Every finding on record at Marina Garden Nursing Center

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week for five days. This failure had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 11/20/2024 at 10:36 a.m. with the Administrator (ADM), Licensed Nurse Work Hours Spread Sheet, dated June 2023, was reviewed. ADM confirmed, there was no RN coverage 8 hours a day 7 days a week on 6/23/23, 6/26/23, 6/27/23, 6/28/23 and 6/29/23. During an interview on 11/20/2024, at 10:55 a.m. with the Director Of Nursing (DON), DON stated, it was important to have an RN available in the facility because, RNs are responsible for critical decision making. DON further added, RNs have a broader scope of practice like intravenous (IV- a device inserted into a vein to give fluids, medicine, or nutrients directly into the bloodstream) insertion in an emergency situation. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, undated, the P&P indicated, .3.the facility will use the services of a registered nurse for at least eight (8) consecutive hours a day, seven (7) days a week.

Based on observation, interview, and record review the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 1 and Laundry Staff (LS) 1 were wearing face masks below their nose. 2. Laundry staff 1 did not perform hand hygiene prior to putting on gloves and after removing gloves during linen handling. These failures had the potential for cross contamination and spread of infections among residents and staff at the facility. Findings: 1(a). During an observation on 11/18/24 at 10:53 a.m. in the facility hallway, CNA 1 was wearing a face mask below the nose. During a concurrent observation and interview on 11/20/24 at 10:39 a.m. with CNA 1 in the facility hallway, CNA 1 was wearing a face mask below the nose covering the mouth. CNA 1 stated the face mask should cover the nose and the lips. CNA 1 stated wearing the face mask was protection for patients, staff, and visitors from getting a respiratory infection and contamination. 1(b). During an observation on 11/20/24 at 9:06 a.m. in the facility hallway, LS 1 was wearing a face mask below the nose. During a concurrent observation and interview on 11/20/24 at 9:39 a.m. with LS 1 in the laundry room, LS 1 was wearing a face mask below the nose covering the mouth. LS 1 stated the face mask should cover the nose and the mouth. LS 1 stated wearing a face mask was to protect her, the residents, and other employees from virus. During an interview on 11/21/24 at 11:36 a.m. with the Director of Nursing (DON), the DON stated wearing a face mask was mandated by the county. The DON stated all facility staff should wear a face mask. The DON stated the face mask should cover the nose and mouth to protect self and residents from any respiratory virus. During a review of undated facility's policy and procedure (P&P) titled, Personal Protective Equipment-Face Mask, the policy indicated, The use of face mask prevents transmission of infections agents through the air . Be sure that face mask covers the nose and mouth while performing treatment or services for the patient. 2. During a concurrent observation and interview on 11/20/24 at 9:27 a.m. with LS 1 in the laundry room, LS 1 was observed putting on white hair covering, blue disposable gown then proceeded to wear gloves on left and right hands without performing hand hygiene. LS 1 stated the hair covering, disposable gown and gloves were one time use. During an observation on 11/20/24 at 9:33 a.m. with LS 1 in the laundry room, LS 1 transferred the dry linen with her gloved hands from the dryer machine into the beige cart and pushed the cart into the linen room. LS 1 then transferred the wet linen with the same gloved hands from the washer into the stainless-steel cart and moved the wet linen into the dryer. LS 1 transferred the soiled linen with the same gloved hands from the yellow bin into the washer. During an observation on 11/20/24 at 9:37 a.m. with LS 1 in the laundry room, LS 1 removed her gloves, gown, and hair cover and discarded in the black garbage bin. LS 1 proceeded to enter the linen room and folded the dry linen without performing hand hygiene. During an interview on 11/20/24 at 9:39 a.m. with LS 1 in the laundry room, LS 1 stated hands should be sanitized before touching clean linen and after touching dirty linen to be protected from the virus, but the sanitizer was inside the supply room. LS 1 stated she should have washed her hands with soap and water at the sink. During an interview on 11/21/24 at 11:38 a.m. with the DON, the DON stated, hand hygiene should be performed before wearing gloves and after removing gloves when handling dirty linens. The DON stated hand hygiene served as precaution in contracting body fluids that was in the linen. The DON stated hand hygiene prevents the spread of infection or virus. During a review of undated facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, the policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infections . Perform hand hygiene before applying non-sterile gloves . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water after removing gloves. During a review of undated facility's P&P titled, Laundry and Linen, Soiled, the policy indicated, Soiled laundry/linen shall be handled, transported, and processed according to best practices for infection prevention and control . All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting) During a review of undated facility's P&P titled, Personal Protective Equipment-Gloves, the policy indicated, Use gloves when handling soiled linen . Wash hands after removing gloves.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink. 2. Pop-up toaster was not cleaned regularly and had buildup of black and brown debris inside the bottom surface. 3. Scoop was stored inside the rice grain container. 4. Open carton of powdered potatoes was not sealed. 5. Two chest freezers had crystallization (freezer burn) inside the compartment. These failures had the potential to cause food borne illnesses for 28 residents who received food from the kitchen for a facility census of 29. Findings: 1. During a concurrent observation and interview on 11/18/24 at 9:20 a.m. with the Dietary Manager (DM), DM indicated the two-compartment sink was used for both food preparation and dishwashing sink. DM stated, there was no air gap for the sink. DM further stated, it was important to have an airgap so that food being prepared in the sink does not get contaminated if there was a clogged pipe. During a concurrent observation and interview on 11/19/2024 at 11:15 a.m. with Maintenance Supervisor (MS), in the presence of Administrator (ADM), MS confirmed the drainpipe from the sink was connected directly into the wall. MS also stated, it is pumped directly into wastewater system/sewer. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 2. During a concurrent observation and interview on 11/18/24 at 9:30 a.m. with Kitchen Staff (KS) 1, in the presence of DM, the pop-up toaster on the kitchen counter was dirty with black and brown debris in the inside bottom. KS 1 stated the toaster does not get cleaned regularly because there was no removable bottom tray for easy cleaning. DM confirmed the toaster was dirty and had debris accumulated inside. DM also stated the toaster should be cleaned after each use to prevent bacterial growth. During a review of the facility's policy and procedures (P&P), titled Operating & Cleaning Dietary Equipment, dated 2014, indicated under Cleaning Pop-Up Toaster: .5. Frequency of cleaning and sanitizing - daily after each use. 3. During a concurrent observation and interview on 11/18/24 at 9:35 a.m. with DM, the rice scooper was stored inside the rice grain storage container. DM stated, the scooper should not be left inside the storage container after each use. DM further stated, the scooper can harbor bacteria and can contaminate the rice if left inside. During a review of the facility's P&P titled, Food Service Management, dated 2014, the P&P indicated, .e.3. Scooping utensils are not kept in contact with the food . 4. During a concurrent observation and interview on 11/18/24 at 9:40 a.m. with DM, one 3.55 pound carton of powdered potatoes was not sealed. DM stated the potatoes should have been sealed in a clear plastic container once opened. DM further added the unsealed carton of food can attract pests. During a review of the facility's P&P titled, Food Service Management, dated 2014, the P&P indicated, .e. Opened dry staples (such as flour and sugar) are stored in labeled containers of corrosion-resistant material with tight fitting lids . 5. During a concurrent observation and interview on 11/18/24 at 9:44 a.m. with DM, chest freezer 1 and chest freezer 2 had crystallization on the inside compartments. Chest freezer 1 had two bags of frozen French fries with freezer burn. DM stated freezer burn on food items meant freezers were not working properly. DM also added, the two bags of frozen French fries with freezer burn may be an indication that the food was thawed and re-frozen. During a telephone interview on 11/21/24 at 11:21 a.m., with the Registered Dietician (RD), RD stated, it was important to have an airgap between the sink and drain system to prevent water from flowing back into the sink. RD further added, without an airgap, there was risk that dirty water, like sewage, could flow back into the sink, contaminating the food being prepared. RD also stated, the toaster should be cleaned after each use. RD added, bacterial growth can occur on food particles inside the toaster if left unclean. RD noted, scoops left inside the rice storage container can pick up moisture, which can cause bacteria to grow. RD stated, dry staples such as powdered potatoes should be sealed properly because unsealed cartons can attract pests. Furthermore, freezer burns on food items affect food quality and texture because freezer burn is a sign that the food item has been defrosted and refrozen.

