Every finding on record at La Vida Llena

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: Expired foods were stored in the main kitchen and the serving kitchen. This deficient practice is likely to affect all 46 residents listed on the resident census list provided by the Administrator on 12/15/25 and is likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 12/15/25 at 9:07 am during the initial tour of the main kitchen revealed the following: Smal Refrigerator (Fridge): Two pink drinks in covered cups were marked use by 12/13/25. Large Fridge: One container of salsa had a use by 12/07/25 date. One container of boiled eggs had a use by 12/13/26 date. One individual package of cheese slices had a use by 12/13/25 date. B. On 12/18/25 at 1:52 pm during a follow-up observation of the main kitchen revealed the large fridge had one box of fresh spinach that had a use by date of 12/03/25.C. On 12/18/25 at 2:12 pm during an observation of the small serving kitchen, revealed the refrigerator had one container of salsa that had a use by date of 12/07/25. One medium sized container of plain yogurt expired was expired on 12/17/25. D. On 12/18/25 at 2:22 pm during an interview with the Dietary Manager (DM), he verified the expired foods and stated the expectation is the kitchen staff, including himself, be more diligent in monitoring the use by date on all foods and disposing of expired food items. He stated residents are at risk of food borne illnesses, should they receive expired food items.

Based on observation and interviews, the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) regarding residents of the 600-nursing unit, where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 12/17/25 at 9:11 am during an observation of the unit medication cart located by the fireplace in the common room, a white piece of paper with PHI containing resident's names and resident vital signs was visible to all and left unattended. B. On 12/17/25 at 9:12 am during an interview with Licensed Practical Nurse (LPN) #2, she confirmed the unattended white piece of paper contained PHI and was left visible on the medication cart. C. On 12/17/25 at 2:39 pm during an observation, the 600-unit medication cart was left unattended outside of room [ROOM NUMBER] with PHI containing full resident names, prescribed medications, and allergies visible to the public on the computer. D. On 12/17/25 at 2:40 pm during an interview with Registered Nurse (RN) #1, he confirmed the PHI contained full resident names, prescribed medications, and allergies were visible to anyone that walked by the computer. RN #1 confirmed the best practice is to ensure resident PHI is not visible to everyone. E. On 12/18/25 at 7:55 am during an observation, the daily unit census with PHI containing full resident names and room numbers was unattended and visible to anyone that walked by the 600-unit medication cart. F. On 12/18/25 at 7:55 am during an interview with LPN #3, she confirmed the PHI of resident names and room numbers was unattended and visible to anyone that walked by the 600-unit medication cart. LPN #3 confirmed this information should always be covered to protect resident PHI. G. On 12/18/25 at 10:07 am during an interview with the Director of Nursing (DON), she stated the expectation is for PHI to be protected and not to be open for anyone's ability to view.

Based on record review and staff interviews, the facility failed to protect and promote the resident's rights to dignity, self-determination, and freedom from unnecessary restrictions for 1 (R #34) of 1 (R #34) resident reviewed for restrictive devices, when: R #34, who was documented as cognitively alert and oriented, was placed on a Wanderguard (a wearable elopement-prevention tracking device) without any documentation of unsafe wandering behaviors or elopement attempts. Additionally, there was no evidence that less restrictive interventions were considered or implemented prior to applying the device.If the facility uses unnecessary restrictive measures, such as a placement of a Wanderguard on cognitively intact residents, then residents are likely to be at risk for significant psychosocial harm and restrictions. The findings are: A. Record review of the facility's Elopement and Hazardous Wandering policy, dated 07/2010, revealed the following: Elopement is a situation in which a resident with impaired cognition and/or demonstrated a lacks safety awareness or judgment successfully leaves the organization or a secured area, as defined by the organization, undetected or unsupervised by staff,All residents will be assessed for the risk of elopement through the pre-admission and/or admission process, All elopement occurrences will be documented,Assess and identify residents at risk of elopement,During the admission process residents will be assessed for risk of elopement. B. Record review of the facility's Wandering Resident Management (Wanderguard) policy, dated 08/2010, revealed the following: Restraining a resident who is ambulatory (to move from place to place) simply to prevent wandering away in unacceptable,Residents need to feel they are being allowed their freedom, although they are under very close observation at all times,Residents will be assessed for unsafe wandering/elopement upon admission, quarterly or significant changes in condition,Resident's care plan should reflect the Wanderguard and risk of wandering,C. Record review of R #34's admission Record, dated 12/19/25, revealed an admission date of 09/20/25 with the following diagnoses: Type I Diabetes Mellitus with hyperglycemia without coma (Type 1 diabetes where the body does not make insulin, causing high blood sugar levels, but the person is awake and not in a diabetic coma),Long-term use of insulin (use of insulin regularly over a long period to control blood sugar levels),Unspecified symptoms and signs involving cognitive functions and awareness (general, non-specific problems with thinking, memory, or awareness without a clear diagnosis),Dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety, (dementia of unspecified severity, without behavioral disturbance, psychotic features, mood disorder, or anxiety, is a neurocognitive disorder characterized by progressive cognitive impairment affecting memory and executive functioning, with the degree of severity not specified and no associated psychiatric or behavioral symptoms),Anxiety disorder (feelings of fear or apprehension),Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). D. Record review of R #34's Care Plan, dated 09/20/25, revealed the following: Background and customary routine (a residents usual health history and the standard or routine medical practices related to their care) prior to admission to healthcare: Resided on campus in independent living with spouse, The resident will show competency in glycogen (a substance deposited in bodily tissues as a store of carbohydrates) administration by reverse demonstration,Resident will inform nurse when she leaves healthcare (long-term care side of the facility),Resident's cognitive status is alert,Resident is an elopement risk/wander related to history of attempts to leave the facility unattended,Monitor location every 15 minutes and document wandering behavior and attempted diversional interventions in behavior log,Resident has expressed her desire to independently choose engagement of choice,Resident's daily activity preference will be maintained by R #34 and her husband,Identify pattern of wandering purposefully, aimless or escapist,Resident uses a security bracelet related to poor safety awareness and forgetfulness related to Type 1 diabetes,Resident will remain free of complications related to security bracelet use, including altered mental status, isolation or withdrawal,Ensure valid consent on chart prior to initiating restraint,Resident to remain free of complications related to security bracelet use. E. Record review of R #34's Speech Therapy Discharge summary, dated [DATE], revealed the following: Dates of service: 09/24/25 through 01/15/26, Discharge reason goals met:The Montreal Cognitive Assessment (MOCA; is a brief, standardized test used to evaluate a person's cognitive function, including memory, attention, language, visuospatial skills, executive functions, and orientation, and is commonly used to detect mild cognitive impairment or early dementia): R #34's test results were a 28 out of 30 which indicated R #34 passed the assessment and did not have severe cognitive impairments. Residents' prior cognitive assistance: no supervision needed. F. Record review of R #34's Neuropsychological Evaluation (a comprehensive assessment that evaluates various mental functions, including general intellect, language use, attention, and concentration), dated 10/23/25, revealed the following: Resident was referred for comprehensive neuropsychological evaluation regarding current cognitive and psychological functioning to provide a diagnostic clarity and assist with treatment planning,Dementia screening was negative, Medical Director (MD) at the facility agreed with the diagnosis of neuro cognitive disorder (category of mental health disorders characterized by a decline in cognitive abilities, including memory, problem-solving, and perception, often affecting daily functioning) and disagreed with the dementia diagnosis. G. Record review of R #34's PHQ-2to 9 Evaluation (tool used to screen for depression), dated 09/26/25 through 10/23/25, revealed the following: 09/26/25: 1. Feeling down, depressed or hopelessness-symptom present: Yes. 2. Feeling down, depressed, or hopeless-symptom frequency: 2 to 6 days. Assessment was incomplete.10/23/25: 1. Feeling down, depressed or hopelessness-symptom present: Yes. 2. Feeling down, depressed, or hopeless-symptom frequency: 2 to 6 days. Assessment was incomplete. H. Record review of R #34's Medical Safety Device Assessment (used for Wanderguard placement), dated 10/28/25, revealed the assessment was incomplete. I. Record review of R #34's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 09/26/25, revealed the following: Brief Interview for Mental Status (BIMS; screening for cognitive impairment) score of 15 (indicates intact cognition),Wandering, presence and frequency: behavior not exhibited,Feeling down and depressed: Yes (2 to 3 days). J. Record review of R #34's complaint intake form dated 11/07/25, revealed the following: R #34 stated she was placed on a Wanderguard and not allowed to leave her unit in the facility to attend activities offered elsewhere within the facility campus. R #34 stated she does not wish to leave the campus but feels isolated in her unit, where most residents have cognitive deficits. R #34 stated seclusion has caused feelings of depression and has negatively affected her mental health. She stated she is also unable to attend worship or socialize with people on the independent living side where she resided for four years. Facility Socials Services Director (SSD) for additional information. The SSD stated the R #34 has Type 1 diabetes and fragile blood sugars, and the facility Medical Director (MD) stated she is not safe to participate in off-unit activities. R #34's Medical Power of Attorney (MPOA; legal document which allows a person to appoint someone else to make healthcare decisions on their behalf if they are unable to make decisions themselves) agreed with the MDs decision. K. Record review of R #34's complaint intake form dated 11/13/25 revealed, R #34 stated the Wanderguard was on her ankle and was going to ask the MD to remove it. R #34 stated she would like to have more rights to do more things she enjoys, and she feels like a chained elephant in a cage. R #34 stated having a Wanderguard makes her depressed. L. Record review of R #34's facility meeting notes (with R #34, SSD, MD, MPOA, and the Administrator) dated 11/18/25 revealed the following: R #34 expressed interest in participating in on-campus activities which provide her pleasure and purpose. The MD reported multiple recent hospitalizations and concerns regarding R #34's ability to manage her Type I diabetes, despite R #34 having a BIMS score of 14 and good memory recall. The MD also noted that R #34 has been unable to consistently follow established safety protocols for leaving the unit, including checking her blood sugar, notifying the nurse, and remaining off the unit for no more than two hours. There have been instances in which R #34 left without notifying staff or signing out, which the facility considers elopement. On one occasion, R #34's blood sugar monitoring device reported critical glucose levels while R #34 was unaccounted for, requiring staff to locate her on campus. Suggestions were made for R #34 to attend activities of her choice. The MPOA stated she would refer to medical concerns as needed but declined responsibility for providing, initiating, or monitoring off-unit activities. M. Record review of R #34's complaint follow-up form dated 11/26/25, revealed the facility is working on a new safety contract so R #34 can be on campus for three hours at a time if her blood sugars are around 80 (within normal blood sugar range) before leaving the healthcare unit (long-term care). N. On 12/19/25 at 9:30 am during an interview with the Director of Nursing (DON), she stated R #34 was assessed for elopement and considered a moderate risk. The DON stated a Wanderguard was placed on R #34 after the assessment. The DON also stated there were concerns with R #34's diabetic management, including missed insulin doses and inconsistent blood sugar monitoring. The DON confirmed in order for R #34 to leave the facility, R #34 was supposed to notify staff and nursing staff were to check her blood sugar before leaving, but this did not always happen which led to R #34 experiencing a blood sugar level of 400 (abnormally high blood sugar level). O. On 12/19/25 at 12:07 pm during an interview with the MD, she stated a Wanderguard was placed on R #34 after two other less restrictive safety measures failed. The MD described periods where R #34 demonstrated clarity followed by behavioral escalation, including removal of the wander guard, attempts to elope to see her husband and dog in independent living, and aggressive behaviors. The MD stated safety concerns were more important than R #34's independence, emphasizing the need for skilled care to manage her diabetes, though these restrictions resulted in significant limitations to R #34's freedom of movement and self-determination. P. On 12/22/25 at 8:20 am during an interview with R #34's spouse, he stated R #34 is capable of independent activities within the area but requires transportation and supervision for certain outings. He stated it was his understanding if R #34 was on the long-term care side of the campus, she could leave the main building if she told a staff member. R #34's spouse stated his wife had left to attend to her dog and upon her return, the Wanderguard was placed on her leg. Q. On 12/19/25 at 3:20 pm during an interview with Licensed Practical Nurse (LPN) #2, she stated R #34 told her that she (R #34) felt like she was losing her independence due to the Wanderguard use. LPN #2 stated R #34 usually communicated her plans when leaving the unit, and her husband typically visited and walked with her in the courtyard. LPN #2 also stated R #34 wanted a sense of freedom and when she reported leaving, LPN #2 would inquire about her blood sugar and determine if medication was needed. LPN #2 confirmed R #34 was able to recognize when her blood sugar was dropping and managed accordingly. LPN #2 also stated R #34 had no issues communicating with nursing staff or other staff members. R. On 12/22/25 at 1:47 pm during an interview with the Social Services Director (SSD), she stated the MD was involved in R #34's Wanderguard placement due to behavioral and diabetic concerns and recommended psychiatric evaluations at a behavioral health hospital. She stated R #34 was having emotional moments, including crying, shaking, and becoming upset about issues important to her, particularly related to loss of her independence and Wanderguard use. The SSD stated R #34 was upset about the placement of the Wanderguard and expressed frustration about not being allowed to leave unattended. The SSD confirmed she was unaware of any elopement attempts by R #34, and R #34 had a BIMS of 15, indicating R #34 did not have cognitive concerns. S. On 12/22/25 at 1:50 pm during an interview with the Nurse Practitioner (NP) #1, she stated R #34 experienced emotional distress with crying due to R #34's loss of independence using the Wanderguard. The NP #1 stated R #34 verbalized feelings of being a caged animal and losing her independence and control of her life due to the placement of a Wanderguard.

