Every finding on record at Mission Hills Post Acute Care

Based on interview and record review, the facility failed to ensure eight out of twenty sampled residents' (Residents 85, 30, 4, 9, 91, 59, 12, and 77) advance directives (AD) were obtained and documented in the medical record in accordance with the facility's policy.This failure had the potential to result in the facility providing care or treatment that was inconsistent with the residents' documented advance directive treatment plans.FINDINGS:A review of Resident 85's Face Sheet indicated Resident 85 was admitted to the facility on [DATE].A review of Resident 30's Face Sheet indicated Resident 30 was admitted to the facility on [DATE].A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE].A review of Resident 9's Face Sheet indicated Resident 9 was admitted to the facility on [DATE].A review of Resident 91's Face Sheet indicated Resident 91 was admitted to the facility on [DATE].A review of Resident 59's Face Sheet indicated Resident 59 was admitted to the facility on [DATE].A review of Resident 12's Face Sheet indicated Resident 12 was admitted to the facility on [DATE].A review of Resident 77's Face Sheet indicated Resident 77 was admitted to the facility on [DATE].On 8/13/26 at 9:14 A.M., a joint interview and record review was conducted with the social services director (SSD). The SSD stated she was responsible for the facility's AD process. The SSD stated that within 72 hours of admission, she would greet the resident and offer information regarding ADs. The SSD stated that when a resident did not have an AD, she would document the absence of an AD under Social Services Assessment/Evaluations in the medical record. The SSD further stated that if the resident had an AD, she was supposed to obtain a copy to be included in the resident's medical record. A review of the Social Services Assessment/Evaluations undated assessment was conducted. The SSD reviewed section D, Advance Directives, which indicated, Resident has issued advance directives about his/her care and treatment: a. No. b. Yes-obtain a copy of such advance directives to be included in the resident's medical record. The following residents' Social Services Assessment/Evaluations were reviewed with the SSD:Resident 85 had documentation of having an AD on 8/7/26, however a copy was not included in the resident's medical record.Resident 30 had documentation of having an AD on 7/27/26, however a copy was not included in the resident's medical record.Resident 4 had documentation of having an AD on 7/9/26, however a copy was not included in the resident's medical record.Resident 9 had documentation of having an AD on 7/2/26, however a copy was not included in the resident's medical record.Resident 91 had documentation of having an AD on 8/10/26, however a copy was not included in the resident's medical record.Resident 59 had documentation of having an AD on 8/6/26, however a copy was not included in the resident's medical record.Resident 12 had documentation of having an AD on 3/5/26, however a copy was not included in the resident's medical record.Resident 77 had documentation of having an AD on 8/10/26, however a copy was not included in the resident's medical record.The SSD stated that if the resident had an AD, it should have been in the resident's medical record. The SSD further stated It was important for residents who already formulated an AD to have the AD in the medical record because it documented the residents' wishes regarding medical and financial decisions.On 8/13/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated if the resident had an AD, a copy of the AD should have been uploaded to their medical record. The DON stated that if the resident had an AD and it was not uploaded to their medical record, the facility may not be following the resident's documented requests or wishes regarding their care and treatment.On 8/13/26 at 5:31 P.M., an interview was conducted with the administrator (ADM). The ADM stated acquiring documentation of a formulated AD was very important because it ensured the resident's wishes were honored towards the end of the resident's life. The ADM stated it was extremely important to honor the residents' wishes. A review of the facility's policy titled Advance Directives and Associated Documents, revised April 2025, indicated .c. inquire whether they have completed an Advance Directive.5 When an Advance Directive is completed. d. Obtain a copy of the Advance Directive.and place them in the resident health record.

Based on observation, interview, and record review, the facility failed to ensure a clean and comfortable homelike environment for residents when:Shower room [ROOM NUMBER] had a broken electrical outlet with visible wiring and a nail sticking out. Shower room [ROOM NUMBER] also had dark streaks on the floors and the lower portion of the walls, and the shower head was observed touching the floor. Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER] had circular, black-specked patches along the bottom hems of the shower curtains. In addition, the facility did not document or maintain cleaning logs that Shower room [ROOM NUMBER] or Shower room [ROOM NUMBER] had been routinely cleaned. 2. Resident 16 was given roommates (Resident 96) who screamed and yelled frequently.These failures had the potential to result in an environment that was not comfortable, clean, or homelike for residents who use the shower rooms. In addition, Resident 16 stated she could not sleep and felt tired due to the uncomfortable sound levels. FINDINGS: On 8/11/26 at 8:13 A.M., a joint observation and interview was conducted with certified nursing assistant (CNA) 21 in Shower room [ROOM NUMBER]. An electrical outlet was observed on the back wall of the shower room under the shelving with a cracked cover that exposed loose wiring and a nail. The shower curtain had circular, black-specked patches along the bottom hem. Dark streaks were observed on the floor and lower portions of the walls. The shower head was hanging from the shower hose and was touching the floor. CNA 21 stated Shower room [ROOM NUMBER] looked dirty and it should be cleaned. CNA 21 stated the shower head was contaminated. CNA 21 looked at the exposed electrical outlet and stated, rodents could come out the hole in the wall. On 8/11/26 at 8:22 A.M., a joint observation and interview was conducted with the infection preventionist nurse (IPN) in Shower room [ROOM NUMBER]. The IPN stated the black-specked patches along the bottom hem of the shower curtain were, black mold and the shower curtain needed to be replaced. The IPN stated Shower room [ROOM NUMBER] did not look clean, and it should have been clean. The IPN further stated the hole in the wall was exposed electrical wiring and should not have been like that. On 8/11/26 at 8:37 A.M., a joint observation and interview was conducted with the director of environmental services (DES) in Shower room [ROOM NUMBER]. The shower curtain had circular, black-specked patches along the bottom hem. Dark streaks were observed on lower portions of the walls. The DES stated Shower room [ROOM NUMBER] looked dirty and it should have been cleaned after each use. The DES touched the shower curtain and stated, I should probably wash my hands now. On 8/11/26 at 10:10 A.M., an interview was conducted with CNA 22. CNA 22 stated he showered three to four residents per day and that residents showered twice a week. CNA 22 stated that after he showered residents, he removed all dirty linens from the shower room and only used a bath towel to wipe down the shower room. CNA 22 stated he did not perform deep cleaning of the shower room and verbally notified maintenance and housekeeping to clean the shower rooms after resident use. CNA 22 stated CNAs were not responsible for deep cleaning the shower rooms and that deep cleaning was the responsibility of housekeeping. On 8/11/26 at 10:21 A.M., a joint interview and record review was conducted with the DES and the environmental service director (ESD). The ESD stated it was the maintenance department's responsibility to oversee that the shower rooms were cleaned, and housekeeping staff were responsible for performing the deep cleaning. The ESD stated housekeeping staff were responsible for deep cleaning the shower rooms daily and as needed using bleach. The ESD stated machines were not used to clean the shower rooms and that housekeeping staff, get on their hands and knees and scrub. The ESD stated CNAs were responsible for sanitizing the shower chairs, walls, and grab bars with bleach wipes after each resident's use of the shower room. The ESD stated CNAs were then required to document the cleaning on the Resident Shower Log and Clean Up Checklist. The Resident Shower Log and Clean up Checklist was reviewed with the ESD and the DES. The checklist instructed staff to initial after cleaning the shower room and contained documentation of linen disposal, garbage removal, cabinet clearance, and equipment sanitization. The checklist did not include a designated area to document sanitization of the shower room, grab bars, shower chairs, or walls. The records reviewed contained entries dated from January 2026 through June 2026, with the most recent entry dated 6/14/26. No documentation was provided from 6/15/26- 8/11/26 to demonstrate that the required shower room cleaning by the CNAs had been performed during this time. The DES stated the Resident Shower Logs and Clean up Checklists provided were the only records to demonstrate that CNAs had sanitized the shower rooms. The DES stated there was missing documentation. The DES further stated the facility did not have a shower deep-cleaning log for housekeeping staff to document when the shower rooms had been deep cleaned daily or as needed. The DES stated it was his expectation that both shower rooms were deep cleaned daily and as needed. The ESD stated that if there was no documentation demonstrating the shower rooms had been deep cleaned daily or as needed, then it did not happen. On 8/13/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated that the shower rooms should have been cleaned after each resident's use. The DON stated the CNAs were responsible for cleaning the shower rooms after each use with bleach wipes or bleach spray, and the housekeeping staff were responsible for performing a more thorough, deep cleaning of the shower rooms daily or as needed. The DON stated there should have been current documentation demonstrating the cleaning performed by the CNAs after each use and the deep cleaning performed by the housekeeping staff. The DON further stated that if the shower rooms were in her own home she would expect them to be clean. A review of the facility's policy titled Resident Rights Safe and Homelike Environment, revised July 2026, indicated .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 2. A review of Resident 16's Face Sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses to include Neoplasm (an abnormal and uncontrolled growth of tissue, commonly referred to as a tumor) related pain and Multiple Myeloma (a cancer that forms in a type of white blood cell) not having achieved remission. A review of Resident 16's Brief Interview for Mental Status (BIMS, a mental status assessment) dated 7/6/26, indicated the resident had a score of 15 of 15 (meaning the cognitive function was intact). A review of Resident 96's Face Sheet indicated Resident 96 was admitted to the facility on [DATE] with diagnoses to include Encounter for Palliative Care (specialized medical care for people with serious illnesses). A review of Resident 96's BIMS dated 8/10/26, indicated the resident had a score of 7 of 15 (meaning severe cognitive impairment). A review of Resident 96's progress note dated 8/7/26, indicated, .Behaviors observed: some calling out. On 8/10/26 at 9:54 A.M., an observation and interview was conducted with Resident 16. Resident 16 stated her roommate (Resident 96) had been yelling day and night. Resident 16 stated Resident 96 had been yelling the name, Mike. Resident 16 stated she hardly got any sleep. Resident 16 stated Resident 96 had started yelling and groaning a couple of days after Resident 96 was placed in her room. Resident 16 stated the facility always put residents who yelled as her roommate. Resident 16 stated she felt tired and did not get proper rest because of the yelling. Resident 16 stated she informed the staff and was told Resident 96 would be her roommate for a while. Resident 96 who was in the bed next to Resident 16 was observed yelling, Mike! On 8/12/26 at 8:07 A.M., another interview was conducted with Resident 16. Resident 16 stated prior to having Resident 96 as her roommate, the facility gave her another roommate who was confused and kept on waking her up at night. Resident 16 stated she told the facility staff about the incompatibility and was told the facility was working on her roommate situation. Resident 16 stated that prior roommate had stayed there until the resident was discharged . On 8/12/26 at 8:57 A.M., an interview was conducted with certified nursing assistant (CNA) 11. CNA 11 stated Resident 16's prior roommate was always moaning and yelling. On 8/12/26 at 9:35 A.M., an interview was conducted with CNA 31. CNA 31 stated Resident 96 frequently yelled. CNA 31 stated she would not like it if she was given a roommate who frequently yelled. On 8/12/26 at 9:59 A.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated Resident 96 was confused and yelled. The ADON stated she would feel frustrated if she had a roommate who yelled. On 8/13/26 at 4:36 P.M., an interview was conducted with the director or nursing (DON). The DON stated she expected the facility's staff to bring Resident 16's complaints regarding roommate compatibility to her attention so she could provide the resident with comfortable sound levels in her room. A review of the facility's policy titled Safe and Homelike Environment revised 7/2026, indicated, .The facility will maintain comfortable sound levels in the facility.

