Every finding on record at Kingsburg Center

Based on interviews and record reviews, the facility failed to ensure the food service manager met state requirements when the Dietary Account Manager (DAM) hired for this role did not meet the qualifications required for food service managers.This failure had the potential to place residents at risk for compromised food safety and inadequate oversight of dietary operations for the 75 residents who received food from the kitchen.Findings: During a review of the California Health and Safety Code (HSC) 1265.4, dated 1/1/25, the California Health and Safety Code 1265.4 indicated seven qualification pathways of the full-time position responsible for the day-to-day operation of dietetic services. Pathway five indicated the manager is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager (CDM) credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.During an interview on 6/2/26 at 8:15 a.m. with the DAM, the DAM stated she was employed full time and was the manager responsible for the day-to-day operations of the dietetic services at the facility. The DAM stated she had a bachelor's degree in hospitality recreation and tourism and was scheduled to take the CDM exam on 6/9/26. The DAM stated the Registered Dietitian Consultant (RDC) went to the facility every week for 8 hours and provided oversight and assistance while in the facility and stated she could reach out to the RDC as well via telephone with any questions or concerns she had at any time.During a review of the DAM's employee file (File), (undated), the file indicated a document titled, California State University, East Bay degree of Bachelor of Science in hospitality and tourism, dated May 13, 2023. The facility was unable to provide a certificate verifying that the DAM was a CDM. The DAM's file indicated her start date with the facility was on 12/10/25.During a concurrent interview and record review on 6/4/26 at 2:36 p.m. with the DAM and the Dietary District Manager (DDM), the California HSC 1265.4, dated 1/1/25 was reviewed. After reviewing the California HSC 1265.4, the DAM and the DDM stated they both believed the Bachelor of Science degree in hospitality and tourism held by the DAM met the requirements to qualify her as the manager of food and nutrition services.During a concurrent interview and record review on 6/4/26 at 3:10 p.m. with the Administrator (ADM) and the Regional Dietitian (RD), the California HSC 1265.4, dated 1/1/25 was reviewed. After reviewing the California HSC 1265.4, the ADM stated understanding of unmet requirements for the HSC 1265.4 regarding required qualifications for food service managers. During an interview on 6/5/26 at 1:45 p.m. with the RDC, the RDC stated she was present at the facility every week for 8-12 hours total and was not employed full time. The RDC stated it was her expectation to have a qualified food service manager and stated it was important to follow requirements and state mandates for a qualified person running the kitchen to ensure the facility was doing things according to regulations, meeting standards and for food safety and so staff have a qualified person to reach out to.During a review of the facility's policy and procedure (P&P) titled, Verification of Licensure, dated 04/07/2026, the P&P indicated, .This policy is to ensure that only legally qualified and/or otherwise appropriately qualified staff are employed according to state regulations and standards.

Based on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program were incomplete for February 2026, March 2026, April 2026, and May 2026. These failures had the potential to place residents at risk for an adverse effect (bad reaction or unwanted result) of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use. Findings: During a concurrent interview and record review on 6/5/26 at 8:58 a.m. with Infection Preventionist (IP), the facility's Surveillance Log (Log), dated February 2026, March 2026, April 2026, and May 2026 were reviewed. The IP stated she had been working for the facility for 10 years and assumed the position as IP in February 2026. The IP stated she tried her best to complete the antibiotic surveillance log (continuous, systematic monitoring of how bacteria develop defenses against medications [resistance] and how often doctors prescribed these drugs) as soon as she assumed the IP position. The IP stated the Log indicated for the months of February, March, April, and May, the surveillance log was incomplete. The IP stated the Log was missing signs (what the doctor or designee see) or symptoms (what you feel), no laboratory results, culture and sensitivity (C&S-two-part lab procedure used to identify the exact cause of an infection and find the best medication to cure it) or X-ray results (quick, painless test that uses invisible energy beams to take pictures of the inside of the body). The IP stated the Log should be complete and accurate to ensure residents were receiving the right antibiotic and were meeting the criteria for antibiotics. The IP stated she was not sure if the antibiotics ordered for residents were appropriate, not knowing whether the bacteria was susceptible (vulnerable) or resistant to the medication. The IP stated she was aware one of her main duties was to ensure residents were meeting the criteria to receive antibiotics and were beneficial to them. During an interview on 6/5/26 at 11:48 a.m. with the Director of Nursing (DON), the DON stated the IP took over the position in February 2026 after the previous IP left. The DON stated her expectation was for the IP to ensure the monthly antibiotic stewardship (infection surveillance log) was accurate and complete. The DON stated it was important for the IP to review the antibiotics used in the facility to ensure residents were prescribed the right antibiotic to prevent unnecessary medications which put residents at risk for developing tolerance to antibiotics. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 9/18/23, the P&P indicated, .The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in or residents . When a culture and sensitivity (C&S) is ordered lab results and the current clinical situations will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . During a review of the facility's P&P titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, dated 9/18/23, the P&P indicated, . 2. The IP, or designee, will review antibiotics utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking log . During a review of a professional reference from the CDC (Centers for Disease Control) found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html dated CDC (Centers for Disease Control), the Professional Reference titled, The Core Elements of Antibiotic Stewardship for Nursing Homes (found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html) indicated, . Leadership Commitment . Nursing home leaders commit to improving antibiotic use. Facility leadership, both owners and administrators, as well as regional and national leaders if the facility is part of a larger corporation, can demonstrate their support in the following ways . Communicate with nursing staff and prescribing clinicians the facility's expectations about use of antibiotics and the monitoring and enforcement of stewardship policies . Create a culture through messaging, education . which promotes antibiotic stewardship . Accountability . Nursing homes identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership . Empower the Director of Nursing to set the practice standards for assessing, monitoring and communicating changes in a resident's condition by front-line nursing staff. Nurses and nurse aides play a key role in the decision-making process for starting an antibiotic . Therefore, the importance of antibiotic stewardship is conveyed by expectations set by nursing leadership in the facility . Infection program coordinator . Infection program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility . Tracking and Reporting Antibiotic Use and Outcomes . Process Measures: Tracking how and why antibiotics are prescribed . Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians . Antibiotic use measures: tracking how often and how many antibiotics are prescribed . Track the amount of antibiotic used to review patterns of use and determine the impact of new stewardship interventions .

Based on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) were completed and documentation was maintained demonstrating delivery of the notices to the resident and/or responsible party (RP) for one of three sampled residents (Resident 90). This failure had the potential to prevent Resident 90 and or RP from being fully informed of Medicare coverage termination, potential financial liability, and appeal rights. Findings:During an interview on 6/4/26 at 8:24 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated the process for issuing a NOMC included discussing residents during weekly interdisciplinary team (IDT) meetings. The MDSN stated when a resident met their goals and was determined to be safe for discharge home, the IDT identified the last covered day. The MDSN stated she created the NOMC and provided the form to social services for completion. The MDSN further stated social services notified the residents and or RP and initiated discharge planning. During a concurrent interview and record review on 6/4/26 at 8:40 a.m. with the Social Services Assistant (SSA), Resident 90's electronic health record (EHR), dated 1/26/26 was reviewed. The SSA stated the Social Services Department was responsible for issuing beneficiary notification forms. The SSA stated the EHR indicated the facility provided the beneficiary notification documents for Resident 90 and stated the NOMNC was issued on 1/26/26. When asked what form was used to document the telephonic delivery of the NOMNC, the SSA was unable to provide an answer. The SSA stated she used the signed document when verbally delivering the SNF-ABN over the telephone but was unsure how the NOMNC was delivered. The SSA stated the NOMNC was likely delivered by telephone; however, she was unable to determine how the delivery was documented. The SSA stated she would generally document in a progress note how beneficiary notices were delivered; however, no progress note was identified in the EHR indicating how the NOMNC or SNF ABN were delivered. The SSA stated the NOMNC informed the resident and or RP of the date Medicare coverage would end and provided appeal rights if additional skilled services were believed to be necessary. When asked about the purpose of the SNF-ABN, the SSA stated it informed the resident and/or RP of Medicare non-coverage but was unsure what specific information the form provided. The SSA further stated the SNF ABN form had not been completed, as only the resident's name had been documented and no additional information had been entered on the form. When asked how she would proceed if a resident refused to sign the beneficiary notification forms, the SSA stated she could not answer and did not know the process. The SSA stated her usual practice was to read the forms aloud in person or over the telephone, answer questions, and ask how the resident or RP preferred to receive copies of the forms. The SSA stated if copies were mailed, she would complete an ICE CMS Optional Form 2/15 and document in a progress note that copies were provided and how they were delivered. The SSA stated the EHR indicated the ICE CMS Optional Form 2/15, which is the documentation indicating the beneficiary notification forms were mailed, or a progress note describing how the NOMNC or SNF ABN were delivered to the resident or RP could not be found. The SSA stated the previous Social Services Director (SSD) did not complete the portion of the telephonic delivery form indicating the forms were mailed and did not complete an ICE CMS Optional Form 2/15. The SSA stated she believed the previous SSD may have used the telephonic delivery form for both the NOMNC and SNF ABN. The SSA stated beneficiary notification forms were important because they were part of the resident's rights. During an interview on 6/5/26 at 1:30 p.m. with the Administrator (ADMIN), the ADMIN stated his expectation regarding issuance of the NOMNC and SNF ABN forms was that the IDT met and determined when Medicare coverage would end for residents receiving Medicare services. The ADMIN stated the MDSN prepared the NOMNC and the Social Services Department issued the beneficiary notification forms. The ADMIN stated the Social Services Department provided the notices to the residents and/or RP, and Medical Records uploaded copies of the completed forms into the residents EHR. The ADMIN stated the residents, or RP signed the notices in person when available and if the resident or RP was unavailable to sign, the facility attempted to fax or mail notices. The ADMIN stated a progress note should have been completed documenting how the notices were delivered. The ADMIN stated his expectation was that the NOMNC should have been completed and signed, the SNF ABN should have been completed, and any mailing of beneficiary notification forms should have been documented. The ADMIN stated this process was important because residents had rights to be informed of information affecting their Medicare coverage and appeal rights. During a review of facility policy and procedure (P&P) titled, Medicare and Medicaid Benefits, revised date 4/2021, the P&P indicated, .when changes are made to items and services covered by Medicare or Medicaid plans, residents are informed of these changes as soon as possible.During a review of facility P&P titled, Medicare Advanced Beneficiary and Medicare Non-Coverage Notices, undated, the P&P indicated, .written notices are provided in person to the beneficiary when possible. A copy of the notice is provided to the beneficiary (or authorized representative) immediately after the notice is signed.During a review of facility P&P titled, Acknowledgement of Resident Rights and Responsibilities, undated, the P&P indicated, .each resident (or resident representative) will be provided and must acknowledge receipt of a written copy of resident rights and all rules, regulations and policies governing the resident's conduct and responsibilities during his/her stay in the facility.signed dated copies of the residents acknowledgement of rights and responsibilities and any subsequent revisions are maintained in the residents medical record.

