Every finding on record at Marycrest Manor

Based on observation, interview and record review, the facility failed to ensure for 43 of 44 medically compromised and vulnerable residents who received food from the kitchen: Ensure food items were labelled with opened and use by dates.Ensure dented cans were separated from useable stock and placed in specified labeled area. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins). Findings: 1.During a concurrent observation and interview on 1/6/2026 at 8:38 a.m., with Cook (CK) 1 in the kitchen, there were food items with no open or use-by date as follows: Opened and used caesar dressing without opened date or used by date. Cajun seasoning with opened date of 4/21/2025, missing used by date. Low sodium soy sauce with opened date of 9/29/2025, missing used by date. CK 1 stated dietary staff are responsible for labeling all food items with an opened date and use by date once a food item was opened. CK 1 stated labeling food items was important to ensure expired food items are not used when preparing meals for residents. CK 1 stated using food items past their used by date can effect the quality of food and place residents at risk of developing foodborne illness. During an interview on 1/7/2026 at 12:55 p.m. with the Registered Dietician (RD), the RD stated once a food item was opened, kitchen staff should label with an opened date. The RD stated kitchen staff use a product sheet based on food code to label foods with a used by date. The RD stated labeling food items was important because using expired foods can place residents at risk of gastrointestinal sickness. During a review of facility's policy and procedure (P&P) titled, Labeling and Dating of Foods dated 2020, indicated Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines. 2.During a concurrent observation and interview on 1/6/2026 at 9:02 a.m., with [NAME] (CK) 1 in the dry storage area, there were dented cans observed in remaining stock and not placed in specified area labeled Dented Cans Here as follows: One dented hoisin sauce can Three dented apple sauce cans One dented white beans can The CK 1 stated when new inventory was brought to the kitchen, staff assisting with organization of cans are responsible for identifying dented cans and placing them in designated dented can area. CK 1 stated dented cans should be separated because there was a risk of air and bacteria entrance, which can result in residents getting sick. During an interview on 1/7/2026 at 12:55 p.m. with the Registered Dietician (RD), the RD stated dented cans should be placed in designated dented can area. The RD stated dented cans can harm the integrity of food inside. During a review of facility's policy and procedure (P&P) titled, Food Storage-Dented Cans dated 2018, indicated All dented cans and rusty cans are to be separated from remaining stock and placed in specified labeled area for return to purveyor for refund.

Based on observation, interview and record review the facility failed to ensure therapeutic menu (meal plan that controls the intake of certain foods or nutrients) portion sizes were followed for 43 of 44 medically compromised and vulnerable residents who received food from the kitchen. This deficient practice had the potential to place residents at risk for not having nutritional needs met and potential weight gain. Findings: During an observation on 1/6/2026 at 11:55 a.m. in the kitchen, [NAME] (CK) 1 was observed scooping polenta onto resident's plates using one half cup scoop size. During a concurrent interview and record review on 1/6/2026 at 12:20 p.m. with [NAME] (CK) 1, the therapeutic menu spreadsheet dated 1/6/2026 was reviewed. The therapeutic menu spreadsheet indicated polenta to be served with a one third cup scoop size for a regular sized diet. CK 1 stated one third cup scoop size should have been used for residents on regular portion diet. CK 1 stated serving larger portions of food places residents at risk for unintended weight gain. During an interview on 1/8/2026 at 11:30 a.m. with the Registered Dietician (RD), the RD stated some residents have small or large portions indicated on their meal ticket and the amount of food served will align with their meal portion. The RD stated the cook should have served polenta with a one third cup scoop size to residents with a regular portion diet. The RD stated following the therapeutic menu portion sizes was important because it ensures all nutrient needs are being met. During a review of facility's policy and procedure (P&P) titled Therapeutic Diets dated 2018, indicated It is the policy of the facility to ensure that all therapeutic menus are planned, prepared and served in accordance with current Federal and State regulations.Menus must provide a variety of foods, indicate standard portions.

Based on observation, interview and record review, the facility failed to ensure residents had an alternative system of notification of lunch menu substitutions when an overhead page was not heard by three of three sampled residents. (Resident 4, Resident 23 and Resident 24). This deficient practice had the potential for residents to not be notified and substitutions and preferences to not be honored. Findings: During a concurrent observation and interview on 1/6/2026 at 11:55 a.m. with [NAME] 1 (CK1) in the kitchen, the food prepared for lunch was observed. CK1 stated the lunch dessert cranberry crunch square was substituted with raspberry parfait and the lunch vegetable broccoli was substituted with sauteed spinach. CK1 stated per facility policy, residents must be notified when substitutions to the menu are made. During an interview on 1/7/2026 at 3:00 p.m. with Resident 4, Resident 4 stated she was not notified of the vegetable or dessert change for the lunch menu on 1/6/2026. Resident 4 stated she would like to be notified when changes to the menu are made so that she can request alternatives if she does not like what was being served. During an interview on 1/7/2026 at 2:52 p.m. with Resident 23, Resident 23 stated no one notified her of lunch menu changes on 1/6/2026. Resident 23 stated she likes to know what food is being served and wants to be notified if any menu changes are made. During an interview on 1/7/2026 at 3:00 p.m. with Resident 24, Resident 24 stated he remembers eating lunch yesterday (1/6/2026) and he was not notified of any lunch menu substitutions. During an interview on 1/8/2026 at 11:30 a.m. with the Registered Dietician (RD), the RD stated notifying residents of menu substitutions was important because notification gives the residents the opportunity to request an alternative if they do not like what is being served. The RD stated residents have the right to know what they are being served, and not notifying residents of menu substitutions could result in residents preferences not being honored. During a review of facility policy and procedure (P&P) titled Food Substitutions During Trayline dated 2020, the P&P indicated, When a menu item is not available, the cook will provide a substitute of similar nutritive value, document the change and the reason, and communicate the substitution to residents as appropriate.The menu substitutions will be approved by the dietician.

