Every finding on record at Mission Care Center

Based on interview and record review, the facility failed to ensure the written notice of proposed transfer and discharge was provided to the resident or resident representative (RR), for one of four residents reviewed (Resident 2). This failure had the potential for the resident or resident representative not to be aware of the transfer/discharge rights and process to appeal the transfer/discharge. Findings: On May 20, 2026, at 11:06 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding discharge. On May 20, 2026, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure with hypoxia (the lungs have a long-term, ongoing problem getting enough oxygen into your bloodstream), tracheostomy (a surgically created hole in the front of the neck that leads directly into the windpipe), and dependence on respirator (ventilator) ( body relies on a machine to breathe because your lungs or the muscles that control them cannot do the job on their own).A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated April 21, 2026, indicated Resident 2 had a BIMS (Brief Interview of Mental Status - a cognitive assessment tool) score of 05 (severe cognitive impairment- unable to understand and make decisions). A review of Resident 2's COC (Change of Condition)/eINTERACT ASSESSMENT FORM, dated May 1, 2026, at 11:30 a.m., indicated, .during routine rounds by respiratory .observed that resident looks different .tried to wake him up .stimulate him but no response .vital signs taken within normal range .no respiratory distress noted .on ventilator .altered mental status .placed a call to MD (medical doctor) .will transfer to acute hospital via 911 .A review of Resident 2's eINTERACT Transfer Form, dated May 1, 2026, at 11:40 a.m., indicated, .transfer .sent to .hospital .05/01/2026 (May 1, 2026) at 12:10 p.m altered mental status .A review of Resident 2's Physician Orders, dated May 1, 2026, indicated, .Transfer to acute hospital for ALOC (altered level of consciousness), bed hold x 7 days if admitted .On May 20, 2026, at 2:14 p.m., a concurrent interview and record review was conducted with Social Services Director (SSD). The SSD stated the facility transfer process was to notify the responsible party (RP) over a telephone call when there was a change in condition and physician orders were received to transfer the resident to acute care setting. The SSD stated the Notice of Proposed Transfer/Discharge document will be completed and faxed to the Ombudsman, then mailed via standard mail or emailed to the RR. The SSD stated she did not keep record or documentation of when she mailed or emailed the Notice of Proposed Transfer/Discharge document. The SSD stated the Notice of Proposed Transfer/Discharge was mailed to Resident 2's RR via standard mail and she did not know if the RP received the Notice of Proposed Transfer/Discharge. The SSD stated she should have followed up with a phone call and email to ensure that Resident 2's RR received the Notice of Proposed Transfer/Discharge, understood the document, understood their rights to appeal and if they had any further questions. On May 20, 2026, at 4:21 p.m., a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated to ensure that the RR received the Notice of Proposed Transfer/Discharge, the facility should send the Notice of Proposed Transfer/Discharge by certified mail. A review of the facility's policy and procedure titled, Transfer and Discharge (including AMA), dated December 19, 2022, indicated, .the facility's transfer/discharge notice .will be provided to the resident and the resident's representative in a language and manner .in which they can understand .The notice will include all of the following at the time it is provided .specific reason and basis for transfer or discharge .effective date of transfer or discharge .the specific location .to which the resident is to be transferred or discharged .an explanation of the right to appeal the transfer or discharge to the State .name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests .information on how to obtain an appeal form .information on obtaining assistance in completing and submitting the appeal hearing request .name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman .

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice, for one of nine residents (Resident 2), when nursing staff did not use appropriate safe handling precautions for a hazardous drug (medication that can cause birth defects and requires special handling for safety), letrozole (used to treat breast cancer), in accordance with professional standards and the facility's policy and procedure. This failure had the potential to expose residents and staff to serious reproductive risks such as infertility, miscarriage, or other pregnancy related complications. Finding: A review of Resident 2's admission Record, dated May 6, 2026, indicated Resident 2 was admitted on [DATE] with diagnoses including breast cancer. A review of Resident 2's medical record indicated a physician's order for letrozole 2.5 mg (milligram, unit of measurement) oral tablet, give 1 (one) tablet via G-tube (gastrostomy tube, a small flexible tube inserted through the belly directly into the stomach) one time a day for breast cancer, dated February 4, 2026. On May 5, 2026 at 8:45 a.m., during a medication pass observation for Resident 2 at nursing station 1 in the hallway in front of Resident 2's room, Licensed Vocational Nurse (LVN) 1 was observed preparing and crushing eight medications on top of medication cart B without wearing gloves. The medications included one letrozole 2.5 mg tablet. The pharmacy label on the letrozole 2.5 mg tablet medication bubble pack (a specialized packaging system prepared by a pharmacy) indicated, Caution.Warning Do Not Use If you are pregnant, suspect that you are pregnant, or while breastfeeding consult your doctor or pharmacist.A review of The National Institute for Occupational Safety and Health (NIOSH, the federal organization responsible for making recommendations for the prevention of work-related injury and illness) List of Hazardous Drugs in Healthcare Settings, dated 2024, indicated, The drugs in Table 2 meet the NIOSH definition of a hazardous drug .These drugs may exhibit one or more of the types of toxicity described in the NIOSH definition of a hazardous drug.Some of these drugs may also present an occupational hazard to those workers who are actively trying to conceive, who are pregnant or may become pregnant, and who are breastfeeding because the drugs may be excreted in breast milk.Table 2 .Letrozole .Developmental and/or Reproductive Hazard.On May 6, 2026 at 10:21 a.m., during an interview with LVN 1, LVN 1 stated she did not wear gloves when she crushed the letrozole 2.5 mg tablet during the medication pass for Resident 2 on May 5, 2026 at 8:45 a.m., because she did not know letrozole was considered a hazardous drug and stated gloves should have been worn.On May 6, 2026 at 10:33 a.m., during a concurrent interview and review of Resident 2's medical record conducted with Registered Nurse (RN) 1, RN 1 stated Resident 2 was prescribed letrozole in February 2026. RN 1 stated she was unfamiliar with the medication and unaware letrozole was considered a hazardous drug. RN 1 stated the pharmacy would have called and notified nursing staff if the medication was hazardous and required special handling precautions. RN 1 stated nursing staff needed to wear gloves when handling hazardous drugs because if they touched it, the medication could cause harm if absorbed by the body.On May 6, 2026 at 10:44 a.m., during a concurrent interview and review of Resident 2's medical record conducted with the Director of Staff Development (DSD), the DSD stated hazardous drugs were expected to be handled according to recommendations from the pharmacy written on the bubble pack label. The DSD stated nursing staff were instructed to use gloves, gown, and a mask depending on the pharmacy's recommendation for the specific medication. The DSD stated she was not aware letrozole was considered a hazardous drug.On May 6, 2026 at 10:58 a.m., during a concurrent interview and review of Resident 2's medical record conducted with the Infection Preventionist (IP), the IP stated the facility's process for handling hazardous drugs was as follows: the pharmacy would notify the facility if a medication was hazardous, the pharmacy would provide instructions regarding proper safe handling on the medication label, and nursing staff were expected to wear gloves and a mask when dispensing, crushing and administering hazardous drugs. The IP stated she was unaware letrozole was considered a hazardous drug.On May 6, 2026 at 11:01 a.m., during a telephone interview with the Consultant Pharmacist (CP), the CP stated letrozole was on the NIOSH hazardous drug list and had reproductive risks. The CP stated nursing should have worn personal protective equipment (PPE) such as gloves for safety when handling letrozole.On May 6, 2026 at 11:10 a.m., during a follow-up concurrent interview and review of the facility's Nursing Drug Reference Handbook, dated 2021, with the DSD regarding letrozole administration, the Nursing Drug Reference Handbook indicated, .Drug is a hormonal agent and considered a potential teratogen (any substance or drug that can cause birth defects or interfere with normal fetal development during pregnancy). Follow safe handling procedures . The DSD stated this meant that letrozole was considered a hazardous drug.On May 6, 2026 at 11:48 a.m., during a concurrent interview and review of Resident 2's medical records conducted with the Director of Nursing (DON), the DON stated Resident 2 had been on letrozole since February 2026, and stated he was unfamiliar with the medication and was unaware it was considered a hazardous drug. The DON stated the pharmacist was expected to inform the facility when medications required special handling by including the instructions on the bubble pack label. The DON stated the expectation was for nursing staff to follow safe handling procedures for hazardous drugs according to pharmacy recommendations. The DON stated nursing staff would have needed to use PPE such as gloves, gowns and a mask when they crushed hazardous drugs. The DON stated it was important to follow safe handling procedures for hazardous drugs to ensure the safety of staff. On May 6, 2026 at 12:36 p.m., during a follow-up telephone interview conducted with the CP, the CP stated for Resident 2's letrozole prescription, the pharmacy should have included instructions for safe handling of the hazardous drug on the pharmacy label and stated it was not done. A review of the facility's policy and procedure (P&P) titled, Hazardous Drugs Administration, dated January 2026, indicated, .The facility will establish safe handling of hazardous drugs.Handling hazardous drugs includes, but is not limited to.administration, and disposal.The system shall include policies and procedures to prevent the unintentional entry of hazardous drugs into the body due to handling of hazardous drugs and/or touching contaminated surfaces.The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following.safe work practices. proper use of appropriate Personal Protective Equipment (PPE).Pharmacy prescription labels will also include if a packaged medication is a Hazardous Drug.A review of the facility's P&P titled, Handling of Hazardous Drugs, dated December 19, 2022, indicated, .Definition of Hazardous Drug: A hazardous drug is defined as a drug which poses a significant risk to a healthcare worker by virtue of its teratogenic.or reproductive toxicity potential.Preparation and Administration of Oral Hazardous Drugs.Wear a protective gown.gloves.face shield and eye protection while administering the medication if spillage or splashing is possible.If medication is provided in tablet or capsule form and the patient/resident is unable to swallow it, tablets/capsules should be taken to the medication prep room to be crushed.