Based on interviews and record reviews, the facility failed to provide the required bed hold notice at the time of transfer to the hospital for two of six sampled residents (Resident 1 and Resident 13), when:1. Resident 1 was transferred to the hospital on 3/8/26 due to low oxygen levels and was not given the required facility document titled, Bed Hold Notice of Policy & Authorization (BHNPA).2. Resident 13 was transferred to the hospital on 5/25/26 due to shortness of breath (SOB-the feeling that you cannot get enough air into your lungs) and was not given the required facility document BHNPA. These failures had the potential to result in Resident 1 and Resident 13 being unaware of their right to return to the facility under state and federal laws and regulations and the option to privately pay to hold their bed if they were a Medicare beneficiary, private pay resident, or insurance resident.Findings:1. During a review of Resident 1'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 6/5/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Covid-19 (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) acute and chronic respiratory failure with hypercapnia (when the lungs cannot properly remove carbon dioxide [a colorless, odorless gas at room temperature] from your blood leading to a dangerous buildup), pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection) unspecified organism, heart failure unspecified, muscle weakness (generalized), other abnormalities of breathing, mixed irritable bowel syndrome ( alternating bouts of constipation and diarrhea). The AR indicated under the contacts section of the document that Resident 1 was her own responsible party (RP-indicates that the resident holds the legal, medical, and financial authority over their own care).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/24/26, the MDS section C indicated Resident 1 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 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 1 was cognitively intact.During a review of Resident 1's facility document titled, BHNPA, dated 3/8/26, the BHNPA indicated, .Resident Name.[Resident 1's name listed].Agreement to Pay Charges Privately for Bed Hold.Resident/Representative [area for signature blank].Date [blank].During a concurrent interview and record review on 6/5/26 at 8:44 a.m. with the Medical Records (MR), the policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022 and Resident 1's EHR, undated were reviewed. The MR stated she could not state whether the Bed Hold Notice of Policy & Authorization form was provided to Resident 1 when being transferred to the hospital, upon her return from the hospital (a couple of hours later the same day) or within the required 24hr period timeframe as stated in the P&P. The MR stated the EHR indicated based on the inability to provide the signed document by the resident, and no documentation in Resident 1's chart whether the form was provided to the resident, the P&P was not followed. The MR stated it was important to complete and provide residents' with written notices for all transfer documents including the BHNPA form to honor resident's rights and for the resident to be informed. 2. During a review of Resident 13's AR, dated 6/5/26, the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of interstitial pulmonary disease unspecified (inflammation, scarring, or both in the tiny tissues that surround the air sacs in your lungs), pulmonary candidiasis (fungal infection of the lungs), pulmonary fibrosis (chronic lung disease characterized by buildup of scar tissue in the lungs), acute respiratory failure with hypoxia (a sudden, life threatening condition where the lungs cannot get enough oxygen into the bloodstream), heart failure (when the heart is too weak or stiff to pump blood efficiently), major depressive disorder ( a serious mental health condition that causes a deep, persistent feeling of sadness or a loss of interest in activities). The AR indicated under the contacts section of the document that Resident 13 was his own RP.During a review of Resident 13's MDS, dated [DATE], the MDS section C indicated Resident 13 had a Staff Assessment for Mental Status. Section C0700. Short-term Memory OK indicated, 0. Memory OK and section C1000. Cognitive Skills for Daily Decision Making indicated, 1. Modified Independence-some difficulty in new situations only.During a concurrent interview and record review on 6/4/26 at 10:33 a.m. with the MR, Resident 13's EHR, date 5/25/26 was reviewed. The MR stated nurses were to complete a three page packet for every discharge or transfer that included: First page -Ombudsman Transfer or Discharge Fax Cover Sheet, 2nd page- Notice of Proposed Transfer and Discharge (to be signed by resident) and 3rd page- Bed Hold Notice of Policy & Authorization (BHNPA) (to be signed by resident). The MR stated the EHR indicated she did not have the BHNPA form and the form was not in the EHR for Resident 13's most recent transfer. The MR stated she had been having issues with the nurses because not all nurses were completing the required three-page document packets upon transfers and stated it was possible the BHNPA form did not get filled out for Resident 13's transfer on 5/25/26. The MR stated not all nurses completed the forms as required. The MR stated she had noticed quite a bit of items that were not consistent with documents and paperwork and needed to figure out a plan to correct this issue, so the three-page document packets were filled out and there was consistency every time. The MR stated it was important to have completed paperwork for every transfer or discharge so the Ombudsman could keep track of the discharge (DC) to ensure it was safe and necessary and so that residents could be informed of the information and their rights regarding the bed hold.During an interview on 6/5/26 at 10:20 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated during a transfer nurses knew there was a three-page document packet which included the Transfer or Discharge Fax cover sheet, Notice of Proposed Transfer and Discharge form and the Bed Hold Notice of Policy & Authorization form which needed to be filled out and was a requirement for every transfer. LVN 1 stated it was important for the nurses to ensure the Transfer or Discharge Fax cover sheet, Notice of Proposed Transfer and Discharge form and the Bed Hold Notice of Policy & Authorization form was provided to the residents, so residents knew and were aware of their rights to return to the facility and residents knew that they had that option. LVN 1 stated providing residents with the BHNPA form was important because returning to the facility was usually a big concern to the residents when being transferred out.During an interview on 6/5/26 at 1:16 p.m. with the Director of Nursing (DON), the DON stated it was important for all transfer paperwork including the BHNPA form to be completed when a resident was transferred to the hospital to inform the doctor and family and so that residents could be informed of their rights for bed hold during transfers.During a review of the facility's P&P titled, Bed-Holds and Returns, dated 10/2022, the P&P indicated, .Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies.Residents, regardless of payer source, are provided written notice about these policies.at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of six sampled residents (Resident 2 and Resident 84) when:1.Resident 2's surgical incision was not coded in the quarterly MDS assessment dated [DATE].2.Resident 84's use of oxygen was not coded in the annual MDS assessment dated [DATE].These failures had the potential for Resident 1 and Resident 84's needs to not be met and changes in status not monitored which could lead to wound and respiratory complications. Findings: 1. During an observation on 6/3/26 at 11:40 a.m. with Resident 2, Resident 2 was sitting up in her wheelchair in the dining/activity room with other residents. Resident appeared well groomed holding on to a doll while another resident was trying to engage her to talk. Resident 2 did not respond to questions asked but was mumbling with words. During a review of Resident 2's admission Record (AR- a document containing resident profile information), dated 6/4/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat), end stage renal disease (ESRD- irreversible kidney failure) and diabetes mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's Order Summary Report (OSR), dated 6/4/26, the OSR indicated, . [status post (S/P)] right [R] thoracotomy [surgical procedure to open the chest] incisions [cut] to [R] lateral ribs cleanse with [normal saline (NS )- salt water], pat dry . Order Date: 2/9/26 . Start Date: 2/10/26. During an interview on 6/4/26 at 9:25 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 2's care. CNA 1 stated Resident 2 had a dressing on her back. CNA 1 stated she was not sure what Resident 2 had under the dressing because she had never watched the nurse change the dressing. CNA 1 stated she only knew the nurse changed the dressing every day. During an interview on 6/4/26 at 9:55 a.m. with CNA 2, CNA 2 stated she was familiar with Resident 2's care. CNA 2 stated Resident 2 did not have any pressure ulcers, but she had seen the nurse change the dressing on Resident 2's back. CNA 2 stated Resident 2 had surgery done on her back but was not sure how long. During a concurrent interview and record review on 6/4/26 at 2:10 p.m. with the Director of Staff Development (DSD), Resident 2's electronic health record (EHR), undated was reviewed. The DSD stated the EHR indicated Resident 2 had a thoracentesis (chest tap- procedure where a doctor uses a small needle and tube to drain excess fluid from space just outside the lungs) performed at the acute hospital. The DSD stated she was not sure of the date it was performed. The DSD stated the treatment order was still active. During a concurrent interview and record review on 6/4/26 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 2's EHR, undated was reviewed. LVN 2 stated the EHR indicated Resident 2 had a surgical wound on her right side. LVN 2 stated the dressing change on her right side was changed daily during the morning shift. LVN 2 stated she was not sure if the wound had healed because the treatment was still active and was signed every day indicating the treatment was completed daily. During an interview on 6/4/26 at 4:38 p.m. with the Minimum Data Set Nurse (MDSN), Resident 2's quarterly MDS assessment section M (Skin Conditions), dated 5/5/26 was reviewed. The MDSN stated Resident 2's surgical wound and surgical wound care was not coded in the quarterly MDS assessment. The MDSN stated Resident 2 should have been coded as having a surgical wound and receiving care for her surgical wound. The MDSN stated Resident 2's quarterly MDS assessment did not accurately reflect Resident 2's status.2. During an observation on 6/2/26 at 9:32 a.m. during initial tour in Resident 84's room, Resident 84 was lying in bed, oxygen via nasal cannula (nasal prongs- thin, flexible plastic tube) connected to oxygen concentrator (medical device that gives you extra oxygen) and set at three liters (L-unit of measurement) per minute. Resident 84 did not respond to questions asked. During a review of Resident 84's AR, dated 6/4/26, the AR indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included unspecified intracranial injury (head injury-any physical damage to the brain or skull), hydrocephalus (water on the brain) and palliative care (specialized medical care for anyone living with a serious illness). During a review of Resident 84's OSR, dated 6/4/26, the OSR indicated, . Oxygen two - four [2-4] L/min [liter per minute] via nasal cannula, [oxygen (O2)] saturation to remain above 90 percent [%] as needed for shortness of breath [SOB] . order date: 3/10/26, start date: 3/10/26. During an interview on 6/4/26 at 9:19 a.m. with CNA 1, CNA 1 stated she was familiar with Resident 84's care. CNA 1 stated Resident 84 was dependent on staff to meet all his daily needs like turning and repositioning, bathing, and dressing. CNA 1 stated Resident 84 had always used oxygen since she could remember. CNA 1 stated she did not remember Resident 84 not using oxygen.During an interview on 6/4/26 at 3:40 p.m. with LVN 2, LVN 2 stated she worked afternoon shift and was familiar with Resident 84's care. LVN 2 stated Resident 84 had always been on continuous oxygen as long as she could remember. During a concurrent interview and record review on 6/4/26 at 4:29 p.m. with the MDSN, Resident 84's annual MDS assessment section J (Health Conditions), dated 5/26/26 was reviewed. The MDSN stated the MDS indicated she answered No, Resident 84 did not receive oxygen. The MDSN stated she based her answer on the review of documentation from nursing staff and did not interview staff. The MDSN stated Resident 84's use of oxygen was not coded accurately in the annual MDS assessment. The MDSN stated Resident 84 should have been coded as receiving oxygen. The MDSN stated it was her responsibility to ensure resident assessments were accurate. The MDSN stated it was important to ensure accurate assessments were completed because it reflected the care provided to each resident.During an interview on 6/5/26 at 11:45 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the MDSN to do bedside assessments of residents to ensure accuracy of assessments and not rely on documentation from staff. The DON stated each member of the nursing staff completing a section in the MDS was responsible for ensuring their assessments were accurate to provide the care needed by residents.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Residents 27 and 84), when:1. Resident 27's physician order for daily dressing changes to the left breast wound were not followed. This failure had the potential to increase the risk of infection and result in inaccurate medical record documentation. 2. Resident 84's physician order for oxygen was not followed, and there was no documentation and monitoring of oxygen saturation (measures the percentage of oxygen in the blood). This failure placed Resident 84 at risk for receiving too much oxygen or too little oxygen without adequate monitoring which could cause damage to the lungs, brain, and eyes. Findings: 1. During a concurrent interview and observation on 6/2/26 at 9:01 a.m. in Resident 27's room, Resident 27 stated staff had not changed the dressing to her left breast as ordered. Resident 27 stated the dressing was to be changed daily and had not been changed for two days. Resident 27 then displayed the dressing to the surveyor. Observation revealed the dressing was dated 5/30/26. During a review of Resident 27'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 6/5/26, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (cancer, a disease in which abnormal cells grew uncontrollably and can spread to other parts of the body) of unspecified site of left female breast (the exact location of the cancer within the left breast was not identified in the medical record). During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/10/26, the MDS indicated Resident 27 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 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 27 was cognitively intact. During a concurrent interview and record review on 6/5/26 at 9:37a.m. with Licensed Vocational Nurse (LVN) 1, Resident 27's electronic health record (EHR), dated 6/5/26 was reviewed. LVN 1 stated Resident 27 had two wound care orders, including an order for the left breast area to be cleansed with normal saline (a sterile solution used to clean wounds and help prevent infection) and covered with a dry dressing once daily. LVN 1 stated the EHR indicated the left breast dressing change was documented on the TAR as completed daily from 5/30/26 through 6/3/26. LVN 1 stated the process for completing and documenting wound treatments was to perform the treatment and then document completion on the TAR. LVN 1 stated dressings were expected to be dated and initialed when changed and that dating and initialing dressings was important to verify treatments were completed as ordered, confirmed the frequency of dressing changes and support infection prevention practices. LVN 1 stated resident refusals were documented on the TAR. LVN 1 stated the EHR indicated there was no documentation indicating Resident 27 had refused dressing changes on 5/31/26, 6/1/26 or 6/2/26. When informed that observation on 6/2/26 revealed a dressing dated 5/30/26 remained in place on Resident 27's left breast, LVN 1 stated a dressing dated 5/30/26 on 6/2/26 would not have been consistent with daily dressing changes and indicated the treatments had been missed. LVN 1 further stated it would not have been accurate to document a dressing change as completed if the treatment had not been performed. When asked how a dressing dated 5/30/26 remained in place on 6/2/26 when the TAR indicated daily dressing changes had been completed, LVN 1 stated, It was obviously not done. LVN 1 stated the risk of not completing the dressing change as ordered was potential for infection due to the wound not being cleansed and redressed as prescribed. During a review of Resident 27's Care Plan Report (CP), dated 4/3/26, the CP indicated Resident 27 was identified as being at risk for unavoidable skin breakdown and had an open wound to the left breast. The CP indicated interventions included providing wound treatment as ordered. During an interview on 6/5/26 at 9:55 a.m. with the Director of Nursing (DON), the DON stated it was her expectation that staff followed physician orders for dressing changes. The DON stated nursing staff should assess the wound area, complete the dressing change and notify the physician of any changes in the wound condition. The DON stated wound treatments were verified as completed through documentation on the TAR. The DON stated if a dressing dated 5/30/26 remained in place on 6/2/26, that would indicate the dressing had not been changed. The DON further stated a dressing dated 5/30/36 on 6/2/26 would not be consistent with an order for daily dressing changes. The DON stated it would not be accurate documentation if a treatment was marked as completed when it had not been performed. The DON stated the risk to the resident from not completing ordered dressing changes was infection and stated, This is not my expectation. During a review of the facilities policy and procedure (P&P) titled, Charting and Documentation, undated, the P&P indicated, documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care. 2. During an observation on 6/2/26 at 9:32 a.m. during initial tour in Resident 84's room, Resident 84 was lying in bed, oxygen via nasal cannula (nasal prongs- thin, flexible plastic tube) connected to oxygen concentrator (medical device that gives you extra oxygen) and set at three liters (L-unit of measurement) per minute. Resident 84 did not respond to questions asked. During a review of Resident 84's admission Record (AR-a document containing resident profile information), dated 6/4/26, the AR indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included unspecified intracranial injury (head injury-any physical damage to the brain or skull), hydrocephalus (water on the brain) and palliative care (specialized medical care for anyone living with a serious illness). During a review of Resident 84's Order Summary Report (OSR), dated 6/4/26, the OSR indicated, . Oxygen two – four [2-4] L/min [liter per minute] via nasal cannula, [oxygen (O2)] saturation to remain above 90 percent [%] as needed for shortness of breath [SOB] . order date: 3/10/26, start date: 3/10/26. During an interview on 6/4/26 at 9:19 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 84's care. CNA 1 stated Resident 84 was dependent on staff to meet all his daily needs like turning and repositioning, bathing, and dressing. CNA 1 stated Resident 84 had always used oxygen since she could remember. CNA 1 stated she did not remember Resident 84 not using oxygen. During an interview on 6/4/26 at 9:50 a.m. with CNA 2, CNA 2 stated she was familiar with Resident 84's care. CNA 2 stated Resident 84 did not respond when spoken to. CNA 2 stated Resident 84's oxygen was always on since she started working with him when he was moved to room [ROOM NUMBER] but do not remember how long. During a concurrent interview and record review on 6/4/26 at 2:10 p.m. with the Director of Staff Development (DSD), Resident 84's oxygen order, dated 3/10/26 and Resident 84's electronic medical record (EMR), dated 6/1/26-6/30/26 were reviewed. The DSD stated the oxygen order indicated oxygen was ordered as needed, and was to be given only to maintain his oxygen saturation above 90%. The DSD stated Resident 84's oxygen was always on, but she did not find documentation in the EMR to indicate the oxygen saturation was checked. The DSD stated there should have been documentation or monitoring of Resident 84's oxygen saturation but there was none. The DSD stated a resident given oxygen when not needed could lead to confusion, disorientation, and unresponsiveness. During a concurrent interview and record review on 6/4/26 at 3:40 p.m. with LVN 2, Resident 84's EMR, dated 6/1/26-6/30/26 was reviewed. LVN 2 stated she was familiar with Resident 84's care. LVN 2 stated Resident 84's oxygen order was not followed. LVN 2 stated the EHR indicated Resident 84's oxygen order was as needed to keep oxygen saturation above 90%. LVN 2 stated Resident 84 had always been on continuous oxygen as long as she could remember. LVN 2 stated she did not remember checking and monitoring oxygen saturations and did not remember documenting in the electronic Medication Administration Record (eMAR-digital checklist used by nurses and caregivers) or the electronic Treatment Administration Record (eTAR-digital checklist) for Resident 84. LVN 2 stated she could not find Resident 84's documentation of oxygen saturation results in the EMR. LVN 2 stated it was important to monitor and document Resident 84's oxygen saturation but there was none. During an interview on 6/5/26 at 11:20 a.m. with the DON, the DON stated the oxygen order needed to be followed. The DON stated her expectation was for the licensed nurses to monitor and document the oxygen saturation of Resident 84 and notify the medical doctor to change the order if Resident 84 had been using oxygen continuously. The DON stated there should have been documentation and monitoring of Resident 84's oxygen saturation to justify why he was on oxygen but there was none. During a review of facility's P&P titled, Oxygen Therapy, dated 4/7/26, the P&P indicated, .Verify physician order.Oxygen therapy must be initiated based on a physician's order or facility-approved standing order. The order should be updated as settings/lpm [liter per minute] change. Monitoring: 1) Continuous or intermittent pulse oximetry per condition and physician order. 2) Reassess and document peripheral capillary oxygen saturation [SpO2-blood oxygen level or oxygen saturation]: a. At least every shift. b. After titration. c. With changes in condition. d. Document resident tolerance, respiratory status, and interventions. Notify physician if: . SpO2 is persistently below or above the target range despite titration [process of finding the exact right dose of supplemental oxygen]. Obtain new orders as needed.Documentation 1. Record: a. Date/time of titration. B. Flow rate before and after adjustment. c. SpO2 levels and resident response. d. Reason for change.

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information was consistently posted in a prominent location that was readily visible and accessible to residents, and visitors, in accordance with regulatory requirements. The facility census was eighty residents. This failure had the potential to prevent residents, visitors and family members from readily accessing required staffing information necessary to make informed decisions regarding resident care and services. Findings:During a concurrent observation and interview on 6/3/26 at 12:28p.m. with the Administrator (ADMIN), the surveyor observed the main lobby and other prominent locations within the facility in an attempt to locate the posted daily nurse staffing information. The ADMIN approached surveyor and asked if assistance was needed. When the ADMIN was informed the surveyor was looking for the posted nurse staffing hours, the ADMIN stated the staffing hours were not posted. The ADMIN then reached over the nurses' station counter, retrieved an unlabeled binder, and presented a daily work schedule, stating this is what they used. During an interview on 6/4/26 at 3:36 p.m. with the Director of Staff Development (DSD) and the Infection Preventionist (IP), the DSD stated it was her responsibility to ensure there were no gaps in the staffing schedule. The IP stated the facility posted the Form CMS-612 using information from the previous day. The IP stated the facility utilized the census report and daily assignment sheets from both the previous and current day to complete the posting and that this task was completed daily. The IP stated the actual hours worked were to be posted. When asked whether the required staffing information had been posted on 6/3/26, the IP stated the staffing information was posted following the surveyor's interview with the ADMIN regarding the absence of the staffing posting. The IP further stated it was not a consistent practice to post the staffing information. When asked whether a resident or visitor would have been able to locate the required staffing information on 6/3/26, the IP stated the information would have needed to be requested from the scheduler. The IP stated it was important for staffing information to be readily available to residents and visitors because it promoted communication, provided reassurance regarding resident care and helped ensure residents and family members felt comfortable and safe. During a concurrent interview and record review on 6/4/26 at 3:59 p.m. with the DSD and the IP, the Appendix PP tag F732, dated 2/3/23 was reviewed. The DSD and the IP escorted the surveyor to the location where the daily nurse staffing information had been posted following identification of the concern. The posting was located on a wall in the facility's main lobby The DSD and the IP stated the Appendix PP tag F732 indicated, the daily nurse staffing information was required to be posted each day in a prominent location that was readily visible and accessible to residents and visitors and that the posting was required to occur consistently. The DSD and the IP stated after reviewing the Appendix PP, they now understood the requirements of the facility to post the nurse staffing information.During a concurrent interview and record review on 6/5/26 at 10 a.m. with the Director of Nursing (DON), the Appendix PP tag F732, dated 2/3/23 was reviewed. The DON stated her expectation was to maintain sufficient staffing to provide care to residents. The DON stated it was important for residents and visitors to know there was adequate staff available to provide care. The DON further stated posting the staffing information in a visible location had not previously been a consistent practice. The DON stated the Appendix PP indicated daily nurse staffing information was required to be posted each day in a prominent location that was readily visible and accessible to residents and visitors and that the posting was required to occur consistently. The DON stated after reviewing the Appendix PP, she verbalized understanding that daily nurse staffing information was required to be posted daily in a prominent location. During a review of facilities policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, undated, the P&P indicated, within two hours of the beginning of each shift, the number of licensed nurses and number of unlicensed nursing personnel directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (medicines or products made from living organisms) was labeled in accordance with current professional standards of practice and facility procedures for one of four sampled residents (Resident 84), when Resident 84's morphine sulfate (strong opioid pain medication) medication label directions did not match the medication order in the electronic medical administration record (EMAR-digital version of a patient's medication chart).This failure placed Resident 84 at risk of receiving too much or too little pain medication which could lead to more serious health conditions such as not experiencing pain relief or slow or shallow breathing or even unconsciousness. Findings: During a review of Resident 84's admission Record (AR-a document containing resident profile information), dated 6/4/26, the AR indicated Resident 84 was admitted to the facility on [DATE] with diagnoses which included unspecified intracranial injury (head injury-any physical damage to the brain or skull), hydrocephalus (water on the brain) and palliative care (specialized medical care for anyone living with a serious illness). During a review of Resident 84's Order Summary Report (OSR), dated 6/4/26, the OSR indicated, . Morphine Sulfate (Concentrate-) Oral Solution 100 [milligram (MG)-unit of measurement]/five [5] [milliliter (ML )-unit of measurement] (Morphine Sulfate) Give 0.5 ml via [through] G-tube [gastrostomy tube-soft, flexible feeding tube placed directly into the stomach through a small opening in the abdomen) every 4 [four] hours for pain. Order Date: 5/23/26, Start Date: 5/23/26.During medication administration observation on 6/4/26 at 11:21 a.m. in station four with the Director of Staff Development (DSD), the DSD prepared Resident 84's medications including Morphine Sulfate. The DSD entered Resident 84's room and administered medications through the G-tube. During a concurrent interview and record review on 6/4/26 at 1:43 p.m. with the DSD, Resident 84's electronic health record (EHR), dated 6/1/26-6/31/26 and Resident 84's morphine sulfate medication label (Label), dated 5/22/26 were reviewed. The DSD stated, There are so many things that went wrong during the medication pass. The DSD stated during medication pass, the practice was to check and compare the medication order directions and the directions on the medication label to make sure they were the same. The DSD stated the EHR indicated Resident 84's morphine sulfate order was to be administered through the G-tube. The DSD stated the label indicated the morphine sulfate directions on the medication box was to give medication by mouth or under the tongue. The DSD stated she should have clarified the order with Resident 84's doctor because the direction on the medication label and the order were not the same. The DSD stated she did not call Resident 84's doctor and she should have. During a concurrent observation and interview on 6/4/26 at 3:45 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she worked full time on the afternoon shift and was familiar with Resident 84's care. LVN 2 stated during medication pass the practice was to compare the medication label directions with the medication order to prevent a medication error. LVN 2 stated she administered Resident 84's morphine sulfate through his G-tube. LVN 2 checked Resident 84's morphine sulfate medication label directions and stated, The direction in the label was to give the medication by mouth or under the tongue. LVN 2 stated she was not aware and just assumed all medications were given through the G-tube since Resident 84 was nothing by mouth (NPO). LVN 2 stated when a medication label direction and medication order were not the same, the medical doctor (MD) should have been called to clarify the order.During an interview on 6/5/26 at 10:15 a.m. with LVN 1, LVN 1 stated, You have to compare the medication direction with the order and make sure they matched. LVN 1 stated the MD should be called to clarify orders if the medication directions and the order did not match. LVN 1 stated the pharmacy should also be notified to correct the label direction to match the order. LVN 1 stated the nurse could also place a Direction Changed sticker until pharmacy sent a new medication.During an interview on 6/5/26 at 11:07 a.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to always compare the medication label with the eMAR. The DON stated, If instructions or directions does not match, call pharmacy and have them send new medication with new instruction. The DON stated not comparing medications could lead to medication errors which could lead to health complications. During a review of the facility policy and procedure (P&P) titled, Medication Labels, dated 4/14, the P&P indicated, .Labels are permanently affixed to the outside of the prescription container. Each prescription medication label includes: 1) Resident's name 2) Specific directions for use, including route of administration. If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order label on the container indicating there is a change in directions for use. When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when:1. One of three dietary staff (Dietary Aid [DA]) did not have facial hair (mustache) properly restrained.2. A [Brand name] (a commercial-grade food processor machine) lid had left over residue of food and was stored on a standing rack that contained dry, clean, and ready-to-use equipment.These failures had the potential to cause cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth 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) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for the 75 residents admitted to the facility who received meals from the kitchen.Findings: 1. During a concurrent observation and interview on 6/2/26 at 8:30 a.m. with the Dietary Account Manager (DAM) in the kitchen, the DA was observed working in the kitchen with an exposed mustache and facial hair not restrained. The DAM stated the DA had exposed hair and the expectation was that all employees washed their hands and donned (to put on) hair nets, including facial hair coverings, so all hair was covered while in the kitchen. The DAM stated it was important for all hair to be covered in the kitchen so there was no physical contamination (any foreign objects that accidentally get into the food) of the food. The DAM stated hair could also get on the plates and that would cause contamination that could lead to foodborne illness.During an interview on 6/5/26 at 1:42 p.m. with the Registered Dietitian Consultant (RDC), the RDC stated her expectation was that staff in the kitchen wore hair restraints and facial hair coverings including beard and mustache coverings anywhere and anytime they were in the kitchen. The RDC stated it was important that hair restraints and facial coverings were worn because it was not sanitary for hair to be exposed and there was a risk for cross- contamination of food that could lead to foodborne illness.During a review of the facility's policy and procedure (P&P) titled, Staff Attire, dated 10/2023, the P&P indicated, .All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.2. During a concurrent observation and interview on 6/2/26 at 9:30 a.m. with the DAM in the kitchen, a [Brand name] lid was observed with leftover food residue stored on a standing rack. The DAM stated all bowls, pans, equipment etc., including the [Brand name] that was on the standing rack was dry, clean and ready for use. The DAM stated there was left over residue of food on the [Brand name] lid. The DAM stated it was her expectation to not have leftover food on equipment after an item has been washed and cleaned. The DAM stated the left-over food could have mold and stated left over food residue could contaminate other foods going into that equipment if not properly cleaned and sanitized. The DAM stated improperly cleaned and sanitized equipment could lead to cross-contamination and foodborne illness. During a review of the facility's P&P titled, Equipment, dated 9/2017, the P&P indicated, .All foodservice equipment will be clean, sanitary, and in proper working order.During a review of the facility's P&P titled, Food: Preparation, dated 2/2023, the P&P indicated, .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological [living microorganisms such as bacteria, viruses, and parasites], and chemical contamination [when food is accidentally tainted by toxic substances used in the kitchen environment].