Based on observation, interview and record review, the facility failed to develop an individualized care plan for four of 20 sampled residents (Resident 12, 91, 48, 54) when:1. Resident 12 's preference to eat by hand instead of using utensils was not developed into an individualized care plan.2. Resident 91's reports of constipation were not developed into an individualized care plan.3. Resident 48's episodes of urinary incontinence were not developed into an individualized care plan.4. Resident 54's prescribed oxygen use was not developed into an individualized care plan. These deficient practices had the potential to negatively affect the residents' well-being.Findings: 1. A review of Resident 12's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include aphasia (brain condition that makes it hard to talk, understand words, read or write), hemiplegia (a medical condition that causes partial or total body paralysis) affecting right side of the body, recurrent major depressive disorder (mental health condition causing feeling of sadness, emptiness and loss of joy in life) and need for assistance with personal care. A review of Resident 12's minimum data set assessment (MDS, a comprehensive assessment tool) section GG-Functional Abilities, dated 6/4/26, indicated the resident needed set-up or clean-up assistance with her eating. On 8/10/26 at 12:12 P.M., a concurrent observation and interview with certified nursing assistant (CNA) 31 was conducted in Resident 12's room. Resident 12 was sitting up in bed with her eyes closed, and a plate of food was on the resident's lap. Resident 12 was scooping soft food from the plate into her mouth using her left hand. CNA 31 was in Resident 12's room and stated she placed the plate of food on the resident's lap. CNA 31 stated the resident would not use eating utensils and preferred to use her hands. CNA 31 stated Resident 12 could not speak but would yell and scream if in need of something. On 8/12/26 at 8:10 A.M., a concurrent observation and interview with the rehabilitation director (RED) was conducted in Resident 12's room. Resident 12 was loudly screaming, alalala. The RED was at Resident 12's bedside with a maintenance staff. The RED stated the resident was upset because the resident's television was not working. The RED stated she knew the resident well and that she had worked with Resident 12 for years. The RED stated she knew Resident 12 before the resident had her stroke (a medical emergency when blood flow to part of the brain was cut off) and when Resident 12 was able to speak, walk, and dance. The RED stated Resident 12 always ate with her hands and would refuse to eat if spoon fed by staff. The RED stated Resident 12 always liked finger foods. The RED stated after the resident's stroke, Resident 12 had right-sided weakness and would now use her left hand to eat. On 8/13/26 at 9:10 A.M., a concurrent interview and record review was conducted with the assistant director of nursing (ADON). The ADON stated she knew Resident 12 well. The ADON stated she had worked with the resident for many years. The ADON stated Resident 12 used her hands to eat and would not use eating utensils. The ADON stated Resident 12 would refuse meals if spoon fed by staff. The ADON reviewed Resident 12's care plan and stated a care plan was not developed for the resident's preference. The ADON further stated Resident 12 was an individual with her own preferences, likes and dislikes, and that the resident's preference for eating with her hands should have been care planned. On 8/13/26 at 4:22 P.M., an interview was conducted with the director of nursing (DON). The DON was aware of Resident 12's preference to eat using her left hand, without using eating utensils. The DON stated there was no care plan developed related to Resident 12's preference. The DON stated an individualized care plan should have been developed for the resident's preference to assure all the staff taking care of Resident 12 would be aware of the resident's preference. The DON further stated this would ensure the resident's food intake would not be negatively impacted by not following Resident 12's preference. 2. A review of Resident 91's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include displaced bimalleolar fracture of right lower leg (broken ankle). On 8/10/26 at 8:53 A.M., an observation and interview was conducted with Resident 91 in her room. Resident 91 was sitting on a bedside commode next to her bed. Resident 91 was crying. Resident 91 stated she had surgery a few days ago prior to admission to the facility. Resident 91 stated she had been constipated since then. On 8/12/26 at 4 P.M., an interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated Resident 91 had an order for a routine laxative. Resident 91's bowel movement (BM) log was reviewed with LN 1. The BM log indicated Resident 91 did not have a BM on 8/7/26, 8/8/26, and 8/11/26. Resident 91 had a small and medium formed/soft/normal BM on 8/9/26, a large constipated/hard BM on 8/10/26, and a medium soft/formed/normal BM on 8/12/26. LN 1 reviewed Resident 91's clinical record and stated there was no care plan for Resident 91's constipation. LN 1 stated Resident 91's constipation should have been care planned. LN 1 stated it was very important to have Resident 91's constipation care planned so it could be addressed and managed. 3. A review of Resident 48's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include a need for assistance with personal care and abnormalities of gait and mobility. On 8/10/26 at 8:48 A.M., an interview was conducted with Resident 48 in her room. Resident 48 stated she got herself up from bed to toilet herself. Resident 48 stated she did not always make it to the bathroom and urinated on herself and onto the floor about five to six times since being admitted to the facility. On 8/12/26 at 3:39 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 48 did not use her call light too often. LN 1 stated Resident 48 had occasional urinary incontinence. LN 1stated he worked last weekend when Resident 48 had an episode of urinary incontinence while she ambulated to the bathroom. LN 1 reviewed Resident 48's clinical record and stated Resident 48's urinary incontinence was not care planned. LN 1 stated it should have been care planned. LN 1 stated it was very important to have care planned the incident so other team members had the most updated information to best care for Resident 48. 4. A review of Resident 54's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm (cancer) of unspecified part of right bronchus or lung and other nonspecific abnormal finding of lung field. On 8/10/26 at 9:55 A.M., an observation was conducted with Resident 54 in her room. Resident 54 was sitting in her wheelchair. Resident 54's oxygen concentrator (a medical machine that pulls in regular room air and gives the user pure oxygen through a tube or mask) was not in use. A review of Resident 54's physician order dated 8/9/26, indicated the resident had an order for oxygen at 2 lpm (liters per minute) as needed for shortness of breath. On 8/12/26 at 4:15 P.M., an interview and record review was conducted with the director of staff development (DSD) and Infection Preventionist (IPN). The DSD and the IPN reviewed Resident 54's physician order that indicated an oxygen order for 2 lpm as needed for shortness of breath. The IPN reviewed Resident 54's clinical record and stated the oxygen order was not care planned. The IPN stated Resident 54's oxygen use should have been care planned. The IPN stated, I will put it in now. The IPN stated it was very important to have Resident 54's oxygen therapy care planned so licensed staff would know what to do if Resident 54 became short of breath. On 8/13/26 at 4:37 P.M., an interview was conducted with the director of nursing (DON). The DON stated changes in resident's orders, changes in resident's condition, and any resident concerns should have been care planned. The DON stated it was very important to have any updates or changes to residents' care to have been care planned to ensure other staff were updated with the residents' condition and changes. A review of the facility's policy titled Care Planning Implementation and Revision, revised 2026, indicated, .The facility shall develop, implement.an individualized, person-centered care plan for each resident.necessary to attain or maintain the resident's highest practicable.well-being. Care plans shall be based on comprehensive assessment findings, resident goals and preferences.3. Care Plan Content.shall identify resident strengths.shall reflect resident preferences.and individualized care needs.

Based on observation, interview, and record review, the facility failed to implement infection control practices when:Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER] had circular, black-specked patches along the bottom hems of the shower curtains. Shower room [ROOM NUMBER] had dark streaks on the floors and the lower portion of the walls, and the shower head was observed touching the floor. In addition, the facility did not document or maintain cleaning logs that Shower room [ROOM NUMBER] or Shower room [ROOM NUMBER] had been routinely cleaned.Resident 12 who ate lunch using her bare hands was not provided with hand hygiene. (Resident was dependent on staff to wash her hands). Cross reference F656.Medication Cart 3 had a sharps container (hard plastic box used for sharp tools, needles, and syringes) filled above the designated fill line, with sharps protruding from the container lid.Resident 17's shared privacy curtain between bed B and C was hanging inside and touching the resident's trash can while LN 21 continuously discarded residual gastric aspirate (stomach contents) from the resident's gastrostomy tube (a tube inserted into the stomach) feeding into the trash can and onto the floor.Two certified nursing assistants (CNA 2 and CNA 3) entered and exited a resident's room without performing hand hygiene (process of cleaning the hands).These failures had the potential to result in the transmission and spread of infection, cross-contamination, and unsafe conditions. FINDINGS: 1.On 8/11/26 at 8:13 A.M., a joint observation and interview was conducted with CNA 21 in Shower room [ROOM NUMBER]. The shower curtain had circular, black-specked patches along the bottom hem. Dark streaks were observed on the floor and lower portions of the walls. The shower head was hanging from the shower hose and touching the floor. CNA 21 stated Shower room [ROOM NUMBER], looked dirty and it should be cleaned. CNA 21 further stated the shower head was contaminated. On 8/11/26 at 8:22 A.M., a joint observation and interview was conducted with the infection preventionist nurse (IPN) in Shower room [ROOM NUMBER]. The IPN stated the black-specked patches along the bottom hem of the shower curtain were, black mold and the shower curtain needed to be replaced. The IPN stated Shower room [ROOM NUMBER] did not look clean, and it should have been clean. On 8/11/26 at 8:37 A.M., a joint observation and interview was conducted with the director of environmental services (DES) in Shower room [ROOM NUMBER]. The shower curtain had circular, black-specked patches along the bottom hem. Dark streaks were observed on lower portions of the walls. The DES stated Shower room [ROOM NUMBER], looked dirty and it should have been cleaned after each use. The DES touched the shower curtain and stated that, I should probably wash my hands now. On 8/11/26 at 10:10 A.M., an interview was conducted with CNA 22. CNA 22 stated he showered three to four residents per day and that residents showered twice a week. CNA 22 stated that after he showered residents, he removed all dirty linens from the shower room and used a bath towel to wipe down the shower room. CNA 22 stated he did not perform deep cleaning of the shower room and verbally notified maintenance and housekeeping to clean the shower rooms after resident use. CNA 22 stated CNAs were not responsible for deep cleaning the shower rooms and that deep cleaning was the responsibility of housekeeping. On 8/11/26 at 10:21 A.M., a joint interview and record review was conducted with the DES and the environmental service director (ESD). The ESD stated it was the maintenance department's responsibility to oversee that the shower rooms were cleaned, and housekeeping staff were responsible for performing the deep cleaning. The ESD stated housekeeping staff were responsible for deep cleaning the shower rooms daily and as needed using bleach. The ESD stated no machines were used to clean the shower rooms and that housekeeping staff, get on their hands and knees and scrub. The ESD stated CNAs were responsible for sanitizing the shower chairs, walls, and grab bars with bleach wipes after each resident's use of the shower room. The ESD stated CNAs were then required to document the cleaning on the Resident Shower Log and Clean Up Checklist. The Resident Shower Log and Clean up Checklist was reviewed with the ESD and the DES. The checklist instructed staff to initial after cleaning the shower room and contained documentation of linen disposal, garbage removal, cabinet clearance, and equipment sanitization. The checklist did not include a designated area to document sanitization of the shower room, grab bars, shower chairs, or walls. The records reviewed contained entries dated from January 2026 through June 2026, with the most recent entry dated 6/14/26. No documentation was provided from 6/15/26 to 8/11/26 to demonstrate that the required shower room cleaning by the CNAs had been performed during this time. The DES stated the Resident Shower Logs and Clean up Checklists provided were the only records to demonstrate that CNAs had sanitized the shower rooms. The DES stated there was missing documentation. The DES further stated the facility did not have a shower deep-cleaning log for housekeeping staff to document when the shower rooms had been deep cleaned daily or as needed. The DES stated it was his expectation that both shower rooms were deep cleaned daily and as needed. The ESD stated that if there was no documentation demonstrating the shower rooms had been deep cleaned daily or as needed, then it did not happen. On 8/13/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated that the shower rooms should have been cleaned after each resident's use. The DON stated the CNAs were responsible for cleaning the shower rooms after each use with bleach wipes or bleach spray and the housekeeping staff were responsible for performing a more thorough, deep cleaning of the shower rooms daily or as needed. The DON further stated there should have been current documentation demonstrating the cleaning performed by the CNAs after each use and the deep cleaning performed by the housekeeping staff. 2.A review of Resident 12's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include aphasia (brain condition that makes it hard to talk, understand words, read or write), hemiplegia (a medical condition that causes partial or total body paralysis) affecting right side of the body, and need for assistance with personal care. On 8/11/26 at 11:17 A.M., an observation was made inside Resident 12's room. Resident 12 was asleep in her bed. No meal tray was present at bedside. From 11:17 A.M. to 12:21 P.M., continuous observations were conducted regarding the delivery of meal trays and hand hygiene practices outside Resident 12's room. Staff were not observed performing hand hygiene on Resident 12 prior to the resident receiving her meal tray. At 12:21 P.M., licensed nurse (LN) 21 was observed bringing Resident 12's meal tray to the room. LN 21 performed hand hygiene on herself using hand sanitizer prior to providing the meal tray to Resident 12. Resident 12 then began eating a fruit cup using her bare hands to feed herself. No hand hygiene was performed on Resident 12 prior to her eating. At 12:23 P.M., an interview was conducted with LN 21. LN 21 stated she did not wash or sanitize Resident 12's hands prior to the resident eating. LN 21 stated Resident 12's hands should have been sanitized or washed prior to eating because of, germs. LN 21 further stated it was the responsibility of the CNAs to sanitize or wash resident's hands prior to meals. On 8/11/26 at 12:28 P.M., an interview was conducted with certified nursing assistant (CNA) 22. CNA 22 stated the staff member who delivered the meal tray was responsible for ensuring the resident performed hand hygiene prior to eating. CNA 22 further stated that responsibility was not limited to CNAs and could include licensed nurses. On 8/13/26 at 10:19 A.M., an interview was conducted with the infection preventionist nurse (IPN). The IPN stated Resident 12 should have had her hands washed with warm, soapy water prior to eating as an infection prevention measure. The IPN stated Resident 12 touched multiple surfaces with her hands and could have had, feces on her hand then used her bare hands to feed herself. On 8/13/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 12 ate with her bare hands, and it was important for Resident 12 to have received hand hygiene prior to meals as an infection control measure. 3.On 8/12/26 at 7:38 A.M., an observation of medication cart 3 was conducted. The sharps container mounted to medication cart 3 was filled above the designated fill line, with used sharps protruding through the opening of the container lid. On 8/14/26 at 10:19 A.M., an interview was conducted with the infection preventionist nurse (IPN). The IPN stated sharps containers should have been replaced when they were three-fourths full. The IPN further stated an overfilled sharps container could have resulted in a needlestick injury and potential exposure of a blood borne pathogen (disease causing germ that lives in blood). On 8/14/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated sharps should not be protruding from the sharps container because that could have led to a needlestick injury. The DON further stated the sharps container should have been replaced when it was three-fourths full. 4. On 8/12/26 at 8:24 A.M., an observation of Resident 17's gastrostomy tube medication administration was conducted with licensed nurse (LN) 21 inside Resident 17's room. Resident 17's shared privacy curtain between beds B and C was observed touching the inside of Resident 17's trash can. During the medication administration, LN 21 continuously discarded residual gastric aspirate from Resident 17's gastrostomy tube into the trash can which also spilled onto the floor. The privacy curtain remained in contact with the trash can throughout the medication administration. On 8/12/26 at 12:46 P.M., an interview was conducted with the infection preventionist nurse (IPN). The IPN stated Resident 17's shared privacy curtain between beds B and C was, contaminated and needed to be changed immediately. On 8/14/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 17's shared privacy curtain was soiled and constituted an infection control issue. A review of the facility's policy titled Infection Prevention and Control Program, revised April 2025, indicated .2. Process Surveillance. hand hygiene.injection safety.infection control practices during the provision of resident care and treatments.managing bloodborne pathogen exposure.3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.5. The facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste.6.b. Safe use of disposal and single use supplies and equipment.c. Effective cleaning and disinfecting equipment as needed, to including bathing areas between each resident use. 5. On 8/12/26 at 4:05 P.M., an observation and interview was conducted with CNA 2 outside of Resident 54's room. CNA 2 was observed to have entered and exited Resident 54's room without performing hand hygiene. CNA 2 stated he did not perform hand hygiene upon entering and exiting Resident 54's room. CNA 2 stated he should have performed hand hygiene before entering and after exiting Resident 54's room. CNA 2 stated the process before entering and after exiting residents' rooms was to perform hand hygiene. CNA 2 stated it was very important to perform hand hygiene before entering and after exiting residents' rooms to avoid the spread of germs to other residents and staff. On 8/12/26 at 4:10 P.M., an observation and interview was conducted with CNA 3 outside of Resident 75's room. Resident 75's call light was on. CNA 3 knocked on Resident 75's door, entered Resident 75's room and picked up Resident 75's meal tray. CNA 3 entered and exited Resident 75's room without performing hand hygiene. CNA 3 stated she should have performed hand hygiene before entering and after exiting Resident 75's room. CNA 3 stated it was important to perform hand hygiene to keep everyone safe and not spread germs. On 8/13/26 at 2:13 P.M., an interview was conducted with the infection preventionist nurse (IPN). The IPN stated his expectations from the facility staff was to sanitize their hands before entering and after exiting the residents' rooms. The IPN stated this was very important so illness and disease would not spread. The IPN stated it was especially important since the residents in the facility were highly susceptible to getting sick. The IPN also stated proper hand hygiene would prevent germs from going home to the staff's families. On 8/13/26 at 4:40 P.M., an interview was conducted with the director of nursing (DON). The DON stated the facility staff were expected to perform hand hygiene before entering and after exiting the residents' rooms. The DON stated it was important to prevent infection and illness. A review of the facility's undated policy titled Infection Control Prevention and Control Program-Hand Hygiene, indicated, .hand hygiene.the primary means to prevent the spread of infections.before and after direct contact with residents.after contact with objects.in the vicinity of the resident.

