Every finding on record at Mountains Community Hosp DP/SNF

Based on interview and record review, the facility failed to ensure residents' comprehensive care plan (person centered, individualized roadmap used to outline specific care interventions for a nursing home resident) was updated to address psychotropic (chemical that affects how the brain works, changing a person mood) medications for one of two sampled residents (Resident 13) .This failure had the potential to result in inconsistent implementation of care, missed monitoring for effectiveness, adverse side effects (harmful, unintended reactions to medications), lapses on non-pharmacological interventions (evidence-based non-drug methods used to prevent or manage symptoms), and individualized approaches to care. Findings:During a review of Resident 13's LTC (Long term care) History & Physical (contains medical information), dated July 18, 2025, the LTC History & Physical indicated, .she [Resident 13] has a long h/o [history of] depression [mood disorder causing persistent feelings of sadness] .During a review of Resident 13's Medication List, dated July 28, 2026, the Medication List indicated, .Bupropion HCL [hydrochloride- antidepressant medication- used to treat depression] ER [extended release] 450 mg [milligram-unit of measurement] PO [by mouth] daily. and .Venlafaxine HCl [antidepressant medication] 225 mg PO Daily.During a concurrent interview and record review on July 29, 2026, at 1:16 PM, with the Minimum Data Set Licensed Vocational Nurse (MDS LVN), Resident 13's Care Plan, dated July 18, 2025, was reviewed. The Care Plan indicated, Problem. Medication Side Effects . Intervention . Monitor for s/s [signs and symptoms] medication side effects . Review medications for dose reductions. Problem . Behavior Crying and Anxious . Interventions . Encourage involvement in self care. Problem . Depression: Mood state. The MDS LVN verified and confirmed Resident 13's care plan did not contain Resident 13's current condition with psychotropic medications. The MDS LVN stated, the care plan should have been developed and updated to reflect Resident 13's specific condition. The MDS LVN further stated, she should have updated Resident 13's care plan to include Bupropion and Venlafaxine medications.During a concurrent interview and record review on July 30, 2026, at 10:25 AM, with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Resident Assessment and Care Planning (Policy) - Skilled Nursing Facility, dated November 20, 2025, was reviewed. The P&P indicated, .to establish a method.to develop and implement person-centered care that promotes quality of life. 6. Use of Assessment in Care Planning. b. The plan is updated every 90 days. The DON stated she did not check Resident 13's care plan to ensure it was updated.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines for a universe of 19 residents when expired medical supplies were found in procedure cart and medical supply room and were readily available for use. This failure had the potential to cause unsafe care provided to the facility's 19 residents with beyond the use date (expired) supplies, which could potentially cause infection, injuries, and/ or death. Findings: During a concurrent observation and interview on [DATE], at 6:10 AM, in the facility's treatment cart and medical supply room, with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN 2). The medical supplies were observed as follows: 1. 41 safety intravenous (IV) catheters (a thin, flexible tube inserted into vein to deliver fluids, medications or blood products directly into the blood stream) Size 24 gauge (size of catheter) with an expiration date of [DATE] (3 days expired). 2. Nine IV extension set (flexible tube used to extend the length of existing IV lines) with an expiration date of [DATE] (4 days expired). The DSD and LVN 2 verified and confirmed that 41 safety IV catheters and nine IV extension sets have been expired and should have been discarded. During a concurrent interview and record review on [DATE], at 10:10 AM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Infection Prevention and Control, dated [DATE], was reviewed. The P&P indicated, . 4. The Infection Prevention and Control Plan Policy objectives read in number one through eight: 1) Decrease the risk of infection to patients and personnel. 2) Monitor for occurrence of infection and implement appropriate control measures. 3) Identify and correct problems relating to infection prevention practices. 4) Limit unprotected exposures to pathogens throughout the hospital. 5) Minimize the risk associated with procedures, medical devices and medical equipment. 6). Maintain compliance with state and federal regulations relating to infection prevention . The CNO stated medical supplies should have been checked regularly and expired items should have been discarded, as using expired medical supplies can cause infections and injuries. The CNO further stated the facility did not follow the infection prevention and control policy.

Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 9) was free from significant medication error, when a furosemide (a medication commonly called as water pill that used to eliminate water and salt from the body) was held for a systolic blood pressure (the top number in a blood pressure reading and represents the pressure in the arteries when the heart beats) less than 100 without a hold order. This failure resulted in lack of appropriate documentation and had the potential to cause adverse health outcomes by not achieving the effective purpose of the medication and miscommunication amongst the following nursing staff. Findings: During a review of Resident 9's History and Physical (H&P- a formal assessment document by the physician), dated April 30, 2025, the H&P indicated, Resident 9 was admitted on [DATE], with diagnoses of benign prostatic hyperplasia (BPH-refers to a non-cancerous enlargement of the prostate gland, hypothyroidism (when your thyroid gland doesn't make and release enough hormone into your bloodstream), and cerebral palsy (is a group of lifelong movement disorders that occur due to brain damage before, during, or shortly after birth). During a concurrent medication administration observation and interview on June 3, 2025, at 9:03 AM, with Licensed Vocational Nurse (LVN 1), in front of the dining area, a furosemide medication was held for Resident 9. LVN 1 stated, Resident 9's furosemide would be held today because the parameter is to hold for systolic blood pressure < less than 100. During a concurrent interview and record review on June 3, 2025, at 2:24 PM, with LVN 1, Resident 9's medications orders, initiated on May 6, 2025, was reviewed. The medication orders indicated, furosemide (Lasix) 20 mg [milligram-unit of dosing medication] PO [by mouth] DAILY tablet and had a clinical indication for fluid retention. The order did not have any hold parameters. LVN 1 verified and stated that the current order for furosemide did not have any hold parameters. LVN 1 stated that the previous order furosemide order initiated on April 20, 2024, fell off on May 6, 2025, and that when the order was renewed, whoever put in the order did not put the hold parameters as the previous order . LVN 1 stated, it is important to have appropriate hold parameters in the orders, so that any nurse that takes over the resident's care know what to do. During a follow-up telephone interview on June 5, 2025, at 10:55 AM, with LVN 1, LVN 1 stated that furosemide order was not followed when it was held without any hold parameters. LVN 1 further stated she contacted the pharmacist to fix the order after it was brought up to her attention. During a concurrent interview and record review on June 5, 2025, at 1:14 PM, with the Chief Nursing Officer (CNO) the facility's policy and procedure (P&P) titled, medication errors and adverse reactions (policy), dated June 30, 2023, was reviewed. The P&P indicated, .Policy: All medications prescribed for and/or administered to patients and residents of the [Facility Name] shall be handled in a safe and effective manner, and properly recorded into the patient/resident's medical record. Deviations from this policy resulting in medication errors . may be related to: prescribing, order communication . Categories: Order communication, Types: Written order not entered into E-MAR [Electronic medical administration record- place on the electronic health record where staff can record the administration of medication], and Examples: written order not entered into E-MAR different from written or telephone order . The CNO agreed that according to the policy it is a medication error related to renewal of a written order into E-MAR. The CNO stated it was a system error and should have not happened.

