the sandwich. CNA 1 stated she cut the sandwich in half, but not into small pieces. CNA 1 stated Resident 1 took a few bites and began choking. She stated Resident 1 got out of bed and ran toward the nurse's station. CNA 1 stated she performed the [MEDICATION(S)] maneuver on Resident 1 and then CPR was performed, while awaiting paramedics' arrival. CNA 1 stated the paramedics arrived and took Resident 1 to the hospital. She stated staff was later informed Resident 1 had died . During that same interview, CNA 1 stated when passing out meal trays, the staff was required to check the tray ticket to verify each resident got the diet they were ordered. CNA 1 stated snacks did not have such a system. CNA stated she believed LN 1 would have told her if Resident 1 needed chopped diet. CNA 1 did not recall training related to food texture. On [DATE] at 9:30 A.M, an observation was conducted of the refrigerator at the nurse's station where resident snacks are stored. No chopped sandwiches were found in the refrigerator. On [DATE] at 9:40 A.M., an interview was conducted with KW 2. KW 2 stated the kitchen staff left sandwiches at night for after-hours snacks for residents. KW 2 stated the snack sandwiches were stored in the nurse's station refrigerator. KW 2 stated, We always leave chopped sandwiches. KW 2 stated resident snacks were not labeled for individual residents. On [DATE] at 9:52 A.M., an interview was conducted with the DON. The DON stated Resident 1 was known to be a fast eater and that staff often reminded him to slow down. The DON stated Resident 1 was able to make it known if he wanted to eat. The DON stated that while she was not in the facility during the incident, she was told that staff awakened Resident 1 to offer him a snack. The DON stated she believed it was acceptable to awaken a resident to eat because some residents had nutrition or weight loss problems. The DON stated Resident 1 did not have any low-weight concerns and was not at risk for poor nutrition. The DON stated LNs informed CNAs of residents with modified diet orders, such as chopped or soft. On [DATE] at 11:00 A.M., an interview was conducted with CNA 2. CNA 2 stated she was working in the facility the evening of the incident. CNA 2 stated she witnessed Resident 1 approaching the nurse's station while he was choking. CNA 2 stated LN 1 pounded on Resident 1's back but did not perform the [MEDICATION(S)] maneuver. CNA 2 stated CNA 1 performed the [MEDICATION(S)] maneuver after Resident 1 fell to the floor. CNA 2 stated she then left the nurse's station to open the door for the paramedics. During the same interview, CNA 2 stated Resident 1 only ate a chopped diet. She stated Resident 1 only ate sandwiches that were cut up. CNA 2 stated she knew Resident 1's diet order because she was familiar with his care but did not remember how she was first informed of this. CNA 2 stated if Resident 1 was hungry, he made hand motions to show staff. She stated if Resident 1 was sleeping, and not asking for food, he was not hungry. On [DATE] at 10:42 A.M., an interview was conducted with CNA 3. CNA 3 stated she was at the facility the evening when Resident 1 choked. CNA 3 stated she had witnessed CNA 1 performing the [MEDICATION(S)] maneuver on Resident 1 while he was lying on the floor. CNA 3 stated LN 1 told her to take Resident 1's temperature, and then to open the door for the paramedics. CNA 3 stated Resident 1 had a chopped diet and ate cut up sandwiches. CNA 3 stated if a sandwich was not cut, she knew she had to cut it with a butter knife. CNA 3 stated it was not usual to wake any residents up to offer them a snack. On [DATE] at 2:06 P.M., an interview was conducted with Resident 1's doctor who was also the facility's medical director. The doctor stated Resident 1 had orders for a soft/chopped diet. He stated he expected staff to follow diet orders for Resident 1. The facility did not provide documentation regarding CNA training for modified diets. According to the facility's undated Description of House Diets, .Chopped-Modification of Regular diet due to chewing difficulty. Foods that have been cut with a knife into course bits .Ground=Mech. Soft-Modification of Regular Diet due to chewing difficulty. Foods that have been minced, flaked, or passed through a grinder . According to the facility's undated policy, Nutrition and Meals, Assisting Residents With: .It is the policy of the SNF (Skilled Nursing Facility) that each resident receives assistance with meals according to individual needs .7. Prepare the meal for resident as determined by resident's functional level .