Based on observation, interview, and record review, the facility failed to ensure one of three resident's (Resident 59) oxygen therapy was provided according to the physician's orders when Resident 59's oxygen concentrator (a medical device that pulls in room air, removes nitrogen, and delivers 90% to 95% pure oxygen to people who have trouble breathing) was set to 5 lpm (liters per minute). In addition, there was no documentation of a nurse's assessment prior to the resident being put on 5 lpm of oxygen.As a result, there was the potential for Resident 59 to experience respiratory distress.Findings:A review of Resident 59's Face Sheet indicated the resident was admitted to the facility on [DATE]and was re-admitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD, a group of long-lasting lung conditions that damage the airways and make it hard to breathe), unspecified.A review of Resident 59's physician's order dated 8/4/26, indicated, Oxygen Concentrator 2-3LPM via nasal cannula for sob[shortness of breath]/comfort Continuous every shift.A review of Resident 59's care plan dated 1/5/21, indicated, .potential for: SOB/dyspnea.Give oxygen therapy as ordered by the physician.On 8/10/26 at 11 A.M., an observation and interview was conducted with Resident 59. Resident 59 was lying in bed. The head of the bed was elevated. Resident 59 stated she could not breathe. Resident 59 was using a nasal cannula, and the oxygen concentrator was observed to be running on 5 lpm.On 8/10/26 at 4:50 P.M., an observation and interview was conducted with Resident 59. Resident 59 was groaning and stated she could not get a good breath. Resident 59 stated she could not breathe. The oxygen concentrator was running at 5 lpm.On 8/10/26 at 5:24 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she had just observed Resident 59 and was not sure who adjusted Resident 59's oxygen concentrator to 5 lpm. The ADON stated Resident 59 was not capable of adjusting the oxygen concentrator by herself. The ADON stated Resident 59's oxygen concentrator should have been set between 2-3 lpm. The ADON stated Resident 59 had COPD and Resident 59's oxygen concentrator should have never been set to 5 lpm.A review of Resident 59's progress note dated 8/10/26 at 7:09 P.M., indicated, Writer was informed patient reported difficulty breathing. Oxygen concentrator was noted to be running at 5LPM.Writer notified RN [registered nurse] to reassess oxygen saturation and titrate oxygen back down to 2-3LPM per MD [medical doctor] orders.orders placed in [electronic health record] to monitor concentrator LPM and to never titrate above 3LPM per MD orders. Staff education provided: only RNs are permitted to adjust oxygen concentrators. MD notified of concentrator running at 5LPM from 11:00 to approximately 16:30 [4:30 P.M.].On 8/13/26 at 8:37 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IPN). The IPN stated Resident 59 had COPD. The IPN stated it was not advisable for a resident with COPD to be administered oxygen at 5 lpm. The IPN stated giving a resident with COPD oxygen at 5 lpm was very dangerous and it could cause the resident to stop breathing. The IPN stated a registered nurse should assess the resident before titrating the oxygen. The IPN stated it was important to follow the physician's order of 2-3 lpm. The IPN stated somebody set Resident 59's oxygen at 5 lpm as the resident was not physically able to manipulate the oxygen concentrator by herself. The IPN stated Resident 59's physician's order for oxygen concentrator dated 1/5/21 was still active and had not been followed. The IPN stated there was no documentation of a nursing assessment that would explain putting the resident at 5 lpm. The IPN stated there was no documentation the physician had an order to run the oxygen concentrator at 5 lpm.On 8/13/26 at 12:50 P.M., an interview was conducted with the medical records director (MRD). The MRD stated the facility did not have a policy for respiratory care.On 8/13/26 at 4:36 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was important to follow physician's orders. The DON stated only the RNs were allowed to titrate the oxygen concentrator. The DON stated giving oxygen at 5 lpm to residents who have COPD could cause shortness of breath and respiratory distress to the residents.A review of the facility's policy titled Physician Orders revised 6/2024 indicated, .it is the policy of the facility.to implement orders.of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on interview and record review, the facility failed to ensure one of four residents (Resident 77) received dialysis (process where a resident's blood passes through a machine that removes toxins and excess fluid) care that was consistent with professional standards of practice when:1. LNs were not documenting Resident 77's fluid intake; only the output (urine).2. Certified nurse assistants (CNA) documented fluid intake that was outside of the physician's ordered fluid restriction and there was no documentation LNs were made aware.3. There was no documentation that Resident 77's fluid intake was monitored by the licensed nurses (LN).As a result, there was the potential for Resident 77 to experience being fluid overloaded (happens when too much water and salt build up in the body putting strain on the heart). Findings:A review of Resident 77's Face Sheet indicated the resident was admitted on [DATE] with diagnoses to include end stage renal disease and dependence on renal dialysis.A review of Resident 77's physician order dated 7/24/26, indicated, 1200 ml [milliliters] fluid restriction daily: Breakdown - Days: Nursing: 240 ml; Dietary breakfast: 240ml; PM: Nursing 240 ml; Dietary 120 ml : NOC: Nursing 120 ml; Dietary dinner 240 ml.A review of Resident 77's Medication Administration Record (MAR) for July 2026 indicated, Strict I & O [intake and output] every shift for fluid overload prevention. The same MAR further indicated that LNs were only documenting the resident's output from 7/23/26 through 7/31/26 for all three shifts. There was no LN documentation of the resident's intake amounts.A review of Resident 77's Task: Fluid Intake [CNA documentation] indicated:-7/24/26, the resident was documented as having received 1320 ml of fluid. -7/26/26, the resident was documented as having received 2420 ml of fluid. -7/28/26, the resident was documented as having received 1240 ml of fluid. -7/30/26, the resident was documented as having received 1620 ml of fluid.8/1/26, only one shift recorded the resident's intake at 0 ml.A review of Resident 77's Nurse Dialysis Communication Records (a form to communicate resident care/treatment between the facility and the dialysis clinic) from 7/24/26 through 7/31/26, indicated:7/24/26: the resident's pre-treatment weight was 74.2 kg (kilograms) and post-treatment weight was 72.8 kg. The resident weight loss 1.4 kg (equivalent to 3.08 pounds [lbs.]).7/25/26: the resident's pre-treatment weight was 74.8 kg (kilograms) and post-treatment weight was 73.9 kg. The resident weight loss was 0.9 kg (equivalent to 1.98 lbs.).7/27/26: the resident's pre-treatment weight was 74.5 kg (kilograms) and post-treatment weight was 72.1 kg. The resident weight loss was 2.4 kg (equivalent to 5.28 pounds lbs.). The dialysis communication further indicated from the clinic, .Fluid restriction.pls [please].7/29/26: the resident's pre-treatment weight was 76.7 kg (kilograms) and post-treatment weight was 72.7 kg. The resident weight loss was 4 kg (equivalent to 8.8 pounds lbs.).7/31/26: the resident's pre-treatment weight was 74.9 kg (kilograms) and post-treatment weight was 71.9 kg. The resident weight loss was 3 kg (equivalent to 6.6 pounds lbs.).A review of Resident 77's progress notes dated 8/2/26, indicated, Resident complain of sob [shortness of breath]. Resident states that he feels like he is drowning. Appears to show increase WOB [work of breathing]. [medical doctor] said to send resident out.A review of Resident 77's progress notes dated 8/3/26, indicated the resident was admitted to the hospital for fluid overload.On 8/13/26 at 11:45 A.M., a joint interview and record review was conducted with the infection prevention nurse (IPN). The IPN reviewed Resident 77's clinical record and stated the resident had a physician's order for a strict fluid restriction of 1200 ml of fluids per day cumulative from the nursing department and dietary (drinks served with meals). The IPN reviewed Resident 77's Task: Fluid Intake CNA documentation from 7/23/26 through 7/31/26 and stated CNAs should have been documenting fluid that the resident consumed during meals. The IPN stated CNAs were documenting fluid intake values that exceeded the resident's strict I & O order. The IPN reviewed Resident 77's clinical record and stated there was no documentation the LN was made aware of this. The IPN further stated there was no documentation LNs were overseeing the resident's fluid intake amounts or monitoring them. The IPN reviewed Resident 77's July 2026 MAR and stated LNs were not documenting how much fluid nursing was providing the resident through tasks such as medication administration. The IPN stated LNs were only documenting Resident 77's output. The IPN reviewed Resident 77's Nurse Dialysis Communication Records from 7/24/26 through 7/31/26 and stated the resident was having significant weight changes pre and post dialysis treatments on 7/29/26 (8.8 lbs.) and 7/31/26 (6.6 lbs.). The IPN stated it would have concerned him to know the resident had four to five pounds of fluid removed during dialysis. The IPN stated the dialysis clinic could only take off so much fluid without causing harm to the resident. The IPN stated these pre and post weights should have been monitored along with the intake amounts. The IPN stated this should have been monitored closely by the LN because too much fluid in the resident's body could kill the resident. On 8/13/26 at 2:10 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated Resident 77 had a history of not following his fluid restriction. The DON reviewed Resident 77's IDT [interdisciplinary team] -Care Plan Review note dated 7/30/26 and signed 8/1/26, indicated, .Pt [patient] is non compliant with fluid restriction and prefers to keep water pitcher at bedside despite ongoing education by nursing, RD [registered dietitian] and dietary manager. The DON stated she expected clear oversight of the resident's intake by the LNs and monitoring of the CNA intake documentation even with the resident's non-compliance. The DON stated there should have been a weekly summary of Resident 77's intake and output done by LN. The DON stated there needed to be more education provided to CNAs of what to chart regarding resident intakes and when to report it to the LN. The DON stated LNs should have been documenting what nursing was providing to the resident as fluid intake and that output only was insufficient. The DON stated the charge nurse should have reviewed the I & O to ensure fluid restriction orders were being followed. The DON stated the consequence of not following the physicians strict I & O orders was that the resident could have fluid overload. The DON stated residents receiving dialysis have kidneys that do not work and cannot get rid of excess fluid. The DON stated even if the resident refused to follow the strict fluid restriction, there should have been careful accounting and documenting of what nursing and dietary gave and the resident consumed.A review of Resident 77's Nurse Dialysis Communication Records dated 7/24/26 through 7/31/26 did not have documentation that the facility communicated to the dialysis clinic that the resident was non-compliant with fluid restrictions. On 8/13/26 at 5:08 P.M., an interview was conducted with the DON. The DON stated the facility did not have a policy that addressed resident fluid intake and output. The DON stated it was the expectation that the physician's order would be followed.A review of the facility's policy titled Renal Dialysis, Care of Resident revised 6/2019, did not provide guidance related to fluid restriction or intake and output for residents receiving dialysis.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided in accordance with professional standards of practice for two of three (Resident 4 and Resident 91) residents when:1. Licensed Nurse (LN) 22 did not administer Resident 4's Vitamin B Complex-C Oral Capsule during an observed medication pass.2. Resident 91 had duplicate orders for Polyethylene Glycol 3350 (medication to treat constipation) 17 grams listed on the medication administration record (MAR) and Order Summary Report (OSR), both of which LN 23 documented as administered.These failures had the potential to result in inaccurate medication records, missed medication doses, and adverse resident outcomes.FINDINGS:1. A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE].On 8/12/26 at 10:15 A.M., an observation of Resident 4's medication administration with LN 22 was conducted. LN 22 administered the following medications to Resident 4:Eliquis (blood thinning medication) 2.5mg, 1 tabLosartan Potassium (medication to treat high blood pressure) 50mg, 1 tabHydralazine Hydrochloride (medication to treat high blood pressure) 50mg, 2 tabsSertraline (antidepressant medication) 100mg, 1.5 tabsBuspirone Hydrochloride (anti-anxiety medication) 5mg, 1 tabNifedipine ER (medication to treat heart conditions) 30mg, 2 tabsMetoprolol tartrate (medication that lowers blood pressure and heart rate) 100mg, 1 tabClopidogrel (medication to prevent blood clots) 75mg, 1 tabSenna Plus (medication to prevent constipation) 50mg, 1 tabThiamine (vitamin) 100mg, 1 tabGabapentin (medication to treat nerve related pain) 100mg, 1 tabDocusate Sodium (medication to treat constipation) 250mg, 1 tabHydromorphone Hydrochloride (medication to treat severe pain) 2mg, 2 half tabsFluticasone Propionate/ Salmeterol DISKUS Inhaler (medication to reduce inflammation), 1 puffOn 8/12/26 at 11 A.M., a review of Resident 4's OSR was conducted. Resident 4's active orders indicated, Vitamin B Complex-C Oral Capsule (B complex w/ C). Give one tablet by mouth one time a day for supplement. Order Status Active. Order Date 7/8/26. The medication was scheduled to be given at 9 A.M.A review of Resident 4's MAR indicated that on 8/12/26, LN 22 documented that Vitamin B Complex- C Oral Capsule was administered to Resident 4.On 8/12/26 at 12 P.M., an interview was conducted with LN 22. LN 22 stated he documented that he administered Vitamin B Complex- C Oral Capsule to Resident 4. LN 22 stated he did not administer Vitamin B Complex- C Oral Capsule to Resident 4.On 8/13/26 at 4:32 P.M., an interview was conducted with the director of nursing (DON). The DON stated a LN should never document a medication as administered when the LN did not administer the medication. The DON stated that, depending on the medication, failure to administer a medication as ordered could negatively impact the resident. The DON further stated that Resident 4 should have received her medications as ordered by the provider and that the LN should have documented medication administration accurately.2. A review of Resident 91's Face Sheet indicated Resident 91 was admitted to the facility on [DATE].On 8/12/26 at 8:55 A.M., an observation of Resident 91's medication administration with LN 23 was conducted. Resident 91 stated she had a, clay-like bowel movement last night but previously she had not had a bowel movement for a week. Resident 91 requested additional laxatives. LN 23 left the room to prepare Resident 91's medications. At 9:11 A.M., Resident 91 stated she was on the phone with her healthcare provider and asked LN 23 to return in 15 minutes to administer her medications.At 9:53 A.M., an observation of Resident 91's medication administration with LN 23 was conducted. LN 23 administered the following medications to Resident 91:Acetaminophen 325 (medication to treat minimal to moderate pain) MG Oral Tablet, 2 tabsVitamin C (vitamin) 500mg, 1 tabAspirin 81 MG (blood thinning medication) Chewable Table, 1 tabPolyethylene Glycol 3350 (medication to treat constipation) 17 grams, 17 gramsVitamin D 3 (vitamin) 25mcg 1000, 2 tabsAmlodipine (medication to lower blood pressure) 10 MG Oral Tablet, 1 tabPantoprazole (medication that lowers the amount of acid made in your stomach) 40mg, 1 tabFluoxetine (medication to treat depression) 20mg, 1 tabFinasteride (medication to treat hair loss) 5mg, 1/4 tabThiamine B1 (vitamin) 100mg, 1/2 [NAME] 8/12/26 at 11 A.M., a review of Resident 91's MAR dated 8/12/26 was conducted. LN 23 documented that MiraLax Oral Powder 17 GM/Scoop and Glycolax Powder (Polyethylene Gycol 3350) 17 GM/Scoop were administered to Resident 91 at 9 A.M. In addition, both medications were documented as administered on 8/11/26 at 9 A.M. by another LN.On 8/12/26 at 12:30 P.M., an interview was conducted with LN 23. LN 23 stated she did not administer MiraLax Oral Powder 17 GM/Scoop and only administered Glycolax Powder (Polyethylene Gycol 3350) 17 GM/Scoop. LN 23 stated she documented on the MAR that MiraLax Oral Powder 17 GM/Scoop was administered, even though she did not administer the medication.On 8/13/26 at 10:50 A.M., a joint interview and record review was conducted with the director of nursing (DON). The assistant director of nursing (ADON) and the clinical consultant lead (CCL) were also present. The DON reviewed the OSR and the MAR for Resident 91 and stated the orders for Glycolax Powder (Polyethylene Gycol 3350) 17 GM/Scoop and MiraLax Oral Powder 17 GM/Scoop represented an incorrect and, duplicate medication order. The DON stated that MiraLax Oral Powder 17 GM/Scoop was a, duplicate order and there should not have been two orders for the same medication listed on the OSR and the MAR. The DON stated the LN should have reviewed the OSR and the MAR before an additional medication order was entered and the LN should have recognized and questioned that the same medication was listed twice under a generic and brand name. The DON stated the LN's failure to identify and question the duplicate order was not consistent with best practice. The CCL agreed and stated LNs should have questioned the duplicate medication order.A review of the facility's policy titled Pharmacy Services Medication Administration/med carts and storage revised June 2026, indicated .Review and verify MD orders.

