Every finding on record at Kings Healthcare & Wellness Center LP

Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data by the required deadline.This failure resulted in CMS not knowing how many direct care staff provided daily care and services for 61 residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings:During an interview and record review on 6/1/2026 at 8:39 a.m. with the Administrator (ADM) and Director of Nursing (DON) during the Facility Entrance Conference, the CMS document titled, Payroll Based Journal (PBJ) Staffing Data Report, dated Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) was reviewed. the document indicated, .Metric.Failed to Submit Data for the Quarter.Result.Triggered.Definition.Triggered = No Data Submitted for Quarter. The ADM stated the PBJ data was submitted for the wrong quarter. The ADM stated Corporate headquarters notified her that the wrong information was submitted, but it was too late to submit the correct information before the deadline.During an interview on 6/4/26 at 11:25 a.m. with the Payroll Coordinator (PR), the PR stated the PR will input hours into the payroll system and the Corporate Office will pull the payroll information from the system and submit the PBJ information to CMS. The PR stated the Corporate Office will notify the ADM if a reporting quarter was missed. The PR stated the PBJ information should have been submitted to be in compliance with reporting staffing data.During an interview on 6/4/26 at 11:37 a.m. with the ADM, the ADM stated the Corporate Office submitted the wrong information to CMS for the PBJ reporting quarter. The ADM stated the Corporate Office pulls information from the payroll system to submit the PBJ data to CMS. The ADM stated the PBJ data was important to meet the staffing needs of the residents. The ADM stated the Facility Assessment (an assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) was based off resident diagnoses and the needs of the residents, and the PBJ ensured staffing was in place for the care required for the residents. The ADM stated the PBJ should have been submitted before the reporting deadline.During a review of the professional reference document titled, Staffing Data Submission Payroll Based Journal (PBJ), dated 5/6/26, retrieved from https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission, the document indicated, .The Centers for Medicare & Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home's ability to provide quality care. CMS has utilized staffing data for a myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes. We post staffing information on the CMS Nursing Home Compare website, and it is used in the Nursing Home Five Star Quality Rating System to help consumers understand the level and differences of staffing in nursing homes. Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered.

Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for three of 11 sampled residents (Resident 34, Resident 76, and Resident 78) when:1. Resident 34's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered according to the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident).This failure resulted in Resident 34 not receiving her oxygen therapy as ordered by the physician, which had the potential to result in shortness of breath, and respiratory distress (difficulty breathing).2. Resident 34's oxygen tubing and nasal cannula (n/c-flexible, clear tube that connects to an oxygen source and placed in the nostrils to deliver oxygen) were not labeled with the date and time and were not stored appropriately when not in use.These failures had the potential for Resident 34 to use a dirty and contaminated nasal cannula and oxygen tubing, which put Resident 34 at risk of infection.3. Resident 78 was administered oxygen therapy without a physician's order or care plan.This failure resulted in Resident 78 receiving unnecessary treatment, which put Resident 78 at risk of nasal dryness, shortness of breath, oxygen toxicity (damage to the lungs that happens from breathing in too much oxygen, which can cause coughing, trouble breathing, and even death in severe cases.4. Resident 76 was a high fall risk and her bed was not in the lowest position.This failure resulted in facility fall protocol not being followed while Resident 76 was lying in bed which could result in accidents, falls or injury. Findings: 1. During a concurrent observation on 6/1/2026 at 10:08 a.m. with Resident 34, in Resident 34's room, Resident 34 was observed dressed, sitting in a wheelchair, wearing an oxygen (O2) nasal cannula. Resident 34's O2 infusion rate was set at 1.5 Liters per minute (L/m - a unit of measurement for oxygen flow rate). Resident stated she had been in the facility since January 2026 due to a fall and was getting physical therapy. During a review of Resident 34's admission Record (AR - a summary of information regarding a patient), dated 6/4/26, the AR indicated Resident 34 was initially admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital with diagnoses of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), wedge compression fracture of lumbar vertebrae (a break in the front of the spinal bone in the lower back causing the bone to collapse), low back pain, muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 4/16/26, the MDS section C indicated Resident 34 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 34 was cognitively intact. During a concurrent interview and record review on 6/3/26 at 2:15 p.m. with Registered Nurse (RN) 1, Resident 34's Order Summary Report (OSR), undated was reviewed. the OSR indicated, .Oxygen 3 liters per minute (LPM) via nasal cannula continuously. RN 1 stated Resident 34's O2 was to be at a 3 L/min rate. During a concurrent observation and interview on 6/3/26 at 2:17 p.m. with RN 1 in Resident 34's room, Resident 34 was observed dressed sitting in a wheelchair in her room wearing O2 tubing. Resident 34's O2 rate was observed to be set at 2.5L/min. RN 1 asked Resident 34 if she changed her O2 rate settings knob, which Resident 34 denied. RN 1 stated the O2 rate was only slightly lower than the physician's order. RN 1 stated Resident 34's O2 rate should have been set at 3 L/min. RN 1 stated it was important to have a physician's order for O2 as it was considered a medication and staff should have followed the order for Resident 34's O2 rate setting. During an interview on 6/3/2026 at 3:15 p.m. with the Director of Nursing (DON) the DON stated staff should have followed the physician orders for Resident 34's O2 rate. The DON stated nurses should check resident's O2 setting every time they went into the resident's room, such as during medication pass and when they checked the residents. During an interview on 6/4/24 at 11:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the nurses checked resident's oxygen. LVN 1 stated there was a monitoring log in the Medication Administration Record (MAR) in the resident's chart. LVN 1 stated physician orders were important so all staff could do their part in caring for the residents. LVN 1 stated even Certified Nursing Assistants (CNA)s could have checked residents on oxygen and told the nurse if they saw a resident with their nasal cannula on their head and not in the nose. 2. During a concurrent observation and interview on 6/03/2026 at 8:31 a.m. in Resident 34's room, Resident 34 was observed sitting on her bed dressed, with her O2 tubing and NC on the floor on the other side of her bed. Resident 34 stated she was waiting for her bath. Resident 34 stated she just took off her NC and dropped it. During a concurrent observation and interview on 6/3/26 at 2:15 p.m. with Resident 34 and RN 1 in Resident 34's room, Resident 34 was observed dressed sitting in wheelchair in her room wearing O2 tubing. Resident 34's tubing was unlabeled with the date and time it was placed on Resident 34. Another labeled O2 tubing and NC was observed on Resident 34's bed. Resident 34 stated she did not know who put the old O2 tubing on her bed, or who placed the new O2 tubing on her. Resident 34 stated someone disconnected her old tubing and connected a different O2 tubing to her tank and took her to therapy. RN 1 stated only RNs were to disconnect and connect residents' O2 tubing. RN 1 stated Resident 34's O2 tubing should have been changed if it was on the floor. RN 1 stated the old tubing should have been thrown away and not put on Resident 34's bed as it was a risk of infection to the resident if it was dirty and was used. RN 1 stated the new tubing should have been labeled so staff knew when to change it. During an interview on 6/3/26 at 2:20 p.m. with the DON, the DON stated only RNs were to connect, disconnect and set resident's O2 rate as it was beyond other staff's scope of practice. The DON stated Resident 34's O2 tubing should have been changed and labeled, and the old tubing should have been thrown away so no one would use it. The DON stated it was a risk of infection to the resident if the dirty O2 tubing was put back on the resident. During an interview on 6/4/2026 at 2:37 p.m. with the DON, the DON stated staff did resident rounds two times a day. The DON stated caring for residents on oxygen was a nursing team effort, but the DON was ultimately responsible for making sure residents on oxygen therapy had the correct setting for the oxygen rate, O2 tubing and NC were labeled and changed weekly or when contaminated. 3. During a concurrent observation and interview on 6/1/2026 at 10:14 a.m. with Resident 78 and Resident 78's Responsible Party (RP - individual authorized to act on a resident's behalf regarding care), in Resident 78's room, Resident 78 was observed dressed, sitting in her wheelchair wearing an O2 nasal cannula with oxygen infusing at 2 L/min. Resident 78 stated she had been in the facility for a while but did not remember why she was in the facility. Resident 78 stated she was unable to remember things. Resident 78's RP stated Resident 78 had been in the facility for one week and had pneumonia. During a review of Resident 78's AR, dated 6/4/26, the AR indicated Resident 78 was admitted from an acute care hospital on 5/20/26 with diagnoses of wedge compression fracture of lumbar vertebrae, fractures of ribs (several breaks in the rib bones), pubis fracture (a break of the ring of bones that connect your spine to the hips), dysphagia (difficulty swallowing), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid). During a review of Resident 78's MDS, dated 5/29/26, the MDS section C indicated Resident 78 had a BIMS score of 3, which indicated Resident 78 was severely cognitively impaired. During a review of Resident 78's MDS, dated 5/29/26, the MDS section O (Special Treatments, Procedures, and Programs) Respiratory Therapy indicated, .number of days this therapy was administered for at least 15 minutes a day in the last 7 days.number of days.7. During a concurrent observation and interview on 6/03/2026 at 10:04 a.m. with Resident 78's RP in Resident 78's room, Resident 78 was observed dressed, in bed, not wearing an O2 NC. Resident 78's RP stated Resident 78 was on O2 therapy while on transport from the hospital to be admitted to the facility. Resident 78's RP stated Resident 78 was no longer using O2. During an interview on 6/3/2026 at 3:00 p.m. with RN 1, RN 1 stated if a resident was admitted to the facility from the hospital on O2, staff checked for O2 discontinuation orders from the hospital and contacted the physician to inform why the resident was using O2 and get orders if the resident was to continue O2 therapy. RN 1 stated there was an emergency such as a resident's O2 was dropping, staff continued giving O2. During an interview on 6/3/2026 at 3:05 p.m. with the DON, the DON stated once the facility received report from the hospital of a new resident on O2 therapy, staff continued the orders on admission and informed the physician for new orders. During a concurrent interview and record review on 6/4/26 at 11:45 a.m. with LVN 1, Resident 78's medical record was reviewed. LVN 1 stated there were no physician orders or care plan for Resident 78's use of O2. LVN 1 stated if a resident was on O2 therapy on admission, and if the hospital's admission orders did not follow the resident from the hospital, staff were to call the physician to receive orders. LVN 1 stated the RNs assessed the residents and administered O2 therapy. LVN 1 reviewed Resident 78's hospital records and stated there were no orders for Resident 78's O2 use from the hospital. LVN 1 stated he did not know if Resident 78 was on oxygen, since it was not listed in her file. Resident 78's admission Assessment, undated was reviewed. LVN 1 stated there was no O2 therapy noted on Resident 78's admission Assessment. Resident 78's Weights and Vitals Summary (WVS), dated 5/1/26-6/1/26 was reviewed. the WVS indicated from 5/22/26 through 6/2/26 Resident 78's oxygen saturation (O2 sats – a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) measurements were documented with Resident 78 wearing a nasal cannula. LVN 1 stated the measurement documented via nasal cannula indicated Resident 78 was receiving O2 therapy. LVN 1 stated Resident 78 should have had a physician's order for O2 therapy since it was considered a medication and so staff would monitor Resident 78's oxygen levels. LVN 1 stated there was a risk to a resident if there was no order for O2 therapy and the resident needed O2 therapy, but the resident was taken off O2, the resident could become hypoxic (low levels of oxygen in the tissues). LVN 1 stated if resident had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and received too much O2, the resident would contain carbon dioxide (CO2 – a colorless, odorless gas that is a waste product made from the body and exhaled during breathing) and not exchange properly. LVN 1 stated if a resident was on O2 therapy and there was no order for O2 therapy, there was a risk for the resident to receive too much oxygen. During an interview on 6/4/2026 at 2:37 p.m. with the DON, the DON stated monitoring residents on O2 therapy was a nursing team effort, but the DON was ultimately responsible for verifying residents on O2 therapy received orders for O2 therapy and it was administered as ordered. During a review of the facility's policy and procedure (P&P) titled NP94 Oxygen Therapy, dated 10/31/25, the P&P indicated, .oxygen is administered under safe and sanitary conditions to meet resident needs.oxygen will be initiated with a provider order and initiated and/or titrated by a respirator therapist [RT] or registered nurse[RN]. During a review of the facility's P&P titled P-NP94 Oxygen Therapy, dated 10/31/25, the P&P indicated, .administer oxygen and obtain oxygen saturation levels as ordered by the provider.oxygen equipment shall be maintained as follows.the tubing and mask should be changed at least every 7 days and labeled with the date of change. 