Every finding on record at Milpitas Care Center

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for progress notes, charting and documentation for therapy services (treatments and interventions aimed at improving functional abilities and quality of life) / treatments for five out of five sampled residents (Resident 1,2,3,4, and 5).This failure had potentially effect on plan of care, monitor functional progress, and communication for above sampled residents.Findings:Review of Resident 1's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 1 was admitted to facility on 5/1/2014 and discharged from facility 1/7/2021.Review of Resident 1's diagnoses included muscle weakness (a reduction in strength, able to contract and perform tasks).Review of Resident 1's order summary report indicated Resident 1 had an order for PT (physical therapy, a healthcare field where movement experts help to restore, maintain, and improve physical function, mobility and quality of life) 5x/week (5 times per week) x12 weeks (for 12 weeks), dated 11/27/2020 and OT (occupational therapy, a healthcare field that develop, recover, and maintain the skills needed for daily living) 2x/week x12 weeks, dated 11/27/2020.Further review of Resident 1's electronic medical record (digital, real time version of resident's medical documentation) indicated there was no documented evidence for PT and OT treatment/services received. Review of Resident 2's FS indicated, Resident 2 was admitted to facility on 10/16/2020 and discharged from facility on 12/7/2020.Review of Resident 2's diagnoses included muscle weakness and abnormalities of gait and mobility (an irregular walking pattern).Review of Resident2's order summary report indicated there was an order for PT 5x/week x 12 weeks, dated 10/23/2020, OT 2x/week x 4 weeks, dated 11/12/2020, and ST (speech therapy, a healthcare specialty, that helps to improve communication, and swallowing ability) 2x/week x 4 weeks, date ordered on 10/24/2020.Further review of Resident 2's electronic medical record indicated there was no documented evidence for PT, OT, and ST treatment/services received.Review of Resident 3's FS indicated Resident 3 was admitted to facility on 10/21/2025 and discharged from facility on 11/19/2025.Review of Resident 3's diagnoses included abnormalities of gait and mobility.Review of Resident 3's order summary report indicated an order for PT 5x/week x 12 weeks, dated 10/30/2025 and OT 1x/week x 8 weeks, dated 11/10/2025.Review of Resident 3's electronic medical record indicated there was no documented evidence for PT and OT treatment/services received.Review of Resident 4 FS indicated Resident 4 was admitted to facility on 10/30/2025 with diagnoses included abnormalities of gait, mobility and dysphagia (difficulty swallowing). Resident 4 currently residing in facility.Review of Resident 4's order summary report indicated an order for PT 5x/week x 12 weeks, dated 10/30/2025 and ST 2x/week x 4 weeks, dated 11/4/2025.Review of Resident 4's electronic medical record indicated there was no documented evidence for PT and ST treatment/services for Resident 4.Review of Resident 5 FS indicated Resident 5 was admitted to facility on 11/5/2025 with diagnoses included abnormalities of gait and mobility. Resident 5 currently residing in facility.Review of Resident 5's order summary report indicated an order for PT 5x/week x 12 weeks, dated 11/21/2025.Review of Resident 5's electronic medical record indicated there was no documented evidence for PT treatment/services for Resident 5.During a concurrent record review of therapy treatment notes for therapy for above residents and interview with facility's minimum data set (resident clinical and functional assessment tool) coordinator (MDSC) on 11/21/2025 at 1:38 p.m., MDSC confirmed there were no documented evidence for OT, PT and ST treatment and services notes available in facility's electronic clinical documentation system. MDSC stated therapy notes should have documented in electronic medical record system by therapy staff after each therapy session for residents.During an interview with facility's medical record director (MRD) on 11/21/2025 at 2:04 p.m., MRD confirmed there was no documented evidence for PT, OT, and ST treatment/service notes and care plans for all above residents. MRD stated she does not have access for any therapy documentation for all residents. MRD also stated therapy treatment and service documentation should have been part of the resident's electronic medical record and facility staff should have access as needed.During an interview with license vocational nurse (LVN) on 11/21/2025 at 2:15 p.m., LVN stated unable to access PT, OT and ST documentation for residents. LVN also stated it would be nice to have access to therapy documentation for residents to know how the residents were making progress with their functional status to communicate with residents or resident's significant family members as needed.During an interview with director of nursing (DON) on 11/21/2025 at 2:22 p.m., DON confirmed there were no therapy treatment documentation available with facility's electronic medical record. DON stated facility staff should have access to review therapy documentation for residents as needed.During an interview over the telephone with facility's director of rehabilitation (DOR) on 11/21/2025 at 2:45 p.m., DOR confirmed therapy treatment and service's documentation not included in facility's electronic documentation. DOR stated takes long time to load these documentation to facility's electronic documentation system, only providing these documents upon request by resident, family member or facility. DOR also stated these documents part of the resident's medical record, and should have been included in facility's medical record system. Review of facility's P&P titled, Progress Notes, revised April 2007, the P&P indicated, Progress notes shall be maintained for each resident who is receiving specialized rehabilitation services.Review of facility's P&P titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Treatments or services performed;

Based on interview, and record review, the facility failed to develop person -centered care plan that included target symptoms, measurable objectives, and interventions for five of five sampled residents (Resident 1, 2, 3, 4, and 5) when:1. No care plan for rehabilitation ((treatments and interventions aimed at improving functional abilities and quality of life) services/treatments for Resident 1, 2, 3, 4, and 5. Above failures had the potential to result in not meeting sampled residents' needs and plan of care.Findings:Review of Resident 1's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 1 was admitted to facility on 5/1/2014 and discharged from facility 1/7/2021.Review of Resident 1's diagnoses included muscle weakness (a reduction in strength, able to contract and perform tasks).Review of Resident 1's order summary report indicated Resident 1 had an order for PT (physical therapy, a healthcare field where movement experts help to restore, maintain, and improve physical function, mobility and quality of life) 5x/week (5 times per week) x12 weeks (for 12 weeks), dated 11/27/2020 and OT (occupational therapy, a healthcare field that develop, recover, and maintain the skills needed for daily living) 2x/week x12 weeks, dated 11/27/2020.Review of Resident 1's care plans indicated there was no documented evidence of person centered care plan for PT and OT services/treatments.Review of Resident 2's FS indicated, Resident 2 was admitted to facility on 10/16/2020 and discharged from facility on 12/7/2020.Review of Resident 2's diagnoses included muscle weakness and abnormalities of gait and mobility (an irregular walking pattern).Review of Resident2's order summary report indicated there was an order for PT 5x/week x 12 weeks, dated 10/23/2020, OT 2x/week x 4 weeks, dated 11/12/2020, and ST (speech therapy, a healthcare specialty, that helps to improve communication, and swallowing ability) 2x/week x 4 weeks, date ordered on 10/24/2020.Review of Resident 2's care plans indicated there was no documented evidence of individualized care plan for PT, OT, and ST treatment/services.Review of Resident 3's FS indicated Resident 3 was admitted to facility on 10/21/2025 and discharged from facility on 11/19/2025.Review of Resident 3's diagnoses included abnormalities of gait and mobility.Review of Resident 3's order summary report indicated an order for PT 5x/week x 12 weeks, dated 10/30/2025 and OT 1x/week x 8 weeks, dated 11/10/2025.Review of Resident 3's care plans indicated there was no documented evidence of care plans for PT and OT treatment/services.Review of Resident 4 FS indicated Resident 4 was admitted to facility on 10/30/2025 with diagnoses included abnormalities of gait, mobility and dysphagia (difficulty swallowing). Resident 4 currently residing in facility.Review of Resident 4's order summary report indicated an order for PT 5x/week x 12 weeks, dated 10/30/2025 and ST 2x/week x 4 weeks, dated 11/4/2025.Review of Resident 4's care plans indicated there was no documented evidence of care plans for PT and ST treatment/services.Review of Resident 5 FS indicated Resident 5 was admitted to facility on 11/5/2025 with diagnoses included abnormalities of gait and mobility. Resident 5 currently residing in facility.Review of Resident 5's order summary report indicated an order for PT 5x/week x 12 weeks, dated 11/21/2025.Review of Resident 5's care plans indicated there was no documented evidence of care plans for PT treatment/services.During a concurrent record review of care plans for therapy for above residents and interview with facility's minimum data set (resident clinical and functional assessment tool) coordinator (MDSC) on 11/21/2025 at 1:38 p.m., MDSC confirmed there were no care plans for PT, OT, and ST for all above residents for services and treatments as ordered. MDSC stated therapy staff responsible to initiate and implement care plans for therapy services and treatments provided as ordered for above residents. MDSC also stated therapy staff should have initiated person centered care plan for each therapy when resident was received or currently receiving.During an interview with director of nursing (DON) on 11/21/2025 at 2:22 p.m., DON confirmed there were therapy treatments as ordered for Resident 1, 2, 3, 4, and 5. DON stated therapy staff responsible to initiate care plans for therapy services and they should have initiated care plans when provided services to residents.During an interview over the telephone with facility's director of rehabilitation (DOR) on 11/21/2025 at 2:45 p.m., DOR stated therapy staff should have initiate the care plans separate for therapy as it should be. Review of facility's P&P titled, Care Planning- Interdisciplinary Team, revised September 2013, the P&P indicated, The care plan is based on the resident's comprehensive assessment and is developed by a care planning/ interdisciplinary team which includes, but is not necessarily limited to the following personnel: Therapists (speech, occupational, recreational, etc.), as applicable;