Based on observation, interview, and record review, the facility failed to ensure kitchen sanitation practices were maintained when:1.) Three cans of chocolate pudding had rust at the top of each can and 15 cans of diced sweet red peppers had rust on the bottom outer rims.2.) The dietary staff did not take the temperature of the second tray of lasagna prior to service.These deficiencies had the potential to contaminate food and could cause food borne illnesses to residents who consumed the food.Findings:1.) On 8/10/23 at 7:26 A.M., a concurrent observation and interview was conducted in the kitchen storage room with the dietary supervisor (DS). The registered dietician (RD) was also present. There were 15 cans of diced sweet red peppers that had rust at the bottom of each can. Additionally, there were 3 big cans of chocolate pudding that had rust at the top of each can. The RD took a towel and rubbed a can along the rust build-up. Part of the rust transferred onto the towel leaving a red stain on the towel. The RD removed the cans with rust from the dry storage room. The RD stated the facility should have returned the cans to the supplier. On 8/13/26 at 10:10 A.M., an interview was conducted with the DS. The DS stated rusted cans should not have been kept in the dry storage room. The DS stated the rust on the cans could cause foodborne illness. The DS stated the facility received the cans of diced sweet red peppers and the cans of chocolate pudding on 7/20/26. The DS stated he conducted inspection inside the storage room when food was delivered two to three times a week. The DS stated he did not keep a log of when he conducted the inspection of the food inside the storage room.A review of the facility's policy titled STORAGE OF FOOD AND SUPPLIES dated 2026, indicated, .15. Food in.rusty. cans.shall not be retained or used.2.) On 8/12/26 at 12:18 P.M., an observation was conducted in the facility's kitchen during the lunch tray line. The cook (CK) was serving lasagna, green beans, and bread during the tray line. The CK pulled out a second tray of lasagna that had been stored in the oven. The CK started serving the lasagna and putting slices onto the plates. The CK did not take the temperature of the lasagna prior to serving. The August 2026 Temperature Log was reviewed with the RD. The RD stated there was no temperature recorded for the second tray of lasagna. The RD stated the temperature of the lasagna should have been taken.On 8/13/26 at 10:10 A.M., an interview was conducted with the DS. The facility's RD was also present. The DS stated the final cooking temperature was different from the safe serving temperature. The DS stated the temperature for the second tray of lasagna was not taken before it was served and the temperature should have been taken prior to serving it to the residents. The RD agreed with what the DS stated.A review of the facility's policy titled MEAL SERVICE dated 2023 indicated, .The Food and Nutrition Services Staff member will take the food temperatures prior to service of the meal with a thermometer.