Based on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when pipes on top of two of two washers in the laundry room were observed covered with thick white and green build up. This failure had the potential to affect the efficiency of the washers to clean the personal clothing of 80 residents and linens used in the facility. Findings: During a concurrent observation and interview on 6/4/26 at 8:30 a.m. in the laundry room with Laundry Person (LP) 1, observed two washers with thick white and green hard build up around the pipes connected to the top of the washers. LP 1 stated she did not remember cleaning the top of the washers and was not sure who was responsible to clean the top of the washers. LP 1 stated she only cleaned the lint trap on the bottom of the dryers and wiped down the front lid of the washers. During a concurrent observation and interview on 6/4/26 at 8:33 a.m. in the laundry room with the Housekeeping/Laundry Account Manager (HLAM), the HLAM stated there was thick white and green hard build up covering the pipes on top of each washer. The HLAM stated he was not sure who was responsible to clean and maintain the top of the washers. The HLAM stated laundry staff only wiped down the front of the washers and not the top. The HLAM stated he was not sure if it was part of their contract to clean the top of the washers. The HLAM stated the heavy build up around the pipe could eventually affect the machines efficiency and would affect routine washing of linens and residents personal items. The HLAM stated he will start to include daily cleaning of the top of the washers to not disrupt the routine cleaning schedule. During a concurrent observation and interview on 6/4/26 at 8:35 a.m. with the Director of Maintenance (DM) in the laundry room, the DM stated the white build up on top of the washers were calcium deposits (crusty, chalky white residue left behind when hard water evaporates or is heated up by the machine). The DM stated it would potentially affect the machine making it work harder and could cause the washer to break down prematurely. The DM stated he was not sure who was responsible to maintain and clean the machines. The DM stated he would include the cleaning of the machine to his to do list and would inspect the washers at least weekly. During an interview on 6/5/26 at 1:12 p.m. with the Administrator (ADM), the ADM stated he talked to the manager of the contract company providing housekeeping, laundry, and dietary services to the facility. The ADM stated there was no clear writing in their contract whose responsibility it was to maintain the equipment, but It does not mean it is not their responsibility. The ADM stated he saw the buildup on top of the machines and did not think it affected how the machine washed clothes and linens. The ADM stated the machines still needed to be maintained and the DM will be inspecting washers regularly and laundry staff will be cleaning machines after each use or before their shift ends. During a review of facility document titled, Washer-Extractors, maintenance manual guide, dated 7/18, the maintenance manual guide indicated, . Routine maintenance maximizes operating efficiency and minimizes downtime . Beginning of Day . Inspect the water inlet valve hose connections . Inspect the chemical connections for machines equipped with an automatic chemical system by inspecting all connections and chemical hoses for leaks or cracks . End of Day . Clean the machine's exposed surfaces with all-purpose cleaner . During a review of facility document titled, Director of Maintenance, Job Description, revised date 7/24, the document indicated, . Conduct ongoing inspections of facility to identify areas and equipment requiring improvement/repairs. Develop and implement a preventative maintenance program including routine inspection and servicing. Examine equipments, systems and physical plants [i.e., buildings] to determine needed installations, service or repairs. Supervise work of contractors in connection with the maintenance and improvement of buildings and facilities . During a review of contract facility's policy and procedure (P&P) titled, Laundry Handling & Processing Policy, reviewed date 2/1/25, the P&P indicated, .committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices . Washing: Adhere to manufacturer's recommendation and instructions . The lip of the washer door should be disinfected prior to closing and starting the cycle . The laundry area and equipment should be routinely cleaned and disinfected . Almenar, [NAME] (40641) - RESIDENT NOTE No Notes

Based on observation, interview, and record review the facility failed to ensure that care and services were provided in accordance with the manufacturer's instructions for use for an air loss mattress (specialized medical mattress with internal air tubes and tiny holes that continuously circulate air to keep skin dry, cool, and reduce pressure, preventing bedsores (pressure ulcers) by shifting pressure points) and facility staff were trained and competent to use their air loss mattresses safely for one of two sampled residents (Resident (RES)) 2, when RES 2 who had a history of a recent fall (12/9/25) while on an air loss mattress at the facility. RES 2 weighed 124.4 pounds (lbs. -unit of weight measurement) and weight settings on the air loss mattress indicated weight was set at 245 -285 lbs. The nurses assigned to RES 2 did not know what pressure settings should be set on the air loss mattress, and there was no record of any training, education, in-service or competency record for air loss mattress use for the nurses.These failures had the potential to cause harm to RES 2 and other residents who used air loss mattresses and placed these residents at risk for skin breakdown due to pressure injury, pain, increased risk for falls and decline in physical functioning.During a review of RES 2's Physician Progress Note, dated 6/3/2025, the Physician Progress Note indicated RES 2 was a [AGE] year-old Male with an initial admission date of 9/28/24 and was readmitted to the facility on [DATE] for continuation of medical care. RES 2 had a past medical history of [Traumatic Brain Injury (TBI - damage to the brain from a sudden jolt, blow, or penetrating injury to the head, affecting brain function with mild to severe outcomes, ranging from temporary confusion to permanent disability or death)] [status post (after)] [Ventriculoperitoneal Shunt (VPS -Thin, flexible, plastic tube (called a catheter) that is placed under the skin to drain the extra fluid from brain and send it to belly to prevent high pressures inside brain)] placement, [high blood pressure], and venous thromboembolism (a serious condition involving a blood clot (thrombus) forming in a deep vein, most commonly in the legs). RES 2 was admitted to [Hospital A] on 05/22/2025 due to diaphoresis (sweating profusely), [shortness of breath] and [high blood pressure]. RES 2 underwent extensive workup and was sent to the facility for acute rehabilitation [high-intensity program designed to help people regain physical and thinking skills lost due to a severe injury, illness, or surgery]. During a concurrent interview and record review on 1/7/26 at 2:40 p.m. with the Nurse Unit Manager (NM), RES 2's medical record, undated was reviewed for recent falls. The NM stated RES 2 had a fall on 12/9/25 with no injuries. The NM stated RES 2 was currently on-an air loss mattress and she was unable to find the physician order for use of an air loss mattress for RES 2. The NM stated RES 2 was on an air loss mattress at the time of the fall on 12/9/25 and the facility review did not identify any issues with the settings or functionality of the air loss mattress at the time of the fall. The NM stated the Interdisciplinary Care Conference note dated 12/10/25 at 11:59 a.m. indicated . IDT investigated root cause: resident continues on air loss mattress, settings are correct and functioning well.During a concurrent observation and interview on 1/7/26 at 3:00 p.m. in room RES-2's room with the NM, observed RES 2 on a bed with an air loss mattress. The NM validated the settings on mattress were set at a maximum weight of 285 pounds. The NM stated the air loss mattress was not set to the correct settings. NM stated RES 2 did not weigh 285 pounds. NM stated RES 2's weight on January 2, 2026, five days ago was 124.4 lbs. NM stated the air loss mattress should be set according to the resident's weight. NM stated the therapeutic effect would be affected by incorrect settings on the mattress and placed residents at risk for discomfort, pressure injuries to skin and falls from the bed. During a concurrent observation and interview on 1/7/25 at 3:16 p.m. with LVN 1 & the NM, observed RES 2's air loss mattress settings. LVN 1 stated she was assigned to RES 2 today. LVN 1 validated and stated the mattress settings were set at maximum settings of 285 lbs. LVN 1 stated she was unsure what the settings should be for RES 2. LVN 1 stated she would have to check physician orders for the settings. LVN 1 stated she was not sure what RES2's weight was but stated RES2 did not appear to be 245-285 lbs. LVN 1 stated nurses were expected to check that air loss mattresses were functioning properly each shift. During a concurrent interview and record review on 1/7/26 at 3:18 p.m. with LVN 1 & the NM, RES 2's medical records, undated were reviewed for the physician order for air loss mattress. LVN 1 stated that she was unable to find a physician's order for use of the air loss mattress and order for settings of the air loss mattress for RES 2. LVN 1 stated and validated the weight in the medical record and stated the most recent weight of RES 2 this week dated 1/2/26 was 124.4 lbs. LVN 1 stated that setting the wrong weight on the air loss mattress was not acceptable and have the potential to cause pressure injuries to skin and harm to the patient. LVN 1 stated that she was not aware that she should be checking the weight settings on the air loss mattress and going forward she will make sure air loss mattresses had the correct weight settings. LVN 1 stated as far as she was aware, use of an air loss mattress required a physician order. During an interview on 1/7/26 at 3:37 p.m. with the Director of Staffing Development (DSD), the DSD stated she was in charge of the staff training. The DSD stated she was familiar with RES 2. The DSD stated RES2 was on an air loss mattress and required two people to assist with turning and care. The DSD stated facility staff were trained on the use of air loss mattresses and it was important to have the correct weight setting on the air loss mattress. The DSD stated that 245-285 lbs. setting for a resident that only weighed 124.4 lbs. was not safe and was not aligned with instructions for use. The DSD stated incorrect weight-based settings may have the potential to cause harm to the patients. The DSD stated that Director of Nursing (DON) would be best to answer that question regarding weight settings and expectations for nursing staff training.During an interview on 1/7/26 at 3:53 p.m. with the ADM, the ADM stated he was familiar with RES 2. The ADM stated the fall on 12/9/25 for RES 2 was investigated as per facility policy, no injuries were identified, and RES 2's care plan was updated as needed. The ADM stated an air loss mattress use or settings on the air loss mattress were not identified as the cause for the fall. The ADM stated that he was not sure if the physician order was required for use of an air loss mattress and as far as he was aware, it was used as a nursing intervention. The ADM stated he would have to follow up and check with his clinical staff about the requirement for an order for the use of air loss mattress. The ADM stated RES 2 was on hospice care (a specialized, holistic support system for people with terminal illnesses, focusing on comfort, dignity, and quality of life when a cure is not possible, rather than curative treatment) and hospice nurse and physician was treating the patient. Requested to speak with director of nursing (DON) and ADM stated that DON is out on leave due to unforeseen circumstances. Requested training record for nurses assigned to RES 2 on the shift when fall occurred on 12/9/25 and LVN 1. The ADM stated he would have to follow up with his team and submit via email.During a phone interview on 1/20/26 at 12:41 p.m. with the ADM, the ADM stated the facility did not have any policy for use of an air loss mattress and the facility staff were expected to follow manufacturer's instructions for use. The ADM stated he was made aware of the weight settings of 245-285 lbs. on RES 2's air loss mattress on 1/7/26 and agreed it was not set correctly. The ADM stated that the weight setting on the air loss mattress was not aligned with the instructions for use. The ADM stated he was not able to comment on whether setting an air loss mattress weight setting at 245-285 lbs. for a resident that weighs 124.4 lbs. had the potential to cause harm to the patient. The ADM stated he was unaware of any harm caused to RES 2 that were due to incorrect settings on the air loss mattress. The ADM stated the facility also did not have any training records for LVN 1 on the use of an air loss mattress or RN 1, nurse assigned to RES 2 on 12/9/25 when RES2 had a fall. The ADM stated the DON is not available for interview at this time and was still out on leave with a potential return date on [DATE]. The ADM stated the training for air loss mattress use could be beneficial but the facility at this time did not have a policy requiring training on the air loss mattress use or as an annual training requirement. During a phone interview on 1/20/26 at 3:33 p.m. with the DSD, the DSD stated she was in charge of education and in-services and training at the facility. The DSD stated that she worked with the DON and unit manager for nurse's training. The DSD stated and validated that she was unable to find any training or in-service record that indicated nurse [RN 1] assigned to RES 2 on 12/9/25 at the time of fall and LVN 1 assigned on 1/7/26 had received any in-service or training on air loss mattress use. The DSD stated the last in-services for air loss mattress was completed on 6/27/25 and 12/17/25 of last year. The DSD stated the in-service and training covered the settings on an air loss mattress and should be set according to the resident's weight . During a review of the air loss mattress's instruction for use provided by facility administrator (ADM), retrieved from https://vimeo.com/848769965, the instructions for use indicated . to prepare the mattress for the resident turn the dial to the correct weight of the resident . During a review of the document titled [model number], Low Air-Loss Mattress Replacement System With Alternating Pressure User's Manual, undated, provided by [company name] customer service, the document indicated . Intended Use Auto-pressure control Medical Air Mattress is designed for bed sore and wound care therapy treatment and prevention, which may occur during an extended hospital stay and nursing home/long term care environment . Warnings . refer to the manual before use and under proper medical supervision. Improper operation of this system may cause damage to the product and possible injury to the user . Do not use this product or any available optional equipment without first completely reading and understanding this instruction manual. If you are unable to understand the warnings, cautions or instructions, please contact a healthcare professional, dealer or authorized technician before attempting to use this equipment, otherwise injury or damage may occur. Only qualified personnel trained in the treatment and prevention of pressure injuries should operate this device . attention has to be paid to a potential danger that requires correct procedures or practices in order to prevent personal injury . Close supervision is necessary when this product is used by, on, or near children or persons with a disability .

