Every finding on record at Legacy Post Acute Care

Based on interview and record review, the facility failed to ensure timely reporting of an abuse allegation incident, to the California Department of Public Health (CDPH), for one of four sampled residents (Resident 1). This failure interfered with the timely investigation of abuse allegation and had the potential to prevent further abuse.The alleged abuse incident occurred on 2/25/26 at around 6 a.m. and the facility reported the incident to CDPH on 2/26/26 at 8:40 a.m.Findings:During a review of the facility's abuse incident fax report, dated 2/26/26, the fax report indicated that a report to CDPH was faxed on 2/26/26 at 8:40 a.m. regarding an alleged abuse incident involving Resident 1. During a review of Resident 1's face sheet, dated 4/3/26, the face sheet indicated Resident 1 has stage 4 kidney disease (severe kidney failure), anxiety, and dementia (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain).During an interview on 4/2/26 at 11:35 a.m., with Director of Nursing (DON), DON stated the alleged abuse on Resident 1, occurred the morning of 2/25/26 at around 6 a.m. and it wasn't until the next day, on 2/26/26, that the facility's Director of Staff Development [DSD] was made aware of the alleged incident.During interview on 4/2/26 at 12:26 p.m., with Certified Nursing Assistant (CNA)1, CNA 1 stated that she witnessed CNA 3 pull Resident's 1 hair during activities of daily living (ADL) care (self-care tasks such as bathing, dressing, getting out of bed and toileting) on 2/25/26. CNA 1 stated she told CNA 2 about the incident the next day, 2/26/26. CNA 1 stated she told CNA 2 that she had 24 hours to report the incident.During an interview on 4/2/26 at 1:50 p.m., with Director of Staff Development (DSD), DSD stated that she received a call on 2/26/26, from CNA 2 stating that CNA 1 had told her that she saw CNA 3 pull patient's hair during the morning of 2/25/26. DSD stated that on the morning of 2/26/26, she then called CNA 1 to write a statement of the incident. DSD stated that the alleged abuse reporting should have been reported immediately, and that the alleged abuse incident reporting was delayed, and did not meet the facility's abuse training and policy expectations.During an interview on 4/3/26 at 1:33 p.m., with CNA 2, CNA 2 stated that CNA 1 had mentioned to her that she witnessed CNA 3 pull Resident 1's hair but CNA 1 had not reported the incident. CNA 2 stated she told CNA 1 that she had to report the incident immediately. CNA 2 stated she notified the facility's DSD in the early morning of 2/26/27 of the alleged abuse incident. CNA 2 stated that alleged abuse reporting needs to happen immediately, and failure to report could put residents and the staff at risk of harm.During an interview on 4/3/26 at 2:26 p.m., with the Director of Nursing (DON), DON stated that CNA 1 did not report the abuse allegation to her directly. DON stated that DSD had called CNA 1 the day following the alleged incident [on 2/26/26] and DSD requested CNA 1's written report of the incident. DON stated that it was unacceptable to delay any abuse reporting, and the delayed reporting (of Resident 1's alleged incident) did not meet her expectations.During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revision dated 12/2016, the P&P indicated, All reports of resident abuse. shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.During a review of the facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, dated 11/2016, the P&P indicated, It is the responsibility of all employees to immediately report to facility administrator, and to other officials in accordance with Federal and State law, any incident of suspected or alleged abuse.All reports shall be timely and thoroughly investigated.

Based on interview and record review, the facility failed to provide Resident 1's requested copies of medical records in a timely manner when Resident 1 submitted a request for his medical records in January 2025 and did not receive the records until June 2025. This failure resulted in a delay in obtaining Resident 1's medical records. Resident 1 received the medical records from the facility three days before a scheduled court date, which did not allow him sufficient time to prepare and share the information with the judge.Findings:During a record review of Resident 1's admission Record (AR) printed on 12/3/25, the AR indicated Resident 1 was admitted to the facility on [DATE] and discharged on 11/25/2022. During a phone interview on 12/3/25 at 9:24 a.m., Resident 1 stated that in December 2023 he verbally requested copies of his medical records from Administrator (ADM) 1. Resident 1 also stated that in mid-January 2024, he went into the facility and submitted a written request for copies of his medical records with the facility's receptionist. During a phone interview on 12/3/25 at 9:30 a.m., Resident 1 stated in January 2024, the Facility's Attorney (FA)1 contacted him and told him he no longer needed to go into the facility and that she would facilitate any medical record requests he had made from the facility. During a phone interview on 12/3/25 at 9:35 a.m., Resident 1 stated he informed FA 1, both verbally and by e-mail, that he wanted a copy of his medical records. Resident 1 stated there were several subsequent emails and text messages sent to FA 1 and to other attorneys of the facility making the same request for his medical records. During a phone interview on 12/3/25 at 9:33 a.m., Resident 1 stated he received the medical records in mid-June 2025, which was three days before his scheduled court date. During a phone interview on 12/4/25 at 9:09 a.m., Resident 1 stated he went into the facility and handed his written request for medical records to the receptionist in January 2025. Resident 1 stated at that time, no one asked him to sign a consent form. During an interview on 12/4/25 at 9:55 a.m., Receptionist stated in January or February 2025, Resident 1 came into the facility one afternoon and dropped off a lined piece of notebook paper with handwriting on one side, asking her to give it to ADM 2. The Receptionist stated she did not read the content of the paper and gave the paper to ADM 2. During an interview on 12/3/25 at 10:11 a.m., Medical Record Coordinator (MRC) stated that in early 2025 she received a call from Resident 1 requesting his medical records. MRC stated she told Resident 1 he would need to come into the facility to complete a consent form titled HIPAA (Health Insurance Portability and Accountability Act) Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508. MRC stated she had not released Resident 1's medical records. MRC stated she had never seen Resident 1 nor received the completed consent form. During a concurrent interview and record review on 12/3/25 at 10: 30 a.m., with MRC, emails between the Administrator (ADM) 1 and MRC were reviewed. An email dated 2/6/25 indicated ADM 1 instructed MRC to gather Resident 1's complete medical record for the defense firm. A subsequent email dated 2/21/25 indicated that MRC sent the Electronic Medical Record (EMR) of Resident 1 to ADM 1 on that date. During an interview on 12/3/25 at 11:37 a.m., MRC stated medical records should be provided to a resident within 72 hours of a request being made. During a phone interview on 12/4/25 at 10:43 a.m., with FA 1 and FA 2, FA 1 stated she formally received Resident 1's request for his medical records on 7/15/25 via email from Legacy Post Acute Care. FA 1 stated Resident 1 received his medical records via certified mail on 7/22/25. FA 1 stated she could not provide the certified mail receipt due to the presence of resident information. A review of the facility's policy titled Request for Resident Records, no revision date, the policy stated, Requests can be honored without an authorization if they are for the purposes of treatment, payment or health care operations. This may occur when a resident's protected health information is needed for a transfer to another health care institution or clinic (for continuity of care purposes), when required by law, for thirty party payment, or when requested by the resident (including the legal representative).