Based on observations, interview, and record reviews, the facility failed to establish a comprehensive care plan (an individualized plan that includes residents' health problems, preferences and goals) consistent with the resident's medical needs for one of four residents (Resident 6) when the facility staff did not update Resident 6's care plan after identifying a change of condition. This failure resulted in inadequate response to Resident 6's changing needs, and had the potential increased risk of harm, delayed treatment, and reduced quality of life. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with the Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set (MDS-a standardized, comprehensive assessment that collects information about a resident's functional, medical, psychosocial, and cognitive status.) quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During an interview on June 5, 2025, at 11:28 AM, with LVN 3, LVN 3 stated that anytime a resident gets speech therapy added to the facility's electronic health record (EHR) system, nursing staff will get a pop up to that asks if the nursing staff want to incorporate it into the resident's care plan. LVN 3 further stated that the nurse can also manually put it into the resident's chart if the care plan needs to be updated. During a review of Resident 6's LTC [long-term care] progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. During a concurrent interview and record review on June 6, 2025, at 1:18 PM, with the Chief Nursing Office (CNO), Resident 6's care plan, undated, was reviewed. The care plan indicated that the last time it was reviewed was May 18, 2025. The CNO stated she did not see that the care plan was reviewed after Resident 6's change of condition. During a concurrent interview and record review on June 6, 2025, at 1:20 PM, with the CNO, the facility's policy and procedure (P&P) titled Change of Condition Resident (Policy)- Skilled Nursing Facility [SNF], dated January 21, 2021, was reviewed. The P&P indicated, . 7. A care plan will be developed by the SNF Licensed Nurse receiving the orders, addressing the change of condition, goals of treatment and interventions . The CNO stated the policy was not followed and it is important to update the care plan for resident safety and overall care.

Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed accurately for one of eight sampled residents (Resident 6) when the MDS assessment did not show Resident 6's current condition of having functional limitations to the right upper extremity and speech impairments. This failure resulted in inaccurate documentation of assessment for Residents 6 and had the potential to cause inadequate care planning, delay of necessary interventions that can lead to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an interview on June 2, 2025, at 9:00 AM, with the Education Manager (EM), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and the Director of Quality and Regulation Compliance (DQRC), they stated that Resident 6 was the president of resident council (an organized group of residents in the long-term care (LTC) facility to discuss concerns and suggest improvement). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During a review of Resident 6's LTC progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. During a review of the Speech language pathologist [SLP] Speech evaluation (SLP speech evaluation), dated May 24, 2025, the SLP speech evaluation indicated, [Resident 6's last name] struggled to hold a conversation. She demonstrated word-finding difficulties during spontaneous speech . under the indication for speech therapy it indicated, impaired motor speech, impaired spoken language expression. During a review of the SNF [skilled nursing facility] interdisciplinary resident care conference (SNF interdisciplinary care), dated April 22, 2025, the SNF interdisciplinary care indicated, Resident 6 had new onset right sided weakness. During a concurrent interview and record review on June 6, 2025, at 1:12 PM, with the CNO, the facility's policy & procedures (P&P) titled change of condition resident (Policy)- skilled nursing facility, dated January 21, 2021, was reviewed. The P&P indicated, . 8. as necessary, a significant change in status assessment MDS will be generated within fourteen (14) days of change of condition. The CNO stated Resident 6's assessment was not accurate, and a change of condition should have been done according to the facility's policy.

Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) for a change of condition was completed within 14 days as stated within their policy and procedures (P&P) and in accordance with the federal submission timeframes for one of eight sampled residents (Resident 6) when Resident 6's condition was changed from having clear speech and no impairment with movements to unable to lift right arm, speech was very weak and was having difficulty making a sentence. This failure resulted in inadequate monitoring of Residents 6 and had the potential to delay necessary interventions leading to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE]. and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an interview on June 2, 2025, at 9:00 AM, with the Education Manager (EM), Chief Executive Officer (CEO), Chief Nursing Officer (CNO), and the Director of Quality and Regulation Compliance (DQRC), they stated that Resident 6 was the president of resident council (an organized group of residents in the long-term care (LTC) facility to discuss concerns and suggest improvement). During an observation on June 2, 2025, at 10:58 AM, with Resident 6, Resident 6 was unable to complete a full sentence, attempted to say her name, but was having difficulty. Resident 6 was unable to lift her right arm. During concurrent interview and record review on June 4, 2025, at 2:36 PM, with Licensed Vocational Nurse/Director of staff development (LVN/DSD), Resident 6 's Minimum Data Set quarterly assessment (MDS quarterly assessment), dated April 21, 2025, was reviewed. The MDS quarterly assessment indicated, under section B. hearing, speech and vision that Resident 6's speech was clear, under section C. cognitive [related to mental process such as thinking and reasoning] patterns the Brief Interview for Mental Status (BIMS- a measure of cognitive function in individuals, typically used in long-term care facilities with a score ranges from 0-15, a score of 0-7 suggests severe cognitive impairment, 8-12- moderate impairment, 13-15 suggests intact cognition ) was 15, under section gg. Functional abilities functional limitation of the upper extremities it indicated no impairment, and under section i. active diagnosis in the neurological there was no aphasia (loss of ability to communicate) documented. The LVN/DSD verified and confirmed that the MDS quarterly assessment is not accurate, and no change of condition has been made for Resident 6. The LVN/DSD stated that Resident 6 had shown a decline in status for about a month. The LVN/DSD further stated that it has been over 14 days since the change in Resident 6's status. During a review of Resident 6's LTC progress note, dated May 20, 2025, by the physician, the LTC progress note indicated, . Right are unable to move up or close hand and voice very weak. During an interview and record review on June 6, 2025, at 1:12 PM, with the CNO, the facility's P&P titled, Change of condition Resident (Policy)-Skilled Nursing Facility, dated January 21, 2021, was reviewed. The P&P indicated, . 8. as necessary, a significant change in status assessment MDS will be generated within fourteen (14) days of change of condition. The CNO stated the policy was not followed and should have been as per regulation.

Based on observations, interviews, and record reviews, the facility failed to properly close the dumpster (large outdoor trash container) lids when two of eight dumpsters were found with trash bags exceeding the fill line of the dumpster. This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 18 medically compromised residents. Findings: During a concurrent observation and interview with the Registered Dietician/ Dietary Supervisor (RD/ DS), on April 17, 2023, at 12:04 PM, the outdoor garbage storage area had two dumpsters with trash bags exceeding the fill line of the dumpster, with the lids not fully closed. The RD/DS stated, the lids should be fully closed. During a concurrent observation and interview with the Environmental Service Manager (ESM), on April 17, 2023, at 12:07 PM, the ESM verified the two dumpsters had trash bags exceeding the fill line, preventing the lids from being fully closed. The ESM stated, the dumpster lids should always be closed because of the risk of attracting vermin. During an interview with the ESM, on April 17, 2023, at 12:30 PM, the ESM stated, they do not have a Policy and Procedure (P&P) for the outdoor garbage storage area. During a review of the FDA Federal Food Code, 2022, it indicated in 5-501.113, .Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT .

Based on observations, interviews, and record reviews, the facility failed to maintain professional standards for food safety when: 1.The ice machine was found to have black build up. 2.The dishwashing machine was not sanitizing. 3.There was no air gap (a separation between the water supply and potentially contaminated water in a sink or other plumbing fixture) found at the food preparation sink. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness (food poisoning that can cause nausea, vomiting, and diarrhea) to a population of 18 immuno-compromised (decreased ability to fight off infections and diseases) residents who received food from the kitchen. Findings: 1.During a concurrent observation and interview with the Director of Facilities (DOF) and the Lead Facilities Technician (LFT), on April 17, 2023, at 12:40 PM, the ice machine was observed to have black build up around the motor of the ice machine and the metal part of the ice chute (where ice falls down from the ice maker). A white cloth was used to wipe inside the metal part of the ice chute and a black substance was noted on the white cloth. During a joint interview with the DOF and the LFT, on April 17, 2023, at 12: 44 PM, the DOF stated, the facilities staff are responsible for cleaning the inside of the ice machine. The facilities staff clean the ice machine monthly and do a deeper cleaning quarterly (every three months). The DOF stated, the ice machine instruction manual is followed when cleaning the ice machine. The DOF and the LFT stated, there should not have been any black build in the ice machine. During a concurrent interview and record review with the DOF, on April 19, 2023, at 10:48 AM, the Cublet Icemaker/ Dispenser manual titled, [Company name] Cubelet Icemaker/ Dispenser Instruction Manual, dated November 15, 2013, was reviewed. The manuel indicated, .Sanitizing Procedure .3) Scrub the inside of the storage bin, inside the bin top, the agitator, drip ring, ice chute area, spout A, spout B, grille, and the inside of the drain pan using a nylon scouring pad, brushes, and sanitizing solution. Rise all parts thoroughly with clean water . The DOF stated, the ice machine instruction manual was not followed. During a concurrent interview and record review with the DOF, on April 19, 2023, at 10:50 AM, the Policy and Procedure (P&P) titled, Ice Machine Chute Cleaning Monthly Cleaning, dated January 2022, indicated, .3. Removed screw on chute and remove chute. 4. Mix 1 to 3 ratio De-scaler to warm water. 5. Soak chute in solution for 15 minutes. 6. Rinse chute. 7. Replace chute and screw back in screw . The DOF stated, the P&P was not followed when the ice machine contained black build up, which could result in widespread food borne illness. The DOF stated his expectation for the ice machine is to be clean with no black build up. During a record review of the Federal FDA 2022 Food Code 4-204.17, indicated The potential for mold and algae growth in this area is very likely due to the high moisture environment. Molds and algae that form are difficult to remove and present a risk of contamination to the ice stored in the bin. According to the CDC's (Center for Disease Control) Guidelines for Environmental Infection Control in Health Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised July 2019, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf), microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferal of organisms from hands. Ice from contaminated ice machines has been associated with .blood stream infections, pulmonary (having to do with the lungs) and gastrointestinal (having to do with the stomach and intestinal tract) illnesses. Recommendations for a regular program of maintenance and disinfection have been published. Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. 2.During a concurrent joint observation and interview with the Registered Dietician/ Dietary Supervisor (RD/DS) and kitchen assistant (KA 1), on April 18, 2023, at 8:06 AM, KA 1 stacked food trays in the dish rack. KA 1 then pushed the dish rack into the dishwashing machine and had it run a cleaning cycle. KA 1 checked the sanitation level (parts per million [ppm - unit of measurement] of chlorine [chemical used to kill bacteria] used to reduce the number of microorganisms [bacteria] to a safe level) of the dishwashing machine with a [Company Name] Chlorine Test Paper, but the chlorine test strip did not turn color, which indicated there was no chlorine in the dish machine. The RD/DS verified that the chlorine test strips indicated there was no chlorine, and the dishwashing machine was not sanitizing. The RD/DS stated, the machine gets checked monthly and the staff who run the dishwashing machine is supposed to check the sanitization with the test strips three times a day before meals and record the number of ppm. The chlorine test strip should read at least 50 ppm. During a concurrent interview and record review, on April 19, 2023, at 9:52 AM, the RD/DS reviewed the operation Manual titled, [Company Name] Series Installation/ Operation Manuel, dated October 29, 2007, which indicated, .MINIMUM CHLORINE REQURED (PPM) 50 . The RD/DS stated, the operation manuel was not followed. During a concurrent interview and record review, on April 19, 2023, at 9:55 AM, the RD/DS further reviewed the P&P titled, Dishwashing Sanitation, dated March 17, 2022, which indicated, .e. Complete a chlorine test at the start of each scheduled dish washing, breakfast, lunch, and dinner, patient and resident dishes, to measure the sanitizer level to assure the machine is functioning correctly with the correct level of sanitizer being dispensed. Follow the policy and procedure posted by the dish machine . f. The chlorine test must read 50-100 ppm . The RD/ DS stated her expectation is that the chlorine level is at 50 ppm to ensure bacteria is removed from the dishes. The RD/DS stated the P&P was not followed. 3.During a concurrent joint observation and interview with the RD/DS and the DOF, on April 19, 2023, at 8:27 AM, in the kitchen, one sink used for food preparation did not have an air gap. The DOF verified the sink drainpipes did not have an air gap. The DOF stated, that he did not know there should have been an air gap. The DOF stated, without an air gap, dirty water can back up into the sink and contaminate the food preparation sink. During an interview with the RD/DS on April 19, 2023, at 9:54 AM, the RD/DS verified there was no P&P regarding air gaps for the food preparation sink or the kitchen area. The RD/DS stated, her expectation is there should be an air gap where the food is prepared and where meats and poultry are defrosted. The RD/DS stated, an air gap is important because of the risk of pipes back flowing into the sink and contaminating the food preparation sink. A review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . A review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow .

Based on observations, interviews, and record reviews, the facility failed to follow their Policies and Procedures (P&P) regarding infection control practices during an eye drop medication administration for one of eighteen sampled residents (Resident 16). This failure had the potential to introduce bacteria into one resident's eyes in a population of eighteen sampled residents (Resident 16). Findings: During a review of Resident 16's clinical record titled, History and Physical (H&P- past and current medical history) Examination- Final Report , dated, July 19, 2021, at 2:26 PM, by Physician (Phys. 1) indicated, Resident 16's diagnoses included Type 2 Diabetes (inability to control blood sugar), Congestive Heart Failure (CHF- condition in which the heart does not pump blood efficiently), and yeast dermatitis (fungal infection on the skin). During an observation on April 19, 2023, at 6:44 AM, inside Resident 16's room, with the Licensed Vocational Nurse (LVN 1), observed the LVN 1 put on gloves, electronically scan (hand held scanner) Resident 16's name card (card that contains the resident's name and a bar code), and scan the medications Famotidine oral medication (decreases stomach acid) and Olopatadine Solution (0.2% - eye drop medication - used to treat eye infections). The LVN 1 proceeded to administer the oral medication (Famotidine) to Resident 16 and then adjusted the side bed rails (plastic rails attached to the bed used for repositioning and safety) and bed blankets. The LVN 1 then administered Resident 16's eye drop medication (Olopatadine). The LVN did not wash her hands or change her gloves prior to administering the eye drop medication. During an interview on April 19, 2023, at 6:55 AM, with the LVN 1, acknowledged, after the oral medication was administered to Resident 16, the LVN 1 should have taken off her dirty gloves, washed her hands, and put on clean gloves prior to administering the eye drop medication. The LVN 1 stated, by not washing her hands and changing her gloves prior to eye drop medication administration, Resident 16 was placed at risk for infection. During a review of Resident 16's clinical record titled, Patient Chart Orders, dated February 18, 2023 at 2:12 pm, by Phys. 1, indicated, Olopatadine Ophthalmic Solution (0.2% - eye drops) was ordered to be given to Resident 16 every 12 hours, one drop of medication in both eyes. During a review of Resident 16's clinical record titled, Patient Chart Orders, indicated, Olopatadine Ophthalmic Solution (0.2%) was given to Resident 16 on April 19, 2023, at 6:46 AM by the LVN 1. During a concurrent interview and record review on April 20, 2023, at 11:49 AM, with the Infection Preventionist Nurse (IP Nurse), The Lippincott Manual of Nursing Practice indicated, . Instillation of Medications .2. Solution or ointment is administered using clean technique . The IP nurse stated, clean technique would include washing hands and putting on clean gloves prior to eye medication administration. During a concurrent interview and record review on April 20, 2023, at 11:52 AM, with the IP Nurse, Nursing Procedure Reference Manual (Policy) - PC, dated July 22, 2022, was reviewed. The Policy and Procedure (P&P) indicated, PURPOSE: To provide an informed method of performing general nursing procedures. POLICY: 1. The Lippincott Manual of Nursing Practice, has been adopted as a reference for clinical/nursing procedure which are not specifically listed in the Department P&P Manual or Clinical Service Manual . The IP Nurse acknowledge the P&P was not followed. During a concurrent interview and record review on April 20, 2023, at 12:00 PM, with the Director of Nursing (DON), the P&P titled, Hand Hygiene, Employees (Policy) - IC, dated July 22, 2022, was reviewed. The P&P indicated, PURPOSE: TO ESTABLISH HAND HYGIENE GUIDELINES FOR EMPLOYEES. Policy: 1. Hand hygiene is considered the most important single procedure for preventing healthcare associated infections. All employees shall follow the following guidelines for hand hygiene. 2. Indications for hand hygiene (before or after): a. ANY patient contact, b. invasive procedures . The DON acknowledged that washing hands is the most important single procedure for preventing healthcare associated infections.