Based on record review and interview, the facility failed to complete a significant change in condition (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 2 (R #24 and R #51) of 2 (R #24 and R #51) residents reviewed for hospice care. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: R #24: A. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language),Dysphagia (difficulty with swallowing food or liquid),Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Alzheimer's disease (a type of dementia that affects memory, thinking and behavior),Pulmonary embolism (is a blockage of an artery in the lungs). B. Record review of R #24's physician orders dated 11/17/25 indicated an order to refer R #24 to hospice for a diagnosis of Dementia. C. Record review of R #24's nursing progress notes dated 11/18/25 revealed R #24 began receiving hospice services. D. Record review of R #24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R #24 was not receiving hospice services, even though R #24 began receiving hospice services on 11/18/25. R #51: E. Record review of R #51's face sheet revealed R #51 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language),Dysphagia (difficulty with swallowing food or liquid),Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Heart Disease (describes a range of conditions that affect the heart),NSTEMI Myocardial Infarction (type of heart attack in which a minor artery of the heart is completely blocked, or a major artery of the heart is partially blocked),Peripheral vascular disease (PVD is a slow and progressive narrowing or blockage of the blood vessels),Hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides). F. Record review of R #51's physician orders dated 08/25/25, indicated an order to refer R #51 to hospice for a heart disease related diagnosis. G. Record review of R #51's hospice admission form dated 08/25/25 indicated R #51 began receiving hospice services. H. Record review of R #51's MDS assessments revealed a significant change in condition MDS was not completed after R #51 began receiving hospice services. I. On 12/18/25 at 2:02 pm during an interview with MDS Coordinator (MDSC), she stated a significant change in condition MDS should always be completed when a resident begins hospice services. The MDSC confirmed R #24 and R #51 did not have a significant change in condition MDS completed after they both began hospice services, and they should have.

Based on observations, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards for 2 (R #s 2 and 24) of 2 (R #s 2 and 24) residents reviewed for falls when the facility: Used a mechanical transfer device (a device designed to help staff move a resident from one place to another within a room or from one position to another) to transfer R #2, who did not require the use of a mechanical transfer device, which led to a fall. Failed to complete a fall risk assessment as required for R #24. Failed to follow R #24's care plan and provide a fall mat. If the facility is not using fall mats for residents' safety as care planned, completing fall risk assessments as required, and inappropriately using a mechanical transfer device, then this deficient practice could likely result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and serious harm. The findings are: R #2: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: Dementia, (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior).B. Record review of R #2's care plan dated 12/10/24 revealed R #2 is dependent on staff for most of her activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). C. Record review of R #2's Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) indicated R #2 was a one person stand and pivot transfer with gait belt (safety device used to assist individuals with mobility issues, providing support during transfers and helping to prevent falls). A mechanical transfer device was not documented as being necessary to assist R #2 with transfers. D. Record review of R #2's electronic medical record (EMR) revealed there was no documentation available that indicated R #2 required a Sara lift (also known as a sit-to-stand lift, is designed to assist partially mobile individuals in transitioning from a seated to a standing position) or any mechanical transfer device to assist with transfers. E. Record review of R #2's emergency room (ER) visit follow-up dated 12/15/25 revealed R #2 was discharged to the hospital after experiencing a witnessed fall in the facility after being transferred using a Sara lift. R #2 sustained a head injury and a skin tear to her left wrist. R #2 was discharged back to the facility on [DATE]. F. On 12/16/25 at 2:33 pm, during an interview with R #2's son, he stated R #2 recently fell, and the reason she fell had to do with her being transferred incorrectly by the facility nursing staff. R #2's son confirmed R #2 fell when she was being transferred from her bed to a wheelchair. G. On 12/16/25 at 1:00 pm during an interview with Certified Nursing Assistant (CNA) #8, he stated CNAs should be familiar with how each resident is transferred prior to transferring a resident. H. On 12/19/25 at 8:08 am, during an interview with the Director of Nursing (DON), she stated the fall experienced by R #2 occurred because a CNA used a Sara lift to transfer R #2, and R #2 does not require a Sara lift. The DON stated R #2 fell while being transferred with the Sara lift, which required R #2 to go to the hospital. The DON confirmed all nursing staff should be familiar with the transferring needs and requirements of each resident prior to assisting with a resident transfer. R #24: I. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language),Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life),Alzheimer's disease (a type of dementia that affects memory, thinking and behavior). J. Record review of R #24's care plan dated 08/10/25 revealed R #24 has had nine falls. R #24 had fallen out of bed and out of his wheelchair on multiple occasions, related to leaning forward in his wheelchair, confusion, balance problems, poor communication/comprehension, and R #24 is unaware of safety needs. Facility staff interventions for the falls included a fall mat on both sides of the bed, when R #24 is in bed. K. Record review of R #24's fall assessments located in R #24's electronic health record (EHR) revealed a fall assessment had not been completed as required for R #24 since September 2024. L. On 12/15/25 at 3:03 pm, during an interview with R #24's wife, she stated R #24 has had many falls. He has fallen forward out of his wheelchair and has sustained a head injury at least four times. R #24's wife stated she does not think the facility is preventing R #24's falls like they should be. M. On 12/18/25 at 2:30 pm, during an observation of R #24, he was observed lying in bed sleeping. R #24's fall mat was not below his bed as required and was stored against the wall. N. On 12/22/25 at 10:55 am during an interview with the DON, she stated residents are expected to have fall assessments completed upon admission, quarterly, and after each fall experienced by a resident. The DON confirmed R #24 did not have fall risk assessments completed as required and should have. The DON also confirmed R #24 should have a fall mat present anytime he is lying in bed, and he did not.