Based on interview and record review the facility failed ensure that one of six sampled residents' (Resident 69) medical record contained a current copy of Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated). This failure had the potential for Resident 69 to be placed at risk of receiving unwanted treatment and not receiving appropriate care based on his wishes. Findings: During a review of Resident 69's undated Admission Record, the Admission Record printed on 1/8/25 indicated, Resident 69 was admitted in the facility 12/2024 with an admission diagnosis of cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). During a record review of Resident 69's Minimum Data Set (MDS- an assessment used to guide plan of care) dated 12/9/24, MDS indicated Resident 69's Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating intact mental status. During a concurrent interview and record review on 1/8/25 at 9:29 a.m. with the Social Services Director (SSD) in the SSD's office, Resident 69's Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration.) dated 12/3/24 was reviewed. The POLST indicated, Resident 69's undated Advance Directive was available and reviewed. SSD stated Resident 69's Advance Directive copy was not uploaded in the Electronic Health Record. During a concurrent observation and interview on 1/8/25 at 9:33 a.m. with the SSD in the nursing station, SSD flipped through Resident 69's paper chart looking for the copy of Advance Directive. SSD stated the copy of Resident 69's Advance Directive was not in the paper chart. SSD stated, the Medical Records Director (MRD) audits the POLST and follows up getting a copy of Advance Directive from the family. During a concurrent observation and interview on 1/8/25 at 9:37 a.m. with MRD in MRD's office, MRD checked Resident 69's EHR and paper chart. MRD stated, the copy of Resident 69's Advance Directive was not in the EHR nor in the paper chart. During a follow up interview on 1/8/25 at 2:12 p.m. with SSD, SSD stated, the copy of Resident 69's Advance Directive was emailed today by his wife. SSD stated the purpose of having a copy of the Advance Directive in the facility for the facility to know who the healthcare decision maker for the resident in case of emergency. During an interview on 1/9/25 at 9:00 a.m. with Resident 69 in Resident 69's room, Resident 69 stated, it was important for the facility to have a copy of his Advance Directives as it would serve as a guideline to staff of what he wants if something suddenly happened to him. During an interview on 1/9/25 at 9:12 a.m. with Registered Nurse (RN) 2, RN 2 stated, it was important to have the copy of Advance Directive accessible to staff as fast as possible to know what to do for the resident during an emergency. During a review of the facility's policy and procedure (P&P) titled Advance Directives, dated 12/16, the Advance Directive indicated, 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family member and/or his or her legal representative, about the existence of any written advance directive.

Based on observation, interview, and record review the facility failed to follow their infection prevention control policy and protocol when nursing staff did not transport one out of five residents' (Resident 21) personal clothes in a clean linen cart used for transportation. The failure had the potential to cause cross contamination and spread of infection among the residents. Findings: During an observation on 1/8/2025 at 12:18 p.m. in the hallway near the laundary room, adjacent to room [ROOM NUMBER], Housekeeper/Laundary Staff (HKLS) held residents clothing, without gloves, about 5 to 6 of them, on clothes hangers, close to his body and walked down the hallway from the laundry room to Resident 21's room. There were other staff, two residents seated in their wheelchairs in the hallway, a housekeeper cleaning cart and a lunch tray cart in the hallway. During an observation on 1/6/2025 at 10:32 a.m., Resident 25, Resident 70, Resident 55, Resident 15, Resident 1, and Resident 4 were on Enhanced Barrier Precautions in the same hallway as Resident 21. During a review of the facility's list of Residents on Enhanced Barrier Precautions on 1/8/2025 at 1:00 p.m, the facility's list of Enhance Barrier Preacaution indicated 12 Residents on Enhanced Barrier Precautions, which included Residents 25, 70, 55, 15, 1, 4, and 33. During an interview on 1/8/2025 at 10:29 a.m, with Infection Control Preventionist (IP) Nurse, IP stated the facility had a COVID outbreak from around December 1, 2024 to January 7, 2025. IP further stated facility had 32 residents and 15 staff test positive for COVID, and the facility was still waiting to get cleared by the County. During an interview on 1/8/2025 at 12:26 p.m. with HKLS, HKLS stated he has been trained to handle clean laundry without using clean laundry transport cart. HKLS stated this is how he does it and also stated the clothes he was transporting were room [ROOM NUMBER] A's clothing. During an interview on 1/8/2025 at 12:33 p.m., with HouseKeeper/Maintenance Supervisor HKS, HKS stated the residents' clean laundry should be transported in a cart, covered during transport. During an interview on 1/8/2025 at 12:45 p.m. with IP and Director of Staffing Development (DSD) , both DSD and IP stated laundry should be separated by soiled laundry and clean laundry. DSD further stated clean resident laundry should be transported to the resident's room in a clean cart. During an observation on 1/8/2025 at 12:55 p.m., HKS walked into the facilty from the parking lot with his laundry apron on and walked down the hallway heading towards the laundry room. During an observation on 1/9/2025 at 08:57 a.m., HKS walked out of the facilty to the parlking lot with his laundry apron on. During an observation on 1/9/2025 at 09:17a.m., HKS walked back into the facility with the same laundry apron on and resumed work.

