Every finding on record at Niles Canyon Post Acute

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) had physician orders for hemoglobin A1C (a blood test that shows average level of blood glucose, also called blood sugar, over the past two to three months) monitoring every 6 months and or blood glucose capillary/fingerstick assessments (a rapid diagnostic method used to measure blood sugar found in the bloodstream, serving as the body's main source of energy for cells, tissues, and the brain) at least twice weekly. This failure resulted in Resident 2 having weakness and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE].During record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide care) dated 2/14/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 6 out of 15, indicated Resident 2 had severe cognitive impairment. MDS indicated Resident 2 had a diagnosis of malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and type 2 diabetes (a chronic condition causing high blood sugar because the body cannot properly produce or use insulin, a hormone needed to turn food into energy).During an interview on 2/10/25, at 1:57 p.m., the Director of Nursing (DON) stated a physician's order is needed to perform a blood glucose capillary/fingerstick, but Resident 2 had no physician orders for blood glucose monitoring. DON stated it was important to assess Resident's blood glucose to determine blood sugar status and monitor resident's treatment plan.During an interview on 2/11/26, at 07:55 a.m., the Attending Provider (MD) stated residents receiving oral diabetic medication with a stable diabetic diagnosis should have an order set (a pre-defined, standardized group of medical orders such as labs, medications, imaging, nursing instructions) used in electronic medical record (EHR; a comprehensive, digital, and real-time version of a patient's paper chart, containing medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and lab results) for hemoglobin A1C monitoring every 6 months.During a record review and concurrent interview on 2/11/26, at 2:39 p.m., DON stated Resident 2 was admitted in March 2024 with a diagnosis of diabetes, received orders for oral sitagliptin (an oral prescription-only medication used to lower blood sugar levels in adults with type 2 diabetes), but did not have an order for hemoglobin A1C monitoring every 6 months. During a record review and concurrent interview on 2/13/26, at 10:46 a.m., MD stated hemoglobin A1C monitoring every 6 months was a standard order set that was automatically placed by MD on admission for residents with type 2 diabetes and on oral diabetic medication, but was unsure why Resident 2 did not receive the order set. MD stated they review all orders and placed new orders based on communication from nurses. During a record review and concurrent interview on 2/13/26, at 1:15 p.m., Medical Records (MR) and Administrator (Admin) stated MD had access to the EHR, but used personal electronic medical record system, where MR uploaded SOAP notes (Subjective, Objective, Assessment and Plan; a structured, standardized method of clinical documentation used by healthcare providers to record patient encounters efficiently), history and physical (a formal, comprehensive, and essential document in healthcare created by a clinician upon a patient's admission to a hospital or during a new consultation), laboratory results, past medical history, and current medications from hospital medical records for MD review. MR stated they upload relevant documents monthly into MD's personal EHR for record review, per request. During a review of Resident 2's Order Listing Report, there was no ordered hemoglobin A1C monitoring every 6 months by MD initiated at admission.During a review of Resident 2's Weights and Vitals Summary, there were no blood sugar assessments between admission, 3/11/24, and 3/18/25.During a review of Resident 2's Facesheet from the General Acute Care Hospital (GACH), dated 3/9/2025, Resident 2 was admitted to GACH on 3/9/25 at 3:47 p.m. with altered mental status, including lethargy, confusion, partial responsiveness, and weakness. During a review of Resident 2's Labs from the GACH, dated 3/9/25 at 6:26 p.m., Resident 2's blood glucose was greater than 800 mg/dl. During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol, the P&P indicated, The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management.the provider will adjust treatments based on these results and other factors such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. Assess glycemic status by A1C measurement, blood glucose monitoring by capillary/fingerstick devices. Examples of blood glucose monitoring for various situations might include the following: For the resident on oral medication(s) who is well controlled monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages); monitor A1C on admission (if no results from a previous test are available) or when diabetes is diagnosed and every 6 months thereafter.

Based on observation, interview, and record review, the physician failed to provide laboratory orders for routine monitoring of one of two sampled Residents' (Resident 2) who was ordered oral sitagliptin (an oral prescription-only medication used to lower blood sugar levels in adults with type 2 diabetes).This failure resulted in Resident 2 having weakness and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE].During record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide care) dated 2/14/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 6 out of 15, indicated Resident 2 had severe cognitive impairment. MDS indicated Resident 2 had a diagnosis of malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and type 2 diabetes (a chronic condition causing high blood sugar because the body cannot properly produce or use insulin, a hormone needed to turn food into energy).During a record review and concurrent interview on 2/11/26, at 2:39 p.m., with the Director of Nursing, the Lab Results Report was reviewed. DON stated Resident 2 was admitted in March 2024 with a diagnosis of type 2 diabetes and received orders for oral sitagliptin. DON stated the Lab Results Report with reported date of 3/16/2024 at 2:31 p.m., ordered by Attending Provider (MD), indicated hemoglobin A1C (a blood test that shows your average level of blood glucose, also called blood sugar, over the past two to three months) was 10.8%, and estimated average glucose (estimated average of your blood glucose levels over a period of 2 to 3 months) was 263 mg/dL. DON stated lab results should have been communicated to MD via fax. DON stated the lab results report was reviewed by Assistant Director of Nursing (ADON), which indicated ADON opened lab results report in EHR. During a record review and concurrent interview on 2/13/26, at 10:46 a.m., MD stated they relied on nursing staff to communicate abnormal lab reports to MD by phone or text message. MD stated the Lab Results Report with reported date of 3/16/2024 at 2:31 p.m., ordered by MD, indicated hemoglobin A1C was 10.8%, and estimated average glucose was 263 mg/dL, which was elevated, very high and warranted additional orders. MD stated 3/16/2024 lab report was not reviewed by MD. MD stated Comprehensive Metabolic Panel (a common, 14-substance blood test that evaluates overall health, including kidney and liver function, blood glucose, calcium levels, protein levels, and electrolyte balance) collected on 2/21/2025 at 1:55 p.m., ordered by MD, indicated glucose was 273 mg/dL, was high and warranted MD notification for additional orders. MD stated it was the nurses' responsibility to call MD with abnormal lab results. MD stated he does not follow up on ordered lab results, only relied on nurses to communicate abnormal results. MD stated it was important for abnormal lab results to be communicated to MD for proper interventions.During a record review and concurrent interview on 2/13/26, at 1:15 p.m., Medical Records (MR) and Administrator (Admin) stated MD had access to the electronic medical record (EHR; a comprehensive, digital, and real-time version of a patient's paper chart, containing medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and lab results), but used personal electronic medical record system, where MR uploaded SOAP notes (Subjective, Objective, Assessment and Plan; a structured, standardized method of clinical documentation used by healthcare providers to record patient encounters efficiently), history and physical (a formal, comprehensive, and essential document in healthcare created by a clinician upon a patient's admission to a hospital or during a new consultation), laboratory results, past medical history, and current medications from hospital medical records for MD review. MR stated uploads relevant documents monthly into MD's personal EHR for record review, per MD's request. During a review of Resident 2's Facesheet from the General Acute Care Hospital (GACH), dated 3/9/2025, Resident 2 was admitted to GACH on 3/9/25 at 3:47 p.m. with altered mental status, including lethargy, confusion, partial responsiveness, and weakness. During a review of Resident 2's Labs from the GACH, dated 3/9/25 at 6:26 p.m., Resident 2's blood glucose was greater than 800 mg/dl. During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol, the P&P indicated, The provider will order desired glucose targets and monitoring regimes. The provider will individualize monitoring frequency based on the complexity of the resident's regimen combined with the risk of hypoglycemia.Assess glycemic status by A1C measurement, blood glucose monitoring by capillary/fingerstick devices. During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical, the P&P indicated, The physician will identify and order diagnostic and lab testing based on resident's diagnostic and monitoring needs.