4. During an observation on 6/1/26 at 9:43 a.m. with Resident 76, in Resident 76's room, Resident 76 was observed lying in bed. Resident 76's bed was observed elevated, raised in the highest position off the ground. During a concurrent observation and interview on 6/1/26 at 9:51 a.m. with Certified Nursing Assistant (CNA) 2 with Resident 76, in Resident 76's room, Resident 76 was observed lying in bed. Resident 76's bed was observed elevated, raised in the highest position off the ground. CNA 2 stated Resident 76's bed was elevated, raised in the highest position off the ground. CNA 2 stated Resident 76 was a high fall risk because she was confused and unpredictable. CNA 2 stated Resident 76's bed should always be in the lowest position, closest to the ground. CNA 2 stated Resident 76 was at risk for falls and injuries if she tried to get out of bed with the bed in the highest position off the ground. During a concurrent interview and record review on 6/3/26 at 9:08 a.m. with LVN 2, Resident 76's Electronic Medical Record (MAR), dated 6/3/26, was reviewed. LVN 2 stated Resident 76 was admitted to the facility on [DATE] for worsening altered mental status after sustaining a fall which resulted in a left arm injury. LVN 2 stated on admission to the facility Resident 76 was assessed as a high fall risk. LVN 2 stated facility fall protocol interventions were implemented on admission for Resident 76 which included always maintaining the bed in the lowest position to the ground, keeping personal items and the call light within reach, and wearing non-skid footwear. LVN 2 stated it was facility fall protocol and nursing standard of practice to ensure resident beds were maintained in the lowest position, closest to the ground when residents were lying in bed to prevent accidents, falls, or injuries. LVN 2 stated Resident 76 was placed at risk for falls, injuries or worsening of her left arm injury when her bed was in the highest raised position, off the ground, and she was in the bed. During a concurrent interview and record review on 6/4/26 at 9:40 a.m. with the Director of Nursing (DON), facility policy and procedure (P&P) titled, Fall Management Program, dated 11/11/25, and Resident Safety, dated 4/15/21, were reviewed. The DON stated Resident 76 was confused and had a history of falls with injury which made her a high fall risk. The DON stated facility fall protocol interventions included, maintaining the bed in the lowest position to the ground, keeping personal items and the call light within reach, and wearing non-skid footwear. The DON stated facility P&P, facility fall protocol, and nursing standard of practice for safety were not followed when Resident 76 was a high fall risk and her bed was not in the lowest position, closest to the ground, to maintain a safe environment. The DON stated Resident 76 was placed at risk for accidents, falls, and injuries when her bed was elevated, in the highest position, off the ground. During an interview on 6/4/26 at 2:33 p.m. with the DON, the DON stated she completed rounds two times a day on all residents. The DON stated she was responsible for ensuring facility P&P, facility fall protocol and nursing standards of practice for safety were being implemented for all high fall risk residents. During a review of Resident 76's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/3/26, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (altered brain function due to an underlying condition), unsteadiness on feet, muscle weakness, dementia (decline in mental ability), altered mental status, and contusion of upper arm (direct impact causing damage to muscle fibers and blood vessels). During a review of Resident 76's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/20/26, the MDS indicated Resident 76 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 9 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 76 was moderately cognitively impaired. During a review of Resident 76's Fall Risk Evaluation, dated 5/15/26, the Fall Risk Evaluation, indicated Resident 76 had a fall risk score of 19. The Fall Risk Evaluation indicated, .if the total score is 10 or greater, the resident should be considered a high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. During a review of Resident 76's Care Plan (CP), dated 5/15/26, the CP indicated, .the resident is at risk for falls [related to] gait/balance problems.fall risk score 19.follow facility fall protocol. During a review of facility policy and procedure (P&P) titled, Fall Management Program, from the Manual Title, Nursing Manual-General Nursing, dated 11/11/25, the P&P indicated, .as part of the admission and re-admission assessment, the licensed nurse will complete a fall risk evaluation and document interventions on the Resident's care plan.the interdisciplinary team (IDT) and/or licensed nurse will develop a care plan according to the identified risk factors. During a review of P&P titled, Fall Management Program, from the Manual Title, Nursing Manual-General, dated 11/11/25, the P&P indicated, .the facility will maintain an environment free from accident hazards, provide adequate supervision and assistive devices to prevent avoidable accidents, and implement an interdisciplinary fall prevention program that includes risk screening, individualized care planning, targeted interventions.purpose.to reduce the risk of avoidable falls and fall-related injuries and to ensure timely, evidence-based post fall evaluation and management consistent with best practices, federal and state guidance requirements for resident safety, supervision and quality of care. During a review of facility P&P titled, Resident Safety, dated 4/15/21, the P&P indicated, .provide a safe and hazard free environment.to observe the safety and wellbeing of the Residents, a Resident check will be made at least every two hours around the clock by nursing service personnel.during the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident's safety risk [examples] fall.as well as any other Resident specific safety risks.after a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors. During a review of the professional refence article titled, Heights of Occupied Patient Beds: A Possible Risk Factor For Inpatient Falls dated 2/9/09, retrieved from https://pubmed.ncbi.nlm.nih.gov/18482143/, the article indicated, .if the patient bed can be manually or automatically adjusted, nurses must lower the height of the bed to the lowest position after completing treatments or tasks. This after-procedure activity should be enforced and monitored regularly as part of a hospital's patient fall prevention program. Low beds should be used for patients at high risk of falling.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for one of three sampled residents (Resident 81), when Resident 81 did not have a care plan for the use of Cervical Collar (C-Collar -a neck brace used to support and immobilize a person's neck) for cervical spinal cord injury (damage to the uppermost part of the spine located in the neck area).This failure had the potential for Resident 81 to not receive the necessary care required for cervical collar, increasing the risk for skin breakdown, improper alignment, and compromised airway. During an observation on 6/1/26 at 9:35 a.m. during initial tour in Resident 81's room, Resident 81 was observed lying in bed, eyes opened, and C-Collar in place. The resident did not answer questions asked.During a review of Resident 81's Face Sheet (FS - a summary of information regarding a resident which includes resident identification, past medical history, care providers, family contact information and other pertinent information), dated 6/4/26, the FS indicated Resident 81 was admitted to the facility on [DATE] with a diagnoses which included Central Cord Syndrome ( the most common type of spinal cord injury) at unspecified level of Cervical Spinal Cord ( the bundles of nerves running through the neck).During a concurrent interview and record review on 6/3/26 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 81's Order Summary Report (OSR), the OSR indicated . C-collar to neck at all times. start date 6/1/26. LVN 4 stated Resident 81 was admitted on [DATE] and arrived wearing a C-Collar. LVN 4 stated Resident 81 did not have a care plan in place for the C-Collar upon admission and a care plan should have been initiated at the time of admission. LVN 4 stated the importance of having a care plan in place upon admission for a C-Collar was to ensure continuity of care and to provide facility staff with guidance on how to properly care for Resident 81and manage the C-Collar. LVN 4 stated it was important to monitor the C-Collar to prevent skin breakdown, ensure comfort and proper fit, and maintain safety precautions while Resident 81 was wearing the C-Collar.During an interview on 6/4/26 at 12:41 p.m. with the Director of Nursing (DON), the DON stated a care plan for the C-Collar should have been started upon admission. The DON stated the nurse developed the care plan based on the resident's assessment and needs. The DON stated the purpose of the C-Collar care plan was to monitor the residents' condition and ensure the provision of proper and safe care for both the residents and staff. The DON stated the absence of a C-Collar care plan may increase the risk of complications, such as neurological injuries. The DON stated it was her responsibility to ensure the residents' care plans are updated and are being implemented by facility staff.During a review of facility's policy and procedures (P&P) titles, Person- Centered Care Planning, effective date 5/22/26, the P&P indicated, . The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections when, two of two licensed nurses (Licensed Vocational Nurse [LVN] 3 and LVN 4), failed to follow the manufacturer's instructions for use (IFU- the official step by step directions provided by the maker of a product) by not maintaining the required germicidal disposable wipes dwell time (the exact amount of time a disinfectant must stay visibly wet on a surface to completely kill germs) during the disinfection (chemical process that kills harmful germs) of a glucometer (a medical device used for determining the amount of sugar in the blood) after use on Resident 13, Resident 21, Resident 40, Resident 65, and Resident 85. This failure had the potential to result in the spread and transmission of communicable (infectious disease - a condition that can be transmitted from one person to another through various means including direct contact and indirect contact) diseases and blood born infections (viruses that are carried in the blood) among residents in the facility.During an observation on 6/3/26 at 11:20 a.m. outside Resident 40's room, LVN 3 was observed gathering supplies to perform a blood glucose test (a method of measuring the concentration glucose [sugar] in the blood) on Resident 40. After obtaining a blood sample from Resident 40, LVN 3 was observed using one germicidal wipe (a germicidal [kills germs] disposable wipe used for disinfecting surfaces) to clean the glucometer. The glucometer was placed on the medication cart and allowed to air-dry. LVN 3 was observed setting a two-minute timer. The glucometer was observed to be dry within one minute after being cleaned with the germicidal wipe by LVN 3. The glucometer did not remain wet for two minutes.During an observation on 6/3/26 at 11:27 a.m. outside Resident 21's room, LVN 3 was observed gathering supplies to perform a blood glucose test on Resident 21. After obtaining a blood sample from Resident 21, LVN 3 was observed using one germicidal wipe to clean the glucometer. The glucometer was placed on the medication cart and allowed to air-dry. LVN 3 was observed setting a two-minute timer. The glucometer was observed to be dry within one minute after being cleaned with the germicidal wipe by LVN 3. The glucometer did not remain wet for two minutes.During a concurrent observation and interview on 6/3/26 at 11:30 a.m. with LVN 3, outside Resident 13's room, LVN 3 was observed gathering supplies to perform a blood glucose test on Resident 13. After obtaining a blood sample from Resident 13, LVN 3 was observed using one germicidal wipe to clean the glucometer. The glucometer was placed on the medication cart and allowed to air-dry. LVN 3 was observed setting a two-minute timer. The glucometer was observed to be dry within one minute after being cleaned with the germicidal wipe by LVN 3. LVN 3 stated she cleaned the glucometer with one (brand name) germicidal wipe after resident use and allowed the glucometer to air-dry for two minutes. LVN 3 stated the glucometer did not remain wet for two minutes.During an observation on 6/3/26 at 11:41 a.m. with LVN 4, outside Resident 85's room, LVN 4 was observed gathering supplies to perform a blood glucose test on Resident 85. After obtaining a blood sample from Resident 85, LVN 4 was observed using one germicidal wipe to clean the glucometer. The glucometer did not remain wet for two minutes.During an observation on 6/3/26 at 12:26 p.m. with LVN 4, outside Resident 65's room, LVN 4 was observed gathering supplies to perform a blood glucose test on Resident 65. After obtaining a blood sample from Resident 65, LVN 4 was observed using one germicidal wipe to clean the glucometer. The glucometer did not remain wet for two minutes.During a concurrent interview and record review on 6/3/26 at 2:51 p.m. with the Infection Preventionist (IP), the glucometer manufacturer guidelines titled, [brand name] Blood Glucose Monitoring System Quality Assurance/ Quality Control Reference Manual, undated, and the germicidal wipes manufacturer's instructions titled, General Guidelines For Use [brand name] Germicidal Disposable Wipe, undated, were reviewed. The IP stated glucometers were expected to be cleaned and disinfected, per glucometer and germicidal wipe manufacturer guidelines, after use on each resident, to prevent the spread of communicable diseases and blood-borne pathogens. The IP stated the germicidal wipe manufacturer guidelines indicated the glucometer required a two-minute wet time (the amount of time the item needs to remain visibly wet in order to kill specific bacteria) to ensure disinfection.During an interview on 6/3/26 at 3:23 p.m. with the IP and the Director of Nursing (DON), the IP stated one germicidal wipe was used to clean the glucometer, a second germicidal wipe was used to disinfect the glucometer and then a two-minute timer would be started to monitor and ensure a two-minute wet time, after disinfection. The IP stated the glucometer began to dry at the one-minute mark and required a third germicidal wipe to maintain a two-minute wet time. The IP stated after maintaining a two-minute wet time on the glucometer, the glucometer was then air dried before use. The DON stated the glucometer needed to remain wet for two minutes to be sure it killed germs on the glucometer and did not contaminate the next resident it was used on.During an interview on 6/4/26 at 9:40 a.m. with the DON, the DON stated nursing staff had not followed manufacturer guidelines or facility policy and procedure when only one germicidal wipe was used to clean the glucometer. The DON stated nursing staff did not disinfect the glucometer or maintain a two-minute wet time. The DON stated nursing staff did not properly clean and disinfect the glucometer between resident use which could result in the spreading of communicable diseases and blood-borne infections.During a review of the facility's lesson plan titled, Disinfecting Blood Glucometers, dated 12/22/25, the lesson plan indicated, .maintain wet contact time according to facility policy/manufacturer instructions; allow to dry.During a review of the facility's policy and procedure (P&P) titled, Infection Control-Policies & Procedures, dated 1/1/12, the P&P indicated, .facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections.During a review of the glucometer manufacturer's instructions titled, [brand name] Blood Glucose Monitoring System Quality Assurance/ Quality Control Reference Manual, undated, the manufacturer's instructions indicated, .to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The [brand name] Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. please read the manufacturer's instructions before using their wipe on the meter.many wipes act as both a cleaner and disinfect. If blood is visibly present on the meter, two wipes must be used, one wipe to clean and a second wipe to disinfect.treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions.During a review of the germicidal wipe manufacturer's instructions titled, General Guidelines For Use [brand name] Germicidal Disposable Wipe, undated, the manufacturer's instructions indicated, .allow treated surface to remain wet for two (2) minutes. Let air dry.