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 01/07/25, three medication errors were observed out of twenty-six opportunities for two out of five residents, resulting in an error rate of 11%. This failure had the potential to result in harm in the health and safety of residents. Findings: 1. A review of the manufacturer's insert for Breyna (Budesonide-Formoterol) indicated that Breyna is a medication used to help people with asthma and COPD (chronic obstructive pulmonary disease) breathe easier. The insert emphasizes that it is essential to hold the breath for 10 seconds after administration to ensure the medication is properly absorbed. Omitting this instruction could compromise the medication's effectiveness and potentially impact the resident's treatment outcomes. During an observation on 1/7/25, at 8:15 AM, it was noted that RN1, while administering Breyna to Resident 31, did not instruct the patient to hold their breath for at least 10 seconds after inhalation. RN1 handed the inhaler to Resident 31, and although he held his breath, he did not hold it for the recommended 10 seconds as specified by the manufacturer. According to the manufacturer's website, when administering two puffs of Breyna, patients should wait at least one minute between puffs to ensure proper medication delivery and effectiveness. This waiting time is crucial for allowing each dose to disperse and be absorbed by the lungs, maximizing the therapeutic benefits of the medication. Waiting one minute between puffs also helps prevent potential side effects associated with incorrect medication administration, such as local irritation or systemic absorption of the medication. During an observation on 1/7/25, at 8:15 AM, it was noted that RN1 did not wait between puffs when administering two puffs of Breyna to Resident 31. Allowing sufficient time between each puff is crucial for the medication to disperse effectively in the respiratory system. By not waiting, the delivery of the medication may have been hindered, potentially affecting the treatment's efficacy. It's important to follow proper techniques when administering inhaled medications to ensure the best possible therapeutic outcomes for the patient. During an interview conducted on 1/7/25, at 8:30 AM, RN 1 acknowledged that she did not instruct Resident 31 to hold their breath for at least 10 seconds after using the Breyna inhaler. Additionally, she admitted that she did not wait the recommended one-minute interval between puffs when administering the inhaler. RN 1 stated that she will adhere to these proper administration guidelines in the future. 2. A review on 1/7/25, of the manufacturer's insert for Dorzolamide (Dorzolamide is an eye drop used to lower high pressure inside the eye in people with open-angle glaucoma or ocular hypertension) indicated that the tip of the bottle should not make contact with any surface, including the eye or surrounding area. This precaution is essential to maintain sterility and prevent contamination of the medication, which could potentially lead to adverse effects such as eye infections. Proper administration technique, as outlined by the manufacturer, is critical for ensuring the safety and efficacy of the medication. During an observation on 1/7/25, at 9:15 AM, Licensed Vocational Nurse 1 (LVN1) administered one drop of dorzolamide in each eye to Resident 35. However, LVN1's technique was flawed, as they held the bottle's tip too close to the resident's eyelashes. Consequently, the eyedrop made contact with the eyelashes rather than landing directly in the eye as intended. Proper administration of eyedrops requires maintaining a short distance between the dropper and the eye to ensure the medication reaches the intended target. During an interview conducted on 1/7/25, at 9:30 AM, LVN 1 admitted that she accidentally touched the tip of the eye drop bottle to Resident 35's eyelashes. She stated that she will ensure this does not happen again and that she will be more careful in the future. 3. A review on 1/7/25 of the manufacturer's insert for QVAR, proper administration involves instructing the patient to fully exhale before inhaling the medication from the inhaler. After inhalation, the patient should be advised to hold their breath for at least 5 to 10 seconds. This practice ensures effective absorption of the medication into the lungs, optimizing its therapeutic benefits. Healthcare professionals must adhere to these guidelines to maximize the medication's benefits and minimize the risk of potential adverse effects. QVAR is an inhaler medication used to prevent asthma attacks by reducing inflammation in the airways. During an observation on 1/7/25 at 9:15 AM Licensed Vocational Nurse 1 (LVN1), administered QVAR inhaler to Resident 35. It was observed that LVN1 did not instruct the resident to exhale before inhaling the medication. As a result, the resident did not exhale prior to inhaling the medication. Additionally, LVN1 did not instruct Resident 35 to hold their breath for 5 to 10 seconds after inhalation, which is an essential step to ensure proper absorption. Consequently, Resident 35 did not hold their breath for the recommended duration, potentially compromising the medication's effectiveness. Adhering to proper administration techniques is crucial for optimal therapeutic outcomes, as outlined by the manufacturer's instructions and professional guidelines. During an interview conducted on 1/7/25, at 9:30 AM, LVN 1 stated that she did not instruct Resident 35 to exhale prior to using the inhaler or to hold their breath for 5-10 seconds after inhalation. She acknowledged the oversight and stated that she will adhere to proper administration techniques in the future.

Based on interview and record review, the facility failed to provide a written summary of the baseline care plan to one of five sampled residents (Residents 59) when Resident 59 did not receive a copy of the summary. This failure resulted in Resident 59 to be uninformed of the initial plan of care and services. Findings: During a review of Resident 59's undated Admission Record, the Admission Record printed on 1/8/25 indicated, Resident 59 was admitted in the facility on 12/15/24 with an admission diagnosis of metabolic encephalopathy (a brain dysfunction that occurs when there's an imbalance of chemicals in the blood, usually due to an underlying medical condition.). The record indicated, Resident 59 was their own responsible party (RP or legal guardian). During a record review of Resident 59's Minimum Data Set (MDS- an assessment used to guide plan of care) dated 12/21/24, the MDS indicated Resident 59's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 14 out of 15, indicating intact mental status. During an interview on 1/8/25 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the baseline care plan summary was discussed to the resident and RP during the Interdisciplinary Team (IDT) Care Conference. LVN 2 stated, copy of the baseline care plan summary was provided to residents or RP upon request. During a concurrent interview and record review, on 1/8/25 at 12:36 p.m. with the Minimum Data Set Coordinator (MDSC) 1, Resident 59's Interdisciplinary Team (IDT) Care Conference Notes dated 12/18/24 was reviewed, the IDT Care Conference Notes indicated, Baseline Plan of Care was not given to the resident and/or RP. The MDSC 1 stated, Resident 59's daughter attended the IDT Care Conference via telephone. The MDSC 1 stated, the Baseline Care Plan Summary was not provided to Resident 59's daughter because she did not request a copy. During a review of Resident 59's Baseline Care Plan Summary dated 12/15/24, indicated, resident or RP acknowledging the summary was received was unsigned and undated. During an interview on 1/9/25 at 9:14 a.m. with Resident 59 in Resident 59's room, Resident 59 stated, they did not receive a copy of the baseline care plan summary nor signed the form. During a review of the facility's policy and procedure titled Care Plans-Baseline, dated 3/17, indicated, 4. The resident and/or representative are offered a copy of the baseline care plan.