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) received treatment and care in accordance with professional standards of practice when nurses assessed both of Resident 1's legs as discolored and one leg as swollen on [DATE], contacted the physician for orders and did not follow physician's orders to obtain a vascular consult ordered on [DATE]. A Change in Condition (CIC- documentation completed when nurse's identify a change from a resident's baseline condition) was not completed on [DATE] due to the changes in Resident 1's legs. The nurse assessed Resident 1's left leg as more swollen than the right leg on [DATE] and failed to complete a CIC. A weekly head-to-toe assessment was done on [DATE] and should have been repeated on [DATE] and was not. These failures resulted in a delay in acting on Resident 1's symptoms, delayed treatment and care and contributed to an acute change of pain and swelling on [DATE] for which Resident 1 was transported to an acute care hospital for higher level of care. Resident 1 was diagnosed with a deep vein thrombosis (DVT- condition where a blood clot forms in one of the large veins [blood vessel that carries blood back to the heart], usually in the legs or arms) of left leg and experienced a corrective surgical procedure and remained in the hospital from [DATE] to current. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history), dated [DATE], the AR indicated, Resident 1 had diagnoses which included .ACUTE RESPIRATORY FAILURE WITH HYPOXIA [inadequate exchange of gases between the lungs and the blood which leads to low levels of oxygen in the blood and tissues] .CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD- a long lasting lung disease causing difficulty in breathing] .HYPERTENSION [high blood pressure] .DIFFICULTY IN WALKING .ABNORMAL POSTURE . The AR indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 13 (0-7 severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), 8-12 moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), 13-15 no cognitive impairment), which indicated Resident 1 had no cognitive impairment. During a concurrent interview and record review on [DATE] at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated [DATE], and Resident 1's Weekly Summary Documentation (WSD- a head-to-toe assessment completed on each resident once a week), dated [DATE] were reviewed. The PN indicated, [DATE] [11:04 p.m.] .Duplex scan [type of ultrasound (US- a non-invasive imaging technique which uses sound waves to create pictures of internal structures like organs and tissues inside the body) imaging used to look at the speed of blood flow and the structure of veins and/or arteries (blood vessel that carries blood away from the heart) which uses both Doppler (type of ultrasound which aims to assess blood flow) and conventional ultrasound imaging] ordered per [Doctor of Medicine (MD)] for dependent edema [swelling from fluid which pools due to gravity in the hands, feet and legs] .Author: [LVN 5] . The WSD indicated, .Effective Date: [DATE] .Resident . able to make needs known to staff .Will continue with current [Plan of Care (POC)] as ordered .Signed By: LVN 3] . LVN 1 stated, Resident 1 was able to make her needs known to the staff and answer the staff's questions appropriately. LVN 1 stated, a WSD for every resident was required to be completed every week. LVN 1 stated, a schedule was in a binder at the nurse's station and indicated which days and shifts each resident was to be assessed every week, according to room number. LVN 1 stated, Resident 1's last WSD was completed on [DATE] and there was no WSD completed on [DATE]. LVN 1 stated, the WSD was important to assess for any new changes to the Resident 1 and to follow up on those changes with Resident 1's physician, Representative Party (RP) and the Director of Nursing (DON). LVN 1 stated, Resident 1 was sent to the hospital on [DATE] due to a lower leg DVT. During an interview on [DATE] at 10:28 a.m. with LVN 2, LVN 2 stated, a WSD should have been completed on every resident once a week. LVN 2 stated, the WSD was a head-to-toe assessment performed by the nurse to assess for any changes or abnormalities to Resident 1. LVN 2 stated, if there was an issue identified with Resident 1, then the resident would have a nursing assessment performed every day. LVN 2 stated, the WSD was important to perform every week because the nurses could catch a change with Resident 1 like a skin change or other abnormality within the resident. LVN 2 stated, if a change was identified, a Change in Condition (CIC) form would be completed and Resident 1's physician, RP and the administrator would be notified. During a concurrent interview and record review on [DATE] at 11:10 a.m. with the DON, the Station 1 Weekly Summaries and Skin Assessments (WSSA), dated [DATE], and Resident 1's Change in Condition Evaluation (CIC), dated [DATE] were reviewed. The WSSA indicated, .[Night Shift- the shift that facility staff work from 10:00 p.m. until 6:30 a.m. (NOC)] .SUNDAY .1b .NOC SHIFT- please do the weekly summary and body checks for the day you come in (before midnight) . The CIC indicated, .New onset of dark spot to Left lower leg medial [situated towards the middle of the body] area accompanied with pain .This started on XXX[DATE] .Monitored left lower leg pain complaint and noted darkening spot-on medial area. Able to get a copy of doppler study of the lower legs and notified MD of the result. MD ordered to send out to hospital for further evaluation and treatment. MD order carried out. [Responsible Party (RP)] (daughter) notified and amenable resident to be send out to [name of acute care hospital] .Describe skin changes .Discoloration .Site .Left lower leg (front) .New onset of dark spot to left lower leg medial area accompanied with pain .Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain) .5 .Signed By .[Registered Nurse (RN)] . The DON stated, Resident 1's physician ordered an ultrasound of her legs and was completed on [DATE]. The DON stated, on [DATE], Resident 1's daughter was concerned about Resident 1's leg and Resident 1 was complaining of pain. The DON stated, the nurse noticed Resident 1's left lower leg had a dark spot on the medial area of the leg. The DON stated, Resident 1 went to the hospital on [DATE] and was still at the hospital. The DON stated, the final results of the ultrasound were faxed to the facility on the evening of [DATE] and had shown severe bilateral (both sides) arterial (pertaining to an artery) disease, no hemodynamically (how blood flows through your blood vessels) significant stenosis (abnormal narrowing) and a possible occlusion (blockage) of the left proximal (nearer to the center of the body or the point of attachment to the body) deep femoral artery (DFA- a blood vessel in the leg which supplies blood to the thighs and buttocks). The DON stated, a WSD was a head-to-toe assessment completed on each resident every week. The DON stated, the expectation was a WSD was completed to catch new abnormalities or changes with the residents. The DON stated, the WSD was important to ensure care of the Resident's problem before it gets worse. The DON stated, any changes identified during the WSD were reported to the MD, RP and DON. The DON stated, the WSD provided a way for those changes to the residents to be followed up on further. The DON stated, Resident 1's last WSD was completed on [DATE] and she left for the hospital on [DATE]. The DON stated, the CIC on [DATE] showed Resident 1 had a new onset of a dark spot to her left lower leg accompanied by 5/10 (a pain level of 5 based on a based on a scale where 1 is the lowest pain and 10 is the most severe pain) pain. The DON stated, the nurse contacted Resident 1's MD, notified him of the final ultrasound results in addition to the current assessment. The DON stated, based on all the information, the MD ordered for Resident 1 to be sent to the hospital. The DON stated, according to the WSSA, Resident 1 should have had a WSD completed on [DATE] but it was not completed. During a concurrent interview and interview on [DATE] at 12:02 p.m. with the DON, Resident 1's PN, dated [DATE], and MD Progress Note (MDPN) dated [DATE] was reviewed. The PN indicated, [DATE] [6:11 a.m.] .[Doctor] review final results for doppler study gave new order for vascular consult [an appointment with a physician who specializes in the vessels that carry blood in the body] and to elevate bilateral lower extremities. orders carried out resident made aware .Author: [LVN 4] . MDPN indicated, .[DATE]. Upon review of the final results for doppler study the new order is for vascular consult to be scheduled and to elevate bilateral lower extremities .[DATE]. Resident seen today for routine follow- up .had Doppler recently per previous notes but no results are in [computer charting system] .Due to patient's advanced age and multiple comorbid [relating to multiple diseases or medical conditions present in a patient at the same time] conditions patient at high risk for multiple medical complications including but not limited to .DVT . The DON stated, the MD ordered a vascular consult to be made for Resident 1 and to elevate her legs based on the ultrasound results. The DON stated, a vascular consult was never made for Resident 1. The DON stated, there was no documentation of any attempts made to obtain a vascular consult appointment. The DON stated, Resident 1 had not received a WSD since [DATE], did not have a vascular consult appointment made for her and then was sent to the hospital where she was diagnosed with a DVT. During a phone interview on [DATE] at 2:32 p.m. with LVN 3, LVN 3 stated, she was Resident 1's nurse on [DATE] during the AM shift (the shift that facility staff work from 6:00 a.m. until 2:30 p.m.). LVN 3 stated, she received report from the NOC shift nurse on [DATE] who had cared for Resident 1 during the prior night. LVN 3 stated, the NOC shift nurse reported staff attempted to get Resident 1 up from bed and Resident 1's lower extremities had turned a purple color so they laid her back down. LVN 3 stated, because of Resident 1's lower extremity discoloration, the nurse had called Resident 1's MD and received an order to obtain an ultrasound of both lower legs. LVN 3 stated, Resident 1's ultrasound was completed during her AM shift on [DATE]. LVN 3 stated, she had sent the MD a picture of Resident 1's preliminary ultrasound results to MD's cell phone on [DATE]. LVN 3 stated, the MD did not respond to the message so she documented a PN indicating there were no new orders at the time. LVN 3 stated, a WSD was completed once a week for every resident in the facility according to the WSSA. LVN 3 stated, the WSD was important in order to get an update on the resident and assess for any changes from the resident's baseline, which were documented by the nurse. LVN 3 stated, a CIC would be completed if there was a change from baseline. LVN 3 stated, a CIC required the nurse to notify the resident's physician, RP and DON. LVN 3 stated, it was important to follow physician's orders to get the resident the care they needed regarding any underlying issues or new diagnoses they may have had. LVN 3 stated, if the physician gave an order for a vascular consult to be made for a resident, the nurse would have entered an order in the computer charting system, create a PN and notified the DON. LVN 3 stated, the DON, Assistant Director of Nursing (ADON) or a unit manager would have carried out the order and scheduled the consult, according to the physician's orders. During a phone interview on [DATE] at 2:53 p.m. with LVN 4, LVN 4 stated, a WSD was a head-to-toe assessment performed on each resident once a week. LVN 4 stated, a WSD was important to complete every week to assess for any changes which may have developed or progressed since the previous week. LVN 4 stated, she had texted the MD Resident 1's final ultrasound results on [DATE] at approximately 3:00 a.m. and the MD had responded back they already knew Resident 1 needed a vascular consult. LVN 4 stated, the MD did not specify who already knew about the vascular consult. LVN 4 stated, there was no order in the computer charting system so she put in the order for the Resident 1's vascular consult on [DATE]. LVN 4 stated, she gave report to the AM shift nurse on [DATE] and told her about the MD's response to the final ultrasound results and the AM shift nurse responded saying everybody knew about the vascular consult. LVN 4 stated, the former ADON was the staff member who normally handled all the resident's referrals and appointments. LVN 4 stated, she was not informed by management who was in charge of creating the appointments currently, but assumed the new ADON would make the appointments. LVN 4 stated, it was important to follow the physician's orders in order to prevent the resident's condition from getting worse and being overlooked. During a phone interview on [DATE] at 4:48 p.m. with RN, RN stated, she worked with Resident 1 on [DATE] during the PM shift (the shift that facility staff work from 2:00 p.m. until 10:30 p.m.). RN stated, Resident 1's daughter wanted RN to assess Resident 1's left lower leg on [DATE] because it appeared abnormally swollen. RN stated, she assessed Resident 1's left lower leg and noticed some increased swelling compared to Resident 1's right lower leg. RN stated, she searched in the computer charting system and saw PNs about an ultrasound which was completed for Resident 1, but could not find any results. RN stated, RN asked the DON about where she could find Resident 1's final ultrasound results and the DON instructed RN to call the diagnostic imaging company to obtain the results. RN stated, she received the final results from the [DATE] ultrasound on [DATE] via fax and RN stated she saw there may be a possible occlusion according to the ultrasound results. RN stated, she immediately sent the results to the MD but he did not reply that night. RN stated, she informed the [DATE] NOC shift nurse about the ultrasound results, the swelling to Resident 1's left lower leg and they were awaiting a reply from the MD. RN stated, the MD texted RN back on the morning of [DATE] and RN forwarded the message to the nurse working the [DATE] AM shift. RN stated, she worked the PM shift on [DATE] and around 2:30 p.m., she finished receiving report and went to check on Resident 1. RN stated, Resident 1 had a significant change with increased swelling and a dark-colored spot to the left lower medial leg with 5/10 pain. RN stated, this increased change to Resident 1's condition coupled with the ultrasound results showing a possible clot (clumps that occur when blood hardens from a liquid to a solid) made her contact the MD again. RN stated, the MD immediately ordered Resident 1 to be sent out to the hospital. RN stated, an emergency room (ER) doctor from the hospital Resident 1 was sent to had called RN and informed her Resident 1 was diagnosed with a DVT. RN stated, a DVT can travel to the heart and cause a heart attack (occurs when blood flow to the heart is blocked, depriving the heart muscle of oxygen) or travel to the brain and cause a stroke (occurs when blood flow to the brain is disrupted, leading to damage or death of brain tissue). RN stated, a WSD was a head-to-toe assessment required to be completed on every resident in the facility and divided up evenly according to a schedule. RN stated, a WSD was completed to check for changes to the resident because often elderly residents would not tell you about their problems, so the nurse needed to complete an assessment to look for those changes. RN stated, a WSD helped identify changes to vital signs (measurements of the body's most basic functions), swelling, new skin conditions or other changes beyond the resident's usual baseline. RN stated, it was important to follow physician's orders because there could be harm to the resident if orders aren't followed. RN stated, the facility's goal was to heal the resident. During a phone interview on [DATE] at 1:09 p.m. with LVN 5, LVN 5 stated, on [DATE], Resident 1's daughter had Resident 1 sitting up in bed and Resident 1's legs became discolored. LVN 5 stated, Resident 1's legs looked pinkish, reddish, not quite purple in color. LVN stated, Resident 1 also had swelling to one leg, but could not recall which leg had more swelling than the other. LVN 5 stated, Resident 1's daughter had stated Resident 1 had never seen a vascular physician before and requested some sort of scan to be performed because Resident 1 had some issues with blood flow to her feet. LVN 5 stated, she elevated Resident 1's feet, contacted the MD and he ordered a doppler scan for Resident 1's legs. LVN 5 stated, although she did notify Resident 1's physician of the change in condition, she did not complete a CIC form on [DATE] and should have completed a CIC form. LVN 5 stated, a CIC form was completed when there was a change identified in the resident. LVN 5 stated, a CIC required the nurse to notify the resident's physician, RP, and the DON. LVN 5 stated, a CIC prompted the MD to respond with orders and the staff would follow the orders. LVN 5 stated, a CIC sometimes prompted the nurses to monitor a resident more closely for 72 hours. LVN 5 stated, a CIC was important because it provided documentation of what change occurred, created a plan to look further into the change in condition, and treated the Resident accordingly. LVN 5 stated, Resident 1 should have received the treatment and care she required to better her health, ensure dignity and for her overall well-being. During a phone interview on [DATE] at 1:39 p.m. with the MD, the MD stated, Resident 1 had a blood clot in her leg and was sent to the hospital on [DATE]. The MD stated, Resident 1 had swelling to her lower extremities so he ordered the Duplex scan. The MD stated, the preliminary results for the Duplex scan came back on [DATE] and appeared normal so he wanted to wait for the final results to come in. The MD stated, Resident 1's final Duplex scan results from [DATE] showed a possible occlusion of the DFA with severe bilateral lower extremity (BLE- both lower legs) peripheral artery disease (PAD- condition where narrowed blood vessels reduce blood flow to the legs or arms). The MD stated, he had ordered Resident 1 to receive a vascular consult and for staff to elevate Resident 1's feet to help reduce the swelling. The MD stated, he does not remember if staff made him aware if Resident 1 was in pain or not. The MD stated, Resident 1 was sent out to the hospital on [DATE] because Resident 1 complained of pain in addition to the [DATE] Duplex scan results. During an observation and interview on [DATE] at 2:12 p.m. with Resident 1 in her hospital room, Resident 1 was laying in her hospital bed. Resident 1 stated, her leg was sore. During an interview on [DATE] at 2:20 p.m. with the Hospital RN Charge Nurse [HRNCN], the HRNCN stated, Resident 1 came from the Skilled Nursing Facility for shortness of breath (SOB) and discoloration to her leg. HRNCN stated, Resident 1 was diagnosed with a left lower extremity DVT. HRNCN stated, Resident 1 had a successful suction thrombectomy [medical procedure which involves the removal of a blood clot from a blood vessel] with the removal of a large amount of chronic [continuing over a long time] and acute [sudden onset] clots and an Inferior Vena Cava (IVC) filter (small, metal device placed in a large blood vessel in the abdomen to prevent blood clots from traveling to the lungs which can be life-threatening) placed. During a concurrent phone interview and record review on [DATE] at 11:32 a.m. with the DON, Resident 1's Preliminary Lower Arterial Ultrasound Report (PLAUR), dated [DATE], and Resident 1's Lower Bilateral Arterial Final Report (LBAFR), dated [DATE] were reviewed. The PLAUR indicated, PRELIMINARY LOWER ARTERIAL ULTRASOUND REPORT XXX[DATE] .12:27 pm .[Resident 1] .Indication: Edema .RIGHT/ LEFT/ BOTH LEGS WERE EVALUATED TO ASSESS ARTERIAL FLOW .TECHNICALLY ADEQUATE/ INADEQUATE STUDY . The PLAUR indicated, handwritten ovals were circled around the words BOTH LEGS and ADEQUATE. The LBAFR indicated, .PROCEDURE: Lower Bilaterial Arterial. The DON stated, signs and symptoms of a DVT were swelling, pain and a difference in appearance between one leg and the other leg. The DON stated, a venous ultrasound was needed to confirm a DVT diagnosis, not an arterial ultrasound. The DON stated, according to the PLAUR and LBAFR, Resident 1 had a lower extremity arterial ultrasound completed. The DON stated, the only ultrasound completed for Resident 1 during her admission to the skilled nursing facility was on [DATE]. The DON stated, a CIC was conducted when nurses identified any symptoms and symptoms of any changes like abnormal swelling or other changes to the resident's condition that wasn't there previously. The DON stated, the nurses were expected to contact the resident's physician, family and sometimes the DON when a CIC was completed. The DON stated, a CIC was important to communicate changes to the physician, follow physician's orders and resolve issues to prevent the issues from developing further. The DON stated, when LVN 5 had identified a change to Resident 1's legs on [DATE], a CIC should have been completed. The DON stated, if RN identified a change to Resident 1's legs on [DATE], a CIC should have been completed. The DON stated, on [DATE], she had told RN to call the imaging diagnostic company to obtain the final ultrasound results from [DATE]. The DON stated, it was important for residents to receive the care and treatment they require because otherwise the resident's problems and concerns could progress negatively. During a phone interview on [DATE] at 1:05 p.m. with the MD, the MD stated, when an ultrasound was ordered, the diagnostic imaging company could assess both the veins and arteries or sometimes just the arteries. The MD stated, Resident 1 had two prior ultrasound scans completed during her hospitalization prior to admission at the skilled nursing facility and both scans were negative for DVTs. The MD stated, a DVT could have developed at any time. The MD stated, Resident 1 was sent to the hospital on [DATE] due to the acute pain, swelling and skin changes. During a phone interview on [DATE] at 2:02 p.m. with the US Imaging Company Co-Owner (USIC), the USIC stated, the MD's order for Resident 1's US on [DATE] was may have duplex scan to bilateral extremities to rule out edema. The USIC stated, the order did not state which extremities the MD wanted the ultrasound to be performed on so the US technician needed to clarify the order. The USIC stated, LVN 5 confirmed the order and another nurse revised the order at the facility on [DATE]. The USIC stated, Resident 1 had a bilateral lower extremity arterial ultrasound performed on [DATE]. The USIC stated, the US results on [DATE] showed Resident 1 had severe bilateral arterial disease, no arterial stenosis and a possible occlusion of the left proximal DFA. The USIC stated, a DVT would have only been able to be seen on a venous ultrasound, not an arterial ultrasound. During a review of Resident 1's Hospital US Final Report (USFR), dated [DATE], the USFR indicated, .US Lower [Extremity] Vein Duplex [Left] .There is no evidence of deep venous thrombosis .Unremarkable left lower extremity duplex venous ultrasound . During a review of Resident 1's PN, dated [DATE], the PN indicated, .Ultrasound doppler scan performed this shift .[related to] edema noted to bilateral lower extremities. Preliminary report sent to MD, [no new orders] at this time. Final report pending .Author: [LVN 3] . During a review of Resident 1's LBAFR, dated [DATE], the LBAFR indicated, .PROCEDURE: Lower Bilaterial Arterial .a real-time lower extremity arterial Doppler study with image documentation was performed .REASON FOR EXAM .Peripheral vascular disease .CONCLUSION: 1. Severe bilateral lower extremity arterial disease. 2. No hemodynamically significant stenosis is identified on either side. 3. Possible occlusion of [left proximal] DFA . The LBAFR indicated, the fax date and timestamp at the top of pages one and two was [DATE] at 11:01 p.m. The LBAFR indicated, a handwritten note at the bottom of page one which specified Sent to [MD]. During a review of Resident 1's PN, dated [DATE], the PN indicated, .Notified MD of resident's severe pain on left lower leg when touched. With a spot with darkened color. MD ordered to send out to hospital. MD order carried out .sent out to [name of acute care hospital] .Author: [RN] . During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, .Darkening spot on left lower leg- medial area accompanied with pain . Interventions .Coordinate with health team members on the results of the diagnostic studies .Monitor for any changes and notify [Doctor of Medicine (MD)] .Notify MD and RP . During a review of Resident 1's MDPN, dated [DATE], the MDPN indicated, .Electronically Signed and Reviewed by [MD] [DATE] [10:25 p.m.] .[DATE]. The patient was sent out to acute for severe [left lower extremity (LLE)] pain. There was suspicion for DVT . Reports from 5/8 show severe BLE PAD and possible occlusion of left proximal DFA unknown chronicity [how long condition has persisted over time]. In the absence of DVT on [preliminary] results patient was not started on blood thinners [medications that help prevent blood clots from forming or growing larger] or statins [type of medication used to reduce levels of fats in the blood]. Risk factors will include a recent diagnosis of cancer .and limited mobility [ability to move] . During a review of Resident 1's Hospital Hospitalist History & Physical (H&P), dated [DATE], the H&P indicated, .Patient presents with .SOB .swelling and discoloration to left lower calf sent out to [rule out] DVT .Patient endorses progressive swelling and pain in her left lower leg over the past week .Denies history of DVT or [Pulmonary Embolism- a sudden blockage of a blood vessel in the lungs, typically caused by a blood clot that has traveled from another part of the body, often a leg vein (PE)] .Has outpatient arterial doppler .Severe bilateral lower extremity arterial disease .No hemodynamically significant stenosis is identified on either side .Possible occlusion of [left proximal] DFA .LLE edema and tenderness . During a review of Resident 1's Hospital [Interventional Radiology - medical specialty that performs various minimally invasive procedures using medical imaging guidance (IR)] Thrombectomy Venous Left Final Results (IRT), dated [DATE], the IRT indicated, .PROCEDURE: Left lower extremity DVT thrombectomy .Left lower extremity swelling and pain found to have extensive DVT .DVT thrombectomy was requested .Suction thrombectomy was performed of the left lower extremity with aspiration [drawing something out using a sucking action] of large amount of clot . During a review of Resident 1's Interdisciplinary Progress Notes (IPN), dated [DATE], the IPN indicated, .Brought forward for review; resident [complained of] pain to LLE, nurse noted darkening spot to medial lower extremity. MD notified and ordered to send resident to acute [due to] doppler study showing possible occlusion of [left proximal] DFA. Resident sent out to acute care . During a review of Resident 1's Hospital Hospitalist Daily Progress Note (HDPN), dated [DATE], the HDPN indicated, .As per IR .Extensive LLE DVT Successful suction thrombectomy with removal of large amount of chronic and acute thrombus .Successful placement to infrarenal [situated below the kidney] IVC filter . During a review of Resident 1's Order Summary Report (OSR), dated [DATE], the OSR indicated, .Elevate [bilateral] lower extremities every shift for related to edema XXX[DATE] .May have Vascular consult XXX[DATE] .May send out to hospital for further evaluation and treatment XXX[DATE] . During a review of the facility's document titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), dated 5/22, the document indicated, .The primary purpose of this position is to provide nursing care to residents under the supervision of a physician and/or registered nurse .Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care .Monitor residents for and immediately report developments of acute changes of condition .Maintain documentation of all nursing care and services provided to residents .Transcribe telephone, verbal .orders from providers as appropriate .Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care .Must be able to communicate information concerning a resident's condition . During a review of the facility's document titled, Registered Nurse (RN), dated 5/22, the document indicated, .The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician .Ensure .periodic comprehensive assessments and care plans are completed with required timeframes .Initiate requests for consultations or referrals as requested .Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc .Provide nursing services to residents in accordance with scope and practice, facility policies and professional standards of care .Monitor residents for developments of acute changes of condition .conduct assessments and notify the provider as needed .Monitor the chronic health conditions of residents; be familiar with reportable changes and potential causes for concern .Maintain documentation of all nursing care and services provided to the residents .Transcribe telephone, verbal .orders from providers as appropriate .Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served .Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care .Must be able to communicate information concerning a resident's condition . During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, dated [DATE], the P&P indicated, .PURPOSE .to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition .A Facility must immediately inform the resident, consult with a Resident's physician and/or [Nurse Practitioner], and notify, consistent with his/her authority, Resident Representative when there is .A signific[TRUNCATED]