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 7)'s mouth was rinsed after administration of prescribed inhaler Arnuity Ellipta [an inhaler used as a maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and fill with mucus)].This failure had the potential to result in Resident 7's developing irritation of the mouth, discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the mouth after inhaler use.Findings:During a review of Resident 7's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 7 on 5/14/2024 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), morbid obesity (serious disease that involves excess body fat that increases risk of health problems), obstructive sleep apnea (a sleep disorder when breathing repeatedly stops and starts during sleep because the airway shrinks or blocked), and dysphagia (difficulty swallowing).During a review of Resident 7's History and Physical (H&P) dated 9/12/2025, the H&P indicated Resident 7 had the capacity to make needs known but was unable to make medical decisions.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 11/28/2025, the MDS indicated Resident 7 had normal thinking and memory. The MDS indicated Resident 7 was independent with eating and oral hygiene, needed maximum assistance from staff with toileting, showering, lower body dressing, putting on and taking off footwear, and needed partial assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort to complete the activity) with upper body dressing and personal hygiene.During an observation on 1/8/2026 at 8:07 a.m. during medication administration with Licensed Vocational Nurse (LVN) 3 in Resident 7's room, LVN 3 did not instruct Resident 7 to rinse her mouth after administration of inhaler Arnuity Ellipta.During a review of pharmacy's label for Arnuity Ellipta 200 mcg (micrograms - a unit of measurement) inhaler starting 1/2/2026 indicated, inhale one puff by mouth one time a day for COPD rinse mouth with water after use.During an interview on 1/8/2026 at 9:19 a.m. with LVN 3, LVN 3 stated she did not instruct Resident 7 to rinse her mouth after taking the inhaler. LVN 3 stated the importance of rinsing mouth after the inhaler was to prevent the growth of bacteria or fungus in the mouth. LVN 3 stated if the resident did not rinse her mouth after taking the inhaler, there would be a potential that the resident could develop infection in the mouth leading to a greater infection.During an interview on 1/8/2026 at 2:51 p.m. with the Director of Nursing (DON), the DON stated the importance of following pharmacy instructions to rinse mouth after administration of inhaler was to prevent mouth infection. The DON stated if the resident did not rinse her mouth after taking the inhaler, there would be a risk for mouth infection that would lead to other infections of the body.

Based on interview and record review, the facility failed to:1. Document the medical appointment for one of one sampled resident (Resident 14).This deficient practice had the potential to place Resident 14 of not receiving appropriate care and delay in communication among staff due to incomplete medical records.Findings:During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls).During a review of Resident 14's History and Physical (H&P), dated 6/9/2025, the H&P indicated, Resident 14 can make needs known but could not make medical decisions.During a review Residewas4's MDS assessment, dated 11/14/2025, the MDS assessment indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 14 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene.During a review of Resident 14's Outpatient Referral Form, dated 12/1/2025, the Outpatient Referral Form indicated, Resident 14 to be referred to orthopedic surgery (a medical specialty that focuses on treating injuries and diseases of the musculoskeletal system) to evaluate for limited range of motion ([ROM] - full movement potential of a joint) of right shoulder and pain. The Outpatient Referral Form indicated, Resident 14 had a history of right shoulder rotator cuff injury (one or more of the tendons connecting your upper arm bone to your shoulder blade are torn, inflamed, or damage) and dislocation.During a review of Resident 14's Order Summary Report (a document containing active orders), dated 1/8/2026, indicated the physician placed a telephone order on 12/2/2025 for Resident 14 to have orthopedic surgery appointment on 12/22/2025.During a concurrent interview and record review on 1/8/2026 at 9:32 a.m., with the Director of Nursing (DON), Resident 14's Progress Notes, were reviewed. The DON stated Resident 14's medical records were incomplete. The DON stated there was no documentation by nursing staff indicating Resident 14 went to the orthopedic surgery appointment on 12/22/2025. The DON stated there was no documentation on Resident 14's Progress Notes that she refused to go to her scheduled orthopedic surgery appointment on 12/22/2025. The DON stated resident's medical records should be complete for coordination of care among interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) and for resident's continuity of care.During a review of the facility's policy and procedure (P&P) titled, Documentation by Nursing Personnel, dated 5/1/2019, the P&P indicated Resident documentation will reflect the resident's condition in a timely and accurate manner.

Based on interview and record review, the facility failed to develop a person-centered care plan for two of 12 sampled residents (Residents 5 and 14) by failing to:Address Resident 5's diagnosis of schizophrenia (a mental illness that is characterized by disturbance in thought).Address Resident 14's allergy to aspirin (drug used to reduce pain, fever, and prevent blood clot).This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 5 and Resident 14.Findings: A. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 5 on 8/2/2017 and was readmitted on [DATE] with the diagnosis of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), metabolic encephalopathy(a problem in the brain caused by a chemical imbalance in the blood), atrial fibrillation (AFib - an irregular and often rapid heart rhythm), schizophrenia (a mental illness that is characterized by disturbances in thought), and depressive disorder (depression – a mental disorder involving a depressed mood or loss of interest in activities for long periods of time). During a review of Resident 5's History and Physical (H&P) dated 1/8/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool) dated 11/18/2025, the MDS indicated Resident 5 had severe problems with thinking, making decisions and memory. The MDS indicated Resident 5 had an active diagnosis of schizophrenia. During a record review on 1/6/2026 at 11:02 a.m. of Resident 5's care plans, there was no care plan for Resident 5's active diagnosis of schizophrenia. During a concurrent interview and record review on 1/7/2026 at 10:28 a.m. with Licensed Vocational Nurse (LVN) 1 Resident 5's MDS was reviewed. LVN 1 stated, the MDS indicated Resident 5 had an active diagnosis of schizophrenia. During a concurrent interview and record review on 1/7/2026 at 10:33 a.m. with LVN 1 of Resident 5's Care Plan, LVN 1 stated there was no Care Plan for schizophrenia. LVN 1 stated there should be a Care Plan for every diagnosis to ensure the resident receives interventions specific to the diagnosis. LVN 1 stated if there was no Care Plan in place for a specific diagnosis, the resident would not progress or would get worse because the resident does not have interventions specific to a diagnosis. During a concurrent interview and record review on 1/7/2026 at 1:41 p.m. with the Director of Nursing (DON) Resident 5's MDS dated [DATE] and care plans were reviewed. The DON stated the MDS indicated Resident 5 had an active diagnosis of schizophrenia. The DON stated care plans should be implemented for every diagnosis to ensure the resident receives interventions specific to the diagnosis and to monitor the residents' decline or improvement. The DON stated if care plans were not implemented, the resident would not receive the interventions that could worsen the diagnosis. During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plan revised 10/16/2017, the P&P indicated, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objective and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.12. Care Plans are to be reviewed, on a minimum, once every quarter (every 90 days) and whenever necessary, either as a result of significant change in resident's status and condition, or if discontinued plan of care based on new information derived from the resident's assessment to assure the continued accuracy of the assessment. B. During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Resident 14's History and Physical (H&P), dated 6/9/2025, the H&P indicated, Resident 14 can make needs known but could not make medical decisions. During a review Resident 14's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/14/2025, the MDS assessment indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 14 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 14's Order Summary Report (a document containing active orders), dated 1/7/2026, the Order Summary Report indicated, Resident 14 was allergic to aspirin. During a concurrent interview and record review on 1/9/2026 at 9:49 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 14's clinical records were reviewed. LVN 2 stated there was no care plan to address Resident 14's allergy to aspirin. LVN 2 stated Resident 14's allergy to aspirin was already identified on the Order Summary Report and that was the reason why facility did not develop a comprehensive care plan. LVN 2 stated it was important to develop a comprehensive care plan for each resident in order to provide the needs of the resident. LVN 2 stated it was important to have a care plan for a resident with known medication allergy for resident safety and to provide interventions promptly in case resident develop an allergic reaction (set of symptoms that happen after you touch, inhale, or administered something you are allergic to). During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, dated 10/16/2017, the P&P indicated It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated care plans must show evidence of facility's effort to address or manage risk factors.