Based on observation, interview, and record review, the facility staff contacted the physician on two occasions regarding one of two sampled Residents' (Resident 2) elevated blood sugar levels, but physician did not review the recorded laboratory results, talk to nurse regarding Resident's status or order changes to Resident 2's treatment regimen. This failure resulted in Resident 2 having weakness, and elevated blood glucose above 800 mg/dL. During record review of admission record, printed on 2/9/26, Resident 2 was admitted on [DATE].During record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide care), dated 2/14/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 6 out of 15, indicated Resident 2 had severe cognitive impairment. MDS indicated Resident 2 had a diagnosis of type 2 diabetes (a chronic condition causing high blood sugar because the body cannot properly produce or use insulin, a hormone needed to turn food into energy).During a record review and concurrent interview on 2/13/2026, at 12:46 p.m., the Director of Nursing (DON) stated labs were filed in electronic medical record (EHR; a comprehensive, digital, and real-time version of a patient's paper chart, containing medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and lab results) by Medical Records (MR) after received and reviewed by nurses. DON stated physicians have access to EHR, but nurses were also responsible for placing lab results within paper chart. DON stated nurses also communicated with Attending Provider (MD) by phone or text and should write MD notified with date, time and signature on lab results after communicated with MD. During a record review and concurrent interview on 2/13/26, at 10:46 a.m., MD stated they relied on nursing staff to communicate abnormal lab reports to MD by phone or text message. MD stated the Lab Results Report resulted on 3/16/2024 at 2:31 p.m., ordered by MD, indicated hemoglobin A1C was 10.8%, and estimated average glucose was 263 mg/dL, which was elevated, very high and warranted additional orders. MD stated 3/16/2024 lab report was not sent or reviewed by MD. MD stated the Comprehensive Metabolic Panel (a common, 14-substance blood test that evaluates overall health, including kidney and liver function, blood glucose, calcium levels, protein levels, and electrolyte balance) resulted on 2/21/2025 at 3:16 p.m., ordered by MD, indicated glucose was 273 mg/dL, was high and warranted MD notification for additional orders. MD stated it was the nurses' responsibility to call or text MD with abnormal lab results. MD stated reviewed all orders and placed new orders based on communication from nurses during Resident assessments. MD stated important for abnormal lab results to be communicated to MD for proper interventions.During a record review and concurrent interview on 2/13/26, at 1:15 p.m., Medical Records (MR) and Administrator (Admin) stated MD had access to the EHR, but used personal electronic medical record system, where MR uploaded SOAP notes (Subjective, Objective, Assessment and Plan; a structured, standardized method of clinical documentation used by healthcare providers to record patient encounters efficiently), history and physical (a formal, comprehensive, and essential document in healthcare created by a clinician upon a patient's admission to a hospital or during a new consultation), laboratory results, past medical history, and current medications from hospital medical records for MD review. MR stated they uploaded relevant documents monthly into MD's personal EHR for record review, per request. During a review of Resident 2's Lab Results Report, with a result date of 3/16/2024 at 2:31 p.m., ordered by MD, indicated hemoglobin A1C (a blood test that shows your average level of blood glucose, also called blood sugar, over the past two to three months) was 10.8%, and estimated average glucose (estimated average of your blood glucose levels over a period of 2 to 3 months) was 263 mg/dL. The MD did not sign laboratory results to indicate results were reviewed or initiate any new orders.During a review of facility's physician notification text messages, MD was notified of Resident 2's lab results on 3/17/2024 at 7:00 a.m. with three photos of Resident 2's laboratory results, in which MD did not respond via text message. During a review of Resident 2's Comprehensive Metabolic Panel (CMP), resulted on 2/21/2025 at 3:16 p.m., ordered by MD, indicated glucose was 273 mg/dL. Written on CMP was MD notified by Licensed Vocational Nurse (LVN) 1 on 2/21/25 at 10:58 p.m. The MD did not sign laboratory results to indicate results were reviewed or initiate any new orders. During a review of Resident 2's Facesheet from General Acute Care Hospital (GACH), dated 3/9/2025, Resident 2 was admitted to GACH on 3/9/25 at 3:47 p.m. with altered mental status, including lethargy, confusion, partial responsiveness, and weakness. During a review of Resident 2's Labs from GACH, dated 3/9/25 at 6:26 p.m., Resident 2's blood glucose was greater than 800 mg/dl. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, the P&P indicated, The practitioner is responsible for.Responding in a timely manner to calls; especially regarding Immediate Notification problems.Communicating sufficient detail to appropriate staff about the assessment and management of the problem and the resident/patient.During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical, the P&P indicated, a Physician can be notified by phone, fax, voicemail, email, mail. Pager or telephone message to another person acting as the physicians agent.Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report. Alternatively, the staff and physician may also establish designated times during the day when they will review test results with physician by phone. A physician will respond within an appropriate time frame, based on the request from nursing staff and clinical significance of the information.A physician should respond within one hour regarding a lab result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response.