Based on interview and record review, the facility failed to ensure documentation in the medical records was clear and complete for two of 20 sampled residents (Resident 48 and Resident 80) when:1. Resident 48's episodes of urinary incontinence (the lack of voluntary control) were not documented.2. Resident 80's dialysis care and outcome of a transfer to the hospital was unclear.As a result of these failures, it could not be determined what care and treatment was provided to the residents. In addition, a lack of documentation had the potential to impact the delivery of care. FINDINGS: 1. A review of Resident 48's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include other abnormalities of gait and mobility and need for assistance with personal care. On [DATE] at 8:48 A.M., an interview was conducted with Resident 48 in her room. Resident 48 stated she did not always make it to the bathroom and urinated on herself and onto the floor about five to six times since being admitted to the facility. On [DATE] at 3:39 P.M., a concurrent interview and record review was conducted with license nurse (LN) 1. LN 1 stated Resident 48 did not use her call light too often. LN 1 stated Resident 48 had occasional urinary incontinence. LN 1 stated he worked last weekend when Resident 48 had an episode of urinary incontinence while she ambulated to the bathroom. LN 1 stated Resident 48's urinary incontinence was not documented in the resident's clinical record. LN 1 stated it should have been documented. LN 1 stated it was very important to document the incident so other team members were updated on the care and treatment needed for Resident 48. LN 1 stated, we have to document everything. On [DATE] at 4:37 P.M., an interview was conducted with the director of nursing (DON). The DON stated changes in resident orders or conditions should have been documented. The DON stated documentation was very important, so other staff was updated with the residents' condition and changes. The DON stated the facility did not have a documentation policy. 2. A review of Resident 80's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include end stage renal disease and dependence on renal dialysis (process where a resident's blood passes through a machine that removes toxins and excess fluid). A review of Resident 80's progress note dated [DATE], indicated, Appointment with: [name omitted] Dialysis Center. Received notification that patient missed scheduled dialysis treatment for today. Contacted dialysis center and rescheduled patient for tomorrow. A review of Resident 80's progress note dated [DATE], indicated, Pt [patient] went to dialysis in the evening on [DATE]. This was her third attempt at this treatment. First attempt pt was too lethargic to consent to treatment while at the dialysis center. The second attempt pt was rejected and sent back to facility due to unspecified low BP [blood pressure]. This third attempt, pt did not receive treatment due to unspecified low BP. [Name of clinic staff omitted] [doctor] decided to send the pt to [hospital].Awaiting further information. On [DATE] at 2:16 P.M., a joint interview and record review was conducted with the assistant director of nursing (ADON). The ADON reviewed Resident 80's clinical record related to her missed dialysis appointments referenced in the resident's progress note dated [DATE]. The ADON stated she would need to review the resident's clinical record further and check the resident's dialysis binder for more information on what happened to the resident. On [DATE] at 2:40 P.M., another interview was conducted with the ADON. The ADON stated there was no documentation in Resident 80's clinical record to provide information as to what was clinically occurring with the resident on the first or second days she missed her dialysis appointments as referenced in the [DATE] progress note. The ADON stated she would need to contact the dialysis clinic to get more information. On [DATE] at 4:22 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 80's clinical record and stated information regarding what was happening to the resident when she missed appointments was clarified this afternoon by calling the dialysis clinic. The DON stated the facility was not sure what happened to Resident 80 and why she did not return to the facility after being sent to the hospital on [DATE]. The DON stated the dialysis clinic informed her this afternoon that Resident 80 had died at the hospital. The DON stated there was missing information in Resident 80's clinical record. The DON stated the documentation that was there was unclear and had missing information. The DON stated, Documentation should be clear, this is unclear. Even I got confused. The DON stated documentation in residents' clinical records should have been complete and clear.

Based on interview and record review, the facility failed to fully implement their antibiotic stewardship program for one of three residents (Resident 6) when:1. Resident 6, who had long-term use of a urinary catheter (a tube placed in the body to collect urine) was ordered a urine culture without documentation of any signs and symptoms of a urinary tract infection (an infection in any part of your urinary system).2. Resident 6 was prescribed and administered Amoxicillin Oral Tablet 500mg (an antibiotic) and Ciprofloxacin HCI Oral Tablet 250 MG (an antibiotic) for five days without performing an antibiotic review as indicated in the facility's policy.These failures had the potential to result in unnecessary antibiotic therapy, antibiotic associated complications, and the development and spread of antibiotic resistance (when bacteria can change) organisms.FINDINGS:A review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility on [DATE].A review of Resident 6's Progress Notes dated 7/27/26 indicated, New Orders from [healthcare clinic]. 1. Do UA [urine test to determine infections] with reflex to culture [a two-step urine test]. Ciprofloxacin HCI Oral Tablet 250 MG (Ciprofloxacin HCI) Give 3.5 tablet by mouth two times a day for UTI x 5 days for 5 Days -Order Date 07/31/2026. Amoxicillin Oral Tablet 500 MG (Amoxicillin) Give 1 tablet by mouth three times a day for x 5 days UTI for 5 Days -Order Date 07/31/2026 On 8/11/26 at 4:21 P.M., a joint interview and record review was conducted with the assistant director of nursing (ADON). The ADON stated that the medical record reflected an order from [healthcare clinic] for a urinalysis (UA) for Resident 6 which was received by the facility on 7/27/26. The ADON reviewed the Infection Note dated 8/2/26 which stated, give antibiotics for UTI. The ADON stated that the medical record did not indicate if Resident 6 was transported to [healthcare clinic] for the evaluation or whether the healthcare provider evaluated Resident 6 at the facility prior to the UA order. The ADON further stated that Resident 6 had a long-term catheterization and that his urine could have been colonization (bacteria that is living in urine that do not cause active illness or symptoms). The ADON was unable to locate documentation from [healthcare clinic] or the healthcare provider in the medical record or a provider assessment identifying signs or symptoms of a UTI for Resident 6.On 8/11/26 at 4:33 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated Resident 6 had an order for an Indwelling Catheter dated 5/31/26. The DON stated Resident 6 had an order for a bladder trial on 7/21/26, however the indwelling catheter was reinserted on 7/22/26 because the resident could not urinate on his own. The DON stated the only documented sign or symptom identified in the medical record in relation to the UTI was, urinary retention. The DON was unable to locate additional documentation from the [healthcare clinic] or the healthcare provider identifying signs and symptoms of UTI in the medical record.On 8/13/26 at 4:25 P.M., a joint interview and record review was conducted with the infection preventionist nurse (IPN). The IPN reviewed Resident 6's medical record and stated a UA was ordered on 7/27/26 and antibiotic orders were received 8/1/26. The IPN reviewed Resident 6's medication administration record (MAR) and stated Resident 6 received a five-day course of Amoxicillin and Ciprofloxacin from 8/1/26 through 8/6/26. The IPN reviewed Resident 6's microbiology report dated 8/1/26 and stated the amoxicillin should have been discontinued based on the sensitivity of the results. The IPN stated Resident 6 should not have remained on two antibiotics and as part of the facility's antibiotic stewardship program. The IPN stated the antibiotic orders should have been questioned. The IPN stated the order for the UA should also have been questioned because there were no documented signs or symptoms of a UTI in Resident 6's medical record. The IPN stated Resident 6 had a long-term indwelling urinary catheter and therefore it was especially important to assess and document signs and symptoms of a UTI because the presence of bacteria in the urine could have represented colonization rather than an active infection. On 8/13/26 at 4:33 P.M., an interview was conducted with the DON. The DON stated the Amoxicillin and Ciprofloxacin prescribed for Resident 6 should have been reviewed, monitored, and questioned as part of the facility's antibiotic stewardship program. The DON stated the antibiotic stewardship program was important to prevent unnecessary antibiotic use and antibiotic resistance.A review of the facility's policy titled Infection Prevention and Control Program Antibiotic Stewardship, revised June 2026, indicated .4. Action. a. Facility may consider antibiotic 'time-out'(TO) practices. i. A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of a resident do not support the diagnosis of the 'infection.' ii. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process also known as an 'antibiotic time-out' for all antibiotics prescribed in the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and [sic] choice of an antibiotic when the clinical picture is clearer and more information available.

Based on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility following a hospitalization. In addition, the facility failed to offer a bed hold to Resident 1 per facility policy.As a result of this failure, Resident 1 had the potential to not receive continuity of care, prolonged Resident 1's hospital stay unnecessarily, and violated Resident 1's rights to return to the facility. Findings:During a record review, the document titled admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time), and type 2 Diabetes (a condition where the body cannot effectively use the insulin it makes).According to the MDS (Minimum Data Set- a federally mandated assessment tool), dated 3/23/26, Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to assess thinking skills) of 14, which indicated Resident 1 had intact cognition.During an interview with Licensed Nurse (LN) 1 ON 6/18/26 at 9:12 A.M., LN 1 stated on 6/15/26, Resident 1 was transferred to an acute care hospital for being verbally aggressive, and for waving a pair of bandage scissors at a staff member. LN 1 stated He didn't want to give us the scissors so we called 911 and he was taken on a 5150 [a 72-hour involuntary psychiatric hold used when an individual experiences a mental health crisis].During a telephone interview with Certified Nursing Assistant (CNA) 1 on 6/18/26 at 11:08 A.M., CNA 1 stated he was Resident 1's assigned nursing assistant on 6/15/26. CNA1 stated on 6/15/26, Resident 1 requested a shower when CNA 1 was getting ready to provide care to another resident. CNA 1 stated when he told Resident 1 he could not shower until later that day, Resident 1 became verbally aggressive. Per CNA 1, [Resident 1] called me lazy, and all the Spanish [curse] words. CNA 1 stated while Resident 1 was sitting in bed, he observed Resident 1 wave a pair of bandage scissors in the air. The CNA stated Resident 1 was transferred out of the facility following the incident.During a record review of the acute hospital document titled Hospital Medicine Progress Note dated 6/18/26 at 10:11 A.M., the note indicated, [Resident 1] with depression presenting after behavioral outburst at SNF [Skilled Nursing Facility].patient now calm, cooperative, and stable without recurrence of agitation.Psychiatry consulted on 06/15/2026- recommended lifting 5150.return to facility. The document further indicated, Patient medically stable for discharge but unable to discharge due to lack of accepting SNF, prior facility declined readmission due to behavioral concerns, no family support for home discharge.During a concurrent interview and record review with the Director of Nursing (DON) on 6/18/26 at 11:33 A.M , the DON stated on 6/15/26 the facility was notified that Resident 1 was medically cleared to return to the facility. The DON stated the facility refused to allow Resident 1 to return. The DON further stated on 8/20/25, during a similar incident of aggression with another staff member, Resident 1 was sent to the hospital for behavior management. The DON stated Resident 1 was accepted back to the facility after being medically clear, Because we had to [take him back].During a follow-up telephone interview with the DON on 6/26/26 at 12:33 P.M., the DON stated residents should be offered a bedhold prior to transfers, or within 24 hours of a transfer. The DON stated bed holds were important, to ensure a resident can return to the facility, if appropriate. During a review of the facility's policy titled Admission, Transfer and Discharge revised 11/2016, the policy indicated, A physician shall document if the transfer or discharge is necessary because the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident OR because the health of individuals in the Facility would otherwise be endangered.It the Facility determines that a resident, who was transferred with an expectation of returning to the Facility, cannot return to the Facility, this constitutes a discharge and this policy shall apply. Therefore, a refusal to readmit the resident to the Facility is considered a discharge, and the requirements of 42 CFR Section 483.15 in terms of documentation, notice before transfer, and orientation for transfer/discharge apply. The policy did not offer guidance regarding allowing a resident to return to the facility following hospitalization.During a review of the facility's undated policy titled Bed Hold, the policy indicated, It is the policy of this facility to inform the resident, or the resident's representative, in writing, of the right to exercise the bed hold provision of seven (7) days, upon admission and before transfer to a general acute care hospital or before the resident goes on therapeutic leave.

Based on observation, interview, and record review the facility failed to ensure sufficient staffing for the facility when: 1. Payroll data report from Centers for Medicare & Medicaid Services (CMS-government agency overseeing nursing health facilities) indicated quarter one 2025 triggered for Excessively Low Weekend Staffing .October 1- December 31. 2. Residents in the confidential resident council meeting verbalized not having enough staff. This failure in excessively low weekend staffing resulted in not meeting staffing requirements by CMS and had the potential for residents to not receive an appropriate quality of care. Findings: 1. During a review of the facility's PBJ [Payroll Based Journal] Staffing Data Report [staffing and payroll data submitted to CMS by nursing homes] .Quarter 1 2025 [October 1-December 31], the PBJ report indicated excessively low weekend staffing was triggered which meant the facility submitted PBJ reports with excessively low weekend staffing. 2. A confidential resident council meeting was conducted with facility residents on 6/17/25 at 10 A.M. Confidential Resident (CR) 1 stated it took a long time for call lights to be answered. CR 2 and CR 3 stated it took 30-minute wait for call lights to be answered. CR 4 stated, Waited two hours to be assisted. CR 2, 3 and 4 stated it was a long wait time for brief change, and it occurred mostly in the morning time. CR 2 stated having to wait for a long time to answer call light made her feel, Pissed off. CR 3 stated having to wait a long time made her feel, Sad. CR 4 stated having to wait a long time for call light to be answered made her feel, Bad. During an interview on 6/18/25 at 10:32 A.M. with certified nurse assistant (CNA) 1, CNA 1 stated the facility was short staffed at least once a week. CNA 1 stated the CNAs worked short staffed twice in the previous week. During an interview on 6/18/25 at 10:40 A.M. with CNA 3, CNA 3 stated CNAs worked short staffed a couple of times per week. During an interview on 6/18/25 at 10:45 A.M. with CNA 2, CNA 2 stated the CNAs worked short staffed at least once a week. CNA 2 stated there were usually eight CNAs assigned for morning shift, but two weeks ago there were only six CNAs. CNA 2 stated residents complained when there were only six CNAs. CNA 2 further stated it was stressful when short staffed. An interview on 6/19/25 at 9:23 A.M. was conducted with the Director of Nursing (DON). The DON stated it was important to have enough staff to provide quality care for residents. The facility did not provide a policy and procedure regarding staffing upon request.