Based on observation, interview, and record review, the facility failed to ensure medication was available to administer or given according to the physician's order for one of nine sampled residents (Resident 13) when Resident 13's Jardiance (medication used to help lower blood sugar levels) was not available for administration. This deficient practice had the potential for worsening of Resident 13's clinical condition. Findings: During a medication pass observation on 11/19/24 at 7:59 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering six medications to Resident 13. These medications included one capsule of duloxetine (medication used to treat depression and anxiety), one tablet of hydrochlorothiazide (medication used to treat high blood pressure and used to reduce edema (fluid retention)), one tablet of valsartan (medication used to treat high blood pressure), one tablet of metformin (medication used to help lower blood sugar levels), one tablet of Eliquis (blood thinner medicine that reduces blood clotting), and levalbuterol (medication used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness caused by lung disease such as asthma and chronic obstructive pulmonary disease (COPD a group of diseases that affect the lungs and airways). During a review of Resident 13's undated Admission Record, printed on 11/20/24, the Admission Record indicated, Resident 13 was admitted to the facility on [DATE] with multiple diagnoses, which included an admission diagnosis of type 2 diabetes mellitus (a disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), high blood pressure and pulmonary embolism (a blockage in a lung artery caused by a blood clot that has traveled from elsewhere in the body). During a review of Resident 13's Order Summary Report, dated 10/10/24, the Order Summary Report indicated Resident 13 had an order for Jardiance 25 milligrams (mg) one tablet in the morning for type 2 diabetes mellitus. During a concurrent observation and interview on 11/19/24 on 10:01 a.m. with LVN 1, LVN 1 opened the medication cart to check Resident 13's Jardiance medication supply. LVN 1 stated she can't find Resident 13's Jardiance medication supply inside the medication cart. LVN 1 stated Resident 13's Jardiance medication scheduled at 7:30 a.m. was not given. During a review of Resident 13's November 2024 Medication Administration Record, printed on 11/20/24, the November 2024 Medication Administration Record indicated Resident 13 did not receive the Jardiance medication at 7:30 a.m. on 11/19/24. LVN 1 documented in the administration note: Medication pending. Will follow up with pharmacy. During a review of Resident 13's Incident Note, dated 11/19/24, the Incident Note indicated Resident 13's Jardiance medication was not in the medication cart and was not given. During a review of the facility's policy and procedure (P&P) titled Medication Administration, dated 2007, indicated Medications are administered in accordance with written orders of the prescriber.