Based on observation, interview, and record review, the facility failed to provide ongoing monitoring and assessment, for one of four residents reviewed (Resident 4), when there was a change of condition of increased drainage from the resident's neck lesions/wounds on January 14, 2026. In addition, there were no care plan developed to address Resident 4 who was at risk for infection due to increased wound drainage and odor. Findings:On February 3, 2026, at 9:53 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care and treatment.On February 3, 2026, Resident 4's medical record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of tongue (a serious oral cancer) and tracheostomy (an opening in the neck leading directly to the windpipe).A review of Resident 4's Minimum Data Set (MDS- an assessment tool), dated December 12, 2025, indicated Resident 4 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 15 (cognitively intact).A review of Resident 4's COC (Change of Condition)/INTERACT ASSESSMENT FORM, dated January 14, 2026, at 3:02 p.m., indicated, .while dressing change.neck tumors .increased drainage and odor noted.recommendations: transfer to ER (emergency room).rule out infection.A review of Resident 4's Progress Notes, dated January 14, 2026, at 3:38 p.m., indicated, .called doctor.notified regarding resident refusal to be seen at hospital.continue monitor.increase the frequent of wound treatment.every shift.A review of Resident 4's Progress Notes, dated January 15, 2026 at 9:47 p.m., indicated, .per daughter.brought to ER.for the swelling to his neck and drainage.treatment to neck was administered at the hospital.to neck.lateral (side) areas.not the medial (middle).requests it be treated in the morning by the treatment nurse.A review of Resident 4's physician orders indicated the following:-On December 12, 2025, anterior (front) neck cancer lesion: cleanse with hibiclens (antiseptic and antimicrobial skin cleanser) solution pat dry and apply oil emulsion dressing and cover with ABD pad, every day shift.-On January 14, 2026, Cleanse with hibiclens solution pat dry and apply oil emulsion dressing and cover with ABD pad two times a day for Right lateral (side) posterior (back) neck cancer lesion.-On January 14, 2026, Cleanse with hibiclens solution pat dry and apply oil emulsion dressing and cover with ABD pad, two times a day for Right medial posterior neck cancer lesion.A review of Resident 4's progress note, titled, Skilled Evaluation, dated January 16, at 8:57 a.m., indicated, .skin.skin issue : 003: skin issue has not been evaluated.location: anterior neck.Further review of Resident 4's record indicated there was no documented evidence of the status or condition of the anterior, medial, or lateral neck wounds after there was a change in condition of the neck wounds on January 14, 2026. In addition, there was no updated care plan to address the increased drainage from the neck wounds or risk for infection. after the change of condition on January 14, 2026.On February 3, 2026, at 1:17 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated wound care on Resident 4's neck wounds was performed daily due to increased wound drainage. LVN 1 stated the wound dressings had approximately 50-100% saturation of drainage. On February 4, 2026, at 12:02 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 1. RN 1 stated Resident 4's anterior, medial and lateral wounds were odorous prior to leaving the facility for his oncology appointment on January 15, 2026. RN 1 stated she did not change the dressings. RN 1 stated after Resident 4's oncology appointment, he went to the ER for further evaluation of his neck wounds swelling and drainage. RN 1 verified that on January 15, 2026, at 7:34 p.m., she spoke with the ER nurse for report and was informed that the drainage is to be expected and to just monitor and administer treatment as needed. RN 1 stated she was informed that Resident 4 would be discharged back to the facility once the tracheostomy site was cleaned. RN 1 stated on January 15, 2026, Resident 4's wounds were still odorous upon returning to facility from the ER. RN 1 stated Resident 4 only wanted the treatment nurse to change his wound dressings. RN 1 stated the resident's care plans should be updated after a change of condition is identified. On February 4, 2026, at 12:54 p.m., an interview was conducted with RN 2. RN 2 stated after a change of condition, the nursing staff will document a daily progress note, every shift to monitor the resident's condition and status related to the change of condition findings. RN 2 stated the care plans should be updated as well.On February 4, 2026, at 4:33 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated after a change of condition the nursing staff should monitor the resident for 72 hours and document in a progress note. The DON stated care plans should be updated if the change of condition is new. The DON stated the 72 hour monitoring process was not followed.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated January 2012, indicated, .the nurse supervisor/charge nurse.will record.resident's medical record.information relative to changes .medical/mental condition or status. and .assessment related to the change in condition.will be documented . 72 hours.A review of the facility's policy and procedure titled, Documentation of Wound Treatments, dated September 2, 2022, indicated, .the following elements are documented as part of a complete wound assessment.color of wound bed.condition of peri-wound skin.presence, amount and characteristics of wound drainage.presence or absence of odor.A review of the facility's policy and procedure titled, Provision of Quality Care, dated December 19, 2022, indicated, .a comprehensive care plan.will be developed.for each resident.in accordance with.procedures for development.care plan.A review of the facility's policy and procedure titled, Skin Assessment, dated December 19, 2022, indicated, .documentation of skin assessment.document observations.type of wound.describe wound (measurements, color, drainage, odor) .

Based on interviews and record review, the facility failed to ensure the code status (a legal document or instruction that outlines a patient's wishes regarding medical care, particularly if they experience a cardiac or respiratory arrest) and presence of medical device was communicated accurately to the receiving facility when the resident was transferred to the acute hospital, for one of three residents sampled (Resident A). This failure had the potential to result in Resident A not to receive the correct code status during the resident's hospital stay, and could have a delay in care and treatment when the presence of medical device was not initially communicated to the receiving facility. Findings: On [DATE], at 9:30 a.m., an unannounced visit to the facility was conducted to investigate for a complaint of resident rights and quality of care. On [DATE], at 10 a.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included respiratory failure, tracheostomy (a surgical procedure where an opening is created in the neck to insert a tube into the trachea, allowing air to enter the lungs and bypass the mouth, nose, and throat), and aphasia (a language disorder resulting from brain damage). Resident A's POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order that helps people with serious illnesses make and communicate their choices about medical treatments they do or do not want to receive during serious illness), dated [DATE], indicated, .attempt resuscitation/CPR (cardio-pulmonary resuscitation-a method used to revive the heart and lungs, to sustain life) .full treatment . Resident A's Hospital Transfer Form, dated [DATE], at 12:35 p.m., indicated .Code status .DNR (do not resuscitate) .02 at 1% . The document did not include the type and size of the tracheostomy tube. Resident A's Respiratory Therapy (RT) Notes, dated [DATE], at 1:16 p.m., indicated .O2 (oxygen) 98% . trach (tracheostomy tube) secured and intact .removed off vent (ventilator-a medical device that helps a person breathe when they are unable to do so on their own) per husband's request and placed on T-bar (a medical device, placed on a tracheostomy tube, to help with breathing and allows for the delivery of oxygen) tolerated well .husband refused for downsized trach from Shiley (a type of tracheostomy tube that is flexible) 7 cuffed (an option on a tracheostomy tube) to Shiley 6.5 cuffless even after husband requesting to downsize trach . A review of Resident A's Social Service Notes, dated [DATE], at 12:10 p.m., indicated . [family member] .was able to sign the new POLST for FULL code .he wants her (Resident A) out to the acute hospital. He wants to admit her (Resident A) to the hospital and hold her there until he can take her home . On [DATE], at 1 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated when a resident was sent out, transferred to the hospital, the facility would fill in a transfer form, which would include most of the information about the resident. The RN stated the type of trach and size of the trach should be noted on the transfer form, and the current code status should also be indicated in the transfer form. On [DATE], at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A's transfer form indicated DNR, and the tracheostomy size and type should have been indicated on the transfer form, the [family member] changed the POLST to full code the morning of Resident A ' s transfer. On [DATE], at 1:20 p.m., an interview was conducted with the Respiratory Therapist (RT). The RT stated at the time of Resident A's discharge from the facility, on [DATE], Resident A was a full code, not a DNR. A review of the facility's policy titled Transfer and Discharge, dated [DATE], indicated, .For transfer to another provider .Advanced directive information .resident status .all special instructions and/or precautions for ongoing care .treatments and devices .all other information necessary to meet the resident's needs .Anticipated transfers or discharges-resident-initiated discharges .obtain physicians' orders .the interdisciplinary team completes relevant sections of the discharge summary. The nurse caring for the resident at time of discharge is responsible for ensuring the discharge summary is complete and includes .resident's status .the comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes .supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility .

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly disposed off the facility grounds when multiple items were observed stored and stacked on top of each outside a trailer container. This failure had the potential to attract and harbor pest and rodents. Findings: On February 12, 2025, at 2:54 p.m., during a tour outside the facility with the Maintenance Supervisor (MS), multiple items of discarded wood, poles, signs, broken fans, metal frames, bath chairs, wooden pallets, bags of cement mix, and hoses stacked on top of each were observed beside the storage trailer. In a concurrent interview, the MS verified those items beside the storage trailer were discarded items. The MS stated discarded items should not be stored beside the storage trailer and should be disposed properly in the garbage binto prevent harboring of pests and rodents. A review of the facility's policy and procedures titled, Disposal of Garbage and Refuse, dated December 19, 2022, indicated, .Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized .Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned a frequency necessary to prevent them from developing a buildup of soil or becoming attractions for insects and rodents .

Based on observation, interview, and record review, the facility failed to store, prepare, handle, and serve food, in accordance with professional standards for food service safety for a highly vulnerable population of seven (7) residents who eat frood from the facility kitchen, when, two (2) oven gloves were observed with dark stains thick brown/black substance on the fingers and multiple patches of white substance. This failure had the potential to result in cross contamination and cause food borne illnesses in a highly vulnerable population of seven (7) residents who eat food from the kitchen. Findings: On February 10, 2025, at 10:53 a.m., during the initial tour of the kitchen with the Dietary Manager (DM), two (2) oven gloves were observed hanging on a hook on the wall for use by the cook. The oven gloves were observed with dark stains and a thick brown/black substance on the finger tips and, along the posterior of the hand piece and multiple patches of white substance were obsered up the sleeve of the overn gloves. One oven glove had worn area with loose threads with discoloration. In a concurrent interview, the DM stated the oven gloves should have been replaced and should not be used, due to possibility of cross-contamination and possible food borne illness to vulnerable residents. On February 10, 2025, at 10:58 a.m., [NAME] 1 stated the oven gloves should have been thrown away, to avoid cross-contamination and possibility of food-borne illness to the residents. On February 11, 2025, at 3:36 p.m., an interview was conducted with the Registered Dietician (RD). The RD stated the dirty oven gloves should not have been used and should have been laundered or replaced with new oven gloves. The RD further stated the oven gloves should not be used in that condition as it could cause cross-contamination and possible food borne illness to facility vulnerable residents. A review of the facility's policy and procedure titled, Food Safety and Food Storage, dated November 2024, indicated, .food will be .prepared, distributed and served .with professional standards of food service safety .food safety practices shall be followed throughout the entire food handling process .to include .other equipment that comes in contact with food .take precautions in critical control points to prevent, reduce, or eliminate potential hazards .all equipment used in the handling of food shall be clean and sanitized, and handled in a manner to prevent contamination .