Based on observation, interview, and record review the facility nursing staff did not accurately complete one out of three residents' (Resident 73) discharge assessment when the wrong discharge disposition was entered. This failure to accurately encode (to enter information into the facility MDS software in the computer) Resident 73's assessment had the potential to not effectively monitor and keep track of resident's progress or decline over time and also cause delay in providing resident information for payment and quality measure purposes. Findings: During a review of Resident 73's Face Sheet, (undated), the Face Sheet indicated Resident 73 was admitted to the facility in 2024 with included diagnoses of Acute Osteomyelitis right ankle and foot (osteomyelitis - a serious bone infection that happens after an infection spreads to the bone marrow and bones through bloodstream). During a review of Resident 73's Minimum Data Set (MDS - a resident assessment tool use to guide care) dated 10/12/2024, the MDS indicated Resident 73 was discharged to a Short-Term General Hospital (acute care hospital). During an interview on 01/08/2025 at 10: 23 A.M. with Minimum Data Set Coordinator (MDSC), MDSC stated Resident 73 was discharge to home and not to the hospital. MDSC further stated the entry coded in MDS was an error entry and she will correct it. During a review of Resident 73's Interdisciplinary Treatment (IDT) Discharge Summary notes, dated 10/11/2024, the discharge summary notes indicated Resident 73 was discharged to home. During a review of Resident 73's Physician Discharge Summary dated 10/12/2024, and signed by Physician 10/17/2025, Physician Discharge Summary indicated Resident 73 to be discharged home . During a review of Resident 73's Physician Order Summary dated 10/10/2024, the Physician Order Summary indicated Resident 73 to be discharge on 10/12/2024; Where To: home; To be followed by: PT, OT, RN, HHA, Durable Medical Equipment: no DME one time only for Discharge until 10/12/2025 23:59. During an interview 01/08/2025 10: 25 AM with Director of Nursing (DON), DON stated it is important to have correct encoding for accuracy reasons. DON further stated facility would modify the incorrect entry. During a review of facility's policy and procedure (P & P), title Resident Assessment Instrument, dated 2010, page 20, the PNP indicated, the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on observations, interviews, and record reviews conducted during the assessment, it was identified that the facility did not maintain the medication refrigerator within the required temperature range of 36 F to 46 F, as outlined in their policy. This failure potentially exposes medications to an environment where their efficacy may be compromised due to improper storage conditions. Findings A review of the facility policy, effective December 1, 2007, titled Storage and Expiration Dates of Medications, Biologicals, Syringes, and Needles, indicates that the facility should ensure that medications are stored at appropriate temperatures. Medications requiring refrigeration should be maintained between 36 F and 46 F. During an observation at 9:21 AM on 01/08/25, it was noted at the nursing station medication refrigerator that multiple medications, including insulin, vaccines, eye drops, and a refrigerated emergency kit containing various medications, were stored at a temperature of 34 F, as indicated by the thermometer. A review conducted on 01/08/25, of the medication refrigerator temperature logs revealed that for the month of January, there were four documented instances where the temperature was recorded as 32 F. Additionally, for the months of December and November 2024, there were a total of seven instances where temperatures were supposed to be documented but were either missing or not recorded. During an interview on 01/08/25, at 9:25 AM, the Assistant Director of Nursing acknowledged that the temperature of 34 F in the medication refrigerator was too low. She further noted that the refrigerator contained vaccines, eye drops, insulin, and multiple medications, including an emergency refrigerator kit with several medications. As a corrective measure, she mentioned that she would adjust the thermostat to a higher setting and closely monitor the temperature to ensure it remains within the acceptable range of 36 F to 46 F. The Assistant Director also admitted that she was previously unaware of the refrigerator's temperature being excessively low and acknowledged the facility's policy of maintaining refrigerator temperatures between 36 F and 46 F.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. A kitchen wall and equipment were not clean; 2. Multiple food items were unlabeled, and undated; 3. Staff food was stored in refrigerator #3. This failure had the potential to put residents at risk for cross contamination and food born illnesses. Findings: During a concurrent observation and interview on 10/10/22, at 09:25 AM, with Dietary Director (DD), the wall behind Refrigerator #2 had dust, and black and gray particles. DD stated, the wall was dirty and needed to be cleaned. The can opener had black and brown particles and residue on the blade and on multiple surfaces. The toaster had black and brown particles on the crumb tray, and inner surfaces. In the dry storage, there was 1 dented can of Tuna 4.16 pounds. In the dry storage, there was a container of individually packaged syrups that were not labeled had an open or expiration dates. In the dry storage, there was an opened 10-pound Box of graham crumbs that was not labeled with open or expiration dates. Refrigerator #1 had a half gallon container of milk that was not labeled with an open date. Freezer #2 had 1 package of opened hash and 1 package of frozen dinner rolls that were not labeled with open or expiration dates. DD stated, the dented can and food items that were not labeled with open or use by dates needed to be thrown away. Refrigerator #3 had 60 unpasteurized eggs. DD stated, eggs belonged to staff , and shouldn't have been stored in the resident's refrigerator. During a concurrent observation and interview on 10/10/22, at 2:11 p.m., with DD, the resident refrigerator in the staff break-room had an open box of peanut brittle, had no open or expiration dates. DD stated, it should have a received date label. During an interview on 10/11/22, at 02:16 p.m., with Registered Dietician (RD), RD stated, the kitchen walls should have been cleaned at end of each day and the dirty wall pose a risk for food borne illnesses. RD stated, the can opener should have been cleaned between each RD stated, the toaster should have been cleaned at end of each day. RD stated, dented cans should be put and aside and returned to the distributor. RD stated, food should've been labeled when it was received and opened. RD stated, incorrectly labeled food pose a risk for contamination and food borne illnesses to the residents. RD stated, staff's un-pasteurized eggs shouldn't have been in the resident's refrigerator. During a review of the facility's policy and procedure (P&P) titled, Walls Ceilings, and Light Fixtures, reviewed 9/19/22, the P&P indicated, Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently as necessary. During a review of the facility's policy and procedure (P&P) titled, Can Opener and Base, reviewed 9/19/22, the P&P indicated, The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. During a review of the facility's policy and procedure (P&P) titled, Electrical Food Machines, reviewed 9/19/22, the P&P indicated, Toasters. 1. Clean daily. 2. Remove crumbs from the crumb tray daily and wipe the toaster case with a soft damp cloth . During a review of the facility's policy and procedure (P&P) titled, Food Storage-Dented Cans, reviewed 9/19/22, the P&P indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, reviewed 9/19/22, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P indicated, Food delivered to facility needs to be marked with a received date. The P&P indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date .