Based on observation, interview, and record review, the facility failed to report hypotension (blood pressure less than 100/60 mm/Hg) to physician for one of two sampled residents (Resident 1).This failure resulted in Resident 1 being found hypotensive with a blood pressure of 76/44 and altered mental status (a sudden or gradual change in a person's baseline mental state, including confusion, decreased alertness, or disorientation).During record review of admission record, printed on 2/5/26, Resident 1 was admitted on [DATE].During record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 12/4/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 15 out of 15, indicated Resident 1's cognition intact.During a review of Resident 1's Care Plan Report, initiated 12/5/25, the report indicated, [resident 1] has altered cardiovascular status r/t persistent.hypotension . The 'Goals' within the care plan indicated, Resident 1 will be free from complication of cardiac problems through the review date.During a review of Resident 1's Order Listing Report, initiated 12/1/25, the report indicated, Metoprolol Tartrate Oral Tablet 100 MG (Metoprolol Pharmacy Tartrate) Give 2 tablets by mouth at bedtime for HTN. Hold if SBP <100 or HR <60. During a review of Resident 1's Weights and Vitals Summary, dated 12/1/25 to 12/9/25, the summary indicated ten separate instances where Resident 1's SBP was less than 100 mm/Hg and not reported to physician. During a review of Resident 1's Change of Condition documentation, dated 12/9/25 at 10:41 p.m., the documentation indicated Resident 1 noted with hypotension but asymptomatic and altered mental status.noted to have hypotension after routine night medications around 2030. Current blood pressure measured at 75/44, Pulse: 76 at 11:30 p.m.Rechecked blood pressure several times mostly in range of 73-85 systolic and 37-46 diastolic.During an interview on 2/2/26, at 1:20 p.m., Licensed Vocational Nurse (LVN) 2 stated a low and reportable blood pressure is systolic blood pressure (SBP; top number in a blood pressure reading indicating the pressure in arteries when the heart contracts) less than 90 millimeters of mercury (mmHg; the standard medical unit used to measure blood pressure). LVN 2 stated a SBP less than 90 mmHg warranted a blood pressure recheck and communication to the physician, once blood pressure is confirmed. LVN 2 stated blood pressure should be assessed before and after any blood pressure medications were given to ensure resident safety and to assess for hypotension and hypertension. During a concurrent interview and record review on 2/2/26, at 1:36 p.m., Assistant Director of Nursing (ADON) stated blood pressure should be assessed before blood pressure medication administration, despite physician order for vital sign frequency. ADON stated Resident 1's blood pressure readings of 90/56 mm/Hg on 12/2/25 at 9:56 p.m., 86/56 mm/Hg on 12/8/25 at 6:58 p.m., and 86/56 mm/Hg at 10:20 p.m. should have been reported to physician. ADON stated there was no documentation that indicated the physician was notified of two instances of hypotension on 12/8/25. ADON stated it was very critical to report hypotension to physician, so physician is aware. During a concurrent interview and record review on 2/9/26, at 10:32 a.m., Director of Nursing (DON) stated a reportable blood pressure was defined in physician orders. DON stated nurses should follow physician ordered parameters despite Blood Pressure Measuring policy and procedure (P&P) indicating to report hypotension to physician, and Guidelines for Notifying Physicians of Clinical Problems indicating BP<90 systolic. DON stated importance of reporting hypotension to physician was to ensure physicians were aware of resident blood pressure assessment. During a review of Resident 1's Facesheet, printed 2/18/26, the face sheet indicated Resident 1 was admitted to [General Acute Care Hospital-GACH] on 12/9/25 at 11:10 p.m. due to low blood pressure and confusion. During a review of Resident 1's Physical Exam note, done at GACH and printed 2/18/26, the physical exam note indicated on 12/9/25 at 11:45 p.m. Resident 1's blood pressure was 87/39 mmHg. During a review of the facility's policy and procedure (P&P) titled, Blood Pressure, Measuring, the P&P indicated, Hypotension is defined as blood pressure less than 100/60 mm/Hg, . Hypotension should be reported to the physician.During a review of the facility's guidelines titled, Guidelines for Notifying Physicians of Clinical Problems, the guidelines indicated, these guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely manner, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record,. Change in vital signs. Follow these general guidelines.Blood pressure <90 systolic.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 held Basic Life Support (BLS; a professional credential verifying training in life-saving techniques for healthcare providers and public safety personnel) certification.This failure had the potential to result in residents' increased risk of adverse events during life-threatening, cardiac or respiratory emergencies. During a review of LVN 1's competency and skills folder, the BLS certification indicated, Renew by 07/2024.During a concurrent interview and record review on [DATE], at 2:16 p.m., the Director of Staff Development (DSD) stated LVN's need BLS and cardiopulmonary resuscitation (CPR; emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) training. DSD stated importance of BLS is to ensure staff competency in life saving measures in the event of a critical situation.During a review of the facility's policy and procedure (P&P) titled, Emergency Procedures-Cardiopulmonary Resuscitation, the P&P indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Preparation for Cardiopulmonary Resuscitation.Obtain and/or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) that adheres to the American Heart Association Guidelines for all clinical staff members, including non -licensed personnel.

Based on interview and record review, the facility failed to follow doctor's orders to perform STAT (immediately or without delay) X-ray (imaging of inside of body) for over 10 hours for one of three sampled residents (Resident 1) after a fall at the facility. Resident 1 was later diagnosed with fracture (broken bone) of the Right Tibia (shin) and Fibula (calf bone) related to the fall. This failure resulted in Resident 1 to stay in pain/discomfort for over 10 hours and caused a delay in treatment.During a review of Resident 1's admission record printed on 1/8/26, the record indicated Resident 1 was admitted to the facility on [DATE].During a review of Resident 1's Minimum Data Set (MDS, a resident assessment used to create individualized care plan) dated 5/2/25, the assessment indicated Resident 1's Brief Interview for Mental Status (BIMS, short-term memory screening tool), score was nine (9) out of 15, indicating moderately impaired thinking or memory. The assessment indicated Resident 1 required staff supervision or touching assistance with toileting transfer.During an interview on 1/5/26 at 12:50 p.m. Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted Resident 1 for toileting on 7/8/25, while Resident 1 used a bedside commode (a portable toilet). CNA 1 stated after toileting, Resident 1 got up from the commode, got stuck, couldn't turn or walk to the bed, and she ended up assisting Resident 1 onto the floor.During an interview on 1/5/26 at 1:15 p.m., Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the assigned nurse for Resident 1 when she fell on 7/8/25 at 2:00 pm. LVN 1 stated Resident 1 complained of three out of 10 pain (mild pain) after the fall incident on 7/8/25 and was given Tylenol for pain management.During a phone interview on 1/6/26 at 11:31 a.m. LVN 2, LVN 2 stated she was the evening shift (3:00 p.m.- 11:00 p.m.) nurse on 7/8/25 for Resident 1. LVN 2 stated Resident 1 had non-verbal cues of pain and she gave her another dose of Tylenol. LVN 2 stated she noticed an increase in swelling on Resident 1's right ankle and called the doctor. LVN 2 stated around 4:00 pm, the doctor ordered a STAT x-ray for Resident 1's bilateral knees and right ankle. LVN 2 stated STAT orders should be completed within four (4) hours, however Resident 1's X-ray was not completed even until end of her shift.During a record review of Resident 1's progress notes dated 7/8/25 the progress notes indicated, at 3:40 p.m. LVN 2 noted bilateral (both) knee and right ankle swelling with complaint of three out of 10 pain and at 4:00 p.m. Resident 1's doctor was notified who ordered STAT x-ray.During a record review of Resident 1's Order Listing Report (Doctor's orders) printed on 1/6/26, the order report indicated to complete STAT X-ray on bilateral (both) knee and right ankle for swelling [related to fall on 7/8/25].During a phone interview on 1/8/26 at 2:05 p.m., LVN 3 stated she was the assigned night shift nurse (11:00 pm on 7/8/25 through 7:00 am on 7/9/25) for Resident 1. LVN 3 stated she noted swelling, pain and purple discoloration on Resident 1's right ankle. LVN 3 since the STAT X-ray for bilateral knee and right ankle was still not conducted until she came on shift, she notified Resident 1's doctor at 11:39 p.m. and got an order to send Resident 1 to an acute care hospital for further evaluation.During a record review of Resident 1's Medication Administration Record (MAR) for July 2025, the MAR indicated on 7/8/25 Resident 1 required pain management after the fall and received two tablets of Acetaminophen (Tylenol) 325 milligrams (mg) (a total of 650 mg) at 2:27p.m, 3:10p.m, and 9:30p.m.During a record review of Resident 1's progress notes dated 7/8/25, LVN 3 documented Resident 1 was sent to acute hospital -Emergency department at 12:49 am on 7/9/25.During a record review of Resident 1's acute hospital Discharge summary dated [DATE], indicated fracture of tibia/fibula (shin and calf bone) related to the fall at the facility on 7/8/25.During a phone interview on 1/6/26 at 2:12 p.m., the Director of Nursing (DON) stated that STAT orders need to be followed through within four hours the order was received. The DON also stated if facility was unable to meet the timeline for a STAT order, the doctor needed to be notified to rule out any significant change, or to transfer to an acute care hospital.During a review of facility's Policy and procedure (P&P) titled Acute Condition Changes - Clinical Protocol dated 03/2018, the P&P indicated, The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less) . If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency Room.