Based on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 12 sampled residents (Resident 14) by failing to:1. Ensure Resident 14's Plavix (classified as antiplatelet agent drug used to prevent blood clots) was not encoded as anticoagulant (blood thinner) medication.This failure resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 14.Findings:During a review of Resident 14's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls).During a review of Resident 14's History and Physical (H&P), dated 6/9/2025, the H&P indicated, Resident 14 can make needs known but could not make medical decisions.During a review Resident 14's MDS assessment, dated 11/14/2025, the MDS assessment indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 14 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene.During a review of Resident 14's Order Summary Report (a document containing active orders), dated 1/8/2026, indicated the physician placed a telephone order on 5/21/2024 for Resident 14 to start on Plavix 75 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to take one 1 tablet by mouth in the morning for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) prevention.During a review of Resident 14's Medication Administration Records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 11/1/2025 to 11/30/2025, indicated Resident 14 received Plavix 75mg by mouth once a day.During a concurrent interview and record review on 1/7/2026 at 11:36 a.m., with the Minimum Data Set Nurse (MDSN), Resident 14's MDS assessment, dated 11/14/2025, was reviewed. The MDSN stated MDS Section N (Medications) look back period (the specific time frame within which certain resident conditions and events are assessed) was 7 days before the completion date. The MDSN stated Resident 14's MDS assessment was completed inaccurately. The MDSN stated there should be no checked mark on Resident 14's MDS Section N0415 (High-Risk Drug Classes) E (anti-coagulant e.g., warfarin, heparin, or low-molecular weight heparin) since Plavix was not classified as anti-coagulant medication. The MDSN stated coding of medications in the MDS assessment should be based on the drug classification. The MDSN stated accuracy of MDS assessment was important in order to reflect the actual clinical condition of the resident. The MDSN stated inaccuracy of MDS assessment would affect the plan of care of the resident.During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set Resident Assessment, dated 9/1/2024, the P&P did not disclose the medications coding instructions and importance of completing the MDS assessment accurately.During a review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page 481, under Coding Tips and Special Populations, indicated Code medications in item N0415 according to the medication's therapeutic category and/or pharmacological classification, not how it is used.

Based on interview and record review, the facility failed to:1. Submit and transmit the Minimum Data Set ([MDS] - a resident assessment tool) within the regulatory timeframe to the Center for Medicare and Medicaid Service (CMS) for one of 12 sampled residents (Resident 3).This deficient practice had the potential to result in billing error and inaccurate data on resident care needs.Findings:During a review of Resident 3's admission Record, the admission Record indicated, Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included left femur fracture (break in the thigh bone), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips, and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 3's History and Physical (H&P), dated 8/8/2025, the H&P indicated, Resident 3 can make needs known but could not make medical decisions.During a review Resident 3's MDS assessment, dated 12/6/2025, the MDS assessment indicated, Resident 3's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 3 was dependent (helper does all of the effort) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of the CMS MDS 3.0 Nursing Home (NH) Validation Report, the CMS 3.0 NH Validation Report indicated, Resident 3's MDS assessment was submitted late for more than 14 days after Z0500B (the date that the Registered Nurse Assessment Coordinator signed the assessment as complete).During a concurrent interview and record review on 1/7/2026 at 11:18 a.m., with the Minimum Data Set Nurse (MDSN), Resident 3's MDS assessment, dated 12/6/2025, was reviewed. The MDSN stated Resident 3's MDS Assessment was completed on 12/20/2025 and submitted late to the CMS on 1/5/2026. The MDSN stated Resident 3's MDS assessment data should have been submitted and transmitted within 7 days after the completion date. The MDSN stated each member of the interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) has their own responsibility to complete each section of the MDS. The MDSN stated the facility Social Service Director (SSD) was taking some time off and that was the reason for the late submission of Resident 3's MDS assessment to the CMS. The MDSN stated it was a federal requirement to complete, submit and transmit any MDS assessment in a timely manner to be compliant with the regulation and for the CMS to know the condition and plan of care of the resident.During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set Resident Assessment, dated 9/1/2024, the P&P indicated, The completed MDS records shall be encoded and transmitted to the State repository in accordance with Center of Medicare and Medicaid Services (CMS) established record specifications and timeframes.During a review of the facility's P&P titled, Transmission of MDS, dated 3/8/2024, the P&P indicated, All MDS assessment (admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS IQIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.

Based on interview and record review, the facility failed to: 1. Maintain and notify the dietary supervisor of the temperature being out of range in one of the walk-in refrigerators during the month of February. This deficient practice had the potential for food spoilage and can cause foodborne pathogens in the residents. Findings: During a review of the Refrigerator Temperature Log, dated February 2025, it indicated the walk-in refrigerator located towards the back of the kitchen for February 2025 had the following temperatures recorded: 44 Fahrenheit ( F- measurement of temperature) on 2/6 at 5:00 a.m. 42 F on 2/8 at 5:30 a.m. 45 F on 2/10 at 5:30 a.m. 45 F on 2/11 at 5:40 a.m. During a concurrent interview and record review on 2/16/2025 at 9:30 a.m. with Kitchen Aide (KA), the Refrigerator Temperature Log for February 2025 was reviewed. KA stated that the individual who arrives the earliest, usually around 5:30 a.m. would check the temperatures of the refrigerator and freezer and record it on the temperature log. KA stated they check it when they first come in because the refrigerator and freezer isn't being opened or closed which could affect the temperatures, so the first temperature taken when then first staff member arrives is the most accurate temperature. KA stated there are several dates in February where the refrigerator exceeded 41 F and there were no comments written the in the column for corrective action/comments and there should have been so the staff could see what was done to correct the issue. KA stated that the individual who took the temperature that is out of range need to report it to the dietary supervisor and they are the ones who would fill out the column corrective action/comments. KA further stated it is important for food to be stored at the appropriate temperature because if not the food can go bad and can make the food unsafe to eat. During a concurrent interview and record review on 2/16/2025 at 9:43 a.m. with the Dietary Supervisor (DS), the Refrigerator Temperature Log for February 2025 was reviewed. FSM stated he or the maintenance supervisor would fill out the column titled corrective action/comments after they addressed the temperature being out of range. DS stated he was not notified about the temperature being out of range and it is unknown if there were any corrective actions taken to address the temperatures on the dates it was out of range. During a review of the Refrigerator Temperature Log dated February 2025, it indicated to maintain the refrigerator temperature at 40 F or below during stable times and to complete corrective action column if temperatures are not in proper ranges.