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were implemented when emergency water was stored in a clean environment. This failure had the potential for the spread of contaminates and/or infections to residents and staff. Findings: On February 12, 2025, at 2:54 p.m., an observation of the storage shed outside the facility was observed with the Maintenance Supervisor (MS). Several gallons of emergency water bottles were observed stored inside the storage shed. The water bottles were observed directly placed on the soiled and dusty floor next to chemical containers with warning labels. The top of the water bottles were observed with loose dirt. The water bottles were stored in a cluttered area with various items, including tools, soap dispensers, a broken fan, a broom, and mop sticks, and other items. The ceiling of the storage shed were observed to have loose particles and debris which had accumulated and fallen onto the water bottles. There was buildup of debris by the hole in the shed, which led to area filled with piled discarded items. The MS stated pests could get into the hole and further stated the water had been stored in the shed for many years. On February 13, 2025, at 5:46 p.m., an interview with the MS was conducted. The MS stated the water had always been stored in the storage shed in the back of the facility. The MS stated the emergency water bottles should be stored in a clean environment. A review of the facility's policy and procedures titled, Emergency Water Supply, dated December 19, 2022, indicated, .Water will be stored in medication rooms or other clean utility rooms until distributed to the individual resident room or other point-of-use areas, as needed .

Based on observation, interview, and record review, the facility failed to provide the required bedroom space measuring at least 80 square feet per resident, in 15 resident rooms (Rooms: 1, 2, 3, 4, 5, 6, 7, 8 , 11, 12, 14, 15, 16, 17, and 18). On February 10, 2025, at 10 :00 a.m., an interview was conducted with the Director of Nursing (DON) regarding the room sizes for resident rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The DON stated the rooms did not meet the space requirement of at least 80 square feet per resident in the above mentioned resident rooms. The DON stated the facility has a waiver for the rooms. During the survey dates February 10,11, 12 and 13, 2025, the above listed rooms were observed at different times of the day. There were no adverse effects that impacted the quality of life of the residents who resided in the rooms as observed during the survey dates. On February 12, 2025, at 10:15 a.m., the DON provided the request for room waivers for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. On February 13, 2025, during interviews with the residents in rooms 6A, 10A, 10C, 17B and 18A, the residents stated there were no issue with room size or crowding. During interview with the nursing staff, they stated they have a good system for working in the rooms and have not had any issues attending to their residents. The facility requested a continued waiver for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. Approval of the waiver is recommended. Granting this waiver will not adversely affect the residents' health and safety and is in accordance with the special needs of the residents.

Based on observations, interview, and record review, the facility failed to ensure appropriate infection control were followed when: 1. The facility's water system was not tested for Legionella (a bacteria whichcould cause a serious type of pneumonia [lung infection]) and other waterborne diseases. This failure had the potential to place residents at risk for health complications related to Legionella; and 2. Three suction tubings (flexible tubes used for the removal of secretions) and one Yankauer (a tool used to suction oral secretions) were not dated, for three of three residents (Residents 2, 17 and 34). In addition, two Yankauers were not changed according to the facility's policy and procedure, for two of three residents (Residents 1 and 17.) This failure had the potential to cause an increased risk for respiratory infection for Residents 2, 17 and 34. Findings: 1. On January 10, 2024, at 11:06 a.m., an interview with the Maintenance Director (MTD) was conducted. The MTD stated the facility had a water management program which included conducting water sampling analysis for Legionella. The MTD stated there was no water sampling analysis nor assessment done for the facility for years 2020, 2021, 2022, and 2023. The MTD stated had contracted a company to conduct the water sampling analysis on December 11, 2023, but the company didn't come. The MTD stated he should have contacted another company to perform the water analysis for the facility. On January 11, 2024, at 4:18 p.m., an interview was conducted with the Infection Preventionist Nurse (IP). The IP stated water sampling had not been conducted in the facility prior to January 11, 2024. In addition, the IP stated the facility's policy on water management indicated water analysis for Legionella should be done annually. On January 11, 2024, at 5:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not conduct annual water analysis for Legionella according to their policy and procedure. A review of the undated facility document titled, Legionella Water Management Program, indicated, . CDC elite legionella testing will be performed quarterly . According to the article published by Centers for Disease Prevention and Control (CDC) titled, Water Management in Healthcare Facilities, dated March 25, 2021, indicated, .CDC encourages healthcare facilities .to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission .Water management programs should therefore be monitored for their efficacy in reducing the risk for a variety of pathogens . 2. On January 11, 2024, at 2:05 p.m., Resident 2 was observed lying in bed with a tracheostomy (a small, surgical opening through the skin into the windpipe) tube connected to a ventilator (a machine that helps people breathe when they cannot breathe naturally). The suction tubing was observed not to be dated and the Yankauer tip was dated January 1, 2024 (10 days from observation date). On January 11, 2024, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own), and dependence on ventilator. On January 11, 2024, at 2:10 p.m., Resident 34 was observed lying in bed with a tracheostomy tube connected to a ventilator. The suction tubing and the Yankauer tip were not dated. On January 11, 2024, Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, and tracheostomy. On January 11, 2024, at 2:21 p.m., Resident 17 was observed lying in bed with a tracheostomy tube connected to a ventilator. The suction tubing was not dated and the Yankauer tip was dated December 24, 2023. On January 11, 2024, Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included with diagnoses which included respiratory failure, tracheostomy, and dependence on ventilator. On January 11, 2024, at 2:15 p.m., a concurrent interview and observation for Residents 2 and 34 were conducted with Respiratory Therapist (RT) 1. Resident 2 was non-verbal and was observed in bed with tracheostomy tube connected to a ventilator. In a concurrent interview with RT 1, he stated Resident 2's suction tubing was not dated and the Yankauer tip was dated January 1, 2024. Resident 34 was non-verbal and was observed in bed with a tracheostomy tube connected to a ventilator. In a concurrent interview with RT 1, he stated Resident 34's suction tubing and the Yankauer tip were not dated. RT 1 further stated the suction tubings should be dated when changed every three days and the Yankauer tips should have been changed every Monday (January 8, 2024). On January 11, 2024, at 2:30 p.m., a concurrent interview and observation for Resident 17 was conducted with RT 2. Resident 17 was non-verbal and observed in bed with a tracheostomy tube connected to a ventilator. In a concurrent interview with RT 2, he stated Resident 17's suction tubing was not dated and the Yankauer tip was dated December 24, 2023 (18 days prior to observation date). RT 2 further stated the Yankauer tip should be changed every Monday and if not changed can potentially cause infection when used. The undated facility's policy and procedure titled, Changing the Yankauer, was reviewed. The policy indicated, .all Yankauers will be changed every week . The undated facility's policy and procedure titled, Changing Suction Canisters, was reviewed. The policy indicated, .all suction canisters with tubing will be changed every week .

Based on observation, interview, and record review, the facility failed to ensure, two (2) microwave ovens, six (6) refrigerator shelves, six (6) dry storage room shelves, one (1) refrigerator gasket, and one (1) freezer gasket were maintained in a safe operating condition. These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 8, 2024, at 11:12 a.m., during the kitchen observation with the Dietary Supervisor (DSS), the top area of the microwave oven was observed to have six (6) open circular areas with brown-copper discoloration and peeled paint. In a concurrent interview with the DSS, she stated, the microwave oven paint is melting, and the six open circular areas were with rust. The DSS further stated the rust and paint could fall on the residents' food and cause contamination. The DSS stated the microwave oven should have not been used for resident safety and to prevent foodborne illness. On January 8, 2024, at 11:22 a.m., during the kitchen inspection with the DSS, the reach-in refrigerator #1, there were 6 shelves observed to have brown-copper discoloration. In a concurrent interview with the DSS, she stated the brown-copper discoloration on the six (6) shelves inside the refrigerator were rust. The DSS further stated rust should have not been there and all shelves needed to be free of rust for food safety and to prevent food cross contamination. On January 8, 2024, at 11:36 a.m., refrigerator #2 door gasket (rubber piece that lined on the door to prevent cool air sip out) was observed torn. In a concurrent interview with the DSS, she stated the refrigerator gasket was torn. The DSS further stated it should not be like that, the refrigerator cannot close properly and cannot keep the appropriate temperature to prevent foodborne diseases if the gasket was torn. On January 8, 2024, at 11:46 a.m., the freezer door gasket was observed not intact. In a concurrent interview with the DSS, she stated the freezer gasket was broken and torn. The DSS further stated it should not be like that, the freezer cannot close properly and cannot keep the appropriate temperature to prevent food borne illness if the gasket was broken. On January 8, 2024, at 11:50 a.m., during an observation of the dry storage room, there were six (6) metal rack shelves observed to have brown-copper discoloration. On January 8, 2024, at 3:40 p.m., during a concurrent observation and interview with the DSS and the Maintenance Director (MTD), both stated the six (6) metal rack shelves in the dry storage room were rusted. The DSS further stated rust should have not been there and all shelves should be free of rust for food safety and to prevent food cross contamination. On January 8, 2024, at 4:32 p.m., during a concurrent observation and interview inside the activity room with Certified Nursing Assistant (CNA) 1, the microwave was observed to have brown-copper discoloration with peeled paint inside the front bottom area and the inside left upper top corner area of the microwave oven. In addition, the inside top middle area of the microwave oven was observed to have five (5) paint bubbles. In a concurrent interview with CNA 1, she stated the microwave oven was being used to warm resident's food during the nigh) shift. CNA 1 further stated the microwave was old, the paint bubbled and peeled inside the microwave, and the brown-copper discoloration was rust. CNA 1 stated rust and peeled paint should not be there and could fall on the resident's food when heated up. CNA 1 further stated this was not safe, and could cause food contamination and foodborne disease. On January 10, 2024, at 9:38 a.m., during an interview with the Registered Dietician (RD). The RD stated rust and peeled paint, or any kitchen equipment with decomposition should have not been used in the kitchen. The RD stated rust and peeled paint was a food safety hazard that could fall into food and could cause cross contamination and foodborne disease. The RD stated torn gaskets had the potential to not be able to keep the refrigerator or freezer at right temperature zone which could cause food borne illness. The RD expectation was all equipment used in the kitchen was in the safe operation condition with free of rust and peeling paint. A review of the facility policy and procedure titled, Operation and Sanitation, dated August 31, 2018, indicated, .When equipment is not functioning correctly . request repair of equipment and follow up to assure repair work is completed . A review of the undated facility policy and procedure titled, Equipment Maintenance, indicated, .The maintenance department is responsible for inspecting equipment annually, or more often .to ensure proper working order . According to the Federal and Drug Administration (FDA) Food Code 2022, .FOOD-CONTACT SURFACES of EQUIPMENT .shall be .to have a smooth, easily cleanable surface and .Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures .

Based on observation, interview, and record review, the facility failed to ensure food was served and prepared in a sanitary condition and in accordance with professional standards for food service safety practice when: 1. There were multiple areas in the kitchen, kitchen equipment, and food storage areas that were not clean; 2. The kitchen floor was not clean and had pores, indentation, cracked, and missing flooring tiles; and 3. The resident refrigerator had multiple unlabeled food items. These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: 1. On January 8, 2024, at 10:10 a.m., during a walk-through observation inside the kitchen with the Dietary Supervisor (DSS), the following were observed: - The storage pitcher shelves and multiple spice container lids were observed to have a whitish-gray debris; - The fire extinguisher metal bracket to the right top corner area of the coffee machine was observed to have hair like debris; - The walls at the right side and behind the coffee machine were observed to have black hair like debris; - The ceiling above the workstation was observed to have gray-brown hair like debris; - The pipes and ventilation on the hood above the stove was observed to have grayish hair like debris; - The can opener in front of the stove was observed with dry, black [NAME]-like residue and hair like debris; - The reach in refrigerator #1 door gasket was observed with black grime and the right upper corner air ventilation inside the refrigerator was observed to have grayish hair like debris; and - The reach in refrigerator #2 door was observed with black [NAME]-like grime. On January 8, 2024, at 10:23 a.m., during an interview with the DSS, she stated the whitish-gray debris on the storage pitcher shelves and on the lids of multiple spices were dust. The DSS further stated there should be no dust on those areas. The DSS stated the kitchen areas should have been cleaned and wiped to prevent cross contamination of the dust particles with food. On January 8, 2024, at 10:35 a.m., during an interview with the DSS, she stated the hairlike debris on the extinguisher, the blackish hair like debris on the walls to the right side and behind the coffee machine and the gray-brown hair like debris above the workstation were accumulated dust fibers. The DSS stated the dust fibers should not be there and those areas should have been cleaned and wiped to prevent cross contamination of the dust particles with food. On January 8, 2024, at 11:06 a.m., during an interview with the DSS, she stated the hood ventilation and pipes had dust fibers, and the can opener had hair, and the black [NAME] was dried grease. The DSS stated the hood ventilation and pipes, and the can opener should have been cleaned more frequently to prevent food cross contamination and foodborne diseases. On January 8, 2024, at 11:22 a.m., during an interview with the DSS, she stated the air ventilation inside Refrigerator #1 was covered with dust and the refrigerator gasket had black grime. The DSS further stated it's not supposed to be there, and it should have been cleaned to prevent cross contamination on food and prevent foodborne diseases. On January 8, 2024, at 11:36 a.m., during an interview with the DSS, she stated, the black-[NAME] debris inside refrigerator #2 door was mold. The DSS further stated mold should not be there and it should have been cleaned to prevent food borne diseases and for resident safety. On January 10, 2024, at 9:38 a.m., during an interview with the Registered Dietician (RD), he stated, dust on shelves, refrigerator, refrigerator vents and refrigerator fans or on any food preparation area should not be there. The RD further stated the kitchen should be free of debris and dust to prevent cross contamination of the food that can lead to foodborne diseases. A review of the facility policy and procedure titled, Shelves and Other Surfaces, dated August 31, 2018, indicated, .Keep fans clean and free of dust particles . According to the Federal and Drug Administration (FDA) Food Code 2022, .4-602.13 Nonfood-Contact Surfaces .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. On January 8, 2024 at 11:10 a.m. during the initial kitchen observation with the DSS, the following were observed of the kitchen floor: - The kitchen floors were observed with black grime; - The floor on the dirty area of the kitchen was observed to have pores, indentations, not smooth, with grease and black grime build up, and with approximately 14 tiles cracked and chipped; - The floor under the dish wash station was observed to have two (2) missing tiles and with brown-yellowish [NAME] like grime; and - The flooring on the dry storage room had one cracked tile and two missing tiles. During a concurrent interview with the DSS, he stated the kitchen floors had grime and needed to be deep cleaned. The DSS further stated the floor in the dirty area of the kitchen was not smooth, had indentations and needed to be replaced and was very dirty. On January 8, 2024, at 3:40 p.m. during an interview with the DSS and the Maintenance Director (MTD), both stated, the dry storage room floor had one (1) tile cracked and broken and there were two (2) missing tiles, and the floor was bare. On January 8, 2024, at 3:47 p.m. during an interview with MTD, he stated the floor under the dish wash station had two (2) missing tiles and is bare concrete. The MTD further stated there was grime build-up and the floor was very dirty. The MTD stated kitchen flooring should not be bare, cracked, or chipped, and should be clean with no grime build-up. The MTD further stated bacteria can grow if the floors are bare or not intact and not clean, it can cause sickness. On January 10, 2024, at 9:38 a.m., during an interview with the RD, he stated the kitchen floors should be clean, with a smooth surface, free of cracks and chipping to prevent build up and bacterial growth that can potentially cross contaminate the food items that were being prepared in the kitchen. A review of the facility policy and procedure titled, Shelves and Other Surfaces, dated August 31, 2018, indicated, .Clean floor drains and keep free of debris . A review of the facility policy and procedure titled, Floors/Floor Mats/ Baseboards, dated August 31, 2018, indicated, .Assure drains are scrubbed and free of debris . A review of the facility policy and procedure titled, Food Storage, dated August 31, 2018, indicated, .The walls, ceilings and floor should be maintained in good repair and regularly cleaned . A review of the Federal and Drug Administration (FDA) Food Code 2022, .6-201.12 Floors, Walls, and Ceilings, Utility Lines .Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned .Requirements and restrictions are intended to ensure that regular and effective cleaning is possible, and that insect and rodent harborage is minimized . 3. On January 8, 2024, at 4:32 p.m., during an observation of the resident refrigerator located in the activity room with Certified Nursing Assistant (CNA) 1. The resident refrigerator was observed to have the following foods not labeled and dated with the resident's name and room number: - One (1) 20 oz. (ounce - unit of measurement) bottle of ketchup; - Eight (8) boost glucose control drink 8 oz; - One (1) 11 oz protein shake; - One (1) 6 oz. yogurt; and - Seven (7) food containers containing green salsa (two), cheese cake, brown ground food, rice with meat, apple sauce, and soup. During a concurrent interview with CNA 1, she stated the process on storing resident food was for the food needed to be labeled and dated with the resident's name and room number. CNA 1 further stated the food was only allowed to be kept in the resident's refrigerator for three days and it has to be discarded after. CNA 1 stated the bottle of ketchup, boost glucose control drinks, protein shake, yogurt, and the seven (7) food containers were not labeled and dated with the resident's name and room number. CNA 1 further stated she did not know who the food belongs to or when and how long the food had been in the refrigerator and the food might be spoiled. CNA 1 stated all the food items in the resident's refrigerator should have been discarded for resident safety and to prevent foodborne disease. On January 10, 2024, at 9:38 a.m., during an interview with the RD, he stated the food in the resident's refrigerator should be labeled and dated with the resident's name and room number, when the food was received. The RD further stated unlabeled foods can cause foodborne disease since there was no way of knowing how long the food was in the refrigerator or who the food belongs to. A review of the facility policy and procedure titled, Food: Safe handling for Foods from Visitors, dated September 13, 2023, indicated, .When food items are intended for later consumption .Label foods with the resident name and the current date .Daily monitoring for refrigerated storage duration and discard of any food items that has been stored for > (greater than) 7 (seven) days .

