Every finding on record at Mission Pines Nursing and Rehab Center

Based on observation, interview, record review and document review, the facility failed to ensure a resident was free from abuse for 1 of 7 sampled residents (Resident 1). The deficient practice had the potential to result in physical injury, pain, emotional distress, fear, and psychosocial harm to the resident as a result of resident-to-resident physical aggression. Findings include:Resident 1 (R1) was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, schizophrenia, and anxiety disorder.The Brief Interview of Mental Status dated 05/08/20206, documented a score of 11/15, indicating R1's cognitive status was moderately impaired.Resident 2 (R2) was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, post-traumatic stress disorder, anxiety disorder, bipolar disorder, and hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial loss of strength on one side of the body).The Brief Interview of Mental Status dated 05/08/20206, documented a score of 15/15, indicating R2's cognitive status was intact.A facility report dated 05/08/2026, documented residents had a verbal altercation which escalated to a physical altercation. R1 made physical contact with open palm to the right arm of R2. No physical aggression received in return. Both residents involved were immediately separated by staff.A Nursing Progress Note dated 05/07/2026, documented R2 was in the dining room waiting for a scheduled smoke break when R2 became involved in a verbal altercation with R1 and called out to staff for assistance. Staff immediately intervened, separated both residents, and placed them on one-to-one observation. A skin assessment was completed, which revealed no injuries, redness, or bruising. R2 denied pain. The physician and family were notified of the incident. Physician orders were obtained for monitoring and a psychiatric evaluation.A Physical Aggression Report dated 05/07/2026 at 11:00 AM, documented R1 was involved in a verbal altercation with R2 while seated in the south dining room. The report indicated R1 was alert and oriented to person, place, time, and situation. Following the verbal altercation, R1 initiated physical contact with R2, resulting in resident-to-resident physical aggression.The Employee (Receptionist) Statement dated 05/07/2026 documented R1 and R2 were involved in a verbal altercation in the south dining hall. The receptionist reported hearing the residents arguing and, upon looking toward the area, observed R1 strike R2 on the right arm. The receptionist documented R1 made a comment about being first; however, the receptionist was unable to determine the exact nature or context of the dispute.On 06/17/2026 at 9:35 AM, a Certified Nursing Assistant (CNA) indicated R1 could engage in conversation but frequently demonstrated impaired recall. The CNA described R1 as verbally aggressive at times, could become angry and curse at staff. The CNA reported not witnessing the resident-to-resident altercation involving R1 and R2 on 05/07/2026, but was informed the incident occurred during the transition to smoke break. The CNA indicated R1 and R2 were roommates at the time of the incident and frequently spent time together. The CNA indicated that following the altercation, the residents were immediately separated, no longer permitted to sit together, relocated to separate rooms on opposite sides of the unit, and placed on increased monitoring.On 06/17/2026 at approximately 11:10 AM, a Licensed Practical Nurse (LPN) who was the assigned nurse during R1 and R2's altercation on 05/07/2026. The LPN indicated was assigned to the unit at the time of the incident but did not witness the actual altercation. The LPN reported both residents were in the dining room preparing to line up for a scheduled smoke break. According to information reported to the LPN by staff and residents, R1 and R2 engaged in a verbal disagreement regarding who would be first in line for the smoke break. The LPN indicated R1 became upset with R2's response and made physical contact with R2 occurred in the south dining room. The LPN indicated was familiar with R1 prior to the incident and described R1 as having fluctuating moods and behaviors. The LPN indicated that one moment R1 could be pleasant and cooperative, while at other times R1 could become angry if something occurred that R1 did not like. The LPN reported R1 was known to become upset when redirected, including when staff limited smoking privileges due to safety concerns. The LPN indicated staff received abuse prevention education routinely and had received recent abuse training approximately one month prior to the incident.On 06/18/2026 at 8:52 AM, during a telephone interview, R2 indicated while seated in the hallway outside the dining room she asked R1 ([NAME]) to move slightly to allow room. R2 reported R1 became upset, accused R2 of attempting to take R1's spot, and intentionally struck R2 on the arm. R2 denied any prior altercations with R1 and reported experiencing temporary pain but no bruising or injury. R2 stated there were no staff members physically present in the immediate area when the incident occurred. R2 expressed the incident was a significant concern because physical aggression occurred without provocation or reason and no resident should be struck by another resident.On 06/18/2026 at 9:16 AM, during a telephone interview, the Receptionist indicated witnessing R1 and R2's physical aggression. The Receptionist indicated being stationed at the reception desk and hearing a verbal altercation coming from the dining room area. Upon looking toward the area, the Receptionist observed R1 strike R2 on the arm. The Receptionist explained approximately six residents were present in the dining area at the time of the incident. The Receptionist indicated no staff members were physically present in the dining room or immediate area and confirmed residents were not being directly monitored at the time of the altercation. The Receptionist reported being the only staff member who witnessed the incident and the first staff member to respond. The Receptionist indicated residents frequently gathered in the area while waiting for smoke breaks and there was no designated staff assignment to supervise residents in the hallway or dining area except of mealtimes or smoking times. The Receptionist indicated resident supervision was not a direct responsibility of the receptionist position due to other assigned duties at the reception desk; however, resident activity remained within view of the reception area. The Receptionist reported attention was drawn to the incident after hearing the residents arguing and immediately responded upon observing physical contact.On 06/18/2026 at 9:31 AM, during a telephone interview, the Director of Nursing (DON) believed the residents were preparing for a scheduled smoke break at the time of the incident and were arguing regarding the smoking line. The DON acknowledged residents preparing for smoke breaks should have been monitored and indicated residents were discouraged from lining up early for smoke breaks because conflicts could occur. The DON reported residents were expected to be supervised during mealtimes, activities, and smoking-related activities. The DON indicated staff were generally present during meals, activity staff supervised organized activities, and residents preparing for smoke breaks were expected to be monitored. The DON indicated the altercation may have been prevented had a staff member been physically present with the residents during the smoking line-up. The DON acknowledged the incident could have been prevented through staff intervention, including having a staff member present and separating the residents once the verbal escalation began. The DON indicated R2 was frustrated but did not sustain any observed injury and there were no indications of trauma following the incident. A facility policy titled Resident Rights (undated), indicated a resident is entitled to be free from mental and physical abuse.A facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 04/2021, documented residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.FRI 3009520

Based on observation, interview, record review and document review, the facility failed to ensure a comprehensive care plan was updated to include interventions surrounding supervised visitation by a specific family member with criminal history for 1 of 7 sampled residents (Resident 4). The deficient practice had the potential to compromise the safety of the resident and violate the privacy of other residents in the secured unit.Findings include:Resident 4 (R4) was admitted on [DATE], with a diagnoses including unspecified dementia, anxiety and schizophrenia.On 06/17/2026 at 8:25 AM, R4 was seated in the common lounge located at the center of the secured unit. There was a total of 13 residents in the lounge seated near one another. Upon the survey team's request, R4 was assisted to the room by a staff member for an interview.On 06/17/2026 at 8:31 AM, R4 was pleasant, cooperative and able to respond to questions with moments of confusion noted. R4 indicated being a resident at the facility for about four years and was satisfied with the care provided by nursing staff in the unit.On 06/17/2026 at 8:43 AM, a Certified Nursing Assistant (CNA) steadily assigned to the secured unit was familiar with R4 and indicated R4 was under public guardianship but there was one family member who visited R4 mostly on weekends.On 06/17/2026 at 9:00 AM, the charge nurse steadily assigned in the secured unit indicated being very familiar with R4 who a resident at the facility for about four years had been and was in the secured unit due to dementia. The nurse indicated R4 was under public guardianship and did not get any family visits until a biological child was released from prison after a 20-year sentence. The charge nurse emphasized the family member was on supervised visits due to taking unauthorized photos of R4 and to prevent unauthorized photography of other residents in the unit.The medical record lacked documented evidence R4's comprehensive care plan was updated to include safety measures which would be put in place to ensure R4 and other residents' rights were respected and honored during visits by the family member with a criminal history.On 06/17/2026 at 11:43 AM, a representative from the public guardian's office confirmed R4 had a family member who surfaced after serving a long prison sentence and the facility informed the public guardian's office that visitation for this family member would be supervised due to making false allegations and unauthorized photography.On 06/17/2026 at 1:30 PM, the Director of Nursing (DON) indicated receiving a report from a nurse regarding unauthorized photography by R4's family member. The DON indicated speaking with R4's family member who maintained only photos of R4 were taken and not of the other residents. The DON indicated the incident occurred in the common lounge where the residents in the secured unit would often be seated close to each other. The DON indicated visits were not to occur outside the secured unit under observation by staff.On 06/17/2026 at 2:39 AM, the Administrator and DON indicated R4's care plan for public guardianship initiated on 03/17/2023 should have been updated to include observed visitation by R4's family member and monitoring R4 for signs and symptoms of psychosocial distress.On 06/18/2026 in the morning, the Administrator clarified visitation by R4's family member who had a criminal history should be supervised due to reports of possible unauthorized photography. Visitations would be conducted outside the secured unit, in other areas of the facility such as the dining area, patio or any available areas with consideration to the residents' preference. The Administrator indicated R4's care plan should have been updated to reflect said intervention related to visitations by R4's family member.The Comprehensive Care Plan policy revised March 2022, documented assessments of residents were ongoing, and care plans were revised as information about the residents changed.FRI 2790348FRI 2971681