Based on observation, interview, and record review, the facility failed to ensure food was stored and served safely in accordance with professional standards of food service safety for 57 out of 57 residents eating at the facility when 4 single serve pre-prepared ice cream cups and an opened box of kielbasa rope sausage were in the freezer past the use by date.This failure resulted in food items being retained past the use by date which could lead to the serving of expired food items and foodborne illness.During a concurrent observation and interview on 6/1/26 at 9:02 am with the Certified Dietary Manager (CDM), in the kitchen, 4 single serve pre-prepared ice cream cups were observed with a use by date of 5/29/26. The label indicated the 4 single serve pre-prepared ice cream cups were 3 days past the use by date. An opened box of kielbasa rope sausage was observed with a use by date of 5/22/26. The label indicated the opened box of kielbasa rope sausage were 10 days past the use by date. The CDM stated all kitchen staff were expected to accurately and correctly label all food items with a received, opened and use by date. The CDM stated all kitchen staff were expected to discard food items by the labeled use by date. The CDM stated food items retained past the use by date were considered expired and needed to be removed from the kitchen to prevent accidental serving of expired food which could lead to foodborne illness.During an interview on 6/3/26 at 8:33 a.m. with the Registered Dietitian (RD), the RD stated all food items were expected to be accurately and correctly labeled by kitchen staff with a received, opened and use by date. The RD stated it was important to adhere to labeled use by dates to prevent the serving of expired food items. The RD stated serving expired food items could result in loss of palpability and/or foodborne illness.During an interview on 6/4/26 at 9:40 a.m. with the Director of Nursing (DON), the DON stated kitchen staff were expected, per food safety standards of practice and facility policy, to correctly and accurately label all food items with a received, opened and use by date. The DON stated kitchen staff were expected, per food safety standards of practice and facility policy, to remove food items from the kitchen by the use by date to prevent serving of expired food items which could result in foodborne illness. The DON stated standards of food safety standards of practice and facility policy were not followed when the kitchen freezer contained 4 single serve pre-prepared ice cream cups 3 days past the use by date and an opened box of kielbasa rope sausage were 10 days past the use by date.During an interview on 6/4/26 at 2:33 p.m. with the DON, the DON stated she completed monthly kitchen audits. The DON stated she was responsible for ensuring kitchen staff followed facility policy and procedure.During a review of the facility's document titled, Diet Type Report, dated 6/4/26, the document indicated 57 residents received food from the facility kitchen.During a review of the facility's kitchen in-service training document titled, Labeling/Dating/Expired Products, dated 3/21/26, the document indicated, .how to label/date items:.receive date.opened date.expiration date from receive date (may not use manufacturers).use by date from opened date (be sure use by date does not go past manufacturers date).all shifts should check for expired items daily throughout the shift. Any items that are to be found expired should be discarded immediately.every shift is responsible for expired or not labeled items.it is the dietary department's responsibility to ensure all items are correctly stored. If items are found to be mislabeled, it is your responsibility to correct or discard them as necessary.everyone in the department is liable for the correct storage of all items in the dietary department.During a review of the facility's kitchen in-service training document titled, Empower Employees Through Food Safety Training, dated 3/21/26, the document indicated, .labeled with a use-by date seven days from when the food was first thawed, opened, or prepared. The day that the food was opened or prepared counts as day one.foods should be labeled with the earliest use-by date of any of its ingredients. if a food is not served or sold before its use-by date, it must be thrown away.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure controlled substance medications (is a drug that is strictly regulated by the government because of high risk of misused and abused) are administered and recorded accurately in accordance with the facility's policies and procedures for one of two sampled residents (Resident 39) when Licensed Vocational Nurse (LVN) 2 failed to accurately document Resident 39's controlled substance medication on the controlled substance log to accurately reflect the controlled substance administration. This failure placed Resident 39 at potential risk for medication errors, duplicated dosing and undetected controlled substances diversion (theft or illegal redirecting of a regulated drug).During a medication administration observation on 6/3/26 at 8:28 a.m. with Licensed Vocation Nurse (LVN)2 in Resident 39's room, Resident 39 was lying in bed, with facial grimacing and moaning. LVN 2 left Resident 39's room and prepared pain medication from the medication cart. LVN 2 prepared Morphine Sulfate (a controlled medication concentrate oral solution used to treat moderate-to-severe pain). The prescribed dose was 0.5ml [milligrams - unit of measurement], equivalent to 10mg [milligrams - unit of measurement], to be administered orally every 4 hours as needed for moderate pain. LVN 2 administered the medication to Resident 39. LVN 2 documented the medication on the Individual Narcotic Record (INR - a log used by healthcare facilities to track the receipt, administration, and disposal of controlled medication), sheet for Resident 39. LVN 2 documented the administration of Morphine Sulfate 0.5ml on the routine INR sheet instead of on the designated as-needed INR sheet. During a concurrent interview and record review on 6/3/26 at 8:40 a.m. with LVN 2, Resident 39's INR sheet undated was reviewed. The INR sheet for Routine Morphine Sulfate indicated, at 8:34 a.m., LVN2 documented the administration of Morphine Sulfate 0.5 ml orally every 4 hours as needed. LVN 2 stated Morphine Sulfate 0.5ml was administered as needed and not routinely. LVN 2 stated there were two separate INR sheet: one INR for Routine Morphine Sulfate 0.5ml administered orally every 6 hours, and another INR for as-needed Morphine 0.5 ml administered orally every 4 hours as needed for pain. LVN 2 signed the INR sheet for Routine Morphine Sulfate 0.5ml administered orally every 6 hours instead of the INR as-needed Morphine Sulfate 0.5ml administered orally every 4 hours as needed for pain. LVN 2 stated, I should have signed on the Morphine Sulfate every 4 hours as needed narcotic record and not on the Morphine sulfate every 6 hours routine narcotic record. LVN 2 stated incorrect signing on the narcotic log could cause medication discrepancies and potentially lead to medication errors. During a review of Resident 39's Order Summary Report (OSR) dated 6/4/26, the OSR indicated, .Morphine Sulfate (Concentrate) Oral Solution . Give 0.5 ml by mouth every 4 hours as needed for Moderate Pain . Morphine Sulfate (Concentrate) Oral Solution . Give 0.5ml by mouth every 6 hours for CHRONIC PAIN.During an interview on 6/4/26 at 11:05 a.m. with the Director of Nursing (DON), the DON stated the nursing staff were expected to accurately sign the INR. The DON stated that if a narcotic was administered routinely, it should have been documented on the routine INR, and if the narcotic was administered on an as-needed basis, it should have been documented on the as-needed INR. The DON stated the improper narcotic documentation could have created medication discrepancies, potentially lead to medication errors, and placed resident safety at risk. The DON stated it was her responsibility to ensure the accuracy and compliance of narcotic documentation within the facility.During a review of the facility's policy and procedure (P&P) titled, MEDICATION ADMINISTRATION, dated 3/2026, the P&P 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, Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Certified Nursing Assistants (CNA) were not posted for 61 residents and visitors to view.This failure resulted in 61 residents and visitors not knowing how many direct care hours were actually provided daily for each resident by licensed and unlicensed staff.Findings:During an observation on 6/03/26 at 12:23 p.m. a facility document titled, [NAME] HealthCare and Wellness Center Staffing Information (Staffing Information), dated 6/3/26 was observed posted in the hallway. The document did not indicate if the posted hours were anticipated or actual hours worked by licensed and non-licensed staff. During an interview on 6/3/2026 at 3:27 p.m. with the Director of Staff Development (DSD) the DSD stated she was responsible for staff scheduling and completing the Staffing Information form. The DSD stated she scheduled staff based on the needs and acuity of the residents.During an interview and record review on 6/4/26 at 11:14 a.m. with the DSD, the facility's Staffing Information document was reviewed. The DSD stated the posted document was the anticipated hours of licensed and non-licensed patient care staff. The DSD stated she did not use the CDPH 612 form titled, Census and Direct Care Service Hours Per Patient Day (DHPPD) for the breakdown of patient care hours for CNAs and nurses. The DHPPD form, dated 6/2/26 was reviewed. The DSD stated payroll fills out the DHPPD form with documented actual hours of nurses and CNAs.During an interview and record review on 6/4/26 at 11:25 a.m. with the Payroll (PR) coordinator, the DHPPD form dated 6/2/26 was reviewed. The PR stated she completed the form the next day after the night shift hours were calculated and kept the forms in a binder. The PR stated the DHPPD information was important to be sure the facility was in compliance with scheduling staff according to the facility census. The PR stated not having enough staff can affect direct care hours for the residents.During an interview on 6/4/2026 at 2:37 p.m. with the Director of Nursing (DON), the DON stated completing the DHPPD form was important, so residents and visitors were aware of staff hours and the census. The DON stated during standup report, she told staff what the staffing hours and census numbers were for the day. The DON stated she was responsible for the accurate daily posting of licensed and non-licensed staffing hours. During a review of the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Postings, dated 7/2018, the P&P indicated, .to ensure that adequate number of nursing personnel are available to meet resident needs.the Facility will employ Nursing Staff that will be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care.in staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs, and such information will be posted as required.the Facility will post the following information on a daily basis.the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.Registered Nurses.Licensed Vocational Nurses.Certified Nurse Aides.Resident Census.the Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift.During a review of the facility job description document titled, Director of Nursing Services, undated, the document indicated, .under the direction of the Administrator, the Director of Nursing Services is responsible for the administration and management of Nursing services to residents in accordance with orders of the physicians and total needs of the residents.assumes ultimate responsibility for coordinating plans for the total care of each resident which comply with physician's orders, governmental regulations, and facility resident care policies.assists in controlling nursing service hours.assures adequate 24-hour nursing coverage in the facility each day.During a review of the facility job description document titled, Director of Staff Development, undated, the document indicated, .oversee monthly schedule and daily assignments for all CNA's.post Daily Staffing Projected NHPPD Hours.review Daily Staffing, PPD/Overtime to ensure required minimum hours are met.

Based on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 43) was assessed to safely store and self-administer medication at bedside when Resident 43 had a bottle of [brand name C 1000mg (over the counter vitamin C medication supplement)] medication bottle stored at bedside for self-administration without a physician's order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside).This failure resulted in Resident 43 storing and self-administering medications at bedside without nursing oversight which could lead to duplicate drug therapy, adverse medication interactions (when two medications mixed inside the body caused unexpected bad reactions) and unsafe bedside medications storage.During a concurrent observation and interview on 6/1/26 at 10:25 a.m. with Resident 43, in Resident 43's room, Resident 43 was observed sitting on her bed. Resident 43 was observed with [brand name C 1000mg] medication bottle on top of her bedside table. Resident 43 stated [brand name C 1000mg] medication bottle was brought from home, and she had stored the medication bottle at her bedside for some time. Resident 43 stated she took one to two vitamin tablets daily, sometimes up to three tablets per day, depending on what she remembered. Resident 43 stated the facility staff had seen the medication bottle in her room and had never said anything about it. Resident 43 stated the facility staff were aware she was taking the medication and keeping it in her room.During a concurrent interview and record review on 6/3/26 at 2:50 p.m. with Licensed Vocational Nurse (LVN)4, Resident 43's Order Summary Report (OSR), undated was reviewed. LVN 4 stated Resident 43 did not have a physician's order for Vitamin C or for medication self-administration. LVN 4 stated Resident 43 should have a physician's order and a completed Medication Self-Administration Assessment (MSA) form to store, and self-administered medications. LVN 4 stated Resident 43 was at risk for adverse medication interactions, duplicate therapy, and unsafe medication storage. LVN 4 stated all unlicensed and licensed nursing staff were responsible for identifying medications stored and self-administered at bedside to ensure residents safety. LVN 4 stated Resident 43 had a Brief Interview for Mental Status (BIMS - a standardized screening test used by healthcare professionals to evaluate a resident's cognitive function, memory, and orientation) score of 15 and was alert and able to verbalize needs and concerns.During an interview on 6/4/26 at 12:55 p.m. with the Director of Nursing (DON), the DON stated residents had the right to store and self-administer medications at bedside but required a physician's order and an MSA to ensure the residents could safely store and self-administer their own medications. The DON stated unlicensed and licensed staff were responsible for identifying medications stored and self-administered at bedside. The DON stated the facility's policy and procedures was not followed when Resident 43 had a bottle of [brand name C 1000mg] medication stored at bedside and was self-administering with no physician order and a complete MSA. The DON stated Resident 43 was at potential risk for duplicate therapy, adverse medication interactions and unsafe medication storage. The DON stated she was accountable for all medication administration and safety protocols in the facility.During a review of the facility's policy and procedure (P&P) titled, Medication - Self Administration, dated 8/19/25, the P&P indicated, .Residents have the right to self-administer medications when it is safe and appropriate.Residents will be assessed and monitored for their ability to self-administer medications.and must include physician approval, which will be documented in the resident's medical record.The Licensed Nurse completes the Self Administration of Medication Assessment, which evaluates the residents'.Cognitive function.Physical Ability.Medication Knowledge.Knowledge of proper storage and safety.Knowledge of administration of each route.

Based on observation, interview, and record review, the facility failed to ensure residents' room measured at least 80 square (sq) feet (ft) per resident in 16 (Rooms 101 - 104 and Rooms 110 - 121) of 29 resident rooms in the facility. Findings included: The Client Accommodations Analysis, dated 01/13/2025, revealed the following measurements: - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 77 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 71 sq ft for each resident. - In room [ROOM NUMBER], there was 73 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 76 sq ft for each resident. - In room [ROOM NUMBER], there was 75 sq ft for each resident. - In room [ROOM NUMBER], there was 77 sq ft for each resident. During the initial tour of the facility on 01/13/2025 at 10:38 AM, no residents voiced any concerns regarding the size of their room. During the Resident Council meeting on 01/15/2025 at 10:30 AM, Resident #44 stated the room sizes were small, but it did not affect the care they received. Resident #11 stated it was tight in their room, but the staff made it work. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2024, revealed Resident #344 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 11/04/2024, revealed Resident #11 had a BIMS score of 13, which indicated the resident had intact cognition. During an interview on 01/15/2025 at 12:25 PM, Certified Nurse Aide (CNA) #1 stated room size did not affect the care she provided to the residents. During an interview on 01/15/2025 at 2:30 PM, CNA #2 stated resident rooms were not the size they were supposed to be, but she could provide the care the residents needed without any issue. During an interview on 01/15/2025 at 2:34 PM, the Assistant Administrator stated the facility did not have policy for room size. During an interview on 01/15/2025 at 2:36 PM, Housekeeping Service Worker #3 stated there had been no issues with the room sizes affecting care and the room measurements were all accurate. During an interview on 01/16/2024 at 8:57 AM, the Director of Nursing stated no one had ever had issues with the room size affecting care. Recommend waiver continue in effect. Don [NAME], HFEIIS 1/27/25 ---------------------------------------------------------- Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ----------------------------------------------------------- Administrator Signature Date

Based on interview and record review the facility failed to ensure residents were free from abuse for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 hit Resident 1 in the shoulder during transfer from the bed to the wheelchair. This failure violated Resident 1's right to be free from abuse. Findings: During a review of Resident 1's Admission Record (a document containing demographic information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 4/8/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, .Dementia (progressive or persistent loss of intellectual functioning) .Parkinson (a brain disorder that causes unintended or uncontrollable movements) .Type 2 Diabetes Mellitus (high blood sugar) . During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 8 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderate impairment, and 00-07 indicates sever impairment) which indicated Resident 1 had moderate cognitive impairment. During a concurrent interview and record review on 4/29/24 at 8:45 am., with the Administrator (ADM), Resident 1's Facility Reported Event dated 4/8/24, was reviewed. The ADM stated CNA 1 was providing care to Resident 1. The ADM stated Resident 1 became combative with staff while care was being provided and bit CNA 1. The ADM stated CNA 1 hit Resident 1 on the back. The ADM stated CNA 1 should have not hit Resident 1. The ADM stated it was a staff to resident abuse. During a telephone interview on 4/29/24 at 9:05 am., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/8/24 CNA 4 notified me Resident 1 was uncooperative during care and CNA 1 hit Resident 1 in the back. LVN 1 stated it was an abuse to resident and should have never happened. During a telephone interview on 4/29/24 at 9:17 am., with CNA 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 was uncooperative with care and verbally aggressive. CNA 1 stated she was helping another CNA transfer Resident 1 from the bed to the wheelchair and Resident 1 bit her. CNA 1 stated she reacted and hit Resident 1 on her back. CNA 1 stated it was not appropriate to hit residents. CNA 1 stated what she did was physical abuse to Resident 1. During an interview on 4/29/24 at 11:35 am., with Director of Staff Development (DSD), the DSD stated she was made aware of the incident on 4/8/24 by the ADM. The DSD stated it was reported CNA 1 hit Resident 1 while providing care. The DSD stated when Resident 1 became agitated, nursing staff should have stopped the care immediately. The DSD stated CNA 1 abused Resident 1 by hitting her on the back. The DSD stated residents have the right to be free from any types of abuse. During a telephone interview on 5/1/24 at 10:05 am., with CNA 4, CNA 4 stated she was assigned to Resident 1 on 4/8/24 on the night shift. CNA 4 stated she was in Resident 1's room with CNA 1 and a CNA orientee. CNA 4 stated CNA 1 helped her transfer Resident 1 from bed to wheelchair and had sat Resident 1 up on the side of the bed. CNA 4 stated during the transfer CNA 1 called out Resident 1 had bit her and immediately afterwards she heard a slap but did not see it happen. CNA 4 stated when staff hits a resident it was considered elder abuse. Review of facility P&P titled, Abuse-Prevention, Screening, &Training Program dated 07/2018 the P&P indicated, .To address the health, safety, wellness, dignity and respect of residents by preventing abuse .and mistreatment .The facility does not condone any form of resident abuse .and or mistreatment . and to provide a environment free from abuse .The Administrator as the abuse coordinator is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program .Abuse is defined as the willful, deliberate infliction of injury, .it includes verbal abuse, physical abuse .Physical Abuse is defined as .hitting, slapping, punching and/or kicking .