Based on observation and interview, the facility had fifteen resident's rooms (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 11/21/24, at 10:30 a.m., the following rooms and corresponding square footage (SQF) per bed were identified: room [ROOM NUMBER] had 2 beds, total SQF is 139.34 and SQF per bed is 69.67. room [ROOM NUMBER] had 2 beds, total SQF is 140.26 and SQF per bed is 70.13. room [ROOM NUMBER] had 2 beds, total SQF is 138.90 and SQF per bed is 69.45. room [ROOM NUMBER] had 2 beds, total SQF is 139.68 and SQF per bed is 69.84. room [ROOM NUMBER] had 2 beds, total SQF is 140.88 and SQF per bed is 70.44. room [ROOM NUMBER] had 2 beds, total SQF is 142.80 and SQF per bed is 71.40. room [ROOM NUMBER] had 2 beds, total SQF is 140.40 and SQF per bed is 70.20. room [ROOM NUMBER] had 2 beds, total SQF is 140.36 and SQF per bed is 70.18. room [ROOM NUMBER] had 2 beds, total SQF is 140.20 and SQF per bed is 70.10. room [ROOM NUMBER] had 2 beds, total SQF is 139.88 and SQF per bed is 69.94. room [ROOM NUMBER] had 2 beds, total SQF is 138.14 and SQF per bed is 69.07. room [ROOM NUMBER] had 2 beds, total SQF is 139.88 and SQF per bed is 69.94. room [ROOM NUMBER] had 2 beds, total SQF is 140.68 and SQF per bed is 70.34. room [ROOM NUMBER] had 2 beds, total SQF is 140.40 and SQF per bed is 70.20. room [ROOM NUMBER] had 2 beds, total SQF is 155.34 and SQF per bed is 77.67. During random observations of care and services from 11/18/24 to 11/21/24 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the fifteen rooms. Granting of room size waiver recommended.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. a stainless-steel pasta tong had rust on its surface. 2. the ice machine had six wet black spots inside ice compartment and white build up residue on the right corner rim inside opening. 3. the mounted can opener had rust on the blade and surrounding parts. These failures had the potential to cause food contamination and food borne illness. Findings: 1. During the initial tour of the kitchen and concurrent interview on 10/2/23 at 9:45 a.m. with the Dietary Service Supervisor (DSS), a stainless-steel rusty tong was stored in the clean kitchen utensil storage bin. The DSS stated the tong was actively being used. The DSSacknowledged the tong was rusty then disposed the tong in the trash. During an interview on 10/4/23 at 10:23 a.m. with the Registered Dietitian (RD), RD stated, there should not have been any utensils with rust in the kitchen due to risk for botulism (serious illness caused by toxin that attacks the body's nerves) toxin if rust goes in the food that residents ingest. During a review of facility's policy and procedure (P&P) titled, Infection Control - Cleaning Procedure, dated 2014, the P&P revealed, 1. The DSS routinely checks all sanitation and housekeeping procedures within the Dietary department. 2. The DSS spot checks work performance and counsels employees as needed to ensure that all cleaning meets high standards. 2. During an observation and concurrent interview on 10/2/23 at 10:00 a.m. the facility's ice machine had six wet black spots inside ice compartment and white build up residue on right corner opening. DSS proceeded to wipe the black dots with white paper towel. DSS stated, staff inspects ice machine daily, but missed the black spots inside ice bin. DSS further added, residents could get sick if contaminated ice was consumed. During an interview 10/4/23 at 10:33 a.m. with the RD, RD stated, dirt inside interior compartment of ice machine was a potential for health hazard. RD further added, dirt from inside ice machine can carry bacteria such as e. coli (Escherichia coli- can cause severe stomach cramps, bloody diarrhea and vomiting) and salmonella infections (bacterial disease) which can get the residents very sick. RD further added, there should not have been any spots or dirt inside icecompartment. During a review of facility's P&P titled, Ice Machine Cleaning and Sanitization, dated, 10/2023, the P&P indicated, the ice machine will be used and maintained to assure a safe and sanitary supply of ice. During a review of facility's P&P titled, Infection Control - Cleaning Procedure, dated 2014, the P&P showed, 9. c all stainless-steel equipment, ice machines, the storeroom (including the shelves), carts ovens, and racks are cleaned and sanitized. During a review of the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendation of CDC and Healthcare Infection Control Practices Advisory committee (HICPAC), revised 7/19, the CDC Guidelines indicated, Microorganisms (an organism seen only by a microscope) may be present in ice, ice-storage chests, and ice-making machines ice from contaminated ice machines has been associated with blood stream infections, pulmonary (having to do with the lungs), and gastrointestinal (having to do with the stomach and intestinal tract) illnesses Some waterborne bacteria found in ice could potentially be a risk to immunocompromised (weakened immune system) patients if the consumed ice or drink beverages with ice. 3. During a follow up kitchen observation and concurrent interview on 10/3/23 at 10:35 a.m. with DSS, the mounted manual can opener had rust on the blade and surrounding parts. DSS acknowledged the can opener was rusty and stated it will be replaced immediately. DSS also added, if rust gets in the food, it could be potential risk to the health being of residents. During an interview on 10/4/23 at 10:23 a.m. with the RD. RD stated, she was aware the mounted manual can opener was replaced yesterday due to rust. RD stated, there was risk for botulism toxin if rust goes in the food that residents ingest. During a review or facility's P&P titled, Food Service Management - Equipment Maintenance dated, 2012, the P&P indicated, 1. The DSS will periodically check all equipment and report items needing repair to the maintenance department following facility procedure. 2. The maintenance department routinely monitors all equipment for proper functioning and safety and performs routine preventative maintenance as per facility procedures. During a review of facility's P&P titled, Infection Control - Cleaning Procedure, dated 2014, the P&P revealed 1. the DSS routinely checks all sanitation and housekeeping procedures within the Dietary department. 2. The DSS spot checks work performance and counsels employees as needed to ensure that all cleaning meets high standards.9. c .all stainless-steel equipment, ice machines, the storeroom (including the shelves), carts ovens, and racks are cleaned and sanitized