Based on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 52, 75 and 233), were notified when the menu changed. This failure had the potential to negatively affect Residents 52, 75 and 233's nutritional intake. Findings: During an interview on 10/10/22, at 2:51 p.m., with Resident 233, Resident 233 stated, the menu was changed 2-3 times a week, since her admission on 9/18/22. Resident 233 stated, staff didn't tell her when or why the menu changed. Resident 233 stated, on 10/9/22, dinner was a hamburger and potato salad, when the menu had chicken strips in sweet lemon sauce with garlic ginger noodles. Resident 233 stated, on 10/10/22, lunch was a bowl of bean soup, corn bread and salad, when the menu had pot roast and gravy. Resident 233 stated, she was upset and disappointed when staff changed the menu without telling her. During an interview on 10/10/22, at 3:05 p.m., with Resident 52, Resident 52 stated, the menu was changed 2-3 times a week, since her admission on 9/3/22. Resident 52 stated, staff didn't tell her when or why the menu changed. Resident 52 stated, on 10/9/22, dinner was a hamburger and potato salad, when the menu had chicken strips in sweet lemon sauce with garlic ginger noodles. Resident 52 stated, on 10/10/22, lunch was a bowl of bean soup, corn bread and salad, when the menu had pot roast and gravy. Resident 52 stated, she was upset and disappointed when staff changed the menu without telling her. During an interview on 10/11/22, at 9:14 a.m., with Resident 75, Resident 75 stated, the menu was wrong a few times a week. Resident 75 stated, staff didn't tell him when or why the menu changed. Resident 75 stated, last week, he got a ham sandwich when the menu was chicken and noodles. Resident 75 stated, he felt disappointed when staff changed the menu without telling him. During an interview 10/11/22, at 2:16 p.m., with register dietitian (RD), RD stated, they didn't notify each resident when the menu changed. RD stated, menu changes can cause residents to be emotionally dissatisfied. RD stated, it can affect residents clinically and cause residents to eat less, lose weight or not gain weight. During a review of the Menu Item Substitution List, dated 10/10/22, the list indicated on 10/10/22, lunch was changed from pot roast, mashed potatoes, Brussels sprouts and sweet corn salad to beef chili with mixed green salad and cornbread. During a review of the Substitution List, dated 10/7/22 through 10/9/22, the list indicated the menu was changed on 10/7/22 breakfast and lunch, 10/8/22 breakfast and 10/9/22 lunch and dinner.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Resident 4's expired inhaler and Resident 56's undated opened inhaler were found in medication cart 2. 2. One opened and undated PPD 1 ml. (milliliter, unit of measure) vial was found in medication room in Station 1. 3. The temperature of a room used for medication storage was not being monitored. 4. Loose pills were found in medication cart 3. 5. Two bottles of blood glucose test strips in medication cart 3 were not dated when opened. 6. Four opened unlabeled and undated vials of Insulin (medication to lower blood sugar level) were found in medication cart 3. 7. Resident 21's opened Insulin Kwik Pen (a type of insulin) in medication cart 3 was not dated when opened. These failures had the potential for medication misuse, drug diversion and medication ineffectiveness. Findings: 1. During an observation and concurrent interview with Registered Nurse (RN 2) on [DATE], at 9:23 a.m., Resident 4's Breo Ellipta inhaler (medication administered by breathing in and helps with breathing issues) with an open date of [DATE], was found in the medication cart 2 drawer. Inhaler manufacturer's instructions on the medication box indicated, inhaler should be discarded in 6 weeks after opening. During an observation and concurrent interview with RN 2 on [DATE], at 9:23 a.m., Resident 56's Anoro Ellipta inhaler (medication administered by breathing in and helps with breathing issues) had no open date label found in medication cart 2 drawer. During a review of Anoro Ellipta Inhaler Inhaler manufacturer's instructions, instructions indicated, inhaler should be discarded 6 weeks after opening. RN 2 acknowledged resident 56's inhaler should have an open date label. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated ,d+[DATE], indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 2. During a concurrent observation of medication room in Station 1 and interview with Licensed Vocational Nurse (LVN 6), on [DATE], at 9:57 a.m., one opened Purified Protein Derivative vial (PPD is a test used for skin test to identify a lung infection) had no open date label, found inside the refrigerator in the medication room. LVN 6 acknowledged PPD vial should be labeled of date when opened. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated ,d+[DATE], indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container . 3.During a concurrent observation of the medication storage room and interview with the Minimum Data Set Coordinator (MDSC), on [DATE], at 10:11 a.m., the central supply room was observed to have no temperature log. MDSC stated the thermometer in medication storage room was broken and acknowledged there was no record to monitor the temperature of the central supply room. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated ,d+[DATE], indicated, . Facility should ensure that medications and biologicals are stored at their appropriate temperatures . guidelines for temperature ranges . Room Temperature: 59 to 77 degrees Fahrenheit (a scale for measuring temperature) . 4. During a concurrent inspection of Med Cart 3 and interview with LVN 5 on [DATE], at 10:41 a.m., 6 whole and 3 broken loose pills were found in the Med Cart 3 drawer. LVN 5 verified 6 whole and 3 broken loose pills were found in Med Cart 3 drawer. During a review of facility policy Storage of Medications, dated [DATE], indicated, .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 5. During a concurrent inspection of Medication Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., found 2 undated opened blood glucose test strips (strips used to test blood sugar). LVN 5 verified the blood glucose test strips had no open date labels. LVN 5 read and acknowledged the manufacturer recommendation in the test strip bottles indicated blood glucose test strips expiration in 6 months once bottle is opened. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated ,d+[DATE], indicated, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 6. During a concurrent inspection of Med Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., four opened unlabeled and undated 10 ml. vials of Regular, Novolog, Lantus and Levemir insulins (medications to lower blood sugar), were found in the medication cart drawer. LVN 5 stated, insulin vials should have been labeled with residents' names and open dates. During a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals . dated ,d+[DATE], indicated, Once any medication or biological package is opened, facility should follow manufacturer/ supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. During a review of the facility policy titled, Interim, Stat, Emergency Supplies of Medications, dated ,d+[DATE], indicated, .To avoid waste, facility staff should place a sticker or label with the resident's name and room number on the multi dose container to assure the medication is identified as belonging to the specific resident. Facility may also place a sticker on the medication container to refer to the directions for use on the physician's order and/or the current medication administration record. Record date opened if applicable. 7. During a concurrent inspection of Med Cart 3 and interview with LVN 5, on [DATE], at 10:41 a.m., Resident 21's opened Humalog Insulin 3 ml. Kwik Pen (an injection insulin pen used to treat high blood sugar) was found in the medication drawer had no open date label. LVN stated, insulin pen should have had an open date label. During a review of the facility policy titled, administering medications dated ,d+[DATE], indicated, . When opening a multi dose container, the date opened shall be recorded on the container . Insulin pens will be clearly labeled with the resident's name or other identifying information .

Based on observation, interview and record review, the facility failed to assure oxygen supplies and equipment were maintained according to policy and the operator's manual for four (4) of five (5) sampled residents (Resident 16, Resident 54, Resident 1, Resident 56). This deficient practice had the potential for the delivery of unclean and inadequate oxygen concentration to the residents. Findings: During the initial tour on 10/10/22 at 9:20 a.m., Resident 16 was using a concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). The concentrator had a filter on its side which was covered with a thick layer of gray fluffy matter. Licensed Vocational Nurse 1 (LVN 1) stated, the filter was supposed to be cleaned regularly. During an observation on 10/11/22 at 9:30 a.m., Resident 54 was observed using a concentrator had a filter which was covered with a thick layer of gray fluffy matter. During an observation on 10/11/22 at 10:10 a.m., Resident 1 was observed using a concentrator had a filter which was covered with a thick layer of gray fluffy matter. Resident 56 was also observed using a concentrator on 10/11/22 at 10:45 a.m. using a concentrator had a filter which was covered with a thick layer of gray, fluffy matter. During an interview on 10/11/22 at 11:15 a.m. with IP, IP stated the filters of the concentrators needed to have a cleaning schedule, and this task should be appointed to a specific staff member. According to the facility's policy and procedure titled Concentrator Maintenance dated 8/5/09, it indicated .clean the gross particle filter. The Operator's Manual: Section 6-Maintenance, stated: 1. Remove each filter and clean at least once a week depending on environmental conditions.