Based on interview and record review, the facility failed to perform a resident comprehensive assessment and provide pain management services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's left hip internally rotated (twisting movement of the thigh inward from your hip joint) and experienced severe pain with a pain scale level of eight out of 10 (is a tool that measures pain intensity to help assess a person's pain; 0- no pain, 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain) and License Vocational Nurse (LVN) 3 did not perform a resident comprehensive assessment. LVN 3 did not reassess Resident 1's pain level an hour after LVN 3 administered pain medication to assess the medication effectiveness. These failures resulted in Resident 1 experiencing severe pain on 1/25/23 at 5:11 a.m. to 10:48 a.m. with a delay in transferring Resident 1 to the acute care hospital for treatment of a hip dislocation. Findings: During a review of Resident 1's Admission Record (AR- document containing resident's brief medical history and contact information), undated, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, left hip replacement (surgical procedure in which hip joint is replaced by artificial implant) and Dementia (the loss of cognitive functioning including thinking, remembering, and reasoning which interferes with daily life and activities). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 1/25/23, indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 8 of 15 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired, and 0-7 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately impaired. During a review of Resident 1's Occupational Therapy Treatment Encounter Notes ([NAME]), dated 1/25/23, the [NAME] indicated, .Once removed covers noticed pt [patient] lying with LLE [left lower extremity] flexed (hip and knee) and internally rotated. When attempting to correct position of LLE pt experienced pain/discomfort. Did not continue to reposition due to pt pain. Noted hip joint appeared to protrude in such position, palpated [examine body by touch] hip area and hip joint felt as if possible dislocation . During an interview on 2/8/23, at 9:55 a.m., with the Certified Occupational Therapy Assistant (COTA), the COTA stated on 1/25/23 at around 8:55 a.m. she entered Resident 1's room to perform therapy for Resident 1 and noticed Resident 1's hip was internally rotated with the knee flexed (lower leg bent) and the left hip joint protruded (sticking out). The COTA stated when she touched Resident 1's foot Resident 1 yelled Ow. The COTA stated on 1/24/23 Resident 1 was able to stand on her left leg during therapy. During interview on 2/8/23, at 10:12 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was assigned to Resident 1 on 1/25/23 during the day shift. CNA 2 stated at around 6:40 a.m., she went to Resident 1's room and checked on Resident 1. CNA 2 stated she noticed Resident 1's left leg was bent at the knee and in a weird position. CNA 2 stated, When I went in there and barely touched her, she just screamed. CNA 2 stated Resident 1 refused to get up for breakfast or dressed and transferred to the wheelchair which was not normal for her. CNA 2 stated Resident 1 does not normally refuse getting dressed and up to her wheelchair. CNA 2 stated she notified LVN 2 of Resident 1's change in behavior. CNA 2 stated screaming is not normal for Resident 1. CNA 2 stated Resident 1 is confused but can say when she is in pain. During an interview on 2/8/23, at 10:34 a.m., with Resident 1, Resident 1 stated she did not remember what happened to her hip. During a review of Resident 1's physician orders titled, Order Summary Report (OSR), dated 2/2023, the OSR indicated, .hydrocodone-acetaminophen [a medication used to treat severe pain] 5-325 mg [milligrams- unit of measurements] Give 2 tablet[s] by mouth every 6 hours as needed for Severe Pain (8-9) . During a concurrent interview and record review on 2/8/23, at 10:43 a.m., with LVN 1, Resident 1's Medication Administration Record (MAR), dated 1/2023, was reviewed. The MAR indicated Resident 1 was administered hydrocodone-acetaminophen 5/325 mg, 2 tablets on 1/25/23 at 5:11 a.m. for severe pain, 8 of 10 . LVN 1 stated LVN 3 did not document a pain reassessment after an hour of having administered pain medication to Resident 1 to ensure the pain medication was effective and Resident 1 was comfortable. LVN 1 stated the expectation was to do a pain reassessment an hour after administration of pain medication. During a concurrent interview and record review on 2/8/23, at 11:31 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Orders-Administration Note (OAN), dated 1/25/23 at 5:11 a.m. was reviewed. The OAN indicated, . hydrocodone-acetaminophen give 2 tablet[s] by mouth every 6 hours as needed for Severe Pain (8-9) . Resident c/o [complains of] lower extremity [leg] pain 8/10 on pain scale, not relieved by non-pharm [pharmacological] methods (pain management utilizing alternative therapies such as comfort therapy without the use of pain medication) . The ADON stated Resident 1 had a history of hip replacement surgery and LVN 3 should have assessed Resident 1's lower extremity including range of motion, positioning, and neurovascular assessment (to evaluate sensory, motor function, and blood circulation of the leg) to determine the cause of the pain. The ADON stated LVN 3 did not perform a pain reassessment after an hour of administering the pain medication to Resident 1. The ADON stated LVN 3 did not follow the facility's policy and procedure to perform a pain reassessment after an hour of pain medication administration to ensure the pain medication was effective in relieving pain. The ADON stated if LVN 3 would have done a pain reassessment she should have known the pain medication was ineffective and notified the physician. During a review of Resident 1's Order Note (ON), dated 1/25/23, at 9:23 a.m., the ON indicated, .This writer [LVN 2] was notified by therapy staff that patient was complaining of pain to her left hip and that her hip looked displaced . [name of physician] notified via phone. New order obtained: Send to [name of acute care hospital emergency room ] for further evaluation r/t [related to] intractable pain [severe, persistent pain not controlled with standard medical care] to left [hip] . During a review of Resident 1's ED [Emergency Department] Physician Notes (EPN), dated 1/25/23, at 10:48 a.m., the EPN indicated, .BIBA [brought in by ambulance] with left hip pain . patient status is post (after) left hip replacement . patient noted to be in pain on arrival . surgical history . hip arthroplasty hemi (left partial) (a surgical procedure in which the surgeon removes the diseased part of the hip joint and replaces them with new artificial parts) 10/16/2022) . Hip arthroplasty revision (Left) [reoperation of hip replacement] (11/20/2022) . Labs/imaging reviewed . + [positive for] left hip dislocation . During a phone interview on 2/8/23, at 3:21 p.m., with LVN 2, LVN 2 stated she was assigned to Resident 1 on 1/25/23 during the day shift. LVN 2 stated she was called into Resident 1's room by the COTA around 9:00 a.m. LVN 2 stated Resident 1's left leg was turned inward with the knees tucked in and her hip looked out of alignment. LVN 2 stated Resident 1 was moaning in pain, guarding (involuntary reaction to protect an area of pain) her hip, and crying. LVN 2 stated Resident 1's physician was notified and gave an order to send Resident 1 to the ED. LVN 2 stated when a resident complained of pain the process was to assess the cause of the pain, location, pain level from one to 10 and administer pain medication if needed. LVN 2 stated the pain should be reassessed within one hour of administering pain medication and the physician should be notified if the medication was ineffective. During a phone interview on 2/8/23, at 5:06 p.m., with LVN 3, LVN 3 stated she was assigned to Resident 1 on 1/24/23 during the night shift which started at 7 p.m. and ended on 1/25/23 at 7 a.m. LVN 3 stated on 1/25/23 at 5 a.m., she was near Resident 1's room and CNA 3 was changing Resident 1. LVN 3 stated, I could hear her [Resident 1] grunt in pain when the CNA changed her brief. LVN 3 stated when she assessed Resident 1's pain she noticed both legs were bent with the left leg positioned to the side, but she thought Resident 1's leg had just fallen asleep. LVN 3 stated Resident 1 requested pain medication at that time. LVN 3 stated CNA 3 told her it was unusual for Resident 1 to complain of pain. LVN 3 stated, I didn't want to move her too much, so I didn't do a full assessment [of her leg]. LVN 3 stated she did not perform an assessment to Resident 1's leg considering the odd position of the leg and Resident 1's complaint of severe pain. LVN 3 stated she should have performed an assessment to Resident 1's leg. LVN 3 stated she did not perform a pain reassessment after an hour in which she had administered pain medication to Resident 1. LVN 3 stated it was important to perform a pain reassessment to ensure the pain medication was effective, and to look for further cause and notify the physician if the pain continued. LVN 3 stated the physician was not notified of Resident 1's severe pain not relived by the pain medication. During a telephone interview on 2/9/23, at 7:48 a.m., with CNA 3, CNA 3 stated she was assigned to Resident 1 on 1/24/23 during night shift which started at 11 p.m. and ended on 1/25/23 at 7 a.m. CNA 3 stated when she entered the room on 1/25/23 at 5:00 a.m. she had noticed Resident 1's knee was pulled up to her chest which was not her normal position. CNA 3 stated, She [Resident 1] was in really bad pain when I tried to take off her brief. CNA 3 stated Resident 1 whimpered in pain and was not able to turn herself in bed. CNA 3 stated Resident 1 normally turned herself during care, but at that time it required 2 CNAs to move her and change her brief. During a review of Resident 1's nurses note titled, OAN, dated 1/25/23, at 9:07 a.m., the OAN indicated, .PRN [as needed] Administration was: Ineffective . Patient still complaining of severe pain to left hip during movement. Repositioned patient, patient is comfortable when not moving patient. Notified [name of physician] via phone . Sending patient to acute [hospital] due to intractable pain . Follow up [note] to: 1/25/23 5:11 a.m . During an interview on 5/23/23, at 1 p.m., with the Director of Nursing (DON), the DON stated on 1/25/23 around 9 a.m., she was notified by the rehabilitation therapist Resident 1's left leg was abnormally positioned and complained of severe pain with movement. The DON stated Resident 1 had a previous hip replacement done on 10/16/22. The DON stated, She [Resident 1] was in bed lying on her back and the left leg was bent to the back. I could tell just from looking at her the hip was dislocated. The DON stated she did an investigation into Resident 1's hip dislocation. The DON stated, At some point between 2 a.m. and 5 a.m. her [Resident 1] legs must have been crossed and the hip dislocated. The DON stated when she interviewed LVN 3, LVN 3 stated she did an assessment when she noticed Resident 1's left leg internally rotated. The DON stated when she reviewed Resident 1's clinical record, she was unable to locate an assessment, or a progress note from LVN 3. The DON stated LVN 3 did not document her nursing assessment of Resident 1's leg. The DON stated if the assessment was not documented that indicated it had not been done. The DON stated she reviewed Resident 1's MAR and was unable to find a pain reassessment after LVN 3 administered pain medication to Resident 1 on 1/25/23 at 5:11 a.m. to assess if the pain medication was effective or not. The DON stated LVN 3 did not follow the facility's policy and procedure (P&P) for pain management. During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 11/2016, the P&P indicated, .facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible . After medications/interventions are implemented, the licensed nurse will reevaluate the resident's level of pain within one hour . if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician . Pain Assessments will be maintained in the resident's medical record . During a professional reference review, retrieved from https://my.clevelandclinic.org/health/diseases/22222-hip-dislocation titled, Hip Dislocation, dated 12/21/21, the reference indicated, .Hip dislocation occurs when the ball joint [junction of two or more bones] of your hip (femur [thigh bone]) pops out of its socket . It's a medical emergency . A dislocated hip is acutely [severity of sudden onset] painful and disabling . Immediate care reduces the chance of long-term complications . A dislocated hip is a medical emergency . It causes acute pain and disables your leg until it's corrected . It can also cause secondary injuries to the surrounding blood vessels [tubes through which blood circulates through the body], nerves [fibers that sends and receives messages between the body and the brain], ligaments [band of tissue that connects bones and joints] and tissues [group of cells] . Hip dislocation can cause long-term damage, especially if it's not treated right away . If you're looking at the injury from the outside, you'll first notice that your leg is locked in a fixed position rotated either inward or outward. About 90% of the time, your hip joint is forced backward out of its socket (posterior dislocation), which leaves your knee and foot pointed inward . symptoms of hip dislocation . Acute pain . leg is rotated inward or outward . Hip is visibly out of place . A trained healthcare provider can often identify a dislocated hip by looking at it . Surgery may also be recommended when your displaced hip is an artificial hip replacement .