Based on observation, interview, and record review, the facility failed to protect one of 15 sampled residents (Resident 164's) property from loss when their cell phone went missing. This failure had the potential to cause Resident 164 anxiety and stress. Findings: During a review of Resident 164's admission Record, printed 6/25/25, the record indicated Resident 164 was admitted to the facility in June 2025 with a diagnosis of Depression and Chinese as their primary language. During a review of Resident 164's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 6/18/25, the MDS indicated, Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS also indicated, Ability To Understand Others . Usually understands - misses some part / intent of message but comprehends most conversation. During an interview on 6/23/25, at 3:04 p.m., with Resident 164 and their caregiver (CG) 1, CG 1 stated Resident 164's cell phone went missing on 6/21/25. CG 1 stated they told staff, but no one did anything or got back to them. CG 1 stated Resident 164 was anxious because Resident 164 couldn't call their family with their cell phone. Resident 164 stated they needed to talk to their daughter and family, but they couldn't because their cell phone was missing. During a concurrent interview and record review on 06/25/25, at 09:57 a.m., with Social Services Director (SSD), the Theft and Loss Binder, dated 2025, was reviewed. The binder indicated Resident 164's missing cell phone was not reported. SSD stated Resident 164's cell phone was not reported to them. SSD stated they were responsible for investigating and resolving theft and loss issues. SSD stated staff should have filled out a Theft and Loss Report and notified SSD as soon as possible when Resident 164's cell phone went missing. SSD stated it was important to resolve Resident 164's missing cell phone immediately because it could have caused Resident 164 frustration if they could not talk to their family. During an interview on 6/25/25, at 4:49 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CG 1 told LVN 1 Resident 164's cell phone went missing on 6/22/25. LVN 1 stated they did not fill out a Theft and Loss Report and did not notify SSD. During an interview on 6/26/25, at 12:16 p.m. with Director of Nursing (DON), DON stated it was important to resolve Resident 164's missing cell phone as soon as possible so Resident 164 could have had peace of mind and Resident 164 really needed their cell phone because of their language barrier. During a review of Resident 164's Inventory of Personal Effects, dated 6/12/25, the Inventory of Personal Effects, indicated, Resident 164 had 1 Cell Phone During a review of the facility's policy and procedure (P&P) titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised November 2010, the P&P indicated, All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated.

Based on observation, interview, and record review, the facility failed to ensure resident food was stored in a safe and sanitary manner. This failure had the potential to cause infection and food borne illness to the residents that received food from the kitchen. Findings: During an observation on [DATE], at 10:17 a.m., the dry food storage and freezer room was observed. Sixteen prune juice cups, 118 mL (milliter) each, had a manufacturer's use by date of [DATE], were stored on a shelf. An open box of bananas, a container with 17 quarts of brown rice, a container with 9 quarts of white rice, and a container with 48 cups of flour were stored on shelves about 3.5 inches above floor. Freezer 3 had a box of frozen dinner rolls that were unsealed and had a manufacturer's use by date of [DATE]. Freezer 2 had a 3-gallon container of strawberry ice cream with an unsealed ripped lid. Freezer 1 had a 15-pound box of fish fillets and an opened bag of frozen chicken unsealed, a 300-slice box of bacon unsealed with a use by date of [DATE], beef that was not labeled with date, and frozen meat and a bag of chopped meat that was unlabeled and undated. During a concurrent observation and interview on [DATE], at 11:02 a.m., with Dietary Manager (DM) the dry storage and freezer room was observed. DM stated anything expired and without a label should have been thrown out. DM did not know the minimum storage height for food. DM stated unsealed frozen food in freezer was ok. During an interview on [DATE], at 2:00 p.m., with Registered Dietician (RD), RD stated frozen food in freezer should always be sealed and it was important to prevent freezer burn, maintain the quality, texture, and palatability of the food, and to prevent infection and food borne illness. RD stated food should have been stored at least 6 inches above the floor to prevent contamination from pests, infection, and food borne illness. RD stated it was the facility's policy to label all food items with received, opened, and use by date. RD stated it was important to throw out unlabeled, undated, and expired food because it could have caused the residents to get infection and food borne illness. During a review of the facility's policy and procedure (P&P) titled, Freezer Storage, dated 2023, the P&P indicated, Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. The P&P indicated, All frozen foods should be labeled and dated. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, All food and food containers are to be stored 6 off the floor and on clean surfaces in a manner that protects it from contamination. The P&P indicated All food will be dated - month, day, year.