Based on interview, record review and document review, the facility failed to ensure the medical record contained complete information for 1 of 7 sampled residents (Resident 4). The deficient practice had the potential to negatively impact on the resident's quality of care.Findings include:The Charting and Documentation policy revised July 2017 documented all services provided to residents and any changes in the residents' psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the inter-disciplinary team (IDT). Documentation would include events and incidents involving the residents and documentation must be objective, complete, and accurate. Resident 4 (R4) was admitted on [DATE], with a diagnoses including unspecified dementia, anxiety and schizophrenia.On 06/17/2026 at 9:00 AM, the charge nurse steadily assigned in the secured unit indicated being very familiar with R4 who a resident at the facility for about four years had been and was in the secured unit due to dementia. The nurse indicated R4 was under public guardianship and did not get any family visits until a biological child was released from prison after a 20-year sentence. The charge nurse emphasized the family member was on supervised visits due to taking unauthorized photos of R4 and to prevent unauthorized photography of other residents in the unit.The medical record lacked documented evidence the facility addressed, discussed, care planned and communicated to the interdisciplinary team (IDT) the change in R4's situation, specifically, the reappearance of R4's biological child who had a significant criminal history after the family member's release from prison.On 06/17/2026 at 11:43 AM, a representative of the office of the public guardian confirmed R4 was a protective ward and conveyed a note dated 05/20/2026 which read, R4's family member had been placed on supervised visits due to making false allegations and taking unauthorized photography.The medical record lacked documented evidence the information made to or received from the office of the public guardian regarding supervised visits for R4's family member was discussed by the IDT, communicated to the physician and included in R4's care plan.On 06/17/2026 at 1:30 PM, the Director of Nursing (DON) recalled receiving a report from a nurse regarding R4's family member taking unauthorized photography in the common lounge of the secured unit. The DON indicated speaking with R4's family member regarding facility rules and explained visits would be outside the secured unit and observed by staff members moving forwards.The medical record lacked documented evidence of the aforementioned incident by the DON. On 06/17/2026 at 2:39 PM, the Abuse Coordinator indicated extensive conversations with the public guardian regarding R4's family member should have been documented.The Visitation Sign-In form revealed R4's family member visited the resident on 11/30/2025, 03/20/2026, 04/05/2026, 04/18/2026, 05/06/2026, 05/25/2026 and 06/05/2026.A behavior note dated 06/05/2026, revealed R4's family member visited and the nurse took R4 to the conference room.The medical record lacked documented evidence visits occurred outside of the secured unit with staff supervision on 11/30/2025, 03/20/2026, 04/05/2026, 04/18/2026, 05/06/2026, and 05/25/2026.On 06/17/2026 at 4:04 PM, the DON confirmed there was no documentation visits were supervised when R4's family member came to the facility on [DATE], 03/20/2026, 04/05/2026, 04/18/2026, 05/06/2026, and 05/25/2026. The DON could not speak to whether the safety of R4 was compromised since the DON did not know the extent of the family member's criminal history.On 06/18/2026 at 7:45 AM, the supervisor of R4's public guardian (PG) indicated R4 had been under guardianship since 10/05/2021. The PG supervisor confirmed R4 had a biological child who was released after serving a 20-year prison sentence in 2025. The PG supervisor confirmed R4 and the family member had been out of touch and the family member was able to locate R4 with the help of a police detective. According to the PF supervisor, visitation by this family member should be allowed unless there was a court order to discontinue visits.On 06/18/2026 at 7:57 AM, the PG supervisor indicated a facility nurse notified the PG regarding R4's family member videotaping other residents in the unit on 04/27/2026 which resulted in future visits being supervised. The PG supervisor indicated taking photographs of protective wards were permitted only for medical purposes such as taking photos of wounds or a photo for a face sheet. PGs were careful with allowing photographs of protective wards even by family members because these photos may circulate in social media or inappropriately used. The medical record lacked documented evidence of the nurse's observation of R4's family member videotaping other residents in the secured unit, reporting the incident to the DON, and notification to the public guardian was documented in R4's medical record.On 06/18/2026 at 9:46 AM, the DON indicated not being informed by any nurse regarding R4's daughter videotaping other residents in the secured unit on 04/27/2026. The DON indicated this incident should have been reported to the DON and documented in R4's medical record. According to the DON, this should have also been included and addressed in the resident's care plan.The facility permitted residents to receive visitors subject to the protection of rights of other residents in the facility. The facility reserved the right to change the location of a visit is such visit infringes upon the rights of other residents in the facility. FRI 2790348FRI 2971681

Based on interview and record review, the facility did not ensure the Water Management Program was complete and included all required elements.Findings include:Review of the facility's Water Management Program (WMP) revealed the WMP Team included the Director of Maintenance, Infection Preventionist/Director of Nursing, the Administrator, the Assistant Administrator, and the Maintenance Assistant. The WMP included a written narrative of the water flow in the building. This text narrative indicated the facility included 109 resident rooms; 56 rooms with two shared shower rooms on the North side, and 53 rooms with [NAME] and [NAME] shower set up on the South side. The text narrative specified there were nine 100-gallon water heaters and three 100-pound ice machines. The WMP contained a flow diagram for the path of water through the facility. The flow diagram of the path of water through the facility lacked detail to identify areas where potentially dangerous conditions or limited flow could occur:The flow diagram did not specify the locations within the building where potentially dangerous conditions would occur. A potential area where a dangerous condition may occur is known as a control point. Control measures are actions the facility can take to limit the growth or spread of Legionella. Control limits are an acceptable minimum and maximum limits for a control measure. The flow diagram did not state where in the water path to measure potentially dangerous conditions existed, what the acceptable range for measures would be, or what corrective actions to take if control measures were outside of acceptable limits. The WMP stated in part, Areas Where Legionella Could Grow and Spread: Bacteria growth is more likely in piping systems that are rarely flowed. Dead legs and fixtures that see little use. Shower heads and faucet aerators that collect debris are also more likely to have bacterial growth. Areas of piping of limited flow, should be flushed to avoid bacterial growth. These areas of limited flow were not identified in the facility's WMP.The WMP did not address control points, control measures, control limits, and corrective actions to be taken if needed.On 11/6/2025 in the morning, the Maintenance Director explained the facility had five ice machines, and nine water heaters. The Maintenance Director explained the facility did not monitor for disinfectant levels, and water temperatures were monitored by the dishwasher in the kitchen and the washing machine in the laundry room. The Maintenance Director explained the dishwasher and washing machines would not operate if the temperatures were not within acceptable limits.On 11/6/2025 in the morning, the Infection Preventionist stated the facility did not have any residents with Legionella since the last survey.

Based on observation, interview, and document review, the facility failed to ensure 1) a medication with instructions to refrigerate was stored in the refrigerator, 2) an opened multi-dose vial (MDV) was labeled with opened date and 3) expired over the counter (OTC) medications were discarded. The deficient practice had the potential to affect the efficacy of medications being provided to residents.Findings include:Medication not refrigeratedOn 11/07/2025 at 9:51 AM, an inspection of the OTC cabinet in the 200-Hall medication storage room revealed two boxes of Arformoterol Tartrate 12 micrograms (mcg) per two milliliters (ml). A blue sticker which read Refrigerate was affixed on the medication container and was labeled with the name of an active resident (Resident 6). The product insert instructed to store the medication inside a refrigerator between 36 degrees Fahrenheit to 46 degrees Fahrenheit. The recorded room temperature for 11/07/2025 was 68.2 degrees Fahrenheit.On 11/07/2025 in the morning, the Assistant Director of Nursing (ADON) confirmed the medication which had a manufacturer's instruction to refrigerate was stored at room temperature inside the OTC cabinet. The ADON explained R6's Arformoterol was discontinued on 10/09/2025 and should have been discarded by the nurse who was tasked to routinely inspect the medication room.MDV not labeled with opened dateOn 11/07/2025 at 10:09 AM, one opened MDV of Lorazepam injection 2 mg/ml with contents remaining was not labeled with an opened date.On 11/07/2025 in the morning, the ADON confirmed Lorazepam MDV had been accessed with remaining contents but was not labeled with opened date. The ADON explained MDVs must be dated because they were good for 28 days once opened.Expired OTC medications On 11/07/2025 at 10:26 AM, an inspection of the OTC cabinet in the 500-Hall medication room revealed 30 vials of Lubricating eye drops (Carboxymethylcellulose sodium 0.5% Lot number 230860 with expiration date August 2025 and a box of Earwax softener drops with expiration August 2025.On 11/07/2025 in the morning, the ADON confirmed the expired OTC medications. The ADON indicated being uncertain who was responsible for inspecting the medication rooms and how frequently inspections were done.On 11/07/2025 at 10:39 AM, the Director of Nursing (DON) indicated the ADON was expected to be familiar with the process of checking medication rooms such as who was responsible and how often. The DON clarified night shift staff should check medication rooms at least once a month and discard expired and discontinued medications. The DON confirmed the improperly stored medication in the 100-Hall OTC cabinet, the MDV which was not labeled with opened date and expired medications in the 500-Hall medication room was an oversight. The Medication Labeling and Storage policy revised February 2023, documented 1) medications requiring refrigeration were stored in the refrigerator, 2) multi-dose vials which had been accessed were dated and discarded after 28 days, and 3) the dispensing pharmacy was contacted for disposal of outdated and discontinued medications.

Based on interview and document review, the facility failed to ensure the facility assessment tool contained a staffing plan. The deficient practice had the potential to impact the quality of care provided to residents due to staffing levels. Findings include:The Facility Assessment Policy and Procedure dated 2025, documented the facility shall conduct a facility-wide assessment to determine which resources were necessary to care for its residents competently both day-to-day and during emergencies. The facility shall use the facility assessment to inform staffing decisions to ensure there was a sufficient number of staff with appropriate competencies and skill sets necessary for its residents' needs. Consider specific staffing needs for each resident unit and adjust as necessary based on changes to its population. Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on changes.The Facility Assessment Tool reviewed on 08/28/2025, lacked documented evidence of a staffing plan.On 11/06/2025 at 10:30 AM, Administrator confirmed the facility assessment tool did not include a staffing plan but rather a sample staffing schedule with staff names which included licensed nurses and certified nursing assistants (CNAs) required for each unit and shift. The Administrator acknowledged a staffing plan must be included in the facility assessment which identified the number of licensed nurses and CNAs needed for every shift in each unit to provide quality care for residents.On 11/06/2025 at 10:48 AM, the staff scheduler indicated being familiar with the facility assessment and indicated relying on the sample staffing schedule as a guide for staffing the units.On11/07/2025 at 8:39 AM, the staff scheduler explained the former human resources director trained the scheduler to staff the units based on the sample staff schedule and not a formal staffing plan.

Based on observation, interview, and document review, the facility failed to ensure food was served at a preferable and appetizing temperature for four sampled residents (Residents 12, 54, 72, and 119) and two unsampled residents (Residents 27 and 141). The deficient practice had the potential to negatively affect the amount of nutrients consumed by the residents and therefore affect their nutritional status. Findings include: On 11/07/2024 at 01:31 PM, Resident 12 (R12) verbalized the meal tasted poor and the cool temperature didn't help. On 11/07/2024 at 1:33 PM, Resident 54 (R54) indicated the meal tasted poor and the lukewarm to cool temperatures make it worse. On 11/07/2024 at 1:36 PM, Resident 72 (R72) indicated the meal tasted okay, but the cooler temperature was a problem. On 11/07/2024 at 1:38 PM, Resident 27 (R27) verbalized the meal tasted okay but was not a fan of the cool temperature. On 11/07/2024 at 1:39 PM, Resident 141 (R141) also verbalized the meal tasted okay but was not a fan of the cool temperature. On 11/07/2024 at 1:42 PM, Resident 119 (R119) indicated the meal tasted poor and it was very cold. On 11/07/2024 in the afternoon, a test tray was requested on the 600 hall. At 12:58 PM, the test tray food was temped by the DD with the surveyors in the kitchen before going into the food cart. The temperature of the ravioli was 164 degrees Fahrenheit, and the temperature of the pizza was 154.4 degrees Fahrenheit. At 1:00 PM, the meal cart left the kitchen and was taken to the 600 hall. At 1:03 PM, the meal cart arrived on the 600 hall. At 1:20 PM, the first meal tray was served from the meal cart. Staff members delivered the meal trays. At 1:33 PM, the last meal tray was delivered. At 1:34 PM, the test tray food was temped by the Dietary Director (DD) with the surveyors. The temperature of the ravioli was 123.6 degrees Fahrenheit, and the temperature of the pizza was 115 degrees Fahrenheit. On 11/07/2024 at 1:37 PM, two surveyors and the DD thought the food tasted very good and had nice textures. However, the two surveyors thought the food was cooler than would have liked. The DD acknowledged the food was cooler than what the DD expected. On 11/08/2024 in the morning, the DD explained the food should not have taken over 15 minutes to begin to be served to the residents. The DD also explained the trays should not have been taken out of an insulated cart and put onto an uninsulated cart to then be delivered to the residents. The DD stated the food should be taken to the residents directly from the insulated cart to preserve the food temperatures. On 11/08/2024 in the morning, a test lunch tray was requested on the 600 hall. At 2:20 PM, the test tray food was temped by the DD with the surveyors in the kitchen before going into the food cart. The temperature of the chicken was 122.4 degrees Fahrenheit, the temperature of the rice was 121 degrees Fahrenheit, the temperature of the fish was 132.8 degrees Fahrenheit, and the temperature of the broccoli was 123 degrees Fahrenheit. At 2:24 PM, the meal cart left the kitchen and was taken to the 600 hall. At 2:27 PM, the meal cart arrived on the 600 hall. At 2:30 PM, the first meal tray was served from the meal cart. Staff members delivered the meal trays. At 2:41 PM, the last meal tray was delivered. At 2:42 PM, the test tray food was temped by the Dietary Director (DD) with the surveyors. The temperature of the chicken was 100.4 degrees Fahrenheit, the temperature of the rice was 104.4 degrees Fahrenheit, the temperature of the fish was 113.7 degrees Fahrenheit, and the temperature of the broccoli was 110.3 degrees Fahrenheit. On 11/08/2024 at 2:44 PM, two surveyors thought the food tasted very good and had nice textures. However, the two surveyors thought the food was cold. The DD acknowledged the food was cold based off the temperatures taken of the food. The DD refused to try the food. On 11/08/2024 at 03:51 PM, Resident 12 (R12) verbalized the meal temperature was cold. On 11/07/2024 at 3:53 PM, Resident 54 (R54) indicated the meal temperature was cooler then was liked. On 11/07/2024 at 3:59 PM, Resident 72 (R72) indicated the meal temperature was cold. On 11/07/2024 at 4:01 PM, Resident 27 (R27) verbalized the meal temperature was cooler than was liked. On 11/07/2024 at 4:02 PM, Resident 141 (R141) also verbalized the meal temperature was cold. On 11/07/2024 at 4:04 PM, Resident 119 (R119) indicated the meal temperature was very cold. A Healthcare Services Group policy titled Food: Preparation revised 02/2023, references the use of the FDA 2022 Food Code for Time/Temperature Control for Safety.