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) assessment done quarterly (every three months) as per their written policy and procedure, and failed to initiate elopement risk interventions for Resident 1 when she was assessed to have a significant increase in her elopement risk factors. These failures had the potential to result in Resident 1's elopement from the facility when she was found outside the facility briefly in a confused state early in the winter morning, potentially causing significant risks to Resident 1's health and safety, placing Resident 1 at risk of cold exposure, fear, dehydration and/or other medical complications, or being struck by a motor vehicle. Findings: During a review of Resident 1's Admission Record (AR) , dated 1/27/25, the AR indicated she was admitted to the facility during May 2024. Resident 1 had diagnoses that included dementia (a progressive mental disorder affecting mood, memory, and judgement). During a review of the facility document titled Incident: Elopement (IE) , dated 1/27/25, the IE indicated staff saw Resident 1 safely in bed at 4:40 a.m., and On the morning of 1/23/25 at approximately 4:50 am [Resident 1] was found outside of the facility on the front sidewalk. Staff completed a head-to-toe assessment and found no injury to [Resident 1]. The resident elopement assessment and care plan was updated and an order to place a [security bracelet] was obtained. During a review of Resident 1's Progress Notes (PN) , dated 1/23/25, at 5:05 a.m., the PN indicated, At approximately [4:50 a.m.] kitchen staff informed [Licensed Vocational Nurse, or LVN 1] that resident [1] was found outside in the facility parking lot. Staff stated that resident was with a gentleman that was calling 911. Police not involved once staff proceeded to inform gentleman that resident belonged inside facility. Resident [1] was brought into facility and insisted to try to go outside. Resident was observed during shift trying to go into different rooms and seeking exits. Informed [Resident 1's physician] and gave order to place [security bracelet]. During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 11/7/24, the MDS indicated at Question C0500 a score of 8 out of a possible 15, which indicated Resident 1's cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment) was moderately impaired. During a review of Resident 1's Order Summary Report (OSR) , dated 1/23/25, the OSR indicated Resident 1 had a physician's order for [Security Bracelet]/Wander Elopement Device due to poor safety awareness[.] During a review of Resident 1's Elopement Evaluation (EE) , dated 5/30/24, the EE indicated Resident 1 was able to ambulate or self-propel wheelchair independently and had expressed a desire to leave [the facility]: e.g., go home, talked about going on a trip, attempted to pack belongings[,] and Resident [1] desire to leave[.] During a review of Resident 1's EE , dated 7/29/24, the EE indicated Resident 1 continued to be able to ambulate or self-propel wheelchair independently and had again expressed a desire to leave [the facility]: e.g., go home, talked about going on a trip, attempted to pack belongings[.] The EE dated 7/29/24 also indicated Resident 1 had additional risk factors identified, including has a history of actual elopement or attempted elopement[,] has a history of wandering that places the [resident] at significant risk of getting to a potentially dangerous place, e.g., stairs, outside facility[,] has a history of wandering that significantly intrudes on the privacy and/or activity of others[,] [was] unable to locate significant landmarks without assistance, e.g., bathroom, dining room, patient room[,] exhibits attempts to maintain daily routines and leisure interests not consistent with their new environment routines that may result in exit-seeking behavior[.] During a review of the facility's Policy and Procedure (P&P) titled Elopement of Resident , dated 7/12/23, the P&P indicated, Residents will be evaluated for elopement risk upon admission, re-admission, quarterly [every three months] and with a change of condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention person-centered care plan will be developed. During an interview on 1/24/25, at 1:50 p.m., with the Director of Nursing (DON), the DON stated, [Resident 1] had not ever attempted to elope from the facility before. She didn't have a [security bracelet on, but we have a [security bracelet] on [Resident 1] now. The DON stated Resident 1 was alert to person only [but did not normally know where she was or what the time and date was] and has forgetfulness. During an observation on 1/24/25, at 1:55 p.m., Resident 1 was observed sitting in a wheelchair near the nursing station, with a security bracelet on her left ankle. During an interview on 1/24/25, at 2 p.m., with the Administrator, the Administrator stated the facility just started using a security bracelet with Resident 1. During an interview on 1/24/25, at 2:30 p.m., with the Administrator, the Administrator stated it was determined Resident 1 did not have a security bracelet on when she eloped from the facility. During an interview on 1/30/25, at 10:22 a.m., with LVN 1, LVN 1 stated she was Resident 1's nurse during the night shift ending on the morning of 1/23/25. LVN 1 stated she was giving medications to Resident 1's roommate at about 4:40 a.m. and noted Resident 1 to be asleep in her bed at that time. LVN 1 stated prior to that, Resident 1 was confused, and had been up all night that night, up in her wheelchair, at the nurses' station, talking to me about her husband and taxes. She was trying to go into other resident rooms, we had to redirect her from going into other's rooms. But I've never seen her try to elope before. LVN 1 stated at approximately 4:50 a.m., a kitchen staff person told her Resident 1 was outside the facility and brought her back inside. LVN 1 stated Resident 1 was wearing a shirt and pajama pants. LVN 1 stated, She was in bed just a few minutes [prior to this. Resident 1] can self-transfer [from bed to wheelchair], she is pretty quick in her wheelchair. LVN 1 stated when Resident 1 was returned to the facility, she was confused. Every time I asked her where she was going, she had a different answer. During a concurrent interview and record review, on 2/4/25, at 11:55 a.m., with the Minimum Data Set Nurse (MDS-N), Resident 1's clinical record was reviewed. The MDS-N stated that Elopement Assessments (EE) are normally done prior to the completion of an MDS, which are conducted no less frequently than quarterly. The MDS-N stated she did not see a quarterly EE performed for Resident 1 for the Quarterly MDS completed on 11/7/24, as required by the facility's P&P titled Elopement of Resident . The MDS-N stated, I do not see one. During a concurrent interview and record review, on 2/4/25, at 12:57 p.m., with the DON, Resident 1's clinical record was reviewed. The DON stated Resident 1's Care Plan regarding her Risk for Elopement was created on 1/23/25. The DON stated she herself initiated this Care Plan and the interventions. The Care Plan Interventions included, Utilize and monitor security bracelet per protocol. The DON stated this Care Plan dated 1/23/25 was the first Care Plan in Resident 1's clinical record regarding her elopement risks. The DON stated Resident 1's EE dated 7/29/24 indicated a significant increase in elopement risk factors over the EE dated 5/30/24. The DON stated she did not consider Resident 1's 7/29/24 EE to be inaccurate but could not find any corroborating evidence elsewhere in the clinical record. The DON stated there should have been another EE done in November 2024, to coincide with the MDS dated [DATE], and could not find one. The DON stated an Elopement Risk Care Plan and corresponding interventions to reduce the risk of Resident 1's elopement risks should have been further evaluated in July 2024, in response to the EE dated 7/29/24. During a review of the facility's Policy and Procedure, dated 12/12/24, titled Tab Alarms, Bed Alarms, [Security Bracelet] System (P&P) , the P&P indicated, [Security Bracelet] would be used for residents at risk for elopement. The [Security] bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed. During a review of the National Weather Service website (NWS) Climatological Data for the facility's area, dated 1/23/25, the NWS indicated the area had an overnight low temperature of 36 degrees Fahrenheit.

Based on observation, interview and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established State standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full-time; and 2. Ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the Food and Nutrition Services department. The lack of a qualified, full-time, competent supervisor to oversee Food and Nutrition Services, and lack of frequently scheduled consultation from the RD, placed the 83 residents who were admitted to the facility at risk for receiving incorrect food items, not receiving a well-balanced diet that was approved by the RD which could result in residents receiving over or under nutrition that can increase their nutrition risk and further compromise their medical condition. It also has the potential to place resident's at risk for the growth of microorganisms and food borne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins). Findings: 1. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor (DSS) who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes seven different pathways to be qualified. Two of the pathways include being credentialed as a Certified Dietary Manager with 6 hours of in-service training on the specific training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full -time duties as a DSS at the health facility. During an interview with Certified Dietary Manager (CDM) 1 on the initial kitchen tour on 10/8/24 at 8:28 AM, CDM 1 stated he is the CDM that works 32 hours a week at the facility. CDM 1 stated he was a District Manager for the contact food service company, and he has four different facilities. During an interview with CDM 1 on 10/09/24 at 10:37 AM, CDM 2 stated the Kitchen Supervisor (KS) is in a manager in training (M.I.T.) program with the contract food service company and that CDM 1 & CDM 2 (District Managers for the contract company that have three to four facilities each) provide 32 hours of oversight per week. CDM 1 stated they will be there until KS completes the CDM program. CDM 1 stated he provides oversite 16 hours per week while CDM 2 provides oversight for another 16 hours per week. CDM 1 stated KS has approximately two weeks until he is eligible to take the Certified Dietary Manager exam. During an interview with CDM 2 on 10/10/24 at 9:16 AM, CDM 2 stated he and CDM1 split the oversight of KS. CDM2 stated he is usually onsite Thursday and Friday, but his schedule is flexible. CDM 2 stated he started coming here about 3 weeks ago. CDM 2 stated he will recap menu checks and observe the meal tray process, but KS is responsible for meal tray accuracy at the facility. CDM 2 described the meal tray accuracy as a test tray process. CDM 2 stated when he is at the facility he will do a District Manager recap. During a concurrent review of the recap document, it showed there was items pertaining to the budget and a couple items on the food service operation. No documentation was given to the surveyor to show how they were providing guidance to the unqualified KS when they were onsite. During a concurrent interview with the KS, CDM 2 on 10/10/24 at 10:26 AM, KS stated he still has one nutrition class to complete the CDM pathway and then once it is completed, he can take the exam for the CDM. CDM 2 confirmed CDM 1 and 2 are only on site for 32 hours a week. KS stated he was the person who had completed staff competencies on the kitchen staff not the CDMs. Review of the kitchen schedule dated 8/24, 9/24 and 10/24, showed the KS was the Manager and worked five days a week from 8 AM until 5:30 PM. On the bottom of the schedule CDM 1 name and phone number were listed as the District Manager. CDM 1 and CDM 2 were not on the schedule. Review of the KS job description, it showed required credentials to be in States that have established standards for food service managers, meet State requirements. 2. During the Re-Certification survey from 10/8/24 - 10/10/24, multiple issues were identified regarding: kitchen staff competency (Cross Reference F802), not following the planned menu (Cross Reference F803), puree food not the proper form when a whole green bean was found in the puree salad (Cross Reference F805), resident food preferences were not accommodated when they were given food they disliked and there was no alternate food given when residents did not like spinach (Cross Reference F806), and food was not prepared in accordance with professional standards for food service safety when the sanitizer solution was not the appropriate concentration to sanitize food preparation areas and equipment (Cross Reference F812). During an interview with KS and Certified Dietary Manager (CDM) 1 and CDM 2 on 10/10/24 at 11:35 AM, KS stated the RD was remote and had been here once since KS started working here and the RD reviewed the substitution logs. During an interview on 10/10/24 at 2:41 PM, RD stated he works 8 hours a week and on Fridays at the facility. RD stated he was working remotely until about two weeks ago however he was there in person two weeks ago then was sick last week, so he had not been back in person yet. RD stated he was a consultant for the facility. RD stated he does not review or approve the facility menu. He stated he is aware that the KS is not qualified. RD stated the kitchen was going to pick up tray audit tasks but have not yet. RD stated the last time he did a kitchen a sanitation report was sometime in the last quarter of 2023. RD stated most of his time was as a clinician and not in food service. He stated he would dabble in food service but most of the time doing clinical work. RD confirmed he does not evaluate or identify concerns in the food service operations and relies on the KS to let him know what type of in-services may be needed. RD stated KS had not needed any in-services for the food service staff. During an interview with the Administrator on 10/10/24 at 4:20 PM, Administrator stated he was working with the contractor to ensure the RD was in-person for a couple weeks since the RD had been remote, and he was aware that would not work. During an interview with the Regional Resource RD (REG RD) on 10/11/24 at 11:15 AM, the REG RD stated her role at the facility was doing kitchen sanitation walk-throughs and to work with the facility RD and be their resource. REG RD stated she identifies areas that are not in compliance and brings it to the facilities attention and the facility RD and KS would review her report and do an action plan to address concerns and they will determine the time frame to work on the concerns. REG RD stated she does not have oversight of the kitchen and the facility RD is the oversight of the facility kitchen. REG RD stated she was aware the facility RD was remote and that she thought it was for several months. Review of the RD contract dated 6/29/22, showed the description of the project was the RD services as directed by the facility and the hourly rate. Review of a document titled Contracted RD Tasks, undated, showed the position included completing clinical nutrition assessments, documenting using the Nutrition Care process in the electronic medical record system, collaborating with the interdisciplinary care plan team, completing Section K of the Minimum Data Set (MDS), calculating tube feeding (enteral nutrition - feeding nutrition through tube into the gut), and making recommendations for wounds and significant weight changes. There were no RD responsibilities for the food service operations or to have any oversight or frequently scheduled consultation with the KS. There was no documentation provided to validate the RD provided frequently scheduled consultation to the KS. During an interview with the Administrator on 10/14/24 at 10:16 AM, Administrator stated he had obtained the scope of the RD, and it was a couple bullets on a word document. He stated this contract was in place prior to him being the administrator for the building. Administrator confirmed the RD scope was limited and they would need the RD to do more moving forward.

Based on observation, interview, and record review the facility failed to post the results of the most recent survey document titled Statement Survey Binder in a place readily accessible for 83 of 83 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction. Findings: During an observation on 10/10/24 at 9:31 a.m., a binder titled, State Survey Binder was located in the hallway near the Director of Nursing's (DON) office. During a review of the facility's, State Survey Binder binder, undated, the binder did not contain results for the facilities last recertification survey conducted on 7/14/23. During a concurrent interview and record review on 10/10/24 at 9:07 a.m. with the Administrator (ADM), the facility's State Survey Binder, undated, was reviewed. The State Survey Binder did not contain the results from the facility's last recertification survey on 7/14/24. The ADM stated the last recertification survey's results were not included in the binder. The ADM stated the survey results should have been included, accessible, and available to everyone. During a concurrent interview and record review on 10/10/24 at 9:07 a.m. with the DON, the facility's State Survey Binder, undated, was reviewed. The State Survey Binder did not contain the results from the facility's last recertification survey on 7/14/24. The DON stated she could not find the last recertification survey's results in the binder. The DON stated the last survey results should have been available in the binder for people to see. During a review of the facility's policy and procedure titled, Resident Rights', dated 12/2021, indicated, .1. Federal and state laws guarantee certain basic right to all rights of this facility. These rights include the resident's right to: w. examine survey results .