Based on observation, interview, and facility document review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 18 sampled residents (Resident 12) when Resident 12 experienced an unplanned insidious weight loss of 10 pounds, 6.8% in three months and 16 pounds 9.8% weight loss in six months. This had the potential to result in muscle wasting, loss of independence, decreased quality of life, and increased disease complications. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed in part, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ Involuntary weight loss can lead to muscle wasting . depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician). A publication titled Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. A publication from the Academy of Nutrition and Dietetics titled What Resources Are Available to Assist in Assessing Body Weight in Older Adults. July 1, 2025, indicated usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in older adults. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). The State Operations Manual (SOM) provides a definition for insidious weight loss: Gradual unintended weight loss over time is known as insidious weight loss. This can be where an older adult loses only 1-2 pounds per month, but for a continued period. When addressing unintentional weight loss, one needs to figure out why, if possible, the root cause of unintended weight loss (Geriatric Dietitian, 3/31/22). Review of the facility Policy and Procedure (P&P) titled Weight Assessment and Intervention dated 2001, showed resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe; b. 3 months- 7.5 % weight loss is significant; greater than 7.5% is severe; c. 6 months - 10% weight loss is significant; greater than 10% is severe. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes but is not limited to the resident's target weight range and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake and the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (an eating disorder characterized by a restriction of food intake leading to low body weight), weight loss or increasing risk of weight loss. Interventions for undesirable weight loss are based on careful consideration of the following including but not limited to: Resident choice and preferences; nutrition and hydration needs; the use of supplementation. Review of the admission Record (a document containing the most pertinent information for a resident) for Resident 12, indicated Resident 12 was [AGE] years old. Resident 12 was initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: acute chronic congestive heart failure (worsening of an existing heart failure symptoms), type 2 diabetes (a condition in which the body has trouble controlling blood sugar), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt things such as heart rate, body temperature, and metabolism), Alzheimer's disease (a progressive disease that destroys memory and other important functions), and dementia (a group of thinking and social symptoms that interfere with daily functioning). A record review of Minimum Data Set (MDS, an assessment used to plan care) Section K - Swallowing/Nutritional Status from 5/24/24 to 4/3/25 created for Resident 12 showed: 5/24/24 Quarterly Assessment: Weight 170 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 8/24/24: Quarterly Assessment: Weight 165 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 11/24/24 Quarterly Assessment: Weight 164 pounds, no weight loss of 5% in 1 month or 10% in 6 months; no swallowing issues, received a therapeutic diet. 2/22/25 Annual Assessment: Weight 160 pounds, no weight loss or weight gain of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/12/25 Significant Change Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 3/21/25 Discharge Assessment: Weight 158 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. 4/3/25 readmission Assessment: Weight 154 pounds, no weight loss of 5% in 1 month or 10% in 6 months, no swallowing issues, received a therapeutic diet. During a record review of Resident 12's Weights and Vitals Summary from 4/3/24 to 6/23/24, the following monthly weights for Resident 12 were shown: 4/3/24: 175 lbs 5/3/24: 163 lbs (6.9 %, - 12 lb weight loss in 30 days [comparison weight 4/3/24 175 lbs]) 6/8/24 164.2 lbs 7/12/24 167.2 lbs 8/5/24 165 lbs 9/2/24 164 lbs 9/30/24 163 lbs 11/11/24 164 lbs 12/4/24: 164 lbs 1/2/25: 162 lbs 2/4/25: 160 lbs 3/3/25: 158 lbs 3/27/25: 154.6 lbs 5/1/25: 154 lbs 6/2/25: 148 lbs Resident 12's documented weights represented an insidious loss in body weight of 16 pounds/9.8% from 12/4/24 to 6/2/24, and 10 pounds, 6.8% in three months from 3/3/25 to 6/2/25. A record review showed on 12/18/24, Resident 12 was prescribed MedPass Sugar Free 90 ml, QD. (MedPass Sugar Free is a nutrition supplement providing extra calories and protein and typically provided during the medication pass. It provides approximately 160 - 180 calories per 90 ml). RD recommended MedPass to be discontinued on 2/20/25 due to resident refusals. The Medication Administration Record [MAR] dated 1/1/25-1/31/25 showed out of 31 days Resident 12 was offered MedPass, he consumed 10% two (2) days, 20% one (1) day, 25% three (3) days, 50% four (4) days, and 100% 7 days. The MAR dated 2/1/25-2/28/25, showed out of the 21 days Resident 12 was offered MedPass, he consumed 100% two (2) days, and 50% three (3) days. A record review for orders showed on 6/19/24 Add snacks BID [twice a day], Document % intake. This order was discontinued on 3/24/24 and was not started again after readmission on [DATE]. On 6/5/25, the RD recommended adding snacks BID. A record review showed Resident 12 was prescribed a No added Salt, Consistent Carbohydrate (CCHO; a diet typically prescribed to maintain blood sugar) diet from 6/8/24 to 3/27/25. A record review showed when Resident 12 was readmitted on [DATE], his diet order was a Cardiac - Low Fat Low Cholesterol, Low Salt, Diabetic No Concentrated Sweets (NCS) diet (a diet restricting foods and drinks with added sugars and simple carbohydrates; According to a progress note dated 6/5/25 RD recommended to change NCS diet to CCHO in house diet). A professional review titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the America Diabetes Association, Diabetes Care 2016 showed, Liberal diets have been associated with improvement in food and beverage intake in the LTC population to better meet caloric and nutrient requirements. While carbohydrate intake should be taken into consideration, no concentrated sweets or no sugar diet orders are ineffective for glycemic management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes on mealtime insulin. Review of the facility's 2023 Diet Manual for Long Term Care Facilities showed the CCHO diet provided 1900 - 2000 calories per day; and the Low Fat/Low Cholesterol Diet provided 1800 - 2000 calories per day. Calculations in accordance with the Diet Manual show a CCHO diet provided (the combination of a CCHO diet and Low Fat/Low Cholesterol may have provided fewer calories according to the diet manual): 1444- 2000 calories with an intake of 76-100%. 969 - 1500 calories with an intake of 51-75% 494 - 900 calories with an intake of 26-75% Review of Resident 12's record included a physician Progress Note dated 3/30/25, showed Resident 12 was transferred out on 3/21/25 for chest pain and was readmitted to the facility on [DATE]. A record review from December 2024 to June 2025 showed the following RD Nutrition Progress Notes and Assessments: Nutrition Assessment dated 2/20/25 showed Resident 12's weight was 160 pounds, estimated caloric needs were 1818 - 2181 kcals (kilocalories, often referred to as calories), meal intake was 76-100% on average, supplement MedPass Sugar Free 90 ml (milliliters) QD (every day), refusing MedPass supplement on average. No significant weight changes in the last 30, 90, and 180 days. PO intake is meeting ENN [estimated nutrition needs include caloric intake and protein intake]. RD's only recommendation in this assessment was to discontinue the nutritional supplement MedPass due to the resident refusing the supplement. Although the RD documented Resident 12's intake was meeting his ENN in her 2/20/25 Nutrition Assessment, no additional interventions were implemented to address the insidious weight loss of 164 to 160 pounds from 12/4/24 to 2/25. While the RD documented in her 2/20/25 Nutrition Assessment, Resident 12's average meal intake was 76-100%, no time frame was specified. A record review of the Meal intake Documentation Nutrition - Amount Eaten for Resident 12, from 12/1/24 to 2/19/25, showed: from 12/21/24-12/31/24, Resident 12 consumed 76-100% for 62% of meals (56 out of 90 meals); from 1/1/25 to 1/31/25, Resident 12 consumed 76-100% for 59% of meals (54 out of 92 meals); and from 2/1/25 to 2/19/25, Resident 12 consumed 76-100 % for 58% of meals (32 out of 55 meals). Progress Note dated 3/20/25 showed Resident 12 weighed 158 pounds, average meal intake was 84%, average snack intake was 50%. . No significant weight changes in the last 30, 90, 180 days. PO (by mouth) intake meeting ENN . no new recommendations at this time . Although the RD stated Resident 12 was meeting his ENN in her 3/20/25 progress note, Resident 12 experienced an insidious weight loss of 6 pounds between 12/4/24 and 3/3/25. While RD documented in her 3/20/25 progress note, Resident 12's average meal intake was 84%, no time frame was specified. A record review of the Meal intake Documentation Nutrition - Amount Eaten for Resident 12, from 2/21/25 to 3/19/25 (dates between RD nutrition assessment on 2/20/25 and RD progress note on 3/20/25), showed: from 2/21/25-2/28/25, Resident 12 consumed 76-100% for 67% of meals (16 out of 28 meals); and from 3/1/25 to 3/19/25; Resident 12 consumed 76-1 00% for 48% of meals (25 out of 52 meals). Nutrition Assessment dated 4/3/25 showed Resident 12 weighed 154 pounds, estimated caloric needs were 1750 - 2100, average meal intake was 50-75%, and no supplements. PO intake meeting ENN. No new recommendations at this time. While RD documented Resident 12's intake was meeting ENN in her 4/3/35 Nutrition Assessment, calculations including percent intake and calories provided by the diet manual, showed Resident 12 did not meet ENN. RD stated Resident 12's average meal intake was 50-75%, but no time frame was specified. RD did not show how many calories 50-75% intake provided. According to the diet manual 50-75% intake of a CCHO diet provided [PHONE NUMBER] calories which did not meet Resident 12's ENN of 1750-2100 calories per RD's assessment dated [DATE]. Resident 12 experienced insidious weight loss of 9.4 pounds between 12/4/24 and 3/27/25. Progress Note dated 6/5/25, showed Weight changes: -3.9%/-6# x 30 days, -6.3%/-10# x 90 days, -9.8%/-16# x 180 days . [AGE] year old male noted with significant weight loss of -6 # [pounds] x 30 days . Weight loss is undesirable as resident is meeting only 93% of IBW [Ideal Body Weight] . Resident may benefit from resuming snacks BID to increase calorie and protein intake and monitor on weekly weights x 4 weeks. RD did not recommend interventions to address weight loss until Resident 12 experienced an unplanned weight loss of 6 pounds between 5/1/25 and 6/2/25, 10 pounds between 3/3/25 and 6/2/25, and 16 pounds between 12/4/24 and 6/2/25. During a concurrent phone interview and record review with Registered Dietitian (RD) on 6/25/25 at 9:53 a.m., Resident 12's weight log, progress notes, assessments, and physicians' orders from 3/5/2024 to present, were reviewed. RD stated she began working at the facility in January 2025. RD confirmed Resident 12 continuously lost weight from 12/4/24 to 6/2/25. RD stated she considered Resident 12's weight loss to be insidious. RD stated insidious weight loss was a weight loss that was slowly down trending. RD stated she did not consider interventions for weight loss from January to June 2025 because Resident 12's meal intake was meeting his estimated nutrient needs (ENN) according to PO nutrition intake documentation. RD confirmed she did not recommend an intervention for weight loss until 6/5/25 when she documented Resident 12 had significant weight loss of 6 pounds between 5/1/25 and 6/2/25. In addition, RD stated she was not involved with Interdisciplinary Team (IDT) meetings. RD stated she did not know what was discussed in the IDT meetings. RD also stated she did not speak to resident representatives (RPs), it was up to the dietary manager to speak with RPs to determine resident weight goals, and she did not attend IDT meetings since she worked at the facility only four hours a week. During a meal observation on 6/25/25 at 11:54 p.m., Resident 12 ate his lunch in the dining room. Resident 12 consumed 50% of his milk (8 ounce cup), 100% his juice (6 ounce cup), 100% of his dessert (which he ate first), less than 25% of his vegetables, and 25% of his fish filet. Resident 12 appeared agitated and yelled at staff no when staff asked if he wanted anything else to eat. In an interview on 6/25/25 at 12:01 p.m., Licensed Vocational Nurse (LVN) D stated Resident 12 ate in his room or the dining room depending on his mood. LVN D stated his food intake at meals was inconsistent. During an interview on 6/25/25 at 2:30 p.m., RD stated weight loss was discussed with nursing only when residents trigger for significant weight loss. During an interview with the Interim Director of Nursing (IDON) on 6/25/25 at 3:02 p.m., IDON stated RD came into the facility weekly and reviewed resident weights. Resident weights were discussed in weight variance IDT meetings only when there is a significant weight change. IDON confirmed the RD was not present in the IDT meetings. During a consecutive interview and document review with IDON on 6/26/25 at 9:59 a.m., weight variance IDT meeting documentation was reviewed. From 12/2024 to 6/2025, weight variance IDT meeting documentation showed there were no weight variance IDT meetings to address Resident 12's insidious weight loss of 10 pounds from 12/4/24 to 5/1/25. An IDT meeting was not held until 6/6/2025 after the RD documented Resident 12 had a significant weight loss of 6 pounds from 5/1/25 and 6/2/25. The documentation showed the only staff present in the meeting were the Certified Dietary Manager (CDM), IDON, and a Minimum Data Set (MDS) staff. Only information repeated from RD 6/5/25 progress was documented in the weight variance IDT meeting minutes, such as Resident 12's weight at 148 pounds, a weight loss of 6 pounds in a month, recommend snacks twice a day, and start weekly weights. IDON confirmed the RD was not present for IDT meetings. IDON stated dietary manager presents the RD recommendations from the RD assessments/progress notes, but possible causes of weight loss were not discussed. IDON confirmed she could not find documentation to show the Resident 12 was on a planned/prescribed weight loss program. During an interview and concurrent record review on 6/26/25 at 10:43 a.m., the MDS Coordinator (MDSC) reviewed MDS Section K - Swallowing/Nutritional Status dated 5/24/24 for Resident 12. MDSC confirmed stated Resident 12's significant weight loss of 6.9% in one month (4/3/24 to 5/3/24) was not reflected on the 5/24/24 MDS section K but the weight loss should have been reflected. MDSC stated a Registered Nurse (RN) reviewed section K for accuracy. During an interview and concurrent document review on 6/26/25 at 11:19 a.m., IDON reviewed MDS Section K - Swallowing/Nutritional Status dated 5/24/24 for Resident 12. IDON confirmed an RN was to review section K of the MDS for accuracy. IDON confirmed Resident 12's 5/24/24 MDS section K should show Yes [loss of 5% or more in the last month .] not on a physician-prescribed weight-loss regimen because Resident 12 lost more than 5% weight in one month from 4/3/24 to 5/3/34 and he was not on a physician prescribed weight loss program. On 6/26/25 at 11:40 a.m., Resident 12's Responsible Party (RP) was interviewed. RP stated his father (Resident 12) was always overweight before he was admitted to the facility. RP stated his father began losing weight when he was admitted to the facility. RP stated he visited the facility on the weekends, and his father expressed he did not like the facility food, that it had no taste. RP stated his father mainly liked Filipino food. During a dining observation on 6/26/25 at 12 p.m., Resident 12 at lunch in his room. Resident 12 consumed 100% of his milk, 80% of his juice, 25% of rice, 75% of chicken, 100% of dessert, did not eat any vegetables, and did not eat his bread. During an interview and concurrent record review with RD on 6/26/25 at 12:21 p.m., RD confirmed weight maintenance was her goal for Resident 12. RD stated weight loss due to PO intake was not desirable for Resident 12. RD stated weight loss can be caused by other things other than food intake, such as skin breakdown and medication. RD confirmed she did not discuss possible causes of weight loss with IDT. RD also stated prescribed snacks equal about 100 to 150 calories, so snacks BID would add about 200 to 300 calories a day. During an interview on 6/26/25 at 2:04 pm., CDM stated she did not talk to family members or RP regarding Resident 12's food preferences, instead she spoke to Resident 12. CDM stated Resident 12 was not picky with food and liked coffee. CDM stated currently Filipino food was not served at the facility. While CDM stated she could speak to Resident 12, a record review of the MDS for Resident 12, dated 4/3/25, indicated Resident 12 had a score of 4 on the Brief Interview for Mental Status (BIMS, an assessment of a resident's cognition skills; a score of 0-7 indicates severe cognitive impairment).