Based on observation, interview and record review the facility failed to follow food safety requirements when the following were noted: 1. Dietary staff did not perform hand hygiene after entering the kitchen. 2. Dishwasher did not reach 120ºF (degrees Fahrenheit) each time. 3. Multiple items were unlabeled and undated in the unit refrigerator. These failures had the potential for cross contamination. Findings 1. During an observation on 4/11/22 10:24 a.m., in the kitchen, Dietary Aide (DA) was observed donning an apron and gloves, without first performing proper hand hygiene. During an interview on 4/12/22, at 2:20 p.m., with Dietary Manager (DM), DM stated everyone should stop and wash their hands before doing anything in the kitchen. DM stated it's a risk for cross contamination. 2. During a concurrent observation and interview on 4/11/22, at 9:50 a.m., with DA, observed temperature reading on thermometer used to test dishwasher temperature at 110ºF, DA stated the dishwasher should be 120ºF. DA stated the dishwasher is mostly 120º and sometimes less. DA stated they must run the dishwasher a few times to get to 120ºF. During a concurrent observation and interview on 4/11/22, at 9:50 a.m., with DM, DM stated the dishwasher was supposed to be 120ºF per manufacturer guidance. During a concurrent observation and interview on 4/11/22, at 10:28 a.m., with DM, observed temperature reading on thermometer used to test dishwasher temperature at 110ºF, DM stated the dishwasher was 110ºF, and directed DA to stop the dishwasher and get maintenance. During an interview on 4/12/22, at 2:22 p.m., with Registered Dietician (RD), RD stated the dishwasher temperature should go to 120ºF or there would be a risk that the dishes were not as clean, and it may not get enough debris off. RD stated she was aware that the dishwashing machine temperature did not reach 120ºF. RD stated she did a return demonstration on 3/15/22 and had to run the dishwasher three times to reach 120ºF. During a record review of the ES-2000 & ES-4000 Series Installation/ Operation Manual, revised 5/9/05, the manual indicated the minimum wash and rinse temperature was 120 ºF. 3. During a concurrent observation and interview on 4/12/22, at 1:52 p.m., with Infection Preventionist (IP), IP stated the unit refrigerator between rooms 35 and 37 was used for snacks for short term residents. The following items were found in the refrigerator and were not labeled with resident's name or date: one pre-packaged store-bought lunch item, one string cheese, one opened 330 milliliter (ml) bottle of lemon drink, one opened 330 milliliter (ml) bottle of sparkling water, one opened 236ml milk bottle, and one opened 828ml sports drink. The following items were found in the refrigerator and were not labeled with date: one opened 828ml sports drink labeled Resident 254, and one 500ml water bottle labeled Resident 254. There was one plastic cup of uncovered cut fruit which IP stated was cantaloupe, labeled Resident 206. During a concurrent observation and interview on 4/12/22, at 2:03 p.m., with Certified Nursing Assistant 2 (CNA), CNA 2 stated CNAs are responsible for labeling food. CNA 2 stated the sports drink, and lemon drink were for Resident 254. CNA 2 stated Resident 206 was not in the facility anymore. During a concurrent observation and interview on 4/12/22, 2:07 p.m., with IP, IP stated if food is not labeled and dated, they can go bad, mold and fungus can grow, other food can get contaminated, and it can attract bugs. IP stated residents are risk for upset stomach, and vomiting. IP stated she will throw all the opened and unlabeled food away. During an interview on 4/15/22, at 12:11 p.m. with Director of Nursing (DON), DON stated Resident 206 was discharged on [DATE]. During a record review of the Refrigerator Cleaning Log, dated April 2022, the log indicated all food that has no date and label will be discarded. During a record review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised October 2017, the P&P indicated, Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility prepared food . The P&P indicated, Perishable foods must be stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Based on interview and record review the facility failed to accurately follow through the Preadmission Screening and Resident Review (PASARR) assessment process (a screening tool used to prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) for two of two sampled residents (Resident 1 and Resident 35) when following was noted: 1. Resident 1 did not receive PASSR level II evaluation. 2. Resident 35's PASSR level 1 assessmentwas not completed accurately to reflect the severely impaired cognitive status (mental status). This failure placed Resident 1 and Resident 35 at risk to not receive care and services appropriate to their needs. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. During a review of Resident 1's 'Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/25/21, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of three of 15. Meaning, Resident 1 had severe impaired cognition. The MDS also indicated, Resident 1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's PASARR Level I Screening, dated 11/17/21, the PASARR Level I Screening indicated the level I screening result was positive. The PASARR Level I Screening also indicated, Resident 1 was suspected with mental illness. During a concurrent interview and record review on 4/11/22, at 11:36 a.m., with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 was positive for PASARR Level I. ADON further stated, she did not coordinate PASARR level II Evaluation because she was not aware of the process. 2. During a review of Resident 35's Admission Record dated 4/12/22 indicated Resident 35 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 4/12/22, at 1:56 p.m., with Assistant Director of Nursing (ADON), Resident 35's Preadmission Screening and Resident Review (PASSR) Level 1 Screening Document, dated 5/24/19 was reviewed. Resident 35's PASSR indicated facility answered No to Question 19b. Does the individual have serious difficulty communicating their needs, responding appropriately to direct questions, or otherwise engaging in a meaningful verbal interaction as a result of a cognitive deficit? During a concurrent interview and record review on 4/12/22, at 2:09 p.m., with Social Services Director (SSD), Resident 35's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/17/19 was reviewed. The MDS assessment indicated Resident 35's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was zero out of 15 which indicates severe mental impairment. During an interview on 4/12/22, at 2:11 p.m., the SSD stated since Resident 35's had severe cognition impairment, facility was expected to code Yes to Question 19b on the PASSAR Level I assessment completed on 5/24/19. SSD stated the documentation in PASSR level 1 assessment was incorrect. During an interview on 4/15/22, at 9:03 a.m., the Director of Nursing (DON) stated completing the PASRR Level I assessment accurately was important to identify if residents with mental disorder required Level II evaluation or not. The DON stated Level II evaluation was completed by a State Organization to ensure if the resident with a mental disorder received appropriate and individualized care. The DON stated Resident 35's PASSR assessment was overlooked for accuracy. During a review of the facility's undated Policy and Procedure (P&P) titled, Admission Criteria updated 3/2019, indicated Policy Interpretation and Implementation .9. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process .c. Upon completion of the Level II evaluation, state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 254) received care when following was noted: 1. Resident 254 had long fingernails with black matter underneath on both hands. 2. Resident 254 did not receive shower/bed bath for four of five days within one week of readmission to the facility. This failure resulted in Resident 254 to feel helpless, placed him at risk for infections and hurting himself with long fingernails. Findings: 1. During a review of Resident 254's Admission Record dated 4/14/22, the Admission Record indicated Resident 254 was originally admitted to the facility on [DATE]. During a record review of Resident 254's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/6/21, the MDS assessment also indicated Resident 254's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 15 out of 15 which indicates intact mental status. During a concurrent observation and interview on 4/11/22, at 11:15 a.m., with Certified Nursing Assistant 3 (CNA 3), Resident 254 had long fingernails and black matter underneath fingernails on on both hands. CNA 3 stated Resident 254's could scratch himself and cause skin tears with his long fingernails. During a follow up observation and interview on 4/12/22 at 11:20 a.m., Resident 254 still had long fingernails with black matter underneath on both hands. Resident 254 stated no one helped to trim his fingernails and that made him feel helpless. During an interview on 4/13/22 at 11:31 a.m., with Registered Nurse 1 (RN1), RN1 stated it was important to trim residents' fingernails as it was an essential part of grooming and there was a risk of causing skin tears from scratching. During a review of the facility's undated P&P titled, Fingernails/Toenails, Care of, revised 02/2018, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 2) During an interview on 4/13/22 at 11:32 a.m.,with Resident 254, Resident 254 stated staff delayed the shower time till end of their shift and then never provided him showers since he got readmitted to the facility on [DATE]. During a record review of Resident 254's MDS assessment dated [DATE], the MDS assessment indicated Resident 254 was totally dependent on staff for showers/bed bath. During a review of Resident 254's Care Plan- ADL Self-care deficit, revised on 4/7/22, the care plan indicated to provide one staff assistance to Resident 254 for upper and lower body bathing related to weakness and impaired mobility. During a concurrent interview and record review with the Director of Staff Development (DSD) on 4/15/22, at 9:55 a.m., residents' shower schedule was reviewed. The shower schedule indicated Resident 254 was scheduled to receive shower every Monday and Friday [4/8/22 and 4/11/22 since he got readmitted on [DATE]]. During an interview on 4/14/22, at 9:36 a.m., Certified Nursing Assistant (CNA 3) stated she checked shower schedule every day at beginning of shift to see which resident was scheduled for shower. CNA 3 stated residents received bed baths if they did not want showers on the scheduled days. During a concurrent interview and record review with Assistant Director of Nursing (ADON) on 4/13/22, at 10:53 a.m., Resident 254's Electronic Medical Record (EMR) for shower for the period of 4/7/22 to 4/13/22 was reviewed. The ADON stated Resident 254 did not receive showers and/or bed bath on 4/8/22, 4/9/22, 4/11/22, 4/12/22 since he got readmitted on [DATE]. During an interview on 4/15/22, at 9:03 a.m., the Director of Nursing (DON) stated staff was expected to provide bed bath on non-shower days. The DON also stated the risk of not providing showers/bed bath could result in skin issues getting overlooked and/or getting worse; and affect quality of life of residents. The DON stated not providing the care, that the residents required, was not acceptable. During a review of the facility's undated Policy and Procedure (P&P) titled, Activities of daily living (ADL), Supporting, revised on 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a review of the facility's undated policy and procedure (P&P) titled, Bath, Shower/Tub, revised 02/2018, the P&P indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the conditions of the resident's skin.