Based on observations and interviews, the facility failed to ensure staff properly stored and secured medications for all residents residing on the 600 unit when: Medication carts were not secured and left unattended during medication pass. Medications were not stored appropriately with loose medications in the medication cart. Expired medical equipment was stored in the unit medication storage room. If the facility fails to secure medication carts, properly store medications, or remove expired medical equipment, then residents are likely to experience unauthorized access to medications and the use of expired drugs, potentially resulting in injury or illness. The findings are: A. On 12/17/25 at 8:18 am, during an observation of the 600 unit, a medication cart was left unlocked and unattended outside of Room (RM) #608. B. On 12/17/2025 at 8:19 am during an interview with Registered Nurse (RN) #1, he confirmed that he left the medication cart unlocked and unattended. RN #1 stated the medication carts should not be left unlocked and unattended. C. On 12/17/25 at 12:48 pm during an observation of the medication storage room, revealed the following: Universal Viral Transport for the viruses Chlamydia (common bacterial sexually transmitted infection), Mycoplasmas (bacteria known for lacking a cell wall, making them tiny and resistant to many common antibiotics), and Ureaplasma's (tiny bacteria commonly live in human genital and urinary tracks, can overgrow or be transmitted sexually, related to mycoplasmas) testing swabs were expired and dated 05/14/25 located in drawer #2. D. On 12/17/2025 at 12:48 pm during an interview with RN #1, he confirmed the date of 05/14/25 on the testing swab, and confirmed the swab was expired. RN #1 stated all expired medical supplies, and equipment should be discarded appropriately per policy. E. On 12/17/25 at 12:48 pm, during an observation of the 600-unit medication cart, an oval light blue pill (stamped with SG) was found loose in drawer #2. F. On 12/17/2025 at 12:49 pm during an interview with RN #1, he confirmed and visualized the loose pill located in drawer #2. RN #1 stated the medication carts should be free of loose medications. G. On 12/17/25 at 9:29 am during an observation of the common area, a medication cart was unlocked and unattended. Further observation revealed the medication cart contained residents scheduled medications (oral tablets/capsules), eyedrops, inhalers, and injectable medications. H. On 12/17/25 at 9:31am during an interview with Licensed Practical Nurse (LPN #2), she stated the unlocked and unattended medication cart was her responsibility. She stated it was her expectation to lock the medication cart when it was unattended. LPN #2 stated if a resident had ingested medication not prescribed to them, the resident could have had a bad drug interaction, resulting in the resident becoming sick. I. On 12/18/2025 at 10:07 am during an interview with the Director of Nursing (DON), she stated medication carts should be always locked when nurses are away from the medication cart. The DON further stated it is also an expectation for nurses to keep medication carts clean and free from loose medications, and there should not be expired supplies in the medication rooms or carts.

Based on record reviews and interviews, the facility failed to prevent a significant medication error for 1(R #34) of 1(R #34) resident reviewed for medication errors when: The facility did not administer R #34's medications accurately as ordered. If the facility fails to review and reconcile insulin orders, discontinue prior orders, verify correct dosing parameters, and prevent duplicate orders, then residents are likely to receive incorrect insulin administration and have uncontrolled blood glucose levels, which could potentially lead to serious harm. The findings are: A. Record review of the facility's Medication Administration Assistance Policy, dated 04/2017, revealed the following: Check the medication order. Ensure proper route, dose time, strength frequency and type,A licensed nurse is to notify the resident's physician immediately of problems with medications. B. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE] with the following diagnoses: Type I Diabetes Mellitus with hyperglycemia without coma (Type 1 diabetes where the body does not make insulin, causing high blood sugar levels, but the person is awake and not in a diabetic coma),Long-term use of insulin (use of insulin regularly over a long period to control blood sugar levels),Unspecified symptoms and signs involving cognitive functions and awareness (general, non-specific problems with thinking, memory, or awareness without a clear diagnosis). C. Record review of R #34's physician orders dated 10/02/25 through 10/03/25 revealed the following:10/02/25: Insulin Glargine-yfgn (long-acting insulin used to manage blood sugar levels). Inject 15 units at bedtime for diabetes,10/03/25: Insulin Glargine-yfgn. Inject 15 units at bedtime for diabetes. D. Record review of R #34's Medication Error Incident Report dated 10/04/25 revealed the following: Wrong dose of insulin was provided to R #34. The order was to administer 15 units of long-lasting insulin, but 17 units were given,The incorrect order was not found until 10/07/25 by the physician,R #34 had low blood sugars for multiple days after the additional administration,Order was discontinued and re-written by the physician,Wrong insulin dose was administered to R #34, resulting that required immediate interventions,R #34's niece notified on 10/07/25 at 1:00 pm. E. Record review of R #34's Medication Administration Record (MAR) dated October 2025 revealed the following: 10/02/25: Insulin Glargine-yfgn (long-acting insulin used to manage blood sugar levels). Inject 15 units at bedtime for diabetes. Order was discontinued on 10/07/25. 10/03/25: Insulin Glargine-yfgn. Inject 15 units at bedtime for diabetes. Order was discontinued on 10/07/25. F. On 12/22/25 at 1:07 PM during an interview with the Director of Nursing (DON), she stated a medication error had occurred for R #34. The DON stated R #34 received a duplicate order of insulin for several days and should not have. The DON also stated it is her expectation for all residents to receive the correct medication and dosages, per physician orders.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #24 and #42) of 2 (R #24 and #42) residents reviewed when staff failed to: Obtain physician orders to initiate hospice care for R #24.Follow physician orders to administer the correct dose of a diabetic medication for R #42. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: R #24: A. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language), Dysphagia (difficulty with swallowing food or liquid), Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), Alzheimer's disease (a type of dementia that affects memory, thinking and behavior, Pulmonary embolism (is a blockage of an artery in the lungs). B. Record review of R #24's physician orders dated 11/17/25 indicated an order to refer R #24 to hospice for a diagnosis of Dementia. C. Record review of R #24's nursing progress notes dated 11/18/25 revealed R #24 began receiving hospice services. D. Record review of R #24's quarterly Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff) dated 11/20/25, indicated R #24 was not receiving hospice services, even though R #24 began receiving hospice services on 11/18/25. E. Record review of R #24's care plan initiated on 11/11/25 indicated R #24 was admitted to hospice for a terminal prognosis and multiple comorbidities (the simultaneous presence of two or more diseases or medical conditions in a person). F. On 12/22/25 at 12:38 pm, during an interview with the Director of Nursing (DON), she stated there should be a physician order for every resident to be admitted under hospice care. The DON confirmed R #24 did not have an active order for hospice care and should have. R #42: G. Record review of R #42's Comprehensive Care Plan dated 10/21/24, revealed R #42 had a diagnosis of Type 2 Diabetes Mellitus (DM2; a disease in which the body cannot make or properly use insulin) and an intervention to increase Metformin from 500 mg to 1,000 mg daily. H. Record review of R #42's physician orders dated 12/16/25 revealed an order for Metformin (medication used in diabetic management that treats high blood sugar levels) 1,000 mg (milligrams). I. On 12/17/2025 at 8:37 am during an observation, Registered Nurse (RN) #1 administered 1 tablet of 500 mg of Metformin to R #42 instead of the ordered dose (1,000 mg). J. On 12/17/25 at 8:39 am during an interview with RN #1, he confirmed he did not follow physician's orders when administering R #42's Metformin and should have. K. On 12/18/25 at 10:07 am during an interview with the Director of Nursing (DON), she confirmed the facility nursing staff should follow physician orders and administer the correct dose of medications to residents.

Based on observation, interviews, and record review, the facility failed to develop an accurate comprehensive, person-centered care plan for 1 (R #27) of 1 (R #27) resident reviewed for care planning when the facility staff failed to: Accurately reflect R #27's use of an antiplatelet medication (prevent blood clots by inhibiting the aggregation of platelets, which can help reduce the risk of heart attacks and strokes). These deficient practices are likely to result in residents not having their needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of R #27's face sheet revealed R #27 was admitted into the facility on [DATE] with the following diagnoses: Coronary Artery Disease (CAD is caused by plaque buildup in the walls of the arteries that supply blood to the heart),Paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs intermittently and resolves on its own or with treatment),Congestive heart failure (the heart is unable to supply enough blood to meet your body's needs),Peripheral artery/vascular disease (PVD is a slow and progressive disorder of the blood vessels causing narrowing, blockage, or spasms in a blood vessel can cause PVD). B. On 12/15/25 at 10:43 am, during an observation and interview with R #27, she was observed to have a bruise on both of her hands. R #27 stated she was on an anticoagulant and she bruises easily. C. Record review of R #27's physician orders dated 12/16/25 indicated R #27 was on Clopidogrel Bisulfate (an antiplatelet used to prevent blood clots, inhibiting platelets attaching together to prevent a heart attack or stroke). Give 75 milligrams by mouth in the morning for CAD. Medication was for an antiplatelet and not an anticoagulant. D. Record review of R #27's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/27/25 indicated R #27 was documented as taking an antiplatelet medication and not an anticoagulant medication. E. Record review of R #27's care plan dated 05/28/25 indicated R #27 was on anticoagulant medication therapy and was at risk from taking blood thinning medications. F. On 12/19/25 at 8:08 am, during an interview with Director of Nursing (DON), she stated she did not see in R #27's electronic medical record that R #27 was on an anticoagulant. She confirmed R #27 was care planned for taking an anticoagulant medication, but stated R #27 should be care planned for taking an antiplatelet medication because an antiplatelet is what R #27 is prescribed and taking. The DON stated an anticoagulant thins the blood and an antiplatelet assist the flow of platelets, so they don't attach to the walls, meaning both medications are significantly different.