2. On 6/16/25 at 11 A.M. an observation and interview was conducted with Resident 163. Resident 163 was observed with a PICC line on his right upper arm. On 6/18/25 at 3:20 P.M., an interview and record review was conducted with Licensed Nurse (LN) 5. LN 5 stated the facility received Resident 163 with PICC line from the hospital. LN 5 stated their facility had a batch order for PICC lines including dressing change and flushing. According to Resident 163's record, there was no documented evidence of a physician order related to Resident 163's PICC line length and circumference monitoring and there was no documented evidence of monitoring related to Resident 163's PICC line. A review with LN 5 of the facility's policy entitled Acknowledgements, revised date July 2016, indicated .(5) Length of catheter is specific to resident. This length needs to be documented in the medical record by the person who is placing catheter. The catheter length is usually altered from original manufacturer length according to the resident's measurement. (6) Catheter length is measured for baseline comparison .(9) Upper arm circumference should be measured on admission and weekly to monitor for infiltration. (10) External catheter length should be monitored on admission, and weekly to monitor outward migration of the catheter . During interview and record review with LN 5, LN 5 stated there was no documented evidence of any report received related to Resident 163's baseline PICC line measurements. LN 5 stated she had no in-service education about PICC line care. LN 5 stated she was not aware of any PICC line care which should included he following; a baseline PICC line measurement from the sending provider, a physician order for PICC line upper arm circumference measurement monitoring on admission and weekly and documentation, and a physician order for PICC line external length measurement monitoring on admission and weekly and documentation On 6/19/25 at 11:42 A.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility had a batch order for PICC line and did not include PICC line measurement monitoring. A review of Resident 163's record did not indicate any documented evidence of physician order and documentation related to Resident 163's PICC line measurement monitoring. The DON stated the facility should follow best practices for PICC line, but it was not in the facility policy to measure, monitor and document PICC line measurements. Based on observation, interviews, and record review the facility failed to ensure that staff had the knowledge to care for two of two residents who had a peripherally inserted central catheter (PICC- a thin, flexible tube inserted into a vein in the upper arm used for intravenous medications) reviewed for staff competency. (Resident 7 and Resident 163) This failure had the potential for complications such as catheter dislodgement, pain and infection. Findings: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses including Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics and difficult to treat) according to the facility's admission Record. During an observation on 6/17/25 at 8 A.M., Resident 7 was in bed and licensed nurse (LN) 7 entered Resident 7's room. LN 7 stated Resident 7 she came to draw blood from Resident 7's PICC line. Resident 7 was observed with a PICC line on his right upper arm. A review of Resident 7's physician's orders in the electronic medical record (EMR) was conducted. The physician's orders indicated an order dated 5/28/25, PICC LINE CARE: Change all PICC transparent dressings per sterile technique every 7 days and PRN [as needed] wet, loose, soiled. If site is not visible for assessment, change the dressing every 48 hours. Change injection caps to each lumen upon every 7 days and every PRN Dressing Change. The physician's order did not indicate other measures to prevent PICC line dislodgement or IV infiltration (catheter dislodgement causing the medication to leak into the surrounding tissue). During a review of Resident 7's care plans, the care plans indicated, Risk for infection r/t [related to] IV [intravenous-into the vein] until 6/27/25 .Interventions .PICC line care per MD order .Date initiated 6/18/25. The care plan did not indicate other measures to prevent PICC line dislodgement or IV infiltration (catheter dislodgement causing the medication to leak into the surrounding tissue). An interview was conducted on 6/18/25 at 11:16 A.M. with LN 5. LN 5 stated nursing interventions for Resident 7's PICC line included dressing changes every seven days, no blood pressure at the PICC line site, check if the PICC line was intact and use Enhanced Barrier Protection (EBP-an approach when healthcare workers wore gowns and gloves during high contact with residents to reduce transmission of organisms) during care of the PICC line. LN 5 stated the PICC was not measured and Resident 7's arm circumference at the PICC line site was not measured to determine if there was infiltration. During an interview on 6/19/25 at 9:23 A.M. with the Director of Nursing (DON), the DON stated there had been no in-services or training regarding PICC lines. The DON stated licensed nurses should know how to care for a resident with a PICC to ensure it was properly inserted and working properly. The DON further stated the facility used the Pharmacy Policy and Procedure for guidance regarding PICC lines. A review of the facility's Pharmacy Policy and Procedure (P&P) titled, Peripherally Inserted Central Catheter (PICC), dated July 2016 was conducted. The P&P indicated, This is a very fragile catheter and can be broken easily .Upper arm circumference should be measured on admission and weekly to monitor for infiltration .External catheter length should be monitored on admission, and weekly to monitor for outward migration of the catheter.

Based on observation, interview and record review, the facility failed to properly store and label medications when: 1. An inhaler (a portable device for administering a drug which is to be breathed in) was identified at a resident's bedside, with no label indicating name or dose (Resident 113), and 2. inhalers were not labeled with an open date 3. external and internal medications were stored together As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: 1. Resident 113 was admitted to the facility on [DATE] with diagnoses to include legal blindness, and chronic obstructive pulmonary disease (COPD, a lung disease), per the facility admission Record. A record review was conducted on [DATE]. Resident 113 had a physician's order, dated [DATE], for Symbicort inhaler to be administered twice a day for COPD. An observation and interview was conducted with Resident 113 in her room on [DATE] at 3:20 P.M. Resident 113 stated she was leaving for physical therapy, but she needed to be taken to the therapy department since she was legally blind and could not see where she was going. Resident 113 had a table next to her bed, with a Symbicort inhaler on the table. The inhaler had a manufacturer's name and medication name on it, but no other identifying information. No label was affixed to the inhaler. A concurrent observation and interview was conducted on [DATE] at 3:27 P.M. in Resident 113's room with Licensed Nurse (LN) 11. LN 11 stated she was assigned to Resident 113, and she was familiar with her medications. LN 11 picked up the inhaler and stated, I'm not sure if it is a medication from home, or one provided by the facility. Either way, it should not be kept in the room. LN 11 stated the medication should be labeled with the resident's name and instructions for use. Per LN 11, since Resident 113 was legally blind, it was unsafe to keep a medication in her room. LN 11 stated some residents were allowed to self-administer medications after they had demonstrated they could do so safely, but Resident 113 had not been assessed for self-administration of medications. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9 A.M. Per the DON, Resident 113 had not been evaluated by nursing staff for self-administration of medications. The DON stated the medication should not have been at the bedside, and should always be labeled with the resident's name and the instructions for use. The DON stated it was unsafe to store medications at the bedside unless nurses had educated the resident and ensured she was capable of taking it safely. The DON stated leaving the medication at the bedside could result in the facility not having the medication available when needed, and could result in overuse of the medication. Per a facility policy, revised [DATE] and titled Medication Administration and Storage, .The facility is to also ensure the proper and safe storage of drugs .Drugs .should not be left unsecured/unattended .Inhalers: Administer inhaler as ordered by provider . 2. On [DATE] at 2:33 P.M., an observation, interview and record review were conducted with Licensed Nurse (LN) 4. LN 4 stated there were three medication carts. There were four Fluticasone Propionate and Salmeterol inhalers in LN 4's medication cart not labeled with an open date. According to the manufacturer's recommendation, revised [DATE], indicated, .Discard fluticasone propionate and salmeterol inhalation powder 1 month after opening the foil pouch or when the counter reads 0 . whichever comes first . LN 4 stated the medications were not labeled with open dates. LN 4 stated the medications should been labeled with open date to make sure the medications were not expired according to the manufacturer's guidelines for medication storage. On [DATE] at 11:43 A.M., an interview was conducted with the Director of Nursing. The DON stated inhaler medications should be labeled with an open date to know the expiration according to the manufacturer recommendations for medication storage. 3. On [DATE] at 9:07 A.M., an observation and interview were conducted with the Assistant Director of Nursing (ADON). The facility has one medication room. An observation of the medication room with the ADON was conducted. The medication room was observed with internal medications co-mingled with external medications. The ADON stated she was not aware internal medications could not be co-mingled with external medications. The ADON stated external and internal medication should be stored separately for safety. On. 6/19 25 at 11:54 A.M., an interview was conducted with the Director of Nursing. The DON stated internal and external medications should be stored separately to prevent accidentally ingesting external medications. According to the facility policy entitled Policy/Procedure- Nursing Clinical Section: Medication Administration, revised date 3/2025, indicated, .The facility to also ensure the proper and safe storage of drugs and biologicals .

Based on observation, interview and record review, the facility failed to ensure a kitchen freezer was serviced and maintained to prevent the formation of condensation. As a result, frozen vegetables stored within the freezer had condensation accumulated, resulting in freezer burn and the risk of contamination. Findings: A concurrent observation and interview was conducted in the kitchen on 6/16/25 at 8:28 A.M. with the Director of Food and Nutrition (DFN). The freezer thermometer registered 20 degrees Fahrenheit (F, a unit of measurement). Frozen droplets of water hung down from the top of the freezer. Bagged frozen vegetables were on the top shelf of the freezer, and the bags appeared to have defrosted then refrozen into solid blocks. The DFN stated the freezer should be at zero degrees F, and the foods must have gotten condensation inside. The DFN stated he was not aware the freezer was above a safe temperature range but there was a risk for foodborne illness if the freezer was above zero degrees. The DFN stated it was unsafe to serve the vegetables due to the possible cross-contamination from the condensation. A record review was conducted. The freezer temperature log indicated the freezer was within an acceptable range daily, with recorded temperatures of minus two degrees F to zero degrees F for the month of June 2025. An interview was conducted with the Administrator (Admin) on 6/19/25 at 2 P.M. Per the Admin, the DFN was responsible for ensuring kitchen equipment was maintained in good working order, including the freezers. The Admin stated temperatures were maintained in the correct ranges to keep the residents safe from foodborne illness. Per the facility policy, dated 2023 and titled Cold Storage Temperature Monitoring and Record Keeping, .staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling .if temperatures are not within standards .staff will notify the FNS (Food & Nutrition Services) Director .freezer temperature standards are 0 degrees F or below .