Based on observation, document review and interview, the facility failed to ensure stored foods were stored in accordance with professional standards for food service safety and hand washing areas were accessible to kitchen staff. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 11/05/2024 in the morning, during a tour of the kitchen and dietary areas, an open box of unbaked cookies was found being stored in the 500-hall nourishment freezer without a way to control for contamination of the cookies by facility staff, housekeeping staff, and/or kitchen staff whom all had access to the open box in the nourishment room freezer. A Healthcare Services Group Policy revised 02/2023 with the subject entitled Food Storage: Cold Food revealed all foods, frozen and refrigerated, will be stored in accordance with the guidelines of the FDA Food Code (2022). The Dietary Supervisor verified there were no measures in place to protect the unbaked cookies, being stored in the 500-hall nutrition room freezer, from contamination. The Dietary Supervisor explained the open box of unbaked cookies should not have been placed in/ stored in the nourishment room freezer. The Dietary Manager also mentioned this open box of unbaked cookies did not belong to Activities Department because activities come to the kitchen for their food and does not have a way to bake the unbaked cookies themselves. On 11/05/2024 in the morning, during a tour of the kitchen and dietary areas, there was a dish cart blocking the entrance to the handwashing sink and there was a plunger being stored in the handwashing sink. These two items were blocking the access to and use of the handwashing sink. A Healthcare Services Group Inservice & Policy Training V2 document with the subject entitled Hand Hygiene for Dining Services revealed situations requiring handwashing with soap and water included: after handling dirty dishes or trash, when one takes one step away from their workstation, or between tasks. The Dietary Supervisor acknowledged the handwashing sink in the dish room was inaccessible to be used properly for the above situations.

Based on observation, interview, and document review, the facility failed to ensure the resident's food preferences were honored for one unsampled resident (Resident 60). The failure could have resulted in the resident having an allergic reaction to the provided food. Findings include: On 11/06/2024 at 12:53 PM, a Certified Nursing Assistant (CNA) was observed giving R60 a lunch tray in the dining room. The CNA looked at the plated meal and then looked at the ticket. The CNA informed the resident there was no protein on the plate due to the resident's Dairy Allergen. R60 became upset and wanted to speak to kitchen staff. On 11/06/2024 at 12:58 PM, a kitchen staff member was observed apologizing to the resident and then brought the resident out a piece of meatloaf for the resident to eat. The resident ate the meatloaf. On 11/06/2024 at 1:01 PM, the CNA and surveyor observed R60's plate and the CNA confirmed the meal ticket read, seasoned green peas, herbed rice, dinner roll, and caramel apple upside down cake and confirmed R60's plate did not include the herbed rice but did include a bowl of hamburger toppings without a hamburger. The CNA also confirmed the dairy allergy was notated on the meal ticket. The CNA verbalized discrepancies between meal tickets versus meal trays was a common occurrence. On 11/7/2024 at 2:50 PM, the Dietary District Manager (DDM) explained the reason there was no protein on R60's plate was because the main protein of meatloaf contained dairy in the recipe, and the alternate protein was a quiche which also contained dairy in the recipe. The system did not populate a protein being they both contained dairy and R60 had a dairy allergy. The DDM observed R60's ticket and confirmed the resident's lack of a protein and the dairy allergen. The DDM was also not sure why the resident received hamburger topping without the hamburger, nor was the DDM sure why the resident was not served the rice. The DDM indicated R60's meal ticket had a note which stated, dairy allergen because the resident was allergic to dairy products. The Dietary Manager confirmed there had been a mistake during the plate preparation for R60 which should have included the rice. The DDM confirmed there had also been a mistake in serving the resident the meatloaf being R60 was allergic to its ingredients. The DDM also stated would investigate this situation, so the resident does not have protein again on the next rotation of this menu. A Healthcare Services Group policy revised on 02/2023 titled Meal Distribution revealed for point of service dining, the dining services staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal ticket (in conformity with the individuals diet order, preferences, and plan of care) and present it to the care staff for delivery to the resident.

Based on observation, interview and document review, the facility failed to ensure an opened multi-dose vial (MDV) of Tubersol (used for intradermal Tuberculosis (TB) testing) was dated. The deficient practice could potentially result in inaccurate TB readings which could compromise the facility's TB surveillance protocol. Findings include: On 11/07/2024 at 8:39 AM, an inspection of the 200-Hall medication refrigerator revealed one opened MDV of Tubersol (Lot number 3CA26C1, Expiration 11/07/2024) which was not labeled with an open date. On 11/07/2024 at 8:40 AM, the Assistant Director of Nursing (ADON) confirmed the observation and indicated all MDV vaccines were to be labeled with open date and the discard date would be based on the manufacturer's instruction. The product inserts for Tubersol revealed each one-milliliter vial was good for 10 tests. Once accessed, the MDV was good for 30 days after which the vial must be discarded. The Medication Storage and Labeling policy (undated) documented, once MDVs were accessed (needle-punctured), the vial must be dated and discarded within 28 days unless the manufacturer specified a date whether shorter or longer.

Based on interviews, record review, and document review, the facility failed to ensure a care plan was revised after resident-to-resident incidents for 1 of 38 sampled residents (Resident 167). The deficient practice placed the resident at risk for inappropriate care, supervision, and accidents. Findings include: Resident 167 (R167) R167 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, dementia with behavioral disturbances, anxiety disorder, muscle wasting and atrophy, and cardiac pacemaker. Resident 39 (R39) R39 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, vascular dementia with behavioral disturbances, schizoaffective disorder, diabetes, congestive heart failure, and anxiety disorder. A Nursing Progress Note dated 09/13/2024 at 5:55 PM revealed R167 was in the dining area and was standing up hitting another resident (R39). The residents were separated and taken to their individual rooms. Nursing asked the resident what happened. R167 stated was minding own business when the other resident (R39) started trouble for no reason. No injuries were observed, and no complaints of pain were verbalized. An SBAR Communication form was filled out. The facility's investigation documentation revealed R167 had retrieved R39's cup during an activity in the dining room. When R39 realized R167 had R39's cup, R39 went over to R167 and asked for the cup back. R167 was not able to mentally process the situation, and when R39 went to reach for the cup, R167 pushed R39 backwards causing R39 to fall to the floor from the resident's wheelchair. A care plan for physical aggression had not documented R167 had a resident-to-resident altercation. However, there were new interventions dated 9/13/2024 documenting the facility was going to start eye on eye supervision, initiate a psychiatric evaluation, and separate immediately. Resident 119 (R119) R119 was admitted to the facility on [DATE] with diagnoses including diabetes, major depressive disorder, schizoaffective disorder, chronic obstructive pulmonary disease, chronic pain syndrome, and generalized anxiety disorder. A Nursing Progress Note dated 09/14/2024 at 5:54 PM revealed R119 was in their room when R167 came into the room and stated this room was R167's room. R119 told R167 the room belonged to R119. This is when R167 pushed R119. R119 stumbled back and fell landing on their knees. The residents were separated and R167 was taken to their room. No injuries were observed, and no complaints of pain were verbalized. An SBAR Communication form was filled out. The facility's investigation documentation revealed R167 and R119 were heard shouting during a disagreement. Staff went to the hallway to investigate the situation. Upon arrival, facility staff witnessed R167 physically pushing R119 to the ground, leaving R119 on their knees. A care plan for physical aggression had not documented R167 had another resident-to-resident altercation. However, there were new interventions dated 9/14/2024 documenting the facility was going to legal 2000 discharge the resident to the hospital for physical aggression. Resident 129 (R129) R129 was admitted to the facility on [DATE] with diagnoses including history of other mental and behavioral disorders, dementia with behavioral disturbances, diabetes, cognitive communication deficit, psychosis, and anxiety disorder. Facility investigation report documented on 9/16/2024 at 2:00 PM, R167 and R129 were walking toward each other. R167 pushed their walker into R129 three times, causing R129 to lose their balance and fall to the ground. An SBAR Communication form was filled out for this 9/16/2024 incident. A care plan for physical aggression had not documented R167 had another resident-to-resident altercation and there were no new interventions dated 9/16/2024 documented. Resident 18 (R18) R18 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with behavioral disturbances, schizoaffective disorder, cognitive communication deficit, extrapyramidal and movement disorder, and anxiety disorder. Facility investigation report documented on 11/01/2024 at 6:00 AM, R167 was being escorted to their room by the nurse for verbal aggression. R18 attempted to assist the nurse in escorting R167 back to R167's room which caused R167 to become upset. R167 swung at R18 which caused R18 to swing at R167. Staff attempted to separate the two residents. During the separation, all three parties fell to the floor. Both residents were helped up and escorted to their individual rooms and assessed for injuries and pain. An SBAR Communication form was filled out for this 11/01/2024 incident. A care plan for physical aggression had not documented R167 had another resident-to-resident altercation and there were no new interventions dated 11/01/2024 documented. The medical record lacked documented evidence the care plan for R167 was revised to include the resident-to-resident altercations and new preventative strategies for those altercations for the most recent altercations. On 11/08/2024 in the afternoon, the Director of Nursing (DON) stated an SBAR Communication Form would constitute a change of condition. The DON indicated the resident care plan could be updated after the incident or upon readmission like it was for R167. The DON further explained if there was already a care plan for the situation, the facility won't necessarily update it any further after another event. When asked if the current interventions for R167 were working, the DON agreed the interventions had not worked since there had been another altercation. On 11/08/2024 in the afternoon, the Administrator (Admin) agreed the interventions for R167 had not worked since there had been another altercation. The Admin explained it was important to update the care plan as it is what steers the care to be given and without an updated care plan, monitoring the care can be difficult. The Admin stated each incident should have had a revision to the resident's care plan. A facility policy titled Care Plans, Comprehensive Person-Centered (revised March 2022) documented assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes. The policy also revealed the interdisciplinary team reviews and updates the care plans when there has been a change in the resident's condition, when the desired outcome is not met, or when the resident has been readmitted to the facility from a hospital stay. FRIs #NV00072203, #NV00072209, #NV00072237, #NV00072599