Based on interview and record review, the facility failed to complete a Physician Orders for Life-Sustaining Treatment ([POLST] medical order form that provides instructions to medical staff on what to do in the event of a medical emergency) for one of 18 sampled residents (Resident 15). This failure could have resulted in Resident 15's medical treatment wishes not being followed. Findings: During a review of Resident 15's clinical record titled, History and Physical Examination (H&P- a document that contains past and current medical history) - Final Report, dated, January 15, 2020, at 2:50 PM, by Physician 1 (Phys. 1), indicated, Resident 15 had a past history of stroke (an event where there is oxygen deprivation to the brain), diabetes (inability to control blood sugar), and Chronic Kidney Disease (kidneys do not efficiently filter out waste products). During a review of Patient 15's clinical record titled, Section C Cognitive (thinking, understanding, remembering) Patterns (a section of the Minimum Data Set ([MDS] assessment tool used to assess cognitive skills for decision making), indicated, Resident 15 had a Brief Interview for Mental Status ([BIMS] summary score used to assess for cognitive conditions) score of 10 (score of 8-12 = moderately impaired). During a concurrent interview and record review on April 18, 2023, at 8:30 AM, with the MDS Nurse, Resident 15's clinical record titled, Physician Orders for Life-Sustaining Treatment, dated December 30, 2019, by Resident 15's Legally Recognized Decision Maker ([LRDM] the person assigned by the resident to make medical decisions if the resident is not able to make decisions for themselves) and Physician (Phys. 2), was reviewed. The POLST indicated, Resident 15's primary goal was comfort-focused treatment (relieve pain and suffering with medication). The POLST was not completed when the LRDM's address, phone number, and date of signature was not documented, and whether or not Resident 15 had an advanced directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions independently). The MDS Nurse stated, she is not sure why the POLST was not completely filled out and that the facility needed to update Resident 15's POLST. The MDS Nurse acknowledged, the POLST was supposed to be fully completed and placed in the Resident 15's chart (a folder containing medical information). During a concurrent interview and record review on April 18, 2023, at 11:45 AM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Admission of Resident (Policy) - Skilled Nursing Facility, dated September 15, 2022, indicated, Assessment, Forms and Documents: . 5. Discuss and complete Physician Orders for Life Sustaining Treatment (POLST) with resident and or power of attorney (POA- a legal document that allows for the designation of another person to manage the resident's property, medical, or financial affairs) and have MD (Medical Doctor) sign . The DON stated, the POLST was not completed in its entirety and needed to be updated. The P&P was not followed.

Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) for transmitting resident's assessment data (tool that provides overview of the resident's condition) within the required timeframe outlined by Federal Regulations for three of four sampled residents (Resident 3, Resident 17, and Resident 10). This failure had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day to day operations and emergencies. Findings: 1.During a review of Resident 3's Admission Record (a document that contains demographic and clinical data), the Admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (high sugar levels), chronic (long term) back pain, and hypertension (raised pressure against the vessel walls). During a concurrent interview and record review, on April 20, 2023, at 8:20 AM, with the MDS Nurse, Resident 3's Minimum Data Set 3.0( MDS 3.0-an assessment tool for implementing standardized assessment and for facilitating care management), dated March 4, 2023, signed by the Director of Nursing (DON), was reviewed. The document indicated, the assessment was transmitted to Internet Quality Improvement and Evaluation System (iQIES- federal government information tracking website) on April 19, 2023. The MDS Nurse counted the number of days the MDS assessment was late and stated, the assessment was 32 days late. The MDS Nurse stated, the MDS assessment was supposed to have been transmitted on March 18, 2023. During further record review and interview with the MDS Nurse, on April 20, 2023, at 8:23 AM, the MDS Nurse reviewed Resident 3's MDS 3.0 assessment, dated December 1, 2022, signed by the Registered Nurse (RN 2). The MDS Nurse counted the number of days the MDS assessment was late and stated, the assessment was 16 days late (due December 19, 2022). During a concurrent interview and record review with the DON, on April 20, 2023, at 9:46 AM, the DON reviewed Resident 3's MDS 3.0 assessments and reviewed the Policy and Procedure (P&P) titled, Resident Assessment and Care Planning, dated January 18, 2019, which indicated, .1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirement . The DON stated, the MDS 3.0 assessments were submitted past the 14 days after the Registered Nurse's signature and acknowledged the P&P was not followed. 43943 2. During a review of Resident 17's clinical record titled, Admission Record indicated, Resident 17's diagnoses included, hypertension, anxiety disorder (feeling of worry), and left hip fracture (break). During a concurrent interview and record review on April 19, 2023, at 3:05 PM, with the MDS Nurse, MDS Command Center (a calendar of the assessment due dates), was reviewed. The document indicated, Resident 17's MDS 3.0 assessment was transmitted by the facility on April 13, 2023. The MDS Nurse acknowledged, Resident 17's MDS 3.0 assessment was transmitted to the Command Center 12 days late. The MDS Nurse stated, she tried to remember the due dates, but she missed this one. During a concurrent interview and P&P April 20, 2023, at 9:00 AM, with the DON, Resident Assessment and Care Planning (Policy) - Skilled Nursing Facility, dated January 18, 2019, was reviewed. The P&P indicated, PURPOSE: To identify resident needs and provide a database used in planning the comprehensive nursing care to meet resident's individual needs and to assist residents in reaching the highest level of independence possible. POLICY: 1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirements . The DON acknowledged, the P&P was not followed when Resident 17's MDS 3.0 assessment was not transmitted within 14 days. 3. During a review of Resident 10's clinical record titled, History and Physical (H&P- past and current medical history) Examination - Final Report, dated, October 13, 2022, by Physician 1 (Phys. 1) indicated, Resident 10 had a past medical history of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), stroke (occurs when the blood supply is blocked to part of the brain), and seizure disorder (burst of uncontrolled body movements, behaviors, or states of awareness). During a review of Resident 10's clinical record titled, MDS 3.0., dated, September 16, 2022, by RN 1, indicated, Resident 10 had an MDS 3.0 assessment completed on September 16, 2022. During a concurrent interview and record review on April 19, 2023, at 3:20 PM, with the MDS Nurse, MDS Command Center, dated October 1, 2022, was reviewed. The record indicated, Resident 10's MDS 3.0 assessment was transmitted on October 1, 2022. The MDS Nurse stated, she was the person responsible for submitting the MDS 3.0 assessment, which was one day late. During a concurrent interview and P&P reviewed on April 20, 2023, at 9:15 AM, with the DON, Resident Assessment and Care Planning (Policy) - Skilled Nursing Facility), dated January 18, 2019, indicated, PURPOSE: To identify resident needs and provide a database used in planning the comprehensive nursing care to meet resident's individual needs and to assist residents in reaching the highest level of independence possible. POLICY: 1. A licensed nurse will coordinate the input of appropriate health care professionals in the completion of a resident assessment form designed to obtain minimum data criteria as established by Federal and State requirements . The DON acknowledged, the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food handling and preparation practices in the kitchen when: 1. Racks used for washing, sanitizing, and drying dishware, utensils, and other kitchen equipment were noted to have black grime substance while being used. 2. The food steamer in the kitchen and ice machine in the dining room had no air gap. These failures had the potential to lead to harmful bacteria and cross-contamination (spread of infection from one person to the other) that could lead to foodborne illness (stomach illness acquired from ingesting contaminated food) for a medically compromised population of 20 residents who received food from the kitchen. Findings: 1. During an observation on (MONTH) 21, 2019, at 10:04 AM, in the presence of the Registered Dietitian (RD) and the Nutrition Services Supervisor (NSS), black grime substance was noted on all nineteen racks used for dishwashing, sanitizing, and drying dishware, utensils, and other kitchen equipment. The black grime substance was able to be loosened and wiped off. During an interview with the NSS, on (MONTH) 21, 2019, at 10:04 AM, she confirmed the black grime substance on the 19 racks used for washing, sanitizing, and drying dishware, utensils, and other kitchen equipment and stated it needed to be replaced. During an interview with RD, on (MONTH) 22, 2019, at 9:51 AM, she stated that they de-limed the dishwasher yesterday and noted that the same type of black residue was also inside the dishwasher afterwards. During an interview and concurrent record review with the RD, on (MONTH) 24, 2019, at 9:50 AM, she stated that an (Company name) report obtained on (MONTH) 23, 2019 indicated that the black grime substance on the dish racks was a build-up of mineral deposits due to hard water. The RD also stated that she was not okay with it and was taking precaution by ordering new dish racks. According to the FDA Food Code (YEAR), Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. 2. During an observation and concurrent interview with the Lead Facilities Tech, on (MONTH) 21, 2019, at 3:25 PM, he was unable to identify and show a proper air gap for the ice machine located in the main dining room. There was no air gap that was visible. During an observation and concurrent interview with the Lead Facilities Tech and Chief Executive Officer (CEO), on (MONTH) 22, 2019, at 11:08 AM, pictures taken of the drain lines (pipes) for the ice machine confirmed that there was no air gap. The Lead Facilities Tech also stated that the drain pipe for the ice machine was connected to the sewer system. A review of the (Name of the company), Icemaker/Dispenser Instruction Manual, dated (MONTH) 6, 2009, indicated, that the drain line should not be piped directly to the sewer system. An air gap of a minimum of two vertical inches (5 cm) should be between the end of the drain pipe from the icemaker and the floor drain. During an observation on (MONTH) 22, 2019, at 12:10 PM, in the kitchen, the drain pipe for the food steamer went into the floor drain and there was no air gap between the pipe and the drain. During an interview with the Registered Dietitian (RD) on (MONTH) 22, 2019, at 2:19 PM, she stated she did not know that the food steamer needed an air gap. A review of the manufacturer's installation and operation instructions in Operator's Manual: Electric Counter Convection Steamer, dated (MONTH) 17, 2012, indicated, the drain connection must have an open air gap and piped to an open air gap type drain. During an interview with the Lead Facilities Tech on (MONTH) 24, 2019, at 10:16 AM, he stated that he did not know that the ice machine or the steamer needed an air gap; the steamer was installed before he started working at the facility. According to the FDA Food Code (YEAR), The water outlet of a drinking water system must not be installed so that it contacts water in sinks, equipment, or other fixtures that use water. Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow.