Based on observation, interview, and record review, the facility failed to ensure Resident 22 's fall care plan interventions were in place to prevent or minimize fall related injuries for one of three sampled residents (Resident 22) when Resident 22 was assessed as at risk for falls, had known behavior of leaning forward in her wheelchair and the care plan interventions to use tilt-back feature on the wheelchair was not implemented. This failure resulted in Resident 22 experiencing an unwitnessed fall from the wheelchair on 10/18/22 onto the floor at the facility's hallway, resulting in loss of consciousness, sustaining a laceration (skin tear) and the use of antibiotic. Resident 22 was sent to the general acute care hospital (GACH) for treatment of her fall related injuries on 10/18/22. Dermabond (skin adhesive that is used to glue laceration) was applied to Resident 22's laceration at the GACH. Findings: During an observation on 12/13/22, at 9:41 a.m., in Resident 22's room, Resident 22 laid in bed, her forehead had a healing red scar approximately 3cm (centimeters-unit of measure) in length above her right eyebrow caused by Resident 22's fall on 10/18/22. During a review of Resident 22's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive communication deficit and dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons). During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 22's MDS assessment indicated Resident 22's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 3 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 22 had severe cognitive impairment. During a review of Resident 22' s prior fall titled Progress Note (PN), dated 8/15/22, the PN indicated, .IDT [Interdisciplinary Team] met to review .chart due to a witnessed fall on 8/12/22 .Resident was placed in the hallway .witnessed the resident [Resident 22] lean forward and fall face first from her wheelchair to the floor .noted to have active bleeding from a laceration to her forehead and bleeding from her nose .The charge nurse took report from ER [emergency room ] nurse who stated the resident had a closed fracture to her nasal bone, facial swelling and head laceration. Upon return, the resident had antibiotics ordered from the ER for prophylaxis [preventative measure] .the tilt back will be engaged so the patient can lie back comfortably and be safe if she does tend to fall asleep. Care plan reviewed and Kardex [List of interventions such as safety specific to the resident needs] updated . During a review of Resident 22's prior fall the General Acute Care Hospital (GACH) report titled, ED (Emergency Department Reports), dated 8/12/22, was reviewed. The ED Reports indicated, .brought in by EMS [Emergency Medical Services] personnel, the patient has dementia. she is not ambulatory. she was sitting in her wheelchair and fell forward. she hit her face .she reports no present complaints of pain .Diagnosis closed fracture of nasal bone .Forehead laceration . During a review of Resident 22' s Progress Note (PN), dated 10/18/22, the PN indicated, .Date/Time of Fall: 10/18/22 1:00 PM Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: leaning forward in w/c [wheelchair] .face first in hallway with wheelchair behind her. Resident is known to lean forward in her wheelchair when she is tired and has had a hx [history] of a similar fall. resident had just finished eating and was sat up in her w/c, tilt back was not engaged at the time the incident occurred. assessment findings showed a 2.5cm [centimeters-unit of measure] x 1cm laceration on the right side of resident's forehead .Any similarities between current and post falls: Yes. Prior Fall Note: resident fell forward from w/c resulting in broken nose . During an interview on 12/16/22, at 9:28 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had left Resident 22 unattended in the hallway near the dining room on 10/18/22 with the wheelchair in the upright position. CNA 2 stated, she did not place the wheelchair in the tilt back position to prevent fall and went to search for a CNA to assist her in transferring Resident 22 back to bed. CNA 2 stated, she was aware of Resident 22's history of fall and should have reviewed Resident 22's fall car plan interventions in the Kardex prior to caring for Resident 22 but did not. CNA 2 stated, Resident 22 had fallen to the ground with the wheelchair behind her resulting in her hitting her face on the ground and bled. During a concurrent interview and record review on 12/16/22, at 10:18 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 22's Care Plan (CP), dated 8/12/22 was reviewed. The CP indicated, The resident has had an actual fall 8/12/22-Fall out of wheelchair resulting in fractured nose .10/18/22-fall from w/c .Tilt back wheelchair .Ensure that the tilt back is engaged . LVN 4 stated, Resident 22's fall was avoidable if CNA 2 had implemented the care plan intervention to tilt back the wheelchair. LVN 4 stated, this was Resident 22's second fall from the wheelchair. LVN 4 stated, on 10/18/22 Resident 22 was found on the floor bleeding from her forehead and was sent to the emergency department via ambulance. LVN 4 stated, Resident 22 had a loss of consciousness when she had assessed Resident 22 on the ground. LVN 4 stated, CNA 2 did not tilt back the wheelchair resulting in Resident 22's fall, CNA's have access to the care planned interventions in the resident Kardex and should review at the start of their shift. During a review of Resident 22's PN, dated 10/19/22, the PN indicated, .IDT [Interdisciplinary Team] met to review .chart due to fall on 10/18/22 .was found on the floor in the hallway with her wheelchair behind her on the floor .is known to lean forward in her wheelchair when she is tired and has had a history of similar fall .was placed in hallway by staff, while the CNA went to find someone to help lay the patient down .leaned forward and fell out of her wheelchair. Upon investigation it was noted that the tilt back was not engaged on the wheelchair . During a review of Resident 22's General Acute Care Hospital (GACH) titled, ED (Emergency Department Reports), dated 10/18/22, was reviewed. The ED Reports indicated, .female with history of dementia presents brought in by ambulance after a fall from her wheelchair earlier today. There was possible loss consciousness. She did suffer a small head laceration. She was mildly short of breath after she fell , briefly was at low oxygen but now is back on room air .+3cm linear forehead laceration .Laceration is 3 cm in length . [skin adhesive] was applied .prescribed cephalexin [antibiotic] prophylactically [preventative measure] . x[times] 5 days . During a concurrent interview and record review on 12/16/22, at 2:28 p.m., with the Director of Nursing (DON), the facility policy titled Fall Management Program dated 3/2021 was reviewed. The policy indicated, .The facility will implement a Fall Management Program that supports providing and environment free from fall hazards .If a fall factor is identified, document interventions on the Resident's care plan . The DON stated, Resident 22's fall was avoidable if CNA 2 had implemented the care planned intervention to tilt back the wheelchair but didn't. The DON stated, Resident 22 had hit her head on 10/18/22 fall which resulted in the laceration and was sent out to the hospital to rule out brain bleed. The DON stated, CNA 2 had not implemented the care planned intervention to tilt back the wheelchair. The DON stated, it was her expectation for the CNA's to review the residents fall care plan interventions within the beginning of their shift to ensure they were aware and implement fall interventions. During a review of the facility policy titled Comprehensive Person-Centered Care Planning dated 11/2018. The policy indicated, .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety .needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .

Based on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. Licensed Vocational Nurse (LVN) 2 left the sharps container unlocked and unattended for one of three medication carts (medication cart 2). This failure had the potential for unauthorized access to used medications and sharps which placed residents at risk for needlestick injuries. 2. One of three medication cart was left unlocked and unattended by LVN 2. This failure had the potential for residents and staff to have unauthorized access to medications. Findings: 1. During a concurrent observation and interview, on 12/13/22 at 10 a.m., with LVN 2 at station 3, the sharps container on medication cart 2 was unlocked and unattended on the hallway wall outside room [ROOM NUMBER]. LVN 2 stated, Normally the sharps container is locked. LVN 2 stated, The sharps container should be locked for patient safety. During a concurrent interview and record review, on 12/16/22, at 2:27 p.m., with the Director of Nursing (DON), the facility policy titled Storage of Medications dated 2014 was reviewed. The policy indicated, .Medications and biologicals are stored, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated the medication cart should be locked when unattended for resident safety. During an interview, on 12/19/22, 10:09 a.m., with the DON, the DON stated, Staff should keep the sharps container locked at all times for patient safety to prevent accidental access [used medications and sharps]. 41119 2. During an observation on 12/15/22, at 3:22 p.m., at station 3, LVN 2 was seated at the nurse's station. The medication cart was located across the nurse's station against the wall, the medication cart drawers was facing the hall. The medication cart was unlocked and unattended. During an observation on 12/15/22, at 3:28 p.m., at station 3, LVN 2 was seated at the nurse's station. The medication cart remained unlocked and unattended. During an observation on 12/15/22, at 3:29 p.m., at station 3, LVN 2 left the nurses station and proceeded to walk to the end of the hallway into room [ROOM NUMBER]. The medication cart remained across the nurse's station against the wall, the medication cart drawers was facing the hall. The medication cart remained unlocked and unattended. During a concurrent observation and interview on 12/15/22, at 3:34 p.m., with LVN 2 at nursing station 3. LVN 2 stated, the medication cart was unlocked and she did not have visualization of the cart while in room [ROOM NUMBER]. LVN 2 stated, the medication cart should be locked so residents did not have access to medications they were not supposed to have. LVN 2 stated, leaving the medication cart open could allow unauthorized access to medications and the consequences could be adverse effects leading up to death. During a concurrent interview and record review on 12/16/22, at 2:27 p.m., with the DON, the facility policy titled Storage of Medications dated 2014 was reviewed. The policy indicated, .Medications and biologicals are stored, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . The DON stated, the medication cart should be locked when unattended for resident safety.

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when: 1. The fire hood and ventilators above the stove had black debris and had grease. This failure had the potential risk to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 65 of 65 sampled residents who received food from the kitchen. 2. The reach in refrigerator number (#) 1 and # 2 ventilators had black debris. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 3. The oven had black substance on the bottom and a yellow/brown discoloration around the knobs. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 4. The can opener blade and based in the kitchen was not kept in sanitary condition. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 5. The stainless shelves used to store clean kitchenware were covered with brown grime. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 6. The Dome (a piece of kitchen equipment used as a cover to keep food hot) rack was covered with dust. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 7. There were 4 plastic containers' covers used to store oatmeal, pancake mix, sugar, flour was covered with dust and brown debris. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 8. The reach in refrigerator (facility referred as Milk Fridge) and reach in refrigerator # 2 gray shelves had peeling paint and brown substances. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 9. The floor under the reach in refrigerator # 2, reach in vegetable freezer and refrigerator had food crumbs, trashes, dust, black/brown debris. This failure had the potential risk to promote bacteria and virus grow and attract pests which could cause cross contamination for 65 of 65 sampled residents who received food from the kitchen. 10. A package of opened expired English muffin was found in the kitchen. This failure had the potential risk for 65 of 65 sampled residents who received food from the kitchen consumed expired foods. 11. There were five condiments that were covered with brown and black debris. This failure had the potential risk to promote bacteria and virus grow and attract pests which could cause cross contamination for 65 of 65 sampled residents who received food from the kitchen. 12. There were several food items that were open and exposed to the air in the 3 reach in freezers. Having the food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food for 65 of 65 sampled residents who received food from the kitchen. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) to come in contact with residents' food which would cause food-borne illness to a population of 65 of 65 residents who received food from the kitchen and are medically compromised. Findings: 1. During an observation on [DATE], at 10:21 a.m., in the kitchen above the stoves, there were black/brown debris hanging on the fire hoods. The ventilators above the stove were covered with black debris. Cook 1 (CK1) was using the stoves preparing the residents meals. During a concurrent observation and interview, on [DATE], at 3:19 p.m., with the Registered Dietitian (RD) and the Food and Nutrition service Director (FND). The RD and FND stated there were black/brown debris hanging on the fire hoods and there were black debris ont he ventilator covers. The RD and FND stated the black/brown debris hanging on the fire hoods were dust and the black debris covered on ventilators was grease with dust. The FND and RD stated the dust and grease should not be in the fire hoods and ventilators because it could potentially cause cross contamination. During an interview on [DATE], at 09:22 a.m., with the Regional Registered Dietitian (RRD), The RRD stated there was no policy and procedure for general cleanliness and sanitation of the kitchen. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, Section ,d+[DATE].11 Ventilation Hood Systems, Drip Prevention, indicated, The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. 2. During a concurrent observation and interview, on [DATE], at 2:52 p.m., with the RD and FND, the FND and RD stated the black debris on the ventilator inside the reach in refrigerator # 2. The RD stated, The black debris was buildup of dust and not supposed to be there because there was a potential for dust to fall into foods. During a concurrent observation and interview, on [DATE], at 3:03 p.m., with the FND and RD, the FND and RD stated theere were black debris on the ventilator in the reach in refrigerator #1. The FND and the RD stated the black debris was build up of dust. The FND and the RD stated the potential risk for dust build up in the reach in refrigerator # 1's ventilator was cross contamination when the dust fell on foods. During a review of facility's policy and procedure (P&P) titled, Cleaning Schedule, dated [DATE], the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 3. During an observation on [DATE], at 10:19 a.m., the oven had burning ash/black substance inside on the bottom and there was a yellow/brown discoloration around the knobs of the oven. During a concurrent observation and interview, on [DATE], at 3:32 p.m., with the FND and RD, the FND and the RD looked inside the oven and around the oven nozzles and the RD stated, I can't tell if its rust inside the oven or possibly burnt up food, it's not supposed to be there. The FND and the RD stated grease and dust build up around nozzle should be cleaned. The RD and FND stated there was a risk for potential cross contamination if the oven was not cleaned properly. During a review of the facility's P&P titled, Oven-Conventional (Gas)-Operation and Cleaning, dated [DATE], the P&P indicated under .Sanitation of equipment . A. Remove spills, spillovers, and burned food deposits from the over as soon as practicable . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 4. During an observation on [DATE], at 10:34 a.m., the can opener blade had white substance and the base had brown debris. During a concurrent observation and interview, on [DATE], at 3:28 p.m., with the RD and FND, in front of the space utilized for the can opener, the FND stated There is grime or [NAME], I don't know what it is on the base of the can opener. The RD stated there was a sticky buildup on the base of the can opener and an unknown white substance on the blade of the can opener. The RD stated, The can opener and the base need to be cleaned on a routine basis due to risk for potential cross contamination. During an interview on [DATE], at 9:22 a.m., with the RRD, the RRD stated there was no Policy and Procedure for general cleanliness and sanitation of the kitchen. The RRD stated, This facility followed Food Code. During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, . Food-contact surfaces and utensils are to be clean to sight and touch . 5. During an observation on [DATE], at 10:12 a.m., the stainless-steel shelves under the steam table used to store clean kitchenwares was covered with food particles and brown grime. During a concurrent observation and interview, on [DATE], at 3:17 p.m., with the RD and FND, the FND stated The brown grime possibly is the accumulation of overspray for pan spray and dust. The RD and the FND stated the stainless-steel shelves needs to be cleaned due to possible cross contamination with the clean kitchenwares. During a review of facility's P&P titled, Cleaning Schedule, dated [DATE], the P&P indicated, . The dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 6. During an observation on [DATE], at 10:49 a.m., the dome rack had brown substance/debris . During a concurrent observation and interview, on [DATE], at 3:30 p.m., with the RD and FND, the RD and FND stated the dome rack had visible brown substance/debris buildup. The FND and RD stated the The brown substance/debris buildup is dust and there is a potential for cross contamination if not cleaned. During a review of facility's P&P titled, Cleaning Schedule, dated [DATE], the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 7. During an observation on [DATE], at 10:32 a.m., the four plastic storage container covers' used to store oatmeal, pancake mix, sugar, and flour were covered with brown debris. During a concurrent observation and interview, on [DATE], at 3:23 p.m., the RD and FND stated the four plastic storage container covers used to store oatmeal, pancake mix, sugar, and flour were covered with brown debris. The RD and the FND stated the brown debris were dust and the potential risk for the plastic storage container covers' covered with dust was cross contamination. During a review of facility's P&P titled, Cleaning Schedule, dated [DATE], the P&P indicated, . The dietary staff will maintain a sanitary environment in the dietary . During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 8. During an observation on [DATE], at 9:22 a.m., in the reach in refrigerator Milk Fridge, there was brown discoloration and peeling of the grey paint on all three food shelves. During an observation on [DATE], at 9:50 a.m., the reach in refrigerator's (# 1's) gray shelves had brown discoloration and there was peeling off the grey paint on the shelves. During a concurrent observation and interview, on [DATE], at 3 p.m., with the RD and FND, the FND stated the brown discoloration on the gray shelves in the Milk Fridge and reach in refrigerator # 1 was rust. The FND stated There is a potential for the rust on the edge of the shelves could splinter off into the food so it should be replaced. During a review of facility's P&P titled, Sanitation of Reach in Refrigerator, dated [DATE], the P&P indicated The reach in refrigerator will be maintained in a sanitary condition During a review of the Federal Food Code 2017, the Food code indicates, food-contact surfaces and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, pitting, and decomposition. 9. During an observation on [DATE], at 9:32 a.m., there were food crumbs, trash and black/brown debris on the floor under the reach in refrigerator (#2-) and the milk fridge. During a concurrent observation and on [DATE], at 2:55 p.m., with the RD and FND, the FND and RD stated there were trash, food crumbs, black/brown debris on the floors under refrigerator #2, reach in freezer (facility referred as Vegetable freezer), and Milk Fridge . The FND states Dirty floors could potentially attract rodents. During a review of facility's P&P titled, Cleaning Schedule, dated [DATE], the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a review of the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 10. During a concurrent observation and interview, on [DATE], at 10:05 a.m., with CK 1 (Cook 1), there was an open English Muffin package with a used by date of [DATE]. CK 1 stated the used by date was on [DATE]. CK 1 stated, The English muffin is expired. It is not supposed to be in the kitchen. During an interview on [DATE], at 3:14 p.m., with the RD and FND, the FND stated the open English Muffin package should have been thrown out as indicated by the used by date. The RD stated The English Muffin what was open was expired. We just do not want to serve it to the residents. During a review of the facility's P&P titled, Food Storage, dated [DATE], the P&P indicated Food items will be stored, .with good sanitary practice . All items will be correctly labeled and dated . 11. During an observation on [DATE], at 10:30 a.m., five condiments (A condiment is a spice added to food during preparing/production of foods to enhance the flavor, or to complement the dish) (1 gallon: Browning & seasoning sauce, Worcestershire sauce, liquid smoke concentrated seasoning) (2- 5 pounds containers: Basil leaves and ground black pepper) had sauce spilled over the outside of the bottles and was covered with brown/black debris. During a concurrent observation and interview, on [DATE], at 3:26 p.m., with the RD and the FND, the RD and FND stated the 5 condiments - had sauce spilled over outside the bottles and was covered with brown/black debris. The FND and the RD stated The condiments should be cleaned as there is a potential for cross contamination. During a review of facility's P&P titled, Cleaning Schedule, dated [DATE], the P&P indicated, the dietary staff will maintain a sanitary environment in the dietary department . During a professional reference review according to the Federal Food and Drug Administration (FDA) 2017 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 12. During an observation on [DATE], at 9:45a.m., in the meat freezer, a box packaging of pork sausage was open and the package inside was open, unsealed and exposed to air. During an observation on [DATE], at 11 a.m., two boxes (cookie dough and chocolate chip cookies dough) were open and the packaging was also open to air in the dry storage freezer. During a concurrent observation and interview, on [DATE], at 2:57p.m., the RD and FND stated a box of opened diced carrot was left uncovered and exposed in the reach in vegetable freezer. The RD and the FND stated leaving the food open to air could result in freezer burn and had the potential to alter the food quality and palatability. During a concurrent observation on [DATE], at 2:57 p.m., the RD and the FND stated there was a box of opened pork sausages that was left uncovered and exposed in the reach in meat freezer. During a concurrent observation and interview, on [DATE], at 3:34 p.m., with the RD and FND, the RD and FND stated the cookie dough package in the box was open and exposed to air in the reach in freezer located in the dry storage room. During a review of the facility's P&P titled, Food Storage, dated [DATE], the P&P indicated Food items will be stored, thawed and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. Under the .II. Frozen .Food Guidelines .Foods to be frozen should be store in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers .

Based on observation and interviews, the facility failed to provide appetizing foods for eight of 65 sampled residents (Resident 24, 33, 34, 53, 209, 357, 359, 360). This failure placed Resident 24, 33, 34, 53, 209, 357, 359 and 360 at potential risk of decreased nutritional intake and affect the residents' nutrition status which could compromise their medical status. Findings: During an interview on 12/13/22, at 9:25 a.m., with Resident 357, Resident 357 stated, Food is not good. During an interview on 12/13/22, at 9:42 a.m., with Resident 33, Resident 33 stated, Food is terrible. During an interview on 12/13/22, at 9:53 a.m., with Resident 359, Resident 359 stated, Food is so so. During an interview on 12/13/22, at 9:59 a.m., with Resident 209, Resident 209 stated, Food is not good . Bland and does not taste good. During an interview on 12/13/22, at 10:02 a.m., with Resident 53, Resident 53 stated, Food is terrible. All of it tasted bland. I cannot hardly eat it. During an interview on 12/13/22, at 10:15 a.m., with Resident 360, Resident 360 stated, Provided food could be better. During an interview on 12/14/22, at 12:38 p.m., with Resident 34, Resident 34 stated, All provided meals are so so. It could be better. I told staff here. They know about it, but nothing gets done about it. During a concurrent dining observation and interview, on 12/14/22, at 12:45 p.m., with Resident 24. Resident 24 only consumed 10 percent of the provided entree. Resident 24 stated, Lunch is so so . During an interview on 12/14/22, at 1:27 p.m., with Resident 53, Resident 53 stated, Food is awful. During an interview on 12/15/22, at 9:17 a.m., with the Activities Director (AD), the AD stated during resident council meetings, residents always complained about foods. During an interview on 12/15/22, at 9:22 a.m., with the Regional Registered Dietitian (RRD), the RRD stated there was no policy and procedure regarding palatability, taste, or flavor of the provided foods. During an interview on 12/15/22, at 10 a.m., with the Regional Dietary Manager (RDM) and the Food and Nutrition service Director (FND), the FND stated her expectation was to serve appetizing foods to meet the need of the residents. The RDM and FND stated the potential risk of serving unappetizing foods could result in residents not eating which could cause unintended weight loss. During a telephone interview on 12/16/22, at 11:32 a.m., with the facility Registered Dietitian (RD), the RD stated, I do not know there is a test tray policy in the facility. The RD stated the potential risk for serving unappetizing foods was the residents would not eat and could result in residents losing weight. During a review of the regulation F 804: S 483.60 (d) Food and drink , F 804 indicated, Each resident receives and the facility provides - .S483.60(d)(2) Food and drink that is palatable Food palatability refers to the taste and/or flavor of the food.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Nine of sixteen sampled residents' (Resident 4, 408, 53, 21, 17, 360, 359, 208 and 357) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found with lint and dust. This failure placed Residents 4, 408, 53, 21, 17, 360, 359, 208 and 357 at an increased risk to develop respiratory and healthcare-associated infections. 2. Five bags of wet, soiled mops and cleaning cloths were found on the floor in the laundry area. This failure had the potential to result in cross contamination and placed residents at risk to develop an infection. Findings: 1. During a concurrent observation and interview on 12/13/22 at 11:03 a.m., in Resident 4 and Resident 408's room with Licensed Vocational Nurse (LVN) 1, LVN 1 pulled out the oxygen concentrator filters and stated they were dirty with white and gray dust. LVN 1 stated the filters should be clean and the cleaning schedule was on the medication administration record (MAR). LVN 1 reviewed Resident 4 and 408's December 2022 MAR that cleaning had not been done. During a review of the Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) for Resident 408, the AR indicated Resident 408 was admitted to the facility on [DATE] with diagnoses which included; acute respiratory failure with hypoxia (not enough oxygen in the blood), pneumonia (an infection that inflames the air sacs in one or both lungs), muscle weakness generalized, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and adult failure to thrive (a decline resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability). During a record review of the Resident 408's Mininum Data Set (MDS-an assessment tool which indicates physical, medical and cognitive abilities), dated 12/13/22, Resident 408's Brief Interview for Mental Status (BIMS-assessment of cognitive function) indicated a score of 14 of 15 points which indicated Resident 408 had no cognitive impairment. During a review of Resident 408's Order Summary Report (OSR), dated 12/14/22, the OSR indicated, Oxygen 2 LPM [liters per minute] NASAL CANNULA Continuously every shift DX:ACUTE RESPIRATORY FAILURE WITH HYPOXIA .Order Date 11/29/22 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue DX; ACUTE RESPIRATORY FAILURE WITH HYPOXIA .Order Date 11/29/22 . During a review of Resident 408's care plan (CP), the CP indicated, The resident has oxygen therapy r/t [related to] Ineffective gas exchange . Date Initiated12/01/22 .Interventions .Oxygen 2 LPM [liters per minute] NASAL CANNULA Continuously every shift DX: ACUTE RESPIRATORY FAILURE WITH HYPOXIA Date Initiated 12/01/2022 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue DX: ACUTE RESPIRATORY FAILURE WITH HYPOXIA Date Initiated 12/01/2022 . During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included muscle weakness generalized, anxiety disorder, atrial fibrillation, atherosclerotic heart disease (blood vessels that carry oxygen and nutrients from the heart become thick and stiff, restricting blood flow) and hypertension. During a record review of the Resident 4's MDS, dated [DATE], Resident 4's BIMS score was 6 of 15 points which indicated Resident 4 had cognitive impairment. During a review of Resident 4's OSR, dated 12/14/22, the OSR indicated, Oxygen 5 LPM VIA NASAL CANNULA Continuously every shift DX: COVID .Order Date 11/07/22 .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue .Order Date 11/07/22 . During a review of Resident 4's CP, the CP indicated, The resident has oxygen therapy r/t [related to] Ineffective gas exchange .Date Initiated 11/07/2022 . Oxygen 5 LPM [liters per minute] NASAL CANNULA Continuously every shift DX: COVID .Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM one time a day every Tue .Date initiated 11/07/2022. 44899 During a concurrent observation and interview on 12/13/22, at 11:02 a.m., with Resident 32, in Resident 32's room. Resident 32 had an oxygen cannula (a device used to deliver supplemental oxygen) connected to an oxygen concentrator. The oxygen was being given at 1L/min (LPM/Liters Per Minute, unit of measurement). The oxygen concentrator filter was covered by white and grey material . Resident 32 stated the dirty oxygen filter was not acceptable and possibly the reason for her sneezing today. Resident 32 stated she wanted the oxygen concentrator to be cleaned. During a concurrent observation and interview in Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, Resident 208, and Resident 357's room with Licensed Vocational Nurse (LVN) 2, on 12/13/22, at 11:14 a.m., LVN 2 looked at Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, Resident 208, and Resident 357's oxygen concentrator filters and stated the filters were not clean and were filled with dust and lint. LVN 2 stated facility residents who received supplemental oxygen with dirty filter could contribute to an increase risk of respiratory infections. LVN 2 stated using oxygen concentrators with dirty filter was not acceptable. During an interview with the Director of Central Supply (DCS) on 12/16/22, at 3:40 p.m., the DCS stated he was responsible for checking and cleaning the oxygen concentrator filters on a weekly basis. The DCS stated, I clean the oxygen concentrator filters every Tuesday or Wednesday. The DCS validated Resident 53, Resident 21, Resident 17, Resident 360, Resident 359, and Resident 357's oxygen concentrator filters were dirty. The DCS stated if the oxygen concentrator filters were dirty, the oxygen generated from the machine could cause the residents to become ill. The DCS stated using an oxygen concentrator with dirty filter was not acceptable. The DCS stated he does not have a weekly log of oxygen concentrator filters that he dusted and cleaned. During an interview with the Director of Nursing (DON) on 12/19/22, at 10:12 a.m., the DON stated using supplemental oxygen concentrators with dirty filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the filter was to remove impurities (small particles) and prevent residents from inhaling dirty oxygen. The DON stated residents using supplemental oxygen concentrators with dirty filters could have respiratory infection such as pneumonia or bronchitis. The DON stated she expects oxygen concentrator filters are cleaned weekly and as needed for the safety and well-being of all residents receiving supplemental oxygen. The DON stated, Everyone is responsible in keeping our resident safe. I expect our staff to report dirty oxygen concentrator filters to the charge nurse immediately so she or he can notify the Central Supply Director. During an interview with the Administrator (ADM) on 12/19/22, at 10:50 a.m., the ADM stated using supplemental oxygen concentrators with dirty filter was not acceptable and could potentially worsen resident's respiratory illness. The ADM stated she expects the DCS to follow the physician's order to inspect and clean the oxygen concentrator filters every Tuesday and to report to the ADM or DON for any delay in completing the task. The ADM stated she expects the DCS to have a log for the weekly cleaning of oxygen concentrator filters. During a review of Resident 53's Admission Record, dated 12/14/22, the AR indicated, Resident 53 was admitted from an acute care hospital on 11/18/22 to the facility, with diagnoses which included Respiratory Failure (the inability of the lungs to adequately provide oxygen into the blood), Chronic Obstructive Pulmonary Disease (COPD, (constriction of the airway with difficult breathing), and Hypertension (high blood pressure). During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53's BIMS score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 53's OSR dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 1 LPM [Liters Per Minute, unit of measurement] VIA NASAL CANNULA Continuously every shift DX:COPD . Order Date 11/18/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM [morning] . Order Date 11/18/2022 . During a review of Resident 53's CP dated 12/14/22, the CP indicated, . The resident has COPD . Date Initiated 11/18/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 21's AR, dated 12/14/22, the AR indicated, Resident 21 was admitted from an acute care hospital on 11/17/22 to the facility, with diagnoses which included COPD, Hypertension, and Congestive Heart Failure (CHF, weakness in the heart where fluid accumulates in the lungs). During a review of Resident 21's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA Continuously every shift DX:COPD . Order Date 11/17/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/17/2022 . During a review of Resident 21's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy . Date Initiated 10/20/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 17's AR, dated 12/14/22, the AR indicated, Resident 17 was admitted from an acute care hospital on 11/3/22 to the facility, with diagnoses which included COVID-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus), Muscle Weakness, Hypertension, and Hyponatremia (low level of sodium in the blood). During a review of Resident 17's Order Summary Report (OSR), dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA as needed for SOB [Shortness of Breath] . Order Date 12/14/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/10/2022 . During a review of Resident 17's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t [related to] Ineffective gas exchange . Date Initiated 11/10/22 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 360's AR, dated 12/14/22, the AR indicated, Resident 360 was admitted from an acute care hospital on 12/5/22 to the facility, with diagnoses which included COVID-19, COPD, Malignant Neoplasm of Kidney (cancer of the kidney), Right Leg Pain, and Dependence on Supplemental Oxygen During a review of Resident 360's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 4 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/05/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/05/2022 . During a review of Resident 360's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t Ineffective gas exchange . Date Initiated 12/05/22 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 359's AR, dated 12/14/22, the AR indicated, Resident 359 was admitted from an acute care hospital on 11/30/22 to the facility, with diagnoses which included COPD, Hypertension, Congestive Heart Failure and End Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 359's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/01/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/01/2022 . During a review of Resident 359's CP, dated 12/14/22, the CP indicated, . The resident has COPD . Date Initiated 12/01/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 208's AR, dated 12/14/22, the AR indicated, Resident 208 was admitted from an acute care hospital on 12/2/22 to the facility, with diagnoses which included Congestive Heart Failure, Hypertension, and End Stage Renal Disease. During a review of Resident 208's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 3-5 LPM VIA NASAL CANNULA Continuously every shift . Order Date 12/02/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 12/022022 . During a review of Resident 208's CP, dated 12/14/22, the CP indicated, . The resident has oxygen therapy r/t CHF . Date Initiated 12/02/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of Resident 357's AR, dated 12/14/22, the AR indicated, Resident 357 was admitted from an acute care hospital on 12/9/22 to the facility, with diagnoses which included Respiratory Syncytial Virus (RSV, a common respiratory virus that usually causes mild, cold-like symptoms), Respiratory Failure (a serious condition that makes it difficult to breathe), and Hypertension. During a review of Resident 357's OSR, dated 12/14/22, the OSR indicated, . Order Summary . Oxygen 2 LPM VIA NASAL CANNULA as needed for SOB . Order Date 12/09/2022 . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . Order Date 11/09/2022 . During a review of Resident 357's CP, dated 12/14/22, the CP indicated, . Impaired Gas Exchange Pneumonia . Date Initiated 12/13/2022 . Interventions . Oxygen Humidifier Filter to be clean and dusted weekly on TUESDAY AM . During a review of the facility's document titled, Job Description: Director of Central Supply, undated, the document indicated, . Principal Responsibilities . ADMINISTRATIVE . Operates Medical Records and Flotation Therapy Departments . Participates in meetings and in-services as required . Conducts in-services as required . CONSUMER SERVICE . Adheres to Company standards for resolving consumer concerns . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2016, the manual indicated, .Cleaning the Cabinet Filter .1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent and water. Rinse thoroughly. 3. Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found. 