Based on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 3 of 38 sampled residents (Residents #39, 50, & 82). The deficient practice had the potential to deprive the residents of concern and other residents of necessary behavioral health services. Findings include: Resident 39 (R39) R39 was readmitted on [DATE], with diagnoses including schizoaffective disorder, vascular dementia with behavioral disturbance, and anxiety disorder. On 11/05/2024 in the afternoon, R39 stated had been at the facility for over a year. The resident was happy with the food but would like BBQ foods more often. The resident had an issue with laundry having lost some clothes but has been resolved. The resident was happy with physical therapy and the nursing care. The resident also asked the Activities Department to take the residents on more trips away from the facility which The Activities Department said would take note of. A PASARR level one document dated 01/04/2017, revealed R39 did have the dementia diagnosis, however, no other mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of the resident's medical notes revealed R39's schizoaffective disorder was diagnosed on [DATE] and the resident's anxiety disorder was diagnosed on [DATE]. Resident 50 (R50) R50 was admitted on [DATE], with diagnoses including schizophrenia, unspecified dementia with behavioral disturbance, and major depressive disorder. On 11/05/2024 in the afternoon, R50 was slightly confused. The resident was waiting to see a cop and a schoolteacher and wanted to find the guy upstairs. The resident was otherwise happy with the functioning of the facility. A PASARR level one document dated 04/21/2016, revealed R50 did have the dementia diagnosis, however, no other mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of the resident's medical notes revealed R50's schizophrenia was diagnosed on [DATE] and the resident's major depressive disorder was diagnosed on [DATE]. Resident 82 (R82) R82 was readmitted on [DATE], with diagnoses including schizoaffective disorder, vascular dementia with behavioral disturbance, anxiety disorder, and major depressive disorder. On 11/05/2024 in the afternoon, R82 stated had been at the facility for over 4 years. The resident felt the facility overall was an alright place to reside and liked to participate in activities of interest to the resident. A PASARR level one document dated 07/10/2018, revealed R82 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of the resident's medical notes revealed R82's schizoaffective disorder was diagnosed on [DATE], the vascular dementia with behavioral disturbance was diagnosed on [DATE], the anxiety disorder was diagnosed on [DATE], and the resident's major depressive disorder was diagnosed on [DATE]. On 11/06/2024 in the morning, the Marketer stated Social Services were responsible for the PASARRs. On 11/06/2024 in the afternoon, the Medical Records Staff indicated there was no other PASSAR information available for these residents' indication a PASSAR II referral had been sent. On 11/06/2024 in the afternoon, the Social Services Director explained the SSD was responsible for referring residents who met criteria for PASARR two by completing the PASARR requests and referral was to be completed in their morning meeting. When asked if a residents' diagnoses of anxiety disorder, schizoaffective disorder, schizophrenia, and major depressive disorder would be representative of mental illness, intellectual disability, or a related condition which the Medicaid Service Manual documents a PASARR II must be completed for, SSD agreed these diagnoses would be an indication. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority. The medical record lacked documented evidence referrals for a PASARR level two screening were completed.

Based on interview, employee file review, and document review, the facility failed to ensure verification of a professional license was conducted in accordance with the abuse prevention policy for 1 of 10 sampled employee files (Employee 9). The failure resulted in Employee 9 (E9) working as a Registered Nurse (RN) in the care of residents for over six months using another person's RN license. An unqualified person practicing as an RN could result in an adverse health outcome to residents. Findings: The policy and procedure titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 04/01/2024, indicated the facility would implement procedures for screening potential employees. Background and credential checks would be conducted for each potential employee and documented proof the screening occurred would be maintained. The policy indicated the facility would verify credentials such as licenses prior to an employee beginning work. On 11/08/2024, in the morning, the Payroll/Staffing Coordinator verbalized each RN must possess a valid state license in order to be employed as an RN at the facility. On 11/08/2024, E9's file was reviewed with the HR Administrative Assistant. E9 was hired as an RN on 12/26/2023. Employee screening was performed on 12/26/2023. The background check included documentation of E9's social security number and a copy of the driver's license. The file indicated E9 was permanently hired as an RN on 01/11/2024 by the HR Administrative Assistant. The file indicated E9 was terminated from employment on 07/08/2024. On 11/08/2024, in the morning, the HR Administrative Assistant verbalized E9 had furnished the facility with an RN license number. When the number was checked it indicated the license holder had a different middle and last name than E9. The HR Administrative Assistant revealed E9's name matched only the first of the name of the RN license holder provided. The HR Administrative Assistant verbalized E9 had explained this was because they were in the process of getting a divorce and the name on the license was being changed but this name change had not been completed. The HR Administrative Assistant revealed the status of E9's name change had not been verified with the Board of Registered Nursing. The HR Administrative Assistant revealed the information should have been verified. On 11/08/24 at 1:12 PM, the HR Director verbalized the facility process was to check two forms of identification (ID) for each applicant. The ID must match the professional license. The HR Director revealed E9 had worked as an RN caring for residents in the facility. The HR Director verbalized RN duties included performing health assessments and administering medications. The HR Director verbalized impersonating an RN was dangerous and was considered a crime. On 11/08/24 at 1:37 PM the Administrator verbalized the facility failed to ensure E9's social security number and driver's license matched the name of the RN license number provided. The facility had employed E9 as an RN despite not having the required ID and license match. The Administrator verbalized the facility had repeatedly asked E9 to furnish updated ID to reflect an alleged name change without result. E9 then had failed to show up for work and was terminated. The Administrator verbalized after terminating E9, the Administrator had been contacted by a representative from the Board of Nursing and had been informed E9 had never been licensed as an RN and had supplied the facility with the license number for a different RN. On 11/08/2024, in the afternoon, the Administrator further verbalized the facility should have waited until the ID matched the RN license before employing E9. The Administrator revealed employing a person pretending to be an RN could result in harm to residents under their care. The Administrator stated there had been no known adverse incidents involving E9, however all of the residents had been placed at risk for the duration of E9's employment of over six months. Complaint 72554

Based on interview, record review and document review, the facility failed to ensure the facility followed through on a resident's request regarding personal mail for 1 of 38 sampled residents (Resident 176). The deficient practice had the potential to negatively impact the resident's well-being. Resident 176 (R176) R176 was admitted on [DATE], with diagnoses including idiopathic neuropathy, depression and generalized anxiety disorder. On 11/05/2024 at 11:13 AM, R176 appeared neat, well-groomed with pleasant demeanor while seated inside the resident's room in the semi-secured unit. R176 indicated living in a church-based homeless shelter prior to being admitted to the facility in May 2024. R176 reported having requested the social worker multiple times to have R176's personal mail picked up from the shelter as the resident was expecting some checks, bills and letters which were important to the resident. R176 indicated not hearing back from the social worker and expressed worry regarding several months' worth of personal mail getting discarded. A psychotherapy assessment dated [DATE], revealed R176 was homeless prior to being admitted in May 2024. On 11/06/2024 at 1:07 PM, the Social Services Director (SSD) confirmed the SSD had spoken with R176 on multiple occasions and R176 had requested the SSD to assist the resident to pick up personal mail from the homeless shelter. The SSD explained the facility had two vans which were used to transport residents to appointments. According to the SSD the vans were available on Fridays, but the church office was only open on Tuesdays and Thursdays. The SSD provided an electronic mail (e-mail) correspondence between the SSD and a representative from the shelter. The e-mail correspondence dated 10/14/2024, documented the SSD had reached out to the shelter regarding R176's personal mail. A representative from the shelter responded to the SSD within the day and informed the SSD R176's mail could be picked up anytime during normal operating hours on Tuesdays or Thursdays. On 11/06/2024 at 1:15 PM, the SSD confirmed not communicating R176's request to pick up personal mail with any member of the inter-disciplinary team (IDT) which included facility leadership. The SSD verbalized assuming R176's mail could not be picked up because the vans were busy during the shelter's normal operating hours. The SSD confirmed not updating R176 regarding the status of personal mail since 10/14/2024. On 11/06/2024 at 1:28 PM, the Administrator indicated R176's request to pick up mail from the homeless shelter was a reasonable request which could have been accommodated sooner had the SSD communicated the request with the IDT. The Administrator stated several months' worth of personal mail was of high importance to any resident and the SSD should have sought the assistance of leadership to arrange for the pickup of R176's mail sooner. The Resident's rights policy (undated), documented the resident had the right to make choices regarding personal affairs, be treated with respect and courtesy, receive unopened mail, to complain about care or treatment and receive prompt response to resolve the complaint.