Based on observation, interview, and record review, the facility failed to ensure meals for residents were prepared by methods that conserve nutritive value, flavor, and appearance when a puree lunch on (MONTH) 21, 2019 was not prepared correctly. This failure could change the nutritional profile of the puree meals and has the potential to further compromise the nutritional status of two residents (Residents 8 and 18) receiving puree diets. Findings: During an observation on (MONTH) 22, 2019, at 12:23 PM, in the kitchen, the Nutrition Services Supervisor prepared the following pureed foods: Five ounces of meatloaf pureed with one ounce of hot water and an unmeasured amount of food thickener; one half cup of green beans pureed with one ounce of hot water and an unmeasured amount of thickener; one half cup of mashed potatoes and two ounces of gravy pureed with an unmeasured amount of thickener; and one bread roll pureed with two scoops of gravy. During an interview with the Registered Dietitian (RD) on (MONTH) 24, 2019, at 11:06 AM, she stated that they do not use thickener when preparing puree foods. The RD verified that the Nutrition Services Supervisor should not have added thickener to the pureed food. The RD also stated gravy should not have been used to puree the bread because it changes its consistency and taste. A review of the Cooks Puree Food Guide, not dated, in the presence of the Registered Dietitian (RD), indicated, If desired consistency of applesauce/baby food is not achieved, discard puree food item and redo to above correct consistency, do not use thickener. The guide also specifies to use water to puree all food types, with exception of mashed potatoes which can have two ounces of gravy pureed per therapeutic guide instead of water .

Based on observation, interview, and record review, the facility failed to ensure for one of 12 sampled residents (Resident 13) privacy curtain was provided when Registered Nurse (RN 1) was observed performing a blood glucose check and did not close the door or use privacy curtain exposing Resident 13 to the public view. This failure had exposed Resident 13 to public view and can potentially affect the psychosocial well-being of Resident 13. Findings: A review of Resident 13's clinical record, the face sheet (A document which contains basic information about the resident) indicated Resident 13 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 13's physician's orders [REDACTED]. During an observation on (MONTH) 24, 2019 at 7:45 AM, RN 1 was observed performing a blood glucose check for Resident 13 and did not close the door or use the privacy curtain exposing Resident 13 to the public. During an interview with RN 1 on (MONTH) 24, 2019 at 8 AM, the RN 1 confirmed she did close the door or use the privacy curtain. RN 1 stated, I forgot to provide privacy. A review of the facility's policy and procedure titled, Resident Responsibilities, Rules and Regulation-Skilled Nursing Facility, dated (MONTH) 26, 2019, indicated under E. Resident' Rights: 2. All rights specified in , Patients' Right. A review of the document titled, . Patients' Rights, undated, indicated under 12. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen for one of one sampled residents (Resident 11) when Resident 11 was observed receiving oxygen treatment without a doctor's order in the Electronic Medical Record (EMR). This failure had the potential to result in adverse consequences related to medication being administered with no physician order and no monitoring of effectiveness. Findings: A review of Resident 11's clinical record indicated, Resident 11 was admitted to the facility on (MONTH) 14, 2019 with [DIAGNOSES REDACTED]. During an observation on (MONTH) 21, 2019, at 10:31 AM, Resident 11 was observed receiving humidified oxygen via nasal cannula (a modality for delivering oxygen) at a flow rate of 2 liters per minute (a unit of measurement) via flowmeter (oxygen delivery device) connected to the facility's piped wall oxygen. A review of Resident 11's physician's orders for the month of (MONTH) 2019, with the Licensed Vocational Nurse (LVN 1) there was no documented evidence in the Electronic Medical Record (EMR) that an order was obtained for oxygen treatment for [REDACTED]. During an interview with a Licensed Vocational Nurse (LVN 1), on (MONTH) 21, 2019, at 10:36 AM, LVN 1 stated, she thought she entered the order for the oxygen treatment in the (EMR) when it was brought to her attention. She confirmed there was no physician order for [REDACTED].>A review of the facility's policy and procedure titled, Physician Orders, SNF (Policy)-Skilled Nursing Facility dated (MONTH) 18, 2019, indicated, All medication, care and treatment orders are to be entered into the Electronic Medical Record (EMR) then approved and electronically signed by the attending physician.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for one of 12 sampled residents (Resident 11), when there was no No Smoking sign posted outside Resident 11's room. This failure had the potential to result in a fire hazard. Findings: A review of the clinical record for Resident 11 indicated Resident 11 was admitted to the facility on (MONTH) 14, 2019 with [DIAGNOSES REDACTED]. During an observation on (MONTH) 21, 2019, at 10:31 AM, Resident 11 was observed receiving humidified oxygen via nasal cannula (a modality for delivering oxygen) at a flow rate of 2 liters per minute (a unit of measurement) via flowmeter (oxygen delivery device) connected to the facility's piped wall oxygen. There was no No Smoking sign posted outside Resident 11's room. During an interview with Licensed Vocational Nurse (LVN 1) on 10/21/19 at 11:39 AM, LVN 1 stated they do not use No Smoking signs while the residents are on oxygen therapy. During an interview with Licensed Vocational Nurse (LVN 2) on (MONTH) 24, 2019 at 5:28 AM, LVN 2 stated they do not put oxygen in use signs up for residents on oxygen. LVN 2 acknowledged the No Smoking sign should be posted outside the resident's room to notify visitors, of the fire hazard to smoke around the resident while oxygen is in use. A review of the facility's policy and procedure titled, Oxygen Administration dated (MONTH) 18, 2019, indicated, Post NO SMOKING signs conspicuously in patient's room and in any area where there is oxygen.