Based on observation, interview and record review, the facility failed to ensure a resident received the volume of oxygen as ordered by the physician for two of two sampled residents (Resident 2 and Resident 37). This deficient practice resulted in Resident 2 and Resident 37 receiving more oxygen than required and can negatively impact both resident's the health and well-being. Findings: 1. During a review of Resident 37's Admission Record, the Admission Record indicated, Resident 37 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. During an observation on 4/11/22, at 9:40 a.m., in Resident 37's room, Resident 37 was laying in bed receiving oxygen at three liters (L-liters, unit of measurement) per minute via nasal cannula (NC -a device to provide supplemental oxygen therapy) from an oxygen concentrator (medical device that gives extra oxygen). During a concurrent observation and interview on 4/11/22, at 9:42 a.m., with the Licensed Vocational Nurse (LVN) 1, in Resident 37's room, the oxygen concentrator was delivering three liters of oxygen per minute to Resident 37 via NC. LVN 1 confirmed the oxygen concentrator was set to deliver three liters of oxygen. During a review of Resident 37's Order Summary Report, dated 1/20/21, the Order Summary Report indicated, Give 2L per minute oxygen per nasal cannula as needed (prn) for dyspnea (difficulty breathing) . 2. During a review of Resident 2's Admission Record, the Admission Record indicated, Resident 2 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. During a concurrent observation and interview on 4/11/22, at 9:53 a.m., with LVN 1, in Resident 2's room, LVN 1 confirmed the the oxygen concentrator was delivering three liters of oxygen per minute to Resident 2 via NC. During a review of Resident 2's Order Summary Report, dated 2/16/22, the Order Summary Report indicated, Give 2L per minute oxygen per nasal cannula prn for shortness of breath (SOB). During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under preparation, 1. Verify that there is a physician's order for the procedure, review the physician's order or facility protocol for oxygen administration.

Based on observation, interview and record review, the facility failed to ensure Activity Assistant (AA) performed hand hygiene in between residents while preparing and serving coffee to three of three sampled residents (Resident 52, 11 and 13). This failure placed Resident 52, 11 and 13 at risk for cross contamination. Findings: During an observation on 4/12/22 at 9:00 a.m., Resident 52 was sitting in wheelchair in the activity room. AA repositioned Resident 52's wheelchair while she touched the wheelchair handles, and repositioned Resident 52's feet on the footrest. Without performing hand hygiene, AA then prepared and served coffee to Resident 11 and 13 while touching the inside of coffee mugs. During an interview with AA on 4/12/22, at 9:07 a.m., AA stated she missed to clean hands with a hand sanitizer in between Resident 52, 11 and 13. AA also stated performing hand hygiene was important to protect the residents from Coronavirus (a highly infectious disease, commonly known as COVID-19). During an interview with Director of Staff Development/ Infection Preventionist (DSD/IP), on 4/12/22, at 9:48 a.m., the DSD/IP stated staff was expected to perform hand hygiene anytime they touched resident's environment. DSD/IP also stated hand hygiene was important to break the chain of transmission of infections. During a review of facility's policy and procedure titled Handwashing/Hand Hygiene dated 08/2019 indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antibacterial or non- antibacterial) and water for the following situations: b. Before and after direct contact with residents; o. Before and after eating or handling food .