Based on observation, interview, and record review, the facility failed to ensure: 1. A risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) assessment and least restrictive alternatives were conducted prior to use of bed rails, for sixteen of sixteen residents reviewed for bed rails (Residents 1, 2, 3, 4, 9, 13, 16, 22, 27, 28, 30, 31, 32, 35, 37, and 40). In addition, the risk for entrapment assessment did not indicate the resident's size and weight in relation to the dimensions of the bed being used for the resident according to the facility's policy and procedure. 2. The risk for entrapment assessments conducted were not specific to the bed rails being used by the residents, for six of sixteen residents reviewed for bed rails (Residents 2, 3, 16, 28, 37, and 40); and 3. An appropriate indication for the use of bed rails, for three of sixteen residents reviewed for bed rails (Residents 1, 2, and 9). These failures had the potential for residents to be at risk for injuries and entrapment. Findings: 1. On January 9, 2024, at 12:20 p.m., Resident 27 was observed lying in bed with bilateral (both) half-length bed rails raised. On January 11, 2024, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included seizures (sudden uncontrolled electrical activity in the brain). A review of Resident 27's document titled, Bed Rails, dated March 3, 2023, indicated the use of pillows was used as alternative prior to the use of bed rails, and was ineffective. The document did not indicate the reason why the use of pillows was ineffective. There was no documented evidence other alternatives were used prior to the use of bed rails. A review of Resident 27's physician's order, dated November 22, 2023, indicated bilateral padded half-length side rails (bed rails) for seizure precaution. The facility documented titled, Bed System Measurement Device Test Results Worksheet (entrapment risk assessment), dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated the entrapment risk assessment was conducted after the bed rail assessment on March 3, 2023 (five months after initiation of use of bed rails) and prior to the physician's order, dated November 22, 2023 (more than three months prior to the physician's order). In addition, the entrapment risk assessment did not indicate Resident 27's size and weight in relation to the dimension of the bed being used. 2. On January 9, 2024, at 3:36 p.m., Resident 2 was observed lying in bed with bilateral full length bed rails raised. On January 11, 2024, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (unable to move both arms and legs) and muscle contractures (a permanent shortening of the muscles, tendons, or tissues). A review of Resident 2's documented titled, Bed Rails, dated July 25, 2023, indicated the use of full-length side rails. In addition, the document did not specify other alternatives used, except visual and verbal reminders to use call lights. A review of Resident 2's physician order, dated January 9, 2024, indicated bilateral full-length side rails to keep low air loss mattress in place. There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated bilateral half-length bed rails which was different from the bed rails assessment for the use of full length bed rails, completed on July 25, 2023, and the physician's order, dated January 9, 2024. In addition, the assessment did not indicate Resident 2's size and weight in relation to the dimension of the bed being used. 3. On January 9, 2024, at 3:17 p.m., Resident 1 was observed lying in bed with bilateral half-length bed rails raised. On January 11, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included vegetative state (brain disorder in which a person shows no signs of awareness). A review of Resident 1's document titled, Bed Rails, dated September 16, 2023, the use of bilateral half bed rails. The document indicated pillows were used as an alternative prior to the use of bed rails but did not indicate the reason why the use of pillows was not effective. A review of Resident 1's physician order, dated November 22, 2023, indicated bilateral half bed rails to keep loss air mattress in place. There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bed rails. The entrapment risk assessment was conducted prior to the bed rail assessment on September 16, 2023 (one month prior to the use of bed rails), and the physician's order on November 22, 2023 (three months prior to the physician's order). In addition, the assessment did not indicate Resident 1's size and weight in relation to the dimension of the bed being used. 4. On January 9, 2024, at 3:15 p.m., Resident 9 was observed awake and sitting on the wheelchair. Resident 9's bed was observed to have bilateral padded half bed rails raised. On January 11, 2024, Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE], with diagnosis which included quadriplegia (unable to move both arms and legs). A review of Resident 9's physician's order, dated November 22, 2023, indicated bilateral half side rails to keep low air mattress in place. There was no documented evidence of any medical reason for the use of bed rails, except to keep low air mattress in place. A review of Resident 9's document titled, Bed Rails, dated November 25, 2023, did not indicate specific other alternatives used, except visual and verbal reminder, prior to the use of bilateral half bed rails. The documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of half bed rails. The assessment was conducted three months prior to the physician's order for bed rails on November 22, 2023, and bed rail assessment conducted on November 25, 2023. In addition, the assessment did not indicate Resident 9's size and weight in relation to the dimension of the bed being used. 5. On January 9, 2024, at 2:04 p.m., Resident 3 was observed lying in bed with full-length bed rails raised. On January 11, 2024, Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnosis which included dementia (cognitive impairment) and obesity (overweight). A review of Resident 3's physician's order, dated February 9, 2023, indicated bilateral full-length side rails as enabler. A review of Resident 3's document titled, Bed Rails, dated March 14, 2023, indicated full length side rails as an enabler. In addition, the document did not indicate specific other alternatives used, except frequent staff monitoring. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated half-length bed rails which was different from the physician's order on February 9, 2023, and the bed rails assessment on March 14, 2023. The document indicated the assessment was conducted six months after the physician's order on February 9, 2023. In addition, the assessment did not indicate Resident 3's size and weight in relation to the dimension of the bed being used. 6. On January 9, 2024, at 2:10 p.m., Resident 32 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 32's physician order, dated June 1, 2023, indicated bilateral padded half-length side rails to keep mattress in place and for seizure precaution. A review of Resident 32's document titled, Bed Rails, dated June 1, 2023, indicated no other alternatives used, except pillows, prior to the use of bed rails. The facility documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half rails. The assessment was conducted two months after it was ordered on June 1, 2023. In addition, the assessment did not indicate Resident 32's size and weight in relation to the dimension of the bed being used. 7. On January 9, 2024, at 12:01 p.m., Resident 37 was observed lying in bed with padded full-length bed rails raised. On January 11, 2024, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). A review of Resident 37's physician's order, dated November 22, 2023, indicated bilateral padded full-length side rails for seizure precaution. A review of Resident 37's document titled, Bed Rails, dated November 21, 2023, indicated full length side rails for seizure precaution. The document did not indicate specific other alternatives used, except pillows, prior to the use bilateral full bed rails. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated half-length side rails which was different from the bed rails assessment and physician's order of full length side rails on November 22, 2023. The assessment was conducted three months prior to the use of bed rails on November 22, 2023. In addition, the assessment did not indicate Resident 37's size and weight in relation to the dimension of the bed being used. 8. On January 9, 2024, at 1:57 p.m., Resident 22 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 22's physician's order, dated October 23, 2022, indicated bilateral padded half-length side rails for seizure precaution. A review of Resident 22's document titled, Bed Rails, dated June 23, 2023, did not indicate other alternatives used prior to use of bed rails, except to provide visual and verbal reminder. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of half bed rails. The document was conducted 10 months after the physician's order on October 23, 2022, and two months after bed rail assessment on June 23, 2023. In addition, the assessment did not indicate Resident 22's size and weight in relation to the dimension of the bed being used. 9. On January 9, 2024, at 1:55 p.m., Resident 16 was observed lying in bed with full-length padded bed rails raised. On January 11, 2024, Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included seizure. A review of Resident 16's physician's order, dated January 1, 2021, indicated bilateral padded full-length side rails for seizure precaution. A review of Resident 16's document titled, Bed Rails, dated June 16, 2023, indicated to use full length side rails for seizure precaution. The document did not indicate other alternatives used prior to the use of bed rails, except to provide visual and verbal reminder to use the call light. The documented titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, indicated, Bed Assessment .PASS . for the use of bilateral half bed rails. The document indicated an assessment for the use half-length side rails which was different from the physician's order on January 1, 2021, and bed rails assessment of the use of full-length side rails on June 16, 2023. In addition, the assessment did not indicate Resident 16's size and weight in relation to the dimension of the bed being used. 10. On January 9, 2024, at 2:14 p.m., Resident 31 was observed lying in bed with full-length bed rails raised. On January 11, 2024, Resident 31's record was reviewed. Resident 31 was admitted to the facility on [DATE], with diagnoses which included amyotrophic lateral sclerosis (a disease involving the nerves which affects the spinal cord and the brain). A review of Resident 31's physician's order, dated September 22, 2023, indicated bilateral full-length side rails as an enabler and to keep low air mattress in place. A review of Resident 31's document titled, Bed Rails, dated September 22, 2023, did not include other alternatives used prior to the use of bed rails, except the use pillows. The document did not indicate the reason why the use of pillows was not effective. The facility document, titled, Bed System Measurement Device Test Results Worksheet, dated August 14, 2023, was conducted one month prior to use of bed rails for Resident 31. In addition, the assessment did not indicate Resident 31's size and weight in relation to the dimension of the bed being used. 11. On January 9, 2024, at 12:04 p.m., Resident 35 was observed lying in bed with bilateral half-length bed rails raised. On January 11, 2024, Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included myopathy (type of muscle disease which causes weakness, stiffness, and cramps). A review of Resident 35's physician's order, dated December 4, 2023, indicated bilateral half-length bed rails as an enabler and to keep low air mattress in place. A review of Resident 35's document titled, Bed Rails, dated December 4, 2023, indicated the use of bilateral half bed rails. The document did not indicate other alternatives attempted prior to use of bed rails, except pillows. The document did not indicate a reason why the use of pillows was not effective. The documented titled Bed System Measurement Device Test Results Worksheet (entrapment risk assessment), dated August 15, 2023, was conducted four months prior to the physician's order and bed rail assessment for the use of bed rails on December 4, 2023. In addition, the assessment did not indicate Resident 35's size and weight in relation to the dimension of the bed being used. 12. On January 9, 2024, at 12:01 p.m., Resident 4 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 4's document titled, Bed Rails, dated October 6, 2023, indicated to use bilateral half bed rails. The assessment did not indicate other alternatives attempted prior to the use bed rails, except pillows. The document did not indicate the reason why the use of pillows was not effective. A review of Resident 4's physician's order, dated November 24, 2023, indicated bilateral padded half-length bed rails for seizure precaution. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to the bed rail assessment on order for bed rails on October 6, 2023, and the physician's order on November 24, 2023. In addition, the assessment did not indicate Resident 4's size and weight in relation to the dimension of the bed being used. 13. On January 9, 2024, at 12:52 p.m., Resident 28 was observed lying in bed with bilateral padded full-length bed rails raised. On January 11, 2024, Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 28's physician's order, dated March 27, 2023, indicated bilateral padded full-length bed rails for seizure precaution. A review of Resident 28's document titled, Bed Rails, dated March 24, 2023, indicated to use bilateral half-length bed rails for seizure precaution (different from the physician's order of full-length bed rails). In addition, the document did not indicate other alternatives used prior to the use of bed rails, except the use of pillows. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted five months after the physician's order and bed rail assessment for bed rails on March 27, 2023. The document also indicated full-length side rails which is different from the Bed Rails assessment (half- length side rails) completed on March 24, 2023. In addition, the assessment did not indicate Resident 28's size and weight in relation to the dimension of the bed being used. 14. On January 9, 2024, at 12:08 p.m., Resident 30 was observed lying in bed with bilateral padded full-length bed rails raised. On January 11, 2024, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a type of brain disorder causing seizures). A review of Resident 30's physician's order, dated October 10, 2023, indicated bilateral padded full-length bed rails for seizure precaution and to keep mattress in place. A review of Resident 30's document titled, Bed Rails, dated November 11, 2023, did not indicate other alternatives used prior to the use of bed rails, except to provide visual and verbal reminders to use the call light. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to the physician's order on October 10, 2023, and three months prior to the bed rail assessment on November 11, 2023. In addition, the assessment did not indicate Resident 30's size and weight in relation to the dimension of the bed being used. 15. On January 9, 2024, at 12:13 p.m., Resident 40 was observed lying in bed with bilateral padded full-length bed rails raised. On January 11, 2024, Resident 40's record was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included seizures. A review of Resident 40's physician's order, dated November 22, 2023, indicated bilateral padded full-length side rails for seizure precaution. A review of Resident 40's document titled, Bed Rails, dated November 21, 2023, indicated to use bilateral full-length side rails for seizure precaution. In addition, the document did not indicate other alternatives attempted prior to use of bed rails, except pillows. The document also did not indicate the reason why the use of pillows as alternative was not effective. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted three months prior to the physician's order for bed rails on November 22, 2023. The document indicated the assessment conducted was for the use of bilateral half-length side rails which was different from the bed rail assessment and physician's order for full- length side rails. In addition, the assessment did not indicate Resident 40's size and weight in relation to the dimension of the bed being used. 16. On January 9, 2024, at 12:16 p.m., Resident 13 was observed lying in bed with bilateral padded half-length bed rails raised. On January 11, 2024, Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE], with diagnoses which included vegetative state. A review of Resident 13's physician's order, dated February 27, 2022, indicated bilateral padded half-length bed rails for seizure precaution. A review of Resident 13's document titled, Bed Rails, dated October 28, 2023, did not indicate other alternatives attempted prior to use of bed rails, except to provide visual and verbal reminders to use the call light. The facility document titled, Bed System Measurement Device Test Results Worksheet, dated August 15, 2023, was conducted two months prior to bed rail assessment on October 28, 2023, and more than a year after the physician's order for bed rails on February 27, 2022. In addition, the assessment did not indicate Resident 13's size and weight in relation to the dimension of the bed being used. On January 10, 2024, at 1:30 p.m., an interview with the Maintenance Director (MTD) was conducted. He stated he conducted the entrapment risk assessment for the use of bed rails which he referred to the document titled Bed System Measurement Device Test Results Worksheet. He stated the entrapment risk assessment was being conducted annually for all the beds with bedrails in the facility. However, he stated the assessment was not specific to the size and weight of the residents using the bed rails, and not done prior to use of the bed rails. On January 11, 2023, at 1:37 p.m., an interview with the Director of Nursing (DON) was conducted. He stated the residents were being assessed for the use of bed rails upon admission. He stated bed rails were used for those residents with seizures and as an enabler for those that were alert. He stated bed rails were being used to keep the low air loss mattress in place and keep the residents from falling out of bed when they cough. He stated the risk for the use of bed rails when the resident coughs may result in the resident hitting either side of the bed rails. He stated this concern could causing discolorations or other injuries for the residents. The DON was not able to answer when the DON was asked if bed rails were to be used to keep low mattress in place was a valid indication to use the bed rails. The DON stated the type of bed rails (quarter, half, or full-length bedrails) were not individualized per resident's needs. He stated the type of bed rails use for the residents were based on the availability of the bed rails that come with the bed. The DON stated all residents were to be assessed for entrapment risk with the use of bed rails annually by the MTD, which he referred to the document titled, Bed System Measurement Device Test Results Worksheet, prior to use of bed rails. He stated the entrapment risk assessment was conducted for the bed itself and not specific to the size and weight of the residents using the bed rails. He also stated they did not use other alternatives, other than the use of pillows, prior to the use of bed rails for the residents. The facility's policy and procedure titled, Proper Use of Bed Rails, dated December 19, 2022, was reviewed. The documented indicated, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternatives approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensure correct installation, use, and maintenance of the rails .As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs .Medical diagnosis, conditions, symptoms, and/or behavioral symptoms .Size and weight .The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs .The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include .roll guards .foam bumpers .lowering the bed .concave mattress .If no appropriate alternatives are identified, the medical record should include evidence of the following .purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful .Assessment of the resident, the bed, the mattress and rail for entrapment [NAME] (which would include ensuring bed dimensions are appropriate for resident size/weight) .The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choice .