Based on interview and record review, the facility failed to ensure the Physician order [REDACTED]. number. These failures had the potential for unmet resident care needs in the event of an emergency situation requiring life saving interventions for Residents 1, 3, 6, and 12, due to incomplete medical information. Findings: 1. During a record review of Resident 1's face sheet (contains demographic information), it indicated Resident 1 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. During a record review of Resident 1's POLST, dated (MONTH) 27, (YEAR), the following information was missing: The Physician's phone number and the Physician/Physician Assistant's license number. During an interview and concurrent record review with the Clinical Coordinator, on (MONTH) 24, (YEAR), at 10:43 AM, the Clinical Coordinator reviewed Resident 1's POLST, and verified it had missing information. During an interview with the Skilled Nursing Facility Manager (SNF Manager), on (MONTH) 24, (YEAR), at 10:50 AM, the SNF Manager stated, It (POLST) should have been filled out completely. The facility's policy and procedure titled Admission of Resident revised (MONTH) 15, (YEAR), indicated Discuss and complete Physician order [REDACTED]. The facility's policy and procedure titled Resuscitation Orders revised (MONTH) 23, (YEAR), indicated The POLST (Physician order [REDACTED]. 2. During a record review of Resident 3's face sheet (contains demographic information), it indicated Resident 3 was admitted to the facility on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. During a record review of Resident 3's POLST, dated (MONTH) 15, 2014, the following information was missing: The Physician's phone number and the Physician/Physician Assistant's license number. During an interview and a concurrent record review with the Clinical Coordinator, on (MONTH) 24, (YEAR), at 10:29 AM, the Clinical Coordinator reviewed Resident 3's POLST and verified it had missing information. The Clinical Coordinator stated, I don't know about his (physician's) information (phone number and license number. During an interview with the Skilled Nursing Facility Manager (SNF Manager), on (MONTH) 24, (YEAR), at 10:50 AM, the SNF Manager stated, It (POLST) should have been filled out completely. The facility's policy and procedure titled Admission of Resident revised (MONTH) 15, (YEAR), indicated Discuss and complete Physician order [REDACTED]. The facility's policy and procedure titled Resuscitation Orders revised (MONTH) 23, (YEAR), indicated The POLST (Physician order [REDACTED]. 3. During a record review of Resident 6's face sheet (contains demographic information), it indicated Resident 3 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. During a record review of Resident 6's POLST, dated (MONTH) 4, (YEAR), the following information was missing: The Physician's phone number and the Physician/Physician Assistant's license number. During an interview and concurrent record review with the Clinical Coordinator, on (MONTH) 24, (YEAR), at 10:40 AM, the Clinical Coordinator reviewed Resident 6's POLST and verified it had missing information. The Clinical Coordinator stated, I don't have that kind of information (physician phone number and license number. The Clinical Coordinator further stated, I don't know why the physician did not put it (physician phone number and license number) on there (POLST). During an interview with the Skilled Nursing Facility Manager (SNF Manager), on (MONTH) 24, (YEAR), at 10:50 AM, the SNF Manager stated, It (POLST) should have been filled out completely. The facility's policy and procedure titled Admission of Resident revised (MONTH) 15, (YEAR), indicated Discuss and complete Physician order [REDACTED]. The facility's policy and procedure titled Resuscitation Orders revised (MONTH) 23, (YEAR), indicated The POLST (Physician order [REDACTED]. 4. During a record review of Resident 12's face sheet (contains demographic information), it indicated Resident 12 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. During a record review of Resident 12's POLST, dated (MONTH) 28, 2014, the following information was missing: The Physician's phone number, the Physician/Physician Assistant's license number, and the date the patient signed the form. During an interview and concurrent record review with the Clinical Coordinator, on (MONTH) 24, (YEAR), at 10:44 AM, the Clinical Coordinator reviewed Resident 12's POLST and verified it had missing information. During an interview with the Skilled Nursing Facility Manager (SNF Manager), on (MONTH) 24, (YEAR), at 10:50 AM, the SNF Manager stated, It (POLST) should have been filled out completely. The facility's policy and procedure titled Admission of Resident revised (MONTH) 15, (YEAR), indicated Discuss and complete Physician order [REDACTED]. The facility's policy and procedure titled Resuscitation Orders revised (MONTH) 23, (YEAR), indicated The POLST (Physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure the nursing service staff notified the nutritional services staff of a change in diet order for one of 12 sampled residents (Resident 19). This failure had the potential to impair the nutritional status of Resident 19. Findings: During an observation on (MONTH) 24, (YEAR), at 8:35 AM, Resident 19 was in bed in an upright position being fed breakfast by a Certified Nursing Assistant (CNA 1). Resident 19's breakfast tray with diet card was placed on top of an over-bed table. Resident 19's diet card read, NCS (No Concentrated Sugar- therapeutic diet) Finger food. During a review of Resident 19's face sheet (contains demographic information), it indicated Resident 19 was admitted on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. During a review of Resident 19's physician's orders [REDACTED].Provide NCS diet . During a review of Resident 19's care plan titled Actual weight changes/loss ., revised (MONTH) 17, (YEAR), indicated .Change to NCS diet no finger foods-fed . During an interview and review of Resident 19's clinical record with the Skilled Nursing Facility Manager (SNF Manager), on (MONTH) 24, (YEAR), at 11:00 AM, the SNF Manager, stated Resident 19's current diet was regular texture, NCS diet. The SNF Manager stated, the finger food order was discontinued on (MONTH) 17, (YEAR). The SNF Manager further stated the nursing service should have notified the nutritional services staff through the Dietary Service Supervisor (DSS) whenever there were changes with the residents' diet orders. During an interview with the DSS, on (MONTH) 24, (YEAR), at 11:36 AM, the DSS reviewed Resident 19's diet card, and stated The diet order written on the diet card for Resident 19 is NCS finger food. The DSS further stated Resident 19 was being served finger food. The DSS stated the nursing services staff had not told her that the finger food order was discontinued. During a follow up interview with the SNF Manager, on (MONTH) 24, (YEAR), at 11:46 AM, the SNF Manager reviewed Resident 19's diet card and acknowledged the diet card did not match Resident 19's current diet order. The SNF Manager stated, It (Resident 19's diet card) didn't get changed when it was discontinued. During an interview with the Registered Dietitian (RD), on (MONTH) 24, (YEAR), at 3:42 PM, the facility's policy and procedure titled Diet Orders revised (MONTH) 25, 2014, was reviewed. The RD stated, The policy was not followed. The RD further stated the nutritional services staff were not made aware of Resident 19 's diet change. The facility's policies and procedures titled Diet Orders revised (MONTH) 25, 2014, indicated Nursing service is responsible for informing the Nutritional Service staff of all diet orders and diet changes via computer program. Upon diet order change, the nurse will complete a diet order via a computer program.