Based on observations, interview and review of facility documents, the facility failed to ensure the menu was followed: 1. For the lunch meal on October 8, 2024, when steamed spinach was served instead of creamed spinach for 79 of 81 residents eating spinach at the facility. 2. For the lunch meal on October 8, 2024, when an incorrect scoop size was used for the mechanical (diced) ham given to 24 residents (Resident 34, 185, 1, 16, 33, 51, 42, 22, 24, 43, 46, 26, 60, 2, 29, 186, 27, 40, 21, 30, 76, 184, 18, 35) on the dysphagia advanced (Dys Adv per the National Dysphagia Diet as Level 3-food should be: soft solid, easy-to-cut-meats, fruits and vegetables, requires some chewing ability, meats in soft, bite-size pieces) and the 9 residents (Resident 66, 62, 75, 7, 70, 183, 3, 54, 56) on the dysphagia mechanical (Dys Mech per the National Dysphagia Diet as Level 2-food should be: cohesive, moist semi-solid food, requires some chewing ability, ground or minced meats, moist, ground, soft-textured minced or fork-mashable textured foods) diets; 3. For the lunch meal on October 8, 2024, when fortified mashed potatoes were served instead of whipped sweet potatoes to 9 residents (Residents 25, 53, 17, 11, 68, 6, 12, 48) on a puree diet and 9 residents (Resident 66, 62, 75, 7, 70, 183, 3, 54, 56) on the Dys Mech diets; and 4. For Resident 133 on a vegetarian diet when the resident was given egg salad for lunch and dinner meals on October 8, 2024, and lunch meal on October 9, 2024, and that was not on the planned menu. These failures had the potential for residents' to not meet their nutrition needs which could result in over or under nutrition which can further compromise their medical status. These failures can also result in residents receiving a lack of variety of foods which could lead to a disinterest in eating which could result in residents not meeting their nutrition needs which can further compromise their medical condition. Findings: 1.During an interview during the initial pool process on 10/8/24 at 10:08 AM, unsampled Resident 5 stated the food was terrible, bland and without flavor. At 10:14 AM, unsampled Resident 31 stated the food was like prison food. During the review of facility document titled, hcsg1NewGen 2024 Diet Guide Sheet for 10/8/24, showed 1/2 cup of creamed spinach for the following diets: Regular, Dys Adv, Dys Mech, renal, vegetarian. It showed for the puree diet to serve pureed creamed spinach with a #10 scoop (3/8 cup). During a lunch meal observation on 10/08/24 starting at 12:00 PM, in the kitchen, [NAME] 1 prepared the tray line steam table with: puree (steamed) spinach with a #10 scoop, regular (steamed) spinach with a #8 scoop (1/2 cup). During an interview with [NAME] 1 on 10/8/24 at 12:48 PM, [NAME] 1 stated she prepared 10 pounds (lbs) of frozen spinach, they ran low on spinach and had to make 3-4 more servings to finish the tray line. During an interview with the Kitchen Supervisor (KS) on 10/10/24 at 10:57 AM, KS stated he expects the cook to prepare items on the menu as listed. KS stated he expects the cook to follow recipes and garnish every plate. During a review of the facility document titled Census List: 10/8/24 5:54PM, showed there were 81 residents eating at the facility. Review of meal tickets showed there were two residents who disliked spinach (Cross Reference F806), therefore 79 residents eating spinach at the facility. During the review of the facility document titled, Corporate Recipe-Number: 3340 Spinach, Creamed (frz), showed the ingredients: spinach, chopped, frozen; water; margarine, solids; flour, all purpose; spice, pepper, black, ground; and milk 2% reduced fat, gallon. It showed for 80 servings that 16 pounds of spinach was needed. During an interview with the Registered Dietitian (RD) on 10/10/24 at 2:41 PM, the RD stated he expected staff to follow menus and recipes. 2. During a review of facility document titled, the hcsg1NewGen2024 Diet Guide Sheet dated 10/8/24, the lunch menu noted: Hawaiian Baked Ham ground #10 scoop (3/8 cup) for Dys Adv and Dys Mech diet group. During the lunch meal observation on 10/08/24 starting at 12:00 PM, in the kitchen, the tray line steam table contained mechanical (diced) ham with a #8 scoop (1/2 cup). [NAME] 1 was observed using the # 8 scoop to dish out the diced ham to 24 residents on a Dys Adv diet (Resident 34, 185, 1, 16, 33, 51, 42, 22, 24, 43, 46, 26, 60, 2, 29, 186, 27, 40, 21, 30, 76, 184, 18, 35) and 9 residents (Resident 66, 62, 75, 7, 70, 183, 3, 54, 56) on a Dys Mech diet. During a review of facility document titled Census List: 10/8/24 5:54PM, the following 24 residents had a physician diet order of Dys Adv : Residents 34, 185, 1, 16, 33, 51, 42, 22, 24, 43, 46, 26, 60, 2, 29, 186, 27, 40, 21, 30, 76, 184, 18, 35 and 9 residents had a physician diet order of Dys Mech for Residents 66, 62, 75, 7, 70, 183, 3, 54, 56. During an interview with the Kitchen Supervisor (KS) on 10/10/24 at 10:57 AM, KS stated he expects the cook to prepare items on the menu as listed. KS stated he expects the cook to follow recipes. During an interview with the Registered Dietitian (RD) on 10/10/24 at 2:41 PM, the RD stated he expected staff to follow portion sizes and menus. 3.During the review of facility document titled, the hcsg1NewGen 2024 Diet Guide Sheet dated 10/8/24, showed baked sweet potatoes for regular diet and whipped sweet potatoes for the Dys Adv/Dys Mech/Dys Puree diet group. During the lunch meal observation on 10/8/24 starting at 12:00 PM, in the kitchen, the steam table contained: mashed sweet potatoes and fortified mashed potatoes. There were no whipped sweet potatoes. [NAME] 1 would plate residents' trays with food items from the steam table. [NAME] 1 used a #8 scoop (1/2 cup) of fortified mashed potatoes to the 9 residents (Residents 25, 53, 17, 11, 68, 6, 12, 48) on the puree diet and 9 residents (Residents 66, 62, 75, 7, 70, 183, 3, 54, 56) on Dys Mech diets with the fortified mashed potatoes. During an interview with [NAME] 1 on 10/8/24 at 1:00 PM, at the end of the lunch meal service, [NAME] 1 confirmed that the residents on puree and Dys Mech diets received the fortified mashed potatoes and they did not get sweet potatoes. During an interview with [NAME] 1 on 10/9/24 at 1:02 PM, in the kitchen, [NAME] 1 stated yesterday's lunch served white fortified potato versus the whipped sweet potatoes because she added marshmallows to the sweet potatoes. [NAME] 1 stated the puree potatoes were whipped potatoes and butter which made it fortified. During an interview with the Kitchen Supervisor (KS) on 10/10/24 at 10:57, KS stated he expects the cook to prepare items on the menu as listed. KS stated he expects the cook to follow recipes and garnish every plate. During the review of facility document titled, Census List: 10/8/2024 5:54 PM indicated the following residents were on a physician's order for puree diet for Resident 25, 53, 17, 11, 68, 6, 12, 48 and Dys Mech diet for Resident 66, 62, 75, 7, 70, 183, 3, 54, 56. During an interview with the Registered Dietitian (RD) on 10/10/24 at 2:41 PM, the RD stated he expected staff to follow menus. 4. During an observation on 10/08/24 at 12:07 PM in the kitchen, [NAME] 1 prepared Resident #133's meal tray with egg salad. Review of Resident 133's meal ticket showed she was on a regular diet, and it showed vegetarian. It showed beverages of whole milk and iced tea. There were no other likes or dislikes on the meal ticket. During an interview with KS on 10/08/24 at 4:58 PM, in the kitchen prior to the dinner meal service, KS stated the egg salad sandwich is used for residents who do not eat meat. During a concurrent observation and interview with Resident 133 on 10/09/24 at 1:11 PM, in Resident 133's room, Resident #133 stated yesterday (10/08/24) she had egg salad for lunch and an egg salad sandwich for dinner. Observed Resident 133's entree was egg salad with approximately 25% eaten. Resident 133 stated she is kinda over it as she eats egg salad often. Resident 133 stated she would have like the cheese ravioli that was on the menu for lunch today. Resident 133 stated she met with the KS and informed she is a vegetarian. During an interview with [NAME] 1 on 10/09/24, at 1:16 PM, in the kitchen, [NAME] 1 stated she was told by KS Resident 133 wants egg salad all the time. [NAME] 1 stated KS manages the resident requests and she prepares meals per KS. During an interview with KS on 10/09/24 at 1:18 PM, KS stated Resident 133 was admitted two weeks ago and last week wrote on a meal ticket that she prefers egg salad and fruit. KS stated the preference was not entered in the system and he provided his staff verbal instruction. KS stated he did not enter the dislike on the meal ticket and then stated he may be confusing Resident 133's dislikes with the roommate's information as he interviewed a bunch of residents that day. KS was unable to show documentation of Resident 133's handwritten meal ticket requesting egg salad every day. During an interview with Certified Dietary Manager (CDM) 1 on 10/09/24 at 1:18 PM, CDM 1 stated Resident 133 has a number of special requests, and the food supplier has limited veggie options to purchase. It is unclear why the facility could not purchase vegetarian food items from a local grocery store. During an interview with KS on 10/10/24 at 10:57 AM, KS stated he expects the cook to prepare items on the menu as listed. KS stated he expects the cook to follow recipes and garnish every plate. During a review of Resident #133's meal ticket, dated 10/08/24, the meal ticket indicated the resident is on a regular vegetarian diet. During a review of facility document titled, hcsg1NewGen2024 Diet Guide Sheet, indicated for 10/8/24, the lacto-ovo vegetarian (vegetarian menu for those who eat dairy and eggs) lunch entree listed veggie chicken patty and for the dinner entree. For 10/9/24 for the lunch entree it showed they should get cheese ravioli with marinara sauce and the for the dinner entree it was veggie chicken patty. There was not much variety or variation for these two days on the vegetarian menu. During an interview with the Registered Dietitian (RD) on 10/10/24 at 2:41 PM, the RD stated he expected staff to follow menus and recipes. The RD stated there is a vegetarian menu and that should be followed. The RD stated he has not reviewed or approved the facility menu. During a review of the facility policy and procedure titled Menus - HCSG Policy 004, revised 9/17, showed menus will be served as written and that the RD reviews and approves the menus.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 21 sampled residents (Residents' 48, 52, and 54) when: 1. Resident 52's oxygen nasal cannula (O2 NC- a tube that directs oxygen into the nose) tubing was observed on top of the oxygen concentrator (medical device that supplies oxygen-enriched air to help people breathe easier) was not stored in a plastic bag. This failure placed Resident 52 at an increased risk to develop respiratory and healthcare associated infections. 2. Resident 48's medication syringe was stored in a wet plastic bag and had some orange liquid substance at the tip of the syringe. This failure placed Resident 48 at an increased risk to develop bacterial infection and gastrointestinal illness. 3. Resident 54 who was on Enhanced Standard/Barrier Precautions (EBP- infection control measures that help reduce the spread of multi drug-resistant organisms [MDROs] in nursing homes) and Certified Nursing Assistant (CNA) 7 did not wear proper PPE (personal protective equipment- a type of equipment worn to reduce exposure to workplace hazards that can cause serious injuries or illnesses) while providing personal care. This failure placed residents and staff at risk to develop healthcare associated infections. Findings: 1. During a review of Resident 52's Admission Record (AR), the AR record indicated, Resident 52 was admitted to the facility on [DATE] with an admission diagnosis of palliative care (specialized care for people nearing the end of life). During a review of Resident 52's Order Summary Report (OSR) dated 7/24/24, the OSR indicated, . oxygen at [3 liters (L-unit of measurement) per minute via nasal cannula as needed for shortness of breath (the uncomfortable feeling of not being able to breathe deeply or normally) . During an observation on 10/8/24 at 11:07 a.m., in Resident 52's room, Resident 52's O2 NC tubing was on top of the oxygen concentrator and was not stored in a plastic bag. During an interview on 10/11/24 at 1:50 p.m. with CNA 1, CNA 1 stated when oxygen tubing was not in use by residents, oxygen tubing was supposed to be placed in a bag to keep it clean. CNA 1 stated placing the O2 NC in a bag was done to stop the spread of infections. During an interview on 10/11/24 at 2:02 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 52's O2 NC tubing should have been stored in a bag which protected it from bacteria. LVN 6 stated if Resident 52's O2 NC was not properly stored in a bag when not in use and could result in Resident 52 to develop an infection During an interview on 10/14/24 at 8:50 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 52's O2 NC should have been stored in a protective bag when not in use. The DSD stated having the O2 exposed on top of the oxygen concentrator and touching the wall could placed Resident 52 at risk to develop an infection. During an interview on 10/14/24 at 9:46 a.m. with the Infection Preventionist (IP), the IP stated the O2 NC tubing should have been stored in a bag when not in use. The IP stated if a CNA saw the oxygen tubing not being used by the resident, they should have notified the nurse in order to have the nurse replace the O2 NC and place the new one in a protective bag. The IP stated when a resident did not use their O2 NC, the O2 NC tubing should be labeled, dated and bagged as a standard of practice. During an interview on 10/14/24 at 10:18 a.m. with the Director of Nursing (DON), the DON stated Resident 52 should not have had his O2 NC laying on top of his oxygen concentrator uncovered. The DON stated Resident 52 should have had his O2 NC placed in a protective bag when not in use to prevent Resident 52 from acquiring and infection. The DON stated staff members were expected to identify any oxygen tubing not properly stored in bags and replace them with clean supplies which would then be placed in a protective bag. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control dated 12/2023, the P&P indicated, .The facility adopted P&P to help prevent and manage transmission of diseases and infections .The P&P apply to all personnel, consultants, contractors, residents, visitors, and volunteers .All personal are trained on P&P .including where and how to find and use pertinent procedures and equipment related to infection control .Inquiries concerning infection prevention and control P&P .be referred to the infection preventionist or director of nursing . During a professional reference review, retrieved from https://masvidahealth.com/oxygen-concentrators/maintenance-guide-how-to-clean-a-nasal-cannula-of-an-oxygen-concentrator titled, Maintenance Guide: How To Clean A Nasal Cannula Of An Oxygen Concentrator, undated, indicated, . Always store the nasal cannula in a clean, dry place .Use a dedicated storage container or bag that is also clean and free from contaminants . 40641 2. During a concurrent observation and interview on 10/10/24 at 8:35 a.m. in Resident 48's room, Resident 48 was sitting up in bed watching TV. Resident 48 had a nasal cannula in his nostril connected to an oxygen concentrator. Resident 48 stated he was happy with his care received in the facility. During a review of Resident 48's Admission Record, (AR) dated 10/11/24 the AR indicated Resident 48 was readmitted to the facility on [DATE] with diagnoses which included, encounter for palliative care and hypokalemia. During a review of Residents 48's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [thought process] and physical function) assessment, dated 9/22/24, the MDS indicated Resident 48's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement on a scale of 1-15 with 15 being the highest score) was 00. Resident 40's cognition was assessed as severely impaired. During a concurrent observation and interview on 10/10/24 at 8:42 a.m. with LVN 1 outside of room [ROOM NUMBER] in station 2 hallway, LVN 1 was preparing medications for Resident 48. LVN 1 pulled out the medication bottle and a syringe in a plastic bag. The syringe had orange looking liquid in the tip and was placed in a wet plastic bag. LVN 1 used the syringe to measure medication without rinsing and placed syringe back in the plastic bag without rinsing. LVN 1 stated she was not sure whether she needed to rinse it because she had never done it before. LVN 1 stated, I guess I have to rinse it to prevent contamination, it is an infection control issue . During a review of Resident 48's Order Summary Report, (OSR) dated 10/11/24, the OSR indicated . Potassium Chloride [medication used to treat hypokalemia-low level of potassium in the blood] Liquid 20 MEQ [milliequivalent-unit of measurement]/15ML [milliliter-unit of measurement] 10 %[percent] Give three [3] ml by mouth one time a day . During an interview on 10/10/24 at 10:35 a.m. with the IP, the IP stated, . licensed nurses should have been rinsing the syringe after use and prior to using when the tip of the syringe had discolored liquids in it . The IP stated not rinsing the syringe after use and putting it in the plastic bag could grow bacteria causing resident 48 to become ill. During an interview on 10/14/24 at 2:25 p.m. with the DON, the DON stated Resident 48's syringe was dirty in the plastic bag and it was an infection control issue. The DON stated there was some medication left in the tip of the syringe and the nurse should have rinsed the syringe before she used it to draw out medication from the bottle and rinsed after she used it and placed in a clean plastic bag. During a review of facility's policy and procedure (P&P) titled, Administering Medication, dated 4/19, the P&P indicated, . Staff follows established facility infection and control procedures (e.g handwashing, antiseptic technique, gloves, isolation precaution etc.) for the administration of medications, as applicable . During a professional reference review, retrieved from https://medicina.co.uk/wp-content/uploads/2018/06/LHE-Syringe-Cleaning-Instructions.pdf titled, Cleaning your re-usable syringes undated, the reference indicated, . After use, clean your syringes straight away. Place syringe in warm soapy water. Clean the end of the syringe by drawing soapy water in and out using the plunger until all traces of feed or medication have been removed. Separate syringe and plunger and wash throughly in warm soapy water Rinse both parts of the syringe under the tap, shake off excess water . Store the syringe still separated in a clean dry container with a lid . 49949 3. During a concurrent observation and interview on 10/8/24 at 3:54 p.m., in Resident 54's room, CNA 7 was washing Resident 54's hand with a washcloth. CNA 7 wore gloves but no gown while providing personal care for Resident 54. CNA 7 stated, she was cleaning Resident 54's hand with a washcloth. CNA 7 stated gowns and gloves were needed for residents on contact isolation. CNA 7 stated she did not wear a gown when cleaning Resident 54's hand. During an interview on 10/11/24 at 11: 29 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 54 was on enhanced standard precaution because of dialysis (a treatment that removes excess water, waste products, and toxins from the blood when the kidneys are no longer functioning properly). During an interview on 10/11/24 at 1:43 p.m. with the IP, the IP stated, we put six step signs (a sign describing a core set of infection prevention and control practices that are required in all healthcare settings) outside the doors and a cart for PPE for residents with EBP. The IP stated, the staff should gown up when they are working with the specific area. The IP stated, when wounds are covered, staff do not need to wear a gown. The IP stated, staff needed to wear PPE when changing a wound dressing, providing nutrition feeding, changing a dressing, giving medication to a g-tube (a tube inserted through the belly that brings nutrition directly to the stomach) site. The IP stated the CNA 7 did not need to wear a gown due to the fistula port (a connection that's made between an artery and a vein for dialysis access) being covered up. During an interview on 10/14/24 at 9:25 a.m. with CNA 8, CNA 8 stated, staff should wear gowns and gloves when providing personal care. CNA 8 stated staff should wear a gown when providing care for residents with foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside the body), fistula port (a surgically created connection between an artery and a vein that provides access for dialysis) and anyone residents with any kind of medical lines. CNA 8 stated, CNA 7 should have worn a gown when cleaning Resident 54's hands. During an interview on 10/14/24 at 3:21 p.m., with the DON, the DON stated staff should wear gown and gloves when providing care. The DON stated, Resident 54 had an open port for dialysis and was on enhanced standard precaution. The DON stated, We don't want to cause infection to the residents and other residents. The DON stated, the CNA should wear a gown when providing personal hygiene. The DON stated gowning up was important for resident safety. During a review of Resident 54 's Admission Record (AR-a document with personal identifiable and medical information), dated 10/14/2024 the AR indicated, Resident 54 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, thrombosis (a occurs when blood clots block veins or arteries), atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls), dysphagia (difficulty swallowing),diabetes mellitus type 2 (disease in which your blood glucose, or blood sugar, levels are too high), hypertension (high blood pressure- is when the pressure in your blood vessels is too high (140/90 mmHg or higher) end stage renal disease, (ESRD- is 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), heart failure (when the heart cannot pump enough blood and oxygen to support other organs in the body), pain. During a review of Resident 54's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 8/20/24, indicated the Brief Interview for Mental Status (BIMS) score was 4 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 54 was severely impaired in decision making. During a review of the facility's in -service titled, Class title: Enhanced Standard/Barrier Precautions dated 4/15/24 the in-service indicated, .[Box] staff will be able to identify the correct moment when PPE are required in a room that is on ESP/EBP .[Box] Course Content .When are PPE required when interacting with a resident on ESP/EBP .providing hygiene . During a review of the facility's policy and procedure (P&P) titled, NewGen Administrative Services Enhanced Standard/Barrier Precautions dated No date the P&P indicated, .3.Implementation of Enhanced Barrier Precautions .C. Wear gowns and gloves while performing the following task associated with the greatest risk for MDRO contamination of HCP hands, clothes and the environment .iii. Any care activity where close-contact wit the resident is expected to occur such as bathing, peri-care, providing assistant with personal hygiene, assisting with toileting, changing incontinence briefs, respiratory care, wound care, etc .