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. While feeding the two residents (Residents 25 and 3) certified nursing assistant (CNA) E touched the resident cups without conducting hand hygiene between helping the residents; 2. While assisting a resident (Resident 25) with feeding, CNA E handled the drinking surface of resident's cup; 3. The dry food storage shelves were in poor condition; and 4. Certified Nursing Assistant H (CNA H) walked out of Resident 6's room, did not sanitize her hands, and shifted residents' lunch trays in the meal cart up and down. These failures had the potential to result in bacterial or physical contamination of residents food which could lead to foodborne illness further compromising the health status of 26 residents who received meals. Findings: 4. During an observation on 6/24/25, at 11:50 a.m., certified nursing assistant H (CNA H) walked out of Resident 6's room and did not sanitize her hands. CNA H went to the meal cart which was parked in the hallway and shifted residents' lunch trays up and down. During a concurrent interview with CNA H, she stated she should sanitize her hands went walking out of the residents' rooms and before touching the residents' lunch trays. During an interview with the infection preventionist (IP) on 6/27/25, at 1:59 p.m., she stated the staff should sanitize their hands went walking out of the residents' rooms and before picking up the residents' lunch trays. Review of the facility's policy, Handwashing/Hand Hygiene, dated 10/2023, indicated This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 1. On 6/24/25 at 11:48 a.m., during a dining observation in the dining room, CNA E assisted Resident 25 with drinking juice. CNA E handled the cup to place in the resident's hand. Then CNA E then helped another resident, Resident 3, who was seated across from Resident 25. CNA E handled resident 3's cup to place it closer to her. Resident 3 picked up the cup to drink from. CNA E did not perform hand hygiene between touching Resident 25 and Resident 3 cups. During an interview with the Interim Director of Nursing (IDON) on 6/24/25 at 1:35 p.m., the IDON stated when a staff assist a resident, the staff was expected to perform hand hygiene prior to attending to another resident. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated October 2023, the P&P revealed, Hand hygiene is indicated: immediately before touching a resident; after touching a resident; after touching the resident's environment. 2. On 6/24/25 at 11:48 p.m., during a dining observation in the dining area, Certified Nursing Assistant (CNA) E assisted Resident 25 drinking juice. CNA E handled Resident 25's drinking cup by the rim where Resident 25's mouth came in contact to drink. During an interview with the Interim Director of Nursing (IDON) on 6/24/25 at 1:35 p.m., the IDON stated the staff should have grasp the cup by the lower portion rather than the top to prevent cross contamination and ensure infection control. According to FDA Food Code 2022 indicated, cleaned and sanitized utensils are to be handled so that lip-contact surfaces is prevented. 3. During a concurrent kitchen observation and interview with the Certified Dietary Manager (CDM) on 6/23/25 at 8:55 a.m., it was observed that the shelving in the storeroom, where shelf-stable items and produce were stored, had peeling paint. The shelves had a rough texture due to layers of paint, some of which was coming off. Additionally, a black residue was noted on the surfaces of the shelves. The CDM acknowledged the rough condition of the surfaces and the peeling paint present on the shelving. According to FDA Food Code 2022, physical facilities shall be maintained in good repair. In addition, food is to be protected from contamination by storing the food in a clean location. Materials used in food contact surfaces of equipment may not allow the migration of deleterious substances and under normal conditions are to be durable, corrosion-resistant, finished to have a smooth, easily cleanable surface.

Based on interview and record review, the facility failed to ensure 3 of 6 residents (5, 11, and 79) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 5 received Depakote (used to treat manic depressive illness) without monitoring for side effects and quarterly assessment; 2. Resident 11 received Depakote without quarterly assessment; and 3. Resident 79 received quetiapine (used to treat depressive and manic episodes), lorazepam (used to treat disorders that involve more than occasional worry or fear), haloperidol (used to treat nervous, emotional, and mental conditions), and bupropion (used to treat major depressive disorder) without monitoring for manifested behaviors. These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. Review of Resident 5's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 5's physician order, dated 11/8/23, indicated she received two capsules of Depakote 125 milligrams (mg, a metric unit of mass) two times a day for mood stabilizer. Review of Resident 5's clinical record indicated she was not monitored for the side effects and was not quarterly assessed for the use of Depakote. During an interview with the interim director of nursing (IDON) on 6/27/25, at 2:52 p.m., she reviewed Resident 5's clinical record and confirmed that Resident 5 was not monitored for side effects and was not quarterly assessed for the use of Depakote. The IDON stated Resident 5 should be monitored for side effects and quarterly assessed for the use of Depakote. 2. Review of Resident 11's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 11's physician order, dated 1/13/25, indicated she received Depakote 250 mg in the evening for mood stabilization. Review of Resident 11's clinical record indicated she was not quarterly assessed for the use of Depakote. During an interview with the IDON on 6/27/25, at 2:49 p.m., she reviewed Resident 11's clinical record and confirmed that Resident 11 was not quarterly assessed for the use of Depakote. 3. Review of Resident 79's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 79's physician orders, dated 6/20/25, indicated she had orders for bupropion 150 mg every day for low mood or sadness; haloperidol 2 mg/milliliters (ml, a metric unit of volume) give 0.25 ml, 0.5 ml, or 1 ml every 4 hours as needed for mild restlessness/nausea/vomiting, moderate restlessness/nausea/vomiting, or severe restlessness/nausea/vomiting; Lorazepam 2 mg/ml give 0.25 ml, 0.5 ml, or 0.75 ml every 2 hours as needed for mild nervousness, moderate nervousness, or severe nervousness; and quetiapine 25 mg at bedtime for continuous crying out/screaming. However, there was no monitoring on these behaviors for Resident 79. During an interview with the IDON on 6/27/25, at 2:18 p.m., she reviewed Resident 79's clinical record and confirmed that there was no monitoring on the behaviors for the use of bupropion, haloperidol, Lorazepam, and quetiapine for Resident 79. The IDON stated Resident 79's behaviors for the use of bupropion, haloperidol, Lorazepam, and quetiapine should be monitored. Review of the facility's policy, Psychotropic Medication Use, dated 7/2022, indicated . 3. Psychotropic medication management includes: . d. adequate monitoring for efficacy and adverse consequences; . 8. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes an evaluation of the resident's signs and symptoms in order to identify underlying causes.