Based on observation, interview, and document review, the facility failed to ensure 1) kitchen equipment was cleaned, 2) food items were labeled with dates in the dried food storage, 3) expired food was discarded, 4) pans were not stacked wet, and 5) two of two nourishment room's equipment and surfaces were routinely cleaned, was free of personal items, documented freezer temperature logs, and meal products were labeled and dated. The deficient practice had the potential to serve foods to residents at an increased risk of food safety. Findings include: On [DATE] at 7:52 AM, an initial tour of the kitchen revealed the following: 1) Food equipment not maintained in a sanitary manner: -the water basin in the bottom of the commercial food warmer box was half filled with yellow-colored water and its exterior had white colored buildup stains. -ice machine #2 (on the left) had a growth of heavy black spots on the top interior plastic shield of the ice machine and its exterior had white colored buildup stains. There was water continuously dripping from the growth of black spots onto the ice below. On [DATE] at 7:57 AM, the Regional District Manager explained the water in the commercial food warmer should be replaced daily and described the water as dirty and brownish in color. The Regional District Manager described the commercial food warmer exterior with white calcium build up from the facility's harsh water. The Kitchen Assistant Manager indicated the commercial food warmer should be cleaned at the end of every night shift and there was no log to indicate when it was last cleaned or used. The Kitchen Assistant Manager described the water as dirty, not clear, and the exterior needed to be cleaned. On [DATE] at 8:13 AM, the Regional District Manager described the growth of black spots area as mold covering approximately 2.5 feet of 3 feet of the plastic shield, which they considered to be significant mold buildup, and the exterior of the ice machine had calcium buildup. The Regional District Manager revealed the ice machines were used for all residents and should have been cleaned weekly and deep cleaned monthly. On [DATE] at 8:25 AM, the Kitchen Assistant Manager indicated the kitchen staff were responsible for cleaning the ice machines in the kitchen. The Kitchen Assistant Manager revealed the [DATE] AM/PM Aide Cleaning Schedule indicated the commercial food warmer was not listed and the ice machines were last cleaned on [DATE]. The facility policy titled Equipment revised [DATE], documented all food service equipment would be cleaned, sanitary, and in proper working order. All food contact equipment would be cleaned and sanitized after every use. All non-food contact equipment would be cleaned and free of debris. The facility's Logbook Documentation (undated) documented, ice machine: steps to include sanitizing interior of ice machine per manufacturer's instructions. Clean and wipe down the exterior. 2) Unlabeled or undated open meal products in the dry food storage: -opened box of Quick Creamy Wheat, unlabeled and undated. -opened one gallon jug of barbeque sauce, approximately half consumed was labeled only with received date of [DATE]. -one gallon jug of soy sauce, approximately half consumed was labeled only with received date of [DATE]. -one gallon jug of apple cider vinegar, approximately 10 percent remaining was labeled only with received date of [DATE]. 3) Expired meal products in the dry food storage: -Raisin Bran cereal in large plastic food storage container, measuring approximately eight quarts remaining, had a label with written expiration date of [DATE]. On [DATE] at 8:03 AM, the Regional District Manager confirmed the undated meal products, expired cereal should have been discarded, the staff member who opened a meal product should label the item with the open date, and the dietary manger should be conducting daily audits. The Regional District Manager explained meal products which lack open date labels would refer to manufacture best buy dates or are used within three months once opened, with the exception to soy sauce which had six months. The facility policy titled Receiving revised [DATE], documented all food items would be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility policy titled Food Storage: Dry Goods revised [DATE], documented storage areas would be neat, arranged for easy identification, and date marked as appropriate. 4) Pans were not stacked wet: -one stack of seven large pans and another stack of five large pans were stacked while still wet. On [DATE] at 8:09 AM, the Regional District Manager confirmed the two stacks of large pans were stacked wet and explained the pans should have been dried prior to stacking, which can cause bacteria growth and potentially an infection control issue. The facility policy titled Ware washing revised [DATE], documented all dishes would be air dried and properly stored. 5) On [DATE] at 8:28 AM, an initial tour of the North nourishment room revealed the following: -a half filled pitcher of grape juice in the refrigerator was not labeled or dated. -a personal plastic water bottle in the refrigerator and a frozen dinner meal in the freezer. -no freezer temperature log. -large tub of ice cream was not labeled or dated. -interior freezer compartment had heavy ice buildup covering the bottom and along the seal of the freezer. -ice/water combination machine had white colored buildup stains on the exterior and had yellow-orange discoloration inside the water dispensing spout area. On [DATE] at 8:33 AM, the Kitchen Assistant Manager advised the unlabeled and undated grape juice should have gone back into the kitchen after food service, explained the freezer had not been defrosted by the evidence of the ice buildup and should have been defrosted monthly, the freezer temperature was not documented, and was not sure who was responsible for the maintenance of the refrigerator/freezer unit in the North nourishment room. The Kitchen Assistant Manager described the exterior of ice/water combination machine with a heavy buildup of calcium, which can result in an infection control and safety issue. On [DATE] at 8:36 AM, an initial tour of the South nourishment room revealed the following: -two personal plastic bags of food and two personal plastic water bottles were inside the refrigerator. -exterior of the refrigerator/freezer unit had white colored buildup stains. -no freezer temperature log. -the sink hole area had an orange buildup stain. -ice/water machine combination had yellowish discoloration inside the ice dispensing spout area. On [DATE] at 8:36 AM, the Kitchen Assistant Manager described the South nourishment room as a sanitation problem, bad and very dirty as they pulled out a flat comb with hair from under the ice/water combination machine. The Kitchen Assistant Manager described the sink hole area with rust, the large tub of ice cream was unlabeled and undated, the freezer temperature was not documented, and staff member's personal food items should not be stored in the resident's nourishment room refrigerators or freezers. The Kitchen Assistant Manager indicated the internal ice and water dispensing spouts had mold, which potentially can result in residents becoming ill or a concern for waterborne illness. On [DATE] at 8:42 AM, a Registered Nurse confirmed the South nourishment room was located inside the facility's locked unit and reported the locked unit had a census of 27 residents at the time. A Certified Nursing Assistant (CNA) indicated they were not sure who was responsible for the upkeep of the nourishment rooms and the nourishment rooms were used for residents only. The CNA indicated had last used the ice machine from the South nourishment room that morning and normally used it throughout the day to serve residents. On [DATE] at 8:44 AM, the Maintenance Director reported the ice/water combination machines inside the two nourishment rooms were maintained and cleaned by a contracting party. On [DATE] at 8:47 AM, there was an ice chest filled with ice, positioned across the hall from the South nourishment room. A CNA reported the ice in the ice chest was taken from the kitchen ice machine #1, but staff could use the ice from either kitchen ice machine. The facility policy titled Environment revised [DATE], documented the Dining Service Director will ensure that all employees were knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces and a routine cleaning schedule would be in place for all cooking equipment, food storage areas, and surfaces. The facility policy titled Food Storage: Cold Foods revised [DATE], documented freezer temperature would be maintained at a temperature of 0 degrees Fahrenheit or below. A written record of daily temperatures for each refrigerator and freezer would be recorded. All foods would be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on observation, interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 15 of 15 sampled residents (Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172) with psychiatric diagnoses. The deficient practice had the potential to deprive residents of necessary behavioral health services. Findings include: The Intervention and Monitoring Behavioral Assessment policy revised March 2019, documented all residents would receive a Level one PASARR screening prior to admission. Residents with new onset or changes in behavior indicative of newly evident or possible serious mental disorder, intellectual disability, or a related disorder, would be referred for a PASARR level two evaluation. Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172's indicators included not having a PASARR level two with diagnoses. Review of medical record revealed Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172 had a PASARR level one screening on file which documented the residents did not have mental illness, mental retardation or other related conditions and were appropriate for nursing facility placement. Review of medical records revealed Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172 all had a psychiatric diagnosis with an onset date which occurred after the residents' PASARR level one screening. The residents' psychiatric diagnoses included schizophrenia, schizoaffective disorder, paranoid schizophrenia, unspecified psychosis, post-traumatic stress disorder and major depressive disorder. The medical record lacked documented evidence Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172 were referred for a new level of care (LOC) assessment or a PASARR level two screening after the onset of new psychiatric diagnoses which were identified after the residents' PASARR level one screening. On 10/11/2023 at 2:55 PM, the Social Services Director (SSD) indicated the purpose of PASARR was to ensure each resident was appropriately placed in a nursing facility and the nursing facility was able to provide the services the resident needed, particularly behavioral services. On 10/11/2023 at 2:59 PM, the SSD indicated state PASARR nurses came to the facility on a quarterly basis to audit services being provided to 18 PASARR level two residents who were in the facility. The SSD indicated aside from assisting the state PASARR nurses with information being requested, the SSD was not aware of any other responsibilities of the social services department with regards to PASARR. On 10/11/2023 at 3:06 PM, the SSD verbalized not being familiar with the facility's process of identifying and referring residents who met criteria for a PASARR level two referral. On 10/11/2023 at 3:10 PM, the SSD confirmed Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106, 112, 150, and 172 had PASARR level one determinations in their medical record and each of the residents had a psychiatric diagnosis which were identified after the residents' PASARR level one screening dates. On 10/12/2023 at 9:00 AM, the Admissions Director indicated being responsible for one component of the PASARR process and this was to ensure all residents had a PASARR screening level one or level two prior to being admitted to the facility. Apart from this requirement, the Admissions Director indicated not being involved nor was familiar with the facility's process of identifying and referring residents for a new LOC assessment of a PASARR level two. On 10/12/2023 at 9:24 AM, the Director of Nursing (DON) indicated not being very familiar with PASARR requirements and indicated the social services department was responsible for overseeing PASARR, specifically, the SSD was expected to identify and refer residents who met criteria for a PASARR level two screening. On 10/12/2023 at 9:31 AM, the Administrator indicated there was a process in place with regards to identifying and referring residents who met the criteria for a PASARR level two, but the facility underwent a changeover in social services staff. The Administrator indicated not being aware of the extent of the SSD's knowledge deficit regarding PASARR and verbalized the SSD appeared to not have been properly trained by the former SSD with regards to identifying residents who met criteria and the actual referral process.

Based on interview, record review and document review, the facility failed to provide documented evidence the Minimum Data Set (MDS) assessments were performed in accordance with the Resident Assessment Instrument (RAI) Manual for 1 of 36 sampled residents (Resident 57). The deficient practice had the potential for the facility failing to ensure the assessments accurately reflected the resident's status and failing to identify the correct interventions for the resident. Findings include: Resident 57 (R57) R57 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, pressure-induced deep tissue damage of sacral region and left heel, and pain. R57's MDS for significant change in status assessment dated [DATE], documented the MDS Coordinator electronically signed certain sections of R57's MDS including Section G (Functional Status), J (Health Conditions), L (Oral/Dental Status), and M (Skin Conditions). The RAI 3.0 User's Manual Version 1.17.1 dated October 2019, documented all staff who completed any part of the MDS must enter their signatures, titles, sections, or portion(s) of section(s) they completed, and the date completed. Legally, it was an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS was required to sign the Attestation Statement. The facility failed to provide documented evidence the MDS Coordinator performed interviews with direct care staff and resident/family/significant other, observations, and examination of the resident as required and enumerated in the following Steps for Assessment: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019, documented the RAI process had multiple regulatory requirements. Federal regulations required the assessment process which included direct observation, as well as communication with the resident and direct care staff on all shifts. The RAI Manual documented the Steps for Assessment for the following sections of MDS: - Section G0110: Activities of Daily Living (ADL) Assistance 1. Review the documentation in the medical record for the 7-day look-back period. 2. Talk with direct care staff from each shift who had cared for the resident to learn what the resident did for themselves during each episode of each ADL activity definition as well as the type and level of staff assistance provided. 3. When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed Mobility, observe what the resident was able to do without assistance, and then determine the level of assistance the resident required from staff for moving to and from a lying position, for turning the resident from side to side, and/or for positioning the resident in bed. - Section G0400: Functional Limitation in Range of Motion (ROM) 1. Review the medical record for references to functional range of motion limitation during the 7-day look-back period. 2. Talk with staff members who worked with the resident as well as family/significant others about any impairment in functional ROM. 3. Coding for functional ROM limitations was a 3-step process: - Test the resident's upper and lower extremity ROM. - If the resident was noted to have limitation of upper and/or lower extremity ROM, review G0110 and/or directly observe the resident to determine if the limitation interfered with function or placed the resident at risk for injury. - Code G0400 A/B as appropriate based on the above assessment. - Section J0200: Should Pain Assessment Interview Be Conducted? 1. Interact with the resident using his or her preferred language. 2. Determine whether or not the resident was rarely/never understood verbally, in writing, or using another method. - Section L0200: Dental 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. 2. Ask the resident, family, or significant other whether the resident had or recently had dentures or partials. 3. If the resident had dentures or partials, examine for loose fit. Ask the resident to remove, and examine for chips, cracks, and cleanliness. Removal of dentures and/or partials was necessary for adequate assessment. 4. Conduct exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source which was adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. 5. If the resident was unable to self-report, then observe the resident while eating with dentures or partials, if indicated, to determine if chewing problems or mouth pain were present. 6. Oral examination of residents who were uncooperative and did not allow for a thorough oral exam might have resulted in medical conditions being missed. - M0100: Determination of Pressure Ulcer/Injury Risk 1. Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments. 2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident. 3. Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices were present. Assess key areas for pressure ulcer/injury development. Also assess bony prominences such as elbows and ankles, and skin under braces or subjected to pressure like ears from Oxygen tubing. - M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Steps for completing M0300A-G. Step 1: Determine Deepest Anatomical Stage - Observe and palpate the base of any identified pressure ulcers present to determine the anatomic depth of soft tissue damage involved. Step 2: Identify Unstageable Pressure Ulcers - visualization of the wound bed was necessary for accurate staging. Step 3: Determine Present on Admission. - M0300A: Number of Stage 1 Pressure Injuries 1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles). 2. For the purpose of coding, determine the lesion being assessed was primarily related to pressure and other conditions had been ruled out. 3. Reliance on only one descriptor was inadequate to determine the staging of a pressure injury between Stage 1 and deep tissue injury. 4. Check any reddened areas for ability to blanch by firmly pressing a finger into the reddened tissues and then removing it. 5. Search for other areas of skin that differ from surrounding tissue which might be painful, firm, soft, warmer, or cooler compared to adjacent tissue. - M0300B: Stage 2 Pressure Ulcers 1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles). 2. For the purpose of coding, determine the lesion being assessed was primarily related to pressure and other conditions had been ruled out. 3. Examine the area adjacent to or surrounding an intact blister for evidence of tissue damage. 4. Stage 2 pressure ulcers would generally lack the surrounding characteristics found with a deep tissue injury. 40142 On 10/11/2023 at 10:12 AM, the RAI Regional Coordinator revealed covering for the MDS Coordinator who was not available for interview. The RAI Regional Coordinator indicated both of them worked remotely and relied on the nurses and other interdisciplinary team (IDT) members for entries into the MDS. The RAI Regional Coordinator confirmed the MDS Coordinator, and the Regional Coordinator did not perform bedside assessment but relied on the facility's nurses for entries. On 10/12/2023 at 2:57 PM, the Social Services Director (SSD) explained the social services was responsible in completing Sections B (Hearing, Speech, and Vision), C (Cognitive Patterns), D (Mood), E (Behavior), and Q (Participation in Assessment and Goal Setting) of the MDS. The SSD indicated for all the SSD's portions of the MDS, the SSD would have met face-to-face with the resident. When the resident was unable to complete a portion for example the Brief Interview for Mental Status (BIMS), the SSD would have interviewed the staff using a 7-day look back questionnaire. The SSD explained once the SSD completed their portion and locked it, the system would have prompted the SSD to sign the signature page electronically. On 10/12/2023 at 3:10 PM, the Administrator indicated the facility had an in-house MDS Coordinator prior to the facility contracting with a third-party vendor who provided the facility with an outsourced MDS nurse since August 2022. The Administrator explained the agreement was not detailed but was expected to encompass regulatory requirements of the RAI manual. The Administrator confirmed neither the outsourced MDS Coordinator nor the RAI Regional Coordinator had been to the facility but completed resident assessments by relying on the nursing management team, namely, the Director of Nursing (DON) and Assistant Directors of Nursing (ADON). Virtual visits were done by telehealth, but no face-to-face assessments were performed by the outsourced MDS nurse and RAI Coordinator. The Administrator confirmed the nursing portions of the MDS which included assessment of resident wounds, along with the universal daily assessment (UDA) were done remotely, through virtual visits but not directly such as face-to-face.