Based on observation, interview, and record review, the facility failed to ensure a physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for three of six sampled residents (Residents' 3, 13 and 64) when: 1. Resident 3 was administered escitalopram oxalate tablet (medication used to treat depression [serious mental illness affecting person's though, feelings, behavior, and sense of well-being] from 6/2/24-6/31/24, 7/1/24-7/31/24 and 81/24-8/27/24 and informed consent was not obtained prior to medication administration. 2. Resident 13 was administered sertraline HCl tablet (medication used to treat depression) from 8/1/24 to 10/14/24 and informed consent was not obtained prior to medication administration. 3. Resident 64 was administered buspirone HCl tablet (medication used to treat anxiety [feeling of fear, dread, and uneasiness that can be a normal reaction to stress]) from 8/29/24 to 10/11/24 and accurate informed consent was not obtained prior to medication administration. These failures resulted in Residents' 3, 13 and 64 to be administered psychotropic medications and not be fully informed of the risk and benefits and did not have the knowledge to make an informed decision which placed Residents' 3, 13 and 64 at risks for negative side effects. Findings: 1. During a concurrent observation and interview, on 10/8/24 at 12::40 p.m. in Resident 3's room, Resident 3 was observed sitting at the edge of her bed eating lunch. Resident 3's bed was in the lowest position and a fall mat was at bedside and Resident 3 stated she did not know what she was eating and did not have any complaints. During a review of Resident 3's Admission Record, (AR) dated 10/11/24, the AR indicated Resident 3 was admitted in the facility on 4/26/24 with diagnoses which included Respiratory failure, perforation (hole) of intestine and gastrointestinal hemorrhage (bleeding). During a review of Resident 3's Order Summary Report, dated 10/11/24, the Order Summary Report indicated, . Escitalopram Oxalate Tablet 10 MG[milligram-unit of measurement]. Give one [1] tablet by mouth one time a day . related to DEPRESSION . During a review of Resident 3's Medication Administration Record (MAR-a document that shows the medications ordered and taken by a resident), dated 6/1/24-6/30/24, 7/1/24-7/31/24 and 8/1/24-8/30/24, the MAR indicated, escitalopram oxalate was administered every day starting from 6/1/24 thru 6/30/24, 7/1/24 thru 7/31/24 and 8/1/24 thru 8/1/24 thru 8/28/24. During a concurrent interview and record review on 10/14/24 at 10:15 a.m. with Registered Nurse (RN) 2, RN 2 reviewed Resident 3's clinical record and stated Resident 3's escitalopram oxalate was ordered on 5/30/24. RN 2 stated the informed consent for the medication was signed 8/28/24, RN 2 stated medication was administered everyday to Resident 3 since 6/1/24. RN 2 stated psychotropic medication can not be administered until an informed consent was signed. During an interview on 10/14/24 at 10:45 a.m. with Licensed Vocational Nurse (LVN) 4, she stated psychotropic medications cannot be administered without a signed informed consent. LVN 4 stated informed consent had to be accurate and matched the physician order. 2. During a concurrent observation and interview on 10/8/24 at 8:58 a.m. during an initial tour in Resident 13's room, Resident 13 was observed sitting up in bed with oxygen via nasal cannula (a tube used to deliver supplemental oxygen through the nose). Resident 13 stated she did not know how long she had been in the facility and did not have any complaints. During a review of Resident 13's Admission Record, (AR) dated 10/11/24, the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses which included anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (feeling of sadness and loss of interest). During a review of Resident 13's Order Summary Report, dated 10/11/24, the Order Summary Report indicated, . Sertraline HCl [hydrochloride] Oral Tablet 25MG[milligram-unit of measurement] . related to DEPRESSION . During a review of Resident 13's MAR dated 8/1/24-8/31/24, 9/1/24-9/30/24 and 10/1/24-10/14/24, the MAR indicated, sertraline was administered every day starting from 8/1/24-8/31/24, 9/1/24-9/30/24 and 10/1/24-10/14/24. During a concurrent interview and record review on 10//14/24 at 10:05 a.m. RN 2 reviewed Resident 13's clinical record and stated Resident 13's informed consent for sertraline was incomplete. RN 2 stated sertraline medication should not have been administered to Resident 13 without informed consent. RN 2 stated licensed nurses are responsible in making sure informed consent was accurate and signed. 3. During an observation on 10/8/24 at 9:48 a.m. in Station 1 hallway, Resident 64 was observed sitting up at the edge of the bed, holding a phone to her ear, appeared agitated and crying on the phone. Several facility staff was in the room with Resident 64 talking to her. During a review of Resident 64's Admission Record, (AR) dated 10/11/24, the AR indicated Resident 64 was admitted to the facility on [DATE] with diagnoses which included anxiety and Alzheimer's (progressive disease that destroys memory and other important mental functions. During a review of Resident 64's Order Summary Report, undated, the Order Summary Report indicated, . busPIRone HCl. Give one [1] tablet by mouth two times a day for Anxiety M/b [manifested by] episodes of hyperventilation . During a review of Resident 64's MAR dated 8/29/24-8/31/24, 9/1/24-9/30/24 and 10/1/24-10/14/24, the MAR indicated, buspirone was administered every day starting from 8/29/24-8/31/24, 9/1/24-9/30/24 and 10/1/24-10/14/24. During a concurrent interview and record review on 10/11/24 at 2:45 p.m. with Registered Nurse (RN) 1, Resident 64's informed consent for buspar was reviewed and she stated Resident 64's informed consent was not accurate and therefore was not valid. RN 1 stated buspar should not have been administered to Resident 64 because the informed consent was not accurate. During an interview on 10/14/24 at 1:40 p.m. with the Director of Staff Development (DSD), she stated psychotropic medications can not be administered to a resident without a signed informed consent. The DSD stated licensed nurse receiving the psychotropic medication order should ensure an informed consent was signed by physician and resident or family member. During an interview on 10/14/24 at 8:25 a.m. with Medical Records Director (MRD), she stated she is also an LVN and part of her job was to audit resident's medical records including psychotropic medications informed consents. MRD stated she made sure the informed consents was signed both by family or resident and physician. MRD stated she also checked to ensure the medication order and the informed consent was the same. The MRD stated licensed nurses can not administer psychotropic medications without a signed and accurate informed consent. During an interview on 10/14/24 at 2:55 p.m. with the Director of Nursing (DON), the DON stated, . Psychotropic medications needed to have an updated, accurate and signed informed consent prior to administering medications . DON stated it was the resident's and or resident family's right to be informed of changes in psychotropic medications. During a review of facility's policy and procedure (P&P) titled, . The facility should comply . to the use of psychoactive medications . It is the responsibility of the attending health care practitioner to inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to initiation of the psychotropic medication .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for two of eight sampled residents (Resident 75 and Resident 29) when: 1. Resident 75 did not have a care plan (a document that outlines how a resident's health care needs will be met, and is used by the resident and their care team to facilitate communication and collaboration) for the use of indwelling urinary catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine). This failure placed Resident 75 at risk for her indwelling urinary catheter needs to not be met. 2. Resident 29 did not have a care plan for urinary tract infection (UTI- common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract). This failure had the potential to result in Resident 29's care needs to go unmet. Findings: 1. During a concurrent observation and interview on 10/8/24 at 10:13 a.m. in Resident 75's room, Resident 75 was laying in bed with eyes open watching TV. Resident 75 stated she had been in the facility for three weeks and preferred to stay in bed. There was an indwelling urinary catheter bag that hanged on the side of the bed and covered with a privacy bag. Resident 75 stated she needed the indwelling urinary catheter due to her weakness and had it since she was in the hospital. During a review of Resident 75's Admission Record (AR-a document with personal identifiable and medical information), dated 10/11/24, the AR indicated, Resident 75 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure (sudden decline in kidney function), rhabdomyolysis (skeletal muscle breaks down and releases its content into the bloodstream) and fall. During a review of Resident 75's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 8/19/24, indicated the Brief Interview for Mental Status (BIMS) score was 12 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 75 was moderately impaired in daily decision making. During a concurrent interview and record review on 10/10/24 at 2:45 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 75's clinical record titled Order Summary Report, dated 10/11/24 and stated Resident 75 was admitted to the facility on [DATE]. LVN 2 stated Resident 75 was admitted with an indwelling urinary catheter. LVN 2 stated she did not find a care plan for Resident 75's use of indwelling urinary catheter. LVN 2 stated there should have been a care plan developed and licensed nurses are responsible in creating a care plan. LVN 2 stated a care plan was important to guide nursing staff in providing care to Resident 75's indwelling urinary catheter. During an interview on 10/11/24 at 9:32 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 75 was admitted with an indwelling urinary catheter. The MDSN stated there should have been a care plan initiated for the use of the indwelling urinary catheter but there was none. The MDSN reviewed the MDS admission and 5 day assessment dated [DATE] and stated Resident 75 was coded as using foley catheter and care plan was also triggered in Section V (Care Areas Assessment) CAAs and Care Planning but there was no care plan initiated for Resident 75's use of indwelling urinary catheter. During an interview on 10/14/24 at 2:35 p.m. with the Director of Nursing (DON), the DON stated Resident 75 had been in the facility since 8/17/24 and had the indwelling urinary catheter since admitted in the facility. The DON stated her expectation was for licensed nurses to initiate care plan to monitor for any side effects of the use of indwelling urinary catheter. During a review of facility's policy and procedure (P&P) titled Care Plan Comprehensive dated 8/25/21, the P&P indicated, . An individualized comprehensive care plan that include measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident . The resident's comprehensive care plan is developed within seven (7) days . 49949 2. During a review of Resident 29's AR, dated 10/10/24 the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (disease in which your blood glucose, or blood sugar, levels are too high), hypertension (high blood pressure- is when the pressure in your blood vessels is too high (140/90 mmHg or higher) end stage renal disease, (ESRD- is 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) anemia (blood disorder that occurs when your body doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to your body's tissues) and pain. During a review of Resident 29's MDS, dated [DATE], indicated the BIMS score was 14 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 29 was cognitively intact in decision making. During an observation and interview on 10/8/24 at 10:32 a.m. in Resident 29's room, Resident 29 had an enhanced standard precaution sign outside the door. Resident 29 stated she was taking antibiotic for a urinary tract infection recently but could not recall the date. During a concurrent interview and record review on 10/10/24 at 3:25 p.m. with License Vocational Nurse (LVN) 4 , LVN 4 stated Resident 29's was started on antibiotic for UTI. LVN 4 stated Resident 29 had a SBAR ((Situation, Background, Assessment, Recommendation-is a tool for standardizing and improving interprofessional communication) done on 9/27/24 and started on antibiotics on 9/28/24. LVN 4 stated a UTI care plan should have been done on 9/27/24. LVN 4 stated there was no care plan done on 9/27/24 and a care plan was created on 10/4/24. LVN 4 stated, a UTI care plan was important for patient care. LVN 4 stated, the nurse should have done the care plan when the SBAR was done. LVN 4 stated the care plan allowed the nurse to monitor Resident 29 was getting better or worse. During a concurrent interview and record review on 10/11/24 at 1:43 p.m. with the Infection Preventionist (IP), the IP stated, Resident 29 complained of decreased in urine output on 9/20/24. The IP stated the physician was notified and a urine sample was collected and sent out to the lab for testing. The IP stated, the physician gave a new order to repeat urine analysis on 9/23/24. The IP stated the urine was collected and sent out on 9/24/24. The IP stated the urine result came back on 9/27/24. The IP stated the urine sample was positive for E-coli (bacteria found in many places, including in the environment, foods, water, and the intestines of people and animals) and ESBL (enzymes that make some bacteria resistant to antibiotics, making infections harder to treat). The IP stated the nurse did a change in condition and notified the physician on 9/27/24. The IP stated the care plan should have been done on 9/27/24. The IP stated it was important to start the care plan to monitor Resident 29's condition. The IP stated the care plan updated physician, nurses, interdisciplinary team (IDT- group of professionals with different areas of expertise who work together to achieve a common goal). During an interview on 10/14/24 at 3:21 p.m. with the DON, the DON stated the nurse should update the care plan when there was a change in condition. The DON stated the care plan was not patient centered. During a review of the facility's policy and procedure (P&P) titled, Care Plan-Baseline dated 8/25/25, the P&P indicated, .An individualized comprehensive care plan that includes measurable objective and timetable to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident .1.Each resident's comprehensive care plan is designed to: 1.Indoperate identified problem area .

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of eight sampled residents (Resident 29 and Resident 55) when: 1. License nurses continued to sign the physician's order to monitor for side effects for Resident 29's anticoagulant medication which was discontinued on 9/5/24. This failure resulted in an inaccurate documentation and monitoring of Resident 29's medical symptoms related to the side effects if a medication that has been discontinued. 2. Licensed Vocational Nurse (LVN) 1 prepared and signed Resident 55's medications, and the Infection Preventionist (IP) administered the medication prepared by LVN 1. This failure had the potential for Resident 55 to not received the medication and could lead to medication error and or drug diversion. Findings: 1. During a review of Resident's Admission Record (AR-a document with personal identifiable and medical information), dated 10/10/24 the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (disease in which your blood glucose, or blood sugar, levels are too high), hypertension (high blood pressure- is when the pressure in your blood vessels is too high (140/90 mmHg or higher) end stage renal disease, (ESRD- is 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) anemia (blood disorder that occurs when your body doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to your body's tissues) and pain During a review of Resident 29's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 9/10/24, indicated the Brief Interview for Mental Status (BIMS) score was 14 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 29 was cognitively intact in decision making. During a review of Resident 29's [Facility Name] Order Summary Report (OSR) dated 10/10/24, the OSR indicated, .[Brand name] oral tablet 10 mg (Rivaroxanban) give 10mg PO [by mouth] one time a day for blood thinner take with evening meal. (dinner) .Order Status: Discontinue .Order Date: 09/05/024 .Start Date:09/06/2024 . During a review of Resident 29's Medication Administration Record (MAR) dated 10/24, the MAR indicated, [box] Schedule for October 2024 .[box]Anticoagulant Medication Monitoring [Brand name drug]: Monitor for discolored urine, black tarry stools, sudden severe headache, N&V [nausea and vomiting] diarrhea, muscle join pain, lethargy, bruising, sudden changes in mental status or v/s [vital signs] sob [shortness of breath] .[box]hours .[box]6a-2p .[box]2p-10 [p] 10 p-6 [a] .[box] Thu 10 .[nurse initial] . During a review of Resident 29's Changes since last Review dated no date the changes since last review indicated, .Description .The resident has a diagnosis of diabetes: Insulin Dependent .Revision Date: 10/10/2024 . During a concurrent interview and record review on 10/10/24 at 3:01 p.m. with LVN 4, LVN 4 stated, Resident 29 was not taking [Brand name drug]. LVN 4 stated Resident 29's medication was discontinued on 7/23/24 at 8:00 a.m. LVN 4 stated, the physician order to monitor for side effect of the medication should have been discontinue the same day the medication was discontinue. LVN 4 stated, it was important to update the physician order so that staff can monitor for the correct side effects for the right medication. LVN 4 stated, The potential outcome is we were looking for all side effects that was not there when there could be another issue for her black tarry stool. During an interview on 10/14/24 at 3:01 p.m. with the Director of Nursing (DON) the DON stated, the nurses should update the order when [brand name] medication was discontinued. The DON stated the physician order was not update. The DON stated the physician order to monitor for the [drug name] can cause confusion for the staff. During a review of the professional reference titled, If it's not documented, it's not done. But what if it is documented and it's not done? dated 2/9/2019, retrieved from, https://mnnurses.org/if-its-not-documented-its-not-done-but-what-if-it-is-documented-but-its-not-done, the article indicated, . Untimely documentation may also be considered fraud. False, misleading, and deceitful documentation may result in grave safety issues for the patient because the healthcare team depends on accurate and timely documentation to make patient care decisions. If a medication, assessment, procedure, etc., is not timely then other care providers do not have an accurate account of a patient's condition which may lead to poor outcomes, including death. 40641 2. During a concurrent interview and record review on 10/10/24 at 8:45 a.m. in Station 2 hallway with LVN 1 stated, . Resident 55's eMAR was red and LVN 1 stated Resident 55's lispro and naproxen medications were late and were due at 7 a.m. LVN 1 stated she was not able to go in Resident 55's room to administer his medications, she had to ask another nurse. During a review of Resident 55's Admission Record, (AR) dated 10/11/24 the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (blood supply to the brain is blocked or reduced), diabetes (high blood sugar level) and muscle weakness. During a review of Resident 55's, Order Summary Report, dated 10/11/24, the Order Summary Report, indicated, . Insulin Lispro [medication used to treat diabetes] . before meals related to . Naproxen [medication used Oral tablet . administer with meals . During a concurrent interview and record review on 10/10/24 at 10:15 a.m. Resident 55's MAR was reviewed by LVN 1 and she stated Resident 55's fingerstick blood sugar was checked at 9:09 a.m. and the result was 145, he did not need the lispro insulin. LVN 1 stated the naproxen was administered with acetaminophen at 9:10 a.m. LVN 1 stated medications were administered late. LVN 1 stated she prepared the medications and asked the IP to administer then she signed the eMAR after medications were administered by the IP. LVN 1 stated she was pregnant and could not go in Resident 55's room because Resident 55 was on enhance barrier precaution. LVN 1 stated it was not an acceptable practice and should not have done it but she did. LVN 1 stated she should have just asked the IP to prepare Resident 55's medications and signed after she administered medications. During an interview on 10/10/24 at 10:30 a.m. with IP, the IP stated she administered Resident 55's medications because LVN 1 could not go in the room. The IP stated it was not the acceptable practice to administer medication you did not prepared. The IP stated medications could be given to the wrong resident which could result to adverse reaction or the prepared medications was not the right medications. During an interview on 10/14/24 at 10:36 a.m. with LVN 7, she stated, .Nurses can not administer medication prepared by another nurse . LVN 7 stated it was never acceptable to have a licensed nurse prepares residents medication then asked another licensed nurse to administer then the same nurse who prepared the medication signs the MAR. LVN 7 stated it was for the safety of the resident, it could be given to a different resident. During an interview on 10/14/24 at 2:43 p.m. with the Director of Nursing (DON), the DON stated it was in their policy to prepare medication, administer to resident then sign the eMAR. the DON stated licensed nurses can not prepare medication then asked another nurse to administer to resident then signed the eMAR. The DON stated asking another nurse to administer medication prepared by another nurse could result to medication error which could result to serious health condition. During a review of facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines dated 10/17, the P&P indicated, . Medications are prepared only by licensed nursing . The person who prepares the dose for administration is the person who administers the dose .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given .

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received adequate supervision and assistance in personal care when Resident 1, who was assessed to need two person assistance, had an ordered low air loss mattress, was provided care by Certified Nursing Assistant (CNA) 1 on [DATE] without the benefit of two person assist. This failure resulted in Resident 1 falling from bed on the opposite side while CNA was turning Resident 1. Resident 1 fell to the floor and sustained a laceration to the scalp (head), a skin tear to the left elbow and a vertebral fracture (C4, Cervical vertebrae 4, cervical spine from the base of the skull down to the top of the shoulders labeled C1-C7) and required transport to the hospital for higher level of care. Resident 1 died in the hospital after 3 days on [DATE]. Resident 1's death certificate indicated the ground level fall as an underlying cause of death and C4 fracture listed as a contributing factor. Findings: During a review of Resident 1's Admission Record dated [DATE], the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of fracture of the right femur (a broken thighbone), dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), gangrene to left lower extremity (LLE, localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection), Presence of right hip artificial joint, vitamin D deficiency (lack of vitamin D), dysphagia (difficulty swallowing), acute kidney failure (sudden loss of the ability to eliminate excess salts, fluids, and waste materials from the blood), chronic [CONDITION(S)] (irregular heartbeat), [CONDITION(S)] ( [CONDITION(S)] does not create and release enough [CONDITION(S)] hormone into your bloodstream) and hypertension (high blood pressure). During a review of Resident 1's Progress Note dated [DATE], the Progress Note indicated, .Resident had a fall at [11:20 a.m.] this morning with injury to mid forehead and laceration and skin tear to left elbow. Forehead was bleeding and resident was sent to the hospital for evaluation . Skin check completed: The following New skin injury/wounds were identified: . Description: Laceration to mid forehead and skin tear to L elbow . During an interview on [DATE], at 10 a.m., with CNA 1, CNA 1 stated on [DATE] she was performing perineal care (washing of genitals and anal area) on Resident 1. CNA 1 stated she was by herself while performing care for Resident 1. CNA 1 stated she turned Resident 1 on his right side away from herself and removed Resident 1's brief. CNA 1 stated she turned her back to the resident for a second to grab a washcloth and Resident 1 rolled off the bed on the opposite side from where CNA 1 was standing. Resident 1 had sustained a laceration on his forehead, was bleeding from the head and developed a skin tear to the left elbow. CNA 1 stated the bed was about 33 inches off the floor. CNA 1 stated there was no floor matt next to Resident 1's bed. CNA 1 stated she alerted the nurse and Resident 1 was sent to the hospital for further evaluation. CNA 1 stated Resident 1 was totally dependent of care which meant Resident 1 needed two CNAs to assist with performing perineal care. CNA 1 stated Resident 1 needed a second CNA on the opposite side of the bed to prevent Resident 1 from falling of the bed. CNA 1 stated the staff were trained to use two CNAs to assist residents with perineal care for residents with a low air loss mattress (a ventilated mattress used to prevent pressure ulcers). During a review of Resident 1's Order Summary Report dated [DATE], the Order Summary Report indicated, .Air loss mattress for wound healing and to aid in prevention of further skin breakdown .order date [DATE] . During an interview with CNA 2 on [DATE], at 11:02 a.m., CNA 2 stated residents who were ordered low air loss mattresses needed to have two CNAs providing perineal care. CNA 2 stated two CNAs are needed because the resident could slip and roll off the mattress. CNA 2 stated CNAs were trained on the use of two person assist for perineal care on residents with air loss mattresses. During an interview on [DATE] at 11:19 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when a resident is on a low air mattress the resident must have two CNAs when providing care. LVN 2 stated she will also remind the CNAs to change the setting of the mattress to the firm mattress setting to prevent falls and so it is not slippery. LVN 2 stated an in-service was done by the DON. During a concurrent interview and record review on [DATE], at 11:40 a.m., with the MDS coordinator (MDSC). Resident 1's Minimum Data Set (MDS) assessment (MDS -a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level)) section G (functional assessment) dated [DATE] indicated, Resident 1's assessment for toilet use was total dependence and required a two-person physical assist. Section C (cognitive assessment) indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 2 out of 15 (,d+[DATE] scale [,d+[DATE] severe cognitive deficit, ,d+[DATE] moderate cognitive deficit, ,d+[DATE] no cognitive deficit]) indicating severe cognitive deficit. The MDSC stated Resident 1's MDS assessment indicated Resident 1 needed two people to assist with toileting. The MDSC stated Resident 1 would have needed two CNAs providing perineal care as he was totally dependent of care. During a review of Resident 1's Care Plan (direction on the type of nursing care the individual may need) dated [DATE], indicated, .Resident at risk for falls injuries d/t poor ball,. cognitive loss, lack of safety awareness, history of fall, advanced age, Dx Dementia . the resident is on a LAL (low air loss, a mattress designed to prevent and treat pressure wounds) mattress . The facility in service sign in sheet titled Low air loss mattress, dated [DATE], indicated CNA 1 received training on using a two person assist with residents on a low air mattress. During an interview with the Director of Nursing (DON), on [DATE], at 11:50 a.m., the DON stated Resident 1 need two CNAs to do perineal care on [DATE], when Resident 1 fell from the bed. The DON stated the MDS assessment indicated Resident 1 was a two person assist. The DON stated CNAs should have followed the care indicated in the MDS for Resident 1. The DON stated Resident 1 was taken to the hospital for further evaluation. The DON stated Resident 1 sustained a laceration on his forehead as well as a skin tear to his right elbow. The DON stated in service training was done on the use of two CNAs for perineal care for residents with a low air loss mattress. The DON stated she expected CNAs to follow education on low air loss mattress to provide safe care for Resident 1. The DON stated Resident 1 was expected to return from the hospital but was informed by Resident 1's responsible party (RP) the resident had died on [DATE]. During a review of Resident 1's Neurosurgery Consult Note dated [DATE], the hospital Neurosurgery Consult Note indicated, Resident 1 had a CT scan (a computerized scan used to take X-ray images to detect abnormalities in the body) showing a fracture of the C4 vertebrae (bone in the neck which controls movement of the head) and age indeterminate (fractures which are due to brittle and weak bones caused by age) fractures of T12 (bone in the back) and L1 (bone in the lower back). During review of Resident 1's History and Physical, dated [DATE], the H&P indicated, .Chief complaint Patient presents with fall .Radiology and Diagnostic Studies CT c-spine (prelim) . mildly displaced fx of the anterior endplate of the C4 vertebral body with mild widening of the anterior aspect of C4-C5 intervertebral disc space Nondisplaced fx of the C4 spinous process . During review of Resident 1's Expiration Discharge Summary, dated [DATE], the Expiration Discharge Summary indicated, Resident 1 died on [DATE] at 8:08 a.m. The hospital events leading up to Resident 1's death was increased work of breathing, desaturation (decrease in the oxygen levels in the blood) and [CONDITION(S)] (slower than normal heart rate). During a concurrent interview and record review, on [DATE], at 12:10 p.m., with the Attending Physician (AP), the AP stated Resident 1's CT scan on [DATE] showed fractures of the C4 vertebrae which could have resulted from trauma to Resident 1's neck. The AP stated the trauma to the neck could have been from Resident 1 falling from the bed resulting in a fracture to the C4 vertebrae. During a review of Resident 1's death certificate, dated [DATE], indicated, .date of death [DATE] . Cause of Death . Immediate Cause (final disease of condition resulting in death) (A) Respiratory Failure . conditions . leading to cause of death . (disease or injury that initiated the events resulting in death) . (C) Ground level fall . Other significant conditions contributing to death . C4 Fracture . Injury date [DATE] . The facility policy and procedure titled Activities of Daily Living (ADL), dated [DATE], indicated, . Based on comprehensive assessment of patient and consistent with the patient's needs and choices. The Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's condition demonstrate that such diminution was unavoidable .Activities of daily living (ADLs) include . Elimination- toileting . Patients' ADLs are evaluated by a licensed nurse and members of the interdisciplinary team upon admission and with significant change. A program of assistance and instruction in ADL skills is implemented as appropriate . A patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADLs . A patient who is unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility policy and procedure titled Falls Care Delivery Process dated [DATE], indicated, .identifying appropriate interventions to reduce risk and minimize injury . The Long Term Care Facility Resident Assessment Instrument Manuel (RAI) dated [DATE], indicated, .Items in this section assess the need for assistance with activities of daily living (ADLs) .I. Toilet use: how resident uses the toilet, commode, bedpan, or urinal; transfers on/off toilet .