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was within reached for four of 18 sampled residents (Resident 10, 33, 40 and 3). This deficient practice had the potential to result in the delay of care and services. Findings: 1. During a review of Resident 10's Admission Record, the Admission Record indicated Resident 10 was admitted to the facility on [DATE], with multiple diagnoses that included abnormal posture and abnormalities of gait and mobility (unable to move and walk in a usual way). During a review of Resident 10's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 11/2/21, the MDS indicated Resident 10 required extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene. During an observation on 4/11/22, at 10:07 a.m., in Resident 10's room. Resident 10 was seen crawling on floor mattress. Resident 10 indicated he needed assistance with toilet use. Resident 10's call light was missing from the electrical outlet. During an interview on 4/11/22, at 10:11 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 confirmed, there was no call light connected. CNA 1 stated she was not aware Resident 10's call light was missing. CNA 1 further stated, Resident 10 required assistance with toilet use and needed call light within reached at all times. 2. During a review of Resident 33's Admission Record, the Admission Record indicated Resident 33 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses that included muscle wasting and atrophy (thinning of muscle mass causing numbness, weakness and tingling sensation). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 was totally dependent on staff with bed mobility, dressing, eating, toilet use and hygiene. During a concurrent observation and interview on 4/11/22, at 10:18 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 33's room. Call light was observed on the floor under Resident 33's bed. LVN 1 picked up the call light, placed it within reached on Resident 33's right side. LVN 1 stated, call light should be within reached of Resident 33 all the time. 3. During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses that included [CONDITION(S)] Disease ([CONDITION(S)] - loss of blood flow to part of the brain), muscle wasting and atrophy, abnormal posture, muscle weakness and [CONDITION(S)] [paralysis (loss of ability to move) of one side of the body] and [CONDITION(S)] (minor to severe weakness or paralysis on one side of the body) affecting left non-dominant side. Durng a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40 required extensive assistance with bed mobility, dressing and hygiene. The MDS also indicated, Resident 40 was totally dependent on staff with toilet use. During an observation on 4/11/22, at 10:24 a.m., Resident 40's call light cord was wrapped on left side of bed rail and call light was on the floor. During a concurrent observation and interview on 4/11/22, at 10:26 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), in Resident 40's room, DSD/IP unwrapped call light cord from left bed rails, picked up call light from the floor. DSD/IP then placed call light on right side of Resident 40 and stated, Resident 40's needs must be attended and required call light within reached at all times. 4. During a review of Resident 3's Admission Record, the Admission Record indicated Resident 3 was admitted to the facility on [DATE], with multiple diagnoses that included, extrapyramidal and movement disorder (involuntary or uncontrollable movements, tremors and muscle contractions), muscle weakness and abnormal posture. During a review of Resident 3's MDS, dated [DATE], MDS indicated Resident 3 required extensive assistance with bed mobility. The MDS also indicated, Resident 3 was totally dependent on staff with dressing, toilet use and personal hygiene. During a concurrent observation and interview on 4/11/22, at 10:27 a.m with DSD/IP, in Resident 3's room. Call light was observed on the floor behind Resident 3's bed. DSD/IP was observed picking up the call light, then secured it on Resident 3's bed. DSD/IP stated, call light should be within reached at all times for safety of Resident 3. During an interview on 4/11/22, at 12:16 p.m., with the Director Of Nursing (DON), DON stated, facility protocol should always ensure resident's call lights are within reached so staff can tend to residents needs right away. During a record review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010, the P&P indicated, under general guidelines.4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review facility failed to provide a written summary of baseline care plan to one of three sampled residents (Resident 257). This failure resulted in Resident 257 not being aware of his plan of care. Findings: During a review of Resident 257's Admission Record, dated 4/14/22, the Admission Record indicated Resident 257 was admitted to the facility on [DATE]. The admission record indicated that Resident 257 was his own responsible party. During an interview on 4/11/22, at 10:01 a.m., Resident 257 stated he was not aware of his plan of discharge from the facility. During a concurrent interview and record review on 4/13/22, at 10:10 p.m., with Assistant Director of Nursing (ADON), Baseline care plan v1.1 dated 3/31/22 was reviewed in Resident 257's Electronic Medical Record (EMR). Resident 257's baseline care plan showed the discharge plan was part of the extensive baseline care planning process. ADON stated facility completed Resident 257's baseline care plan on 3/31/22, however it did not indicate if Resident 257 or his family representative was involved in care planning process. ADON also stated there was no evidence if facility provided a written summary of baseline care plan to Resident 257 and or his family representative. During an interview on 4/15/22, at 9:03 a.m., with the Director of Nursing (DON), the DON stated facility didn't have a system to ensure a written summary of baseline care plan was provided to residents. The DON also stated she was aware that baseline care plan must be completed within 48 hours of admission and a written summary must be provided to the residents and/or their representatives. During a review of the facility's undated Policy and Procedure (P&P) titled, Care plans- Baseline, revised on 12/2016, indicated, Policy Interpretation and Implementation .4. The resident and their representative will be provided a summary of the baseline care plan .

Based on observation, interview and record review, the facility failed to ensure the results of past State Inspections were readily accessible to the residents without having to ask the facility's staff for it. This failure placed the facility's residents at risk of not being informed of state inspections results for the past years. Findings: During an observation on 4/11/22, at 9:15 a.m., facility's survey binder with state inspection results was not at the nursing station. During Resident Council Meeting on 4/12/22, at 10:40 a.m., Resident 13 and Resident 29 both indicated they did not know where to find or read state inspection results. During an interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on 4/12/22, at 11 a.m., DSD/IP stated facility kept the past state inspections in a binder. The DSD/IP stated the survey binder was kept on the Nursing Station desk facing the main door of the facility. DSD/IP looked around the nursing station, checked resident's charts cart,and nursing station desk but was unable to find it. DSD/IP then looked into a closed cabinet high above the sink at the nursing station. DSD/IP stated the state inspection survey binder was inside the closed cabinet. During a review of the facility's policy and procedure titled, Residents Rights revised 12/2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include: w. examine survey results.

Based on interview and record review, the facility failed to follow its policy for abuse prevention when one Resident ( Resident 1) of three sampled residents was verbally abused by Certified Nursing Assistant (CNA)1. This failure had the potential to result in Resident 1 feeling offended and disrespected by CNA 1. During an interview with CNA 1 on [DATE], at 11:35 a.m., CNA 1 stated Resident 1 wanted a popsicle at the beginning of the shift on [DATE], but she did not have access to the kitchen. CNA 1 stated she offered Resident 1 a premade sandwich as an alternate choice. CNA 1 stated Resident 1 ate the sandwich and then stated CNA 1 gave him a sandwich with an expired use-by date. CNA 1 reviewed the expiration date with Resident 1stating the sandwich was made on [DATE] and had an expiration date of [DATE]. CNA 1 stated Resident 1 called her a liar because she could not give him a popsicle. Resident 1 used the call button to call for assistance. CNA 1 answered the call light and stated Resident 1 was using expletives at her. CNA 1 stated she stepped out of Resident 1's room because Resident 1 was being disrespectful. Resident 1 rang the call button again and again was using expletives with CNA 1. While CNA 1 was in Resident 1's room, Licensed Vocational Nurse (LVN) 1 entered Resident 1's room. Resident 1 requested a cheese sandwich. CNA 1 left the room to get the sandwich. CNA 1 stated when she stepped out of Resident 1's room and closed the door, she said to herself Oh [OBSCENITY] . CNA 1 brought the cheese sandwich to Resident 1. Resident 1 stated the cheese sandwich was expired. CNA 1 left Resident 1's room and LVN 1 reviewed the expiration date on package with Resident 1. During an interview on [DATE], at 12 p.m., with Resident 3, Resident 3 stated that night she heard a man screaming at CNA 1. Resident 3 said she could not hear what the man said but it was not a kind tone of voice. Resident 3 stated the last words she heard was from CNA 1 which were [OBSCENITY] you. Resident 3 stated CNA 1 stomped out of the room. During a review of the facility's policy and procedure titled, Abuse Prevention Program, dated ,d+[DATE], indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms, and that As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited: facility staff, .