Based on interview and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 28 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness. Findings: During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a concurrent interview and record review with the Director of Staff Development (DSD) on 2/16/2025 at 12:48 p.m., Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for Seroquel 25 mg for dementia psychosis. The DSD stated anti-psychotics are given for a psychiatric diagnosis to help manage behavior. The DSD stated Resident 28 does not have a psychiatric diagnosis. The DSD stated Seroquel is not used for dementia. You must be careful giving anti-psychotics to the elderly because they can become very drowsy and it increases their risk for fall. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication, dated July 2022, the P&P indicated the facility will ensure each resident's drug regimen will be free of unnecessary drugs. Doctors orders will contain the appropriate diagnosis.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) had four padded side rails on the bed per physician's order. This deficient practice had the potential to result in Resident 28 being injured in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) Findings: During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), seizures, and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set ([MDS] a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 28 was dependent on staff for toileting and showering. During a review of Resident 28's care plan, dated 6/20/2024, the care plan indicated Resident 28 required the use of four padded side rails for seizure precautions. The care plan indicated Resident 28 would have padded side rails when in bed. During a concurrent interview and record review on 2/15/2025 at 5:48 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 28's order summary was reviewed. The order summary indicated Resident 28 had a physician's order for four padded side rails to be up when in bed for seizure precautions. During a concurrent observation and interview on 2/15/2025 at 5:50 p.m. with LVN 4 at the bedside of Resident 28, Resident 28 was noted in bed with four unpadded side rails up. LVN 4 stated padded side rails are ordered to decrease the impact and protect from injury during a seizure.

Based on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) was completed as ordered by the physician for one of 12 sampled residents (Resident 18). This deficient practice had the potential for Resident 18 not receiving necessary medical treatment. Findings: During a review of Resident 18's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The Admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order to check the Complete Blood Count ([CBC] - a blood test used to look at overall health conditions and blood disorders), Comprehensive Metabolic panel ([CMP] a test that measures different substances in the blood, and provides important information of your body's chemical balance and how it uses food and energy), Thyroid Stimulating Hormone ([TSH] - a blood test that measures this hormone), Lipid Panel (a blood test that measures the amount of fat in your blood), and hemoglobin A1C (a test that indicates the average level of blood sugar control over the last couple of months, a high number is a sign of poor blood sugar control) on 12/9/2024. During a concurrent interview and record review on 2/15/2024 at 2:31 p.m., with the Director of Nursing (DON), Resident 18's clinical records were reviewed. The DON stated Resident 18's laboratory tests as ordered by the physician on 12/9/2024 was not completed and results were not available. The DON stated Resident 18's physician ordered the laboratory test remotely and did not communicate to the licensed nursing staff. The DON stated it was important for Resident 18's to have a routine blood test to monitor his different diagnoses and clinical condition and to revaluate if the ongoing treatment would continue. During a review of the facility's policy and procedure (P&P) titled, Laboratory and X-ray Services, dated 4/29/2022, the P&P indicated, It is the facility's policy to provide laboratory and x-ray services, as ordered by the physician.

Based on interview and record review, the facility failed to: 1. Ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 18) by failing to: 1. Ensure Resident 18's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 18's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 18 was admitted to the facility on [DATE]. The Admission Record indicated, Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN] - high blood pressure). During a review of Resident 18's MDS assessment, dated 1/22/2025, the MDS indicated, Resident 18's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 18 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 18's Order Listing Report (a document containing active orders), dated 2/16/2025, the Order Listing Report indicated, Resident 18 has an active order of Depakote 500 milligrams ([mg] - metric unit of measurement, used for medication dosage/and or amount) by mouth at bedtime (9 p.m.) for mood disorder (a mental health condition that involves a persistent change in person's emotional state) manifested by hostile behavior. During a concurrent interview and record review on 2/15/2025 at 2:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 18's MDS assessment, dated 1/22/2025 was reviewed. The MDSN stated the MDS assessment was completed inaccurately. The MDSN stated Resident 18 was taking Depakote which is considered as anticonvulsant medication and was not checked on the MDS assessment Section N0415. The MDSN stated per Resident Assessment Instrument ([RAI] - a guide that helps nursing home staff use to assess residents and develop care plans) manual coding of medications should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication not based on the reason it was prescribed. The MDSN stated it was a human error and an oversight on her part by not encoding the Depakote as anticonvulsant medication in the MDS assessment. The MDSN stated accuracy of assessment in the MDS was important because it reflects the care provided by facility staff to the residents. During a review of the facility's policy and procedure (P&P) titled, MDS Assessment, dated 10/15/2021, the P&P indicated, The RAI shall be completed for residents residing in the facility per current RAI manual instructions.

Based on observation, interview and record review, the facility failed to: 1. Ensure proper infection control techniques were performed during wound care treatment for two of two sampled residents (Resident 26 and Resident 9). This deficient practice had the potential to result in contamination of the residents' wounds and placed the residents at risk for infection. Findings: a. During a review of Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle wasting and atrophy (the wasting (thinning) or loss of muscle tissue), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated January 18, 2018, indicated Resident 1 was severely cognitively impaired (process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and required dependent assistance with transfer, dressing, and toilet use. During observation on 2/22/24 at 1:34 p.m. in Resident 26's room with Treatment Nurse (TN 1), TN 1 was observed performing wound care treatment on Resident 26. TN 1 applied Santyl ointment inside of Resident 26's wound with a cotton swab (a long q-tip). TN 1 then re-used the same cotton swab to apply the remainder of the Santyl medication in the medication cup to the wound. Lastly, TN 1 was observed applying hydrogel ointment (an ointment used to heal dead and infected tissue) inside of Resident 26's wound with same cotton swab used for applying Santyl ointment. During an interview on 2/22/24 at 2:40 p.m. with TN 1, TN 1 stated Resident 26's wound is chronic and refuses to heal. TN 1 stated cotton swabs are to be changed after applying ointment. TN 1 stated after applying Santyl ointment with a cotton swab, The wound is 'clean' to me. TN 1 stated the risk of not changing cotton swabs during wound care treatment can carry the burden of spreading germs and can be an infection control issue. 47042 b. During a review of Resident 9's Admission Record, the Admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 9's diagnoses included congestive heart failure (chronic condition where the heart does not pump blood effectively), osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time), and hypothyroidism (the thyroid doesn't create and release enough thyroid hormone into your bloodstream). During a review of Resident 9's History and Physical (H&P), dated 10/9/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set ([MDS] - a standardized assessment and care planning tool) dated 1/13/2024, indicated Resident 9's BIMS - (brief interview for mental status) was 14 (13-15 - indicates cognitive intactness). MDS indicated resident required substantial/maximal assistance with rolling left to right. During an observation on 2/22/2024 at 9:20 a.m. in Resident 9's room with the TN 1, TN 1 was observed performing wound care treatment on Resident 9. TN 1 performed hand hygiene properly and cleaned wound with proper technique. TN 1 opened new cotton swab and applied gentamycin ointment from a small cup to Resident 9's wound, with the same cotton swab went back into the same cup to apply more gentamycin cream, applied to wound, added gauze to the gentamycin cup and with the same cotton swab swirled gauze in the gentamycin cream cup and applied to Resident 9's wound. TN 1 performed hand hygiene and placed clean dressing on wound. During an interview on 2/22/24 at 9:50 a.m. with TN 1, TN 1 stated with Resident 9's used a clean cotton swab, and the gentamycin was in a little cup, I applied medicine on the cotton swab and applied it to the wound. TN 1 further stated I used the same cotton swab twice. During an interview on 2/23/2024 at 12:11 p.m. with Infection Prevention Nurse (IPN), the IPN stated when you are doing wound care you should use a clean cotton swab every time you touch the wound. The IPN stated if you use the same cotton swab in the wound and getting the medication you could cross contaminate. The IPN stated you could potentially slow down the healing process, spread the infection, get sepsis, or have to go to the hospital.