Based on observations and interviews, the facility failed to maintain a safe, sanitary environment to prevent transmission of infectious agents and communicable diseases for 1 (R # 39) of 1 (R # 39) resident reviewed for infection control, when: The facility failed to clean and sanitize vital sign equipment (medical tools used to measure and monitor a patient's essential physiological functions; Blood Pressure Monitors and Cuffs), after use on a resident that was placed on enhanced barrier precautions (use of gowns and gloves during high-contact resident care activities). This deficient practice is likely to result in the transmission of infections agents between residents and staff.The findings are: A. On 12/18/25 at 8:24 AM, during an observation of R #39, Licensed Practical Nurse (LPN) #3 failed to sanitize blood pressure cuffs used for R #39, who is on Enhanced Barrier Precautions. LPN #3 proceeded to document the administration of medication on a facility assigned computer on top of the medication cart. B. On 12/18/25 at 8:25 AM, during an interview with LPN #3, she confirmed she forgot to clean the blood pressure cuffs after use on R #39. LPN #3 stated blood pressure cuffs should have been cleaned prior to leaving resident's room per policy. LPN #3 also confirmed R 39 is on Enhanced Based Precautions.

Based on record review, and interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #3) of 1 (R #3) resident reviewed for nutrition and weight management when: The facility failed to weigh R #3 monthly as ordered by a physician. This deficient practice is likely to lead to the resident suffering from unplanned weight loss and malnutrition which could exacerbate (make worse) other medical conditions or diseases. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the diagnosis of Multiple sclerosis (MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue).B. Record review of R #3's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 12/08/25 revealed there was not a documented weight (base weight on most recent measure in last 30 days; measure weight consistently, according to standard facility practice) for R #3. C. Record review of R #3's physicians' orders revealed the following: 11/14/24: Order for regular texture diet, thin consistency. 02/04/25: Order to weigh R #3 every month for routine monitoring.08/26/25: Order for Prostat (nutritional supplement) in the morning for wound healing; 30 milliliters (ml) by mouth twice daily. D. Record review of R #3's weight tracking located in the electronic health record (EHR) dated 03/01/25 through 12/22/25 revealed the following: 03/25/25 125.4 lbs (pounds), 04/01/25 125.4 lbs,07/01/25 120.8 lbs, There have been zero documented weights since 07/01/25. E. Record review of R #3's care plan dated 08/26/25 revealed R #3 has a potential nutrition risk due to inadequate oral intakes, non-significant weight loss, and increased nutrition needs related to wound care management. Facility interventions include following the diet as ordered, encouraging meal intakes, and weighing per physician orders. F. Record review of R #3's nutritional evaluation dated 10/25/25 revealed R #3 experienced a 3% (percent) weight loss (minus 4.6 lbs, comparison weight on 04/01/25). G. On 12/22/2025 at 10:49 am during an interview with the Director of Nursing (DON), she confirmed R #3's last documented weight in the EHR was in July 2025. The DON stated R #3 should be weighed per physician orders, and if R #3 refuses monthly weights, then that should be documented in the EHR. The DON stated R #3's weights were not being consistently monitored and should have been.