Based on observation, interview, and record review, the facility failed to ensure food that was regular and pureed potatoes were flavorful and served at a palatable temperature. These failures had the potential for residents who received potatoes to eat less and have a decreased amount of nutrient intake. Findings: During a concurrent test-tray observation and interview with the The Certified Dietary Manager (CDM) on 6/23/25 at 12:14 p.m., the temperature of a regular diced potatoes was measured with a calibrated thermometer by CDM at 100 degrees Fahrenheit (F). The CDM mentioned that there was always issues with potatoes temperature. When the potatoes were tasted, they barely felt warm in the mouth. During a concurrent test-tray observation and interview with the CDM on 6/23/25 at 12:20 p.m., when potatoes were tasted, the regular diced potatoes did not have much flavor (bland), and the pureed potato were even more bland. The CDM verified the taste and described the pureed potatoes as milky-bland; and the regular potatoes did not have much flavor. During an interview with the CDM on 6/23/25 at 1:43 p.m., the CDM stated that the service temperature of the food delivered to resident should have been 110 to 120 degrees F. A review of facility's policy and procedure (P&P) titled Meal Service, dated 2023, indicated, the temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. The recommended temperature at delivery to resident for hot entrée, waffles/pancakes, French toast starch, vegetables is equal to or greater than 120 degrees F. In addition, the P&P titled Food Preparation, dated 2023 indicated, prepared food will be sampled to be sure the food has a satisfactory flavor. Increased amounts of herbs and spices (not salt) may be added. It is the position of the American Dietetic Association (ADA; currently known as the Academy of Nutrition and Dietetics) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet. A diet that is not palatable or acceptable to the individual can lead to poor food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. [NAME], B., [NAME] K. C., & [NAME] P.K. (2002). Position of the American Dietetic Association: Liberalized Diets for Older Adults in Long-Term Care. Journal of the American Dietetic Association 102(9), 1316-1323. https://doi.org/10.1016/S0002-8223(02)90289-0

Based on interview and record review, the facility failed to obtain consent (permission or agreement from someone having authority or power) for Coronavirus Disease (COVID-19, a mild to severe respiratory illness that is airborne and is spread from person to person or by contact with infectious material such as respiratory droplets in the air and to a lesser degree on high touch surfaces in the environment) vaccination for one of 5 residents (4). This failure had the potential to result in Resident 4's responsible party (RP, the party responsible to making health care decisions when the principal party is unable to make) not being aware of the risks and benefits of COVID-19 vaccine, and therefore unable to make an informed healthcare decision regarding the vaccine. Findings: Review of Resident 4's admission Record indicated he was admitted to the facility on [DATE], and he had one of his sons as his RP. Review of Resident 4's COVID-19 Immunization Record indicated on 10/30/24, Resident 4's family refused for him to have COVID-19 vaccine. During an interview with the infection preventionist (IP) on 6/26/25, at 5:17 p.m., she reviewed Resident 4's clinical record and was unable to locate the consent from Resident 4's RP on COVID-19 vaccine refusal on 10/30/24. The IP stated the consent should have been obtained for the residents' vaccinations. Review of the facility's policy, Coronavirus Disease (COVID-19) - Vaccination of Residents, dated 5/2023, indicated . 9. Residents must sign a consent to vaccinate form prior to receiving the vaccine. The form is provided to the resident in a language and format understood by the resident or representative.

Based on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for two of 14 sampled residents (Residents 4 and Resident 1) when: 1. For Resident 4, the facility staff did not document the apical pulse (the pulse that is felt at the bottom of the heart) before administering Digoxin (a medication used to treat certain heart conditions); and 2. Resident 1 was given the medication Carvedilol (used to treat high blood pressure) when her diastolic blood pressure (the bottom number in a blood pressure reading, representing the pressure in your arteries when your heart is at rest between beats) was low (a diastolic pressure reading below 60 is considered low) at 50 mmhg (millimeters of mercury, a unit of measurement). These failures had the potential to compromise the residents' care and could cause health complications. Findings: Review of Resident 4's admission record indicated that the resident had a diagnosis of unspecified atrial fibrillation (an irregular and often rapid heart rhythm that can lead to poor blood flow and increase the risk of stroke or heart failure). Review of Resident 4's active Order Summary Report indicated an order date of 1/24/24, for Digoxin 125 micrograms (mcg, unit of measurement) by mouth once daily for arrhythmia (an abnormal heart rhythm) and hold the dose if the heart rate (HR, the number of times the heart beats per minute) is less than 55 beats per minute. Review of Resident 4's Medication Administration Record (MAR) for June 2025 indicated Digoxin was administered at 9:00 a.m. every day, but no apical pulse reading recorded in the MAR prior to administration of Digoxin. Further review of the MAR showed that the apical pulse was recorded twice daily (BID) on the day and evening shifts. However, the readings were not taken during the 9:00 a.m. Digoxin dose and does not confirm the apical pulse was checked immediately before Digoxin administration. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 6/25/25 at 1:30 p.m., the IDON acknowledged that there was no documentation of an apical pulse recorded before giving Digoxin. She stated that it was the facility's practice for nurses to check the apical pulse before administering Digoxin and that the result should have been documented in the MAR next to the administration time. The IDON acknowledged that the BID monitoring of apical pulse does not confirm whether the apical pulse was taken during the 9:00 a.m. Digoxin dose. Review of the Lippincott Nursing Drug Guide (2024 edition) indicated standard nursing practice for Digoxin includes auscultating the apical pulse for one full minute before each dose and withholding the dose if the pulse is below the ordered threshold (typically less than 60 beats per minute). 2. During a medication pass observation on 6/26/25 at 9:36 a.m., Licensed Vocational Nurse (LVN) D administered Carvedilol 3.125 mg (milligram, a unit of measurement) tablet orally to Resident 1. A review of Resident 1's Physician Order indicated, Carvedilol Oral Tablet 3.125 mg give 1 tablet by mouth two times a day for Hypertension [high blood pressure] hold SBP [systolic blood pressure, the top number in a blood pressure reading, and it measures the pressure in your arteries when your heart beats and pumps blood] < 105 Pulse < 55 A review of Resident 1's vital signs dated 6/26/25 at 7:47 a.m. indicated a blood pressure reading of 116/50 mmhg. During a concurrent interview and record review on 6/26/25 at 1:22 p.m. with the Interim Director of Nursing (IDON), the IDON verified Resident 1's physician order for carvedilol and the blood pressure reading of 116/50 mmhg prior to administration of the medication carvedilol by LVN D. The IDON stated Resident 1 was at risk for hypotension (low blood pressure). The IDON also stated that LVN D should have rechecked the blood pressure prior to administering the medication or notified the doctor if it was okay to give carvedilol with a blood pressure of 116/50 mmhg. A review of facility's policy and procedure (P&P) entitled Administering Medications revised April 2019, the P&P indicated, .11. The following information is checked/verified for each resident prior to administering medications: .b. Vital signs, if necessary .

Based on interview and record review, the facility failed to inform and provide written information to one of 5 residents (5), regarding the rights to formulate an advance directive (a legal document that explains how a resident wants medical decisions about him/her to be made if he/she cannot make the decisions himself/herself. It is used to guide the health care team and loved ones when they need to make these decisions or to decide who will make decisions for the resident when he/she can't). This failure had the potential for the facility to provide treatment and services against the residents' wishes. Findings: Review of Resident 5's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 5's clinical record indicated she did not have an advance directive and did not have an Advanced Directive Acknowledgement that an advance directive was addressed or if the resident/resident representative was helped in formulating an advance directive. During an interview with registered nurse A (RN A) on 6/25/25, at 3:50 p.m., RN A reviewed Resident 5's clinical record and confirmed that Resident 5 did not have an advance directive and did not have an Advanced Directive Acknowledgement that an advance directive was addressed or if the resident/resident representative was helped in formulating an advance directive. Review of the facility's policy, Advance Directives, dated 9/2022, indicated . If the resident or representative indicates that he or she had not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident or representative is given the option to accept or decline assistance .

Based on interview and record review, the facility failed to provide that one of 3 residents (Resident 132) reviewed for the SNF Beneficiary Protection Notification Review received a written copy of the Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before the end of Medicare Part A coverage. This failure denied Resident 132 the knowledge to appeal the discharge. Findings: Record review of Resident 132's NOMNC indicated that it was issued to Resident 132's representative on 5/3/25, the date of Resident 132's discharge. Resident 132's last Medicare Part A covered day was also 5/2/25. The NOMNC was issued one day late. During an interview on 6/26/25 at 11:27 a.m., the Social Services Director (SSD) stated that the NOMNC should have been issued at least 72 hours before the last covered day, to allow the resident or representative time to appeal. The SSD acknowledged that the notification was not issued timely and that she did not inform Resident 132 or the representative about the last Medicare covered day prior to discharge. Review of an undated facility's policy titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10095, indicated, A Medicare health provider must give in advance, completed copy of the Notice of Medicare Non Coverage (NOMNC) to enrollees receiving skilled nursing, home health (including psychiatric home health), or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services .

2. Review of Resident 10's admission Record indicated she was admitted to the facility on [DATE] with schizophrenia diagnosis. Review of Resident 10's PASARR Level I Screening, dated 11/22/22, indicated that Resident 10 did not have a serious diagnosed mental disorder such as schizophrenia. During an interview with registered nurse A (RN A) on 6/25/25, at 3:53 p.m., she reviewed Resident 10's 11/22/22 PASARR Level I Screening and confirmed that Resident 10's PASARR Level I Screening should have indicated she had a serious diagnosed mental disorder such as schizophrenia. Review of facility's policy and procedure (P&P) entitled admission Criteria dated 2001, the P&P indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process . Based on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR, a federally mandated program ensures individuals are not inappropriately placed in nursing homes for long-term care) for two (Resident 21 and Resident 10) out of 14 sampled residents when Resident 21's and Resident 10's mental illness diagnoses were not indicated in PASARR. These failures had the potential to result in the residents not receiving the appropriate PASARR level 2 evaluation (used to confirm mental illness and assess whether the resident requires specialized services). Findings: 1. A review of Resident 21's PASARR, dated 4/9/23 indicated, Level 1- Negative .Reason Code: No Serious mental illness .resolution: LII [level 2]: Not Required The individual who completed the PASARR answered No when asked if Resident 21 had a serious diagnosed mental disorder. A review of Resident 21's admission Record indicated Resident 21 was admitted on [DATE] with diagnoses including Schizophrenia (a severe mental illness that disrupts a person's ability to think, feel, and behave clearly). During a concurrent interview and record review on 6/24/25 at 4:51 p.m. with Registered Nurse (RN) A, RN A verified she completed PASARR Level 1 for Resident 21 on 4/9/23. RN A stated that Resident 21 came from a hospital prior to admission in the facility. RN A verified Resident 21's Hospital Discharge Summary prior to admission indicated a diagnosis of Schizophrenia. RN A verified Resident 21's PASARR Level 1 should have indicated the diagnosis of Schizophrenia.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when an opened lorazepam oral concentrate (medication that helps calm the brain and nervous system) was found inside the refrigerator without an open-date label. The deficient practice had a potential for residents to receive medications with unsafe and reduced potency which could lead to unsafe and ineffective medications for the residents. Findings: During a concurrent observation and interview on 6/23/25 at 9:01 a.m. with the Interim Director of Nursing (IDON) in the Medication Room, the IDON verified an opened box of used lorazepam oral concentrate inside the refrigerator. The IDON also verified there was no label for its open-date. The IDON stated it should have been labeled when it was opened. A review of facility's policy and procedure (P&P) entitled Medication Labeling and Storage dated 2001, the P&P indicated, .6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly .

Based on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during medication administration for 1 out of seven residents (Residents 129) when Resident 129's medications, Metformin (medication primarily used to a condition where the body doesn't use insulin properly to control blood sugar levels) and Insulin Lispro (a rapid-acting form of insulin used for the treatment of high blood sugar) were not given according to the Physician's Orders. The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications. Findings: During a medication pass observation on 6/24/25 at 4:25 p.m. with Licensed Vocational Nurse (LVN) C, LVN C administered the medications Metformin 1000 mg (milligram, a unit of measurement) tablet orally and insulin lispro 4 units injected subcutaneously (into the tissue layer between the skin and the muscle) to Resident 129. There were no observed snacks or food on Resident 129's bedside. During an interview on 6/24/25 at 5:10 p.m. with Registered Nurse (RN) A, RN A stated dinner was served at 5:30 p.m. A review of Resident 129's Physician Orders indicated, Metformin Hcl [hydrochloride] Oral Tablet 1000 mg give 1 tablet by mouth two times a day for DM [diabetes mellitus, condition where your blood sugar levels are too high] give with meals and Admelog Injection Solution 100 unit/ml [milliliter, unit of measurement] (Insulin Lispro) Inject 4 units subcutaneously with meals for DM2 [Diabetes mellitus Type 2] management. During a concurrent interview and record review on 6/26/25 at 12:17 p.m. with the Interim Director of Nursing (IDON), the IDON verified Resident 129's physician orders for the medications Metformin and Insulin Lispro. The DON stated it should have been given with food. A review of facility's policy and procedure (P&P) entitled Administering Medications revised 2019, the P&P indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame .5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; .

Based on interview and record review, the facility failed to ensure two of 6 residents (25 and 79) were free from unnecessary medications when Resident 25 and Resident 79 received apixaban (a blood thinner to prevent blood clots) but were not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for the residents to experience unrecognized adverse effects. Findings: 1. Review of Resident 25's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 25's physician order, dated 6/4/25, indicated she had an order for apixaban 2.5 milligrams (mg, a metric unit of mass) two times a day. However, review of Resident 25's clinical record did not indicate that Resident 25 was monitored for the side effects and care-planned on the use of the medication. During an interview with the interim director of nursing (IDON) on 6/27/25, at 2:44 p.m., she reviewed Resident 25's clinical record and confirmed that Resident 25 was not monitored for the side effects and was not care-planned on the use of apixaban. 2. Review of Resident 79's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 79's physician order, dated 6/20/25, indicated she had an order for apixaban 2.5 mg two times a day. However, review of Resident 79's clinical record did not indicate that Resident 79 was monitored for the side effects and care-planned on the use of the medication. During an interview with the IDON on 6/27/25, at 2:06 p.m., she reviewed Resident 79's clinical record and confirmed that Resident 79 was not monitored for the side effects and was not care-planned on the use of apixaban. The IDON stated the residents should be monitored for the side effects and care-planned on the use of apixaban. Review of the facility's policy, Anticoagulation - Clinical Protocol, dated 11/2018, indicated 1. a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.

Based on observation, interview, and record review, the facility failed to ensure an accurate record of medication disposition when number of counted Lorazepam (medication that helps calm the brain and nervous system) tablets for destruction was not correctly documented. This failure had the potential for misuse or diversion of controlled medications. Findings: During a concurrent observation, interview, and record review on 6/24/25 at 10:20 a.m. with the Interim Director of Nursing (IDON), and the Administrator (ADM), a random audit of medications for destruction was done. The IDON verified a bottle of lorazepam 0.5 mg (milligram, a unit of measurement) tablets for destruction contained 24.5 tablets. The IDON and ADM verified the record sheet indicated 14.5 tablets were to be destructed. The IDON stated it should have been recorded as 24 tablets. The IDON also stated she counted the medications with Licensed Vocational Nurse (LVN) B prior to documentation. During a concurrent observation, interview, and record review on 6/24/25 at 10:28 a.m. with LVN B, LVN B verified there were 24.5 tablets of lorazepam to be destructed. LVN B also stated, she counted the lorazepam tablets with the IDON prior to documentation. A review of facility's policy and procedure (P&P) entitled Discarding and Destroying Medications revised November 2022, the P&P indicated, 10. The medication disposition record contains, as a minimum, the following information: .f. The quantity destroyed .

Based on interview and record review, the facility failed to conduct performance review at least once every 12 months for one of 4 certified nursing assistants (CNA F) and one of two licensed vocational nurses (LVN G). This failure resulted in unidentified training needed for the CNA and the LVN to improve their skills in resident care every year. Findings: Review of CNA F's personal file indicated she was hired on 9/26/22, and she did not have a performance review done in 2023. Review of LVN G's personal file indicated she was hired on 8/18/22, and she did not have any performance review done. During an interview with the director of staff development (DSD) on 6/26/25, at 3:05 p.m., she reviewed CNA F's and LVN G's personal files and confirmed that CNA F did not have a performance review done in 2023, and LVN G did not have any performance review done since 8/18/22 when she was hired. The DSD acknowledged that staff performance review should be done every year. Review of the facility's policy, Performance Evaluations, dated 9/2020, indicated The job performance of each employee shall be reviewed and evaluated at least annually.

Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for one of 14 residents (15) when Resident 15 did not receive weekly weight and one-to-one feeding assistance with all meals as ordered by the physician. This failure had the potential to negatively affect the resident's nutritional status, health, and well-being. Findings: Review of Resident 15's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 15's Nutritional Assessment, dated 2/12/24, indicated she had insidious weight loss since 10/2023, and Resident 15 may benefit from one-to-one feeding assistance with all meals to promote intake and gradual weight gain. Review of Resident 15's physician orders indicated she had orders for one-to-one feeding assistance with all meals, started on 2/13/24, and weekly weight in the morning every Tuesday, started on 5/21/24. Review of Resident 15's weight document, from 5/17/24 to 6/2/25, indicated she was weighed about every month, not every week. During observations on 6/24/25, at 11:54 a.m., on 6/26/25, at 5:43 p.m., and on 6/27/25, at 11:54 a.m., Resident 15 was eating her meals herself with no one-to-one feeding assistance. During an interview with the interim director of nursing (IDON) on 6/27/25, at 2:31 p.m., she reviewed Resident 15's physician orders and confirmed that Resident 15 should have been weighed every week and have one-to-one feeding assistance with all meals as ordered by the physician. Review of the facility's undated job description, Registered Nurse, indicated Duties and Responsibilities: . Ensure direct resident care is always provided by licensed and certified nurses.

Based on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident: Findings: Room Total Sq. Ft. Sq. Ft./Bed No. of Beds 6 287.86 71.965 4 7 287.86 71.965 4 10 286.66 71.665 4 During observations throughout the survey, none of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. The residents and staff verbalized no complaints or concerns regarding space and privacy. Continuance of the room waiver is recommended.

Based on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Initiating Transmission- Based Precautions, when the facility failed to implement the transmission-based precautions for isolation precaution (process of creating barriers between people and germs to help prevent the spread of infectious microbes) when residents develop signs and symptoms of productive cough and suspected of respiratory illness during the outbreak for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential to spread infectious disease to other residents and staff at the facility. Findings: During an interview on 12/10/24 at 10:08 a.m., with the Infection Prevention Nurse (IP), the IP stated in March 2024 about eight to nine residents with symptoms of runny nose and cough were reported. The IP stated they notified the doctor to get an order for cough and an order for isolation precaution related to respiratory illness outbreak then placed residents on isolation. During a review of the Long-Term Care Respiratory line list (an excel spreadsheet of all persons involved in the outbreak) the spreadsheet indicated, nine (9) residents had respiratory symptoms (runny nose and cough) from 3/5/24 to 3/7/24 during the respiratory illness outbreak. The spreadsheet indicated 1 staff member had respiratory related symptoms on 2/24/24. 1. During a review of Resident 1's SBAR communication (a structured communication tool that stands for Situation, Background, Assessment, and Recommendation.) dated 3/04/24, the SBAR indicated, Resident was noted to have a persistent cough, non-productive. During a review of Resident 1's physician's order dated 3/11/24, physician's order indicated, guaifenesin (used to relieve chest congestion) oral liquid 100 milligram (mg, unit of measure)/5 milliliter (ml) give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 1 was on isolation precautions during respiratory illness outbreak. During a review of Resident 1's Care plan dated 3/05/24, Care plan indicated, Resident has persistent non-productive cough. During a concurrent interview and record review on 12/10/24 at 11:20 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 1. IP stated there should have a physician order for isolation precaution. The IP stated, there was no evidence documenting Resident 1 was placed on isolation during the respiratory illness outbreak. 2. During a review of Resident 2's SBAR communication dated 3/06/24, the SBAR indicated, Resident was noted with productive cough. During a review of Resident 2's physician's order dated 3/06/24, physician's order indicated, guaifenesin liquid 100 mg/5 ml give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 2 was on isolation precautions during respiratory illness outbreak. During a review of Resident 2's Care plan dated 3/06/24, Care plan indicated, Resident has productive cough. During a concurrent interview and record review on 12/10/24 at 11:21 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 2. IP stated there should have an order for isolation precaution. The IP stated there was no documented evidence for Resident 2 was placed on isolation during the respiratory illness outbreak. 3. During a review of Resident 3's SBAR communication dated 3/07/24, the SBAR indicated, Resident was noted with productive cough. During a review of Resident 3's physician's order dated 3/07/24, physician's order indicated, guaifenesin liquid 100 mg/5 ml give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 3 was on isolation precautions during respiratory illness outbreak. During a review of Resident 3's Care plan dated 3/07/24, Care plan indicated, Resident has productive cough. During a concurrent interview and record review on 12/10/24 at 11:22 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 3. IP stated there should have an order for isolation precaution. The IP stated, there was no documented evidence Resident 3 was placed on isolation during the respiratory illness outbreak. 4. During a review of Resident 4's SBAR communication dated 3/07/24, the SBAR indicated, Resident was noted with productive cough. During a review of Resident 4's physician's order dated 3/07/24, physician's order indicated, guaifenesin oral liquid 100 mg/5ml give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 4 was on isolation precautions during respiratory illness outbreak. During a review of Resident 4's Care plan dated 3/07/24, Care plan indicated, Resident has productive cough. During a concurrent interview and record review on 12/10/24 at 11:23 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 4. IP stated there should have an order for isolation precaution. The IP stated there was no documented evidence Resident 4 was placed on isolation during the respiratory illness outbreak. 5.During a review of Resident 5's SBAR communication dated 3/07/24, the SBAR indicated, Resident noted with productive cough during shift. During a review of Resident 5's physician's order dated 3/07/24, physician's order indicated, guaifenesin liquid 100 mg/5 ml give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 5 was on isolation precautions during respiratory illness outbreak. During a review of Resident 5's Care plan dated 3/07/24, Care plan indicated, Resident has productive cough. During a concurrent interview and record review on 12/10/24 at 11:24 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 5. IP stated there should have an order for isolation precaution. The IP stated, there was no documented evidence Resident 5 was placed on isolation during the respiratory illness outbreak. During a review of the facility's Policy & Procedure (P&P) titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, 6. Outbreak management a. Outbreak management is a process that consists of: . (3) preventing the spread to other residents . During a review of the facility's P&P titled, Isolation-Initiating Transmission- Based Precautions, the P&P indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection .1. If the resident is suspected of, or identified as, having a communicable disease, the charge nurse or nursing supervisor notifies the infection preventionist and the resident's attending physician for evaluation of appropriate transmission-based precautions .