Based on observation, interviews, and record review, the facility failed to provide food in a manner that was in accordance with current food safety guidelines, when there was inadequate oversight by the Registered Dietitian (RD) and Dietary Manager (DM) regarding the development and implementation of person-centered education programs involving food and nutrition services staff. This failure has the potential for food borne illnesses and decreased nutritive value of prepared food for a vulnerable population. Findings: 1. During an observation in the kitchen on 7/22/19 at 8:37 a.m., there was a container of rice in refrigerator #1. The temperature of the rice was 37 degrees Fahrenheit. It was labeled prepared on 7/21/19 and to be used by 7/23/19. During an interview with Cook 1 on 7/22/19 at 9:30 a.m., Cook 1 stated she made the rice. Cook 1 was not able to answer questions regarding the 2 step cool down method for the rice. Review of the Cool Down Log indicated there was no documentation for the rice prepared on 7/22/19. Review of Cook 1's employee file indicated she had been trained on cool down procedure and log documentation on 5/1/19 by DM. 2. During an observation in the kitchen on 7/22/19 at 8:37 a.m., Cook 2 had a beard not covered with a beard guard and the DM had a long ponytail not contained in the hairnet. During an interview with the Infection Control Nurse (ICN) on 7/22/19 at 12:25 p.m., ICN stated the beard should be covered and hair completely contained in the hairnet. Review of the policy for Preventing Foodborne Illness, dated (MONTH) (YEAR), indicated Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 3. During an observation in the kitchen on 7/23/19 at 8:30 a.m., Cook 2 was preparing puree (smooth, creamy textured food) for lunch. Menu indicated(NAME)Lemon Chicken. During an interview with Cook 2 on 7/23/19 at 8:30 a.m., Cook 2 stated he cooked 14 boneless chicken thighs with curry, cumin and garlic to prepare 16 pureed servings. Cook 2 was observed putting chicken in blender along with the liquid chicken was cooked in without measuring liquid. Cook 2 added 1 3/4 cup thickener to puree. Recipe for(NAME)Lemon Chicken called for sauce made from mayonnaise, sour cream and lemon juice and puree chicken with sauce. During an interview with RD on 7/24/19 at 10:20 a.m., RD stated food should be pureed approximately 1 hour prior to serving. RD stated she was not aware Cook 2 was not pureeing chicken cooked according to the recipe. RD stated she was not observing enough.

Based on observation, interviews, and record review, the facility failed to ensure that the Registered Dietitian (RD) and Dietary Manager (DM) directed and coordinated personnel employed in the kitchen to ensure sanitary conditions and food with nutritional value. This failure resulted in the potential for food borne illnesses and decreased nutritive value of prepared food. Findings: 1. During an observation in the kitchen on 7/22/19 at 8:37 a.m., there was a container of rice in refrigerator #1. The temperature of the rice was 37 degrees Fahrenheit. It was labeled prepared on 7/21/19 and to use by 7/23/19. During an interview with Cook 1 on 7/22/19 at 9:30 a.m., Cook 1 stated she made the rice. Cook 1 was not able to answer questions regarding the 2 step cool down method for the rice. Review of the Cool Down Log indicated there was no documentation for the rice prepared on 7/22/19. Review of Cook 1's employee file indicated she had been trained on cool down procedure and log documentation on 5/1/19 by DM. 2. During an observation in the kitchen on 7/22/19 at 8:37 a.m., Cook 2 had a beard not covered with a beard guard and the DM had a long ponytail not contained in the hairnet. During an interview with the Infection Control Nurse (ICN) on 7/22/19 at 12:25 p.m., ICN stated the beard should be covered and hair completely contained in the hairnet. Review of the policy for Preventing Foodborne Illness, dated (MONTH) (YEAR), indicated Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 3. During an observation in the kitchen on 7/23/19 at 8:30 a.m., Cook 2 was preparing puree (smooth, creamy textured food) for lunch. Menu indicated(NAME)Lemon Chicken. During an interview with Cook 2 on 7/23/19 at 8:30 a.m., Cook 2 stated he cooked 14 boneless chicken thighs with curry, cumin and garlic to prepare 16 pureed servings. Cook 2 was observed putting chicken in blender along with the liquid chicken was cooked in without measuring liquid. Cook 2 added 1 3/4 cup thickener to puree. Recipe for(NAME)Lemon Chicken called for sauce made from mayonnaise, sour cream and lemon juice and puree chicken with sauce. During an interview with RD on 7/24/19 at 10:20 a.m., RD stated food should be pureed approximately 1 hour prior to serving. RD stated she was not aware Cook 2 was not pureeing chicken cooked according to the recipe. RD stated she was not observing enough. 4. During an observation and concurrent interview in the kitchen on 7/22/19 at 11:55 a.m., vegetarian/vegan meals were being served without measuring portion size. Cook 2 stated he did not have menus for the vegetarian/vegan meals, so there were no portion sizes to follow. Cook 2 stated staff worked there were not given recipes to use. In an interview with the Registered Dietitian (RD) on 7/24/19 at 10:20 a.m., RD stated the staff should be using recipes and measuring portion size for vegetarian/vegan meals. RD stated she was not aware they did not have recipes or measuring portion size. RD stated she should be observing more. 5. During an observation in the kitchen on 7/23/19 at 8:35 a.m., Cook 2 was wearing gloves during meal prep. Cook 2 removed his gloves and put on another pair of gloves without washing his hands. During an interview with DM on 7/23/19 at 8:35 a.m., DM stated Cook 2 should have washed his hands before putting on gloves. Review of facility Glove Use Policy, dated (YEAR), indicated employees should wash hands when changing to a fresh pair of gloves.

Based on observation, interview, and record review, the facility failed to ensure that dietary personnel had the appropriate skills in place in order to effectively carry out meal preparation and safe food handling when the cook did not correctly follow the menus or infection control policies. This deficient practice could place the residents at risk for malnutrition and unplanned weight loss and the potential for foodborne illness. Findings: 1. During an observation in the kitchen on 7/22/19 at 8:37 a.m., Dietary Manager (DM) had hairnet on but did not have her ponytail contained inside the hairnet and Cook 2 was not wearing a beard guard. In an interview with Infection Control Nurse (ICN) on 7/22/19 at 12:25 p.m., ICN stated hair should be covered by hairnet and facial hair covered by beard guards. Review of facility Preventing Foodborne Illness policy, dated (MONTH) (YEAR), indicated, Hair nets and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 2. During an observation and concurrent interview in the kitchen on 7/22/19 at 11:55 a.m., vegetarian/vegan meals were being served without measuring portion size. Cook 2 stated he did not have menus for the vegetarian/vegan meals, so there were no portion sizes to follow. Cook 2 stated staff worked there were not given recipes to use. In an interview with the Registered Dietitian (RD) on 7/24/19 at 10:20 a.m., RD stated the staff should be using recipes and measuring portion size for vegetarian/vegan meals. RD stated she was not aware they did not have recipes or measuring portion size. RD stated she should be observing more. 3. During an observation in the kitchen on 7/23/19 at 8:35 a.m., Cook 2 was wearing gloves during meal prep. Cook 2 removed his gloves and put on another pair of gloves without washing his hands. During an interview with DM on 7/23/19 at 8:35 a.m., DM stated Cook 2 should have washed his hands before putting on gloves. Review of facility Glove Use Policy, dated (YEAR), indicated employees should wash hands when changing to a fresh pair of gloves. 4. During an observation in the kitchen on 7/22/19 at 8:37 a.m., there was a container of rice in refrigerator 1. The temperature of the rice was 37 degrees Fahrenheit. It was labeled prepared on 7/21/19 and to use by 7/23/19. During an interview with Cook 1 on 7/22/19 at 9:30 a.m., Cook 1 stated she made the rice. Cook 1 was not able to answer questions regarding the 2 step cool down method for the rice. Review of the Cool Down Log indicated there was no documentation for the rice prepared on 7/22/19.