Based on interviews, observation ,and record review, the facility failed to protect 1 (R #1) of 1 (R #1) resident from exploitation and misappropriation of property by a sales consultant (SC) at a sister facility (a facility owned by the same company) who fraudulently obtained a $1,569 refund for R #1's hearing aids after her death. If the facility fails to prevent employees from misusing their positions to access and exploit resident financial information, then residents are at risk for financial harm. The findings are: A. Record review of the facility's Abuse Prevention Policy, dated 05/2024, revealed the following: - All forms of exploitation and financial abuse were prohibited, to include misappropriation of resident property. - Staff to report all suspected abuse immediately Administrator, Director of Nursing, or their designee. - Any staff involved in such allegations will be removed from their assigned duties, pending the outcome of the investigation, pending investigation. B. On [DATE] at 8:00 am, observation of the campus revealed the campus had an independent living facility, an assisted living facility, and a skilled nursing facility. Visitors did not need to sign a log to show they were in the facility and who they visited. Further observation revealed, staff and visitors could move freely throughout the three facilities. C. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 00, severe cognitive impairment. D. Record review of R #1's medical record revealed the following: - admission date of [DATE] to the Skilled Nursing facility. - Diagnoses of metabolic encephalopathy (any disease or disorder which affects the brain's function or structure), altered mental status, and congestive heart failure. - The name and contact information for three emergency contacts: Power of Attorney for Finance (POA-F; a person legally authorized to manage another individual's financial matters), Power of Attorney for Health Care (POA-HC), and another emergency contact (The emergency contact was not an employee of the facility or the corporation.) E. Record review of R #1's progress notes revealed the following: - Dated [DATE], resident was on her second day of admission. She was hard of hearing. The resident was very confused. - Dated [DATE] psychiatric evaluation. The resident came from the Assisted Living facility/Independent Living facility due to altered mental status. On [DATE], the resident was found wandering and was brought back to the facility. Facility staff requested a psychiatric evaluation and reported the resident was unstable. They reported the resident experienced confusion, anxiety, agitation, and disorganization. The resident had a comprehensive workup, but her confusion was ongoing and consistent with dementia. Assessment and Plan: altered mental status related to dementia and at risk of depression. - Dated [DATE], at 10:07 am communication with physician: the resident was lethargic, responded to her name and then went back to sleep. At 10:48 am, received verbal orders from the on-call provider to send the resident to the emergency room (ER) for evaluation and treatment. At 1:57, staff notified POA of the resident's condition and the ambulance arrived to take the resident to the hospital. - Dated [DATE], resident admitted to the hospital. - Dated [DATE], at 10:45 pm, resident was readmitted to the facility and was nonresponsive. - Dated [DATE], resident on hospice with comfort measures. At 8:02 pm, resident was visited by a POA. - Dated [DATE], resident was visited by her brother. - Dated [DATE], Resident's friend (did not state who) stepped out of the resident's room to request a nurse. Resident pronounced deceased at 4:05 pm. - Dated [DATE], Social Worker called R #1's POA-F regarding resident's purse was in the Social Services safe. F. Record review of documentation from an outside company where R #1 had a hearing aid fitting appointment revealed the following: - Internal note, dated [DATE] at 10:15 am, R #1 had an appointment and purchased new hearing aids. Fitting appointment scheduled in two weeks. - Internal note, dated [DATE] at 12:00 pm, member's grandson called to advise that R #1 was not feeling well and could not make it to the fitting appointment. The resident had heart failure and was on hospice. Grandson asked if the outside company could dispense the hearing aids without a measurement or the resident present. - Internal note, dated [DATE] at 5:30 pm, R #1 passed away before returning for fitting. Return of the purchased hearing aids to be processed by the outside company. - Receipt, dated [DATE] at 5:41 pm, the store issued a $1,569 refund for R #1's hearing aids. - Internal note, dated [DATE] at 3:30 pm, R #1's legal guardian (POA- HC) contacted the store to cancel R #1's hearing aid appointment. Store staff informed the guardian that R #1's grandson already canceled the appointment and processed the refund. The guardian stated they were unfamiliar with the grandson and requested more information. Store staff provided to the legal guardian the name and contact information of SC #1, who told the outside company he was R #1's grandson. G. On [DATE] at 12:38 pm and on [DATE] at 12:38 pm,, during an interview, R #1's POA-F stated R #1 used to be her own responsible party, but she became R #1 POA-F about in the Spring of 2024. She stated an anonymous staff alerted her around (did not remember exact date) that SC #1 purchased R#1's private residence under suspicious circumstances in [DATE]. She stated SC #1 had access to R #1's personal financial and social information through the Independent Living facility's intake process, and SC #1 used this knowledge to take advantage of R #1's vulnerability. The POA-F stated she called R #1, and the resident said she felt like she was isolated from her trusted financial and legal advisors and was discouraged from contacting them during the sale of her house. The POA-F stated she was not aware the resident's house was for sale, so she conducted research regarding the sale. She stated she found the paperwork for the sale of the house, and it showed SC #1 bought R #1's house for less than market value. She stated the resident was charged over $25,000 in closing fees from the sale of the house. The POA-F stated she believed the sales money was deposited into R #1's personal bank account. She stated could not verify the money was deposited in the resident's personal bank account, because she could not yet access that account. She stated the facility staff told her the sale of the house was approved by the corporation who owned the Independent Living and the Skilled Nursing facilities. She stated she was told the entire chain of command at the corporation and the Independent Living facility approved the sale. The POA-F stated she was not informed the house was for sale, but she expected to be notified. She stated the resident signed paperwork during the sale of the house, but she most likely signed it because she was told to sign it. She stated she met with R #1 a couple times a year, and she did not believe the resident fully understood what was happening. She stated the R #1 did not have the level of understanding to comprehend the settlement statements and representation during the sale of her house. She stated the resident was vulnerable and easily manipulated. The POA-F stated the resident was on Medicare, and the facility knew how much money the resident had. She stated the resident did not need to sell anything in order to move from the Independent Living facility into the Skilled Nursing facility, because R #1 had plenty of money. She stated there was not a reason for the resident to sell her house below market value. The POA-F stated she contacted the real estate agent who assisted with the sale of R #1's house. She stated the real estate agent became very angry and refused to speak to her. The POA-F stated she went to the visit R #1 at the Skilled Nursing facility three or four days before her death. She stated the resident was asleep when she arrived at the facility. She stated the resident could not hear and preferred to receive text messages. The POA-F stated she texted the resident a message to let her know she stopped by to see her. The POA-F stated the resident's cell phone was on her bedside table, and she saw the message come into the resident's phone. She stated the facility called her after R #1's death and said the resident's belongings were ready for pickup. The POA-F stated the resident's phone was not with her personal belongings. She stated the facility told her they could not find R #1's cell phone. The POA-F stated she still has not received R #1's cell phone. The POA-F stated she was not present at the facility when R #1 passed away, and she knew the POA-HC was not present at the facility at that time. The POA-F stated R #1 did not have any friends, and she did not know who the friend was present in the room when R #1 passed away. R #1's POA-F stated she learned of the hearing aid refund from R #1's POA-HC. She stated the POA-HC called the outside company to cancel R #1's hearing aid fitting appointment, and the outside company told him R #1's grandson already canceled the appointment and collected the refund. The POA-F stated POA-HC asked for more information about the grandson, and the outside company gave him SC #1's contact information. The POA-F stated she contacted SC #1 after she learned SC #1 deposited the $1,569 refund into his personal account rather than R #1's estate account. She stated SC #1 initially denied any knowledge of the refund. She stated SC #1 called her back several days later and admitted to collecting the refund. The POA-F stated she received a cashier's check from SC #1 by certified mail, but the check was made out to the wrong entity. SC #1 stated she was unable to cash the check. The POA-F stated SC #1 mailed the cashier's check without contacting her first, and that was why the information on the cashier's check was incorrect. The POA-F stated she did not contact the facility regarding the hearing aid refund, because she thought the online complaint report (for the State Agency) went to the facility. H. Record review of the home selling/buying website on which R #1's house was listed for sale revealed the resident's house was listed at $353,800 and was sold. I. Record review of R #1's Title Company Record of Sale for R #1's house, settlement date [DATE] and reimbursement date [DATE], revealed the following: - The seller of the house was R #1, Trustee of the R #1 revocable trust dated [DATE]; - The buyer of the house was SC #1 and one female. - Sale price of property $275,000. - The seller paid $25,082.17 in various fees. - The seller received $249, 917 for her house. J. Record review of R #1's Inventory of Personal Effects, dated [DATE], revealed the resident had one cell phone on admission to the facility. K. On [DATE] at 11:45 am, during an interview with the Executive Director, R #1's Life Care Plan [long term care service which residents can purchase which allows them to move between the levels of care (independent, assisted, skilled) as required by their medical needs] and medical record from the Independent Living facility was requested. The Executive Director stated R #1 lived in the Independent Living facility, and the Life Care Plan was a part of her records for that facility. The Executive Director stated R #1's Life Care Plan and medical record while at the Independent Living facility did not have anything to do with the resident's time at the Skilled Nursing facility. He stated the facility did not have any banking documents or statements for R #1 for her time at the Skilled Nursing facility. The Executive Director did not provide R#1's Life Care Plan, medical, and financial records from the Independent Living facility. L. On [DATE] at 12:20 pm and on [DATE] at 2:00 pm, during an interview, the Social Worker stated she was responsible to coordinate the communication with hospitals during resident discharges and admissions, to oversee the Social Services Department, and served as the facility's Admissions Administrator. She stated R #1 moved onto the campus as a resident in the Independent Living facility in [DATE]. She stated R #1 invested in the Life Care Plan while living at the Independent Living Facility. She stated SC #1 assisted R #1 with admission into Independent Living facility and with the purchase of her Life Care Plan in [DATE]. She stated R #1 lived in the Independent Living facility, went to the hospital, and then admitted into the Skilled Nursing facility. She stated R #1 moved to the Long Term Care facility on [DATE]. She stated she spoke with the discharging hospital when R #1 transferred from the Independent Living facility to the Skilled Nursing facility. The Social Worker stated the hospital staff referred to R #1's nephew, and they clarified the nephew was SC #1. The Social Worker stated SC #1 was not R #1's nephew. She stated the only staff who should speak to the hospital were the Social Worker, Administrator, or the Director of Nursing (DON). The Social Worker stated she did not know if anyone reported the hospital staff's statement to the Administration. She stated she might have mentioned it to someone, but she could not remember if she did or who she would have told. M. On [DATE] at 12:25 pm, during an interview, SC #1 stated he currently worked at the facility as a Sales Consultant at the Independent Living facility, and he was familiar with R #1. He stated he and R #1 developed a close friendship during her time at the facility. He stated he met R #1 in [DATE], and he quickly became friends with her. He stated R #1 asked him to buy her house in [DATE], and he decided that it was a good idea. He stated the Executive Administrator was aware of the purchase of the resident's home. He stated R #1 did not have any known family. He stated R #1 passed away in [DATE]. He stated he went to the outside company (where R #1 had a hearing aid fitting appointment) on [DATE], and he received a $1,569 refund deposited to his personal bank account for R #1's hearing aides. He stated he helped R #1 arrange the original purchase of the hearing aides, and he believed he acted in good faith by retrieving the refund. He stated he did not notify the facility's administration that he was going to return the hearing aides for a refund, and he stated he did not request direction from the facility's administration regarding how to handle the resident's property. SC #1 stated he mailed a reimbursement check to R #1's estate in [DATE]. He stated he communicated with the outside company before and after R #1's death regarding the canceled hearing aid order and refund. He stated he identified himself to the outside company as R #1's grandson in order to facilitate the return and refund process. N. Record review of SC #1's receipt, dated [DATE], revealed SC #1 sent a $1,569.95 cashiers' check to R #1's POA-F by certified mail. O. On [DATE] at 12:47 pm, during an interview, an Anonymous Staff stated he first met R #1 in [DATE] when the resident moved into the Independent Living facility. The Anonymous Staff stated a couple months later, R #1 told him that SC #1 bought her house in [DATE], and the resident stated He took my house. He took my house. The Anonymous Staff stated he looked up the house on a home selling/buying website and noted the market value of the house was $353,800. He stated he did his own research and found out the house was never on the market. The Anonymous Staff stated he did not mention this conversation to anyone, because he was a new employee in the Independent Living facility at the time. The Anonymous Staff stated on another occasion (did not remember the date) the resident was still living in the Independent Living facility, and her call light went off. The Anonymous Staff stated he went into R #1's apartment and found SC #1 in there with R #1. He stated SC #1 asked him to check on the resident, because he did not think the resident looked well. The Anonymous Staff stated he checked R #1, and she exhibited some confusion but was fine. The Anonymous Staff stated shortly after the incident the resident went to the hospital, and he called the hospital to check on the resident. He stated the hospital staff asked if he was the resident's POA, SC #1. The Anonymous Staff stated he was alarmed by this question so he brought his concerns to the Human Resource Director (HRD) and the Executive Director. He stated he told them R #1 reported SC #1 took her house from her. The Anonymous Reporter stated he felt uneasy, because his training as a Registered Nurse and a Mandated Reporter emphasized the importance of these concerns and how exploitation can occur. He stated the HRD and the Executive Director said Corporate staff said all was okay with the sale of the house. The Anonymous Staff stated the resident moved to the Skilled Nursing facility when she returned from the hospital. He stated he spoke to the Skilled Nursing facility's Social Worker (SW), and he told the SW about the hospital staff asking him if he was SC #1, the resident's POA. He stated the skilled nursing facility's Social Worker stated she also had a conversation with the hospital, and the hospital also told her SC #1 was R #1's nephew. The Anonymous Staff stated he was aware he was a mandated reporter and he should have reported the information to the appropriate authorities. P. On [DATE] at 2:30 pm and on [DATE] at 2:40 pm, during an interview, the Executive Director stated SC #1 worked as a Sales Consultant on the Independent Living facility side of the campus, and he was aware SC #1 purchased R #1's home in [DATE]. He stated the transaction was reported internally and investigated to ensure it was conducted by an external [NAME] and not through facility influence. The Executive Director stated it would be a concern for an employee to purchase property from a resident of the facility, so it was expected such matters would be handled with full transparency and external oversight. He stated he did not have the facility's investigation records of R #1 home sale, and the records were most likely stored at the corporate level. The Executive Director stated the sale of R #1's home was not relevant to her time at the Skilled Nursing facility, because it occurred while she was a resident at the Independent Living facility. The Executive Director stated residents sell their homes all the time to live in the facility. The Executive Director stated he did not know who the hospital contacted at the facility, because R #1 went to the hospital when she lived in the Independent Living facility. The Executive Director stated the facility's Internal Home Health Team followed up on any residents in the hospital. He stated the Internal Home Health Team coordinated services if the resident needed to go to the Skilled Nursing facility. He stated the team did not provide the hospital updates about the residents' POA matters. The Executive Director stated the hospital contacted whoever was listed as R #1's POA in her medical record. He stated he was not aware SC #1 was listed as the emergency contact/POA for R #1 while at the hospital, and he said it was not his expectation for SC #1 to be listed as R #1's emergency contact/POA. The Executive Director stated it was not his expectation for any staff from the Skilled Nursing facility or the Independent Living facility to be listed as a resident's emergency contact or Power of Attorney. The Executive Director stated he was not aware SC #1 collected $1569 for R #1's hearing aids and deposited the money into his personal bank account. He stated it was not his expectation staff would collect any money for a resident unless they were authorized, such as the Social Worker. He stated if SC #1 did collect R #1's money, then it would trigger a facility investigation involving the Corporate Compliance Team, Legal Counsel, and possibly Adult Protective Services. The Executive Director stated the facility did not require visitors to sign-in in order to enter the skilled nursing facility. He stated there were not any visitor logs to show who visited the residents during their stay. The Executive Director refused to provide R #1's records while she was a resident at the Independent Living facility, because it did not have anything to do with R #1's time at the Skilled Nursing facility

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to: 1. Properly store raw salmon. 2. Maintain expired dry storage items. This deficient practice is likely to affect all 50 residents listed on the resident census list, provided by the Administrator on [DATE], and could likely lead to foodborne illnesses in residents if food is not stored properly and safe food handling practices are not adhered to. The findings are: Food storage: A. On [DATE] at 10:00 am during an inspection of the kitchen, raw salmon was stored in a zip-lock bag above small cups of salsa in the refrigerator. B. On [DATE] at 10:15 am during an interview, the Director of Dining Services stated staff should not store the raw salmon above the cups of salsa, because it can contaminate the salsa. The Director of Dining Services stated all staff are responsible to check and make sure food was stored in the correct places so there was not cross-contamination. C. On [DATE] at 10:19 am during observation of the dry storage, revealed the following: - Four unopened and expired bottles of salad dressings were mixed with unexpired ones. - A bottle of liquid smoke with a broken seal and without a lid. D. On [DATE] at 10:20 am during an interview, Kitchen Staff (KS) #1 stated expired salad dressing should not be in the dry storage area. KS #1 stated staff should throw the salad dressing away when it expires. E. On [DATE] at 10:23 am during an interview, the Director of Dining Services stated staff should check the dry storage area every two days to ensure that expired items were not stored there. The Director of Dining Services stated unsealed items were unacceptable in the dry storage area. He stated the liquid smoke could be retained if it was adequately sealed and labeled with the date.

Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the facility failed to ensure a resident's oxygen nasal cannula [device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose] did not drag on the hallway floor while the resident sat in her wheelchair and headed to an activity for 1 (R #3) of 1 (R #3) residents. Failure to ensure nasal cannulas are not dragging on the floor of the facility could likely cause the spread of infections and illness to the resident. The findings are: A. Record review of R #3's physician orders revealed an order, dated 07/11/2023, for 2 liters per minutes continuous oxygen via nasal cannula for hypoxia (low levels of oxygen in the blood stream). B. On 09/09/24 at 10:07 am during observation of the 600 hall, R #3 sat in her wheelchair in the middle of the hallway near room [ROOM NUMBER] and propelled herself toward an activity. R #3's nasal cannula and oxygen line drug behind her on the facility floor. C. On 09/09/24 at 10:08 am during an interview with R #3, she stated she did not know her oxygen drug on the floor behind her. R #3 further stated she was grossed out the oxygen cannula that she put in her nose drug on the floor that everyone walked on. D. On 09/12/24 at 9:25 am during an interview with the facility Infection Preventionist Registered Nurse, he stated the oxygen tubing and nasal cannula should never drag on the floor. He stated it was an infection control issue due to the possible contamination of the floor with bacteria, viruses, and germs.

Based on observation, interview, and record review, the facility failed to ensure that: 1. Raw poultry and fish were stored on the bottom shelf inside the walk-in refrigerator 2. Food items were stored 18 inches below the ceiling inside the walk-in refrigerator 3. Staff preparing food were wearing hair restraints for their facial hair These deficient practices could lead to foodborne illnesses that could affect all 44 residents identified on the census list provided by the Administrator on 06/26/23 who eat food prepared in the kitchen. The findings are: A. Record review of the facility's policy titled Food Receiving and Storage, last revised 04/01/16, reported [Item] 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. B. Record review of the facility's policy titled, Food Preparation and Service, last revised July 2014, reported [Item] 7. Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. C. On 06/26/23 at 11:05 am, during an observation of the walk-in refrigerator, it was observed that a drip-proof container of raw chicken and a drip-proof container of raw fish were placed on the middle shelf above other food items including; cucumbers and pies. Additional observation of the food on the shelf revealed that food was stacked in boxes on the top shelf above the 18 inch clearance line from the sprinkler heads. D. On 06/26/23 at 11:05 am, during an interview with the Executive Chef, he confirmed that the raw meat items should be placed on the bottom food shelf. He also confirmed that when a sprinkler head is present in a room, the food should be stored 18 inches below the ceiling. E. On 06/28/23 3:30 pm, during an observation of the Sous Chef (a chef who is second in command of a kitchen), he was observed to have a beard that was approximately 2 inches in length without a hair restraint. F. On 06/28/23 3:31 pm, during an interview with the Sous Chef, he confirmed that he usually wears a beard covering but the beard coverings have been on back order. G. On 06/28/23 3:34 pm, during an interview with the Executive Chef, he confirmed that the beard coverings were on back order. He then confirmed that staff with facial hair should be wearing beard coverings and if the covering is not available, they should use a hair net instead. H. On 06/28/23 at 3:59 pm, during an interview with the Infection Prevention Coordinator, when asked what is expected for kitchen staff who have facial hair, she explained I make sure the staff are wearing beard covers. If they don't have the beard covers, I tell them to wear a mask. When asked what her expectations are for the storage of raw meats, she explained, The raw foods should be stored on the bottom shelf.