4. Reinstall the cabinet filter . During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2017, The P&P indicated, . Oxygen is administered under safe and sanitary conditions to meet resident needs . E. If oxygen concentrators are used, the filters will be cleaned per manufacturer's guidelines . F. There will be a log to maintained to identify each time the filters are changed . During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident Care Equipment, dated 1/2012, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC recommendations for disinfection . 2. During a concurrent observation and interview on 12/15/22, at 9:45 a.m., with Laundry Staff (LS) 1, in the laundry area, LS1 stated there were five plastic bags of wet and soiled mops and cleaning cloths on the floor. LS1 stated the housekeeping staff left the bags on the floor, instead of placing the dirty mops and cleaning cloths in a barrel. LS1 stated the housekeeping staff should place their dirty mops and cleaning cloths in a barrel to prevent the spread of infection. LS1 stated the facility does not have a designated barrel for dirty mops and cleaning cloths. During an interview with Housekeeper (HK) 1 on 12/16/22, at 9:37 a.m., HK 1 stated she left five bags of wet and soiled mops and cleaning cloths on the floor in the laundry area yesterday [12/15/22]. HK 1 stated the housekeeping staff does not have a designated barrel to place soiled mops and cleaning cloths. HK1 stated the current practice of placing plastic bags of wet and soiled mops and cleaning cloths on the floor in the laundry area could result in contamination and spread of infection. During an interview with the Director of Plant Maintenance (MAIND) on 12/16/22, at 11:00 a.m., the MAIND stated the housekeeping staff does not have a designated barrel to place soiled mops and cleaning cloths. The MAIND stated the current practice of placing plastic bags of wet and soiled mops and cleaning cloths on the floor in the laundry area was unsanitary and not according to facility's infection prevention and control policy. The MAIND stated the contaminated fluids could leak through the bag and exposed staff handling the laundry to infectious bacteria and viruses. During a review of the facility's document titled, Job Description: Housekeeper, 12/2022, the document indicated, . The housekeeper cleans and maintains the cleanliness of the facility . Responsibilities . 1. Daily cleaning of all resident rooms and bathrooms as assigned . 3. Terminal cleaning of resident rooms and bathrooms at the time of discharge or death or as directed or assigned . 9. Report supply needs to your supervisor . During a review of the facility's document titled, Job Description: Director of Plant Maintenance, undated, the document indicated, . Principal Responsibilities . Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State and Corporate Requirements . During a review of the facility's policy and procedure (P&P) titled, Soiled Laundry and Bedding, dated 9/2016, The P&P indicated, . Contaminated laundry is placed in a bag or container at the location where it is used to prevent contamination during transport . Housekeeping Staff and Nursing Staff place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags, leak-proof bags or leak proof containers . During a professional reference review retrieved from the American Journal of Infection Control, titled, Are hospital floors an underappreciated reservoir of transmission of health care-associated pathogens? dated 2017, the article indicated, . Effective disinfection of contaminated surfaces is essential to prevent nosocomial transmission of pathogens such as Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Efforts to improve disinfection usually focus on surfaces that are frequently touched by the hand s of health care workers or patients (e.g., bedrails and call buttons). Although health care facility floors are often heavily contaminated, limited attention has been paid to disinfection of floors because they are not frequently touched. However, floors are a potential source of transmission because they are often contacted by objects that are subsequently touched by hands (e.g., shoes and socks). In a recent study, it was reported that nonslip socks worn by hospitalized patients were frequently contaminated with MRSA and VRE .

Based on observation, interview, and record review, the facility failed to ensure 1. The Controlled Carbohydrate Diet (a meal plan for diabetic residents) lunch dessert was provided for 17 (Resident 2, 3, 5, 15, 22, 23, 25, 29, 32, 36, 37, 38, 40, 48, 50, 51, 52) of 17 sampled residents who have a physician order to receive Controlled Carbohydrate Diet (CCHO) diet received a regular dessert for lunch on 12/14/22. 2. The fortified dessert was provided for one of one sampled resident (Resident 10) who have a physician order to receive fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement residents' nutrition status) received a regular dessert for lunch on 12/14/22. These failures had the potential to negatively impact the residents' nutritional status and further compromising residents' medical status. Findings: 1. During a dietary production observation, on 12/14/22, at 10:53 AM, in kitchen, Diet Aide 1 (DA) used a spatula to cut the Apple Hill cake from a 15-inch width x 21-inch length x 1-inch depth sheet pan into a single serving size and then put the single serving size Apple Hill cake into a white serving bowl. During a concurrent observation and interview on 12/14/22, at 11:03 a.m., with DA 1, DA 1 stated she cut 40 pieces single size Apple Hill cake with the same size and she was going to serve those Apple Hill cake to regular diet residents, CCHO diet residents and Renal diet residents. During trayline observation on 12/14/22, at 12 p.m., CCHO diet residents received regular dessert. During a concurrent interview and record review, on 12/15/22, at 9:30 a.m., with the Regional Dietary Manager (RDM) and Food and Nutrition service Director (FND), the RDM and FND reviewed the Cooks Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diet) on 12/14/22 CCHO dessert. The RDM and FND stated The CCHO dessert was supposed to get 1/2 size of regular dessert. The FND stated the potential risk for CCHO diet residents who received regular dessert could cause high blood sugar. The FND stated her expectation was for dietary staff to read and follow the Cooks Spreadsheet accurately. During a concurrent telephone interview and record review, on 12/16/22, at 11:32 a.m., with the facility Registered Dietitian (RD), the RD stated dietary staff should cut regular dessert into 1/2 serving size and served to the CCHO diet residents on 12/4/22 lunch dessert. The RD also stated her expectation was for dietary staff to follow Cooks Spreadsheet. The RD stated the potential risk for CCHO residents who received regular dessert would be minor if it occurred only one time but if the incident occurred frequently, it would cause an increase in the residents' blood sugar. During a review of the facility's provided physician diet orders, dated 12/14/22, the physician diet orders indicated, 17 Residents (Resident 2, 3, 5, 15, 22, 23, 25, 29, 32, 36, 37, 38, 40, 48, 50, 51, 52) on Controlled Carbohydrate diet. During a review of the facility's Cooks Spreadsheet, dated 12/14/22, the Cooks Spreadsheet indicated, .Apple Hill Cake (dessert) for Regular diet: 1 piece; CCHO: 1/2 piece. During a review of the facility provided Controlled Carbohydrate Diet, dated 2020, the Controlled Carbohydrate Diet indicated, DESCRIPTION: A controlled carbohydrate diet, (CCHO), is a meal plan .for diabetic residents.the carbohydrates are evenly, systematically and consistently distributed through three meals and H.S. (evening) snack in effort to maintain a stable blood sugar level through the day. 2. During a concurrent observation and interview, on 12/14/22, at 10:05 a.m., in the kitchen, with the RDM and Dietary Aide (DA) 1, DA1 prepared the Apple Hill cake dessert for residents during lunch. DA 1 stated Only fortified diet residents need whipped topping on the Apple Hill cake. During a concurrent dining observation and interview, on 12/14/22, at 12:48 p.m., with the Director of Staff Development (DSD), there was no whipped topping on Apple Hill cake. The DSD read Resident 10's meal tray ticket and stated Resident 10 was on Fortified diet. The DSD validated there was no whipped topping on the Apple Hill cake. During an interview on 12/14/22, at 12:50 p.m., with the RDM, the RDM read Resident 10's meal tray ticket and stated Resident 10 was on Fortified diet. The RDM stated there was no whipped topping on the Apple Hill cake. The RDM stated Fortified diet needs whipped topping on the Apple Hill cake. During a concurrent interview and record review on 12/15/22, at 9:30 a.m., with the RDM and the FND, the RDM and FND reviewed Cooks Spreadsheet on 12/14/22 for fortified diet lunch. The RDM and FND stated The dessert needs whipped topping. The RDM and FND stated their expectation for dietary staff was to read and follow the Cooks Spreadsheet accurately and serve fortified food items to residents on fortified diet. The FND stated the potential risk for residents on fortified diet who did not receive fortified food items was for the residents not to get the extra calories from fortified food items which could cause weight loss. During a concurrent phone interview and record review, on 12/16/22, at 11:32 a.m., with the facility RD, the RD stated her expectation was dietary staff should know how to serve whipped topping dessert to residents on fortified diet. The RD stated because of weight loss, Residents were put on fortified diet. The RD stated the potential risk for residents on fortified diet not receiving fortified food items could cause residents to experience further weight loss. During a review of the Resident 10's physician diet order, dated 12/15/22, the physician diet order indicated, Fortified diet. During a review of the facility's Cooks Spreadsheet for fortified, undated, the Cooks Spreadsheet for fortified indicated, .Dessert: Whipped topping . During a review of the facility's policy and procedure (P&P) titled, Diet Record Maintenance, revised date 06/01/2014, the P&P indicated, Purpose: To ensure that the Facility provides residents with meals that meet the nutritional and consistency requirement per physician orders. Policy: The dietary department will maintain a system to record dietary information necessary to use on the resident's tray card (meal tray ticket). Procedure: I. The diet record system will contain the following information to be reflected on the resident's tray card: A. Name; B. Room number and bed location; . D. Diet order; . During a review of the facility provided FORTIFIED DIET, dated 2020, the FORTIFIED DIET indicated, DESCRIPTION: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. NUTRITIONAL BREAKDOWN: The goal is to increase the calories density of the foods commonly consumed by the residents.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for three of 17 sampled residents (Residents 34, 50 and 2) when: 1. Resident 34 was identified as having a behavior of yelling, cursing and threatening staff on 12/1/22 and licensed nursing staff did not develop an individualized care plan and implement effective interventions. This failure had the potential for Resident 34 to not receive appropriate care and not meet his health, safety, psychosocial, and behavioral needs. 2. Resident 50 did not have an individualized care plan to identify his 1500 milliliters (ml- a unit of measurement) fluid restriction. This failure placed Resident 50's care needs to go unmet and had the potential to result in fluid overload. 3. Resident 2 did not have an individualized care plan to identify the use of low air loss (LAL- an air mattress with fluctuating air). This failure had the potential for Resident 2 to have ineffective pressure management surface for the prevention and treatment of pressure ulcer (an injury that breaks down the skin and underlying tissue). Findings: 1. During a concurrent interview and record review, on 12/16/22, at 2:25 p.m., with Licensed Vocational Nurses (LVN) 5, Resident 34's Nursing Care Plan (CP), dated 12/16/22 was reviewed. The CP indicated, . Focus: . Behavior problem . 12/1/22 cursing, yelling, threatening staff . LVN 5 reviewed Resident 34's CP interventions and stated there were no specific interventions to address Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. LVN 5 stated there was no behavior monitoring related to Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. LVN 5 stated specific nursing interventions and monitoring should be created on the same day the behavior was observed. LVN 5 stated without specific nursing interventions and monitoring, Resident 34's behavior of cursing, yelling and threatening staff could worsen. During a concurrent interview and record review, on 12/19/22, at 9:33 a.m., with the Minimum Data Set Nurse (MDSN), Resident 34's CP, dated 12/19/22 was reviewed. The CP indicated, . Focus: Behavior problem . 12/1/22 cursing, yelling, threatening staff . The MDSN reviewed Resident 34's CP interventions and stated there were no specific interventions to address Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. The MDSN stated there was no behavior monitoring related to Resident 34's behavior of cursing, yelling and threatening staff on 12/1/22. The MDSN stated specific nursing interventions and monitoring should have been created on the same day the behavior was observed to meet Resident 34's needs. During an interview with the Director of Nursing (DON) on 12/19/22, at 10:08 a.m., the DON stated Resident 34's nursing care plan and interventions should have been created on the same day the behavior was observed to meet Resident 34's needs. The DON stated nursing interventions serves as a guide for care staff on how to address the identified behavior. The DON stated without the appropriate interventions, Resident 34's behavior could worsen. During a review of Resident 34's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/16/22, the AR indicated, Resident 34 was admitted from the general acute care hospital (GACH) on 7/27/22 to the facility, with diagnoses which included Mild Cognitive Impairment (decline in memory and thinking), Obsessive-Compulsive Disorder (repeated, persistent and unwanted thoughts, urges or images that are intrusive and cause distress or anxiety) and Hypertension (high blood pressure). During a review of Resident 34's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 12/3/22, the MDS indicated Resident 34's Brief Interview for Mental Status (BIMS) score was 14 of 15 points (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, The P&P indicated, . It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting, health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing . IV. Comprehensive Care Plan . b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition . 44504 2. During a review of Resident 50 's AR, the AR indicated Resident 50 was readmitted to the facility on [DATE] with diagnosis which included End Stage Renal Disease (a disease with kidney failure) dependence on Renal Dialysis (a medical procedure involves diverting blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a concurrent lunch dining observation and interview, on 12/13/22, at 12:26 p.m., with Resident 50 in the dining room. Resident 50's meal tray ticket indicated 1500 milliliter (ml) fluid restriction (fluid allowed to drink within 24 hour). Beverages: 4 ounces (oz- a unit of measurement) (120 ml) Non-Dairy Milk, 8 oz (240 ml) Iced Tea. Resident 50 had 2 cup of 8 oz of Iced tea on her lunch tray. Resident 50 stated, I am on fluid restriction because I am a dialysis patient. I only can have 1 cup 8oz (240 ml) iced tea and another cup fluid smaller than this cup which resident pointed 8 oz cup. During an interview on 12/15/22, at 9:36 a.m., with the Food and Nutrition service Director (FND), the FND stated Licensed Nurses (LNs) received an ordered from the physician regarding fluid restriction and would send the diet communication slip to the kitchen regarding the fluid restriction ordered. The FND would discuss with the LN the breakdown of fluid restriction during mealtimes and medication pass. The FND stated the potential risk of going over the prescribed fluid restriction of 1500 ml/day was for Resident 50 to experience fluid overload. The FND stated she expected dietary staff to follow and provide the prescribed amount of fluids in the meal tray ticket for residents on fluid restriction. During a telephone interview on 12/15/22, at 12 p.m., with the Renal Registered Dietitian (RRD), the RRD stated Resident 50 was admitted to the Hemolysis Center on 9/23/22. The RRD stated the Nephrologist (doctor who specialty in kidney disease) at the Hemolysis Center prescribed 1500 ml fluid restriction and target weight (goal weight used for treatment of dialysis patients) of 64 kilograms (kg- a unit of measurement) for Resident 50. The RRD stated she could not recall she discussed with the facility RD regarding Resident 50's target weight. During a concurrent interview and record review, on 12/15/22 at 2:27 p.m., Resident 50's care plan was reviewed with the DON, the DON stated the process of fluid restriction started first with the prescribing physician then the LN would send the fluid restriction order to the dietary department via a Diet Communication Slip. The DON stated the FND, and LN would discuss the amount distribution of fluid breakdown between dietary and nursing and the FND would put the amount of fluid allowed in the meal tray ticket for each meal from dietary. The DON stated her expectation was for Certified Nursing Assistants (CNAs) and staff to read the meal tray ticket and to ensure the fluid amount indicated in the meal tray ticket to be provided accurately to the residents. The DON stated her expectation was for charge nurses to closely monitor residents on fluid restriction to prevent fluid overload. The DON stated, There was no indication of monitoring residents on fluid restriction by the nurse or a sign off for fluid restriction residents by the nurses . The DON stated the possible outcome for residents who consumed fluids more than their prescribed amount would be fluid overload, respiratory distress, and edema. The DON stated her expectation was for LNs to notify the physician if residents consumed fluids more than their prescribed amount. The DON stated it has been two weeks LNs did not notify Resident 50's physician that Resident 50 consumed fluids more than his prescribed amount of 1500 ml/day. The DON stated, There is no goal weight or target weight for Resident 50's care plan. The DON stated, It could be a good idea to have a target weight or goal weight in her care plan. During a concurrent telephone interview and record review, with the facility's RD 12/16/22, at 11:32 a.m., the RD reviewed Resident 50's care plan and stated, I do not know Resident 50 's goal weight because I did not discuss with her. The RD stated she did not know Resident 50's target weight because she did not discuss with the RRD. The RD stated, I did not see any care plan regarding 1500 ml fluid restriction breakdown for Resident [50]. During a concurrent interview and record review, on 12/16/22 at 2:19 p.m. with LVN 4, LVN 4 reviewed Resident 50's clinical record and stated residents on fluid restriction needs to have a care plan and interventions indicating breakdown of fluids for dietary and nursing. LVN 4 stated there was no evidence in Resident 50's clinical record of the 1500 ml fluid restriction breakdown for Resident 50 prior to 12/14/2022. During a review of Resident 50's Nutrition Care plan, undated, the Nutrition Care plan indicated, Focus: Nutrition: Resident is at risk for weight loss, malnutrition, and dehydration due to diagnosis End stage renal disease on hemodialysis (a medical procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) .Diet: . fluid restriction 1500 ml daily, dated Initiated: 12/08/22; Interventions/Tasks: .Dietary will provide following fluid restriction .Date initiated: 12/08/2022; LVN TO CHECK MEAL TRAY FOR ACCURACY TO PHYSICIAN ORDERS three times a day, Date initiated: 11/22/2022; Provide and serve diet as ordered: .1500 ml fluid restriction, Dated initiated: 12/08/22; .Monitor intake and record every meal, dated initiated 12/8/2022 . In the care plan, there were no evidence documentation of goal weight/target weight, no evidence documentation of intervention indicating breakdown of fluid for dietary and nursing; no evidence documentation of intervention indicating notified doctor if resident consumed fluid more than prescribed fluid restriction. During a review of the facility's P&P titled, Fluid Restrictions, Revised date 04/21/22, the P&P indicated, Purpose: To ensure the adequate provision of care and comfort measures for residents who are on fluid restrictions. Policy: Residents on Fluid restriction will be monitored for intake . for the duration of the Attending Physician order. Procedure: I. Residents on fluid restriction must have an Attending Physician order for the restriction which indicates the amount of fluid allowed within a 24-hour timeframe. III. The Licensed Nurse will: .D. Update the resident's Care Plan. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, Revised date November 2018, the P&P indicated, Purpose: To ensure that a comprehensive person- centered care plan is developed for each resident. Policy: It is the policy of this Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Procedure: . IV. Comprehensive Care Plan a.All goals, .interventions .will be included in the resident's comprehensive care plan. 41119 3. During an observation on 12/13/22, at 10:12 a.m., in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During an observation on 12/13/22, at 2:33 p.m., in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed. The digital control unit indicators were not illuminated. During a concurrent interview and record review, on 12/13/22, at 2:41 p.m., with LVN 3, Resident 2's Braden Scale for Predicting Pressure Ulcer Risk (BR), dated 11/18/22 was reviewed. The BR indicated, .High Risk . LVN 3 stated, Resident 2 was at high risk for skin breakdown and benefits for the use of the LAL mattress. LVN 3 stated, there was no care plan for the use of the LAL mattress. LVN 3 stated, it was the LNs responsibility to develop the care plan when the LAL mattress was implemented. LVN 3 stated, the purpose of the care plan was to develop interventions such as checking the LAL mattress to ensure it was working. During a concurrent observation and interview, on 12/13/22, at 2:49 p.m., with LVN 3, in Resident 2's room, Resident 2 laid in bed with the digital control unit attached to the foot of the bed, the digital control unit indicators were not illuminated. LVN 3 stated the digital control unit was plugged into the electrical outlet but was not working. LVN 3 stated, the lights on the digital control unit were not illuminated indicating the unit was not working. During a concurrent interview and record review, on 12/16/22, at 2:37 p.m., with the DON, the facility policy titled Mattresses dated 1/2012 was reviewed. The policy indicated, .To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure .To reduce pressure and evenly distribute body weight over a larger area of body surface .Be sure the mattress is inflating properly .Check air mattress routinely to ensure that it is working properly .Record the use of the mattress and resident outcome in the resident's medical record . The DON stated, the purpose of the LAL mattress was to prevent pressure injury. The DON stated, the pump (digital control unit) should be in good operating condition and it was the LNs responsibility to ensure it was working. The DON stated, the LAL mattress should be care planned, the care plan should have been developed when the LAL mattress was implemented. The DON stated, the purpose of the care plan was for staff to be aware of the plan of care for residents. During a review of the facility P&P titled Comprehensive Person-Centered Care Planning dated 11/2018. The P&P indicated, .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety .needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .

Based on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions when trash dumpsters were left uncovered, and trash were found on the floor surrounding the trash dumpsters. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness. Findings: During an observation on 12/13/22, at 8:41 a.m., in the facility trash dumpster area near the employee parking spaces, Two of three trash dumpster's lids were open and uncovered. There was an unknown food substance that was yellow in color and there were trashes which included gloves, plastic wrapping and paper on the floor surrounding the trash dumpsters. During a concurrent observation and interview, on 12/13/22, at 3:38 p.m., with the Registered Dietician (RD) and the Food and Nutrition Service Director (FND), outside at the facility's trash dumpster area, two of three trash dumpsters lids were not closed properly, one trash bag hanged over the edge of the dumpster and one bag laid on top of the lid of another dumpster. The RD and FND stated the trash dumpsters should not have bags on top of the trash dumpster lid and there should be no trash bags hanging over the edge of the trash dumpster, The RD stated, It is not okay, it will attract rodents. The FND stated, I am surprised they did not close the lids. The FND and RD stated, it was unacceptable to have the trash dumpsters without the trash lids closed properly because it could attract pests and rodents. During a review of the facility's policy and procedure (P&P) titled, Waste Management, revised April 21,2022, the P&P indicated, .Close and dispose regulated waste according to state and federal regulations . During a review of the Food and Drug Administration (FDA) Food code 2017, Annex 3 section 5-501.15 Outside Receptacles, the FDA food code indicated, Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils.Outside receptacles must be .with tight-fitting lids and covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 359) received information on their plan of care in a language they could understand when staff did not consistently provide an interpreter when communicating to Resident 359 in her preferred language. This failure violated Resident 359's rights to participate in the development and implementation of his plan of care in a language he could understand and placed Resident 359 at risk for not making informed decisions about his care and treatment decisions. Findings: During an observation on 12/14/2022, at 12:09 p.m., in Resident 359's room, there was no communication board (a tool used to help staff communicate with residents) visible in Resident 359's room. During a concurrent observation and interview, on 12/14/2022, at 12:15 p.m., with Resident 359, in the living room, the transport staff arrived to pick resident up for his dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood)) appointment. Resident 359 stated in Spanish, [I] don't know what I'm waiting for. LVN 2 stated in English to Resident 359, It will be one moment. Getting a sack lunch for you. Resident 359 stated he did not understand what LVN 2 told him. Resident 359 stated he had been told his appointment time for dialysis had changed but had not been told why. During a concurrent interview and record review, on 12/15/2022, at 2:45 p.m., with the Social Services Director (SSD), Resident 359's Plan of Care (POC), dated 12/7/2022 was reviewed. The POC indicated, .[Resident 359] is Spanish speaking and is able to verbalize wants and needs to staff .Goal . the resident will improve communication function by using communication board & writing messages through the review date . Interventions .anticipate and meet needs ., be conscious of resident position when in groups, activities, dining room to promote proper communication with others ., communication: resident prefers to communicate in Spanish, resident requires a translator with communication . the resident is able to communicate by a communication board, and translator . The SSD stated, [Resident 359] is Spanish speaking. The SSD stated, she does assessments with new admissions and upon admission I like to know the plan for the resident. The SSD stated the SSD Care Plan Assessment was completed on 12/7/2022 and Resident 359 was admitted on [DATE]. The SSD stated, Some CNAs are Spanish speakers. We have a language communication board. The SSD stated that a communication board was not provided to Resident 359. The SSD stated, I don't know how staff get communication boards for residents. Managers on weekends would know. During an interview on 12/16/22, at 11:56 a.m., with the Director of Staff Development (DSD), the DSD stated there was a high population of Spanish Speaking residents in the facility and staff were expected to provide a communication board and an interpreter in the resident's language of choice. The DSD stated Resident 359 required the use of a communication board and a Spanish interpreter to meet Resident 359's cultural needs and follow his plan of care and this was not provided to Resident 359. During an interview on 12/19/22, at 10:09 a.m., with the Director of Nursing (DON), the DON stated staff should follow Resident 359's plan of care and should provide a Spanish speaking interpreter when communicating with Resident 359. The DON stated a communication board and a Spanish interpreter should have been provided to Resident 359 and was not provided. The DON stated Resident 359 might not understand the instructions or information shared by staff and Resident 359's rights to understand and participate in his plan of care in a language he preferred and understand was not done. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/2012, the P&P indicated, The facility's staff encourages residents to participate in planning their daily care routines (including ADL's) .Residents are encouraged to participate in activities of their choice, including community activities .Each resident is allowed to choose activities, schedules and healthcare that are consistent with his or her interests, assessments and plans of care .In order to facilitate resident choices, Facility staff will: inform (and regularly remind) the resident and family members of the resident's right to self-determination and participate in preferred activities .Gather information about the Resident's personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; and include information gathered about the resident's preferences in the in the care planning process .Residents are provided assistance as needed to engage in their preferred activities on a routine basis . During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning undated, the P&P indicated, The summary must be in a language and conveyed in a manner that the resident and/or resident representative can understand . During a review of the facility's P&P titled, Translation or Interpretation Services, dated 12/1/2013, the P&P indicated, Purpose: To ensure that resident with limited English Proficiency or who have [NAME] deficiencies have the same access to Facility services as other residents .Facility Staff will orally inform the resident in a language they can understand of their right to obtain competent oral translation services free of charge .Family members and friends are not to be relied upon to provide interpretation services for resident, unless explicitly requested by the resident .If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information .