Based on observation, interview, and document review the facility failed to ensure the resident's right of dignity was honored for one unsampled resident (Resident 142). The deficient practice had the potential to have psychosocial impact on residents of the memory care unit. Resident 142 (R142) R142 was admitted on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, and major depressive disorder. A Brief Interview for Mental Status (BIMS) documented R142 had a score of 99 which indicated the resident was not able to complete the evaluation. On 10/10/23 at 12:41 PM, R142 was in dining room calling out for assistance and a Registered Nurse (RN) was sitting at nursing station approximately 25-30 feet away. The RN yelled to the resident to question what was being requested and when R142 did not respond, the nurse kept on working at station and said nope in quiet tone. On 10/10/2023 at 12:45 PM, the RN indicated the resident often will yell out asking for help and it can be repetitive whether nurse walks over or not. The RN indicated the best practice would be to walk to the resident and find out what was being requested rather than yelling through the unit. On 10/12/23 at 9:47 AM, RN2 verbalized when resident was calling out for help it would be best to go directly to resident. The RN indicated it would not be appropriate to yell from the nurses' station to find out what the resident needed. The RN explained most residents have behaviors and it would not be appropriate, and it would also be a dignity and privacy concern for the resident to discuss in a loud voice any concerns as it was unknown to the nurse. The facility policy titled Resident Rights Standard of Practice (undated) documented the resident had the right to be treated with respect and dignity including the right to personal privacy and confidentiality of his or her personal and medical records.

Based on observation, interview, record review, and document review, the facility failed to ensure the correct strength of a medication was available during the medication pass for 1 of 31 sampled residents (Resident 118). This deficient practice could lead to potential medication errors, and increased the risk of administering an incorrect dosage. Findings include: Resident 118 (R118) R18 was admitted on [DATE], with diagnoses including alcoholic cirrhosis of the liver and alcohol abuse. On 10/11/2023 at 8:18 AM, a Registered Nurse (RN) prepared the medications except for the Cholecalciferol tablet 1000 units for vitamin deficiency. A Physician order dated 08/17/2022, documented Cholecalciferol tablet 1000 units, to give 1 tablet by mouth one time a day related to vitamin D deficiency. The Medication Administration Record dated 10/12/2023, documented the Cholecalciferol tablet 1000 units was not administered due to unavailability. On 10/11/2023 at 11:30 AM, a Registered Nurse (RN) confirmed the Cholecalciferol (Vitamin D) tablet 1000 units, was not administered during the medication pass due to its unavailability. The RN explained the available vitamin D in the medication cart was of a different strength, which was 10 micrograms, equivalent to 400 units, and not the 1000 units as ordered. The RN indicated the medication should have been checked before passing to prevent missed or delayed administration. On 10/13/2023 at 1:12 PM, the Director of Nursing (DON) indicated the medication should have been administered one hour in advance or one hour after the scheduled time. The DON indicated the resident's rights in medication administration should have been implemented. A facility policy titled Administering Medications dated December 2012, documented medications were to be administered in a safe and timely manner and as prescribed. Medications had to be administered within one hour of the prescribed time.

Based on observation, interview, record review, and document review, the facility failed to ensure the physician orders for wound healing and management were followed as ordered for 1 of 31 sampled residents (Resident 57). This deficient practice left the resident's wound soaked in urine, posing a potential risk of irritation and infection. Findings include: Resident 57 (R57) R57 was admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body), hemiparesis (one-sided muscle weakness), and diabetes mellitus. The Brief Interview of Mental Status dated 08/23/2023, documented a score of 12/15, which indicated R57's cognitive status was intact. The Minimum Data Set for Skin Conditions dated 08/23/2023, documented R57 had stage 2 pressure ulcers. The Skin/Wound Note dated 10/05/2023, documented R57 presented with multiple deep tissue pressure injuries (DTPIs). R57's underlying comorbidities were currently managed by the facility. R57 was referred to wound evaluation and treatment. Due to the numerous comorbidities, the goal was to prevent the progression of the wound, prevent infection, and prevent hospitalization . A Physician order dated 10/02/2023, documented sacrogluteal stage 2 pressure injury to cleanse with normal saline, pat dry, apply skin prep, cover with foam dressing daily at noon, and as needed if soiled or dislodged. A Physician order dated 10/02/2023, documented a left heel stage 2 pressure injury. Cleanse with normal saline, pat dry, apply skin prep, cover with foam dressing daily at noon, and as needed if soiled or dislodged for wound care. A Physician order dated 10/02/2013, documented sacrogluteal stage 2 pressure injury, cleansed with normal saline, pat dry, apply skin prep, cover with foam dressing daily and as needed (PRN). A Care Plan (undated), documented R57 was at risk for impairment of skin integrity. The interventions included following facility protocols for the treatment of injuries. Keep the skin dry. On 10/10/2023 at 11:29 PM, R31 lay in bed in the supine position and indicated had wounds in the sacrum and on the left heel. On 10/10/2023 at 12:42 PM, a Certified Nursing Assistant (CNA) was observed providing continence care. R57's sacrum had a wound dressing, undated. R31's left heel had no dressing in place. The CNA confirmed the dressing had not been in place for a few days. The Medication Administration Record from 10/02/2023-10/11/2023 documented R57's wounds of the sacrum and left heel were treated, and foam dressing was applied daily as ordered. On 10/11/2023 at 1:23 PM, a Registered Nurse RN, provided wound care to R57. R57's left heel had no old dressing in place. The RN cleansed the left heel wound with saline, treated, and covered it with a foam dressing. The RN repositioned R57 to the left side, and it was revealed R57's open wound at the sacrum was soaked with urine and a small amount of fecal matter, no old dressing was in place. The RN indicated R57's wound should have been covered with a dressing as ordered to protect from friction and should not have been soaked with urine or fecal matter. The RN indicated if the wound dressing was soiled, the CNA should have called the RN to change the dressing, but had not been informed. On 10/11/2023 at 1:35 PM, the assigned CNA, indicated in the morning R57's brief was wet and had been changed, but R57's wound on the sacrum had no dressing in place. The CNA explained the RN assigned to R57, was not informed because the CNA was unaware the wound dressing needed to be reinforced when not in place. On 10/11/2023, the Assistant Director of Nursing (ADON), stated the resident's open wound should have been covered with a wound dressing as ordered to prevent exposure to urine or fecal matter. On 10/11/2023 at 2:36 PM, the Director of Nursing (DON) indicated the staff were expected to follow the physician's orders to promote wound healing. On 10/13/2023 at 8:41 AM, the Assistant Director of Nursing (DON) indicated R57's wounds were facility acquired, it was healed and had reopened. The ADON indicated R57's wounds had active treatments to cleanse, treat and covered with foam dressing daily and to change the dressing if soiled or dislodged. On 10/13/2023 at 8:43 AM, the DON indicated R57's wound was chronic and recurring. The DON indicated the contributing factors correspond with R57's age, impaired mobility and being diabetic. On 10/12/23 at 10:58 AM, the wound physician indicated to promote wound healing, the wound should have been cleansed, the dressing changed as ordered, and there should have been a barrier to prevent the wound from soaking up the resident's urine and fecal matter. The wound physician indicated the staff were expected to follow the wound orders. A facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol (Treatment and Management) dated 04/2018, documented the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, dressings, and the application of topical agents. A facility policy titled Medication and Treatment Orders, dated 07/2016, documented orders for medications and treatments would be consistent with principles of safe and effective order writing. The medications and treatments shall be administered upon written order.