Based on observation, interview and record review, the facility failed to obtain a physician's order for the use of an indwelling urinary catheter (a thin sterile tube inserted into the bladder to drain urine to a collection bag outside of the body) for one of 7 sampled residents (Resident 19). This failure had the potential for insufficient and inadequate delivery of care. Findings: Resident 19 was readmitted to the facility on [DATE] with admitting diagnoses which included stage 4 pressure ulcer of the sacral region. During initial observation on 10/10/22 at 11:45 a.m., Resident 19 was in bed, and had an indwelling catheter drainage bag anchored to his bed frame. The connecting tube from the catheter to the collection bag had blood-tinged urine. During a concurrent record review and interview with licensed vocational nurse (LVN) 2, LVN2 stated, there was no order for the use of an indwelling catheter in Resident 19's electronic health record, and LVN 2 was not aware of Resident 19 having an indwelling catheter. During an interview on 10/11/22 at 11:05 a.m. ,with the nurse supervisor (RN) RN 1, RN1 stated, there should be a physician's order for the use and care of an indwelling catheter. RN 1 did not find a physician's order in Resident 19's electronic health record. The facility policy titled Foley catheter insertion, male resident dated October 2010 indicated .verify that there is a physician's order for this procedure.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that prevents the spread of Coronavirus Disease 2019 (COVID-19, a contagious infection that can result in severe breathing problems and death) when the following were observed: 1. The facility failed to ensure the Staff/Visitor Pre-Visit Screening Tool (documentation of completion of the entry process and results of the screening of individuals for presence or absence of COVID-19 symptoms) was completed upon entry for four individuals (Certified Nursing Assistant 4, Dietary Aide 1, Visitor 1, Visitor 2, during the time period of 1/18/21 to 1/27/21. 2. Two employees (Certified Nursing Assistant 1 and Registered Nurse 1) failed to perform hand hygiene per policy and procedure. 3. One employee (Certified Nursing Assistant 3) exited a resident isolation room and failed to sanitize the face shield used inside the room. These failures had the potential to result in COVID-19 infection and spread of COVID-19 infection. Findings: 1. During a phone interview on 1/28/2021, at 4:00 p.m., with IP, IP stated the facility COVID-19 screening log was used for screening everyone who entered the facility for signs and symptoms of COVID-19. The process included temperature checks, questions about symptoms, exposure to people with COVID-19, and to educate staff and visitors to wash their hands upon entry. IP further added, if the screener forgot to take the temperature before entry, the staff should be removed from direct care for an immediate check of their temperature. During a review of the Staff/Visitor Pre-Visit Screening Tool, the tool reflected rows for individual names, and had multiple columns for the individual's answers to screening questions for COVID-19. The columns included: result of temperature check, questions on presence of COVID-19 symptoms (fever, shortness of breath, cough, chills, fatigue, muscle or body aches, sore throat, congestion or runny nose, headache, nausea, vomiting, diarrhea, loss of taste or smell); close contact with a confirmed positive COVID-19 case; performance of hand hygiene/review of visitation rules/proper PPE (Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) and facility decision on whether or not the individual should be granted access to the facility. At the bottom of the form were instructions which reflected, Pre-screen all individuals prior to entrance Entry automatically denied for active fever (greater than 100 degrees) or active symptoms, including symptoms suppressed with medications, such as cough syrup, ([MEDICATION NAME]), [MEDICATION NAME] Deny entry to COVID-19 exposed individuals with high-risk contact .Refer individuals for Level II screening if status is unclear (referenced to questions regarding close contact with a confirmed positive COVID-19 case). During a review of the Staff/Visitor Pre-Visit Screening Tool, the Tool reflected the following incomplete entries: 1/18/21: CNA 4 had yes written in the column for close contact with confirmed COVID-19 positive case, and a yes in the column for presence of COVID-19 symptoms, with no evidence of Level II screening per directions of the form. The decision column indicated CNA 4 was granted access to the facility. 1/24/21: Dietary Aid 1 (DA 1) had no entry in the column for temperature, the decision column indicated DA 1 was granted access. 1/27/21: Visitor 1 and Visitor 2 had no entries in the temperature column. The decision column indicated Visitor 1 and Visitor 2 were granted access to the facility. During a review of facility's policy and procedure (PNP) titled, COVID-19 Management Policy, dated 1/2021, the PNP indicated, .Implement routine screening, restrictions and monitoring of staff, residents, visitors and vendors for signs and symptoms and exposure risk for COVID-19 utilizing the most current and evolving guidance from CMS, CDC, and local health authorities Restrict facility entry or ask individuals to leave facility premises if they have symptoms of COVID-19, have been in close unprotected contact (i.e. without proper PPE) with a confirmed COVID-19 case, or unable to adhere to core principles of COVID-19 infection prevention. 2. During a concurrent observation and interview on 1/27/21, at 9:50 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 walked in the hallway carrying two plastic bags, one in each hand. CNA 1 placed one plastic bag in a dirty linen bin, and the other plastic bag in a garbage receptacle. CNA 1 then removed gloves, walked to the nursing station sink, and without performing hand hygiene, walked away from the nursing station. CNA 1 stated he had intended to wash his hands but there were no more paper towels. During a concurrent observation and interview on 1/27/21, at 10:19 a.m., Registered Nurse 1 (RN 1) demonstrated the procedure for sanitizing a glucometer, a device for measuring the amount of sugar in the bloodstream. RN 1 stated the glucometer was used for multiple residents, so it required sanitizing between residents. RN 1 walked to the medication cart, and without performing hand hygiene, donned gloves. RN 1 removed the glucometer from the medication cart drawer, wiped the glucometer with a sanitizing cloth, doffed her gloves, and without performing hand hygiene, replaced the glucometer in the medication cart drawer with her bare hands. RN 1 stated the policy and procedure was to perform hand hygiene both before donning and after doffing gloves. During a review of facility's policy and procedure (PNP) titled, Handwashing/Hand Hygiene, revised 8/2015, the PNP indicated, Perform hand hygiene before applying nonsterile gloves After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 3. During an observation on 1/27/21, at 11:55 a.m., CNA 3 exited a resident room Yellow Zone (the area for residents with known Covid-19 exposure and/or unknown COVID-19 status) and performed hand hygiene. CNA 3 wore a face shield (a type of PPE worn for protection of the facial area from splashes, sprays and spatter of body fluids). CNA 3 left the yellow zone isolation room area, walked pass the cleaning area, and without sanitizing the face shield, walked to the green zone unit area (unit where there were no known positive cases of COVID-19). CNA 3 stated the facility policy and procedure was to sanitize face shield using spray disinfectant in the cleaning station after leaving isolation room. During a phone interview on 1/28/21, at 4:00 p.m., with the IP, IP indicated staff were expected to disinfect face shield whenever they left a yellow zone room. During a review of facility's policy and procedure (PNP) titled, Procedural guidance on face mask reuse & other PPE Contingencies dated 4/15/2020, the PNP indicated, Plastic face shields and goggles should be disinfected prior to re-use. Isolation rooms or COVID Units should have an area set up just outside of the doorway to accommodate clean storage and decontamination of gear. The PNP further indicated, .exit room and use hand sanitizer at decontamination station outside door. And apply clean gloves prior to touching face shield or goggles .If using a spray cleaner method, carefully remove protective eyewear. Spray inside of protective eyewear with cleaner and then set down on designated 'dirty' tabletop .Spray exterior surface with another cleaner until visibly wet .allow to air dry.