Based on interview and record review, the facility failed to provide supervision to prevent one of two residents (Resident 1) who were at risk for elopement from leaving the facility without staffs' knowledge and permission when Resident 1's wander guard (device used to keep track of residents), was not checked for functionality and staff did not provide Resident 1 with supervision or assistance. These failures compromised Resident 1's safety, as she was found outside of the facility. Findings: Review of Resident 1's admission record indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (loss of memory), unspecified severity, with other behavioral disturbance, essential primary hypertension (occurs when the abnormally high blood pressure was not a result of a medical condition), mixed hyperlipidemia (high levels of fat particles in the blood), and history of falling. Review of Resident 1's interdisciplinary team (IDT, brings together knowledge from different health care disciplines to help residents with their needs) note dated 4/5/24, indicated, Resident 1 had episode of elopement on 3/31/24. Review of Resident 1's IDT note dated 4/10/24, Resident 1 had episode of elopement on 4/7/24 and was found in the street outside of the facility. Review of Resident 1's minimum data set (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 1/26/24, indicated, Resident 1 needed supervision or assistance with walking and her activities of daily living (ADL, activities related to personal care). Review of Resident 1's post elopement care plan interventions, initiated on 4/1/24, indicated, to monitor wander guard placement every shift to left wrist and to monitor Resident 1's whereabouts frequently. During an interview with licensed vocational nurse A (LVN A) on 5/1/24 at 7:46 a.m., LVN A verified that the wander guard bracelet of Resident 1 was not checked that was the reason the staff did not notice Resident 1 went out of the facility. LVN A further verified that the whereabouts of Resident 1 was not regularly checked. During an interview with the certified nursing assistant B (CNA B) on 6/20/24 at 2:51 p.m., CNA B verified that she was not able to check if the wander guard bracelet of Resident 1 was working, when Resident 1 eloped on 4/7/24 because CNA B was changing another resident that time. CNA B further verified that she was not also able to check the whereabout of Resident 1 that time, because she was busy with another resident. Review of the facility's undated policy and procedure titled, Elopement, indicated, Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Review of the facility's Elopement Summary of Content document dated, 4/8/24, indicated, Checking all wander guard doors and their back up alarms to make sure they are working . Know where the residents are at all times .