Based on interview, clinical record review and document review, the facility failed to ensure 2 of 25 residents maintained their nutritional status (Residents #2 and #3). The facility failed to ensure their policy for Nutritional Service and Weights were followed for 2 or 25 sampled residents (Residents # 2 and # 3). Findings include: The facility's policy entitled,"Clinical Nutritional Services (undated) documented, III Definitions: A. Nutritional Assessment was the comprehensive process for defining an individual's nutrition status and needs using medical, dietary intake, and medication intake histories, physical examination, anthropometric measurements, laboratory data and resident interview as appropriate. IV. Responsibilities: The Registered Dietician (RD) will complete the comprehensive assessment, as well as Dietary consultation requests written by the physician or other healthcare providers." The facility's policy entitled Guidelines for Weights (undated) documented "Monthly weights will begin once the 4 weeks of weekly weights have been completed. Monthly weights will be done on the first Monday of the month. Weights that were found questionable upon entry into the computer system a re-weight will be done. Once the weight was confirmed, no additional re-weights were needed. The Nutrition/Hydration Committee will also validate the weekly weights were being obtained and documented no less than monthly during their weekly meetings. Any identified issues should be reported to the Director of Nursing immediately for resolution of the issue." Resident #2 Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Vital Sings and Weight Record for Resident #2 documented the following: On 2/1/12 weight 99.8 pounds. On 2/8/12 weight 97.7 pounds On 2/29/12 weight 96 pounds On 3/7/12 weight 95 pounds ( 5% weight loss) On 3/14/12 weight 104 pounds (re-weight 104 pounds) On 3/21/12 weight 83 pounds (re-weight 83 pounds) On 3/28/12 weight 104 pounds (re-weight 104 pounds) The February 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation entitled Nutritional Review "Quarterly" dated 2/8/12, indicated "resident grossly underweight Body Mass Index (BMI) 16.6." The resident was on multiple high calorie interventions-"eats well when fed by staff, but doesn't feel well this week possibly related to Keflex (antibiotic) for [MEDICAL CONDITION]." Puree diet tolerated. "Supplement serving to sustain weight within range 97-103" pounds times 4 months. No new recommendations. The resident was on multiple interventions and 1:1 feeding. The documentation indicated Resident #2's current weight was 97.8 pounds and his ability to chew was compromised. Cognitive status confused. "? Nausea, ABT." Medication review discontinued [MEDICATION NAME], decreased [MEDICATION NAME] and Keflex. The comments section documented "8/11: 119.3 # (pounds) super cereal super pudding, snacks TID (3 times a day), health shake TID, House supplement TID, (? a word) Ensure TID." The Nurse's Notes dated 2/4/12 through 2/28/12 lacked documentation the physician had been notified of the resident's continued refusal of meals, supplements and weight loss. The Nurse's notes lacked documentation the resident's weight loss had been addressed at the weekly weight meetings. On 2/12/12, a physician's orders [REDACTED]. The clinical record lacked documentation the Registered Dietitian (RD) had acknowledged the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation entitled CNA (Certified Nursing Assistant) Daily Tracker dated February 2012 indicated Resident #2 had refused his meals 23 times during the month. The CNA Tracker on 2/10/12 and 2/26/12 for breakfast and lunch were blank. There was no documentation to indicate if the resident had refused the meals or how much of the meals the resident consumed. The CNA Tracker form contained an area to document the amount of health shake/supplement the resident consumed. From 2/1/12 through 2/29/12 the resident refused the health shake supplement 8 times and the amount consumed was documented 11 times in the month as zero intake. The rest of the area to document the percentage consumed were blank. The MAR indicated [REDACTED]. The CNA Daily Tracker dated March 2012, indicated Resident #2 had refused his meals times 20 times in the month. The CNA Tracker form contained an area to document the amount of health shake/supplement the resident consumed. From 3/1/12 through 3/31/12, the documentation indicated the health shake/supplement amount the resident consumed was documented 3 times in the month and on 4 occasions as zero documented as the intake amount. The rest of the area to document the percentage consumed were blank. On 3/2/12 a physician's orders [REDACTED]. The clinical record lacked documentation the RD acknowledged or monitored the resident for weight loss in accordance with the physician's orders [REDACTED]. The clinical record lacked documentation the RD had addressed the weight loss on 3/7/12 from 99.8 pounds to 95 pounds. The clinical record lacked documentation interventions had been put into place to slow down or stop the resident's weight loss. The clinical record lacked documentation of an RD assessment after the 2/8/12 entry until 5/2/12. The Nurse's Notes from 3/2/12 through 3/17/12 lacked documentation the physician had been notified of the resident's continued refusal of meals, supplements and the weight loss down to 95.0 pounds (a 5% weight loss). On 9/13/12 at 2:30 PM, the RD stated all facility residents were weighed at a minimum monthly and weekly weights were done as needed per the physician's orders [REDACTED]. The RD verbalized monthly weights were reported to him around the 10th of the month. The RD indicated he would look for residents with significant weight fluctuations up or down. If a resident had a 5% or more increase or decrease in a month he would address the weight gain or loss. The RD indicated insidious weight loss was that of a 4-5 pound weight change and if the resident lost the following month it could result in a significant weight loss. The RD stated he would chart when a resident lost weight twice and checked to see if the resident had eaten well. The RD stated he would try to "nip it in the bud" before the weight loss became a problem. The RD stated when a resident had a weight loss he would check the meal percentages and supplements along with the refusal of meals and/ or supplements. The RD verbalized as part of his assessment he would speak with the Licensed Nurses, Certified Nursing Assistants (CNA)'s, observe the resident during a meal. The RD stated he would also speak with the resident; otherwise the assessment was not complete. The RD indicated the assessment needed to be individualized. The RD indicated he would ask the resident why they had refused the meals/or supplements and discuss food preferences with the resident. The RD stated sometimes a resident would eat better at breakfast than at lunch and dinner, so the facility would provide more food at that meal. During the interview on 9/13/12, the RD stated he had not spoken with the resident in a while and had not asked him why he had refused his meals. The RD indicated there was no documentation on the care plan to indicate Resident #2 had refused meals or supplements. On 9/13/12, during the interview the RD stated a re-weight would be advisable for a resident with a 5% weight loss. The RD indicated the resident's weight loss was 5% in a month and no re-weight was done. The RD stated after the resident's weight went down to 95 pounds the intervention was to continue to monitor his weight. The RD verbalized he was not aware the resident had refused his meals and or supplements. The RD stated there was no documentation in the clinical record to show he had spoken with the resident regarding the refusals or the resident's likes/dislikes were addressed. The RD confirmed there was no documentation to indicate why the resident had lost weight. The RD was asked if the weight from 104 pounds to 95 pounds in a week was significant weight gain and an accurate weight. The RD indicated "It doesn't look like it is". The RD stated when the resident's weight was documented as 83 pounds he did not address the weight. On 9/14/12 at 9:15 AM, a Registered Nurse (RN) stated monthly weights were done on the first Monday of the month and put into the computer system. The residents with a 5%, 7.5% and 10% weight loss or increase were referred to the weekly weight meetings where the weight issues were reviewed. The RN stated the facility had conducted the weekly weight meetings for less than 2 months. The RN indicated the resident's weights were checked against the previous weight and the weights given to the Licensed Nurse (LN). The LN would request a re-weight or the staff member could obtain a re-weight if the weight "looks off" and the scale could be calibrated. The RN stated she did not know how often the scales were calibrated at the facility. The RN verbalized she would have to speak with the Maintenance Staff. The RN did not provide the requested information regarding how often the facility calibrated the scales before the survey team exited the facility. On 9/14/12 at 10:15 AM, a Licensed Nurse (LN) stated if a resident had been refusing their meals the physician would be called. The resident should be asked why they refused the meal. The LN indicated an attempt should be made to determine if it was the food or if the resident had a problem with tooth pain. The LN verbalized when the resident refused the supplement the staff, need to find out why the resident refused. The LN stated the resident should be asked if they did not like a certain flavor such as chocolate and might prefer strawberry or was the supplement served warm and the resident preferred it cold. The LN indicated if the resident did not like a supplement an alternative could be offered. The LN verbalized the refusal of meals or supplements should be documented on the care plan and the physician notified.