Based on interview and record review, the facility failed to provide a copy of Resident 1's medical record to the resident after Resident 1 called the facility, requesting copies of her medical record. This failure resulted in information about Resident 1's medical condition and the treatment provided being inaccessible. Findings: During a review of Resident 1's Admission record (AR), the AR indicated the resident was admitted to the facility with multiple diagnoses, including a [MEDICAL CONDITION] femur (thigh bone), [MEDICAL CONDITION], morbid (severe) obesity, and muscle weakness. During a review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 11/23/19, the MDS indicated a Brief Interview for Mental Status (BI[CONDITION], a tool used to assess mental function) score of 15, meaning Resident 1 was cognitively intact. During a telephone interview on 2/12/20 at 3 p.m. with Family Member (FM 5), FM 5 stated he called and also went to the facility requesting a copy of Resident 1's medical record. FM 5 stated the facility refused to release a copy of Resident 1's medical record without Resident 1's authorization. FM 5 stated that on [DATE] at 12:20 p.m., Resident 1 called the facility, told them who she was, and requested copies of her medical record be sent to her. Resident 1 stated the person she talked with on the phone at the facility said they couldn't and hung up. During an interview on [DATE]20 at 8:30 a.m. with the Minimum Data Set Coordinator (MDSC), MDSC stated the resident or the responsible party must sign a HIPAA compliance form (the HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically). The MDSC stated if Resident 1 was responsible for herself and called the facility to request her records, the facility still required a signed form because how would we know for sure who the caller was? The MDSC stated she remembered FM 5 and a lawyer called the facility asking for Resident 1's medical records, but because FM 5 was not the responsible party, the facility did not release Resident 1's medical records to him. During a telephone interview on [DATE] at 8:40 a.m. with the Medical Record Director (MRD), MRD stated the facility had a HIPAA compliant Authorization form that needed to be signed by Resident 1 in order to release Resident 1's medical information but was not offered nor explained to FM 5. MRD stated the facility needed Resident 1 to authorize FM 5 to get a HIPAA authorization form from the facility for Resident 1 to sign. MRD stated the blank authorization form was not given to FM 5 because FM 5 did not have Power of Attorney (POA) and they were not sure if Resident 1 will be the one signing the authorization form. During an interview on [DATE] at 10 a.m. with the Nursing Home Administrator (NHA), NHA stated she was aware FM 5 was at the facility to get copies of Resident 1's medical records. NHA stated Resident 1 was responsible for herself, and FM 5 did not have POA. NHA stated Resident 1's medical record was available for release anytime as long as there was an authorization from Resident 1. NHA stated the authorization form was not provided to FM 5, and stated, How do we know if it was her that signed the authorization form? During an interview on [DATE] at 10:30 a.m. with the Medical Record Assistant (MRA), MRA stated she did not remember speaking to Resident 1 over the phone. MRA stated MRD was the one dealing with FM 5. During a review of the facility's policy and procedure (P&P) titled, Health Information Record Manual, Chapter IV, Section 4025-Resident Access to Records, dated 2/6/19, the P&P indicated the facility would respond within 48 hours, excluding weekends and holidays, to requests for copies of medical records.

Based on observation, interview and record review, the facility failed to follow the planned menu when less than stated amount of breaded fish or turkey patty was served to residents receiving regular diets. This failure resulted in residents not getting the prescribed amount of protein for lunch and the potential for weight loss and malnutrition. Findings: Review of the undated document titled Cooks Spreadsheet Summer Menus Week 2 indicated the facility was to serve 3-4 oz of breaded fish to residents on regular diet at lunch on 8/12/19. During a trayline observation and concurrent interview with the Director of Food and Nutrition Services (DFNS) and Cook 1 on 8/12/19 at 11:45 a.m., after all the trays were plated, a serving portion of the breaded fish and the turkey patty were weighed by Cook 1. The DFNS and Cook 1 confirmed one piece of the breaded fish weighed 2 ounce (oz- a unit of measurement) and one piece of the turkey patty weighed 1.75 oz. Both the DFNS and Cook 1 confirmed the fish and the turkey weighed less than the required amount of protein on the planned menu. Cook 1 stated she weighed the turkey patties before she cooked them. The DFNS stated the proteins should weigh 3-4 oz according to the spreadsheet. During an interview with Resident 30 on 8/12/19 at 1:30 p.m., Resident 30 stated the patty was very small and would have liked more. During an interview with the Registered Dietitian (RD) on 8/13/19 at 1:10 p.m., the RD stated the dietary spreadsheet/menu should be followed. RD also stated Cook 1 should have served two pieces of turkey patties. RD further stated the facility must provide the required amount of protein to the residents.

Based on observation and interviews, the facility failed to ensure infection control practice was implemented during medication administration to one of four sampled residents (Resident 65). When Registered Nurse 1 (RN 1) brought the whole bottle of [MEDICATION NAME] (live bacteria that are good for the digestive system) inside Resident 65's room. This deficient practice placed residents at risk for contracting infection through medication administration. Findings: During medication administration observation on 8/13/19 at 8:44 a. m., RN 1 brought the whole bottle of previously opened [MEDICATION NAME] inside Resident 65's room and placed it on the bedside table. During an interview with RN 1 on 8/13/19 at 9:10 a. m., she stated she shouldn't have brought the whole bottle of [MEDICATION NAME] inside Resident 65's room. She also stated it is okay to put it back inside the medication cart but she decided to discard the whole bottle. She also mentioned she will find out how to discard the bottle of [MEDICATION NAME]. During an interview with Director of Nursing (DON) on 8/13/19 at 12:50 p. m., she stated the bottle of [MEDICATION NAME] shouldn't have been brought inside Resident 65's room as standard practice. She also stated that wasted or discontinued medicines could be discarded in the sharps container or inside the medication room where there's a bin for wasted/discontinued medicines.

Based on observations, interviews and record reviews, the facility failed to ensure medication error rate of below five percent (%). When: 1. Licensed Vocational Nurse 2 (LVN 2) administered [MEDICATION NAME] ER (medication used for heart related chest pain) beyond the ordered time frame to Resident 48. 2. Registered Nurse 1 (RN 1) administered regular Aspirin to Resident 48 when the order was Aspirin EC ([MEDICATION NAME] coated-medicine dissolves in the small intestine instead of stomach to prevent stomach upset) delayed release. These deficient practices placed Resident 48 at risk of developing complications related to error in medication administration. Findings: 1. During concurrent medication administration observation and interview on 8/13/19 at 9:52 a. m., RN 1 did not give [MEDICATION NAME] ER 60 milligrams (mg) to Resident 48. She stated there was no available medicine to give. During an interview with RN 1 on 8/13/19 at 12:46 p. m., she stated she called pharmacy and was told that [MEDICATION NAME] will be delivered on 8/13/19. She also stated she called the doctor for Resident 48 and notified that medicine was not available and will be delivered on 8/13/19. She said the doctor gave an order to give [MEDICATION NAME] one time when delivered. Review of Medication Administration Record [REDACTED]. MAR indicated [REDACTED]. 2. During medication administration observation on 8/13/19 at 9:52 a. m., RN 1 administered regular Aspirin (chewable) to Resident 48. Review of electronic physician's orders [REDACTED].

Based on observations, interviews and record reviews, the facility failed to obtain medication for one of four sampled residents (Resident 48) when [MEDICATION NAME] ER (medication used for heart related chest pain) was not available to administer to Resident 48. The failure to obtain and administer ordered medication had the potential to delay treatment and prolong healing. Findings: During a review of Resident 48's physician's orders [REDACTED]. During concurrent medication administration observation and interview on 8/13/19 at 9:52 a.m., RN 1 did not administer [MEDICATION NAME] ER 60 milligrams (mg) to Resident 48. RN 1 stated there was no available medicine to administer. During concurrent observation and interview on 8/13/19 at 10:19 a.m., RN 1 together with Licensed Vocational Nurse 1 (LVN 1) opened the drug dispensing machine and [MEDICATION NAME] ER 60 mg was not available. During an interview with Director of Nursing (DON) on 8/13/19 at 1:03 p.m., the DON stated the charge nurses reorder routine medicines electronically or by sending the reorder stickers to the pharmacy. The DON also stated reordering takes place when seven to eight pills remain in the supply to provide adequate time for delivery.