Based on record reviews, interviews, and observations, the facility failed to provide proper infection control practices by: 1. Not performing hand hygiene between resident care 2. Failing to ensure the glucometer's (a medical device to measure glucose [sugar] levels in the blood) are disinfected by manufacturer's protocol 3. Failing to properly disinfect the mobile vital signs machine after use in a resident room who was on isolation precautions (create barriers between people and germs) 4. Failing to cover clean clothes while delivering them 5. Failing to correctly pick up dirty laundry These deficient practices could likely result in the spread of infection agents (viruses and bacteria) between residents and/or staff. The findings are: Hand hygiene: A. Record review of R #193's face sheet revealed that she was admitted to the facility on [DATE] for the following pertinent diagnoses: Enterocolitis (a serious inflammation of the colon) due to Clostridium difficile (C. diff- a type of bacteria that requires patient isolation and healthcare workers caring for the patient need to wear gloves and a gown). B. On 06/26/23, at 12:09 pm, during a observation of the hall #2, Certified Nursing Assistant (CNA) #3 was observed exiting a resident's room, after delivering a lunch meal to R #193 in her room. Signage on the R #193's door identified R #193 to be on contact isolation precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room) and that a gown and gloves were required to be worn prior to entering the resident's room. CNA #3 was observed to remove gloves and gown prior to exiting the room. CNA #3 sanitized her hands using the alcohol based solution dispensed from a dispenser in the hallway, after exiting the R #193's room. No hand washing was observed to be done by CNA #3 before moving on to care tasks for other residents. C. Record review of Centers for Disease Control (CDC) and Prevention's website titled Hand Hygiene in Healthcare Settings found at https://www.cdc.gov/handhygiene/science/index.html stated the following: 1. Under the sub-section titled C. difficile [also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)] and Alcohol-Based Hand Sanitizer stated that C. difficile forms spores that are not killed by an alcohol-based hand sanitizer. 2. In the CDC's Provider Infographic (digital tool [visual aid] used that enables patients to have the required knowledge to understand information on specific diseases, procedures, and trending healthcare topics), last reviewed 05/03/16, titled C. difficile Requires Special Care stated .Always use gloves when caring for patients with C. difficile. In addition, when there is a an outbreak of C. difficile in your facility, wash your hands with soap and water after removing your gloves. D. On 06/27/23 at 8:52 am, during an observation, Licensed Practical Nurse (LPN) #1 was observed not performing hand hygiene before giving medication to R #294. E. On 06/27/23 at 8:57 am, during an observation, Registered Nurse (RN) #1 was observed placing gloves on to rub Voltaren gel (used to relieve joint pain from arthritis) on R #34's back. No hand hygiene was completed prior to putting gloves on. F. On 06/27/23 at 11:05 am, during an observation, LPN #1 was observed giving an injection to R #293 in the right upper arm. The medication given was Humalog (insulin that is fast acting used to control blood sugar), 1 unit. Gloves were put on; however, no hand hygiene was done prior to putting on her gloves. LPN #1 took the gloves off after the injection was completed, and no hand hygiene was performed. G. On 06/27/23 at 1:30 pm, during an interview with the Director of Nursing (DON), she indicated that she expects nursing staff to do handwashing before and after medications/treatments are given and hand sanitize before and after each resident. H. On 06/28/23 at 11:07 am, during an observation, RN #2 was observed going into R #293's room to obtain a blood sugar. No hand hygiene was performed prior to her placing gloves on. I. On 06/29/23 at 11:23 am, during an interview with the Infection Prevention Coordinator (IP), she indicated she expects all staff to perform hand hygiene before entering the resident's room, and when they leave the resident's room. J. Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised date of 04/25/17, stated Use alcohol-based hand rub containing 62% alcohol; or, alternatively, soap and water for the following situations: Before and after direct contact with the residents Before preparing or handling medication After removing gloves Disinfecting the Glucometer: K. On 06/28/23 at 11:07 am, during an observation LPN #1 was observed going into R #293's room to obtain a blood glucose reading. After she completed the reading, the LPN #1 wiped the glucometer down with a single alcohol wipe while in R #293's room. It was observed LPN #1 didn't allow the glucometer to dry and placed the machine back into the small, black case the machine came in. After LPN #1 completed this, she walked out of the resident's room and placed the glucometer back into the hall #2 medication cart dirty. L. On 06/28/23 at 11:15 am, during an interview with LPN #1, she was asked what she was supposed to clean the glucometer with. LPN #1 replied that she is to use an alcohol pad, and then the glucometer will be placed back in the cart. LPN #1 was also asked if this one glucometer was used on all residents. LPN #1 commented that if they had more than one resident who needed a blood sugar taken, they would use the same glucometer. At this time only one resident needed a blood glucometer reading. M. On 06/29/23 at 11:23 am, during an interview with the Infection Prevention Coordinator, she indicated that nurses should be using bleach wipes before and after they use a glucometer to ensure it is clean. Disinfecting the mobile vital signs machine: N. On 06/28/23 at 2:52 pm, during an observation, Certified Nursing Assistant (CNA) #4 was pushing a rolling vital signs machine into the isolation room of R#193 who had Clostridium difficile (C-Diff) (a bowel infection caused by toxin producing bacteria and is a serious infection that can range from mild diarrhea to severe inflammation of the colon that can be life threatening). When the CNA #4 came out of R #193's room, it was observed CNA #4 wiped down the top face (the part with the monitor), but she didn't wipe down the base, the blood pressure cuff, or the wheels of the machine and placed it back at the nurse's station on [name of unit] for others to use. O. On 06/29/23 at 11:23 am, during an interview with the Infection Prevention Coordinator, she stated that there should be dedicated equipment in the room for residents that are in isolation. If they (staff) do take the rolling vital signs machine in the room, it should be wiped down good (as expected). P. Record review of the facility's policy titled, Isolation-Categories of Transmission- Based Precautions, revised date 02/03/17, stated: Resident care equipment. When possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope (a medical device used for listening to sounds of the human body), or a sphygmomanometer (a device used to measure blood pressure) If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. 40671 Q. On 06/26/23, at 12:02 pm, during an observation of [name of residential unit], Laundry Aide #1 was observed to be delivering clean laundry to residents on the unit. The cleaned clothes were observed to be on hangers on a rolling, uncovered garment rack. The rack was pushed down the length of the unit's hallway as the clothes were delivered to several different residents' rooms. The unit was observed to be busy as several various staff members who walked by and around the garment rack in the hallway. R. On 06/27/23 at 11:54 am during observation, Laundry Aide #1 (LA) was delivering clean clothes to resident rooms; clean clothes were hanging on the cart/rack and were not covered. S. On 06/27/23 at 11:58 am during observation, a rack of clean clothes was parked in the hallway with four items of clean clothing hanging on hangers and the rack was uncovered. T. On 06/27/23 at 12:06 pm, during observation, LA #1 was observed pushing the laundry cart with clean clothes (uncovered) while carrying a clear bag containing dirty clothes in the other hand. U. On 06/29/23 at 11:23 am during an interview, Infection Prevention Coordinator stated that there are temporary disposable blood pressure cuffs (medical equipment used to for measuring a person's blood pressure) in R #193's room that are available for staff to use and then dispose of. She stated that it is not acceptable for the portable vital signs machine to be taken into isolation rooms and then not being completely disinfected after bringing it out of the isolation room. She stated that hand hygiene is expected to be done with every procedure with residents. She further stated that staff are supposed to clean the blood glucose machines (device that measures the amount of sugar in blood) every night, and after they are used; they are cleansed with the bleach wipe/cleansers; hand hygiene for rooms on isolation is expected to be done with hand sanitizer every time before they enter the room and sanitize before exiting rooms, then wash their hands at a hand washing station. She stated that the clean laundry is supposed to be covered while being delivered to resident rooms and the dirty laundry is to be taken out in closed bags. There should be a drape (a cloth cover) that goes over the clean laundry rack and that dirty laundry in bags should not be touching the ground or staff's clothing. V. On 06/29/23 at 12:24 pm during an interview, Laundry Aide #2 stated that she was not sure as to whether or not the clean laundry that is being delivered back to residents' rooms should be covered or not because she has received conflicting information from her manager and the Infection Prevention Coordinator. 40795 W. On 06/27/23 at 11:57 am, during an observation of the laundry staff, it was observed that Laundry Aide #1 was pushing an uncovered rack of clean clothes down the hall to return the clothing items to residents. X. On 06/27/23 at 11:58 am, during an interview with Laundry Aide #1, when asked if she covers the rack of clean clothes while transporting them in the hallways, she confirmed no and explained that she was never instructed to cover the clean clothes while in transport. Y. On 06/29/23 at 11:31 am, during an interview with the Infection Prevention Coordinator, when asked if clean clothing should be covered while in transport to the resident rooms, she confirmed, yes. 45426 Z. Record review of the Accreditation Standards for Processing Reusable (capable of being used again or repeatedly) Textiles (any material made of interlacing fibers) for Use in Healthcare Facilities, by The Healthcare Laundry Accreditation Council, implementation date 01/01/2016, stated on page 40: 7. Delivery of Cleaned Healthcare Textiles 7.1. Clean healthcare textiles must be transported, delivered to the customer's storage area, and stored by methods designed to minimize microbial [relating to microbes (very small living things, especially ones that cause disease)] contamination from surface contact or airborne deposition . 7.2 Delivery methods: 7.2.1. Clean textiles shall be transported in containers used exclusively for this purpose and/or including, but not limited to, any of the following methods: 7.2.1.3. Clean textiles shall be placed on a wire rack and covered with a suitable cover .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by not ensuring the facility was free from pests. This deficient practice could likely expose all 44 residents listed on the resident census, provided by the Administrator on 06/26/23, to contaminated food products and spread of disease/infection [by way of a carrier (cockroaches)], which could lead to illness in the residents. The findings are: A. On 06/26/23 at 10:51 am, during an observation of the dishwasher, small cockroaches were observed crawling on the wall behind the dishwasher. B. On 06/26/23 at 10:51 am, during an interview with Cook #1, he confirmed that cockroaches have been observed in the dishwashing area. He then explained that every first of the month they [pest control staff] spray the area for pest control but he doesn't think that is often enough. C. On 06/26/23 at 11:05 am, during an interview with the Executive Chef, he confirmed that the dishwashing area is where the cockroaches have been seen due to the moisture from the dishwashing machine. D. On 06/26/23 at 1:30 pm, during an interview with the Maintenance Staff #1, he confirmed that cockroaches in the dishwashing area have been brought to his attention and that a pest control company comes out once a month. He explained, The cockroaches come up from the sewer. We have to put screens on the drain to make sure they don't get in. The screen prevents the big bugs from getting in but it does not prevent the small bugs from getting in. E. On 06/26/23 at 1:35 pm, during a kitchen observation, the screen on the drain under the dishwashing machine was observed to not be sitting on the drain correctly. A maintenance worker had to move the food trap to fit the screen in the drain correctly. F Record review of pest control reports January 2023-June 2023 revealed that monthly treatments occur where the main kitchen area is treated for German cockroaches. G. On 06/29/23 at 12:38 pm, during an observation of the dishwashing area, the screen for the drain was not sitting properly on the drain. H. On 06/29/23 at 12:40 pm, during an interview with the Executive Chef, when asked if staff are familiar with the purpose of the screen placement on the drain, he answered no.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 4 (R #'s 17, 19, 39 and 40 ) of 8 (R #'s 17, 19, 25, 32, 35, 37, 39 and 40) residents. Failure to develop and implement a person-centered care plan could likely result in staff's failure to understand the needs, and implement the appropriate treatments for residents; possibly resulting in decline in abilities and a failure to thrive. The findings are: Resident #19: A. Record review of Face Sheet dated 11/08/21 (initial admitted ), and included the following diagnosis: Dry eye syndrome (a condition that occurs when your tears aren't able to provide enough lubrication for your eyes) of bilateral (both eyes) lacrimal glands (tear-making glands in the eyes). B. Record review of Minimum Data Set (MDS - tool used to assess the health and needs of nursing home residents) dated 11/16/22 revealed, Section I - Active Diagnoses . Dry Eye Syndrome . C. Record review of Care Plan dated 05/24/23 for R #19 revealed no care plan addressing R #19's Dry Eye Syndrome diagnosis or treatment. D. On 06/26/23 at 9:16 am during an interview with R #19's son, he stated that sometimes it seems like he (R #19) doesn't always get his eye drops. E. On 06/28/23 at 4:29 pm during an interview with the MDS Coordinator, she stated that she does the care plans for nursing and that if a resident has a diagnoses that is being treated; then the resident's care plan should address the use of medications for that condition/diagnosis. 47899 Resident #17: F. Record review of Physician's orders dated 05/04/23, revealed R #17 was on oxygen PRN (as needed) 2 liters via nasal cannula (tubing placed in the nose) as needed for hypoxia (a below-normal level of oxygen in your blood). G. Record review of care plan dated 04/26/23 for R #17 revealed no care plan addressing R #17's oxygen use. Resident #39: H. Record review of Physician's order dated 06/14/23, revealed R #39 was on continuous (all the time) oxygen 2 liters-4 liters via nasal cannula. I. Record review of care plan dated 06/05/23, revised on 06/15/23 for R #39, revealed no care plan addressing R #39's oxygen use. Resident #40: J. Record Review of Physician's orders dated 05/25/23 revealed R #40 was on Oxygen 2L/min (liter per minute) via nasal cannula at bedtime. K. Record review of care plan dated 06/14/23, revealed no care plan addressing R #40's oxygen use. L. On 06/28/23 at 4:29 pm during an interview with the MDS Coordinator, she stated that she does the care plans for nursing and that if a resident has a diagnosis that is being treated, then that resident's care plan should address the use of medications or treatments for the condition/diagnosis.