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and expired food was discarded in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) for 43 out of the 46 residents in the facility by failing to: 1. Ensuring 10 packs of frozen vegetables in Freezer 1, 2 opened 1-gallon milk cartons, a storage bin of lemons and green onions in Refrigerator 2, and [NAME] and Basmati Rice stored in the dry storage room were labeled. 2. Discarding 2 large storage bins of expired jasmine rice (1) and basmati rice (1), 1 large storage bin of pasta noodles, 3 small packs of lasagna pasta noodles in a Ziploc bag, 1 large storage bin of dried split peas and a large box of graham crackers in the dry storage room. 3. Ensuring the dishwasher and sink sanitization levels were within adequate recommended perimeters for 43 residents. These deficient practices had the potential to result in pathogen (germs) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) leading to other serious medical complications and hospitalization . Findings: During a concurrent observation and interview on [DATE] at 8:38 AM in the kitchen with Dietary Cook (DC 1), DC 1 observed frozen vegetables from Freezer 1; along with milk, lemons, and green onions from Refrigerator 2 were not labeled. DC 1 stated all food items in the kitchen have labels with an opened date and use by date. DC 1 stated frozen vegetables, milk, lemons, green onions, [NAME] rice and Basmati rice should have been labeled. DC 1 stated the risk of not labeling food can cause residents to become sick. During a concurrent observation and interview on [DATE] at 9:01 AM in the kitchen with DC 1, DC 1 observed expired pasta noodles, jasmine rice, basmati rice, dried peas and graham crackers on the shelf in the dry storage room. DC 1 stated the kitchen's protocol was the first in, first out method. DC 1 stated all expired foods should be discarded by or on the used by date. DC 1 stated the risk of not discarding expired food could result in residents to become very sick. During a concurrent observation and interview on [DATE] at 9:23 AM in the kitchen with DC 1, DC used sanitization strips to test the kitchen's dishwasher and sink levels. DC 1 stated the dishwasher strips and sink strips were not reading at the recommended levels. DC 1 stated dishwasher strips and sink strips were expired. DC 1 stated the risk of using expired strips to check sanitization levels could result in contamination due to inadequate readings when disinfecting and washing dishes. During an interview on [DATE] at 11:17 AM in the kitchen with Dietary Supervisor (DS 1), DS 1 stated all expired foods were discarded and unlabeled food were labeled as of [DATE]. DS 1 also stated new dishwasher and sink strips were ordered and to be received that day. DS 1 stated the risk of having unlabeled and expired food could result in the residents becoming sick. DS 1 stated Residents can get sick, food can turn, dishes can harbor bacteria if not sanitized correctly. We are cooking for the elderly and since they are more sensitive, their bodies may not be able to handle it. During a review of the facility's policy and procedure, titled Storage of Food and Supplies, dated in 2020, indicated labels should be visible and the arrangement of food items should permit rotation of supplies so that oldest items will be used first. All food will be dated month, day, year. During a review of the facility's policy and procedure, titled Dishwashing, dated in 2018, indicated the dish machine is to be serviced on a regular basis by a technician to ensure accurate measurements of sanitizing agents.

Based on interview and record review the facility failed to: 1. Ensure the quarterly Minimum Data Set ([MDS], a standardized assessment and care planning tool) was submitted to Centers for Medicare and Medicaid Services (CMS) within 14days after completion for three of three sampled residents (Residents 9, 11, and 25) This deficient practice resulted in data not being transmitted to CMS regarding resident's current assessment. Findings: During a review of Resident 9's Admission Record, the Admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 9's diagnoses included congestive heart failure (chronic condition where the heart does not pump blood effectively), osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time), and hypothyroidism (the thyroid doesn't create and release enough thyroid hormone into your bloodstream). During a review of Resident 9's History and Physical (H&P), dated 10/9/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 11's Admission Record, the Admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), and sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep. This can prevent your body from getting enough oxygen). During a review of Resident 25's H&P, dated 4/15/2022, the H&P indicated Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Resident 11's H&P, dated 10/16/2023, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/22/2024 at 1:17 p.m. with MDS Coordinator, the clinical MDS-export ready list was reviewed. Export ready list indicated, Resident 9's transmission should have been submitted by 2/10/2024, Resident 11's transmissions should have been submitted by 2/13/2024, and Resident 25's transmission should have been submitted by 2/19/2024. The MDS coordinator stated that no these have not been submitted to CMS yet. The MDS coordinator stated by following guidelines once MDS assessment is complete it needs to be transmitted within 14 days of completion. MDS coordinator stated that it is transmitted to CMS so Medicare and insurances will know the status of the resident. During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set Assessment, dated 9/1/2022, the P&P indicated, The MDS shall be completed in accordance with the required time frames set forth by the Center of Medicare and Medicaid Services (CMS). The completed MDS records shall be encoded and transmitted to the State repository in accordance with Center of Medicare and Medicaid Services (CMS) established record specifications and time frames.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a two multi-dose vials of heparin were labeled with the dates when the vials were opened. These deficient practices had the potential for unintentional medication administration of possibly expired medication for the residents. Findings: During a concurrent observation and interview on [DATE] at 11:41 a.m. with Licensed Vocational Nurse (LVN) 3 at the med cart station, two opened multi-dose heparin vials were not labeled with the open date on them. LVN 3 stated you can not tell when the vial was opened. LVN3 stated a multi-dose medication should be labeled with the open date as soon as it is opened. LVN 3 stated by know knowing the expiration date there is a potential risk that the medication is expired. LVN 3 stated if the medication is given after the expiration date it can potentially cause an adverse reaction, the strength could be diminished and not help the resident. During an interview on [DATE] at 1:30 p.m. with Director on Nursing (DON), the DON stated a multi-dose medication should be labeled with the date opened. DON stated there is potential for contamination. DON stated that if not labeled you cannot ensure medication is safe to administer. DON stated policy stated label medication with the date opened. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated [DATE], the P&P indicated, When a multidose container is opened, the date opened is recorded.