Based on observation, interview and record review, the facility failed to follow the correct serving sizes to seven Residents for a census of 32 residents (Resident 21, 10, 11, 25, 5, 30 and 2). This deficient practice resulted in residents not receiving the appropriate diet portions to meet each individual needs. Findings: During a concurrent interview and tray line observation on 10/2/23, at 11:45 a.m., with Cook (CK) 1, in the presence of Dietary Service Supervisor (DSS), CK 1 was observed using a number 8 scoop to trays of puree and regular texture cabbage, country fried steak, and mashed potatoes, to serve seven residents. CK 1 stated, he was aware of portion sizes but used number 8 scoop for all serving regardless of what was on the meal cards. During a concurrent interview and record review on 10/3/23, at 12:20 p.m., with DSS, showed facility's color-coded portion control chart. DSS confirmed CK 1 did not follow scoop size for residents as indicated on the chart which showed, gray scoop number 8 is a large portion scoop equivalent to 4 fl-oz (fluid ounce - unit of measurement), green scoop number 12 is regular portion equivalent to 2.6 fl oz. and blue scoop number 16 is small portion equivalent to 2 fl-oz. During a concurrent interview and medical record review on 10/4/2,3 at 10:23 a.m., with Registered Dietician (RD), RD stated it was important to follow color coded scoops in order to meet dietary needs of each individual residents. RD further stated, Residents with Diabetes Mellitus (DM - a disease in which blood sugar levels are too high) should have received small starch portions (SSP), residents with Renal (Kidney) Disease should have received SPP (Small Protein Portions). RD also added, if dietary recommendations are not adequately met, Residents 21, 10, 11, 25, 5, 30 and 2's conditions can get worse. 1. During a review of Resident 21's face sheet on 10/4/23, indicated, Resident 21 was admitted to the facility in 2016 with multiple diagnoses that included Type 2 DM. During a review of Resident 21's order summary, dated 10/4/23, revealed a CCHO diet (Consistent, Constant or Controlled Carbohydrate Diet) pureed texture, regular consistency, SSP . 2. During a review of Resident 10's face sheet on 10/4/23, indicated, Resident 10 was admitted to the facility in 2020 and was readmitted in 2022. The face sheet showed Resident 10 had multiple diagnoses that included, Type 2 DM and Chronic Kidney Disease (CKD - kidney damage or gradual loss of kidney function). During a review of Resident 10's order summary, dated 10/4/23, revealed a CCHO diet . Lower portion sizes, small starch protein portions . 3. During a review of Resident 11's face sheet, on 10/4/23, indicated, Resident 11 was admitted to the facility in 2022 with multiple diagnoses that included Type 2 DM and Acute Kidney Failure also known as Acute Renal Failure (ARF- when kidneys suddenly become unable to filter waste products from the blood). During a review of Resident 11's order summary, dated 10/4/23, revealed a CCHO diet . SSP . SPP . 4. During a review of Resident 25's face sheet, on 10/4/23, indicated, Resident 25 was admitted to the facility in 2022 with multiple diagnoses that included Type 2 DM and ARF. During a review of Resident 25's order summary, dated 10/4/23, revealed a CCHO diet . SSP, SPP . 5. During a review of Resident 5's face sheet, on 10/4/23, indicated, Resident 5 was admitted to the facility in 2017 and was readmitted in 2021 with multiple diagnoses that included ARF. During a review of Resident 5's order summary, dated 10/4/23, in a regular diet. 6. During a review of Resident 30's face sheet, on 10/4/23, indicated, Resident 30 was admitted to the facility in 2023 with multiple diagnoses that included, DM. During a review of Resident 30's order summary, dated 10/4/23, revealed a CCHO diet. 7. During a review of Resident 2's face sheet, on 10/4/23, indicated Resident 2 was admitted to the facility in 2016 with multiple diagnoses that included, DM with CKD. During a review of Resident 2's order summary, dated 10/4/23, revealed a NAS (low sodium) and CCHO diet . SSP . During a review of facility's policy and procedure (P&P) titled, Food Service Management- Portion Control, undated, the P&P indicated, Standard portion control equipment will be available and utilized for measuring and serving resident meal portions. During a review of facility's P&P titled, Small Portion Diet, dated 2022, the P&P indicated, under general description, The small portion diet provides for the normal nutritional needs of residents who require smaller portions than the regular diet.

Based on observation and interview, the facility had fifteen resident's rooms (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in adequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 10/2/23, at 10:30 a.m., the following rooms and corresponding square footage (SQF) per bed were identified: room [ROOM NUMBER] had 2 beds, total SQF is 139.34 and SQF per bed is 69.67. room [ROOM NUMBER] had 2 beds, total SQF is 140.26 and SQF per bed is 70.13. room [ROOM NUMBER] had 2 beds, total SQF is 138.90 and SQF per bed is 69.45. room [ROOM NUMBER] had 2 beds, total SQF is 139.68 and SQF per bed is 69.84. room [ROOM NUMBER] had 2 beds, total SQF is 140.88 and SQF per bed is 70.44. room [ROOM NUMBER] had 2 beds, total SQF is 142.80 and SQF per bed is 71.40. room [ROOM NUMBER] had 2 beds, total SQF is 140.40 and SQF per bed is 70.20. room [ROOM NUMBER] had 2 beds, total SQF is 140.36 and SQF per bed is 70.18. room [ROOM NUMBER] had 2 beds, total SQF is 140.20 and SQF per bed is 70.10. room [ROOM NUMBER] had 2 beds, total SQF is 139.88 and SQF per bed is 69.94. room [ROOM NUMBER] had 2 beds, total SQF is 138.14 and SQF per bed is 69.07. room [ROOM NUMBER] had 2 beds, total SQF is 139.88 and SQF per bed is 69.94. room [ROOM NUMBER] had 2 beds, total SQF is 140.68 and SQF per bed is 70.34. room [ROOM NUMBER] had 2 beds, total SQF is 140.40 and SQF per bed is 70.20. room [ROOM NUMBER] had 2 beds, total SQF is 155.34 and SQF per bed is 77.67. During random observation of care and services from 10/2/23 to 10/5/23 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the fifteen rooms. Granting of room size waiver recommended.