Based on interview and record review, the facility failed to provide adequate supervision to prevent one of two residents (Resident 1) from leaving the facility without staff's knowledge and permission when staff did not follow the plan of care to provide a wander alert (such as WanderGuard, a device applied to the resident's body designed to support caregivers, with simple keypad commands, the option for door bypass using keypads that helps prevent elopement), and to monitor Resident 1's location every 60 minutes. These failures compromised Resident 1's health and safety that resulted in admisson to the acute hospital admission due to contusion of the head, [CONDITION(S)] (CHF, a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet), and [CONDITION(S)] exacerbation (exacerbation of [CONDITION(S)] [[CONDITION(S)]] was an acute event characterized by sustained worsening or flare up of any of the patient's respiratory symptoms (cough, sputum quantity and/or character, dyspnea) that is beyond normal day-to-day variation). Findings: Review of Resident 1's facesheet indicated facility admission on 7/18/2020 with diagnoses of [CONDITION(S)] (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, heart failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet), alcohol dependence, nicotine dependence, history of falling, lack of coordination, and unsteadiness on feet. Review of Resident 1's Wandering Risk assessment dated [DATE] and 10/25/2020 both indicated score of 8 or moderate risk for elopement, with known history of wandering and a known wanderer. The interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) Care Plan Conference Summary dated 10/15/2020 indicated he was confused and rarely communicates, risk for falling and elopement with no discharge plans. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 7/25/2020 and 10/25/2020 both indicated the resident had not used any wander/elopement alarm. His MDS dated [DATE] indicated short term memory problem, with moderately impaired daily decision making (decisions poor, cues/supervision required), and activities of daily living (ADL) that required supervision on transfer, walking in room and corridor, and locomotion in and off unit, one person assist with toilet use. Review of Resident 1's care plan on Risk for Elopement/Wanderer dated 7/18/2020, included wander alert and monitoring of location every 60 minutes. Document wandering behavior and attempted diversional interventions in behavior log. Review of Resident 1's Progress Notes, Psychosocial Notes, dated 7/22/2020 indicated the resident was found outside by the kitchen area, and was escorted back inside the building. He also tried getting out through the side door, and the progress notes also indicated he had another incident of possible elopement reported by staff at 2:00 p.m. that afternoon. Review of Resident 1's Care Plan Conference Summary dated 10/25/2020 indicated the IDT considered him Risk of falling; elopement and doctor indicate he has no capacity to make decisions. Review of Resident 1's Progress Notes dated 11/24/2020 indicated, Besides due to his diagnosis of Dementia, per owner he tends to wanders and leave their house which is independent living. Even though this resident wants to leave this facility, he is not appropriate to be in a board and care not in a residential care home. Review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation/Request, a form of nurses progress notes) dated 11/25/2020, indicated at 2:45 p.m., CNA (certified nursing assistant) reported that resident could not be located for the eye appointment. The director of nursing (DON) and administrator (ADM) were notified, and search for the resident all over the facility was initiated. Review of Resident 1's Progress Notes dated 11/26/2020 at 11:17 a.m., indicated, Resident was found missing search for [Resident 1] was initiated but could not be found, and local police department was notified to search nearby. Today, cops call and still he had not shown up . The Progress notes dated 12/1/2020 indicated resident was found last 11/26/2020 at 2:00, when a store owner noticed him and stayed overnight by his store and called the police. He was taken at .hospital for covid testing . The resident was missing from 11/25/2020 at 2:45 p.m. to 11/26/2020 at 2:00 p.m. (almost 24 hours). A review of Resident 1's November 2020 physician's order included [MEDICATION(S)] (medication to lower blood pressure) 40 mg. (milligrams, unit of measurement) one tablet by mouth daily for [CONDITION(S)] (hypertension), hold for systolic blood pressure (SBP, indicates how much pressure your blood was exerting against your arterywalls) <105; [MEDICATION(S)] 2.5 mg one tablet daily for [CONDITION(S)], hold for SBP <105, [MEDICATION(S)](diuretic) tablet 20 mg. one tablet every Monday, Wednesday and Friday for hypertensive heart disease with heart failure; [MEDICATION(S)] Aerosol soultion (bronchodilator) 2.5 mcg one inhalation one time a day for [CONDITION(S)]. Review of Resident 1's November 2020 medication administration record (MAR) indicated he did not get the morning dose due at 0900 for the following medications: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] inhaler on 11/26/2020. Review of Resident 1's acute hospital EMERGENCY PROVIDER REPORT, HPI (history of present illness) Notes dated 11/26/2020 at 3:18 p.m., indicated, 60 y/o male with a history of [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves), [CONDITION(S)] presented in the ED (emergency department). Per EMS, pt (patient) was reported missing from .since yesterday, today patient discovered laying inside a bush by PD (police department) and EMS(emergency medical services, or ambulance services) was contacted. In the ED, patient states that he fell last night and struck the back of his head on the ground. No LOC (loss of consciousness). Pt currently complains of constant moderate HA (headache) and SOB (shortness of breath). A [CONDITION(S)] (is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. [CONDITION(S)] may progress to septic shock.) alert was initiated Patient was fluid resuscitated. On examination the patient was tachypneic (abnormally rapid breathing) and dyspneic (difficult or labored breathing) with wheezing (is a whistling sound you make when your airway is partially blocked) and crackles (are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation.). The Primary Impression included [CONDITION(S)] ([CONDITION(S)]), secondary impressions included CHF ([CONDITION(S)]), Contusion of head, [CONDITION(S)]. His initial vital signs taken at 3:30 p.m., included BP 172/99, Pulse 110/minute, Respiration 26/minute. Resident 1's Emergency Provided Report indicated he complained of constant moderate headache (HA) and shortness of breath (SOB) when he was being attended in the emergency room (ER). Review of Resident 1's acute hospital's EMERGENCY PATIENT RECORD, dated 11/26/20, indicated Resident 1's emergency room reception arrival on 11/26/2020 at 1504 (3:04 p.m.). The Rapid Initial Assessment done on 11/26/2020 at 1520 (3:20 p.m.) included SEVERE [CONDITION(S)] SCREENING that indicated he was positive for severe [CONDITION(S)]. Resident 1's Emergency Department Course dated 11/26/2020 indicated a [CONDITION(S)] alert was initiated and he was fluid resuscitated with 2,400 ML (milliliter, units of measurement) Sodium Chloride (an electrolyte that regulates the amount of water in your body that is used to treat or prevent sodium loss caused by dehydration, excessive sweating, or other causes). The ED Course also indicated he was administered the following medications: [MEDICATION(S)] Sod/Tazobactam sodium chloride (antibiotic) 3.375 GM (gram, unit of measurement) by intravenous route (IV, administration of medication via the vein), [MEDICATION(S)]/[MEDICATION(S)] (bronchodilators, used to treat and prevent symptoms (wheezing and shortness of breath) caused by ongoing lung disease) 3 ML by nebulization, and IV [MEDICATION(S)] sodium [MEDICATION(S)] (steroid, anti-[CONDITION(S)]) 125 MG. (milligram, unit of measurement). The notes also included, Differential Diagnosis includes acute coronary syndrome with [CONDITION(S)] [CONDITION(S)] pericarditis (is inflammation of the heart muscle, and pericarditis is inflammation of the outer lining of the heart) and acute exacerbation of [CONDITION(S)]. During an interview on 11/23/21 at 9:30 a.m., the social worker (SW) stated she knew Resident 1 very well, who came from another facility, was confused, disoriented, verbalized wanting to go home, and went on wandering and was missing. The SW also stated Resident 1 was considered long term and was no longer appropriate to go back to his previous residential care facility (RCF) because of confusion and wandering. During an interview with registered nurse A (RN A) on 11/23/21 at 10:57 a.m., RN A stated, she remembered Resident 1 was not wearing any WanderGuard during those days when she had worked with him. RN A also stated if resident had a WanderGuard, then the facility's alarm system would sound off when resident went out of the building. During a follow up interview on 11/23/21 at 11:38 a.m., the SW stated, staff had an in-service in the afternoon the day when Resident 1 went missing and could not be found. Police were called and when the police officer checked the facility's video camera, it was seen Resident 1 stepped out of the facility's main door. The SW also stated staff would have heard the door alarm sound if Resident 1 had a WanderGuard, we did not hear any door alarm otherwise we could have responded. During a record review and concurrent interview on 11/23/21 at 12:25 p.m., RN A reviewed Resident 1's clinical record and did not find any documented evidence that Resident 1 had a physician's order for WanderGuard. RN A confirmed Resident 1 had no WanderGuard applied since his admission until the elopement episode happened. RN A confirmed Resident 1 was not an elopement risk and had no previous elopement episode so a WanderGuard was never applied on him. During a follow-up interview on 11/23/21 at 1:35 p.m., RN A stated for any resident with known episode/s of elopement, a wandergurd should be applied. She also stated staff should follow/implement Resident 1's care plan. Review of Resident 1's care plan on Risk for Elopement/Wanderer dated 7/18/2020, indicated interventions that included wander alert and monitoring the location every 60 minutes. Document wandering behavior and attempted diversional interventions in behavior log. During an interview and concurrent record review on 11/23/21 at 1:45 p.m., the administrator (ADM) and director of nursing (DON) both confirmed Resident 1 was at risk for elopement based on the Wandering Risk Assessment completed. Both the ADM and DON reviewed the resident's care plan that included the need for wander alert and monitoring of location every 60 minutes, document wandering behavior and attempted diversional activities in behavior log. The DON stated staff should have followed the care plan and should have applied a WanderGuard since he needed a wander alert device since admission. The DON also stated, if there was no MD (doctor of medicine) order for a WanderGuard, call MD to get an order for it to help prevent elopement from the facility. During interview and concurrent record review on 11/30/21 at 1:10 p.m., RN A reviewed Resident 1's clinical record but could not find any documented evidence that monitoring of the resident's location every 60 minutes was done and documented in a behavior log and wander alert device was applied, as indicated in the care plan dated 7/18/2020. During a telephone interview on 12/1/21 at 2:29 p.m., licensed vocational nurse B (LVN B) stated she was the charge nurse when Resident 1 was found missing on 11/15/2020. LVN B confirmed Resident 1 was confused, ambulatory and walked around the hallways and he did not have any WanderGuard alarm. During an interview on 12/1/21 at 3:53 p.m., certified nursing assistant C (CNA C) stated she worked that day when Resident 1's elopement incident happened. CNA C recalled having responded to Resident 1's bed alarm multiple times because it sounded off as resident kept getting out of bed. CNA C also stated she did not hear the main door alarm sound off whenever Resident 1 would pass by or went near the main door. CNA C stated if Resident 1 had a wander alert in place, the door alarm would sound off. Review of the facility's undated policy, Wandering, Unsafe Resident, indicated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement), reassess at- risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included. Review of the undated facility's policy, Comprehensive Assessments and Care Delivery Process, indicated comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on observation, interview, and record review, the facility failed to implement the intervention of placing a wheelchair alarm to prevent falls for two of 10 sampled residents (Resident 4 and Resident 6). These failures resulted in a fall, scalp laceration that required staples and hospitalization for Resident 4, and recurrent falls and the potential for injury for Resident 6. Findings: 1. Review of Resident 4's clinical record indicated she had [DIAGNOSES REDACTED]. Review of Resident 4's Morse Fall Scale (an assessment tool that can predict the likelihood that a person will fall), dated 10/24/16, indicated her score was 90. A score of 45 and higher indicated a high risk for falls. Review of Resident 4's fall care plan, dated 10/24/16 indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place. There was no documentation that indicated staff ensured Resident 4 had a chair electronic alarm in place. Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 11/6/16, indicated her cognition was moderately impaired and she required extensive assistance with activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring). Review of Resident 4's Situation Background Assessment Recommendation (SBAR) Communication Form (communication tool) and progress notes, dated 1/17/17, indicated that at 4 p.m., registered nurse A (RN A) saw Resident 4 on the floor in the dining room and blood was dripping from her head. RN A applied pressure to the cut with a clean cloth until the bleeding stopped. It further indicated Resident 4 said she was trying to reach for something when she fell . Review of the facility's investigation summary, dated 1/17/17, indicated activity assistant B (AA B) was attending to the needs of another resident, heard a thump, and saw Resident 4 lying on the floor. It further indicated Resident 4 had a lacerated wound to her head measuring five centimeters (cm, unit of measurement) by 0.5 cm with moderate bleeding. Review of Resident 4's Non-pressure Skin Condition Report, dated 1/23/17, indicated she had nine staples in her occipital (back of the head) area, measuring five cm by 0.5 cm. During an observation on 8/1/17 at 12:05 p.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place. During an interview on 8/1/17 at 12:10 p.m., certified nursing assistant C (CNA C) stated Resident 4 did not have a wheelchair alarm. CNA C stated she was unsure if Resident 4 needed a wheelchair alarm. During observations on 8/1/17 at 12:25 p.m. and 2:45 p.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place. During observations on 8/2/17 at 9:15 a.m. and 10 a.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place. During an interview on 8/2/17 at 10:40 a.m., CNA D stated every time Resident 4 was up in her wheelchair, there was no wheelchair alarm attached. During an interview on 8/2/17 at 10:42 a.m., CNA E stated Resident 4 did not have a wheelchair alarm when in her wheelchair. CNA E stated she was not aware that Resident 4 needed a wheelchair alarm. During an interview on 8/2/17 at 10:45 a.m., licensed vocational nurse F (LVN F) stated Resident 4 needs a bed and wheelchair alarm for fall prevention because she had a history of [REDACTED]. LVN F confirmed Resident 4 was in her wheelchair without an alarm, and should have one. During an interview on 8/2/17 at 11:05 a.m., the director of nursing (DON) stated Resident 4 had a history of [REDACTED]. During an interview on 8/2/17 at 2:25 p.m., Resident 4 stated staff placed an alarm on her wheelchair today. Resident 4 stated she never had a wheelchair alarm before this day. During an interview on 8/2/17 at 3:05 p.m., certified nursing assistant G (CNA G) stated he worked with Resident 4 on 1/17/17, assisted her from bed to the wheelchair, and brought her to the dining room. He stated Resident 4's wheelchair did not have an alarm in place. CNA G stated he was not aware that Resident 4 should have an alarm when up in the wheelchair. During a telephone interview on 8/2/17 at 4:35 p.m., RN A stated she was working on 1/17/17 and was by the door of the dining room when Resident 4 fell . RN A stated Resident 4 fell back with her wheelchair and hit the edge of the wall. RN A stated there was no sound of a wheelchair alarm and was unsure if Resident 4 had a wheelchair alarm. During a telephone interview on 8/3/17 at 10:30 a.m., AA B stated on 1/17/17 Resident 4 did not have an alarm on her wheelchair and her wheelchair was not locked. AA B stated Resident 4 fell with her wheelchair when she was trying to reach something. AA B stated Resident 4 hit the edge of the wall. AA B stated she was assisting another resident when Resident 4 fell . 2. Review of Resident 6's clinical record indicated she had [DIAGNOSES REDACTED]. Review of Resident 6's fall care plan, dated 7/8/16, indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place. Review of Resident 6's Morse Fall Scale, dated 10/15/16, indicated her score was 65. A score of 45 and higher indicated a high risk for falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 10/30/16, indicated Resident 6 was in bed at 12 a.m. The notes further indicated at 3 a.m., Resident 6 was found lying on the floor. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 1/4/17, indicated Resident 6 was in a wheelchair in the dining room and slipped from the wheelchair. The notes did not indicate whether there was a wheelchair alarm in place. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 1/31/17, indicated Resident 6 fell to the floor in the dining room from a standing position. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 3/17/17, indicated Resident 6 was found lying on the floor mat next to her bed. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls. During an observation on 8/2/17 at 3:15 p.m., Resident 6 was up in her wheelchair with no alarm in place, and staff wheeled her to the dining room. During medication pass observation on 8/2/17 at 4:10 p.m., LVN H confirmed Resident 6 did not have a wheelchair alarm. When asked if Resident 6 needed a wheelchair alarm, LVN H replied, No. During an observation on 8/2/17 at 4:35 p.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place. During an interview on 8/2/17 at 4:35 p.m., CNA I stated Resident 6 did not have an alarm while up in her wheelchair. CNA I stated she did not think Resident 6 was supposed to have an alarm in her wheelchair. During an observation on 8/3/17 at 11 a.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place. During an interview on 8/3/17 at 11 a.m., CNA J confirmed Resident 6 did not have a wheelchair alarm. During an interview on 8/3/17 at 11:05 a.m., DON stated Resident 6 needed a wheelchair and bed alarm, and the nurses and CNAs should be aware that Resident 6 needed the alarms in place. The DON stated there should be an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) meeting when a resident has multiple falls. The DON stated he could not find documentation of IDT meetings after each of Resident 6's falls. The DON confirmed there was no documentation of any new interventions to prevent future falls after each of Resident 6's falls. During an interview on 8/3/17 at 2 p.m., LVN K stated she was unsure if Resident 6 had a wheelchair alarm. LVN K stated she should check to make sure Resident 6's wheelchair alarm was in place. Review of the facility's 12/2007 policy, Managing Falls and Fall Risk, indicated staff will identify appropriate interventions to reduce the risk of falls. The policy also indicated, if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remain relevant. It further indicated, staff will monitor and document each resident's response to interventions.

Based on observation, interview, and record review, the facility failed to provide medically-related social services for one of 10 sampled residents (5). Resident 5 had a prescribed urgent podiatry referral and he was not scheduled. This failure resulted in Resident 5 not receiving the urgent podiatry care and an infection on Resident 5's left big toe. Findings: Resident 5's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS, an assessment tool) dated 2/1/16, indicated the resident was cognitively intact, required assistance with bed mobility, transfer, hygiene and bathing. Review of Resident 5's physician's orders [REDACTED]. Review of Resident 5's Situation Background Assessment Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication), dated 7/16/16, indicated Resident 5's left big toenail fell off. There was no documentation Resident 5 was seen for urgent podiatry care. Review of Resident 5's Treatment Administration Record (TAR), dated 8/14/16, indicated Resident 5's left big toe was red, swollen with drainage, and there was an order to cleanse with normal saline, pat dry, apply triple antibiotic and cover with dry dressing. Review of Resident 5's physician's orders [REDACTED]. Review of Resident 5's antibiotic therapy care plan, dated 8/14/16, indicated to administer Augmentin 875-125 mg. medication due to his left big toenail infection. During an interview with the social service director (SSD) on 8/17/16 at 8:50 a.m., she confirmed Resident 5 had an urgent podiatry care order on 7/7/16 to look at his left big toenail but there was none scheduled. SSD verified there was no documentation Resident 5 was seen by a podiatrist since his admission to the facility and she stated no appointment was scheduled regarding the urgent podiatry care order dated 7/7/16. During an observation and interview with licensed vocational nurse D (LVN D ) on 8/17/16 at 10:25 a.m., LVN D measured Resident 5's left big toe's open area. It was approximately 1.5 centimeter (cm, unit of measurement) in length, and 1 cm in width. It was swollen, with yellow discharge, and a black scab on the nail bed. LVN D stated she was the assigned nurse on the day when Resident 5's toenail fell off, and stated Resident 5 should have been seen by a podiatrist on 7/7/16. During an interview with the administrator (ADM) on 8/17/16 at 10:40 a.m., she stated she was aware Resident 5 should have been seen by a podiatrist on 7/7/16 and it should have been followed-up by the SSD. During an interview with the primary physician (PP) on 8/17/16 at 3:40 p.m., he stated based on Resident 5's urgent podiatry care order as a diabetic resident, the resident should have been seen by a podiatrist within a week of the order in order to prevent complication and infection. Review of the facility's undated policy, Policy and Procedure for Podiatry Services, indicated podiatry services for residents are scheduled every 60 days and if needed per the physician's orders [REDACTED].>Review of the SSD job description indicated SSD ensured that residents' medical, emotional, and social needs are met.