Based on observation, interview, and record review, the facility failed to maintain the personal privacy and confidentiality rights of three (Residents 68, 16, and 4) of 15 sampled residents. For Residents 68 and 16, uncovered health care instructions were posted on the wall of their room. For Resident 4, personal information including date of birth, physician's name and orders was left exposed to the public at the nursing station. These failures resulted in the potential for unauthorized access to Residents 68, 16, and 4's medical information and violated Resident 68, 16 and 4's right to privacy and confidentiality. Findings: 1. Review of Resident 68's Admission Record indicated she was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. By observation on 9/24/18 at 8:30 a.m., uncovered health care instructions were posted on a wall near the door of Resident 68 and 16's room. The posting included both Resident 68's and 16's names. Review of facility's Policy and Procedure titled, Quality of Life-Dignity, revised (MONTH) 2009 indicated, Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room .Staff shall promote, maintain and protect resident privacy. 2. Review of the Face Sheet dated 9/27/18 showed that Resident 4 was admitted to the facility on [DATE]. By observation on 9/25/18 at 10:33 a.m., at Nursing Station 2, a computer screen was open with Resident 4's confidential medical information exposed. The computer screen was facing the hallway where information could easily be seen and read by the public. By further observation, the information included Resident 4's Date of Birth, the physician's name, and physician's orders [REDACTED]. In an interview on 9/25/18 at 10:36 a.m., Licensed Vocational Nurse (LVN 3) stated, We are not supposed to leave resident information unlocked, at which point LVN 3 turned the privacy screen on the computer. Review of facility's Policy and Procedure titled, Quality of Life-Dignity, revised (MONTH) 2009 indicated, Staff shall promote, maintain and protect resident privacy.

Based on interview, and record review for the facility failed to prevent an accident with major injury for one (Resident 1) of three sampled residents on 9/5/15. Resident 1 had fall in her room. This failure resulted in a fractured hip that required surgery. Findings: According to the clinical record reviewed on 9/9/15, Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a history of [REDACTED]. Review of the Emergency Department visit notes on 9/6/15 confirmed by x-ray Resident 1 sustained a right leg fracture with swelling, redness. Her right leg was placed in an immobilizer (to prevent movement). In an interview on 9/9/15 at 3:05 p.m., Resident 2 stated she heard a thud like sound on the floor next to her on 9/5/15. Resident 2 stated she saw Resident 1's arm located under the curtain which separated the space between Residents 1 and 2. Resident 2 stated she used her call light to call for staff to help Resident 1. Resident 2 stated she told staff Resident 1 might have fallen. Resident 2 confirmed there were three staff members who assisted Resident 1 into a wheelchair. Resident 2 stated she did not hear a bed alarm when she saw Resident 1 on the floor. Resident 2 stated she saw Resident 1 get out of bed without assistance many times since Resident 1's admission. In an interview on 9/16/15 at 12:30 p.m., Certified Nursing Assistant (CNA) 3 confirmed Resident 1 was at risk for falls and would turn the bed alarm off at times. CNA 3 stated Resident 1 would go to the bathroom by herself without assistance, which was located at the far end of Resident 1's room. In an interview on 9/16/15 at 12:50 p.m., CNA 2 confirmed she assisted Licensed Vocational Nurse (LVN) 1 to transfer Resident 1 to the wheelchair on 9/6/15. In a telephone interview on 9/16/15 at 1:05 p.m., LVN 2 stated Resident 1 was at high risk for falls. In a telephone interview on 9/17/15 at 1:50 p.m., Licensed Vocational Nurse (LVN) 1 stated she had walked by Resident 1's room and saw the call light on and confirmed it was Resident 2 who used the call light. LVN 1 stated she called for help to assist Resident 1 up to her wheelchair. LVN 1 stated CNA 1 and CNA 2 assisted her to transfer Resident 1 to the wheelchair. LVN 1 stated she did not hear a bed alarm prior to entering Resident 1 and Resident 2's room. Record review of the Progress Notes dated 9/5/15 showed, Resident with past behavior of turning off bed/chair alarm. Review of the record showed no documentation Resident 1's bed alarm was on at the time of the incident on 9/5/15. Record review of Resident 1's care plan titled, The resident had unwitnessed fall on 8/29/15, dated 8/30/15, showed interventions to, Continue with current fall precautions: Bed alarm. There was no specific care plan to prevent Resident 1 from turning off her bed alarm, which was confirmed by RN 1 on 11/16/15 at 11:45 a.m. in a telephone interview.

Based on observation, interview and record review, the facility failed to provide a safe environment and adequate supervision to prevent falls by failing to ensure that one (Resident 1) of three sampled residents was not able to wheel down the incline from the facility resulting in Resident 1 sustaining several lacerations when his wheelchair hit a fence. Findings: According to the medical record, Resident 1 was admitted to the facility from home on 7/10/12 after a fall. The [DIAGNOSES REDACTED]. The MDS (minimum data set-a full assessment of resident functioning), dated 7/24/12, showed that Resident 1 was totally dependent on staff for assistance to attend to all his needs, was not steady moving from seated to standing position and had short and long term memory problems. There was a Fall Risk Assessment, with a score of 15 on 7/10/12. A score of 10 or above was HIGH RISK. There was a care plan titled "Falls," dated 7/10/12, which showed the approach "Encourage to call for assistance as needed." This care plan was not updated after Resident 1 fell on [DATE] and 9/18/12. There was a new care plan, titled "Post Fall," dated 8/11/12, that showed, "Educate resident on importance of activity and rest, safety awareness and proper use of assistive device." There was a "Post Fall Assessment", dated 8/11/12, that showed that Resident 1 "was trying to ambulate without assistance, fell and was found lying on the floor." The conclusion of this assessment was "Bed alarm not working correctly." The nurses notes, dated 8/11/12, showed "Bed alarm replaced due to malfunction of alarm." The nursing notes showed that on 9/18/12 at 1:40 p.m., Resident 1 was observed by a visitor wheeling himself down the driveway toward the street. He was observed to hit the fence, causing the wheelchair to tip over sideways. The visitor alerted staff and an ambulance was called. Resident 1 was transferred to the emergency room . The emergency room physician's note showed "Final Diagnosis: [REDACTED]. Multiple lacerations (skin cuts) including a significant laceration to the right hand down to the tendons (Fibrous connective tissue that usually connects muscle to bone). Intercranial (bleeding inside the head) bleeding was ruled out and Resident 1 returned to the facility with orders for care of the lacerations. According to the facility's investigative report, CNA 1 saw Resident 1 sitting alone in his wheelchair by the emergency exit at 1:30 p.m., and pushed him to the area by nursing station 1. CNA 1 documented that the charge nurse saw him being brought to the area. At 1:40 p.m., Resident 1 left the facility without being noticed by staff until the visitor alerted them to his fall at the end of the driveway. During interview on 10/19/12 at 9:55 a.m., the DON (director of nurses) stated that the emergency exit was alarmed but, when Resident 1 left through that door, the alarm did not sound "because the volume was turned down too low." When asked how the facility protects a resident who is at high risk for falls, the DON said, "Frequent observation. That's all." When asked about frequent observation, the DON showed documentation that all residents were observed every two hours. During observation of the emergency exit door and driveway with the DON on 10/19/12, it was noted that there was no gate or barrier between the level sidewalk outside the door which led to a very steep driveway which wound down to the street.