Based on observation and interview, the facility had 15 resident (Rt) rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents belongings. Findings: During an observation on 4/19/21, at 9:42 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified. Room Activity Room Size Floor Area (sq. ft. per Resident) 1 Rt room 12'3x 11'4.5 69.67 sq. ft/bed 2 Rt room 11'4x 12'4.5 70.13 sq. ft/bed 3 Rt room 12'2x 11'5 69.45 sq. ft/bed 4 Rt room 11'3x 12'5 69.84 sq. ft/bed 5 Rt room 11'6x 12'3 70.44 sq. ft/bed 6 Rt room 12'5x 11'6 71.40 sq. ft/bed 7 Rt room 11'6x 12'2.5 70.20 sq. ft/bed 8 Rt room 12'3x 11'5.5 70.18 sq. ft/bed 10 Rt room 12'5x 11'3.5 70.10 sq. ft/bed 11 Rt room 12'2.5x 11'5.5 69.94 sq. ft/bed 12 Rt room 12'5 x 11'1.5 69.07 sq. ft/bed 14 Rt room 12'2.5x 11'5.5 69.94 sq. ft/bed 15 Rt room 12'5.5x 11'3.5 70.34 sq. ft/bed 16 Rt room 11'6x 12'2.5 70.20 sq. ft/bed 17 Rt room 13'5 x 11'6 77.67 sq. ft/bed During random observations of care and services from 4/19/21 to 4/22/21, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 15 rooms. Granting of room waiver is recommended.

Based on observation, interview, and record review, the facility failed to implement their infection prevention policy and procedures when: 1. CNA 1 did not perform hand hygiene when donning and doffing gloves. 2. CNA 2 improperly transported soiled linens. 3. RNA 1 did not perform hand hygiene when assisting multiple residents and handling food. These failures had the potential to spread infection among facility residents. Findings: 1. During a concurrent observation and interview on 4/21/21, at 9:27 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed transporting Resident 22 via wheelchair into their room. CNA 1 donned gloves and assisted Resident 22 from wheelchair into bed. CNA 1 removed gloves and pushed wheelchair out of the room, into outside storage area. CNA 1 stated hand hygiene needs to be performed, Every time we touch the resident and after. CNA 1 further states, I just forgot to perform hand hygiene when assisting residents and before donning and doffing gloves. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2020, the P&P indicated, Perform hand hygiene before applying non-sterile gloves and after removing gloves. P&P further indicates, 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. 2. During a concurrent observation and interview on 4/21/21, at 9:47 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 was observed coming out of a resident room carrying soiled linens with bare hands and placing them in soiled linen bin at end of hallway. CNA 2 stated she bundled soiled linens so the outside where she touched was clean. During an interview on 4/22/21, at 11:40 a.m., with Director of Nursing (DON), DON stated staff are to place soiled linens in a bag while in residents' room, then bring bag to soiled linen bin in hallway. During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated 10/2020, the P&P indicated, Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. During a concurrent observation and interview on 4/21/21, at 10:19 a.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 brought a pudding cup from snack cart into Resident 76's room, opened pudding cup and fed Resident 76. RNA 1 left the room, pushed snack cart to another room, poured hot water and juice, opened packet of crackers and gave them to Resident 17. RNA 1 left the room and assisted Resident 19 from hallway into bed. RNA 1 poured juice, opened packet of crackers and gave the the crackers to Resident 19. RNA 1 stated she keeps a bottle of hand sanitizer in her pocket, but stated, she forgot, when asked about performing hand hygiene between care of multiple residents and handling food. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2020, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, before and after eating or handling food, before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to follow nationally accepted infection control standards for the prevention of COVID-19 and their own infection control policy when personal protective equipment (PPE) was not readily available outside of resident rooms where precaution signs indicated its use was necessary. This failure resulted in Certified Nursing Assistant (CNA 1) not wearing a protective gown and gloves while in the room of a resident who was potentially infectious, had the potential to spread COVID-19, and signaled to staff that precautions on signs posted throughout the facility could be ignored. Findings: During an observation on 9/3/20 at 10:40 a.m., of the facility's Persons Under Investigation (PUI) for COVID-19 area of the facility (referred to as the Yellow Zone), signs were posted on the doors of each of the rooms indicating full PPE must be worn in the rooms, including an N95 respirator (mask), eye protection, gloves, and a gown. Further observation revealed PPE supplies were not on or near the doors for staff to easily access when entering rooms where residents were potentially infectious, and signs indicated full PPE use was required. During a concurrent observation of and interview with CNA 1 on 9/3/20 at 10:45 a.m., CNA 1 went into a resident's room in the Yellow Zone wearing an N95 respirator and a face shield, but without donning (putting on) a gown and gloves. CNA was not able to explain why she did not put on a gown or gloves before entering the resident's room. During an interview with the Operations Manager (OM) on 9/4/20 at 9:20 a.m., OM stated the facility experienced an outbreak of COVID-19 two and a half weeks earlier, and they were waiting on the results from a second round of serial testing of all staff and all residents. OM indicated that since the test results from the first round of serial testing were negative, they were anticipating the test results from the second round of serial testing would be negative and had taken away the PPE carts that had previously been by each door in the Yellow Zone. OM did not explain why they had removed the carts but had left the signs on the door. A review of the facility's P&P titled, COVID-19 Policy & Procedures, approved for use in the facility on 3/30/20, indicated the facility's healthcare personnel (HCP, which included CNAs) should follow the guidance on the Center for Disease Control's (CDC) COVID-19 website for using PPE. The P&P also listed the wearing of gloves, gowns, respiratory protection (masks), and eye protection as necessary to adhere to standard, contact, and airborne precautions and referred to Appendix H of the P&P. A review of Appendix H of the P&P, titled, PPE for HCP in direct contact with PUIs (persons under investigation) or Confirmed COVID-19 Patients, displayed a picture from the CDC's website of a healthcare worker wearing eye protection, an N95 mask, a gown, and a pair of clean, non-sterile gloves. A review of the CDC's COVID-19 Infection Control Guidance webpage (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) indicated, HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use (an approved N95 mask), gown, gloves, and eye protection.

Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program (ASP) that reviewed use of antibiotics (medicines that help stop infections caused by bacteria) with prescribers and determined whether appropriate antibiotics had been prescribed. This failure had the potential for the prescription of unnecessary antibiotics drugs. Findings: During a review of the Antibiotic Stewardship Program (ASP) on 2/19/20 at 11:27 a.m., the Director of Nursing/ Infection Preventionist (DON/IP) could not provide documentation to support the implementation of facility's ASP. In an interview on 2/19/20 at 11:57 a.m., the DON/IP stated the residents' use of antibiotics were not reviewed with the prescribers to determine whether appropriate antibiotics had been prescribed. The facility's undated policy and procedure, titled Antibiotic Stewardship, indicated, the facility supports the formation of an interdisciplinary subcommittee tasked with ASP development, implementation and oversight. The subcommittee will regularly communicate progress to licensed providers in the facility.

Based on observation, interview and record review, the facility failed to provide a sanitary environment when Housekeeping staff (HSK) placed soiled wet towels directly on the floor in the laundry room. Used bedside commode and a floor buffer machine were stored next to the washing machine in the laundry room. These failures had the potential for the spread of infection. Findings: During an observation on 2/20/20 at 8:38 a.m., in the presence of Laundry staff (LS) 1, House Keeping Staff (HSK) 1 was observed placing soiled wet towels onto the floor in the laundry room. During an interview on 2/20/20 at 8:39 a.m., HSK 1 stated she was sorry for placing soiled towels on the floor. During an observation on 2/20/20 at 8:30 a.m., accompanied by LS 1, one used bedside commode and floor buffer machine (floor cleaning equipment) were stored next to the washing machine in the laundry room. During an interview on 2/20/20 at 8:31 a.m., LS 1 stated the bedside commode and floor buffer machine was stored in laundry by the Maintenance Manager (MM). LS 1 said she had concerns about infection control issues and had communicated her concerns with the MM. During an interview on 2/20/20 at 8:41 a.m., the Assistant Administrator stated the laundry room was not the proper storage area for bedside commode and buffer machine. The facility undated policy and procedure titled, Laundry department, indicated: All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of clothing and linen.

Based on interview and record review, the facility failed to inquire about an existence of a written Advanced Directives for one (Resident 25) of thirteen sampled residents. This failure had the potential to prevent residents' from the implementation of their advanced directive. Findings: Review of the Admission Record indicated the facility admitted Resident 25 on 12/20/19. Review of Resident 25's Physician order [REDACTED]. During an interview on 2/19/20 at 8:40 a.m., the Social Service Designee (SS), stated Resident 25 had no written advanced directive. SS could not provide documentation to support inquiry about Resident 25's advanced directives. During an interview on 2/20/20 at 9:58 a.m., Resident 25's responsible party (RP) stated facility did not inquire about an existence of Resident 25's advanced directive. RP stated Resident 25 had an advanced directive and she will provide a copy to the facility. The facility's undated policy and procedure titled, Advance Directives, indicated: Prior to or upon admission of a resident to our facility, the Social Services Director or designee will inquire of the resident, and/or his/her family members about the existence of any written advanced directives.

Based on observation and interview, the facility had fifteen resident (Rt) rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 2/18/20, at 8:34 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area 1 Rt room [ROOM NUMBER]'3x11'4.5 69.67 sq.ft/bed 2 Rt room [ROOM NUMBER]'4x12'4.5 70.13 sq.ft/bed 3 Rt room [ROOM NUMBER]'2x11'5 69.45 sq.ft/bed 4 Rt room [ROOM NUMBER]'3x12'5 69.84 sq.ft/bed 5 Rt room [ROOM NUMBER]'6x12'3 70.44 sq.ft/bed 6 Rt room [ROOM NUMBER]'5x11'6 71.40 sq.ft/bed 7 Rt room [ROOM NUMBER]'6x12'2.5 70.20 sq.ft/bed 8 Rt room [ROOM NUMBER]'3x11'5.5 70.18 sq.ft/bed 10 Rt room [ROOM NUMBER]'5x11'3.5 70.10 sq.ft/bed 11 Rt room [ROOM NUMBER]'2.5x11'5.5 69.94 sq.ft/bed 12 Rt room [ROOM NUMBER]'5x11'1.5 69.07 sq.ft/bed 14 Rt room [ROOM NUMBER]'2.5x11'5.5 69.94 sq.ft/bed 15 Rt room [ROOM NUMBER]'5.5x11'3.5 70.34 sq.ft/bed 16 Rt room [ROOM NUMBER]'6x12'2.5 70.20 sq.ft/bed 17 Rt room [ROOM NUMBER]'5x11'6 77.67 sq.ft/bed During random observations of care and services from 2/18/20 to 2/20/20, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the six rooms. Granting of room size waiver is recommended.