Based on observation, interview, and record review, the facility failed to ensure that privacy was provided for three of eight sampled residents (Residents 1, 3, and 6) when staff was taking vital signs (clinical measurements specifically blood pressure, pulse, temperature, respiration, that indicate the state of a patient's essential body function) during meal time. This failure resulted in violation of a right to privacy during provision of care. Findings: During a meal observation at the dining room on October 10, 2017 at 7:40 AM, a certified nurse assistant (CNA 1) was observed taking blood pressure (pressure of circulating blood related to the force and rate of the heartbeat) of Resident 1 while eating her breakfast. After CNA1 took Resident 1's blood pressure, CNA 1 approached Resident 3 and took his blood pressure while he was eating his breakfast. At approximately 7:45 AM, a licensed vocational nurse (LVN 1) was observed taking blood pressure of Resident 6 while eating her breakfast. During an interview with LVN 2 on October 10, 2017 at 8:15 AM, when asked if the staff was to take vital signs during meal time, LVN 2 stated, No, staff should take vital signs before meal time, and not while residents are eating. LVN 2 further stated, staff should have been taking vital signs in resident room and not in the dining room while they (residents) are eating. An interview was conducted with CNA 1 on October 10, 2017 at 2:00 PM. CNA 1 confirmed that she took the vital signs of Residents 1 and 3 at the dining room while Residents 1 and 3 were eating their breakfast. During an interview with Resident 1 on October 10, 2017 at 8:45 AM, she confirmed that her blood pressure was taken while she was eating breakfast. Resident 1 further stated the nurse usually takes it (blood pressure) in the dining room. During an interview with Resident 3 on October 11, 2017 at 1:50 PM, Resident 3 was asked how he felt when CNA 1 was taking his vital signs while eating his meal. Resident 3 responded, It was only a short time, and the staff need to do it. An interview was conducted with LVN 1 on October 11, 2017 at 2:00 PM. LVN 1 confirmed she was observed taking blood pressure of Resident 6 while eating breakfast. A review of the facility's copy of a record titled, Resident's Rights, undated, indicated, Each resident, and his/her legal representative as appropriate, has the right : .10. To be treated with consideration, respect and dignity and assured complete privacy during treatment and when receiving personal care.

Based on observation, interview, and record review, the facility failed to ensure that one expired, multi-dose vial of insulin (a medication used to control sugar levels in the blood) was not available for resident use when, during medication pass observation on [DATE], LVN 2 was observed preparing a dose of Humalog insulin for unsampled Resident A. The Humalog insulin multi-dose vial had an expiration date of [DATE]. This failure had the potential to result in unsampled Resident A, receiving less potent or possibly contaminated medication which could lead to resident harm. Finding: During a medication pass observation on [DATE] at 11:48 AM, LVN 2 stated that unsampled Resident A required two units of insulin, based on the Humalog insulin sliding scale (the insulin dose is based on the resident's blood sugar of 206). LVN 2 was then observed to draw up (into a syringe) two units of insulin from a multi-dose vial of insulin, which was observed to have a label, with an expiration date of [DATE]. LVN 2 then requested for LVN 1 to double check the dosage drawn up. LVN 1 was observed to note the expiration date on the label of the multi-dose vial. LVN 1 informed LVN 2 that the insulin had expired and to discard the insulin. During a concurrent interview with LVN 2, she stated that she missed it, referring to the expiration date on the multi-dose vial of Humalog insulin. During an interview with LVN 1 on [DATE] at 12:23 PM, she stated that it was LVN 2's responsibility to remove the expired Humalog insulin from the medication cart. LVN 1 was asked if the expiration date on the insulin multi-dose vial was [DATE], why was the expired insulin still in the medication cart on [DATE]. LVN 3 stated, It was just one of those things, I don't know. During a review of the clinical record for unsampled Resident A, the admission record indicated unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of the clinical record for unsampled Resident A, the physician's orders [REDACTED]. Unsampled Resident A was to receive Humalog insulin according to the following sliding scale: For BS ,[DATE] = no action BS ,[DATE] = 2 units BS ,[DATE] = 3 units BS ,[DATE] = 4 units BS ,[DATE] = 5 units For BS 401 or greater call MD. The facility policy and procedure titled, Multi-Dose and Single Dose Medication Containers-Use and Exp. Dates (Policy), with approval date: [DATE], indicated under Procedure, number 5, After initial opening, multi-dose (MD) vials intended to be reused on multiple patients shall be labeled with as Discard after 28 days EXP. DATE____auxiliary label. The expiration date noted shall be calculated 28 days after initial opening but no longer that the date specified by the manufacturer.