Based on interview and record review the facility failed to: 1. Ensure a change of condition Preadmission Screening & Resident Review (PASARR) was submitted to the Department of Health Care Services (DHCS) to ensure the resident was re-evaluated for one of one sampled resident (Resident 40) This deficient practice had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs. Findings: During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality.), anxiety disorder (persistent and excessive worry that interferes with daily activities), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.). During a review of Resident 40's History and Physical (H&P), dated 10/16/2023, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated Resident 40 had a Brief Interview for Mental Status(BIMS) of 4 (0-7 - suggested severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment).The MDS section I active diagnoses included dementia, anxiety disorder, depression, and psychotic disorder. During a review of Resident 40's physician order summary report (MD orders), MD orders indicated Resident 40 had an active order dated 10/17/2023 for Seroquel oral tablet 12.5mg enterally two times a day for psychosis. During an interview on 2/23/2024 at 12:40 p.m. with MDS Coordinator , the MDS coordinator stated PASRR's are done before admission, readmission and if there is a change in condition, new mental health diagnosis. The MDS coordinator stated the PASRR is an evaluation to make sure the residents are place at the appropriate facility. The MDS coordinator stated for a positive PASSR II the state gives recommendations for treatments and services needed. The MDS coordinator stated if not resubmitted the resident could possible not get the services they may need. The MDS coordinator stated Resident 40 now had a new diagnosis of psychosis and is taking Seroquel (an anti-psychotic mediation). The MDS coordinator stated that the PASSR should have been resubmitted for Resident 40 and was not. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 7/16/2021, the P&P indicated, Referral for level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. Examples of such changes include but are not limited to: A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination.

Based on observation, interview, and record review, the facility failed to: 1. Provide pharmaceutical services that met the needs one of six sampled residents (Resident 101). Resident 101 did not receive medication at the scheduled time and with food as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings: During a review of Resident 101's Admission Record, the Admission Record indicated Resident 101 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 101's diagnoses included gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and gastric ulcer (Stomach ulcers (gastric ulcers) are open sores that develop on the lining of the stomach). During a review of Resident 101's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 101 had the capacity to understand and make decisions. During a review of Resident 101's Medication Administration Record (MAR), dated 2/1/2024-2/29/2024, the MAR indicated the medication order for pantoprazole sodium (generic name for Protonix, medication used to treat certain conditions in which there is too much acid in the stomach) oral tablet delayed release 40mg 1 tab two times a day for gastric ulcer, due at 7:30 a.m. During an interview on 2/23/2024 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the medication Protonix was due at 7:30am, it was given at 8:45am. LVN 1 stated medication should have been given without food, resident ate around 8 a.m. LVN 1 stated if medications are given late there could potentially be a contraindication with another medication. LVN 1 stated it is important to follow physician orders. During an interview on 2/23/2024 at 1:30 p.m. with Director on Nursing (DON), the DON stated medications should be given one hour before to one hour after scheduled administration time. The DON stated that if medication is given with food and order stated without food the medication could potentially decrease the efficiency of the medication. DON stated should follow physician orders. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated 12/5/2023, the P&P indicated, Medications shall be administered within 60minutes of scheduled time.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. A container of juice attached to the juice dispenser in the kitchen was not dated after being opened. 2. Several food items were not dated, labeled, and sealed after opening in, the walk-in refrigerator. A bag of thawed and open bacon was in an unsealed box with no open date or used by date. Boxes of meat beef, and chicken was stored above containers of juices (cranberry and orange) in the walk-in refrigerator. 3. A bag of block cheese with no label, in the walk-in refrigerator. These deficient practices had the potential lead to contamination and foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 44 out of 49 residents who received food and juices from the kitchen. Findings: 1. During the initial tour of the kitchen and inspection on 3/5/23 at 9:30 a.m. the following Rerasia/Bevolution Juice containers were observed opened and undated: a. One three-gallon bag-n-box orange juice b. One three-gallon bag-n-box apple c. Two juice boxes on the bottom shelf unlabeled and undated. During an interview on 3/6/23 at 9:04 a.m. the Dietary Manager (DM) stated he did not know when the boxes were opened. The DM stated all food containers should be dated to indicate when it was opened. The DM stated he had no instruction from the company on the opened and unlabeled juices. 2. During an observation and interview with the DM on 3/6/23 at 8:43 a.m., there was one bag of thawed bacon opened with no open date or used by date and exposed to the walk-in refrigerator environment. The DM stated dietary staff must have used the bacon for breakfast and forgot to seal the bag closed. During a concurrent observation and interview with the DM on 3/6/23 at 9 a.m. DM stated he did not know who placed the boxes of meat above the juice containers. The DM stated he will in-service the kitchen staff on how to place meat products. During an observation and interview on 3/7/23 at 11:46 a.m., Cook 1 stated the food placed in the walk-in refrigerator should have instructions on storage temperatures for each type of product, as indicated on the refrigerator storage label in front of the walk-in refrigerator door. A review of the facility's policy and procedure (P&P) titled Thawing of Meats dated 2018, indicated to allow 2 to 3 days to defrost, depending on the quantity and total weight of meat. It indicated to label defrosting meat with pull and use buy date, use a drip pan under food being thawed so dripping did not contaminate other food. The P&P indicated to thaw meat on the bottom shelf below prepared, ready-to-eat foods. 3. During an observation on 3/6/23 at 8:40 a.m., there was a bag on block cheese with no label, in the walk-in refrigerator. During a concurrent observation and interview on 3/6/23 at 8:45 a.m., The DM removed two block cheeses from the walk-in refrigerator and stated opened and unlabeled cheeses had the potential to lead to foodborne illness throughout the facility. A review of the facility P&P titled Labeling and dating of food dated 2020, indicated all food items in the refrigerator and freezer need to be labeled and dated. The P&P indicated newly opened food items will be closed and labeled with an open date and used by the manufacturer's guidelines, all prepared foods will be covered, labeled, and dated, items could be dated individually or in bulk and stored on a try with masking tape if used for meal services.