Based on observation, interview and record review, the facility did not ensure appropriate brief size was provided for one of one resident (164). As a result, Resident 164 felt uncomfortable. Findings: On 6/17/25 at 9:33 A.M., an observation and interview was conducted with Resident 164. Resident 164 stated she was not happy since admission because she was placed on a brief size smaller than she needed. Resident 164 stated she was uncomfortable on the brief size the facility provided. Resident 164 stated she developed irritations and rashes on perineal area because the brief was too tight on her. Resident 164 stated she had to purchase the appropriate brief size just to be comfortable. On 6/17/25 at 4:12 P.M., an observation and interview were conducted with two Certified Nurse Assistants (CNAs) during Resident 164 brief change. CNA 21 stated she have worked at the facility for three months, and the facility did not have a 3XL brief size, which was the correct size for Resident 164. Resident 164 was observed with rashes on the perineal area. CNA 21 stated the rashes in this area was because of tight brief. On 6/18/25 at 10:31 A.M. an observation and interview was conducted with CNA 2. The favility's storage rooms did not have a supply of 3XL briefs. On 6/18/25 at 10:45 A.M., an observation, interview and record review was conducted with the CS. The central supply area at the back of the facility had 3XL briefs. The CS stated 3XL briefs were not stocked in the storage areas inside the facility because she kept it for a resident who needed a 3XL brief. The CS stated she was informed about Resident 164 needing 3XL brief only about a week ago. The CS stated Resident 164's family was providing the 3XL brief for Resident 164. On 6/18/25 at 10:57 A.M. an observation and interview were conducted with the CS and Resident 164 in Resident 164's room. Resident 164 was observed crying. Resident 164 stated she was crying because of pain she had to injure coming from the rashes in her perineal area. Resident 164 stated she informed the staff until Sunday about the brief being too tight for her causing her rashes and discomfort. Resident 164 was crying and stated, it was my fault and when you could not take it anymore. The CS stated she would supply Resident 164 3XL briefs once Resident 164's 3XL briefs runs out. On 6/20 25 at 4:44 P.M., an interview and record review were conducted with Treatment Nurse (TN) 1. TN 1 stated she was not aware about Resident 164's skin assessment until today. According to the Skin Evaluation dated 6/18/25 at 8:53 A.M. the record indicated (Resident 164) .has mild erythema from briefs being too small on her, she has switched to bigger size . TN 1 stated the CNAs should communicate any skin changes to residents. TN 1 stated the CNAs did not communicate Resident 164's skin issue with Licensed Nurses (LN) including the TNs. TN 1 stated moisture associated skin damage was identified on Resident 164's breast folds and buttocks but not on the groin. TN 1 acknowledged there was no communication of Resident 164's skin issue and late documentation because the TNs were not aware of Resident 164's skin issue. TN 1 stated there was no physician orders for Resident 164's [NAME] issue but the CNAs were applying a skin barrier cream. TN 1 stated there should be a physician order for Resident 164's skin issue. On 6/19/25 at 11:55 A.M. an interview and record review were conducted with the Director of Nursing (DON). The DON stated the CNAs did not report to LNs about Resident 164's skin issue related to tight brief. The DON stated appropriate brief size should have provided to Resident 164 to prevent further skin breakdown, discomfort, pain and suffering. The DON stated the appropriate brief size was available and should have been provided to Resident 164.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of seven sampled residents (Resident 31) reviewed for MDS accuracy. This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government) and had the potential for Resident 31 to not receive appropriate care. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation and interview on 6/16/25 at 9:19 A.M., Resident 31 was in bed with two small machines on top of the bedside drawer. Resident 31 stated one machine was a bilevel positive airway pressure (BIPAP-machine as breathing support and administered through a face mask or nasal mask) machine and the other was for a breathing treatment. Resident 31 stated she used the BIPAP at night or when she took naps during the day. A concurrent record review and interview was conducted on 6/17/25 at 2:31 P.M. with licensed nurse (LN) 5. LN 5 reviewed Resident 31's physician's orders in the electronic medical record. LN 5 stated Resident 31 had physician's orders dated 4/8/25 for Resident 31 to use the BIPAP at night and during naps. During a concurrent record review and interview on 6/18/25 at 9:25 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN reviewed the MDS completed for Resident 31. The MDSN stated she completed Resident 31's MDS on 4/13/25. The MDSN stated section O of the MDS required an answer for the use of BIPAP. The MDSN stated BIPAP was not coded in Resident 31's MDS, section O. The MDSN stated BIPAP should have been coded to reflect Resident 31's use of a BIPAP machine. The MDSN stated it was important to code MDS assessments accurately because it reflected on the care provided to residents. An interview was conducted on 6/19/25 at 9:37 A.M. with the Director of Nursing (DON). The DON stated it was important to accurately code the MDS assessments to treat the residents according to their diagnoses. A review of the CMS (Centers for Medicare & Medicaid Services-government agency overseeing nursing health facilities) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 was conducted. Chapter 1.2 page seven of the User's Manual indicated the Resident Assessment Instrument (RAI) consisted of the MDS. The User's Manual chapter 1.2, page eight indicated, .The RAI process has multiple regulatory requirement .Federal regulations .require that (1) the assessment accurately reflects the resident's status . Furthermore chapter 5.5, page 668 of the User's Manual indicated, .the MDS must be accurate as of the ARD [Assessment Reference Date]. Minor changes in the resident's status should be noted in the resident's record .in accordance with standards of practice and documentation . The facility did not provide a policy and procedure regarding MDS completion.

Based on observation, interview, and record review, the facility did not develop patient centered care plans for one of six residents reviewed for care plans when: 1. Resident 7's bowel and bladder incontinence was not care planned; 2. Resident 7 did not have a care plan for the use of heparin (blood thinner). Cross reference F690 This failure had the potential for Resident 7 to not receive appropriate care, treatment, and interventions. Findings: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care and other abnormalities of gait (walking) and mobility according to the facility's admission Record. During an observation and interview on 6/17/25 at 8 A.M., Resident 7 was in bed with a urinal (plastic urine bottle) hanging on the left bed rail. Resident 7 stated he used the urinal but had to be changed when he was not able to hold his urine. Resident 7 stated he felt uncomfortable being wet all over. Resident 7 further stated he was able to get up to go to the bathroom when he was at home. A concurrent record review and interview was conducted on 6/17/25 at 2:15 P.M. with licensed nurse (LN) 5. LN 5 stated a bowel and bladder (B&B) evaluation was completed on admission and quarterly. LN 5 reviewed the electronic medical record (EMR) for Resident 7. LN 5 stated a B&B evaluation was completed for Resident 7 on 5/28/25. LN 5 stated Resident 7 was evaluated as continent (ability to control the release of urine and feces) of B&B. LN 5 reviewed documentation by certified nurse assistants (CNAs) in the task section of the EMR. LN 5 stated the CNAs documented incontinent and continent of urine for Resident 7. LN 5 reviewed the Minimum Data Set (MDS-a clinical assessment tool) for Resident 7. LN 5 stated the MDS dated [DATE] indicated occasionally incontinent of urine and always incontinent of bowel. LN 5 reviewed the care plans for Resident 7. LN 5 stated there was no care plan for Resident 7 to address Resident 7's B&B incontinence. LN 5 stated care plans were needed for staff to know how to treat residents. During a concurrent record review and interview on 6/17/25 at 2:56 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated section H of the MDS was completed based on CNA documentation regarding a resident's bowel and bladder status. The MDSN stated if section H had an incontinent status, then there should be a care plan developed for the plan of care for the resident. 2. During a review of Resident 7's physician's orders in the electronic medical record (EMR), the physician's orders indicated, Heparin Sodium [Porcine-derived from pig] Solution 5000 UNIT/ML Inject 7500 unit subcutaneously [fatty tissue, just under the skin] every 12 hours for clotting prevention. An interview was conducted on 6/18/25 at 2:18 P.M. with the Consultant Pharmacist (CP). The CP stated heparin was considered a high-risk medication due to the risk for bleeding. A concurrent record review and interview on 6/18/25 at 3:53 P.M. was conducted with licensed nurse (LN) 5. LN 5 reviewed Resident 7's care plans and stated there was no care plan for the use of heparin. LN 5 stated there should have been a care plan because heparin was a high risk medication and for Resident 7's plan of care. During an interview on 6/19/25 at 9:37 A.M. with the Director of Nursing (DON), the DON stated care planning was important to ensure patient care, goals and interventions. A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated August 2024 was conducted. The P&P indicated, It is the policy of this facility that the interdisciplinary [IDT-team members with various areas of expertise who work together toward the goals of their residents] shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to provide an Activities program to meet a resident's preferences for one of one residents reviewed for Activities (Resident 36). This failure had the potential to not support Resident 36's psychosocial well being. Findings: Resident 36 was admitted to the facility on [DATE] with diagnoses to include macular degeneration (a loss or distortion of vision), per the facility admission Record. An observation and interview was conducted on 6/16/25 at 9 A.M. with Resident 36. Resident 36 was in bed, awake and alert. The room was dark, and the television was off. Resident 36 responded to questions asked by saying yes, and waved her hand. Resident 36 was smiling. An observation was conducted of Resident 36 on 6/17/25 at 3:34 P.M. Resident 36 was awake and alert, in bed. The room was quiet, and the television was off. The television was positioned on the wall across from Resident 36's feet, approximately 10 feet from her head. Resident 36 smiled and waved, answering yes to questions about lunch. No books, pictures, puzzles or other activities were at the bedside. An interview was conducted with Certified Nursing Assistant (CNA) 1 on 6/18/25 at 9:34 A.M. CNA 1 stated he knew Resident 36 well, but had not seen her participate in any activities, either in her room or in the activity room. CNA 1 stated Resident 36's family member visited often and keeps her entertained, but he was only there for an hour or two each day. CNA 1 stated he should have spoken to the Activity Director (AD) about her lack of activities, but he had not done so. An interview was conducted with CNA 11 on 6/18/25 at 9:36 A.M. CNA 11 stated he had never seen Resident 36 participate in any activity. CNA 11 stated she waves her hand to indicate she was fine and did not need anything. CNA 11 stated, I've never seen her watch TV or do a puzzle, I don't know what she likes to do. She's always awake and just lying in bed when I go in. CNA 11 stated he should have discussed this with the AD or nurses in case she was bored or depressed. An interview was conducted with CNA 12 on 6/18/25 at 10:08 A.M. CNA 12 stated Resident 36 did not like to get out of bed to go to activities. CNA 12 stated she asked Resident 36 if she wanted the drapes opened or the television on, but she usually said no. CNA 12 stated she was not aware of whether Resident 36 could see the television at the foot of her bed or not. CNA 12 stated if a resident did not like group activities, the AD usually provided one-to-one activities, like a puzzle or book. CNA 12 stated she had not seen Resident 36 participate in any one-to-one activities, and she did not attend group activities. CNA 12 stated, Maybe we don't know what she likes to do yet. An interview was conducted with Resident 36 and a Family Member (FM 1) on 6/18/25 at 10:24 A.M. Per FM 1, Resident 36 spoke and understood some English although it was not her primary language. FM 1 stated Resident 36 used to teach cooking, and also used to watch many cooking shows on television. FM 1 stated the television was located on the wall across from the foot of the bed, which was too far for Resident 36 to see, considering her macular degeneration. FM 1 stated Resident 36 was starting to lose interest in things as there was nothing for her to do or see throughout the day. FM 1 stated Resident 36 did not enjoy going to the dining room or other group activities due to her limited English and her vision problems. A record review was conducted. Resident 36's Brief Interview for Mental Status (BIMS), dated 6/2/25, indicated moderately impaired cognition. Resident 36's Activity Annual Evaluation, dated 10/3/24, indicated Resident 36 did not enjoy group activities and was more comfortable in her room. The evaluation indicated Resident 36 was very receptive to activity related visits, and that hearing was a barrier. There was no indication of inadequate vision due to macular degeneration, the location of the television in the room, or Resident 36's past history of watching cooking shows or teaching cooking. The evaluation indicated the activity goals and interventions had been partially effective, and Resident 36 was meeting goals for visits and independent leisure with TV. Resident 36's Activity Quarterly Evaluation, dated 6/2/25, indicated she did not participate in group activities but the television was on to several programs in English. No indications of limited vision was documented. Resident 36's Activities care plan, initiated 10/16/23, indicated she had macular degeneration and was blind in one eye, enjoyed baking and cooking, and watched Food Network cooking shows at home. Goals implemented were for Resident 36 to be involved in independent activities three to four times each week. Interventions to achieve the goals included setting up room visits with family, encouraging time outside , and offering music visits and arts and crafts. Television and cooking/baking related interests were not addressed. An interview was conducted with the AD on 6/18/25 at 10:45 A.M. The AD stated she assessed each resident's preferences for activities when they were first admitted , then reevaluated quarterly afterwards. The AD stated Resident 36 did not enjoy leaving the room for group activities, but she did enjoy pet therapy visits and some one-to-one activities. The AD stated she was aware Resident 36 had vision problems, and used to enjoy cooking and watching cooking shows on television, but she did not watch television now. The AD stated she had not considered the television placement, on the wall approximately 10 feet from Resident 36's head, to be a problem but due to macular degeneration, it might impact her ability to watch television. Per an undated facility policy, titled Individual & Room Visit Programs, It is the policy of this care center to provide adequate activity .opportunities to those residents .who choose to stay primarily in their own rooms. The activities shall be reflective of each resident's preferences and individual activity interests .The in-room activity programs will directly reflect the residents' assessed individualized activity interests . Per a facility policy, revised September 2015 and titled Scope of Activity Program, .One-on-One Activities: These programs are designed to provide activities and entertainment that meet the needs and interest as well as capabilities of residents who are confined to their beds or who prefer to engage in activities in their rooms rather than participate in group activities .e.g. books, radio, TV .)