Based on interview and record review, the facility failed to follow their policy and procedure. Resident 1 reported an incident of alleged abuse against a Certified Nurse Assistant (CNA 1). This failure had the potential to result in further abuse and harm to Resident 1 and the other 18 residents. Findings: An allegation of abuse was reported to California Department of Public Health (CDPH) which reflected on October 14, 2014 at 6:30 PM, a facility employee (CNA 2) received a report from Resident 1. Resident 1 told the employee when she needed to go to the bathroom the night before (October 13, 2014), the night shift CNA called the resident a liar and then put the blankets over (Resident 1's) head. A review of the Investigation of Alleged Abuse report conducted by the Chief Operating Officer/Chief Nursing Officer (COO/CNO) revealed, on October 14, 2014 at 6:30 PM, Resident 1 reported to the Certified Nurse Assistant (CNA 2) that she (Resident 1) was afraid. When CNA 2 asked Resident 1 what she was afraid of, Resident 1 replied, the tall nurse with the tall hair. CNA 2 asked, (name of CNA 1)? and Resident 1 replied, that's her! When asked why she was afraid of CNA 1, Resident 1 stated when Resident 1 needed toileting assistance last night (October 13, 2014), CNA 1 got mad. Resident 1 stated CNA 1 called me a liar and pulled the covers over my head. Review of the Investigation of Alleged Abuse report reflected on October 15, 2014 at 8:30 AM, (the next morning) CNA 2 reported the incident to the SNF Manager. The Investigation of Alleged Abuse report revealed CNA 2 was asked what she knew about mandated reporting and CNA 2 stated she knew she was to contact the charge nurse right away so the incident can be reported. CNA 2 stated she was afraid of CNA 1 being accused in this incident and was scared the CNA might retaliate outside of work. The Investigation of Alleged Abuse report revealed on October 15, 2014 at approximately 4:30 PM, the COO/CNO met with Resident 1 accompanied by CNA 2. CNA 2 opened by explaining COO/CNO wanted to talk to her regarding the story Resident 1 had reported. Resident 1 immediately said, Oh, you mean the covers put over my head? Resident 1 told COO/CNO the tall nurse with really tall hair doesn't like when she has to go to the bathroom. Resident 1 stated she had to go a lot. The other night (October 13, 2014) when Resident 1 asked, CNA 1 told her just go to sleep and threw the covers over her head. Resident 1 stated, they took her 'button to press' away. When asked if it happened a lot, Resident 1 stated, They just don't like it when she asks to go to the bathroom. The Investigation of Alleged Abuse report revealed on October 15, 2014 at 9 AM, CNA 1 was called into a meeting with COO/CNO and the SNF Manager. Resident 1's report was explained to CNA 1. CNA 1 stated she did not do that. CNA 1 stated that at 11 PM, she changed Resident 1's roommate and while she was at it, she wakes this resident (Resident 1) up to take her to the bathroom. CNA 1 continued to say she would take Resident 1 to the bathroom at this time because otherwise Resident 1 would be yelling at them soon, Nurse, Nurse .she always has to go to the bathroom. The Investigation of Alleged Abuse report revealed on October 15, 2014 at 10:15 AM, the COO/CNO spoke with the Licensed Vocational Nurse (LVN 3) who was on shift with CNA 1 the evening of 10/13/14. LVN 3 was unaware of the incident and explained there was not a particular person assigned to each resident. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE]. The history and physical dated February 18, 2014 revealed Resident 1 was alert and oriented times three. A physician progress notes [REDACTED]. A review of the facility Daily Assignment Sheet dated October 14, 2014, revealed CNA 1 worked on the night 7 PM -7 AM shift. A review of the nurses notes dated October 14, 2014 through October 18, 2014, revealed there was no documented evidence of the alleged incident nor of any assessment and monitoring of Resident 1's condition. There was no documented evidence to show the facility notified the physician and Resident 1's family members upon being notified by Resident 1 of the incident of alleged abuse on October 14, 2014. A review of the Social Services Note dated October 15, 2014, revealed an entry about the reported incident of alleged abuse for October 14, 2014. There was no documented evidence after this entry to indicate Resident 1 was monitored following the reported incident of alleged abuse for October 14, 2014. A review of Resident 1's care plans revealed there was no documented evidence a plan of care was initiated and developed to ensure Resident 1's safety and physical and psychosocial needs were addressed following the reported incident of alleged abuse. During a phone interview with CNA 2 on July 1, 2015 at 10:30 AM, she confirmed Resident 1 reported the incident of alleged abuse to her on October 14, 2014. CNA 2 stated she reported the incident to the charge nurse (LVN 1) who informed the oncoming charge nurse (night shift LVN 2), to keep (CNA 1) away from (Resident 1). CNA 2 stated she was then instructed to notify the skilled nursing facility (SNF) manager the next morning (October 15, 2014). CNA 2 told the SNF Manager and the Social Worker (SW) the next morning (October 15, 2014), about Resident 1's reported incident of alleged abuse. During further interview CNA 2 confirmed CNA 1 came to work that night (October 14, 2014) at 7 PM. CNA 2 explained the night shift was usually staffed with 2 CNAs. When asked if she had received training about mandated reporting, CNA 2 stated she did, however, she did not know the proper steps and where the forms were located. She stated, It was a learning experience for (SNF Manager) and me. When asked how she assured the safety of Resident 1, she stated by telling Resident 1 verbally that CNA 1 would not be taking care of Resident 1, and by telling LVN 1 about the reported incident. During a phone interview with LVN 1 on July 1, 2015 at 10:40 AM, LVN 1 confirmed CNA 2 reported the October 13, 2014 incident of alleged abuse to her on October 14, 2014, after the management team had already left the facility (before her shift ended). LVN 1 stated she spoke to Resident 1 and notified the oncoming night shift charge nurse (LVN 2) about the incident. LVN 1 and LVN 2 discussed to ensure CNA 1 would not be caring for Resident 1 that night. The next morning (October 15, 2014), the SNF Manager was notified. A review of the nurses notes revealed there was no documented evidence of the reported incident on October 14, 2014. LVN 1 confirmed she did not document on the nurses notes because she was not quite sure if it was something to be documented on the nurses notes. LVN 1 stated she should have documented on it. When asked if the physician and the family were notified of the incident of alleged abuse on October 14, 2014, LVN 1 confirmed they were notified the next day (October 15, 2014). When asked what the facility's process was on monitoring Resident 1's condition after an incident of alleged abuse was reported, LVN 1 stated Resident 1 should have been monitored every shift for signs and symptoms of any effects from the incident for the first 24-48 hours and thereon. LVN 1 confirmed there was no documented evidence Resident 1 was monitored every shift upon being made aware of the reported incident of alleged abuse on October 14, 2014. During a phone interview with the Social Worker (SW) on July 1, 2015 at 3:10 PM, the SW confirmed after her entry on the Social Services notes dated October 15, 2014, of the reported incident of alleged abuse for October 14, 2014, there was no further documentation to indicate Resident 1's condition was monitored. The SW stated, I do not typically go back (to the resident) because the responsibility has been transferred to the manager (SNF Manager). During a phone interview with the SNF Manager on July 1, 2015 at 3:30 PM, she stated typically the staff would have been put on immediate administrative leave as soon as the SNF Manager was made aware. She confirmed she was not made aware of the incident until the next day (October 15, 2014). The SNF Manager confirmed a care plan was not initiated to address the specific incident; There was nothing new needed to be done at that time. During a phone interview with the COO/CNO on July 1, 2015 at 4 PM, a review of the facility's policy and procedure was conducted and when asked how the facility ensured Resident 1's safety, the COO/CNO stated if she would have been made aware of the incident of alleged abuse at the time it was reported, CNA 1 would have been taken off the schedule that night (October 14, 2014) and while the investigation was ongoing. During a phone interview with LVN 2 on July 2, 2015 at 7:20 AM, she stated she worked on October 14, 2014 on the night shift and could not recall anyone telling her about any report of abuse. LVN 2 stated she did not receive any specific instructions not to allow CNA 1 to attend to Resident 1's needs. When asked how the night shift assigned resident care between the two CNAs on this shift, LVN 2 stated the two CNAs worked as a team for all the patients in the unit. When asked how she would have handled the situation if she had received a report of the alleged incident of abuse, LVN 2 stated she would have talked to the manager and would have explained to and instructed CNA 1 to not go to Resident 1's room and have CNA 1 take care of the other residents. When asked how she would have handled a CNA, if a resident had reported an incident of alleged abuse by a CNA working on her shift. LVN 2 stated the CNA would no longer be allowed to be in contact with the resident and have the CNA finish the shift or talk to the house supervisor to see how it would be handled. A review of the facility's policy and procedure titled, Abuse-Dependent Adult-Elder Version #2, Approval Date: 05/22/2014, revealed under PROCEDURE, . 4. The reporting party suspecting abuse of a patient or ECRC (former facility name) resident will immediately assure the safety of the victim and then notify their department manager and the MCH (name of hospital) Social Services department. If neither the department manager nor Social Services is available. The reporting party will contact the House Supervisor for assistance and resolution. The patient/resident's physician will be notified and a plan of care will be initiated and documented by the department manager/House Supervisor/Social Service to insure the protection of a patient or resident during the investigation of the allegations and reporting process .8. Document in the patient/resident's medical record the reporting process with time, date, name and the title of the person receiving the telephone report. The staff are required to document fully and explicitly the nature of the identified issues in the patient/residents medical record. It may be necessary for the staff to document a series of observed actions that give evidence to the abuse of the adult. 9. In the even (event) an employee is suspected of abuse, the Human Resource Director will be contacted Immediately to participate in an investigation. The employee will be placed on administrative leave pending investigation and to assure the employee is unable to contact the alleged victim and/or the victim's family. Following the investigation, appropriate disciplinary action up to and including termination may be implemented.