Based on interview, record review, and policy review, the facility failed to ensure 5 of 24 sampled residents (Resident #7, #15, #23, #24, #19) identified as high risk for pressure ulcers had measures in place to prevent a pressure ulcer, had a complete assessment of the wound when it developed, and received treatment of [REDACTED]. Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The facility policy entitled, Wound Care (undated), documented "Stage I and II wounds are treated in house by licensed nurse following doctors order. Stage III and IV wounds are treated by outside agency. The policy indicated the following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date wound care was given. 3. The name and titled of the individual performing the wound care. 4. Any changes in the resident's condition. 5. All assessment date (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 6. Any problems or complaints made by the resident related to the procedure. 7. If the resident refused the treatment and the reason(s) why. 8. The signature and title of the person recording the data." Resident #7's medical record contained physician's orders [REDACTED]. The medical record contained an as needed (prn) treatment order to apply [MEDICATION NAME] dressing (trade name [MEDICATION NAME] an opaque dressing) to the new stage II wound and notify the physician. The Admission Data Set form dated 8/11/11, documented a full body assessment was completed for Resident #7. The documentation revealed Resident #7 had mild redness to the upper back area, a stage II ulcer on the ischium, along with discoloration on the right inner arm and mid inner arm, and the right inner forearm and the left foot had 3+ [MEDICAL CONDITION]. On 8/11/11, Resident #7's pressure ulcer review indicated the resident was a very high risk for pressure ulcers. Documentation entitled, Weekly Skin Assessment (Head to Toe) by Licensed Nurse dated 8/17/11, did not indicate Resident #7 had a left heel blister. A nurse's note dated 8/28/11, documented a Certified Nursing Assistant (CNA) reported Resident #7 had a pressure sore on the left heel, skin intact at the site. Cleansed with normal saline, [MEDICATION NAME] applied to left heel to prevent more pressure, will continue to monitor. The medical record lacked documentation regarding the size, color, any drainage, description of the wound, or a description of surrounding tissue on the left heel. The medical record lacked documentation Resident #7's physician had been contacted regarding the pressure sore/ulcer or for treatment orders. The medical record lacked documentation regarding Resident #7's left heel pressure ulcer or measures the facility had in place to decrease the pressure on the heel on 8/29/11, 8/30/11, 8/31/11, 9/1/11 and 9/2/11. The medical record lacked documentation to indicate the resident had refused treatment to the left heel. A nurse's note documented Resident #7 was not placed on an air mattress until after 9/2/11. On 9/3/11, a Wound Care Nurse from an outside agency documented the resident's left heel wound bed was purple fluid filled, the surrounding tissue was with in normal limits, no drainage was noted. The length was 4.0 centimeters (cm) and width 5.2 cm. The left heel was off loaded and instructions were given to the floor nurse regarding postioning and off loading of heel. The CNA was informed how to use the speciality mattress for optional pressure relief. On 9/3/11 at 1:30 PM, a physician's orders [REDACTED]. On 9/14/11 at 10:05 AM, the Unit 1 Nurse Manager verbalized according to the facility policy, when a pressure ulcer was noted the documentation in the medical record should include the size, color and description of the wound, description of surrounding tissue and its location. The physician should be contacted and treatment orders received. According to the Unit 1 Nurse Manager a physician's orders [REDACTED]. The Unit 1 Nurse Manager indicated preventive measures for residents at high risk of pressure ulcers included to turn frequently, out of bed, off load heels, weight shifts in the wheelchair to decrease the time and weight on an area. On 9/14/11 at 10:30 AM, the Unit 1 Nurse Manager stated Resident #7 was not admitted to the facility with a pressure ulcer on the left heel and was at very high risk of developing a pressure ulcer. The Unit 1 Nurse Manager stated the nurse's notes lacked documentation regarding the size, color and description of the wound, surrounding tissue. The Unit 1 Nurse Manager was not able to locate documentation the physician had been contacted regarding the blister or treatment orders had been obtained. The Unit 1 Nurse Manager stated a care plan was developed so staff know the problems and how to care for the residents. The Unit 1 Nurse Manager stated the care plan for the pressure ulcer should have been completed with preventive measures documented when the pressure ulcer was found, but it was not. The Unit 1 Nurse Manager stated the resident's care plan related to skin did not have preventive measures documented such as her speciality bed/mattress or the physician's orders [REDACTED]. The Unit 1 Nurse Manager stated a care plan for a blister was not the same as a care plan for a stage II pressure ulcer. On 9/15/11 at 10:30 AM, the Unit 1 Nurse Manager stated she was not able to locate documentation in the nurse's notes which addressed Resident #7's left heel pressure ulcer or preventive measures done to decrease the pressure to the left heel on 8/29/11, 8/30/11, 8/31/11, 9/1/11 and 9/2/11. The Unit 1 Nurse Manager verbalized [MEDICATION NAME] was usually ordered to be changed every 3 days and as needed if it became dirty. The Unit 1 Nurse Manager was not able to locate documentation in the medical record to indicate the Registered Dietician or Dietary Manager were aware of the resident's left heel pressure ulcer. On 9/15/11 at 12 Noon, the Dietary Technician stated the Nutrition At Risk committee looked at wounds and weight loss. A wound report was placed in her mail box every Thursday. The Dietary Technician verbalized she was not notified of the resident's pressure ulcer until 9/8/11. On 9/15/11 at 3:17 PM, Licensed Nurse (LN) #1 and LN #2 stated a blister was considered a stage I if the area was not open and the physician should be contacted when discovered. LN #1 and LN #2 both verbalized when the blister opened it would be considered a stage II pressure ulcer and the physician should be contacted. Both LN #1 and LN #2 verbalized they were not sure if [MEDICATION NAME] was a [MEDICATION NAME] dressing or not. On 9/16/11 at 10:50 AM, the outside agency Wound Care Nurse verbalized on 9/3/11, she was providing wound care for Resident #7's left ischium wound. The Wound Care Nurse stated she had turned the resident onto her side to provide the wound care for Resident #7's left ischium pressure ulcer and saw a deep purple intact blister on the left heel. The Wound Care Nurse verbalized the area was unstageable because she could not see the wound bed. The Wound Care Nurse stated she preferred to use [MEDICATION NAME] because it was see through and you can tell if the blister opens and when the [MEDICATION NAME] was removed it would not open the blister. According to the Wound Care Nurse when [MEDICATION NAME] was removed it will pull off the skin and open the blister. Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Data Set form dated 5/2/11, documented Resident #15 was a high risk for pressure ulcers. physician's orders [REDACTED]. The Treatment Administration Record (TAR) contained an as needed treatment order to apply [MEDICATION NAME] dressing to the new stage II wound and notify the physician. A nurse's note dated 8/27/11 at 7:30 PM, documented the resident was found with a big blister on the left heel during the skin assessment. Cleansed site with normal saline. Applied [MEDICATION NAME] to area. Will continue to monitor. The medical record lacked documentation Resident #15's physician was notified of the blister on the left heel or the wound had been assessed for wound size, color, drainage or a description of surrounding tissue on the left heel on 8/27/11. The medical record lacked documentation a physician's orders [REDACTED]. A nurse's note dated 8/28/11 at 9:30 PM, documented the resident was found with an open area on left heel. Slight bleeding at the site. Cleansed with normal saline. [MEDICATION NAME] applied to the area. The medical record lacked documentation on 8/28/11, the left heel had been assessed for the wound size, color, drainage or a description of surrounding tissue in accordance with the facility's policy. The medical record lacked documentation Resident #15's physician had been notified of the stage II pressure area in accordance with the as needed treatment order. The TAR lacked documentation the [MEDICATION NAME] dressing to new stage II wound was signed by the LN when applied. The medical record lacked documentation on 8/29/11, 8/30/11 or 8/31/11, regarding the stage II pressure ulcer. The medical record lacked documentation from 8/27/11 through 9/7/11, regarding measures in place to decrease the pressure on the heel. On 9/1/11, a physician's orders [REDACTED]. Cleanse with normal saline, pat dry, apply hydrogel gel, daily, cover with dry clean dressing for 7 days then re-evaluate. A comprehensive care plan dated 9/1/11, documented the resident had current skin concerns, open blister on the left heel. The documented approaches included: perform treatment per orders, monitor areas for increase breakdown, signs and symptoms of infection. On 9/16/11 at 8:45 AM, the Unit 1 Nurse Manager verbalized a blister was a stage I pressure ulcer and an open area was a stage II pressure ulcer. The Unit 1 Nurse Manager verbalized the left heel had not been fully assessed because there were no wound measurements or documentation regarding drainage and a description of surrounding tissue. The Unit 1 Nurse Manager was not able to locate documentation the physician had been notified on 8/27/11 regarding the blister or on 8/28/11 when the pressure ulcer was a stage II. The Unit 1 Nurse Manager verbalized the physician should have been called regarding the blister and treatment orders received. According to the Unit 1 Nurse Manager a physician's orders [REDACTED]. The Unit 1 Nurse Manager was not able to locate documentation to show a comprehensive care plan had been initiated when the blister was noted on the resident's heel. The Unit 1 Nurse Manager verbalized the care plan should have been done when the blister was found. On 9/16/11 at 9:50 AM, LN #1 stated if [MEDICATION NAME] was placed on a closed blister and then removed the next day, due to the stickiness of the [MEDICATION NAME] "you would probably break the blister open." Resident #23 Resident #23 was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #23's Weekly Wound Measurement for Pressure Ulcer (Stage I to Stage IV) form identified on 4/15/11, a left buttocks stage II wound measuring 1 cm (centimeter) X 1 cm. The form documented under the treatment section: - " ...cleanse with wound cleanser. Apply [MEDICATION NAME], cover, change every 3 days & PRN (as needed) ... " There was no documented evidence an order was obtained from the physician to change the [MEDICATION NAME] every 3 days for Resident #23. There was no documented evidence Resident #23's [MEDICATION NAME] to the coccyx area was changed every 3 days. There was no documented evidence Resident #23's [MEDICATION NAME] treatment plan was transferred to the treatment administration form to track when the dressings were being changed every 3 days. On 9/16/11 in the afternoon, the Director of Nursing (DON) confirmed an order should have been obtained for Resident #23 to change the [MEDICATION NAME] every 3 days and the order should have been placed on the treatment administration record. Resident #19 Resident #19 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission (MDS) data set [DATE] indicated, "4. Left outer heel stage I - 3x2 slightly red. 5. Stage II R (right) heel - 1.3 x 0.8 superficial open area." The Quarterly (MDS) data set [DATE] indicated, "Res (resident) has an unstageable pressure ulcer on l (left) heel 3 x 4 cm (centimeters), depth = 0.5 cm. [DIAGNOSES REDACTED] = brownish slough center, scant, yellowish drainage..." (There was no documentation of the skin assessment of the right heel.) The Quarterly (MDS) data set [DATE] indicated, "1. L heel pressure ulcer stage III - 0.8 x 1.2 x 0.2 cm (with) scanty serrous drainage, pinkish wound bed. 2. R heel pu (pressure ulcer) stage II 0.3 x 0.2 cm, pinkish, pinkish wound bed. 3. R ankle stage II 0.5 x 0.3 x 0.1 cm, pinkish." The left heel ulcer was identified on 10/15/10, but not measured until 11/9/10. The right heel ulcer was a stage II ulcer which was measured by the Wound Care Agency Nurse on 11/2/10 but was not remeasured until 11/20/10. The Skin/Wound Data Sheets completed by the wound care agency nurse documented the measurements as follows: 10/21/10: R heel, stage II 1.2 cm length, 1.6 cm width, 0.2 cm depth (with) black scab. (There was no documentation of any measurements or any treatment to the left heel ulcer.) 10/26/10: R heel, stage II, 1.0 cm length, 1.4 cm width, 0.2 cm depth, pinkish. (There was no documentation of measurements of the left heel ulcer.) 11/2/10: R heel, stage II, 1.0 cm length, 1.3 cm width, 0.2 cm depth, pinkish. (There was no documentation of measurements of the left heel ulcer.) 11/9/10: L (left) heel outer lateral, stage II, 1 cm length, 0.5 cm width, 0.1 cm depth, pinkish. L heel popped blister with redness on left heel, 3 cm length, 2 cm width, pale pink. (There was no documentation of measurements of the right heel ulcer.) 11/17/10: L heel, stage II, 0.4 cm length, 0.3 cm width, 0.1 cm depth, pinkish. L heel blister, 3 cm width, 2 cm depth, black discoloration inside blister. (There was no documentation of measurements of the right heel ulcer.) 1/20/10: L heel, stage II, 0.7 cm length, 0.5 cm width, 0.1 cm depth. L heel blister, 3 cm x 2 cm blackish. R heel, stage II, 1 cm length, 0.8 cm width, 0.2 cm depth, pinkish. 11/23/10: R heel stage II, 1 cm length, 0.5 cm width, 0.2 cm depth, pale pink. L heel blister turned to Stage II pressure sore (blister popped), 3 cm length, 3 cm width, 0.2 cm depth, blackish. 11/30/10: L heel, blister, 3.0 cm length, 4.0 cm width, necrotic. R heel, stage II, 1 cm length, 1 cam width, 0.2 cm depth, red. 12/2/10: L heel blister, 2.5 cm length, 4.5 cm width, undetermined depth, necrotic. R heel, stage II, 2.75 cm length, 0.75 cm width, .2 cm depth, red. 12/8/10, L heel 3 cm length, 4 cm width, undetermined depth. R heel .3 cm length, .3 cm width, .1 cm depth, pink. (The 12/19/10 and 12/26/10 data sheets indicated the right heel was healed but reddened.) 1/2/11: L heel, (not staged) 3 cm length, 4 cm width, 02 cm depth, black eschar with open lesion around eschar site, serrous drainage, gangrenous odor. The "Weekly Skin Assessment" policy (undated) indicated, "1. Weekly skin assessments will be conducted, per scheduled shift and day on the MAR (Medication Administration Record), by the licensed nurse...5. The weekly wound measurement forms will be filled out weekly until the wound has healed." On 9/16/11 in the evening, the Director of Nursing (DON) indicated the Wound Care Agency nurse is responsible for the measurement of the wounds and the Unit Manager is responsible for tracking of the wounds. On 9/16/11 in the evening, the Director of Nursing (DON) and the Unit 2 Nurse Manager verified there were no consistently documented measurements of the left and the right heel ulcers. The Unit 2 Nurse Manager further verified the care plan did not document the left and the right heel pressure ulcers as a problem until 1/21/11. The DON and the Unit 2 Nurse Manager both indicated there had been some errors made by the wound care agency nurse for the pressure ulcer measurements on Resident #19's heels. The DON stated, "There was some confusion. I think she wrote down the wrong heel almost every time. I don't know which heel she was treating. She kept on making mistakes." Resident #24 Resident #24 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The Admission Skin Check form dated 12/29/10 indicated there was a stage III pressure ulcer on the coccyx, and redness on the right and left heels. The Full Body Skin Inspection section indicated, "Stage 3 sacrum ulcer, 3.5 cm x 1 cm, 2.3 mm depth". The Wounds Document forms by the wound care agency nurse indicated the following: 5/8/11: "Pt lying on side - turned & positioned. Wound care, stool-saturated dressings. Floor nurse aware." 5/15/11: "Wound has deepened. red non-granulating tissue. Pt needs pressure relief when in chair. Pt does not move, legs contracted. Pressure relief cushion could be useful." 5/29/11: "Wound care (with) measurement - improvement. Spoke to unit nurse and made aware pt to not be on coccyx for more than hour. Needs chair cushion...2.6 cm length x 1.9 cm width x 1 cm depth." 6/3/11: "Wound care provided. Bed of wound - red edges pink. Roho Cushion assessed for proper inflation. Released air. Due to cushion to (too) hard released more pressure. Informed floor nurse of care." 6/3/11. Pressure could possibly be from too much air cushion causing (increased) pressure." 6/5/11: "Wound assessment & measurement. Increase of size...pt on Roho Cushion when (up). Possible breakdown due to (increase) to chair (with) cushion full of air. Readjusted the pressure on Friday 6/11/11: "Roho Cushion provided..." 6/12/11: "Wound care provided & measurements taken. Wound measurements (increase) due to cushion for chair inproperly filled..." 6/15/11: "Multiple issues addressed to floor nurse due to pressure continues to increase..." The Care Plan had the following pressure ulcer handwritten documentation: 2/9/11: Res (resident) currently has a stage III pressure ulcer on coccyx that's 1.0 length x 2.2 w (width) x 0.1 cm (centimeter). Currently receiving tx (treatment). 5/4/11: Coccyx stage III pressure ulcer 3.5 length x 2.3 w x 2.0 cm depth. Slough noted. There were the following additional approaches handwritten on the care plan, which were not dated: -Cleanse (with) wound cleanser, pat dry. Apply [MEDICATION NAME] dressing as ordered prn (as needed). -Pressure reducing mattress on chair and bed as needed/ordered. -Home health to do wound treatment as ordered. There was no documentation of coordination of care between the facility and the home health agency Wound Care Nurse regarding the assessment and the monitoring of the pressure in the gel cushion. On 9/16/11 at 4:15 PM, Unit 600 Nurse Manager, verified there was no documentation of a physician's orders [REDACTED]. When she (the wound care agency nurse) came in she said it was too full and she deflated it."