Based on observation, interview and record review, the facility failed to provide supervision and assistive devices to prevent an avoidable accident for one of five sampled residents (1). On 11/18/11, Resident 1 exited from the facility unobserved and was later found by a passerby over a mile away near a freeway. California Highway Patrol (CHP) arrived and found him disoriented and incoherent without any identification. The and report indicated Resident 1 was possibly hit by a vehicle and was transported by ambulance to the emergency room (ER) of a local hospital. At the ER, Resident 1 was diagnosed with [REDACTED]. Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/11/11, Resident 1 was able to have simple conversation, was hard of hearing and English was his second language. The MDS indicated Resident 1 walked around in the facility without difficulty. During record review on 11/22/11, the History and Physical dated 7/28/11 indicated Resident 1 did not have the mental capacity to understand and make decisions. A care plan initially dated 7/15/09 indicated Resident 1 had Alzheimer's disease, was confused and needed supervision for the following: bed mobility, toilet use and locomotion. The physical therapy report dated 9/22/11, indicated Resident 1 had a right side scissoring gait and was a high fall risk with this walking pattern. The facility's sense of initiative/involvement care plan dated 7/11, indicated Resident 1 had a history of [REDACTED]. The care plan did not have any approaches addressing wandering issues. The only undated written approach was for daily reality orientation and redirecting for activities. During an observation at 11 a.m. on 11/22/11, the administrator (ADM) showed the facility's five exit doors. Each door had a magnetic alarm system attached to the door and the door frame. The facility's main door had an alarm that made a loud buzzing sound when opened from outside and inside the building. The other four door alarms were set up the same way. The door near the laundry room opened to the parking lot at the back of the facility with access to a four lane street. During a telephone interview with licensed nurse A (LN A) on 11/22/11 at 2:45 p.m., LN A stated Resident 1 complained of a headache at 7 p.m. on 11/18/11 and LN A medicated him. LN A stated certified nurse assistant 2 (CNA 2) informed him at approximately 8:30 p.m. Resident 1 was missing and a search of the facility was started. LN A stated at 8:40 p.m., he notified the responsible party (RP), the primary care physician (PCP), the ADM and the director of nurses (DON). LN A stated after the RP arrived shortly thereafter and at 9:15 p.m., LN A stated he called 911 and reported to the police department Resident 1 was missing. During an interview with CNA 4 on 11/22/11 at 2:10 p.m., he stated he last saw Resident 1 at 7:10 p.m. in bed. CNA 4 also stated the alarm for the exit door to the parking lot near the laundry room was usually turned off to accommodate another family member who visited from 7 to 10 p.m. daily. CNA 4 stated in the past he had seen Resident 1 open the exit door, trigger the alarm (a very loud buzzing sound) and then close the door. CNA 4 stated he had seen Resident 1 turn off the alarm switch at least weekly and each time CNA 4 would remind him not to do it. CNA 4 stated he warned other facility staff Resident 1 was capable of turning off the manual switch to the alarm system on the exit doors to try to get out of the facility. During an interview with CNA 2 on 11/22/11 at 3:15 p.m., CNA 2 stated she notified the charge nurse and other CNAs when Resident 1 was not in his room at 8:30 p.m. on 11/18/11. CNA 2 stated the exit door alarm near the laundry room was usually off. CNA 2 stated Resident 1 may have gone out through that door since all the other door alarms were on except that door's. CNA 2 stated Resident 1 was "Smart and High Tech and knew how to disarm the alarm" and everyone in the facility knew it because he did it several months ago. CNA 2 stated there was a family member (FM) of another resident who visited after visiting hours (11 a.m. to 8 p.m.) every night who used that door, so they had the alarm off. During an interview and observation with the laundry staff (LS) on 11/22/11 at 1 p.m., she stated the alarm system was not centralized. It was observed each door had a magnetic alarm which anybody could manually set to the on or off position. The exit door near the laundry room was observed with the same alarm system with a manual switch that made a loud buzzing sound when the door was opened. The door provided an exit to the parking lot and to a four lane street with heavy traffic. During an interview with the DON on 11/22/11 at 4 p.m., she stated the facility did not have a centralized alarm system. The DON stated the facility did not have WanderGuard (a device that sets off an alarm attached to a resident's wrist or ankle) to alert staff if a resident wandered out the doors. The DON stated there were five residents at risk for elopement in the SNF. The DON stated there was no system in place to monitor residents who were elopement risks other than the CNA assigned to a group of residents for whom he/she was responsible during his/her shift. The DON stated Resident 1 tried to leave the premises twice in the past (7/5/09 and 8/10) but no elopement risk assessment was done to prevent further attempts by the confused resident to leave the facility. During review of the nurse's notes on 11/23/11, the local police officer (PD) was notified by the facility staff at 9:15 p.m. a resident was missing from the facility. The police report dated 11/18/11 indicated there was a possibility Resident 1 was struck by a vehicle and the ER physician stated he suffered multiple fractures and multiple traumatic injuries on the face, shoulders and hips. According to the ER physician's report, the resident arrived via ambulance on 11/18/11 at 9:08 p.m. unable to state his name. There was no identification band or any documentation of his name and contact information. The ER physician report dated 11/18/11, indicated Resident 1 was intubated (tube was placed and connected to a ventilator) to help the resident breathe and he received 2 units of blood. The report indicated the physician's clinical impression was hemorrhagic shock and pelvic fractures. Resident 1 was admitted to the intensive care unit for further treatment. During a telephone interview with the responsible party (RP) on 11/28/11 at 8:40 a.m., he stated the reason the resident was in the facility was for 24 hour supervision due to his Alzheimer's dementia. The RP stated the resident was getting more confused and since 2009, had been wandering from his residence. The facility staff told him Resident 1 may have used the door near the laundry room to leave the SNF. The administrator (ADM) was interviewed on 11/23/11 at 2:30 p.m. The ADM stated all the doors in the facility should be locked, and the front door was locked at 6:45 p.m. The ADM stated all five exit doors have a magnetic alarm that could be set on and off with a manual switch and should be on all the time. The ADM stated elopement risk residents needed to be closely supervised. However, the ADM stated there was no policy in place regarding supervision of residents who wander. According to the undated facility policy and procedure, "Preventing Resident's Elopement," each CNA was accountable for the residents assigned to him/her during the shift. The door alarms were to be on at all times.

Based on observation, interview, and record review the facility failed to ensure one resident of five sampled (1) was free from an avoidable accident when staff failed to utilize a mechanical lift (a device used to move a resident from one place to another) as indicated in the care plan during transfer on 2/19/11 at 2 p.m. resulting in a right femoral (thigh) fracture superior to the femoral prosthesis (an artificial device to replace a missing body part). Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/29/10 indicated Resident 1 was totally dependent on staff for transfers and bed mobility. It also indicated her cognitive skills in making decisions of daily life were "severely impaired-never/rarely made decisions." An interdisciplinary rehabilitation screening done on 12/29/10 by an occupational therapist (OT) indicated Resident 1 had balance deficits and recommended the use of a mechanical lift as Resident 1 was unable to stand. The physician's orders [REDACTED]. During an interview on 3/8/11 at 1:05 p.m. certified nurse assistant A (CNA A) demonstrated with CNA B how they transferred Resident 1 from her bed to her wheelchair on 2/19/11 around 2 p.m. Resident 1 sat up in bed with her back supported by CNA B. CNA A stated he placed his leg between Resident 1's legs, placed his arms under Resident 1's armpits, and pivoted her a quarter turn to her wheelchair that was placed at a 45? angle to her bed. CNA A stated during the transfer Resident 1 said, "It is hurting." During an interview on 3/8/11 at 1:30 p.m., CNA B stated on 2/19/11 at 2 p.m. she and CNA A sat up Resident 1 in bed. CNA A transferred Resident 1 to her wheelchair when she started "screaming and crying." CNA B stated CNA A then put Resident 1 back to bed. CNA A and CNA B checked her body and saw her right knee was swollen. During an interview on 3/8/11 at 1:40 p.m. with licensed nurse C (LN C), she stated on 2/19/11 at 2 p.m. she was called to Resident 1's room by CNA A and CNA B to assess Resident l. LN C stated, "I could tell that she (Resident 1) was really in pain. I could see that her right knee was swollen." During a telephone interview on 3/10/11 at 10:40 a.m. with the director of nurses (DON), she stated anything listed with an "N" in the "Disc Code" of the care plan, "Impaired physical functioning" indicated which approaches needed to be followed by staff. During review of Resident 1's care plan for "Impaired physical functioning" dated 12/29/10 concerns and problems listed included: Totally dependent on staff for all activities of daily living: bed mobility, transfers, locomotion on and off unit. The plan approach marked with an "N" indicated "Use of mechanical lift during transfers." During review of policy and procedures for "Care Plans - Comprehensive" (undated) it indicated each resident's comprehensive care plan is designed "to aid in preventing or reducing declines in the resident's functional status and/or functional levels." During a telephone interview on 3/10/11 at 1:30 p.m., CNA A stated he could not say why he did not use the mechanical lift on 2/19/11 to transfer Resident 1. He stated some of the certified nurse assistants "told me to carry (Resident 1). I know it's a mistake on my part, poor judgment. I did carry her. I feel bad." He further stated CNA B assigned to care for Resident 1, never said anything about using a mechanical lift to transfer Resident 1. During an interview on 3/15/11 at 9:50 a.m., CNA B stated on 2/19/11 around 2 p.m. she called CNA A to assist with transferring Resident 1 from her bed to her wheelchair. CNA B stated CNA A said he could carry Resident 1 instead of using the mechanical lift to transfer her. CNA B stated, "That's my mistake. It was my decision. She was my patient." She further stated CNA A said he "can carry her" so CNA B let him carry Resident 1 instead of using the mechanical lift. During an interview with the director of staff development (DSD) on 3/15/11 at 1:50 p.m., the DSD stated all staff were provided inservice training during orientation on Fall Prevention, Managing Falls, Transfer Techniques, Safety Rules including use of equipment such as wheelchairs, mechanical lifts, etc. According to the Care Plan dated 12/29/10, Resident 1 had "Impaired physical functioning: Totally dependent on staff for all activities of daily living, bed mobility, transfers... The approach plan indicated the use of mechanical lift during transfers."