Based on interview and record review, the facility failed to ensure residents receives adequate supervision to prevent falls for one of three sampled residents (Resident 55) with known [DIAGNOSES REDACTED]. This failure resulted in Resident 55 falling while trying to stand off the toilet unsupervised, sustaining a right [MEDICAL CONDITION] (broken boke), subsequent hospitalization and surgery. Findings: During a review of the clinical record for Resident 55 titled, Progress Notes dated 5/17/19, at 3:02 p.m., indicated, Staff heard yelling and screaming in the hallway bathroom. Staff went to check and notice that door is closed and resident (55) was yelling inside. Staff pushed the door little hard to open it, because resident was sitting on the floor and back was by the door. Resident was unable to explain what happened. Resident was saying in Spanish they will kill me and it hurts. resident was unable to move her R lower extremity. Resident (55) was also not allowing the staff to touch her R leg. Staff straight (sic) her up on the floor with draw sheet .resident was crying in pain . resident has Hx (history) of falls . Resident is alert with confusion due to dementia (memory loss, word-finding difficulties, impaired judgment, and problems with day-to-day activities.) The facility transported Resident 55 by ambulance to the emergency roiagnom on [DATE], at 2:15 p.m. During a review of the clinical record for Resident 55, the document titled Resident Information (a document with personal identifiable and medical information) dated 5/17/19, indicated Resident 55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 55, the document titled MDS (Minimum Data Set) Assessment (a resident assessment tool used to identify resident cognitive and physical function) dated 4/22/19, indicated the Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) score of 3 out of 15 which indicated Resident 55 had severe cognitive impairment. The functional mobility assessment indicated Resident 55 required two-person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a review of the clinical record for Resident 55, the document titled Fall Risk Care Plan dated 10/24/18, indicated, Monitor (Resident 55) for and assist (with) toileting needs. Bed and wheelchair alram due to high risk of falls. During a review of Resident 55's clincal record the document titeld Physician order [REDACTED]. During a review of Resident 55's Fall Risk assessment dated [DATE], indicated, 17.0 High Risk (for falls). During an interview with Certified Nurse Assistant (CNA 3), on 6/4/19, at 12 p.m., she stated I was assigned to (Resident 55) on (5/17/19). CNA 3 stated she had two student nursing assistants (NA) during her shift following her for a learning opportunity. CNA 3 stated Resident 55 asked her that she needed to use the toilet. CNA 3 stated the restroom in Resident 55's room was in use and she took Resident 55 to shower room in the hallway to use the toilet. CNA 3 stated she transferred Resident 55 from wheelchair to toilet with the help of the two student NA's. CNA 3 stated (Resident 55) requested privacy, so all three of us stepped out and shut the shower room door. CNA 3 stated she was standing by the shower door but did not have a visual of Resident 55. CNA 3 stated she left Resident 1 on the toilet unsupervised because she heard another resident's chair alarm going off down the hallway and went to help that resident leaving Resident 55 unsupervised on the toilet. CNA 3 stated while she was helping another resident down the hallway, she heard Resident 55 yelling, screaming and crying from the shower room. CNA 3 stated Resident 55 was unfamiliar with the shower room toilet because of her confused and was used to her bathroom. CNA 3 stated, I should have stayed with her to supervise her in the shower room. I should have sent the two NA's student to respond to the alarm. During an interview with Licensed Nurse (LN 3), on 6/4/19, at 12:50 p.m., she stated Resident 55 was totally dependent on staff for her transfer needs from one surface to another. LN 3 stated CNA 3 should have stayed in the shower room with Resident 55. LN 3 stated Resident 55 was to be monitored and supervised while using the toilet. LN 3 stated CNA 3 should have stayed in the shower room with Resident 55. During an interview with Director of Nursing (DON), on 6/4/19, at 1p.m., she stated Resident 55 had a history of [REDACTED]. DON stated Resident 55 had a known history of falls prior to admission to facility. DON stated CNA 3 should have stayed with Resident 55 in the shower room to monitor and supervise her for safety and CNA 3 did not do that. During a concurrent interview with LN 4 and clinical record review, on 6/4/19, at 2:30 p.m., she stated Resident 55 needed extensive assistance with transfers from one surface to another. LN 4 stated Resident 55 uses briefs but at times will voice need to use toilet. LN 4 stated Resident 55 should have been monitored and supervised while in the shower room by CNA 3 because of the know prior history of falls. LN 4 reviewed Resident 55's fall care plan and stated Resident 1's care plan indicates Resident 55 required supervision during toilet use, which meant CNA 3 should have stayed in the shower room with Resident 55. LN 4 stated a resident with a known history of falls and confusion may try to get up unassisted because she did not have the ability to recognize that she was not safe as Resident 55 did which resulted in the fall and broken right hip. During an interview with the Rehabilitation Director (Rehab D), on 6/28/19, at 1:35 p.m., she stated Resident 55 had dementia and was incapable of having safety awareness. Rehab D stated Resident 55 needed physical assistance by CNAs to complete her transfer needs and care tasks and should have been supervised at all times. Rehab D stated CNA 3 should have not left Resident 55 alone in the bathroom. During a review of Hospital clinical records titled Order Requisition dated 5/17/19 indicated Resident was diagnosed with [REDACTED]. During a review of the hospital clinical record for Resident 1 titled Operative Report dated 5/18/19, indicated, Procedure performed, Right Hip Open Reduction Internal Fixation (ORIF- a type of surgery used to repair the broken bones) . Pre-Op Diagnosis, right hip intertrochanteric (upper part of the femur or thigh bone) fracture comminuted (reduced to minute particles or fragments). During a review of facility Policy and Procedure titled Falls Management dated 6/4/19 indicated, Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions . monitoring to reduce risk and minimize injury. During a review of facility Policy and Procedure titled Falls: Prevention dated 6/4/19, indicated, All residents will be evaluated for falls risk through routine evaluations. Measures will be taken to reduce the risk of resident falls . Monitoring .

Based on observation, interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when the director of marketing and admissions (DMA) failed to convey Resident 1's history of prior elopements (leaving a facility without permission or supervision) to staff and licensed nurses failed to complete an admission elopement assessment according to facility policy. The facility failed to identify and assess Resident 1's risk for elopement and on 8/14/18 Resident 1 left the skilled nursing facility (SNF) unnoticed and unsupervised. As a result of this failure Resident 1 did not receive required medications and wandered about outside in temperatures that at times exceeded 100 degrees Fahrenheit for five days. Resident 1 was found by police officers on 8/18/18 at a city street seven and one half miles from the SNF. Resident 1 was transported by the police to the general acute care hospital (GACH) for an overnight stay for assessment and treatment of [REDACTED]. Findings: During a review of the clinical for Resident 1, the Admission Record (record containing resident personal information) indicated Resident 1 was a [AGE] year old admitted to the SNF on 8/9/18 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (TBI, a [MEDICAL CONDITION] caused by an outside force, usually a violent blow to the head). During a review of the clinical for Resident 1, the Progress Notes dated 8/9/18, at 4:50 p.m., indicated, Received report from (GACH) .he (Resident 1) is currently on [MEDICATION NAME] (medication to treat mental disorders and severe agitation) due to severe agitation and aggression towards staff while at the hospital .He is able to walk to the restroom . During a review of the clinical for Resident 1, the Progress Notes dated 8/9/18, at 11:47 p.m. indicated, Resident (Resident 1) arrived at the facility at approximately 16:50 (4:50 p.m.) .Resident is A/O x 1 (alert and oriented to self only, not aware of time or location), very confused . During an interview with the administrator (ADM), on 8/15/18, at 1:45 p.m., she stated Resident 1 eloped on 8/14/18. The ADM stated she interviewed staff on 8/14/18 regarding the elopement. The ADM stated during the staff interviews certified nursing assistant (CNA) 1 informed her Resident 1 was last seen in his room at 10:30 a.m. on 8/14/18. The ADM stated that CNA 2 was scheduled to take Resident 1's vital signs (blood pressure and heart rate) at 11 a.m. and was unable to locate him. The ADM stated CNA 2 noticed the sliding glass door leading from Resident 1's room to the outside was open. The ADM stated the staff then searched all interior and exterior areas of the facility. The ADM stated staff was not able to locate Resident 1 on 8/14/18. During an interview with the director of nursing (DON), on 8/15/18, at 2 p.m., she stated on 8/14/18, at 11:15 a.m. she called the local Police Department (PD) and notified the police of Resident 1's elopement. The DON stated as of 8/15/18 Resident 1 was still missing. During an interview with CNA 2, on 8/15/18, at 3:35 p.m., CNA 2 stated she was assigned to care for Resident 1 on 8/13/18 and 8/14/18. CNA 2 stated Resident 1 walked around the facility independently. CNA 2 stated Resident 1 was confused regarding his surroundings. CNA 2 stated on 8/14/18 at 11 a.m. she was unable to locate Resident 1 to take his vital signs. CNA 2 stated she looked in Resident 1's room and bathroom and noticed the sliding glass door from the bedroom to the outside was open. CNA 2 stated she was not able to locate Resident 1 and reported him missing to the ADM. During an observation and facility tour with the DON, on 8/15/18 at 4 p.m., Resident 1's room was located on the back of the building facing north. The sliding door of Resident 1's bedroom opened to a grassy area surrounded by a driveway. Across from the driveway was an empty lot next to a residential area. One block west of the facility was a rail road tracks. Across the facility, on the south was a middle school. The east of the facility was a parking lot and a driveway that went around the facility. During an interview with the DON, on 8/17/18, at 11:55 a.m., she stated Resident 1 still had not been located. The DON stated Resident 1 was prescribed [MEDICATION NAME] (medication to prevent [MEDICAL CONDITION]), [MEDICATION NAME] (medication to control high blood pressure), and aspirin (medication for mild pain and to prevent [MEDICAL CONDITION]). The DON stated Resident 1 needed the medications for his health conditions and he was not administered those medications because he was still missing. During a review of the clinical record for Resident 1, the Order Summary Report (a record containing physician's orders) dated (MONTH) (YEAR), indicated [MEDICATION NAME] Tablet 1000 MG (milligram, a unit of measure) .Give 1 tablet two times a day for [MEDICAL CONDITION] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness), [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth one time a day [MEDICAL CONDITION](hypertension, high blood pressure), Aspirin Tablet 81 MG Give 1 tablet by mouth one time a day for stroke prevention. During an interview with the DON, on 8/20/18, at 10 a.m., she stated the police of a nearby town located Resident 1 roaming the streets at about 4:30 p.m. on 8/18/18. The DON stated the police transported Resident 1 to the GACH emergency department (ED) for an evaluation of his condition. During a review of the document titled, (name of town) PD (police department) Follow-up Report dated 8/18/18, indicated Narrative . Investigation: On 8/18/18 approximately 1713 hours (5:13 p.m.) . (Name of police officer) was dispatched to (address), to assist (name of town) County Deputies who believed they had located ( Resident 1) . an elderly gentleman sitting in the back seat of his patrol vehicle who he believed was ( Resident 1) . The male was wearing the same clothes that were described on the day he was missing . I confirmed ( Resident 1) identity by department issued (brand name) fingerprint reader device and showed to be (Resident 1 and birthdate). I contacted (superior officer) who advised me to transport (Resident 1) to (GACH) . During a review of the clinical record for Resident 1, the Progress Notes dated 8/18/18, indicated At 5:20 p.m. received phone call from (local PD) that resident (Resident 1) found east side of (name of town) .This writer left the building and drive towards (GACH) .arrived at (GACH) ER (emergency room ) at 5:55 p.m.noted resident (Resident 1) was sitting on the chair in ER waiting room, holding water bottle, wear same clothes as prior to leave the facility .his clothes was very dirty, hair was dirty/tangled .speech clear but slow .L[NAME] (level of consciousness) was confused, did not keep up with conversation .Resident states, I am ok, I didn't do any wrong. Hospital staff admit resident in system . The progress note was signed by LN 2. During a review of https://www.mapquest .com (an Internet website to search for a location and directions) indicated Resident 1 was located by police on a street 7.6 miles away from the SNF. During a review of https://www.accuweather.com (an Internet website to search for weather forecast in a specific area) for (MONTH) (YEAR), indicated On 8/14/18 Actual Temp (temperature) 99°/66° (highest temperature/lowest temperature in degrees Fahrenheit), 8/15/18 Actual Temp 97°/65°, 8/16/18 Actual Temp 100°/67°, 8/17/18 Actual Temp 103°/71°, 8/18/18 Actual Temp 105°/74°. During a review of Resident 1's GACH clinical record titled, Emergency Department Reports dated 8/18/18, indicated Associated Diagnoses: [REDACTED]. History of Present Illness: The patient presents with confusion . Patient is [AGE] year old male who has a history of dementia . he wandered away from (SNF) for the last 5 days . He does have some mild [MEDICAL CONDITION]ly related to mild dehydration . The ED report indicated Resident 1 received two liters of intravenous (into a vein) fluid for treatment of [REDACTED]. During an interview with FM 1, on 8/20/18, at 12 p.m., FM 1 stated she was with Resident 1 on 8/9/18 during admission to the SNF. FM 1 stated she informed the admitting staff at that time Resident 1 had a history of [REDACTED]. Keep an eye on him because he will take off or wander off. FM 1 stated she was not certain which staff member she informed about Resident 1's history of elopement. During a concurrent interview and record review with the director of marketing and admissions (DMA), on 8/22/18, at 9:30 a.m., she stated she was a licensed nurse. The DMA stated her responsibilities included determining if the SNF could meet prospective residents' needs prior to admission by reviewing transferring facilities clinical records, communicating with the discharge planner at the GACH to determine patient needs, and completing the SNF admission agreement with a new resident or the resident's responsible party upon admission. The DMA stated she reviewed Resident 1's GACH clinical records prior to accepting Resident 1 for admission to the SNF on 8/9/18. The DMA provided a copy of Resident 1's GACH record titled Progress Notes dated 8/5/18 which indicated . (Resident 1) was with (FM 2) but has wandered and gone missing in the past . The DMA stated she was aware of Resident 1's history of wandering from home based on the GACH record. The DMA stated on 8/9/18 she handed the GACH record to one of the nurses with the history of wandering highlighted. I can't recall which nurse I gave it to. I handed the inquiry to the nurse highlighted. When I highlight the area - it stands out to me that it is significant for the nurse to know. The DMA stated she was present when Resident 1's admission papers were signed on 8/9/18. The DMA stated Resident 1 was at risk for elopement based upon the GACH clinical record. The DMA stated she should have questioned FM 1 and FM 2 regarding Resident 1's history of wandering and elopement, but she did not. During an interview with the DMA and the DON, on 8/22/18, at 11:20 a.m., the DON stated she reviewed Resident 1's GACH records on 8/18/18 and found Resident 1 had a history of [REDACTED]. The DMA stated she did not share the information regarding Resident 1's history of elopement with the DON prior to Resident 1's admission. During an interview with LN 1, on 8/22/18, at 1:49 p.m., LN 1 stated she was the nurse assigned to Resident 1 on 8/9/18, the day of admission. LN 1 stated she did not complete an elopement risk assessment because Resident 1 had not shown signs of wandering on admission. During a concurrent interview and record review with the DON, on 8/22/18, at 1:58 p.m., she reviewed the facility policy and procedure titled, OPS111 Elopement of Patient dated revised 5/15/14. The DON stated The elopement risk assessment has to be done on admission, quarterly, and annually whether the resident has signs and symptoms of wandering or not. We did not follow the policy when Resident 1 was admitted . During a review of the facility policy and procedure titled, OPS111 Elopement of Patient dated revised 5/15/14, indicated POLICY: Patients (Residents) will be evaluated for elopement risk upon admission, re-admission, quarterly and with change of condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce and minimize injury. Elopement occurs when a patient leaves the premises without authorization and/or any necessary supervision to do so . PURPOSE: To provide a process for managing patients at risk for elopement. PR[NAME]ESS: 1. Assessment/Evaluation: 1.1 Identify patient's elopement risk by reviewing the following upon admission, re-admission, quarterly, or with a significant change in conditions as defined by RAI (a resident assessment tool) Manual criteria. 1.1.1 Electronic Medical Record Systems - Nursing Assessment. 1.1.2 Non-electronic Medical Record Systems - elopement Evaluation . During a review of the facility document, undated, titled, Elopement Risk Evaluation indicated Place a (check) in the yes or no column. Able to ambulate (walk), self-propel wheelchair etc. If yes, continue. (Items listed to be checked yes or no included) Verbalizing desire to leave. Aggressiveness/Resistance to Care. Agitation/ Restlessness .Wandering History. Insists on maintaining a pre-admission lifestyle/routine (e.g. daily outdoor walks) and does not exhibit safe decision making, placing the patient at risk for elopement. Prior elopements or attempt .Cognitive (pertaining to memory, reasoning and judgment) [DIAGNOSES REDACTED].Each of the conditions in this Risk Evaluation must be considered in determining the elopement risk for the patient .Any Yes response above indicates a risk for elopement and will have an interdisciplinary care plan developed which addresses each identified risk factor.