Based on record review and interview, the facility failed to complete an accurate baseline care plan for 1 (R #193) of 1 (R #193) resident reviewed for baseline care plans. This deficient practice could likely result in staff not being aware or familiar with resident needs and/or preferences. The findings are: A. Record review of the facility's policy titled Care plans - Preliminary [baseline], last revised 05/22/17, maintained A preliminary [baseline] plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. B. Record review of R #193's face sheet revealed that she was admitted to the facility on [DATE] with the following pertinent diagnoses: Enterocolitis (a serious inflammation of the colon) due to Clostridium difficile (C. diff- a type of bacteria that requires patient isolation and healthcare workers caring for the patient need to wear gloves and a gown), anxiety disorder (a mental health condition where individuals feel fearful or dread), Insomnia unspecified (a sleep disorder that prevents you from sleeping at night), chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), and chronic respiratory failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). C. Record review of R #193's physician visit, dated 06/09/23, revealed that R #193 had tested positive for C. diff and was being treated prior to admission. The signs and symptoms of C. diff were still present so the plan to treat included continue isolation until without diarrhea x [for] 48 hours D. Record review of the baseline care plan, dated 06/08/23, revealed the following documented items: 1. Resident requires assistance with activities of daily living . 2. Potential for falls/injuries . 3. Potential for skin breakdown . 4. Potential for weight loss . 5. New [to] facility and needs time to adjust . E. On 06/28/23 at 11:07 am, during an interview with the Minimum Data Set (MDS) nurse, she explained that upon admission, the floor nurse creates a baseline care plan after completing their admission assessment. When asked if the 48 hour baseline care plan should include information that is pertinent to the resident's reason for admission, she confirmed yes. When asked if isolation and contact precautions should be be included on the 48 hour care plan, she confirmed yes.

Based on record review and interview, the facility failed to provide a comprehensive care plan after seven (7) days of completing the MDS assessment for 1 (R #193) of 1 (R #193) resident reviewed for comprehensive care plans. This deficient practice could likely result in staff not being aware of a resident's needs and preferences. The findings are: A. Record review of the facility's policy titled Care Plans--Comprehensive, last revised 05/22/17, revealed [Item] 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS- Minimum Data Set- a collection of information that reflect the resident's status). B. Record review of R #193's face sheet revealed that she was admitted to the facility on [DATE] for the following pertinent diagnoses: Enterocolitis (a serious inflammation of the colon) due to Clostridium difficile (commonly referred to as C. diff- a type of bacteria that requires patient isolation and healthcare workers caring for the patient need to wear gloves and a gown); anxiety disorder (a mental health condition where individuals feel fearful or dread), unspecified; Insomnia, unspecified (a sleep disorder that prevents you form sleeping at night); chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), unspecified; and chronic respiratory failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). C. Record review of R #193's Physician's note, dated 06/09/23, revealed that R #193 had tested positive for C. diff and was being treated prior to and during admission. The signs and symptoms of C. diff were still present so the plan to treat included continue isolation until without diarrhea x [for] 48 hours D. Record review of Physician orders revealed the following medications: Physician's order, dated 06/08/23, Temazepam - Schedule IV (a controlled substance that acts as a sedative for sleeping), capsule; 15 mg; amount: 1 tab; oral Physician's order, dated 06/08/23, Oxygen 2.5L (liter) via NC (nasal cannula) QHS (every night at bedtime), Twice A Day, 08:30 PM - 10:30 PM, 10:30 PM - 06:30 amPhysician's order, dated 06/08/23, Escitalopram oxalate (an antidepressant/anti-anxiety medication) for anxiety tablet; 20 mg; amount: 1 tab; oral E. Record review of the Minimum Data Set (MDS) assessments revealed that R #193 had a completed assessment on 06/15/23. F. Record review of care plan, last revised on 06/20/23, revealed that the following items were documented: 1. Activities deficit r/t (related to) decreased interest in group activities d/t (due to) gastrointestinal disorders, pain and weakness 2. [Name of resident] is independent with feeding self. She is at potential risk for altered nutrition . Further review of the care plan revealed that the care plan did not include information related to: 1. C. diff isolation precautions 2. The resident's physician order for antidepressant medications 3. The resident's physician order for oxygen. G. On 06/28/23 at 11:07 am, during an interview with the MDS nurse, she explained that seven (7) days after the resident is admitted , she completes the initial MDS assessment. She then collects all data required to complete the care plan 14 days after admission. By the 21st day after admission, the full care plan is made.

The facility failed to ensure that food was prepared and served under sanitary conditions. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of L being identified at 06/27/16 at 11:44 am The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal. Based on the Plan of Removal, interventions included: 1. Facility stopped washing all dishware in the main kitchen. 2. Contacted repair technician for immediate repair of the dishwasher. 3. All dishware, pots and pans will be washed in the healthcare kitchen. 4. Temperatures and sanitizer will be monitored before each meal. 5. All staff will be educated on the importance of sanitation, how to check the sanitation concentration, documenting and how to prime (to run fluid through the tubing) the machine. On 06/27/16 at 12:55 pm, the Plan of Removal was received and accepted. Administrator notified at this time that IJ scope and severity decreased from L to F. Based on observation, interview and record review the facility failed to: 1) ensure that fish was thawed properly, 2) ensure all dishware was properly sanitized and 3) document the parts per million (PPM) of sanitizing chemical solution on the log sheet. These systemic failures had the potential to create a risk for cross contamination and food borne illness which had the ability to affect 44 out of 45 residents that eat food prepared in the kitchen. Residents were identified on the Resident Census list provided by the Administrator on 06/21/16. The findings are: A. On 06/27/16 at 9:35 am, during observation of the kitchen, it was observed that the fish were being thawed in a sink full of water. B. On 06/27/16 at 9:45 am, during an interview with the Dietary Manager (DM), she stated that the proper procedure to thaw meat of any kind would be to thaw it in the refrigerator although having meat in a compartment sink with cold water running over the meat or ice on the bottom would be ok if the refrigerator was not an option. The DM stated that what she meant by it (the refrigerator) not being an option was someone forgetting to pull the meat in time for the next meal and they needed it thawed right away. C. During record review of the 2013 Policy and Procedure Food Storage Section, it stated, Safe Thawing: Frozen meat, poultry and fish should be defrosted in a refrigerator for 24 to 48 hours and, should be used immediately after thawing. D. On 06/27/16 at 10:00 am, during an interview with the kitchen staff (KS) #1, he stated that the fish had been in the sink since 8 am. He also stated that the water had been running but someone had turned it off. He was not aware of the time that the water had been turned off. The DM checked the temperature of the thawed fish and it was 45 degrees. The DM pulled the fish and did not serve it. E. On 06/27/16 at 10:10 am, during observation of kitchen staff #2, he began to test the dish machine sanitizing concentration with test strips. Five test strips were used and all five of the test strips indicated that no sanitizing solution was being used in the dishwasher to sanitize the dishes and pots and pans. F. On 06/27/16 at 10:16 am, during an interview with kitchen staff #2, he stated that the strips he was using were old and he left to find new test strips. When he came back, he stated that he had new test strips and checked the sanitizing concentration again. The test strip still indicated that there was no sanitizing solution being used in the dishwasher. G. On 06/27/16 at 10:17 am, during observation of the DM, she checked the dishwasher during the wash cycle and the test strip indicated that there was no sanitizing solution being used in the dishwasher. H. On 06/27/16 at 10:18 am, during observation of the DM, she told kitchen staff #2 that all the dishes being run through the dishwasher needed to have the sanitizer added by hand and that all of the dishes, pots and pans that had been washed previously, needed to be washed again. I. Record review of the PPM log sheet dated June 2016 indicated that the sanitizer concentration level had not been checked from 06/24/16 to 06/27/16. J. On 06/27/16 at 10:33 am, during interview with the DM, she stated that sometimes, if the dishwasher runs out of sanitizer, the machine has to prime and have a cycle run several times to restore the sanitizer function. The DM stated that she did not know how long the dishwasher had no sanitizer. She stated that the dishwasher water temperature and sanitizer concentration should be checked at least three times a day but verified that it had not been checked since 06/24/16. She stated that the sanitizer ppm (parts per million) concentration should be between 100-200. The DM stated that when the sanitizer was checked that morning, the sanitizer levels were not registering on the test strips which meant there was no sanitizer in the machine and that the machine needed to be fixed immediately as this meant that items washed in the dishwasher were not being cleaned and sanitized properly. K. On 06/27/16 at 11:08 am, during interview with the DM, she stated that pots, pans and steam table trays are washed in the dishwasher in the main kitchen (the machine with no sanitizer) and that residents on the healthcare side of the facility are served from these pots, pans and steam table trays. L. On 06/27/16 at 11:14 am, during interview with the Food Production Manager, she stated that when food is being thawed in the sink, this should be done with water that is constantly running. She stated that the fish that was being thawed this morning was being thawed inappropriately and that she had thrown out the fish when she saw that it was thawing in a sink in still water and that the temperature of the fish was 46 degrees Fahrenheit. She also stated that she did not work Friday or Saturday and is unclear why the kitchen staff had not logged the concentration of the sanitizer since the evening shift on 06/24/16. She stated that the concentration should be logged three times per day and that she does random checks of the concentration. She also stated that she had worked on Sunday but she had not checked the concentration in the dishwasher or the log. M. On 06/27/16 at 11:22 am, during interview with the DM, she stated that the trays on the steam table (where the food is stored prior to serving) are washed in the main kitchen in the dishwasher that was not functioning. The DM stated that she was preparing to serve the food from the steam table but acknowledged that she had no way of knowing if the steam table trays, pots and pans had been properly sanitized. The DM stated that she would serve sandwiches instead of the meal that had been planned since she was unsure of whether the dishes had been sanitized properly. N. On 06/27/16 at 11:30 am, during interview with the Administrator, she stated that the dishwasher technician informed her that the sanitizer had run out of the dishwasher and that, as a result, the dish machine did not have any sanitizer to pull from. She stated that the technician replaced the sanitizer, primed the machine and ran several wash cycles and that the concentration levels were now in range. O. On 06/27/16 at 12:46 pm, during interview with the dishwasher repair technician, he stated that when the sanitizer is run dry and there is no sanitizer left in the bucket, tubing or the dispenser, then just replacing the empty bucket of sanitizer with a full container will not fix the problem. The sanitizer bucket needs to be checked and replaced before it is run dry. He stated that the new bucket of sanitizer needed to be primed before it would run through the machine.