Based on observation, interview, and record review, the facility failed to ensure Cook (CK) 1 had the appropriate competencies and skills sets to follow proper sanitization and food preparation when: 1. CK 1 could not correctly demonstrate how to test the dishwasher's chlorine level, and; 2. CK 1 did not know what the temperature of vegetables and meat on the steam table should be. These deficient practices had the potential to result in an outbreak of foodborne illness. Findings: During the initial kitchen tour and concurrent interview with Cook (CK) 1 on 12/18/18, at 8:04 a.m., CK 1 turned the dishwasher on, immediately opened the dishwasher and dipped a chlorine test strip into the water of the dishwasher to check the chlorine level (method used to measure sanitization level of dishwasher water). The water temperature was 120 degrees Fahrenheit (F). CK 1 compared the chemical test strip to the color chart on the vial of unused chemical test strips and stated the chlorine level was 25 parts per million (ppm). CK 1 stated the chlorine level should be at least 100 ppm. During a concurrent interview and record review with CK 1 on 12/18/18, at 9:04 a.m., CK 1 rechecked the dishwasher's chlorine level, and the level was 25 ppm. CK 1 stated he had not checked the dishwasher's chlorine level that morning and had not washed dishes that morning. CK 1 showed a document titled Weekly Temperature Log, which indicated CK 1 had checked the dishwasher's chlorine 12/18/18 at 8:30 a.m., and the chlorine level was 50 at that time. Further review of this document indicated .The AM cook is responsible to check dishwasher temp and sanitization every shift upon first arrival in the morning .*Chemical sanitizing dishwasher (low temp) use a chemical sanitizing rinse should be 50-100 ppm During an interview with the Dietary Services Supervisor (DSS) on 12/18/18, at 9:18 a.m., the DSS stated the facility's dishwasher was a low temperature dishwasher, and the chlorine level should be 50-100 ppm. DSS stated the dishwasher temperature and the chlorine level should be checked daily. During an interview with the DSS on 12/18/19, at 1:29 p.m., the DSS stated the chlorine level should be tested during the rinse cycle of the dishwasher. The DSS tested the chlorine level during the rinse cycle, and the level was 50 ppm. The DSS stated he knew when the dishwasher was in the rinse cycle by how the machine sounded during that cycle. Review of a document titled Consultant Dietician Report Card, dated 11/2018, indicated .Cleaning & Sanitation-staff should know proper procedure to check chlorine ppm & temperatures Review of the facility's document titled Food & Nutrition: Competency Checklist-Cook, dated 11/22/18, indicated CK 1 met the competency/skill requirements for .Knowledge of proper sanitizer solution range, sanitizing strip log and knowledge of temperature of food and correctly state temperature danger zone . Review of the facility's policy and procedure titled Infection Control(NAME)Washing, dated 2014, indicated .c. When rinse cycle is finished, open the machine. d. Dip strip of test paper into rinse water or place on wet area of serviceware. e. Compare immediately with the color chart on vial. Color of paper dipped in rinse water must compare with color on vial relating to a minimum of 50 parts per million (ppm) Review of the facility's document titled Safe Parameters for dish and Pot Washing, dated 2014, indicated .Low Temperature Dishmachine rinse sanitizer should equal 50 ppm Chlorine . Review of the facility's document titled Specifications-Operating Parameters, not dated, indicated .Minimum Chlorine Required (PPM) was 50 . 2. During a concurrent observation and interview with CK 1 on 12/19/18 at 11:37 a.m. of the lunch tray line, CK 1 stated the temperature of the mixed vegetables (Cauliflower and Peas) and pork should be 180 degrees F. The DSS measured the temperature, and the temperature of the vegetables was 142 degrees F and the temperature of the pork was 146 degrees F. Review of the facility's policy and procedure titled Food Service Management Food Serving Temperatures, dated 2014, indicated .Hot food must be a minimum of 140 degrees F at time of serving .2. The Consultant Dietician determines appropriate serving temperature goals for various categories of food products .goal temperature for meat and vegetables was 150-165 degrees F . Review of a document titled Consultant Dietician Report Card, dated 11/2018, indicated .Food Preparation & Meal Service-staff should know food temperatures meet standards

Based on interview and record review, the facility failed to ensure copies of advance directives (a written instruction, such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated) for two (Resident 16 and Resident 23) of 12 sampled residents were maintained in the resident's medical record and readily retrievable by any facility staff. This deficient practice had the potential to result in Resident 16's and Resident 23's wishes regarding medical treatment not being followed. Findings: 1. Review of the Resident Face Sheet, printed 12/19/18, indicated Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Physician order [REDACTED]. medical condition into consideration. A POST [MEDICATION NAME] for is not an advance directive), dated 4/27/18, indicated Resident 16 had an advance directive. During an interview with the SSD on 12/19/18, at 1:14 p.m., SSD stated she charted Resident 16 had an advance directive, but she was not able to show that a copy of Resident 16's advance directive was in Resident 16's medical record. 2. Review of the Resident Face Sheet, printed 12/19/18, indicated Resident 23 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 23's POLST, dated indicated Resident 23 had an advance directive. During an interview and concurrent record review on 12/19/18, at 1:09 p.m., the SSD was not able to show that a copy of Resident 23's advance directive was in his medical record.