Based on interview and record review, the facility failed to ensure the pneumonia (lung infection) vaccine was offered, for one of five residents reviewed for immunization (Resident 35). This failure had the potential for an increased risk for Resident 35 to acquire pneumonia. Findings: On January 10, 2024, Resident 35's record was reviewed. The facility document titled, Admission Record, indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a small, surgical opening through the skin into the windpipe), and dependence on ventilator (a machine that helps people breathe when they cannot breathe naturally). The document indicated Resident 35 was [AGE] years old. In addition, the document indicated Resident 35's family member as the responsible party to make healthcare decisions for the resident. A review of Resident 35's Pneumococcal Vaccination Record located under the Immunizations tab of her electronic health record (EHR- a digital version of a patient's paper chart) indicated Resident 35 received Prevnar 13 (PCV13 - a pneumococcal vaccine) on January 27, 2016. On January 10, 2024, at 4:09 p.m., a concurrent interview and record was conducted with the Infection Preventionist (IP). The IP stated residents were screened for pneumonia immunization status upon admission. The IP stated the resident or resident representative would be offered to receive the pneumonia vaccine if the resident did not receive the complete series of pneumonia vaccines. The IP stated Resident 35 received PCV 13 on January 27, 2016. The IP further stated Resident 35 should have been offered to receive pneumonia vaccine 20 (PCV20 - a pneumococcal vaccine) upon admission. The facility's policy, and procedure titled, Pneumonia Vaccination, dated May 2009, was reviewed. The policy indicated, . Upon admission the resident will be assessed for eligibility to receive the pneumococcal vaccine and when indicated, provided the vaccination within 60 days of admission to the facility pneumococcal vaccination protocol: an individual received the vaccine prior to reaching the age of 65 and more than 5 years had passed .Administration of the pneumococcal vaccine is made in accordance with current Center for Disease control and Prevention (CDC) recommendation at the time of the vaccination . According to the article published by Centers for Disease Control and Prevention (CDC) titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated September 22, 2023, .adults 19 through [AGE] years old with certain risks conditions .only received PCV13 . give 1 (one) dose of PCV20 .the PCV20 dose should be given at least 1 (one) year after PCV13. When PCV 20 is used, their vaccines are then complete .

Based on observation, interview, and record review, the facility failed to ensure a puree diet (a diet with food texture of smooth pudding-like or smooth mashed potato-like consistency) was prepared and provided, for one of one resident (Resident 30) when the resident received chunks of spinach casserole for lunch on January 10, 2024. This failure placed Resident 30 at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking. Findings: On January 10, 2024, at 11:30 a.m., during an observation in the kitchen of the puree diet preparation with Cook (CK) 1 and the Dietary Supervisor (DSS), CK 1 was observed to grind the cooked spinach casserole in the food processor. The spinach casserole texture was observed to have chunks. In a concurrent interview with CK 1 and the DSS, both stated the texture of the spinach casserole was the right texture for a puree diet. On January 10, 2024, at 12:55 p.m., during a concurrent observation and interview with the Registered Dietician (RD). The RD stated a puree diet needed to be prepared with a smooth mashed potato like texture with no lumps and no chunks. The RD further stated a resident could choke or aspirate if the texture of the puree diet was not prepared correctly. The RD was observed to taste the pureed spinach casserole. The RD stated the pureed spinach casserole was not smooth, had chunks, was very thick and needed more liquid and grinding to achieve the correct puree texture. The RD further stated the pureed spinach casserole did not have the smooth mashed potato-like texture for a puree diet. A review of Resident 30's medical record indicated, Resident 30 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing). A review of Resident 30's physician order, dated October 19, 2023, indicated, .Regular Diet Puree texture . A review of the kitchen Diet Census, on January 10, 2024, indicated, .Resident 30 .Diet order .Regular diet puree texture . A review of the facility' document titled, Pureed Casseroles Recipe, dated August 20, 2018, indicated, .Pureed Casseroles .Place in food processor and process until smooth .If needed, gradually add hot broth or milk .process until smooth in consistency . A review of the facility's policy and procedure titled, Mechanically Altered/Dysphagia Diets, dated September 24, 2018, indicated, .Puree Diet .is designed for people who have severe chewing and/or swallowing problems .All foods are pureed to a smooth pudding-like consistency .Well-cooked pasta .should be pureed to smooth pudding like consistency .

Based on interview and record review, the facility failed to ensure a written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization ) was provided to the resident/and or resident representative, for one of one resident reviewed (Resident 25) when Resident 25 was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility. Findings: On January 12, 2024, Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of the facility document titled, Interact, dated January 4, 2024, indicated Resident 25 was transferred to the acute hospital for a change of condition. There was no documented evidence Resident 25 and/or resident representative was provided a written notice of the facility's bed hold policy at the time of transfer to the acute hospital. On January 11, 2024, at 11:06 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 3. She stated Resident 25's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form, dated January 4, 2024, indicated Resident 25 was transferred to (name of hospital) on January 4, 2024 at 4:57 p.m. due to abnormal hemoglobin or hematocrit (low). RN 3 stated there was no documentation the facility's bed hold notice was provided to Resident 25's representative when she was transferred tot he acute hospital. She stated the bed hold notification should have been provided to Resident 25's representative and documented in the progress notes upon transfer to the acute hospital. On January 11, 2024, at 4:09 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the written notice of bed hold should have been provided upon transfer to Resident 25's representative. The facility's policy and procedure titled, Bed Holds, revised June 2008, was reviewed. The policy indicated, .The resident and/or legal representative will be given written notice of the facility's Bed Hold policy, including the bed hold's duration, on admission to the facility and at the time of transfer to the acute hospital .current regulations require that the facility provide/offer a bed-hold of up to 7 (seven) days when a resident is transferred to the acute hospital .Nurse supervisor/charge nurse shall notify the resident/legal representative of his/her right to a bed-hold at the time of transfer to the hospital and complete the bed-hold notice .

Based on observation, interview, and record review, the facility failed to ensure an enteral feeding (a tube is inserted through the abdominal wall, through which liquid nutrition is administered) was provided within the safe timeframe to prevent bacterial growth in accordance with the enteral feeding manufacturer's recommendations, for one of 34 residents (Resident 30). This failure had the potential to result in food borne illness for Resident 30. Findings: On January 10, 2024, at 1:18 p.m., a concurrent observation and interview with Resident 30 was conducted. One bag of enteral tube feeding formula (Fibersource HN - type of formula) with a label indicating Resident 30's name and dated January 6, 2024, at 7 p.m., were observed hanging on the bedside pole in the resident's room. Resident 30's enteral feeding bag was observed to have approximately 400 milliliters (ml - unit of measurement) of enteral solution. In a concurrent interview with Resident 30, she stated she received enteral feeding on January 9, 2024, at 7 p.m., and was turned off on January 10, 2024, at around 5 a.m. On January 10, 2024, at 3:14 p.m., a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 was conducted. She stated there was an enteral feeding bag of Fibersource HN hanging on the pole for Resident 30 when she started her shift this morning. During a concurrent record review with LVN 1, she stated Resident 30 had an order for enteral feeding of Fibersource HN to start at 7 p.m. and off at 5 a.m. daily. She further stated the enteral feeding bag can be used for several days after it was initially started. On January 10, 2024, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included gastrostomy (surgical procedure used to insert a tube through the abdomen and into the stomach). A review of Resident 30's physician's order, dated December 29, 2023, indicated, .Enteral Feed Order every shift Nocturnal Enteral feeding: Formula: Fibersource HN 1.2 .Rate: 20ml (milliliters) x (times) 10 (ten) hours .START AT 7 PM (p.m.) AND OFF AT 5 AM (a.m.) . A review Resident 30's Medication Administration Record (MAR), from January 6 through 10, of 2024, indicated Resident 30 received enteral feeding daily (7 p.m. to 5 a.m.). On January 10, 2024, at 3:20 p.m., an interview with the Director of Nursing (DON) was conducted. He stated all enteral feeding can be used up to forty-eight hours (48 hours), after it was initially started, per manufacturer's guidelines. The DON stated Resident 30's enteral feeding of Fibersource HN that was dated January 6, 2024, at 7 p.m. and should have been discarded on January 8, 2024, at 5 a.m. The DON further stated the enteral feeding of Fiber Source HN was not changed within the required timeline for safe administration (forty-eight hours after it was started). A review of the Fibersource HN enteral feeding bag, it indicated, .DIRECTION FOR USE .use for a maximum of 48 hours after connection when proper technique is followed .