Based on observation, interview and record review the facility failed to maintain bowel and bladder status for one of three residents reviewed for bowel and bladder incontinence (involuntary loss of feces and urine) . (Resident 7) This failure had the potential for Resident 7 to develop pressure sores and affect Resident 7's dignity and comfort. Findings: Resident 7 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care and other abnormalities of gait (walking) and mobility according to the facility's admission Record. During an observation and interview on 6/17/25 at 8 A.M., Resident 7 was in bed with a urinal (plastic urine bottle) hanging on the left bed rail. Resident 7 stated he used the urinal but had to be changed when he was not able to hold his urine. Resident stated he felt uncomfortable when wet with urine. Resident 7 stated when he was at home, he was able to get up to go to the bathroom by himself. A concurrent record review and interview was conducted on 6/17/25 at 2:15 P.M. with licensed nurse (LN) 5. LN 5 stated a bowel and bladder (B&B) evaluation was completed on admission and quarterly. LN 5 reviewed the electronic medical record (EMR) for Resident 7. LN 5 stated a B&B evaluation was completed for Resident 7 on 5/28/25. LN 5 stated Resident 7 was evaluated as continent (ability to control the release of urine and feces) of B&B. LN 5 reviewed documentation by certified nurse assistants (CNAs) in the task section of the EMR. LN 5 stated the CNAs documented incontinent and continent of urine for Resident 7. LN 5 reviewed the Minimum Data Set (MDS-a clinical assessment tool) for Resident 7. LN 5 stated the MDS dated [DATE] indicated occasionally incontinent of urine and always incontinent of bowel. LN 5 stated Resident 7 declined in his B&B status. During a concurrent record review and interview on 6/17/25 at 2:56 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated the MDS section H was completed based on CNA documentation regarding a resident's bowel and bladder status. The MDSN stated section H of the MDS had Resident 7 as incontinent of bowel and bladder. The MDSN stated for residents who became incontinent, interventions would include establishing a voiding schedule, monitoring of fluid intake, skin inspection and assisting to the bathroom prior to an incontinent episode. The MDSN stated the facility did not have a bowel and bladder program. An interview was conducted on 6/19/25 at 9:37 A.M. with the Director of Nursing (DON). The DON stated residents should have a toileting schedule to determine residents' continent status, offer toileting and anticipate toileting needs to prevent incontinence. During a review of the facility's undated policy and procedure (P&P) titled, Bowel and Bladder Assessment, the P&P indicated, The purpose of the bowel and bladder assessment is to offer a structured, goal oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence.

Based on observation, interview, and record review, the facility failed to ensure nutrition interventions were consistently implemented and re-evaluated for effectiveness to prevent an unplanned severe insidious weight loss of 31.9 pounds (22.7%) in six months, for one of seventeen sampled residents (Resident 29). The resident's nutrition status interventions were not re-assessed for effectiveness, and the care plan goals were not updated to reflect the resident's desired weight goal, according to facility policy and standards of practice. This deficient practice led to continued weight loss and the facility's inability to meet the resident's desirable body weight range, which further impaired nutrition and health status. Cross reference 800, 803, 806 and 809 Findings: Per the facility's Admission Record, Resident 29 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 29's Minimum Data Set (MDS, an assessment and care-screening tool) dated 12/11/21, indicated Resident 29 was able to feed herself and eat without assistance. A review of Resident 29's Weights and Vitals Summary reports, indicated the following weights: 144 lbs. on 4/19/2021 142.7 lbs. on 5/17/2021 140 lbs. on 6/9/2021 133.2 lbs. on 7/11/2021 139.7 lbs. on 7/25/2021 142.3 lbs. on 8/5/2021 138.8 lbs. on 8/11/2021 131.7 lbs. on 9/14/2021 124.2 lbs. on 10/11/2021 120.4 lbs. on 10/29/2021 120.3 lbs. on 11/15/2021 118.8 lbs. on 12/6/2021 108.1 lbs. on 12/13/2021 Resident 29's weight history revealed a severe unplanned weight loss of 31.9 lbs. (22.7%) in 6 months from June 2021 to December 2021, with a gradual total weight loss of 35.9 lbs. (24.9%) since admission in April 2021. Resident 29's BMI was calculated as 17.94, which is underweight using her height of 65 inches and last recorded weight of 108.1 lbs. on 12/13/21. According to the Centers for Medicare Services (CMS) Long term Care Facility Resident Assessment Instrument 3.0, version 1.17.1, dated October 2019, .4. If the last recorded weight was taken more than 30 days prior to the Assessment Reference Date (ARD) of .assessment or previous weight is not available, weigh the resident again . https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf (Chapter 3, Section K, pg. K-5). A review of the laboratory records dated 12/1/21 indicated Resident 29's [MEDICATION(S)] was 2.0 g/dL and was 4.4 g/dL on 4/10/21, according to physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Normal standard [MEDICATION(S)] ranges between 3.4-5.4 g/dL. A review of the Nutrition/Hydration Risk Evaluation dated 12/10/22, indicated Resident 29 was alert and oriented x 3, able to feed herself, experienced a >10% weight loss in the last 6 months, had few food dislikes, and predisposing conditions for a total score of 10. The Directive indicated .for a total score of 10 or greater, a prevention protocol should be initiated immediately and documented in the Care Plan. Per a review of Resident 29's Care plan, dated 10/1/21, indicated the goal was to maintain adequate nutritional status as evidenced by maintaining weight with no signs/symptoms of malnutrition, through the next review date 12/1/21. Care plan interventions included to provide, serve diet as ordered; monitor intake and record every meal. However, the resident's desirable weight range was not included, and previous nutrition interventions to prevent further weight loss were not modified. Care Planning is information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan must address, to the extent possible, identified causes of impaired nutritional status, reflect the resident's personal goals and preferences, and identify resident-specific interventions and a time frame and parameters for monitoring. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf (page 347-348) A review of Resident 29's Order Summary Report dated 1/27/22, indicated ACTIVE since 5/24/21: Diet- Vegetarian, regular texture, thick liquids, fortified; Med Pass NSA (No Sugar Added) four times a day; Mighty Shake three times a day (Breakfast, Lunch and Dinner). A review of the facility's documents titled Nursing & Dietary Supervisor from 9/24/21 through 1/4/22 completed by a Registered Dietitian (RD) Consultant, indicated dietary interventions and recommendations for 42 residents throughout this timeframe but Resident 29 was not part of this list for follow up or re-evaluation for weight loss or food intake concerns. Per review of facility's Quarterly Nutrition Evaluation dated 1/3/22, completed by the Dietary Services Supervisor indicated Resident 29 had a Vegetarian diet order, supplements ordered: Mighty shake, Med Pass NSA; and skin status: pressure ulcers. Per review of the facility's Nutrition Interdisciplinary Team Review record, dated 12/17/21, completed by the DON and RD for Resident 29, indicated .average meal % intake was 37% for seven days .diet .Fortified Lacto-Ovo vegetarian with diet condiments .Health shake 8 oz. with all meals .weekly weights .please provide Vegetarian entree . A review of Resident 29's meal intake from 12/28/21 through 1/26/22 indicated 13 days of 0% intake and the remaining days 25%-50% of meals consumed. Per review of the facility's diet list titled Resident Summary Report All Dining Areas-Selected Meal, dated 1/24/22, indicated Resident 29 was on a Fortified Vegetarian Diet. Per review of the facility's Diet Manual document titled Vegetarian & Vegan Diet, dated 2020, indicated .the diet would provide a total of 2000-2250 calories, 78-85 grams of protein, and 100-105 grams fat per day from breakfast, lunch, and dinner meals . On 1/26/22, a review of Resident 29's initial nutrition evaluation dated 5/3/21 by the Registered Dietitian, indicated the nutrition plan of care was to remain within goal weight range (144-156 lbs.). The nutrition interdisciplinary team note dated 7/15/21 by the RD, indicated to continue vegetarian diet and Mighty shakes at lunch and dinner; and the nutrition interdisciplinary team note dated 12/17/21 indicated change diet to fortified lacto-ovo vegetarian diet with Med Pass NSA supplement QID. However, the reassessments and evaluations did not address whether the nutrition interventions were effective so they could be modified to prevent further weight loss and decline in nutrition status. During an interview with Resident 29 on 1/26/22 at 11:51 A.M., Resident 29 stated she knew she was losing a lot of weight and she was unhappy about it. Resident 29 stated she was on a vegetarian diet since admission to the facility but had not received very many vegetarian meals consistently since last summer 2021. Resident 29 further stated she was supposed to receive the Mighty protein shakes three times a day but had not received them for 5 consecutive days and then she stated, .that means I missed about 1,000 calories from my intake because they're 200 calories each. Resident 29 further stated she liked bananas and the kitchen always runs out of them. On 1/27/22 at 7:43 A.M., an interview was conducted with LN 2 about Resident 29. LN 2 stated she was not aware of any weight loss concerns with resident 29 but knew she was a vegetarian. She stated Resident 29 liked the shakes when they came on the tray, and she also liked bananas but the kitchen runs out a lot. LN 2 further stated one time the kitchen put meat on Resident 29's tray and she was upset. On 1/27/2 at 8:33 A.M., and interview was conducted with Resident 29. Resident 29 began to cry because she stated she did not want to continue losing weight. On 1/27/22 at 9:43 A.M., an interview was conducted with the RD, RD Consultant, ADM, and DON. The RD stated she had not previously assessed Resident 29 but stated typically an assessment would occur monthly for high-risk residents with skin integrity issues and significant weight loss. The RD stated the DSS would complete a quarterly review of the residents preferences, and residents with significant weight loss are placed on a weight committee for weekly monitoring. The DON stated it was important for the weight committee to track and monitor residents with significant weight loss on a weekly basis to determine if they need to get the physician involved to address it. A review of the Resident 29's physician's progress notes dated 1/5/22 indicated the resident's weight had gone down to 108 lbs on 12/13/21. The Physician's note also stated dietary added Med Pass to increase calorie intake, but the patient continued to lose weight. On 1/27/22 at 11:47 A.M., an interview was conducted with Resident 29's Physician (PHY). The PHY stated she was aware of Resident 29's weight loss and the resident was supposed to receive mighty shakes throughout the day. The PHY stated she was unaware the resident was not consistently receiving the mighty shakes as per the diet order. The PHY further stated she would have discussed an appetite supplement as an option with Resident 29 to increase meal intake. A review of the Nursing Progress Notes completed 10/1/21-10/6/21 for Resident 29, indicated a charting alert due to weight loss but the progress notes from 10/7/21-1/27/22, were not provided for review. On 1/27/22 at 2:45 P.M., during an interview with the facility RD and RD Consultant about weight loss practices, the facility RD stated she would offer additional food supplements throughout the day and offer meal substitutes for a person who was losing weight and eating less than 50% of their meals consistently for several days. The RD Consultant stated resident 29's food preferences should have been modified earlier or the use of an appetite stimulant discussed since she was losing a lot of weight. The RD consultant further stated she would explore all avenues with food before discussing a tube feeding option for nutrition for this resident. Both the RD and RD Consultant stated it was important for the kitchen food items to be available including Mighty Shake supplements, especially to residents with weight loss. On 1/27/22 at 3:35 P.M., an interview was conducted with Resident 29. Resident 29 stated she really enjoyed her lunch today because she had a veggie burger. According to the CMS Long term Care Facility Resident Assessment Instrument 3.0, version 1.17.1, dated October 2019, .If significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medication (e.g., diuretics), or changed fluid volume status. Weight should be monitored on a continuing basis .It is important that weight loss is intentional. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf (Chapter 3, Section K, pg. K-5). Per the facility policy dated 2020, titled Nutritional Screening/Assessment/Resident Care Planning .the resident's nutritional status and .nutritional needs will be .planned and implemented and .reassessed for progress .; change in eating habits, differences in eating pattern, eating problems, weight and other problems will be recorded in .resident care plan . Per facility policy updated 7/21/21, titled Food and Nutrition Services section Nutrition Care, indicate .It is the policy of the facility to ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight .; monitoring and evaluating the resident's response to the interventions, especially when there is no progress toward the nutritional goal .