Based on observation and interview, the facility had multiple resident (Rt) rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) with two beds each that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in the identified rooms, or for storage of the resident belongings. Findings: During an observation on 12/18/18, at 8:20 a.m., the following rooms and corresponding square footage per bed (sq.ft/bed) were identified: Room Activity Room Size Floor Area 1 Rt room [ROOM NUMBER].34 sq.ft 69.67 sq.ft/bed 2 Rt room [ROOM NUMBER].26 sq.ft 70.13 sq.ft/bed 3 Rt room [ROOM NUMBER].90 sq.ft 69.45 sq.ft/bed 4 Rt room [ROOM NUMBER].68 sq.ft 69.84 sq.ft/bed 5 Rt room [ROOM NUMBER].88 sq.ft 70.44 sq.ft/bed 6 Rt room [ROOM NUMBER].20 sq.ft 71.40 sq.ft/bed 7 Rt room [ROOM NUMBER].40 sq.ft 70.20 sq.ft/bed 8 Rt room [ROOM NUMBER].36 sq.ft 70.18 sq.ft/bed 10 Rt room [ROOM NUMBER].20 sq.ft 70.10 sq.ft/bed 11 Rt room [ROOM NUMBER].88 sq.ft. 69.94 sq.ft/bed 12 Rt room [ROOM NUMBER].14 sq.ft 69.07 sq.ft/bed 14 Rt room [ROOM NUMBER].88 sq.ft 69.94 sq.ft/bed 15 Rt room [ROOM NUMBER].68 sq.ft 70.34 sq.ft/bed 16 Rt room [ROOM NUMBER].40 sq.ft 70.20 sq.ft/bed 17 Rt room [ROOM NUMBER].34 sq.ft 77.67 sq.ft/bed During random observations of care and services from 12/18/18 to 12/20/18, there was sufficient space for the provision of care for the residents in all 15 rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 15 rooms. Granting of room size waiver recommended.

Based on observation, interview, the facility had multiple resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 17) that measured less than the required 80 square feet per resident for the 30 residents who would occupy these rooms. This limited the space for providing resident care by facility staff and increased the risk for residents not being able to have enough space to accommodate personal belongings. Findings: The rooms identified and the square footage per resident were as follows: room [ROOM NUMBER] had two beds and it measured 139.34 square feet (sq. ft.) providing 69.67 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.26 sq. ft., and provided 70.13 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 138.90 sq. ft., and provided 69.45 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 139.68 sq. ft., and provided 69.84 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.88 sq. ft., and provided 70.44 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 148.20 sq. ft., and provided 71.40 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.40 sq. ft., and provided 70.20 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.36 sq. ft., and provided 70.18 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.20 sq. ft., and provided 70.10 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 139.88 sq. ft., and provided 69.94 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 138.14 sq. ft., and provided 69.07 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 139.88 sq. ft., and provided 69.94 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.68 sq. ft., and provided 70.34 sq. ft. per resident; room [ROOM NUMBER] had two beds and measured 140.40 sq. ft., and provided 70.20 sq. ft. per resident; room [ROOM NUMBER] had two beds and it measured 155.34 sq. ft., and provided 77.67 sq. ft. per resident. During an interview on 1/3/18, at 3:11 p.m., Certified Nursing Assistant (CNA) 1 stated there was one resident who was transferred via hoyer lift (mechanical device that is used to move a totally dependent resident from bed to another surface and back). CNA 1 stated the room had enough space to maneuver the hoyer lift without having to move the other bed. During an interview on 1/4/18, at 8:25 a.m., CNA 2 stated there were no problems with transfers of residents and getting them up in the wheelchair. During random observations of care and services from 1/2/18 to 1/4/18, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the eight rooms. Recommend granting room size waiver.

Based on interview and record review, for one of 12 sampled residents (Resident 30) , the facility failed to issue a notice of discharge to the resident (or resident representative) and to the Office of the Ombudsman. This failure had the potential to result in the lack of coordination of support for Resident 30 during discharge planning or after discharge to the community. Findings: Review of the clinical record indicated Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Summary, dated 8/27/17, indicated Resident 30 underwent closed reduction and internal fixation (implementation of implants (e.g. like nails or screws) to aid in healing of fractured bone). The Discharge Summary also indicated Resident 30 was admitted to the facility for rehabilitation with physical and occupational therapy. Review of the clinical record showed a physician's orders [REDACTED]. During interviews and concurrent record review on 1/3/18 ,at 2:36 p.m., the Director of Nursing (DON) stated Resident 30's discharge was a planned discharge (a plan to treat the resident's medical requirements after release from the facility). The Assistant Administrator stated there was no notice sent to the Office of the Ombudsman regarding Resident 30's discharge to the community. During another interview on 1/3/18 at 2:46 p.m., the Social services Director (SSD) she participated in discharge planning for all discharges from the facility. The SSD stated she did not send notices to the Office of the Ombudsman whenever a resident was discharged . The SSD also stated the facility did not provide written discharge notices to residents or resident representatives as they were only told verbally of their coming discharge. Review of an undated facility's policy and procedure (P&P) titled, Discharging the Resident, undated, indicated .Preparation .8. if the discharge is scheduled, the Office of the State Long-Term Care Ombudsman will be notified up to 30 days prior to the discharge date . If the discharge is not scheduled, the Office of the State Long-Term, Care Ombudsman will be notified at the time of discharge. The P&P did not address the notification of the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.