Based on interview and record review, the facility failed to provide use of bed side rails to prevent a resident from falling during care and repositioning, as stipulated in the facility's policy and procedure for one of three sampled residents (Resident 1). Resident 1, who had contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and required total care with activities of daily living ((ADLs) self-care activities performed daily), fell from the bed onto the floor when the side rail was down while care was being provided by two certified nursing assistants (CNAs). The deficient practice resulted in Resident 1 falling onto the floor and required a transfer to the general acute care hospital (GACH) after sustaining a hematoma (an abnormal collection of blood outside of a blood vessel) and a laceration (a deep cut) to the head requiring suture repair (a stitch or row of stitches holding together the edges of a wound or surgical incision). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] and last readmitted [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2020 indicated Resident 1 was totally dependent and required a two-person physical assist with bed mobility and toilet use. The MDS indicated Resident 1 had impaired range of motion ((ROM) performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) to the upper extremities (arms) and lower extremities (legs)). A review of Resident 1's care plan titled, Resident Exhibits Signs and Symptoms of Pain, dated 2/17/19 indicated Resident 1 had severe joint contractures. A review of Resident 1's care plan titled, Resident has an Activity of Daily Living (ADL) Self-care Performance Deficit, dated 2/17/19 indicated to carefully and gently handle Resident 1. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's care plan, dated 2/17/2020 indicated Resident 1 was at high risk for falls related to incontinence (inability to control bowel and bladder), unaware of safety needs, vision/hearing problems, and use of hypertensive (high blood pressure) medications. The staff approaches included to prevent falls, anticipate and meet Resident 1's needs. A review of Resident 1's care plan, dated 2/17/2020 indicated Resident 1 had activities of daily living ((ADL) everyday activities, which included grooming, toileting, bathing etc.) self-care performance deficit. The care plan indicated Resident 1 was totally dependent on nursing staff for all ADLs. The staff's interventions indicated to be careful and gentle in handling Resident 1. A review of Resident 1's Morse Fall Scale (an assessment used to identify an individual risk of fall), dated 2/20/2020 indicated Resident 1 was at high risk for fall accidents and the Morse Scale indicated Resident 1 did not ambulated (walk) and had a history of [REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Fall Scene Investigation Report, dated 3/8/2020 and timed at 10:45 p.m., indicated two certified nursing assistants (CNAs 2 and 3) were changing Resident 1 and the resident moved down to the center of the bed. The report indicated as the sheet was applied to the bed, the sheet became lodged underneath the resident. CNA 3 was on the right side of the bed and pulled the sheet. CNA 2, who was on the left side of the bed and moved to the bottom corner of the bed to apply the sheet on the mattress. The report indicated Resident 1 was lying in a fetal position (lying on the side with the legs curled up) and rolled off the left side of the bed onto the floor and CNA2 could not get to the resident to prevent the fall. The report concluded when CNA 2 moved to the end of the bed, the left side rail should have been raised to prevent Resident 1 from falling out the bed. A review of Resident 1's physician's telephone order, dated 3/8/2020 and timed at 10:43 p.m. indicated to transfer Resident 1 to the GACH via 911 (emergency services). A review of Resident 1's GACH Emergency Treatment Record, dated 3/8/2020 indicated Resident 1 fell from the bed during care and suffered a [MEDICAL CONDITION] (deep cut). Resident 1 sustained a hematoma (a mass of usually clotted blood that forms in a tissue, organ, or body space as a result of a broken blood vessel) measuring 2.5 centimeters ((cm) unit of measurement) and a laceration to the eyebrow that appeared to have bled fairly profusely through the dressing. Resident 1 required a laceration repair that was closed with sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). Resident 1 was bedridden (confined to bed), had severe contractures to the upper and lower extremities, and limited range of motion. A review of Resident 1's Nursing Progress Note, dated 3/9/2020 and timed at 12:11 a.m. indicated at approximately 10:40 p.m., LVN 1 was called to Resident 1's room by a CNA. The note indicated Resident 1 was on the floor, on the right side of the bed, lying on his right side with bleeding from the head. The note indicated two CNAs were providing care prior to the fall and the two CNAs witnessed the fall. A review of Resident 1's care plan, dated 3/9/2020 indicated Resident 1 had a witnessed fall with injury to the right side of the head. A review of an in-service meeting minutes dated 3/9/2020 and timed at 2:30 p.m., CNA 2 and CNA 3 received an in-service about what went wrong and how Resident 1's fall could have been prevented. A review of Resident 1's physician telephone order, dated 3/9/2020 and timed at 5:30 a.m. indicated Resident 1 was readmitted to the facility from the GACH. A review of Resident 1's Nursing Progress Note, dated 3/9/2020 and timed at 8:21 a.m. indicated Resident 1 was status [REDACTED]. The note indicated Resident 1 was transferred to the general acute care hospital (GACH) on 3/8/ at 10:50 p.m. and returned to the facility, the next day on 3/9/2020 at 5:30 a.m. The note indicated Resident 1 had a laceration with sutures that needed to be monitor for infection and bleeding. A review of Resident 1's history and physical (H/P) Examination, dated 4/20/19, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident's 1's Physician Progress Record, dated 3/13/2020 indicated Resident 1 was transferred to the Emergency Department (ED) due to a fall with trauma to the head with a scalp laceration. During an interview, on 3/31/2020 at 2:21 p.m., CNA 2 stated she was helping CNA 3 clean Resident 1 when he fell from the bed and started to bleed on the front of his head. CNA 2 stated Resident 1 was lying facing the left side, in a fetal position at an angle in the middle of the bed. CNA 2 stated Resident 1's head was positioned lower on the bed, closer to the middle of the bed and the upper half side rails were up and the lower half side rails were down. CNA 2 stated she was on the bottom left side of the bed and CNA 3 was on the middle right side of the bed. CNA 2 stated when they pulled the linen from underneath Resident 1's body, he rolled several times and fell on the floor, from the right side of the bed and landed on his right side. CNA 2 stated Resident 1's fall could have been prevented if the resident was higher up on the bed and the bottom right side rail was up. CNA 2 stated Resident 1 appeared frightened. On 3/31/2020 at 2:44 p.m., during an interview, CNA 3 stated on 3/8/2020 at approximately 10:40 p.m., she was changing the linen on Resident 1's bed with CNA 2 and the linen got caught underneath the resident. CNA 3 stated she was standing on the right side of the bed and CNA 2 was standing at the bottom of the bed. CNA 3 stated the bed had four side rails, the two upper side rails were up and the two lower side rails were down. CNA 3 stated Resident 1 was facing the window, on his left side with his body in the middle of the bed. CNA 3 stated Resident 1 should have been further up on the bed. CNA 3 stated she was trying to put the pillow under the resident and CNA 2 was pulling the fitted sheet to fit on the mattress and Resident 1 rolled to the right. CNA 3 stated CNA 2 did not have time to hold Resident 1 and he rolled to the floor on his right side. The right side of Resident 1's head was bleeding. CNA 3 stated they were supposed to have the lower side rails up to prevent Resident 1 from falling. CNA 3 stated Resident 1 was contracted on both upper and lower extremities and his legs were bent close to his body. CNA 3 stated she was aware that the lower side rails should have been raised. During an interview, on 4/2/2020 at 2:42 p.m., the Director of Staff Development (DSD) stated she in-serviced CNAs 2 and 3 regarding how Resident 1's fall could have been prevented. On 4/6/2020 at 3:21 p.m., during an interview, the DSD stated she had CNAs 2 and 3 demonstrate what they were doing at the time of Resident 1's fall. The DSD stated the fall was preventable and should not have happened. The DSD stated CNA 2 was holding Resident 1 on the left side of the bed and she moved to the edge of the bed and did not put the bottom side rail up. During an interview, on 4/7/2020 at 10:53 p.m., the Director of Nursing (DON) stated Resident 1 was very contracted like a ball. The DON stated, Looking in hindsight she should have put the rail up and Resident 1 would not have flipped out of the bed. The DON stated Resident 1 turned very fast because he was so contracted. During an interview, on 4/8/2020 at 12:26 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was contracted and was unable to stretch his legs or arms. LVN 1 stated Resident 1 was always in a fetal position and when the staff would move the resident (Resident 1) his whole body moved like a ball. LVN 1 stated the fall was preventable because the resident was receiving his usual care and nothing was different. LVN 1 stated she was called to assess Resident 1 and his bed was higher than it should have been, not at hip level, and the two upper side rails were up. LVN 1 stated Resident 1 was on the floor, on his right side, and bleeding on the right side of his head. LVN 1 stated CNAs 2 and 3 told her CNA 2 was pulling the linen on the left side and CNA 3 was pulling on the right side and while they were pulling the linen, Resident 1 moved down on the bed. LVN 1 stated Resident 1's whole body moved together, and he fell . LVN 1 stated Resident 1 rolled and she had to call 911 because it was a life or death situation and stated the fall could have been prevented if the CNAs had raised the lower side rails. A review of the facility's policy and procedure (P/P) titled, Positioning the Resident, revised on 12/14/17 indicated to pull the resident to near side of the bed, and staff should slip both hands under the resident's shoulders with palms up and on signal, pull the resident. Slip hands, one low at the back, the other under hips close to thighs with palms up and on signal, pull towards them. Place hands under knees and ankles and pull towards them. Support joints always from below and to turn the resident on the side, the P/P indicated to the pull side rails up on far side of the bed. The facility's P/P titled Safety of Residents revised 1/31/19 indicated the purpose of the policy was to create a safe environment for the resident and to support the resident's body well during all positioning, transferring, and ambulation. The facility's P/P titled, Fall Prevention revised on 5/15/19 indicated the facility would ensure the safety and well-being of the residents, staff and visitors. The policy indicated the resident's environment would be assessed to see if there were any hazards or clutters on the floor that may increase the chance of falling or injury. The P/P indicated the facility would provide staff awareness through in-service and training regarding management of residents who were identified as a high risk.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure one of three sampled residents (Resident 1) was adequately supervised. Resident 1, who was confused and had a history of [REDACTED]. The deficient practice resulted in Resident 1 getting up unassisted, falling and sustaining a left [MEDICAL CONDITION], which required a transfer and an admission to a general acute care hospital (GACH). Resident 1 underwent a surgical repair of the [MEDICAL CONDITION] and required a blood transfusion. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a care plan, dated 4/3/17 and titled History of Falling, indicated Resident 1 was at risk for falls. The staff's interventions included to remind the resident not to ambulate or transfer without assistance, ensure that the resident wore proper non-skid shoes and used assistive devices. A review of Resident 1's Fall Risk Evaluation, dated 4/9/18, indicated the resident had a score of 12 (10 or greater = high risk for falls). A review of Resident 1's History and Physical report (H/P), dated 4/16/18 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's care plan, initiated on 4/18/18 and last reevaluated on 7/18/18, titled, Fall, identified Resident 1 as having poor safety judgement. The staff's interventions included to remind the resident not to get up without assistance, provide visual checks every hour, use of a sensor alarm in the bed (a device to alert staff if the resident got up unassisted), and use of side rails A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening too, dated 7/11/18, indicated the resident had severe impairment in thought process, with a Brief Interview of Mental Status (BIMS) score of 3 (0-7=severe cognitive impairment). According to the MDS, Resident 1 required a one-person physical assist with bed mobility, transferring to and from bed, chair and/or a standing position, moving from one location to another, dressing, eating and toilet use. The MDS indicated Resident 1 used a walker or wheelchair to ease movement. A review of the facility's Fall Scene Investigation Report, dated 9/7/18, indicated Resident 1 was found lying on the floor in the room by Certified Nursing Assistant 1 (CNA 1) during breakfast. This report also indicated Resident 1 was not wearing any shoes or slippers. A review of the facility's follow-up Investigative Report, dated 9/11/18 indicated on 9/7/18, CNA 1 placed Resident 1 in a wheelchair in the resident's room for breakfast and then left the room. This report indicated when CNA 1 returned to Resident 1's room at 8:10 a.m., she observed Resident 1 lying on the floor, a few steps away from the wheelchair. According to the report, Resident 1's x-ray showed an acute left [MEDICAL CONDITION] and the resident was transferred to a GACH where she underwent a left hip surgery. A review a radiology (x-ray) report, dated 9/7/18, indicated Resident 1 had a left femoral neck fracture (broken hip). A review of the GACH's Progress Note indicated Resident 1 was admitted on [DATE], and was discharged four (4) days later on 9/11/18. These notes indicated the resident was confused, lethargic (sluggish/weak) and had left hip pain. A review of a computerized tomography ((CT) process of taking pictures of body structures/organs to diagnose diseases or broken bones) of the abdomen and pelvis dated 9/8/18, indicated Resident 1 had an impacted (one fragment is firmly driven into the other) left subcapital (fracture line extends through the junction of the head and neck of femur (thigh bone)) femoral neck fracture (broken hip). A review of a left hip x-ray (2 views) results, dated 9/8/18, indicated Resident 1 had left subcapital femoral neck fracture with a superior displacement of the distal fracture fragment (broken hip with rotation of the hip bone). A review of the GACH's progress note, dated 9/9/18 indicated Resident 1 had a left hip surgery with an estimated blood loss of 700 milliliters (ml). The note indicated Resident 1 received one unit of packed red blood cells ((PRBCs) blood transfusion). On 9/11/18, at 4:25 p.m., during an interview, the Director of Nursing (DON) stated that Resident 1 had a history of [REDACTED]. The DON stated that Resident 1 required visual checks to prevent falls and injury. According to the DON, a chair alarm could have alerted the staff when Resident 1 got up out of the wheelchair and could have prevented the resident from falling. On 9/11/18, at 6 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1), stated she left Resident 1 in a wheelchair unattended for breakfast on 9/7/18 at approximately 7:30-8 a.m. CNA 1 stated she returned 15 minutes later to the resident's room and found Resident 1 on the floor. CNA 1 stated Resident 1 should have been taken to the dining room for close monitoring during breakfast. According to CNA 1, Resident 1 was not wearing any socks or shoes when she fell . On 9/11/18, at 6:27 p.m., during an interview, the facility's Administrator (ADM) stated that CNA 1 made a judgement error by leaving Resident 1 unattended in a wheelchair. A review of the facility's policy titled, Fall Prevention with a revised date of 10/30/17, indicated the purpose of the policy was to ensure the safety and well-being of the residents. This policy indicated residents with a history of falls or at high risk for falls would be identified to prevent falls. According to this policy, residents with a fall assessment score of 10 and above were at high risk for falls and would be provided proper fitting shoes with gripper soles to prevent falls.