Based on observation, interview, and record review, the facility failed to ensure medications were disposed timely according to the facility's policy and procedure, for one of one resident (Resident 40), when one intravenous (IV) antibiotic medication was observed hanging on the IV pole, readily available for use after IV therapy was completed. This failure had the potential for Resident 40 to receive discontinued medication and/or could result in medication administration error. Findings: On January 8, 2024, at 12:17 p.m., one bag of IV medication labeled ertapenem (medication to treat infection) with Resident's 40's name and dated January 6, 2024, at 2:25 p.m., was observed hanging on the IV pole near Resident 40's bed side. On January 8, 2024, at 1:07 p.m., Resident 40 was observed with Registered Nurse (RN) 1. One IV medication labeled ertapenem with the resident's name and dated January 6, 2024, at 2:25 p.m., was observed hanging on the IV pole near Resident 40's bedside. RN 1 stated the ertapenem IV medication contained approximately two milliliters (ml - unit of measurement). In a concurrent record review with RN 1, she stated the IV medication ertapenem for Resident 40 was completed on January 6, 2024, at 2:25 p.m. She stated all completed IV medication should be discarded after the last dose administered and/or when therapy is completed. She further stated leaving the IV medication bag could result in medication errors. On January 11, 2024, at 2:56 p.m., an interview the Director of Nursing (DON) was conducted. He stated the IV ertapenem medication for Resident 40 should have been discarded after it was last administered on January 6, 2024, at around 3 p.m., per facility's policy and procedure. The facility's policy and procedure titled, Intravenous Therapy, dated December 19, 2022, was reviewed. The policy indicated, .The facility will adhere to accepted standards of practice regarding infusion practices .Procedures: Continuous Infusion .discard any used supplies .

Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Cook 2 was unable to accurately verbalized the starting temperature of cool down process for hazardous foods. This failure had the potential to cause foodborne illness, for five (5) out of five (5) residents who received food from the kitchen; and 2. Cook 1 served chunks of pureed spinach casserole (pureed foods should be smooth for residents who have difficulty chewing and/or swallowing) during the noon meal on January 10, 2024. This failure had the potential risk of choking, for one out of one resident (Resident 30) who received pureed food from the kitchen. (Cross referred with F805) Findings: 1. On January 8, 2023, at 4:02 p.m., a concurrent interview and record review was conducted with Cook 2 (CK) and the Dietary Supervisor (DSS). CK 2 stated the initial/starting temperature required when hot foods would be cooled down was from 130 F. The facility document titled, Cool Down Log, was concurrently reviewed with the DSS and CK 2. The DSS stated the cool down log indicated the initial/starting temperature required when cooling down hazardous hot foods was from 140 F (Foods Cooling is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 140 F to 41 F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If left out to cool, cooked food can become unsafe to eat in a matter of hours). On January 10, 2023, at 9:34 a.m., an interview with the Registered Dietitian (RD) was conducted. The RD stated the starting temperature during cool down process for hazardous foods was from 140 F. The RD explained if the starting temperature for cooling process started from 130 F, the food was already in the food danger zone which could lead to food borne illness. The RD stated his expectation was for the dietary staff to follow the policy and procedure for the cooling monitor for hazardous foods. A review of the facility's policy and procedure titled, Cooling monitor for Hazardous foods, revised dated May 20, 2020, indicated, .Policy: Food handling rules for cooling hazardous foods should be used by Food and Nutrition or Dining Services department employees. Hazardous foods are defined as: Beans/rice/Pasta, Bean Sprouts, Pies/Pastries, Eggs unpasteurized, Potatoes, Meats/Soy Protein/Drippings used for Sauces or Gravies, Cheese/Whipped Butter, Chicken/Shellfish, Dairy/Non-Dairy Agents, Cut Leafy Greens and Tomatoes, Mayo Mixed Salads, Melons .The food should be cooled from 140 F to 70 F within 2 hours and cooled from 70 to 41 F in an additional 4 hours . A review of the facility's document titled, Job Description Cook, revised dated September 21, 2018, indicated, .Primary Responsibility: Prepared and serves meals according to .monitors methods of food handling, preparation .Specific Responsibilities .Coordinate food preparation and meal service .Monitor temperature of hot .foods through food preparation and service to ensure that established temperature goals are met prior to steamtable transfer . 2. On January 10, 2024, at 11:30 a.m., a concurrent observation and interview was conducted with Cook 1 (CK) and the DSS. She stated the pureed spinach casserole needed to be in a smooth mash-potato like consistency. CK 1 was observed to prepare pureed spinach casserole by placing spinach casserole in a blender and added warm milk to blend. The pureed spinach casserole was observed to have a chunky texture after it was blended. CK1 and the DSS confirmed that was the right consistency of pureed spinach casserole to serve resident on a puree diet. On January 10, 2024, at 12:55 p.m., a concurrent observation and interview was conducted with the RD. The RD stated the pureed diet needed to be prepped in a smooth mash-potatoes like consistency with no lumps and no chunks. The RD further explained if the provided pureed foods had chunks or lumps, the resident could choke, aspirate or had difficulty swallowing the served food. The was observed to taste and test the prepared pureed casserole. The RD stated there were chunks found in the pureed spinach casserole and was not the appropriate texture for puree diet. The RD stated his expectation from the dietary staff was to follow the instructions of the recipe to provide smooth, no chunks, pureed foods. A review of the facility's document titled, Job Description Cook, revised dated September 21, 2018, indicated, . Specific Responsibilities .Coordinate food preparation and meal service .Prepare .serve .main dish .according to .recipes .

Based on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order, for one of five resident (Resident 36) observed during lunch on January 9, 2024, when Resident 36 did not receive the prescribed portion size during lunch meal. This failure resulted in Resident 36 to receive less calories from small portion, and could potentially result in unplanned weight loss, further compromising the nutritional and medical status of Resident 36. Findings: On January 9, 2024, at 11:50 a.m., a concurrent observation, and record review was conducted with Cook 1 (CK). CK 1 was observed to place one scoop of two ounces of meat, mashed potatoes, and peas on Resident 36's plate. Resident 36's meal ticket in the meal tray indicated, Small portions. The facility diet census (a diet list indicated resident's name and the physician's prescribed diet order) provided by the Dietary Supervisor (DSS) on January 9, 2024, indicated Resident 36 was on regular portion. The dietary spread sheet indicated four ounces of meat, mashed potatoes, and peas should be provided for a regular portion diet. On January 9, 2024, at 12:35 p.m., an interview was conducted with CK1. CK 1 stated she served half of regular portions of meat, mashed potatoes and peas to Resident 36 because Resident 36 was on small portion. On January 9, 2024, at 12:45 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 36 had a physician's order of regular diet. He stated Resident 36 was on regular portion and should have received regular portion every meal. On January 10, 2024, at 9:33 a.m., a concurrent interview and record review was conducted with the Dietary Supervisor (DSS). The DSS stated nursing informed her Resident 36 requested for small portion diet. Reviewed Resident 36 diet requisition (diet communication slip between nursing and dietary) with the DSS. Resident 36's diet requisition indicated, small portion, dated on 10/5/23 (October 5, 2023). The DSS stated if a resident requested small portion, it needed to get a physician ordered for small portion. On January 10, 2024, at 9:38 a.m., a concurrent interview and record review was conducted with the Registered Dietitian (RD). The RD stated if a resident requested a small portion, it needed to have a physician order prior to serving to the resident. The RD further explained if a resident had a physician ordered with regular portion and received small portion from dietary, weight loss could happen due to resident receiving less calories with small portion. The RD stated she was unaware Resident 36 received small portion from dietary since October 5, 2023. Reviewed Nutrition Progress Note, dated October 12, 2023, the RD stated he recommended regular portions with all meals for Resident 36. The RD acknowledged the Interdisciplinary team (IDT-a group of health care professionals all working toward a common goal) needed to be involved to collaborate regarding small portion per Resident 36 request. A review of the facility's policy and procedure titled, Small Portions, revised dated December 15, 2016, indicated, .Small portions may be requested by residents who have small appetites or when regular portions seem overwhelming and must be physician ordered . A review of the facility's policy and procedure titled, Provision of Physician Ordered Services, revised May 15, 2023, indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .Dietary modifications: Dietary staff will implement .dietary modifications as prescribed by the physician .

Based on observation, interview, and record review, the facility failed to provide the required bedroom space measuring at least 80 square feet per resident, in 15 resident rooms (Rooms: 1, 2, 3, 4, 5, 6, 7, 8 , 11, 12, 14, 15, 16, 17, and 18). Findings: On January 11, 2024, at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) regarding the room sizes for resident rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The DON stated the rooms did not meet the space requirement of at least 80 square feet per resident in the above mentioned resident rooms. The DON stated the facility has a waiver for the rooms. During the survey dates January 8, 9, 10, and 11, 2024, the above listed rooms were observed at different times of the day. There were no adverse effects that impacted the quality of life of the residents who resided in the rooms as observed during the survey dates. On January 11, 2024, the DON provided the request for room waivers for Rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The survey team recommends the room variance to continue, provided the health and safety of the residents who reside in the above-mentioned rooms, are not adversely affected.

Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of four residents reviewed for weight loss (Resident 3), when: 1. The nutritional needs of a resident requiring tube feeding (way of delivering nutrition directly to the stomach) were calculated based on the adjusted body weight (ABW - a measure used for calculating a person's nutritional needs for a weight loss program, which was lower than the actual body weight) instead of the actual body weight (higher than ABW); and 2. The continued use of [MEDICATION(S)] (diuretic - medication to treat fluid retention) was not evaluated timely when the [CONDITION(S)] (swelling) on both lower extremities was resolved on October 22, 2021. These failures resulted in Resident 3 having a severe weight loss of 24 pounds (lbs - unit of measurement)/9.37% (severe weight loss) in a month (October 1, 2021 to November 2, 2021). In addition, this failure had the potential for Resident 3 to have further weight loss. Findings: On November 30, 2021, at 10:06 a.m., Resident 3 was observed lying in bed and non-verbal. Resident 3 had a gastrostomy tube (G-tube; a tube inserted to the stomach used to administer food and medication) connected to a tube feeding pump. Resident 3 had no signs of [CONDITION(S)] to all extremities. On November 30, 2021, Resident 3's medical record was reviewed. Resident 3 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The general acute care hospital (GACH) document titled, Discharge Summary Report, dated October 2, 2021, indicated Resident 3 was readmitted to the facility on [DATE]. The facility document titled, Weights and Vitals Summary, indicated the following weights of Resident 3: - August 10, 2021; 280 lbs (127 kg [kilogram - unit of measurement]); - September 1, 2021; 278 lbs (126 kg); - October 1, 2021; 256 lbs (116 kg); weight loss of 22 lbs/7.9 % in a month; - October 4, 2021; 253 lbs (115 kg); - October 13, 2021; 247 lbs (112 kg); weight loss of 6 lbs/2.37% in a week; - October 20, 2021; 241 lbs (109.5 kg); weight loss of 6 lbs/2.42% in a week; - October 27, 2021; 236 lbs (107 kg); weight loss of 5 lbs/2.1% in a week); and - November 2, 2021; 232 lbs (105 kg); weight loss of 24 lbs/9.37% in a month. The plan of care, dated August 12, 2021, indicated, .Nutritional Status .has increased potential for altered nutrition, daily caloric intake of less than body requirements due to increased bodily demand or enteral formula rate intolerance .Goal .The resident will maintain weight and nutritional balance through the next review date . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Give 40 mg (milligram - unit of measurement) via (through) G-Tube two times a day for BLE (bilateral lower extremities) [CONDITION(S)] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Only Evaluation, dated October 1, 2021, indicated the following skin conditions: - Stage 3 (full thickness skin loss) pressure injury on the coccyx (tailbone); - Deep Tissue Injury (pressure injury) on the right lateral heel; - +3 (pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound) [CONDITION(S)] on both lower extremities; and - Moisture Associated Skin Damage (MASD - inflammation and erosion of the skin resulting from prolonged exposure to various sources of moisture and potential irritants such as urine, stool, etc.) on the perianal (located around the anus). The Nutritional Assessment, dated October 1, 2021, indicated the following: - Resident 3's weight was 256 lbs (weight loss of 22 lbs from 278 lbs on September 1, 2021); - Estimated nutritional needs: 2125 - 2550 calories; ABW of 188 lbs (85 kg) X (times) 25-30 kcals (kilocalories - unit of measurement); Protein - 127 grams; - .Res (Resident) current TF (tube feeding) rate is not meeting estimated nutritional needs. Res has increased protein needs r/t (related to) wound healing. Recs (recommendations) .DC (discontinue) current TF change to DIABETISOURCE @ (at) 75ml/hr (milliliter per hour) X 20 hrs (hours), provides 1500ml/1800 kcals .; and - .Goal Weight: slow weight loss . The nutritional assessment conducted on October 1, 2021, indicated Resident 3's nutritional needs were calculated according to the ABW of 188 lbs (85 kg) and not the actual weight of 256 lbs (116 kg [required nutritional needs should have been 2900 to 3480 kcal]). The plan of care, dated October 5, 2021, indicated, .Re-admission weight with -25# (lbs)/8.99% .Refer to RD for Eval (evaluation), and monitor weekly weights < (less than) 3% > (more than) weekly x 4 (four) weeks, and Monthly 5+/- .Goal .The resident's weight will return to baseline range between +/- 10% lbs by review date . The Progress Notes, dated October 15, 2021, indicated the following: - .Weekly wt (weight) variance: -6# (six lbs weight loss)/22.3% X 1 (one) week .CBW (current body weight) 247# (lbs); - .ESTIMATED NEEDS: ABW: 186# (85kg) 85kg X 25-30 kcals - 2126 - 2550 .; and - .Planned Slow wt loss desired . The Progress Notes, dated October 22, 2021, indicated the following: - .Weekly wt (weight) variance: -6# (six lbs weight loss)/2.4% X 1(one) week; - .CBW (current body weight) .241# .; - .ESTIMATED NEEDS: ABW: 186# (85 kg) .85kg X 25-30 kcals = 2125 - 2550 .; - .Planned wt loss d/t (due to) BMI > (more than) 30, Per nsg (nursing) resolved [CONDITION(S)] .; - .RD called and left a message for Res (resident) family. RD wanted to inform family member of wt loss and discuss a goal wt .; and - .Recommendation .D/C current TF change to DIABETISOURCE @ (at) 90ml/hr to provide 1800ml/2160kcals . The Progress Notes, dated October 29, 2021, indicated the following: - .Weekly wt variance: -5# (five lbs weight loss)/2% X 1(one) week; - .CBW .236# .; - .ESTIMATED NEEDS: ABW: (83 kg) .83kg X 25-30 kcals = 2075 - 2490 .; and - .RD recommended to increase TF (tube feeding) on 10/22/21 (October 22, 2021) to meet 100% of estimated nutritional needs . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] on Bilateral Lower Extremities resolved . There was no documented evidence indicating the use of [MEDICATION(S)] was evaluated when Resident 3 continued to lose weight and the resident's [CONDITION(S)] had resolved on October 22, 2021. Resident 3 had a further weight loss of nine lbs from October 20, 2021 to November 2, 2021 (within two weeks before [MEDICATION(S)] was discontinued on November 5, 2021). The Nutritional Assessment, dated November 5, 2021, indicated the following: - Resident 3's weight was 232 lbs (weight loss of 24 lbs/9.3% from 256 lbs on October 1, 2021 [one month] and 48 lbs/17.1% on August 10, 2021 [three months]); - .Res with sig (significant) wt loss X 1 mos (month) and 3 mos. Unplanned Wt loss possibly d/t (due to) hospitalization .Res had had a wt loss trend since readmission. Per nsg (nursing), [CONDITION(S)] and P/I (pressure injury) wound have been resolved. Diuretic possibly also contribute to wt loss .wt loss was expected/desired. Current goal is wt maintenance . There was no documented evidence Resident 3's representative was made aware of the severe weight loss since readmission on September 30, 2021. There was no documented evidence Resident 3's representative agreed on a planned weight loss. On November 30, 2021, at 2:17 p.m., Family Member (FM) 1 was interviewed. She stated Resident 3 looked smaller from her recent visit in November 2021. She stated she was not aware Resident 3 had lost weight. On December 1, 2021, at 9:23 a.m., FM 2 was interviewed. She stated she was not aware Resident 3 lost weight. On December 1, 2021, at 10 a.m., a concurrent interview and record review was conducted with the Registered Dietitian (RD). She stated when Resident 3 was admitted , Resident 3 had a BMI (a measure that relates body weight to height) greater than 40 (obese). She stated she documented a desire for slow weight loss based on Resident 3's high BMI. She stated she was not able to discuss with Resident 3's representative regarding the planned weight loss. The RD stated when Resident 3 lost weight on readmission from GACH, she used the readmission weight to calculate the adjusted body weight (ABW) which was lower than the actual body weight. She stated she calculated Resident 3's nutritional needs based on the ABW. She stated maybe I should not be doing that. She stated she used a lower ABW each time Resident 3 lost weight. She stated using the ABW could have contributed to Resident 3's weight loss. The RD stated Resident 3 was bed bound and there was no guarantee Resident 3 would not be losing muscle mass on a planned weight loss program. She stated Resident 3's estimated nutritional and energy needs should have been 2704 - 3240 calories (kcals) if she would have based it on the current actual body weight of 238 lbs. She stated Resident 3's actual nutritional and energy needs were higher than what she estimated and could have contributed to the severe weight loss. On December 1, 2021, at 12:16 p.m., Licensed Vocational Nurse 2 was interviewed. He stated the physician should be notified to evaluate the need for [MEDICATION(S)] if the [CONDITION(S)] had been resolved. He further stated the resident was expected to maintain weight if the [MEDICATION(S)] was discontinued. On December 1, 2021, at 3:20 p.m., the Nurse Practioner (NP) was interviewed. He stated he would refer a resident's weight loss to the RD when he was notified of the weight loss. He stated any recommendations made by the RD was to be relayed to him for appropriate action. The NP stated the expected weight loss for a resident on [MEDICATION(S)] was about three to five lbs. He stated the facility should have notifed him or the physician to re-evaluate the use of [MEDICATION(S)] when the [CONDITION(S)] was resolved on . On December 1, 2021, at 6 p.m., a follow up interview was conducted with FM 2. She stated she talked to Resident 3's representative (RR) and was told the RR was not aware Resident 3 had a significant weight loss and was on a weight loss program. On December 2, 2021, at 11:01 a.m., the Director of Nursing (DON) was interviewed. He stated he could not guarantee Resident 3's weight loss was from water or muscle mass loss. He stated the licensed nurse should notifiy the physician for further instructions when Resident 3's [CONDITION(S)] was resolved. The facility's policy and procedure titled, Nutritional Support Committee, dated May 2007, was reviewed. The policy indicated, .It is the policy of this facility to have a weekly Nutritional Support Committee meeting to review any resident who has an identified nutritional risk and requires interdisciplinary team assessment and development or revision of their plan of care .The goal of the committee will be timely identification of risk factors and appropriate interventions to delay or prevent development of overt symptoms of malnutrition or problems that contribute to compromised nutritional status . The facility's policy and procedure titled, Nutrition Committee Guidelines, dated May 2007, was reviewed. The policy indicated, The Nutrition Committee members will use the data from the resident's clinical record to identify factors that may be affecting the resident's nutritional status and develop a course of action. The committee reviews the plan of care, makes recommendations and evaluates the effectiveness of the recommendations .Residents considered at nutritional risk or have a significant unplanned weight gain or loss (more than 5 (five)% in 30 days, more than 7.5% in 90 days or more than 10% in 180 days) are presented to the committee .The assessment will be used to assist the committee members to identify underlying risks and factors that can guide their interventions .Discussions can include .Recent weekly weight and weight change in the last week .Medication review .Results of the review are discussed with the physician and committee members . The facility's policy and procedure titled, Change in a Resident's Condition or Status, dated January 2012, was reviewed. The policy indicated, .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .The nurse supervisor/charge nurse will notify the resident's attending physician .when there has been .A need to alter the resident's medical treatment significantly .the nurse supevisor/charge nurse will notify the resident's next-of-kin or representative (sponsor) when .There is a significant change in the resident's physical, mental, or psychosocial status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .Assessment related to the change of condition will be documented for 72 hours unless the condition requires continued documentation or the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] According to web article titled, Adjusted or Ideal Body Weight for Nutrition Assessment, published by The Academy of Nutrition and Dietetics, dated 2015, .According to the Academy's Nutrition Care Manual .there is no evidence that substituting adjusted or ideal weight .results in improved accuracy .It also states that many of the RMR (resting metabolic rate- energy needs) equations were developed using actual body weight. ABW (adjusted body weight) will underestimate or overestimate RMR in patients depending on their weight status. In the case of overweight or obese patients, RMR can be underestimated by as much as 42% when using ABW . According to the web article titled, Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, published by the American Dietetic Association, dated October 2010, .Weight reduction in adults with obesity results in loss of both fat mass and lean body mass that may trigger sarcopenia (loss of muscle mass) and functional decline. Individualized diet plans should be implemented with caution, using professional judgment based on the nutrition assessment and an individual's overall health goals and should include physical activity to assist with retention of lean body mass and increased losses of fat mass . According to the web article titled, Excessive Body Weight in Older Adults: Concerns and Recommendations, published by Clinical Geriatric Medicine, dated August 2015, .In the case of obese adults who .have serious chronic illness or disabilities, a weight maintenance approach is best advised, given the scarcity of information about the benefit/risk of weight reduction in these situations . According to the web article titled, Evaluating and Treating Unintentional Weight Loss in the Elderly, published by the American Family Physician, dated February 15, 2002, .Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .