Every finding on record at Orange Healthcare & Wellness Centre, LLC

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their policy to provide medical records for one of three sampled residents (Resident 1). * Resident 1 did not receive the requested medical records timely. This failure resulted in the violation of Resident 1's right to access his medical records. Findings: Review of the facility's P&P titled Resident Access to Protected Health Information (PHI) revised 11/1/15, showed the following:- if the resident and/or their personal representative requests a copy of the resident's medical record, the HIPAA Privacy Officer will provide the resident and/or their personal representative with a copy of the medical record within two working days after receiving the written request. Medical record review for Resident 1 was initiated on 4/8/26. Resident 1 was admitted to the facility on [DATE]. Review of the facility's document titled Request for Access to Protected Health Information (PHI) dated 1/29/26, showed Resident 1 requested for the whole chart and signed by Resident 1 for the second request. Review of the facility's document titled Resident Records Request Intake form dated 1/29/26, under Potential Issues Noted in Request/Chart for Legal showed the box for family raised concerns was checked. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's Brief Interview for Mental Status (BIMS) score was 13, which meant the resident had intact cognition. Review of the facility's document from the MRD's printed email sent from the corporate legal team HIS (Health Information Specialist) dated 3/31/26 at 1702 hours, showed Resident 1's medical record request was approved for release. On 4/8/26 at 0826 hours, an interview was conducted with Resident 1. Resident 1 stated he had signed several request forms to have access and copy his entire medical record since 1/2026 and submitted them to the MRD. In addition, Resident 1 stated it had been several months since he had requested a copy of his entire medical record from the MRD and still he had not received the requested copy. Furthermore, Resident 1 stated they were his medical record and Resident 1 and the complainant had the rights to access and copy all his medical and billing records. On 4/8/26 at 1118 hours, an interview and facility document review was conducted with the MRD. The MRD verified Resident 1 requested for the whole chart on 1/29/26, as a second request, as shown on the form titled Resident Request for Access to Protected Health Information. The MRD verified the above findings. In addition, the MRD stated the facility's policy was to provide access or requested medical records within 48 to 72 business hours. The MRD stated until now Resident 1 and the complainant have not received the copy of Resident 1's entire medical record as requested on 1/29/26. On 4/8/26 at 1352 hours, an interview and facility document review was conducted with the MRD. The MRD verified the form titled Resident Records Request Intake form dated 1/29/26, under the section Potential Issues Noted in Request/Chart for Legal Review, showed the resident's family raised concerns was checked. The printed document from the MRD's email from the corporate legal team HIS dated 3/31/26 at 1702 hours, was also reviewed with the MRD. The MRD verified the email showed Resident 1's request for records was approved for release. The MRD stated after he received Resident 1's request for the copy of the entire medical record on 1/29/26, he sent the request for review to the corporate legal team; then the corporate legal team would review the requested medical records. However, there was no timeframe for how long it would take to receive release of approval of requested medical records. The MRD stated he received the approval to release Resident 1's requested medical record on 3/31/26, via email from the corporate legal team HIS, however; he did not provide the requested medical record to Resident 1. On 4/8/26 at 1615 hours, an interview and facility document review was conducted with the DON. Resident 1's request form titled Resident Request for Access to Protected Health Information requesting for the whole chart was reviewed with the DON. The DON verified Resident 1's request. The DON stated the facility cannot deny the residents' rights to access their medical record. In addition, the DON stated the negative outcome if facility was denying or delaying access to the resident's medical record would be the residents and family members would be suspicious of the facility could be hiding something from them. Furthermore, the DON acknowledged it was not until the nurse surveyor came into the facility for investigation when the MRD provided the requested medical record for Resident 1. On 4/8/26 at 1655 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. On 4/15/26 at 1259 hours, a telephone interview was conducted with Resident 1's family member. The family member stated Resident 1 and her were not informed by facility for the required fees in requesting a copy of Resident 1's entire medical records. In addition, Resident 1's family member stated Resident 1 and her did not sign any forms showing they declined to pay the required fees for the copy of the requested medical records. On 4/15/26 at 1456 hours, a telephone interview was conducted with the Administrator. The Administrator stated she informed Resident 1 and the resident's family member verbally regarding the required fees in requesting a copy of the medical records prior to providing them. Furthermore, the Administrator stated there was no documentation of Resident 1 or Resident 1's family member declining to pay the required fees for the requested copy of the entire medical records.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper medication storage was followed in one of three nurse stations (Nurse Station A), one of two medication rooms (Medication Room A), two of two medication carts (Medication Cart A and Treatment Cart A), and one of two medication refrigerators (Medication Refrigerator A) observe. * Multiple medications were left unattended at Nurse Station A, after the pharmacy delivery. * The facility failed to maintain the recommended medication refrigerator temperatures in Medication Room A. * The facility failed to keep Treatment Cart A free of unnecessary items such as batteries, tools, and insulin syringes. * The facility failed to ensure there were no unlabeled loose medications in Medication Cart A. * The facility failed to ensure the storage bin for the OTC medications in Medication Cart A was free from dirt like debris. * The facility failed to ensure the top exterior part of Medication Refrigerator A was free of white powder like debris. * The facility failed to ensure Medication Cart B storing bin containing Coban (self- adherent, cohesive bandages), etc. was free from dirt like debris. These failures had the potential for the non-nursing staff, residents, and visitors to have access to the medications, as well as the potential for medication degradation and contamination. Findings: 1. Review of the facility's P&P titled Storage of Medication revised January 2025 showed medications are stored safely and securely, and only licensed nurses, pharmacy personnel, and those lawfully authorized ae allowed access to medications. The medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. On 1/8/25 at 0523 hours, RN 1 was observed sitting at Nurse Station A and a stack of 19 medication bubble packs, a large paper bag with a pharmacy medication list with nine medications stapled to it, and three plastic bags with a pharmacy paperwork attached to each bag were observed on top of the nurse station counter. CNA 2 asked RN 1 for assistance and RN 1 was observed leaving the nursing station and leaving the medications unattended. A housekeeping staff member was observed sweeping the floor, just outside the nurse station, and a resident was observed on his wheelchair in the lobby, just down a short hallway from the nurse station. On 1/8/26 at 0532 hours, LVN 4 walked into Nurse Station A and grabbed the large paper bag. LVN 4 stated the paper bags were the pharmacy delivery that arrived a little after 0400 hours that morning. On 1/8/26 at 0605 hours, an interview was conducted with RN 1. RN 1 verified the pharmacy delivery (medications) were left unattended at the nurse station when he left to assist CAN 2. RN 1 stated the medications should have been secured in the medication room until the LVNs were available to secure the medications in the medication carts. 2. Review of the facility's P&P titled Medication Storage in the Facility revised January 2025 showed: - Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring - Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. On 1/8/26 at 0810 hours, an interview and concurrent inspection of Medication Room A was conducted with RN 2. RN 2 was asked to unlock the medication refrigerator Immediate observation of the thermometer inside the refrigerator showed the temperature was 30 degrees. The medications stored in the refrigerator included: - Humulin R (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit; - insulin lispro (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit; - Lantus solostar (insulin used to treat diabetes) and the recommended storage temperature was 36 to 46 degrees Fahrenheit; and -Veltassa powder (used to treat hyperkalemia) and the recommended storage temperature was 36 to 46 degrees Fahrenheit. RN 2 stated the refrigerator temperature should be between 36 and 46-degrees Fahrenheit according to the facility's policy. RN 2 verified a temperature of 30 degrees Fahrenheit was too low for the medication refrigerator. On 1/8/26 at 1247 hours, a follow up observation of the medication refrigerator inside Medication Room A and a concurrent interview was conducted with RN 2. RN 2 was asked to unlock the medication refrigerator. Immediate observation of the thermometer inside the refrigerator showed the temperature was 30 degrees Fahrenheit. RN 2 verified the above findings. 3. On 1/7/26 at 1219 hours, an inspection of Treatment Cart A and concurrent interview was conducted with LVNs 1 and 2. The following was observed: - A storage bin in the top drawer, containing different sized batteries, insulin syringes, and miscellaneous tools. LVN 1 stated he did not know why the items listed above were in stored inside the medication cart. LVN 1 stated the batteries and tools could be stored in the central supply and the insulin syringes were not used when providing wound care treatments to the residents. LVN 2 was also present and stated the above items should be kept in central supply. On 1/7/26 at 1230 hours, an interview was conducted with RN 2. RN 2 stated Treatment Cart A should only have wound treatment supplies stored inside and any other items the licensed nurses needed could be found in the central supply. On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON was informed of the above findings. 4. Review of the facility's P&P on Medication Administration dated 8/19/25, showed to prepare medications for one resident at a time and not to pre- pour medications. On 1/8/26 at 0600 hours, right after the medication administration observation with LVN 5 was completed, five cups of pre-poured unlabeled loose medications (tablets and capsules) were observed in the first drawer of Medication Cart A. LVN 5 verified the following unlabeled loose medications in a transparent medication cup: - 1st medication cup: one blue capsule, one white tablet and one yellow tablet; - 2nd medication cup: one yellow tablet; - 3rd medication cup: one white round tablet; - 4th medication cup: one blue tablet and one blue capsule; and - 5th medication cup: one white round tablet. LVN 5 stated the medications from two of the medication cups were for Resident 52, who wanted to take her medications after she got changed. LVN 5 showed four bubble packs, where she dispensed the medications from for two of the five medication cups for Residents 52 and 67. Reconciled the medications against Resident 52's due medication bubble packs. The unlabeled medications on the 1st medication cup were comparable to bubble pack for Resident 67. The 2nd medication cup was comparable to Resident 52's due medication bubble pack. However, LVN 5 was not able to identify the rest of the medications or the resident's name. On 1/8/26 at 0615 hours, an interview was conducted with RN 1. RN 1 was informed and verified the above findings. RN 1 was shown the five pre-poured medication cups with unlabeled medications on the first drawer of Medication Cart A. RN 1 was unable to account for the remaining unlabeled medications, stated these should have been labeled. 5. Review of the facility's P&P on Medication Storage in the Facility dated January 2025 showed the medication storage areas are kept clean, well - lit and free of clutter and extreme temperatures and medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. On 1/7/26 at 0945 hours, an inspection of Medication Cart A was conducted with LVN 6. Multiple brownish dirt-like debris were observed in one of the storage bins, farthest left of the 1st drawer. LVN 6 verified the findings and stated all the charge nurses clean the medication carts from all shifts; this should have been cleaned. On 1/7/26 at 1006 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified the above findings and stated the medication cart should have been cleaned and sanitized. 6. On 1/7/26 at 1010 hours, an inspection of Medication Refrigerator A was conducted with LVN 7. The top exterior part of Medication Refrigerator A was observed with white powder- like debris and was partially removed when wiped clean with a paper towel. LVN 7 verified the findings and stated all the areas of medication room, including Medication Refrigerator A should have been cleaned by licensed nurses from all the shifts. On 1/7/26 at 1023 hours, an observation and concurrent interview was conducted with the DON. The DON verified the white powder like debris on the top exterior part of the Medication Refrigerator A and stated the refrigerator should have been cleaned. 7. On 1/7/26 at 1027 hours, an inspection of Medication Cart B was conducted with RN 2. Medication Cart B was observed to have dirt like debris to one of the storage bins storing Coban and other items. RN 2 stated the dirt like debris were rusts and could not be removed. RN 2 attempted to clean the dirt like debris and was able to partially remove it. On 1/7/26 at 1119 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above findings and stated the storage bin should have been cleaned. On 1/9/25 at 1508 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * A stainless-steel blender was stored wet. * Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) was not handled safely as the leftover chicken was not maintained at the proper temperature. In addition, there was no documentation of the leftover chicken cooked on the previous day on the cooling down log. These failures had the potential to cause foodborne illness for the residents who consumed food prepared in the kitchen.Findings: Review of facility's document titled Diet Type Report dated 1/6/26, showed 77 out of 85 residents were receiving food from the kitchen. a. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 1/6/26 at 0754 hours, an observation and concurrent interview was conducted with the DSS. A stainless-steel blender was observed on food preparation area. The blender was observed with the lid closed. The DSS opened the lid of the blender, and the blender was observed to be stored wet. The DSS verified the observation and stated the kitchen staff should have air dried the blender before storing it. b. According to the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) Within two hours from 57 Celsius (C) [135 Fahrenheit (F)] to 21 C (70 F); and (2) Within a total of six hours from 57 C (135 F) to 5 C (41 F) or less. Review of the facility's P&P titled Hazardous Foods Cooling Monitor dated 7/1/2014, showed the dietary department employees will follow food handling rules for hazardous foods. Hazardous foods included.chicken/turkey/Shellfish. Under the section procedure showed hot food should be cooled from 140 F to 70 F within two hours and cooled from 70 F to 41 F or lower in an additional 4 hours. Further review of the P&P showed to record the temperature of food every hour, and action taken to achieve proper temperature cooling on cooling monitor log. On 1/6/26 at 0754 hours, an observation and concurrent interview was conducted with the DSS. A container of cooked chicken dated 1/5/26, was observed in the reach in refrigerator. The DSS was asked to measure the temperature of cooked leftover chicken, the temperature reading showed 43 F. The DSS verified the observation and stated the temperature of the leftover chicken should have been less than 41 F. The DSS was asked to show the cooling monitor log, however, the DSS verified the cooling down process was not documented for the leftover chicken. The DSS could not verify if the cooling down process was followed for the above leftover chicken. The DSS was observed discarding the leftover chicken. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure appropriate infection control practices were followed.* The facility failed to test the water supply, and inspect the HVAC filters per the facility's water management program.* The clean linen cart for transferring clean linen in the laundry room had frayed edges and peeling layered duct tape and a non-cleanable surface. * The facility failed to ensure one of three blood glucose monitors (a portable device to measure blood sugar levels at home using a tiny blood sample) was cleaned and disinfected according to the manufacturer's instructions after the blood glucose monitor was used on Residents 3, 33, and 40. These failures resulted in the risk for the spread of microorganisms potentially contaminated areas throughout the facility. Findings: 1. Review of the facility's Legionella (type of bacteria) Water Management plan showed the following: - Maintaining a disinfectant residual of 0.1 mg/liters of free chlorine can help prevent Legionella growth in the water system. The facility will measure the residual disinfectant monthly. - To prevent Legionella growth, the best pH for water is between 6 and 7. The facility will measure the water pH level monthly. - Monitor ventilation systems to ensure optimal performance for removal pf particulates, and elimination of excess moisture. The facility will inspect all HVAC filters monthly. Review of the facility's Water Management Plan Monthly pH/Chlorine Testing Log for 2025 showed checkmarks for monthly chlorine and pH testing. The log failed to sure what the testing results were, and whether the results were an acceptable range. Review of the facility's electronic Logbook Documentation showed the HVAC filters were inspected and filters changed quarterly on 1/30, 4/23, 7/30, and 10/28/25. The facility was unable to locate the documentation to show the filters were inspected monthly. On 1/8/26 at 1052 hours, an interview and concurrent facility document review was conducted with the Director of Maintenance and Property Management. The Property Management reviewed the electronic maintenance logbook and stated the HVAC air filters were changed quarterly (every three months) and verified there were no documentation to show the filters were inspected monthly. On 1/8/26 at 1307 hours, a follow up interview and concurrent facility document review was conducted with the Director of Maintenance and Property Management. The Director of Maintenance and Property Management verified the monthly pH/Chlorine testing log failed to show the testing results, and if the results were an acceptable range. 2. On 1/8/26 at 0938 hours, a laundry room observation was conducted with Housekeeper 1. A wheeled linen cart frame with a flexible tarp-like bag was observed. The linen cart's edges were frayed and torn in places and one area had multiple layers of red duct tape, which was also peeling. Housekeeper 1 stated the cart was used to transport clean dry linen from the dryer to the folding table. When asked what she used to disinfect the cart and clean the linen folding table, Housekeeper 1 stated she used wipes, but was unable to locate any wipes in the laundry room. On 1/8/26 at 0950 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance verified the clean linen cart's tarp-like surface and frayed edges/tape were not cleanable surfaces. On 1/8/26 at 1343 hours, an observation and concurrent interview was conducted with the Director of Maintenance. The Director of Maintenance provided a container of Clorox Healthcare Germicidal Bleach Wipes and stated the wipes were the product used to disinfect the laundry room clean linen cart. The front of the container showed it was to be used on treated, hard, nonporous surfaces. 3. Review of the facility's P&P on Blood Glucose Monitoring dated 5/2/23, showed to clean the monitoring device after each use as noted in the manufacturer's instructions. Review of the Manufacturer's Instructions of the Assure Blood Glucose Monitoring system dated 9/2024 (www. akrayusa.com) showed the cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Only wipes with EPA registration numbers listed in http://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants have been validated for use in cleaning and disinfecting the blood glucose meter. On 1/8/26 at 0558 hours, a medication administration observation was conducted with LVN 5. LVN 5 was observed cleaning the glucometer after checking Resident 3, 33, and 40's blood sugar with an alcohol pad (70 % alcohol). LVN 5 verified the glucometer was wiped clean with the alcohol pads. On 1/8/26 at 0732 hours, an interview was conducted with the IP. The IP stated the glucometers must be cleaned and disinfected using the Super Sani-Cloth wipes (germicidal, bactericidal, tuberculocidal, and virucidal disposable wipes). On 1/9/25 at 1508 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 104) was safe to self-administer medications. * Resident 104 was observed with one unidentified medication tablet and an unlabeled white bottle containing various medication tablets on his bedside table. Resident 104 had no assessment and physician's order addressing Resident 104's self-administration of the medications. This failure had the potential for the resident to administer the medications inaccurately, and the risk of adverse reactions from the medications. Findings: Review of the facility's P&P titled Medication - Self Administration revised [DATE], showed the following:- Residents will be assessed and monitored for their ability to self-administer medications. This must include physician approval, which will be documented in the resident's medical record.- The licensed nurse completes the Self Administration of Medications Assessment, which evaluates the resident's: cognitive function, physical ability, medication knowledge, compliance history, knowledge of proper storage and safety, and knowledge of administration of each route.- A written physician's order is required before a resident begins self-administration- The licensed nurse will inspect the contents of the medication containers for evidence that the resident may not be able to self-administer medications (i.e. non-drug items stored in pill containers, different medications mixed together, medications which have expired or appear to be deteriorating.- Any concerns will be communicated to the physician and IDT immediately.- All self-administered medications must have complete pharmacy labels or intact, readable labels if they are over the counter medications. On [DATE] at 0955 hours, during the initial tour of the facility, Resident 104 was observed in bed with a loose medication tablet and a white unlabeled medication bottle on his bedside table. Resident 104 stated the medications in the bottle were his supplements which was brought in by his wife. Resident 104 stated he administered the supplements himself. Medical record review for Resident 104 was initiated on [DATE]. Resident 104 was admitted to the facility on [DATE]. Review of Resident 104's H&P examination dated [DATE], showed the resident had no capacity to understand and make decisions due to cognitive impairment. Review of Resident 104's Order Summary Report for [DATE] failed to show a physician's order to self-administer the medications. Further review of Resident 104's medical record failed to show an assessment was conducted to determine if Resident 104 was safe to self-administer the medications. On [DATE] at 1004 hours, an observation of Resident 104 and concurrent interview was conducted with LVN 3. Resident 104 was observed in bed with the bedside table positioned across his bed. The resident's bedside table was observed with a loose medication tablet and a white unlabeled medication bottle. LVN 3 stated the loose medication tablet on the resident's bedside table looked like one of Resident 104's supplements that his wife provided and the facility dispensed. However, LVN 3 stated she did not know where the medication tablet came from. LVN 3 stated she did not know what medications were in the white unlabeled medication bottle. On [DATE] at 1010 hours, a follow up interview was conducted with LVN 3. LVN 3 stated she did not know what medications were in the white unlabeled medication bottle or where it came from. LVN 3 stated she was in the resident's room earlier to administer Resident 104's medication and did not question the medication bottle on Resident 104's bedside table. On [DATE] at 1015, an observation of Resident 104 and concurrent interview was conducted with the DON. The DON stated sometimes the resident's wife brought in the supplements for Resident 104 without notifying the facility staff. The DON stated the facility had several discussions with the wife to stop bringing in the supplements for the resident. The DON was observed opening the white unlabeled medication bottle and was unable to verify the contents of the bottle. The DON stated there was a risk of the unknown medication tablets interacting with the medications the facility was administering to the resident. The DON verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident (Resident 20) reviewed for activities. * The facility failed to provide an ongoing activity program for Resident 20 in accordance with the comprehensive assessment, interests, and physical, mental, and psychosocial well-being to ensure the resident maintained their highest mental, physical, and psychosocial well-being. This failure had the potential for the resident to experience feelings of social isolation.Findings: Review of the facility's P&P titled Activities Program dated 5/22/25, showed the facility provides an Activity Program designed to meet the needs, interests, and preferences of each resident. The facility will be staffed and equipped to encourage the participation of each resident, to fully stimulate and support physical and mental capabilities, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. On 1/6/26 at 8030 hours, during the initial tour to the facility. Resident 20 was in his room and was asked if he was attending the facility's recreational activities. Resident 20 stated It is a joke, one to two times a week they play music. I went there sometimes but not my music. They don't have what I like. Resident 20 further stated the activity staff did not go to his room. Resident 20 had the Activities Calendar affixed to his room wall. Resident 20 stated maybe they're just satisfying the state guidelines, they put that up. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 9/25/25, showed Resident 20 could make his own decisions. Review of Resident 20's Activity Evaluation dated 9/25/25, showed Resident 20's activity preferences were as follows: fishing and playing golf, listening to pop, country, and rock and roll, prefer to watch news sports weather talk shows, some game shows like Trivia, Jeopardy, Who wants to be a Millionaire, and comedy movies, reads non-fiction, fiction, and biology books. Review of Resident 20's Quarterly Activity Progress Note dated 12/26/25, showed the Activities Department would encourage/assist/remind Resident 20 to join/participate to the group activity of interest, provide contact room rounds to offer activity material, and socialization as needed or as tolerated. Review of Resident 20's Activities Look Back Report from November to January 8, 2026, showed the following documentation:- on 11/18/25: active 1:1 (one staff to one resident) participation - books /reading materials, education/current topics/ trivia;- on 11/29/25: passive 1:1 participation- books /reading materials;- on 12/9/25: passive 1:1 participation- education/current topics/ trivia;- on 12/13/25: active1:1 participation- books /reading materials;- on 12/27/25: active1:1 participation- books /reading materials; and- on1/3/26: active1:1 participation- books / reading materials, education/current topics/ trivia. On 1/8/26 at 943 hours, an interview and concurrent medical record review was conducted with the Activity Director. The Activity Director stated Resident 20 hardly came to activities and was visited three times a week by the activity staff. Review of Resident 20's Activity Look Back Report was conducted with the Activity Director, which showed Resident 20 had activity staff visits and participated six times from 11/18/25 through 1/3/26, with no documentation of refusals. The Activity Director stated she was not checking the activity staff to make sure the room visits were being done. When asked if the activity staff knew Resident 20's plan of care were, the Activity Director stated, I'm hoping they do. On 1/8/26 at 1000 hours, an interview and concurrent medical record review was conducted with Activity Assistant 1. Activity Assistant 1 stated she conducted the room visits for the residents using the following schedule:- on Mondays and Tuesdays: the residents in Nursing Stations 1 and 2;- on Tuesdays: the residents in Nursing Station 3;- on Wednesdays: the residents in Nursing Stations 1 and 2; and- on Thursdays: the residents in Nursing Station 3.Review of the Activity Look back Report with Activity Assistant 1 showed Resident 20 was visited and participated six times from 11/18/25 through 1/3/26. Activity Assistant 1 verified the above findings and stated the room visits for Resident 20 should have been two to three times a week. Activity Assistant 1 stated she was not sure what had happened.

Based on observation, interview, and medical record review, the facility failed to ensure one final sampled resident (Resident 116) and one nonsampled resident (Resident 120) reviewed for the accident hazards were provided the necessary care and services. * The facility failed to ensure CNA 1 remained awake while providing supervision for Residents 116 and 120, who were on high observation alert due to falls. This failure posed a risk for the residents to sustain further falls and/or injuries.Findings: On 1/8/26 at 0518 hours, during a tour of the facility, an observation of CNA 1 was conducted inside Residents 116 and 120's room. Upon entering the residents' room, CNA 1 was observed with her head down on the nightstand next to Resident 120 (bed A). The privacy curtain was closed with no visual of Resident 116 (Bed B). The surveyor knocked on the wall in attempt to wake CNA 1 but was not successful. Resident 120 was observed awake and moving around in bed and Resident 116 appeared to be sleeping. The surveyor then contacted RN 1 to wake up CNA 1. RN 1 entered the residents' room and tapped CNA 1 on the arm. CNA 1 sat up but did not turn around. RN 1 then tapped CNA 1 on the arm again and CNA 1 stood up to speak with the surveyor as RN 1 exited the residents' room. On 1/8/26 at 0520 hours, an interview was conducted with CNA 1. CNA 1 stated she was asleep. CNA 1 stated she was assigned to provide supervision for Residents 116 and 120 because they were trying to get out of bed unassisted. CNA 1 also stated she was unable to maintain a visual of Resident 116 with the privacy curtain closed. On 1/8/26 at 0541 hours, an interview was conducted with RN 1. RN 1 stated the facility staff assigned to provide supervision for the residents should be sitting by the residents' closet where they would have visual of both residents, or have the privacy curtain open if they chose to sit at the table. RN 1 also stated the facility staff assigned to provide supervision for the residents were not supposed to be sleeping while watching the residents. a. Medical record review for Resident 116 was initiated on 1/8/26. Resident 116 was admitted to the facility on [DATE]. Review of Resident 116's H&P examination dated 1/1/26, showed Resident 116 had the capacity to understand and make decisions. The H&P also showed the physician advised to send Resident 116 to the emergency room for evaluation of fall on 12/31/25. b. Medical record review for Resident 120 was initiated on 1/8/26. Resident 120 was admitted to the facility on [DATE]. Review of Resident 120's H&P examination dated 1/1/26, showed Resident 120 was able to make their own decisions. The H&P also showed the resident had a fall on 1/1/26 at 0400 hours. On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON stated Residents 116 and 120 had physician's orders for high observation because they were new residents in the facility and both residents fell on the day they were admitted to the facility. The DON stated when the facility staff were assigned to watch two residents on high observation, the facility staff could sit wherever they wanted, as long as they could visually see both residents. The DON stated the facility staff should not be sitting at the nightstand if they could not see both the residents. The DON also stated the facility staff should never be sleeping in the residents' room and it was a safety issue for the residents for the facility staff to be sleeping. On 1/9/26 at 1445 hours, an interview was conducted with the Administrator. The Administrator stated Residents 116 and 120 were on high observation because they both fell the day they were admitted to the facility. The Administrator stated the facility staff assigned for high observation should be doing frequent checks of the residents they were assigned to and should never be sleeping.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to obtain the appropriate admission PICC line measurements for one of one final sampled resident (Resident 119) reviewed for the central lines (a long, flexible tube inserted into a large vein in the neck, chest, arm, or groin, ending near the heart, to provide long-term access for delivering fluids, nutrition, and medications). * The facility failed to ensure Resident 119's arm circumference and the PICC line's external catheter were measured upon the resident's admission to the facility. This failure had the potential to delay identifying potential complications of the central line. Findings: Medical record review for Resident 199 was initiated on 1/6/16. Resident 119 was admitted to the facility on [DATE]. Review of Resident 119's IV Administration Record for December 2025 showed a physician's order dated 12/19/25, to measure the resident's arm circumference and PICC lie external catheter lumens every week. The record showed a box for the measurements to be completed on 12/19/25 (the resident's admission date), which was not completed. Further review of Resident 119's medical record failed to show the resident's arm circumference and external catheter length measurements were completed upon the resident's admission to the facility. On 1/8/26 at 0909 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated the arm circumferences and PICC line external catheter lengths measurements were obtained for all the newly admitted residents with PICC lines upon their admission to the facility, and weekly thereafter. RN 3 further stated the changes in the measurements would help identify central line catheter issues, like tubing migration. RN 2 verified Resident 119's medical record failed to show the admission PICC line arm circumference and external catheter length measurements were obtained.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of one final sampled resident (Resident 11) reviewed for pain management. * The facility failed to accurately record Resident 11's highest pain level for the shift, as well as document the nonpharmacological interventions (NPI) implemented prior to administering the PRN (as needed) pain medication. These failures put the resident at risk of their pain level not being documented accurately and receiving unnecessary pain medication without the NPI in place. Findings: Medical record review for Resident 11 was initiated on 1/6/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report showed a physician's order dated 10/2/25, showed to monitor the resident's pain level every shift (on a scale of 0-10, with 0 being no pain, and 8-10 being sever pain) and document the NPI provided. Review of Resident 11's MAR for January 2026 showed the following:- On 1/1/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet (a controlled pain medication) 5-325 mg medication was administered at 1122 hours, for a pain level of 8. - On 1/1/26, during the evening shift, the resident's pain level was documented as 0. However, two tablets of the Percocet 5-325 mg medication was administered at 1530 hours, for a pain level of 8. - On 1/2/26 day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1002 hours, for a pain level of 8, and at 1422 hours, for a pain level of 9. - On 1/2/26 evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1830 hours, for a pain level of 9. - On 1/2/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/3/26 at 0630 hours, for a pain level of 8. - On 1/3/26 during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1038 hours, for a pain level of 8, and at 1440 hours, for a pain level of 9. - On 1/3/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1840 and 2240 hours, for a pain level of 9. - On 1/4/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1030 hours, for a pain level of 7, and at 1444 hours, for a pain level of 9. - On 1/4/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1845 hours, for a pain level of 9. - On 1/4/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/5/26 at 0526 hours, for a pain level of 8. - On 1/5/26, during the day shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 0957 hours, for a pain level of 8. - On 1/5/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1730 and 2130 hours, for pain levels of 8. - On 1/5/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/6/26 at 0530 hours, for a pain level of 8. - On 1/6/26, during the evening shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered at 1838 hours, for a pain level of 7. - On 1/6/26, during the night shift, the resident's pain level was documented as 0, and NA was entered for the NPI. However, two tablets of the Percocet 5-325 mg medication were administered on 1/7/26 at 0417 hours, for a pain level of 8. On 1/7/26 at 1159 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for the pain and NPI documentation in the resident's MAR for each shift, the licensed nurses should document the highest pain level for the entire shift, as well as all the NPI implemented prior to administering the pain medication. The DON verified the above shifts with a 0 pain level documented and the NA for the NPI were incorrect and should have reflected the resident's highest pain level. The DON also verified there was no documentation to show the NPIs were implemented prior to administering the PRN pain medication (except for 1/2/26, during the evening shift).

Based on interview, medical record review, and facility P&P review, the facility failed to ensure there was adequate staffing for the 2300 to 0700 hours shift to meet the physical and psychosocial needs for two of 19 final sampled residents (Residents 20 and 118) and two nonsampled residents (Residents 43 and 81). * The facility failed to ensure Resident 20's call light was answered in a timely manner for assistance in toileting and transfers to and from the bed between the hours of 0200 - 0500 hours on 1/4 and 1/5/26. * The facility failed to ensure Residents 43 and 81 received timely staff assistance during the 2300-0700 hours shift. * The facility failed to timely answer Resident 118's call light to address her toileting needs without the resident experiencing distress over the staff's response time. These failures had the potential for the residents to not be provided with care consistent with professional standards of practice and care as outlined in their person-centered plans of care.Findings: Review of the facility's P&P titled Nursing Department- Staffing, Scheduling and Posting dated July 2018 showed the facility was to ensure adequate number of nursing personnel are available to meet resident needs. The facility will employ Nursing staff that will be on duty in at least the number and with the qualifications required to provide necessary nursing services for residents admitted for care. In staffing an adequate number of Nursing Service personnel, scheduling will be done as needed to meet the residents' needs, and such information will be posted as required. 1.a. On 1/6/26 at 0845 hours, an observation and concurrent interview was conducted with Resident 81. Resident 81 was lying in his bed with a feeding tube connected to his abdomen. Resident 81 stated he was dependent on staff assistance and had a concern with facility staffing during the night shift. Resident 81 stated he did not get the assistance he needed timely during the night shift. Resident 81 stated he was admitted to the facility at around 1900 hours on 12/31/25. The assigned CNA put him on the bed and covered him with the blanket the resident got from the acute care hospital and left. Resident 81 further stated he did not remember getting assistance until the next morning on 1/1/26. Resident 81 stated he remembered pressing the call button multiple times but did not remember getting assistance that night. Resident 81 further stated on 1/4/26 at around 2000 hours, the assigned CNA assisted the resident to change his incontinence brief. Resident 81 stated after around 30 minutes, he needed to be changed again and pressed the call button to ask for staff assistance. Resident 81 stated he did not get any assistance until midnight, almost three hours after he needed assistance. Resident 81 stated he did not feel good to have to wait for the staff for a long time to change his wet incontinence brief. Resident 81 further stated he knew he waited three hours because he looked at the clock so he knew how long he waited. Medical record review for Resident 81 was initiated on 1/6/26. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's MDS assessment dated [DATE], showed Resident 81 was cognitively intact and required staff assistance for his activities of daily living. Review of Resident 81's H&P examination dated 1/1/26, showed Resident 81 could make his needs known and could make his own decisions. b. On 1/6/26 at 1012 hours, an observation and concurrent interview was conducted with Resident 43. Resident 43 was lying in her bed. Resident 43 stated the facility did not have enough staff during the 2300-0700 hours shift. Resident 43 stated she had to wait more than an hour to get assistance at night. Resident 43 stated she remembered an incident when she had to wait for more than 25 minutes to get her colostomy bag changed. Resident 43 stated she remembered because her colostomy bag was full and it was hurting her when she was waiting for the staff to help her. Resident 43 stated she knew she waited more than 25 minutes for assistance because she looked at the clock in front of her. Medical record review for Resident 43 was initiated on 1/6/26. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed an order dated 12/26/24, to provide colostomy care every shift. Review of Resident 43's H&P examination dated 6/11/25, showed Resident 43 had the capacity to understand and make medical decisions. Review of Resident 43's MDS assessment dated [DATE], showed Resident 43 was cognitively intact and dependent on facility staff for her activities of daily living. On 1/9/26 at 1142 hours, the Administrator and the DON were informed and acknowledged the above findings. 2.a. Review of the facility's P&P titled Communication- Call system dated 11/1/12, showed the purpose of the call system is to provide a mechanism for residents to promptly communicate with Nursing Staff. The Nursing Staff will answer the call bells promptly, in a courteous manner. Medical record review for Resident 118 was initiated on 1/6/25. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Summary Report showed a physician's order dated 1/6/25, to monitor for sign and/or symptoms of urinary retention for 72 hours status post indwelling urinary catheter removal. Review of Resident 118's H&P dated 12/26/25, showed the resident had the capacity to understand and make medical decisions. On 1/7/26 at 0947 hours, an interview was conducted with Resident 118. Resident 118 stated after her indwelling urinary catheter was removed yesterday morning, she had a hard time voiding. Resident 118 further stated she now has a hard time getting used to holding in her urine. Resident 118 stated when she has the urge to void, she needs to rush to the toilet. On 1/8/26 at 0511 hours, an interview was conducted with CNA 2. CNA 2 stated she had 18 residents to care for that night. CNA 2 stated about half of her residents did not sleep all night, and many were incontinent and need assistance toileting. CNA 2 stated the residents complain about the call light response time, but some residents were time consuming and she gets overwhelmed. On 1/8/26 at 0521 hours, an interview was conducted with RN 1. RN 1 stated they did get resident complaints during the 2300-0700 hours shift. RN 1 stated the facility currently has five CNAs and two 1:1 sitters (staff assigned to a specific resident for direct supervision) for 88 residents. When asked if the nurses help answer call lights, RN 1 replied the LVNs were pretty busy. RN 1 stated the facility has 88 residents for two LVNs and tries to provide assistance with answering the call lights. RN 1 stated he did rounds and on his last round he answered two call lights while the assigned CNA was busy with another resident. On 1/8/26 at 0542 hours, an observation and concurrent interview was conducted with Resident 118. Resident 118 was awake watching TV in her bed. Resident 118 stated she dreads having to go to the bathroom because she was afraid she was going to have an episode of incontinence and will need to wait 15-20 minutes for the staff to respond to her call light and assist her with toileting. Resident 118 stated the staff just could not get to her timely. b. On 1/6/26 at 0830 hours, during the initial tour of the facility, Resident 20 stated the call light response was not answered timely. Resident 20 stated he went to the bathroom, used the call light for assistance and the staff did not show up. Resident 20 stated he self-transferred and went to bed. Resident 20 further stated there was only one CNA to help the residents because the other one was on break. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 9/25/25, showed Resident 20 could make his needs known and could make his own decisions. On 1/8/26 at 0615 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 20 asked for assistance in toileting one to four times during the shift. Resident 20 was assisted to the shower chair to the toilet and transferred back to the bed. CNA 4 was informed Resident 20 stated he was calling and no one came after 30 minutes, so he self-transferred to the wheelchair then to the bathroom and back to the bed. CNA 4 stated they were not aware of this and the resident did not say anything. On 1/8/26 at 0700 hours, an interview was conducted with CNA 5. CNA 5 stated they usually did not wait to answer the call lights because the sound was annoying. CNA 5 stated they checked the resident to see if the call light was on. On 1/9/25 at 1520 hours, the Administrator was informed of the above findings.

Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure medications were available, administered, and accounted for appropriately for one of five final sampled residents reviewed for unnecessary medication (Resident 116) and for one of two IV E-kit medication kits. * Resident 116's insulin was not available to be administered as ordered. * The facility failed to ensure the IV E-kit in Medication Room A was replaced timely. * The facility failed to ensure the IV E-kit pharmacy log in Medication Room A was accurately completed when accessed by RN 1. These failures resulted in medication not being available to be administered to the residents as well as inaccurate accounting of the emergency medication supply. Findings: 1. Review of the facility's P&P titled Provider Pharmacy Requirements revised January 2025 showed the pharmacy will provide timely services 24 hours a day, seven days a week. All new medication orders will be available for administration on the day they are ordered. Medical record review for Resident 116 was initiated on 1/6/26. Resident 116 was admitted to the facility on [DATE]. Review of Resident 116's Order Summary Report showed a physician's order dated 12/31/25, for Novolog to be administered subcutaneously before meals and at bedtime per the sliding scale (a dose based on the resident blood sugar level). Review of Resident 116's MAR for January 2026 showed on 1/1/26 at 0630 hours, Resident 116's blood sugar was 200 mg/dl. The entry was coded with a 9 for other/see progress notes. Review of Resident 116's Progress Note dated 12/31/25 at 1954 hours, showed the resident was admitted at 1841 hours. Review of Resident 116's Orders – Administration Progress Note dated 1/1/26 at 0646 hours, showed the Novolog insulin medication (antidiabetic) was pending delivery (more than 11 hours after the resident was admitted ). On 1/7/26 at 1535 hours, an observation of the facility's Refrigerated E-kit showed the E-kit included Novolin R insulin and Humalog insulin (antidiabetic medication). On 1/8/26 at 1423 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for new admissions, medications should be delivered by the pharmacy within four to six hours, and the E-kits may be utilized as well. The DON reviewed Resident 116's medical records and verified the Novolog insulin medication should have been available to be administered on 1/1/25 for the 0630 dose. The DON stated even though Resident 116's ordered insulin was not available in the E-kits, the nurse should have contacted the physician for a temporary physician's order for one of the available insulins until the supply was delivered by the pharmacy. 2. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2025 showed the following: - an emergency supply of medications including emergency drugs, antibiotics, controlled substances, and products for infusion is provided in sealed containers in compliance with state regulations - when an emergency dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. - if exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. On 1/8/26 at 0810 hours, an inspection of Medication Room A, interview, and concurrent facility document review was conducted with RN 2. Review of the E-kit log book showed the IV E-kit was accessed on 1/2/26, and was replaced by pharmacy on 1/6/26. On 1/8/26 at 0825 hours, an interview was conducted with the Administrator. The Administrator stated the IV E-kit was replaced on 1/6/26, because she personally called the pharmacy to replace it on 1/6/26. The Administrator stated the policy to replace E-kits was 72 hours and verified the E-kit dated 1/6/26, should have been replaced. 3. On 1/8/26 at 0810 hours, an inspection of Medication Room A's IV E-kit, interview, and concurrent facility document review was conducted with RN 2. The E-kit had a yellow lock. RN 2 stated a yellow lock indicated the E-kit had been accessed and needed a replacement. Review of the E-kit log book showed the E-kit was accessed on 1/2/26, but was replaced on 1/6/26. There were no additional entries in the Pharmacy Log inside of the E-kit or in the E-kit log book to show the E-kit was accessed after 1/6/26. RN 2 stated the IV E-kit must have been accessed after it was replaced on 1/6/26, because it had a yellow lock. RN 2 stated she did not know what happened. RN 2 spoke to RN 1 and determined RN 1 accessed the IV E-kit on the previous shift but did not complete the IV E-kit pharmacy log. On 1/8/26 at 0918 hours, an interview was conducted with RN 1. RN 1 stated he accessed the IV E-kit in Medication Room A to start an IV infusion on a new admission. RN 1 stated he was aware of the policy to fill out the pharmacy log when he accessed the E-kit but forgot. On 1/9/26 at 1254 hours, an interview was conducted with the DON. The DON verified the above findings.

Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents. * The menu spreadsheet was not followed for Resident 62's CCHO (Consistent Carbohydrate Diet/Controlled Carbohydrate) diet. * Resident 68 did not receive a salad listed on the lunch menu. These failures posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.Findings: Review of the facility's document titled Diet Type Report dated 1/6/26, showed 77 out of 85 residents received food from the kitchen. Review of the facility's P&P titled Therapeutic Diets dated 6/1/2014, showed therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the dietitian. Therapeutic diets are reflected on the menu extension. Review of the facility's document titled Winter Menus dated 1/7/26, showed the residents on a CCHO and renal diet are to receive oven crisp fish with tartar sauce, salt free french fries, ketchup, seasonal carrots, apple hill cake 2 x 2 1/2, and milk. Further review of the document showed residents on a CCHO diet were not to receive a wheat roll. Review of Resident 62's Diet Ticket dated 1/7/26, showed Resident 62 was to receive a renal, CCHO, regular texture diet. The Diet Ticket further showed Resident 62 disliked cold cereal and fish. During the tray line observation and concurrent interview with the DSS on 1/7/26 at 1225 hours, the dietary staff set up the tray for Resident 62's lunch. The tray had seasoned carrots, chicken, brown rice, apple hill cake 2 x 2 1/2, milk and wheat rolls. The DSS stated the tray was ready to be served to the resident. The DSS then verified the above tray to be served to Resident 62. The DSS was observed checking the winter menus and verified Resident 62 was on CCHO diet. The DSS verified Resident 62 should not have wheat rolls per the winter menus. Medical record review for Resident 62 was initiated on 1/7/26. Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's H&P examination dated 1/5/25, showed Resident 62 had diagnoses including Type II Diabetes. On 1/9/26 at 1142 hours, the Administrator and the DON were informed and acknowledged the above findings. 2. Review of the facility's January Menu dated 1/6/26, showed the lunch menu consisted of pork chops with pear sauce, polenta, seasoned broccoli, a green salad with dressing, and a cranberry crunch bar. On 1/6/26 at 1241 hours, an observation and concurrent interview was conducted with Resident 68. Resident 68 was eating his lunch in his room. Resident 68's lunch tray did not include a green salad. Resident 68 stated he was not sure what was on the lunch menu, but would have liked a green salad. Resident 68's lunch tray ticket did not show the menu items, but did include the resident's dislikes, which did not show salad. CNA 3 came into Resident 68's room and verified there was no green salad on their tray per the menu.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of one final sampled resident (Resident 100) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to ensure the hospice visit calendar was available in Resident 100's medical record. * The facility failed to integrate Hospice A's plan of care into Resident 100's care and failed to accurately reconcile the physician's orders. These failures posed the risk of the delay in the communication and provision of hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Care of Residents dated 1/1/12, showed if the resident and/or surrogate decision maker decides to utilize hospice care, attending physician will be contacted to make final determination. The hospice and facility will collaborate on a care plan for the residents. Facility and hospice staff will collaborate on a regular basis concerning the residents' care. Review of Hospice A Patient Agreement for Skilled Nursing Inpatient and related Hospice Services dated 9/6/23, under the section Plan of Care showed a written care plan established, maintained, reviewed and modified, if necessary, at intervals established by the interdisciplinary group. A plan of care includes (a) an assessment of each Hospice patient and needs, (b) an identification of the hospice services to be provided in response to assessment, including management of discomfort and symptoms relief, and (c) details concerning the scope and frequency of the Hospice services and facility services needed to meet the patient's and family's needs. The Hospice will develop a coordinated plan of care that is consistent with the state licensure, and Medicare and Medicaid requirements for the provision of Hospice services and is responsive to the unique needs of the Hospice patient who needs who resides in a skilled nursing facility and his/her expressed desire for Hospice care. Further review of the Hospice A Patient Agreement for Skilled Nursing Inpatient and related Hospice Services showed all physician orders communicated to facility on behalf of hospice in connection with the plan of care shall be in writing and signed by the applicable attending physician or hospice physician. Hospice shall maintain all adequate records of all physician orders communicated in connection with the plan of care. Medical record review for Resident 100 was initiated on 1/6/26. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's Order Summary Report showed the following physician's orders:- dated 5/31/25, to admit the resident to Hospice A under routine level of care.- dated 8/18/25, to administer morphine sulphate ( pain medication) oral solution 20 mg per 5 ml to give 0.25 ml ( i.e.1 mg) by mouth every two hours as needed for severe pain, and to hold if the respiration rate less than 12 or sedated. b. Review of Resident 100's medical record failed to show the Hospice A calendar for December 2025 and January 2026 to show the schedule when the hospice staff were visiting Resident 100. c. Review of the Resident 100's plan of care failed to show the hospice care plan was incorporated in the facility's plan of care for the resident. d. Review of the Hospice A medication list for Resident 100 showed a physician's order for morphine concentrate 20 mg/ml oral, to administer 5 mg every two hours as needed for shortness of breath and pain. On 1/8/26 at 0837 hours, an interview was conducted with LVN 6. LVN 6 stated Resident 100 was on under hospice care, and the staff from the hospice visited Resident 100. When asked how often the hospice staff visited Resident 100, LVN 6 stated the hospice aid visited twice a week and the skilled nursing visit was once a week. However, LVN 6 did not know the exact days when the hospice staff came to visit Resident 100. On 1/8/26 at 0846 hours, an interview and concurrent medical record review of Resident 100's medical record was conducted with LVN 7. LVN 7 verified the hospice calendar for December 2025 and January 2026 for Resident 100 was not available in the resident's medical record and the facility's care plan did not incorporate the resident's hospice care plan. LVN 7 stated he was unable to locate the hospice care plan in Resident 100's medical record. LVN 7 also verified the physician's order for the morphine sulfate medication was not accurately reconciled from the hospice medication list. LVN 7 stated the hospice order was for morphine sulfate 20 mg/mL, and to administer 5 mg (0.25 ml). However, the concentration ordered by the facility was 20 mg per 5 ml, which meant when administering 0.25 ml, the resident would only receive 1 mg instead of 5 mg as ordered. LVN 7 stated this could lead to poor pain control for Resident 100. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of three residents (Resident 7) reviewed for close records. * The facility failed to notify Resident 7 and/or their representative in writing regarding the transfer and reasons for the transfer, and the facility's bed hold policy when Resident 7 was transferred to the acute care hospital. In addition, the facility failed to send the copy of notice of transfer discharge to Ombudsman (a neutral advocate who investigates and resolves complaints for residents in healthcare settings like long-term care facilities). These failures had the potential for the resident and/or their representative to be unaware about the transfer and reason(s) of transfer, and their rights to request a bed hold and return to the first available bed should the resident's acute care hospital stay exceeded the seven-day bed-hold period.Findings: a. Review of the facility's P&P titled Notice of Transfer/discharge date d October 2017 showed to provide the resident and responsible party with a written notice of transfer/discharge prior to or at the time of discharge/transfer and their appeal right. Before the transfer or discharge occurs, the facility must notify the resident and, if known, the responsible party, and ombudsman after transfer and reason for the transfer, and document in the resident's clinical record. Review of the facility's P&P titled Bed Hold dated July 2017 showed the facility notified the resident and/or representative, in writing, of the bed hold, option, anytime the resident is transferred to an acute care hospital or requests therapeutic leave. Closed medical record review for Resident 7 was initiated on 1/8/26. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated 5/15/25, showed Resident 7 had the capacity to understand and make decisions. Review of Resident 7's Physician Order dated 1/2/26, showed to transfer Resident 7 to the acute care hospital for confusion, agitation, tachycardia (high heart rate) and for bed hold for seven days, if admitted . Review of Resident 7's progress notes dated 1/2/26 at 1803 hours, showed Resident 7 was transferred to the acute care hospital and Resident 7 was admitted to the acute care hospital due to acute kidney injury (sudden, rapid loss of kidney function, where the kidneys can't filter waste, leading to buildup in the blood), urinary tract infection (bacterial infection in the urinary system, i.e. kidneys, ureters, bladder and urethra) and sepsis ( a life-threatening medical emergency where the body's extreme, overactive response to an infection damages its own tissues, organs, and systems, leading to potential organ failure and death). Review of Resident 7's Notice of Proposed Transfer and discharge date d 1/2/26, showed the transfer location as the acute care hospital and the reason for the transfer was for Resident 7's welfare and Resident 7's needs could not be met in the facility. Under the section for the resident or resident representative signature failed to show any entry. In addition, the Notice of Proposed Transfer and Discharge form did not show if the copy of the form was sent to the Ombudsman. Further review of Resident 7's medical record did not show if a written notice of the transfer/discharge was provided to Resident 7 or their representative when Resident 7 was transferred to the acute care hospital on 1/2/26. In addition, the resident's medical record did not show if the copy of notice of transfer/discharge was sent to the Ombudsman. b. Review of the Resident 7's Bed hold Agreement showed the facility has a bed hold policy and will hold the bed for up to seven days if the resident is transferred to a general acute care hospital or goes on therapeutic leave often of no more than. overnights per calendar days, as long as resident or the representative notifies the facility within 24 hours after transfer leave that they wish to have the facility hold the resident's bed. Resident who are not eligible for Medi-cal/caid are responsible for the cost of the bed hold days not to exceed the patient's daily rate for care. Insurance may or may not cover such charges. You have the options of requesting a bed hold to keep the bed vacant and available for return to the facility. The bed hold begins the day the resident leaves the facility. The bed hold agreement was signed by Resident 7's representative on 9/28/25. Further review of the Bed Hold Agreement did not show if the Bed Hold notice was provided to Resident 7 and/or their representative when Resident 7 was transferred to the acute care hospital on 1/2/26. On 1/9/26 at 1052 hours, an interview and concurrent closed medical record review was conducted with RN 3. RN 3 verified Resident 7 was transferred to the acute care hospital on 1/2/26. RN 3 verified Resident 7's representative was informed regarding the bed hold notice upon the resident's admission to the facility, however, RN 3 was not able to find the documentation to show if the facility's bed hold policy was provided to Resident 7 or their representative in writing when Resident 7 was transferred to the acute care hospital on 1/2/26. RN 3 verified Resident 7's Notice of Proposed Transfer and Discharge form dated 1/2/26 did not have Resident 7's or their representative's signature. RN 3 stated she was not sure how the facility provided the transfer/discharge notices, and the bed hold policies in writing, when the resident was not able to sign the document and the resident representative was not available at the time of the transfer. In addition, RN 3 verified the copy of the Notice of Proposed Transfer and Discharge form for Resident 7 was not sent to the Ombudsman, when he was transferred to the acute care hospital on 1/2/26. On 1/9/26 at 1108 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified the above findings and stated the facility did not mail the written notice of the transfer/discharge and notice of bed hold to the resident or their representative, when residents were transferred to the acute care hospital. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a baseline care plan for one of 19 final sampled residents (Resident 118). * Resident 118's removal of her indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine from the bladder) and interventions in place for monitoring for bladder function were not included in the resident's baseline care plan. This failure had the potential for the resident's plan of care not being communicated to the IDT and a potential delay in identifying a bladder dysfunction. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 4/24/25, showed the baseline care plan must include the minimum information necessary to properly care for each resident, and should include resident specific health and safety concerns to prevent decline or injury, and identify their needs for assistance with ADL care. Review of the facility's P&P titled Indwelling Catheter - Insertion, Maintenance and Discontinuation of revised 7/22/25, showed after removal of the indwelling urinary catheter, the resident's care plan will be updated as necessary. Medical record review for Resident 118 was initiated on 1/6/25. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Summary Report showed a physician's order dated 1/6/25, to monitor for the signs and/or symptoms of urinary retention (inability to fully empty the bladder) for 72 hours status post indwelling urinary catheter removal. Review of Resident 118's Baseline Care Plan failed to address the resident's urinary catheter, including when it was removed, and monitoring the resident for urinary retention. On 1/7/26 at 0947 hours, an interview was conducted with Resident 118. Resident 118 stated after her indwelling urinary catheter was removed yesterday morning, she had a hard time voiding. Resident 118 stated she has had a hard time getting used to holding her urine in and when she had the urge to void, she needed to rush to the toilet. On 1/7/26 at 1157 hours, interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 118's medical record and stated the resident's indwelling urinary catheter was discontinued yesterday morning, and the facility staff were to monitor the resident for bladder retention, like discomfort and distention, for 72 hours. The DON verified the resident's baseline care plan failed to address the resident's indwelling urinary catheter discontinuation and the interventions in place to monitor and assist the resident. The DON stated the resident's baseline care plan should have been updated yesterday, after the indwelling urinary catheter was removed.

Based on interview and medical record review, the facility failed to ensure for an accurate medical record for one of one final sampled resident (Resident 5) reviewed for dialysis. * Resident 5's blood pressure log inaccurately showed his blood pressure was obtained on his left arm, where the resident had an AV shunt (a surgical connection between an artery and a vein). This failure resulted in inaccurate documentation of the resident's blood pressure measurements site.Findings: Medical record review for Resident 5 was initiated on 1/6/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 11/28/25, for no blood pressure checks on the resident's left arm AV shunt. Review of Resident 5's Blood Pressure Log showed the following blood pressure readings were obtained from the resident's left arm:- on 12/17/25 at 0722 hours;- on 12/18/25 at 0639 hours;- on 12/25/25 at 0646 hours;- on 12/25/25 at 2152 hours;- on 12/26/25 at 0655 hours;- on 1/1/26 at 0834 hours; and- on 1/5 at 1928 hours. On 1/7/26 at 1149 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 5 had a left arm AV shunt, and the blood pressures readings should not be checked on the arm with the AV shunt. The DON verified Resident 5's Blood Pressure Log showed the above blood pressure readings were documented as being taken on the left arm. On 1/7/26 at 1415 hours, an interview was conducted with Resident 5. Resident 5 stated the licensed nurses always checked his blood pressure readings on his right arm because his AV shunt was on his left arm.

Based on interview, medical record review, and the facility document review, the facility failed to ensure the Arbitration Agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) was explained in a form, manner, and language the residents or their representatives understood for two of three residents (nonsampled Residents 23 and 72) reviewed for the Arbitration Agreement. * The facility allowed Residents 23 and 72 who had no mental capacity to understand and make medical decisions, to enter and sign the Arbitration Agreement. This failure posed the risk for the residents to not have a clear understanding of the arbitration process.Findings: 1. Medical record review for Resident 23 was initiated on 1/9/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 11/2/25, showed Resident 23 had no mental capacity to understand and make decisions. Review of Resident MDS dated [DATE], showed Resident 23 had severe cognitive impairment. Review of Resident 23's Arbitration Agreement dated 8/12/25, showed Resident 23's signature. Further review of the Arbitration Agreement showed . by signing this contract you are agreeing to have all claims, including claims other than a claim for medical malpractice, decided by arbitration and you are giving up your right to a jury or court trial and you agree that no party shall adjudicate any claim on a class action basis. 2. Medical record review for Resident 72 was initiated on 1/9/26. Resident 72 was admitted to the facility on [DATE]. Review of Resident 72's H&P examination dated 10/12/25, showed Resident 72 had no capacity to understand and make decisions. Review of Resident 72's Arbitration Agreement dated 10/24/25, showed Resident 72's signature. Further review of the Arbitration Agreement showed . by signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. On 1/9/26 at 0953 hours, an interview and concurrent facility document review for Residents 23 and 72 was conducted with the admission Director. The admission Director verified the above findings and stated Residents 23 and 72 had no capacity to understand and make decisions to sign the Arbitration Agreement and the facility staff should have contacted the residents' representatives to explain the Arbitration Agreement for Residents 23 and 72. On 1/9/26 at 1142 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to implement their QAPI plan and their past Recertification Survey POC for F694. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee. Findings: Review of the facility's 2024 Recertification Survey POC accepted by the department on 10/25/24, included the following for F694:- The DON will in-service the RNs on measuring the external PICC line catheters length on admission. - The DON will review residents with PICC lines to ensure RNs are measuring the external catheter length on admission. - The DON will report any findings related to PICC line care to the QA committee monthly for three months. On 1/9/26 at 1545 hours, a review of the facility's QAPI binder was conducted with the Administrator. The facility's QAPI binder failed to show the above POC interventions were completed. The Administrator verified the above findings. Cross reference F694.

Based on observation, interview, medical record review, and facility P&P review, the failed to provide the reasonable accommodations to meet the care needs for two of 13 sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's call lights were answered in a timely manner. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the residents.Findings: Review of facility's P&P titled Communication-Call System dated 1/1/2012, showed the facility will provide a call system to enable residents to alert the nursing staff from their rooms. The nursing staff will answer the call bells promptly, in a courteous manner. In answering to request, the nursing staff will return to resident with the item or reply promptly. a. On 8/28/25 at 0925 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 3 was conducted with CNA 1. Resident 3's call light was turned on from hallway and there was an audible beeping sound on the call light panel at the nurses station. There were two facility staff in the hallway who passed by Resident 3's room without answering the call light. Resident 3 started screaming and was heard in the hallway. No facility staff answered the call light to assist Resident 3. On 8/28/25 at 0945 hours, 20 minutes after Resident 3's call light was on, CNA 1 answered Resident 3's call light. In a concurrent interview, CNA 1 stated Resident 3 needed to be changed. CNA 1 stated she needed to answer the call light right away and if she could not answer the call light, she would ask other staff to answer the call light. Medical record review for Resident 3 was initiated on 8/28/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severe cognitive impairment and needed substantial to maximum assistance for ADL care from the staff. b. On 8/28/25 at 1025 hours, an observation and concurrent interview for Resident 2 was conducted with CNA 1. Resident 2's call light was turned on from hallway and there was an audible beeping sound on the call light panel at the nurses station. LVNs 2 and 3 were sitting at the nurses station. RNA 1 passed by Resident 2's room without answering the resident's call light. No facility staff answered the call light to provide assistance to Resident 2. On 8/28/25 at 1045 hours, 20 minutes after Resident 2's call light was on, CNA 1 answered Resident 2's call light. In a concurrent interview, CNA 1 stated Resident 2 wanted the lunch tray removed from her room. On 8/28/25 at 1050 hours, an interview was conducted with LVNs 2 and 3, and RNA 1. LVN 2 verified she heard the beeping sound of the call light for Resident 2. LVN 2 stated they needed to answer the call light right away when it was turned on. LVN 2 verified she did not answer the call light of Resident 2 right away. LVN 3 verified he heard the beeping sound of the call light for Resident 2. LVN 3 verified he did not answer the call light of Resident 2 right away. RNA 1 verified the call light of Resident 2 was turned on when he passed by the room and acknowledged he did not answer the call light of Resident 2 right away. RNA 1 stated the call light of Resident 2 should have been answered right away. On 9/3/25 at 1655 hours, an interview was conducted with the Administrator and DON was conducted. The Administrator and the DON were informed and verified the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate and complete medical record for two of 13 sampled residents (Residents 12 and 13). * The facility failed to ensure the licensed nurses documented their initials on Residents 12 and 13's TARs (indicating the treatments were provided) as per the facility's P&P. This failure had the potential for the residents' care needs not being met as their medical record information was inaccurate and/or incomplete.Findings: Review of the facility's P&P titled Completion and Correction revised 1/1/2012, showed the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The facility will ensure the medical records are complete and accurate. Entries will be recorded promptly as the event occurs. 1. Medical record review for Resident 12 was initiated 8/29/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 5/20/25, to cleanse Resident 12's sacrum fragile scar tissue with soap and water, pat dry, then apply zinc oxide (skin barrier cream), every shift for skin maintenance. Review of Resident 12's TAR (Treatment Administration Record) for 7/2025 failed to show documentation the licensed nurse performed Resident 12's treatment on 7/7, 7/18, 7/19, and 7/28/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident 12's sacrum and the application of her barrier cream. 2. Medical record review for Resident 13 was initiated on 8/29/25. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed an order dated 7/12/25, to cleanse Resident 13's MASD (sacrococcyx and right left buttocks) with normal saline, pat dry, then apply moisture barrier cream every shift. Review of Resident 13's TAR for 7/2025 failed to show documentation the licensed nurse performed Resident 13's treatment on 7/18/25 and 7/19/25, on the evening shift. The licensed nurse failed to document their initials on the TAR for the cleansing of Resident's 13 MASD (sacrococcyx and right left buttocks) and the application of her barrier cream. On 9/2/25 at 1550 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the findings and stated after a licensed nurse provided resident treatment, the licensed nurse would then document the treatment provided in the resident's medical record (TAR). The DON stated she would contact the nurses who failed to document Resident 12 and 13's treatments were provided and determine whether the nurses failed to provide the treatments or had provided the residents' treatments, however, forgot to document in the residents' medical record.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of a pressure ulcer for three of three sampled residents (Residents 1, 2, and 3) and eight nonsampled residents (Residents LL, MM, NN, OO, PP, QQ, RR, and SS). * Resident 1 was incontinent and was admitted to the facility on [DATE], without a pressure ulcer. Resident 1 developed an unstageable pressure ulcer at the sacrococcyx (tailbone) area on 8/19/22, that had progressed to a Stage 4 on 9/7/22 (19 days after). The facility failed to provide the appropriate and necessary services to ensure Resident 1 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. This failure resulted in Resident 1's cancellation of discharge to home and receiving intravenous antibiotics for a wound infection. * Resident 3 had a reopened Stage 2 pressure ulcer on the right buttock. The licensed nurse failed to assess the pressure ulcer, notify the physician resident's representative, and obtain a treatment order for the pressure ulcer. This failure resulted in the CNA providing inappropriate wound treatment and the potential for Resident 3 not receiving appropriate care and services to promote healing of the pressure ulcer. * The facility failed to follow and implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure posed the risk for delayed healing and worsening of the pressure ulcers. Findings: Review of the facility's P&P titled Skin and Wound Management revised 1/1/12, showed the facility staff will take appropriate measures to prevent and reduce the likelihood that the residents will develop pressure ulcers and other skin conditions. All nursing staff is responsible for the prompt reporting of any skin related conditions to the licensed nurse. The licensed nurse will notify the Attending Physician promptly at the first occurrence of a pressure ulcer or other skin related problems. Review of the facility's P&P titled Pressure Ulcer Management revised 1/1/12, showed at any time when a new pressure ulcer is identified, the licensed nurse will complete the Pressure Ulcer Site Sheet. The Attending Physician will be notified to obtain advise/orders on the appropriate treatment promptly. The Licensed Nurse will notify the responsible party of the presence of the pressure ulcer. The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on April 13, 2016, as follows: - Stage 1 pressure ulcer - intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Deep Tissue Pressure ulcer - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Medical record review for Resident 1 was initiated on 8/31/22. Resident 1 was admitted to the facility on [DATE]. On 8/31/22 at 0942 hours, Resident 1 was observed lying flat on a low air loss mattress (mattress used for prevention or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 1's MDS dated [DATE], showed Resident 1 did not have a cognitive impairment. Resident 1 required total assistance of one staff for toileting (including how the resident was cleaned after elimination and pad changes), personal hygiene, and bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Resident 1 was always incontinent of bowel and bladder. Review of the Clinical Admission Evaluation dated 8/11/22, showed Resident 1 was admitted to the facility without a pressure ulcer. Review of the Skin Only Evaluation dated 8/12/22, showed Resident 1 had a Moisture Associated Skin Damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture) to the sacrococcyx extending to bilateral buttocks. The length and width measurement showed diffuse (spread out). a. Review of the Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/13/22, for the night shift and from 8/15 to 8/17/22, for the evening shifts. Review of the plan of care showed a care plan problem dated 8/18/22, addressing Resident 1's risk for further skin impairment. The interventions included to assist and encourage the resident to reposition every two hours and as needed with a pillow or assistive devices for skin maintenance and integrity. Review of the CNAs ADL Flow Sheet for August 2022 showed Resident 1 was dependent with one staff member for bed mobility. However, there was no documentation to show the frequencies of Resident 1 being turned and repositioned on each shift. Review of the Change in Condition Evaluation dated 8/18/22, showed Resident 1 had a new onset unstageable pressure ulcer/injury to the sacrococcyx extending to right upper buttock, measuring 5.8 cm (length) x 3 cm (width) x UTD (unable to determine, full thickness tissue loss in which the base of the ulcer was covered by slough [excessive pus] and/or eschar [dead tissue]). The wound was described as 50% slough adherent to the wound bed and 50% granulating pinkish/red fragile tissue. On 8/31/22 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 verified Resident 1 was admitted to the facility with MASD to the sacrococcyx extending to bilateral buttocks and treatment was not consistently done as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 3 stated she had no answer. LVN 3 stated the skin breakdown should have been found when it was at least a Stage 2 as the pressure ulcer would not become unstageable right away, considering the size of the pressure ulcer when it was discovered. On 8/31/22 at 1205 hours, an interview was conducted with Resident 1. Resident was observed lying flat on a low air loss mattress. Resident 1 stated she had a wound at .the bottom. When asked if the staff were turning or repositioning her every two hours, Resident 1 stated .not as much. Resident 1 stated the nursing staff were always busy. When asked if she could turn and reposition in bed by herself, Resident 1 stated no, she needed help. On 8/31/22 at 1215 hours, an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 2. Resident 2 needed total assistance from one staff with turning and repositioning. When asked where they documented the turning and repositioning of the resident, CNA 2 stated they did not document these. CNA 2 stated they did not have a turning schedule to follow. On 9/13/22 at 0511, 0645, and 0835 hours, Resident 1 was observed lying flat on a LAL mattress. On 9/13/22 at 0629 hours, an interview was conducted with CNA 5. When asked where the staff would document the turning and repositioning of the resident, CNA 5 stated they did not document turning and repositioning in the ADL flowsheets. CNA 5 stated the facility did not have a turning schedule, but she followed the 12, 2, 4, and 6 schedule (the time on the clock she repositioned the resident). On 9/13/22 at 0641 hours, an interview was conducted with LVN 6. LVN 6 stated the facility did not have a turning schedule. LVN 6 stated he followed the 11, 1, 3, 5, and 7 turning schedule (the time on the clock the resident was repositioned). On 9/1/22 at 0720 hours, an interview was conducted with CNA 1. CNA 1 stated the facility was always short-staffed during the night shift. CNA 1 stated there were times only three CNAs were assigned to provide care to 96 to 100 residents. CNA 1 stated when they were short staffed, the CNAs could only answer call lights and only change the incontinent residents only once. CNA 1 stated they did not have time to turn and reposition the residents. Cross reference to F725, example #1. b. Review of the Wound Assessment and Plan assessment dated [DATE], showed Resident 1 was evaluated by the Wound Consultant for the first time on 8/30/22. The assessment showed Resident 1 had an unstageable pressure injury (same as ulcer) on the sacrum measuring 8.2 cm x 4.8 cm x 0.4 cm. The documentation showed a treatment order to apply Santyl (removes dead tissue from wounds so they can start to heal), nickel thick layer; cleanse the wound with normal saline or sterile water before applying the dressing; and cover with moist gauze daily and as needed. Review of the Skin Only Evaluation dated 8/30/22, showed Resident 1 was seen and evaluated by the Wound Consultant and a bedside sharp debridement was performed. The documentation showed Santyl ointment with moist gauze was the current treatment order. Review of the Order Summary Report showed an order dated 8/31/22, to cleanse the sacroccoccyx extending to right upper buttock pressure injury with normal saline, pat dry, apply Santyl ointment and cover with a dry dressing everyday shift. The wound care treatment order was transcribed incorrectly as per the Wound Consultant's treatment order to cover the wound with moist dressing after applying Santyl ointment instead of the dry dressing. On 9/13/22 at 0910 hours, a wound care observation on Resident 1 was conducted with LVN 2. LVN 2 was observed cleansing Resident 1's sacrococcyx wound with normal saline, applied Santyl ointment, and covered the area with a dry dressing. On 9/19/22 at 1129 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above treatment order was transcribed incorrectly. The Wound Consultant's order was to cover the wound with moist dressing. RN 2 stated he would clarify the order with the physician. c. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment order was not done on the evening shift from 8/24 to 8/30/22. On 8/31/22 at 1222 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified the wound treatment was not done in the evening shift from 8/24 to 8/30/22, as ordered by the physician. d. Review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 8/23/22, LCD (last cover day, last day of Medicare coverage) 9/5, d/c (discharge) 9/6 with home health. - 8/31/22, cancel LCD due to a wound. e. Review of the Physician's Telephone Orders dated 9/7/22, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's primary care physician's Progress Note dated 9/7/22, showed Resident 1's wound was now a Stage 4 with visible bone. A wound culture was ordered. Review of the Sacrococcyx Wound Culture result dated 9/7/22, showed the sacrococcyx wound was positive for pseudomonas aeruginosa (bacteria capable of causing a variety of infections) and enterococcus faecalis (bacteria inhabiting the gastrointestinal tracts of humans associated with nosocomial infections). On 9/19/22 at 1335 hours, a telephone interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she worked as a treatment nurse at the facility. LVN 2 stated she was the one who found out about the unstageable pressure ulcer of Resident 1 on 8/18/22. LVN 2 stated she was just reassigned from another area and the CNA asked her to put . a bandage on Resident 1. LVN 2 stated when she checked the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated the CNA said Resident 1 had a bandage on her bottom. LVN 2 stated when she checked, Resident 1 had an unstageable pressure ulcer at the sacrococcyx extending to the right buttock. LVN 2 stated she could not explain why it was not assessed or evaluated before the pressure ulcer became unstageable. On 9/20/22 at 1357 hours, a telephone interview was conducted with Resident 1's family member. The family member stated the plan was for Resident 1 to be discharged home on 9/5/22; however, because Resident 1 developed a pressure ulcer in the facility, her discharge schedule had been canceled. The family member stated Resident 1 did not have a pressure ulcer when she was admitted to the facility from the acute care hospital. The family member stated they were very involved in Resident 1's care and would visit her often. When asked if the facility staff turned and repositioned Resident 1 every two hours, the family member stated no. The family member stated sometimes Resident 1 was not repositioned or changed for three to six hours. On 9/21/22 at 1035 hours, an interview was conducted with Resident 1's primary care physician. The physician stated Resident 1 developed an unstageable pressure ulcer at the facility for that reason the resident's planned discharge date had been canceled. Resident 1's primary care physician stated she saw Resident 1's wound on 9/7/22, after the treatment nurse reported there was a foul odor coming from the wound and the wound was covered with slough, so she ordered the intravenous [MEDICATION(S)] injection. The physician stated the wound culture came back positive with bacterial infection. 2.a. On 9/13/22 at 0515 hours, an observation of CNA 1 providing incontinence care to Resident 3 was conducted. CNA 1 was observed applying miconazole [MEDICATION(S)] (antifungal cream used to treat athlete's foot, jock itch or ringworm) 2% to Resident 3's buttocks. Resident 3 was observed with an open wound measuring approximately 1.5 cm x 1.5 cm at the right buttock. Medical record review for Resident 3 was initiated on 9/13/22. Resident 3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 3 had moderate cognitive impairment. Resident 3 required extensive assistance from one staff member for toileting and bed mobility. Review of the skin assessments failed to show Resident 3 had a skin impairment at the right buttock. Review of the plan of care showed a care plan problem dated 8/17/22, addressing Resident 3's risk for development of pressure ulcer due to a Stage 2 pressure ulcer at the right buttock which resolved on 8/19/22. Review of the Treatment Administration Record for September 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/13/22 at 0927 hours, an interview and concurrent medical record review was conducted with RN 1 and LVN 2. LVN 2 stated Resident 3 had a pressure ulcer at the right buttock that healed on 8/19/22. RN 1 and LVN 2 verified Resident 3 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/13/22 at 0935 hours, an observation of Resident 3's right buttock wound was conducted with LVN 2. Resident 3 was observed with a Stage 2 pressure ulcer at the right buttock measuring approximately 1.5 cm x 1.5 cm. LVN 2 verified the findings. On 9/13/22 at 1000 hours, an interview was conducted with CNA 2. CNA 2 stated she was assigned to care for Resident 3 today as well as yesterday. CNA 2 stated she noticed an open wound on the resident's right buttock yesterday when she provided incontinence care. CNA 2 stated she reported this to the charge nurse right away; however, she did not see the nurse apply any cream to the resident's right buttock. Review of the medical record failed to show Resident 3's wound at the right buttock was assessed, nor was the physician and the resident's representative notified. On 9/13/22 at 1045 hours, an interview was conducted with RN 2. RN 2 was asked if she received any report from the charge nurse regarding an open wound at Resident 3's right buttock. RN 2 stated no. RN 2 stated any new change in skin condition should be assessed, a change in condition evaluation should be generated including notification of the physician and resident's family/representative, and a treatment order should be obtained. On 9/13/22 at 1119 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated she was not informed by the charge nurse regarding Resident 3's pressure ulcer at the right buttock had reopened yesterday. LVN 2 verified Resident 3 had a treatment order to apply vitamin A&D to the right buttock for skin management every shift; however, she was not able to provide the treatment yesterday because the resident was already out of bed and seated in the wheelchair. b. Review of Resident 3's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/28 and 8/30/22, as ordered by the physician. 3. Further Review of the Treatment Administration Records for August 2022 showed the following residents' pressure ulcer treatment orders were not done on 8/27, 8/28, and 8/30/22, when the facility did not have a treatment nurse on duty. Cross reference to F725, example #2. a. Medical record review for Resident 2 was initiated on 8/31/22. Resident 2 was admitted to the facility on [DATE]. Review of the history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment order was not done on 8/30/22, as ordered by the physician. On 8/31/22 at 1058 hours, an interview was conducted with LVN 4. LVN 4 stated he was informed by the DON yesterday at around 1300 hours, that the other treatment nurse was not coming so he was the only treatment nurse in the facility. LVN 4 stated he was informed late in the day, so he was not able to finish all the treatments yesterday and had informed the DON about it. On 8/31/22 at 1140 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed sitting in his wheelchair, with his left heel observed wrapped with Kerlix (undated). Resident 2 was asked when his left heel dressing was last changed. Resident 2 stated two days ago. Resident 2 stated a wound care was not done on his left heel yesterday. LVN 4 who was present in the room verified Resident 2's wound care treatment was not done yesterday because the other treatment nurse called in. b. Review of Resident LL's Treatment Administration Record for August 2022 showed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 8/21/22, for Resident LL's right upper buttock pressure ulcer to be cleansed with normal saline, pat dry, apply Medi-honey, and cover with a dry dressing daily everyday shift. - 8/20/22, to apply [MEDICATION(S)] (antifungal) cream to the left buttock MASD every day and night shift. However, the documentation showed the treatment orders were not done on 8/30/22, on the day shift. c. Review of Resident MM's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/28 and 8/30/22, as ordered by the physician. d. Review of Resident NN's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the documentation showed the treatment was not done on 8/27 and 8/28/22, as ordered by the physician. e. Review of Resident OO's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/28/22, as ordered by the physician. f. Review of Resident PP's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/28 and 8/30/22, as ordered by the physician. g. Review of Resident QQ's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/27 and 8/28/22, as ordered by the physician. h. Review of Resident RR's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/30/22, as ordered by the physician. i. Review of Resident SS's Treatment Administration Record for August 2022 showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the treatment was not done on 8/28 and 8/30/22, as ordered by the physician. On 8/31/22 at 1058 hours, an interview was conducted with LVN 4. LVN 4 stated he was assigned as one of the facility's treatment nurses. LVN 4 stated there should be two treatment nurses assigned during the day shift as most treatments were ordered to be done during the day shift; however, there were days when he was the only treatment nurse assigned during the day shift. LVN 4 stated when this happened, he would stay and work overtime in order to finish the day shift's wound treatments. LVN 4 stated the facility had no assigned treatment nurse on Sundays and there were times he would come in on Monday and saw the old dressings from two days before. LVN 4 stated yesterday, 8/30/22, he was informed late in the day by the DON that the other treatment nurse did not show up and he was not able to stay overtime and finish the treatment orders. LVN 4 stated he had informed the DON about this. On 8/31/22 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings and stated the treatment orders were not done on the dates when the facility did not have an assigned treatment nurse. On 8/31/22 at 1247 hours, an interview was conducted with the DON. The DON stated she was not aware of the residents' treatment orders not done on the days when the facility did not have an assigned treatment nurse. The DON stated she expected the charge nurses to complete their assigned residents' treatment orders as an additional assignment when the facility had no treatment nurse on duty. The DON verified the expectation was for the facility to have two treatment nurses assigned on the day shift. The DON verified the above findings. The DON stated the facility did not have a turning schedule in place and there was no documentation of turning and repositioning in the medical record. On 9/14/22 at 1347 hours, a telephone interview and concurrent medical record review was conducted with LVN 7. LVN 7 stated she worked as a charge nurse on days when the facility had no treatment nurse on duty. This usually happened on the weekends. LVN 7 stated it was really hard to do the wound treatments in addition to their assigned workload during the day shift. LVN 7 verified the above unsigned treatments were not done as ordered by the physician. LVN 7 stated the RN supervisor was aware the treatments were not done. On 9/21/22 at 1159 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated it was difficult to do the treatment when she worked as a charge nurse and there was no assigned treatment nurse. LVN 8 stated sometimes they could do the treatments but most of the time they could not. LVN 8 verified the treatment was not done when the Treatment Administration Record was not signed.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 20 final sampled residents (Residents 11, 68, and 79) and one nonsampled resident (Resident 599) received the appropriate services to meet their nutritional needs and maintain desirable weights. * The facility failed to identify and address Resident 79's severe unplanned weight loss in a timely manner to prevent further weight loss. The facility failed to identify, implement, monitor, and modify the interventions specific to Resident 79's needs. These failures contributed to a continued weight loss and the development of a Stage 4 pressure ulcer. * The facility failed to provide timely nutritional assessments for Residents 599, 11, and 68. * The facility failed to timely follow the RD's recommendations for Resident 599. * The facility did not provide an RD consult for Resident 11 as ordered by the physician. These failures had the potential for the residents not having their nutritional needs met and the facility not being able to evaluate if the planned interventions were effective. Findings: According to the facility's P&P titled Evaluation of Weight and Nutritional Status revised 1/2019, any resident who varies from previous reporting period by 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, will be evaluated by the IDT - Nutrition and Weight Variance Committee to determine the cause of the weight loss and the interventions required. Once the weight loss is identified, the IDT - Nutrition and Weight Variance Committee will: a. Identify and implement appropriate interventions; b. Update and revise the care plan, as appropriate; c. Notify the responsible party; d. Notify the Attending Physician; and e. Notify the RD. 1. On 1/8/20 at 0800 hours, Resident 79 was observed for breakfast in her room. Resident 79 was being spoon fed by the staff. Resident 79 was observed with eyes closed, however, would open her mouth and swallow every time she felt the spoon in her mouth. Resident 79 consumed 75% of her breakfast. Medical record review for Resident 79 was initiated on 1/8/20. Resident 79 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 79 had severe cognitive impairment and required total assistance of one person for eating. Review of the Individual Resident Weight History showed the following weights dated: - 1/6/19, 154.4 pounds; - 2/3/19, 150.4 pounds; - 3/3/19, 150 pounds; - 4/7/19, 145 pounds; - 5/5/19, 147 pounds; - 6/2/19, 138 pounds; - 7/7/19, 141.4 pounds; - 8/4/19, 137.4 pounds. Review of the Nutritional assessment dated [DATE], showed Resident 79 was 62 inches in height and her usual body weight was 140 to 150 pounds. Resident 79's current weight was 137 pounds. The assessment showed a negative weight trend was identified. The RD recommended the following interventions: - four-ounce shake (protein supplement) three times a day; - four-ounce [MEDICATION NAME] HN (nutritional formula) two times a day with medication pass; - weekly weights times four; - check BMP (basic metabolic panel - information about the body's fluid balance and levels of electrolytes like sodium and potassium), CBC (complete blood count), iron panel; and - mashed potatoes/ice cream at lunch and dinner. Review of the medical record failed to show documentation the above RD's recommendations were acted upon, nor the IDT - Nutrition and Weight Variance Committee had met and addressed the resident's negative weight trend. Further review of the Individual Resident Weight History showed the following recorded weights: - On 9/1/19, 132.4 pounds (11.73% weight loss in six months); - On 10/6/19, 129.2 pounds (12.11% weight loss in six months); - On 11/3/19, 128.4 pounds (12.65% weight loss in six months) ; and - On 12/1/19, 121 pounds (5.43% weight loss in one month, 12.32% weight loss in six months). Review of the medical record failed to show documentation the RD had addressed Resident 79's severe unplanned weight loss in September, October, and (MONTH) 2019. Review of the Weight Variance Committee Evaluations dated 9/20, 10/25, 11/26, and 12/24/19, failed to show the RD's involvement to address Resident 79's weight loss. The IDT meeting notes failed to show the committee had consulted with the RD regarding Resident 79's weight loss. Review of the plan of care showed a care plan problem was developed to address Resident 79's Nutrition and Hydration dated 8/12/19. The care plan failed to address Resident 79's continued, severe, unplanned weight loss. Cross reference to F657, example a. Review of the Nutritional Progress Note showed an entry by the RD dated 12/8/19. The RD recommended to increase the Prostat (nutritional supplement with protein and calorie content) to three times a day and add HPN (high protein nutrition, supplement) three times a day with meals. The note failed to show the RD observed Resident 79 for meals nor contacted the family for the resident's dietary preferences. Review of the medical record failed to show the above RD's recommendations were acted upon, nor documentation to show Resident 79's physician was informed of the above RD's recommendations. Review of the Weight Variance Committee Evaluation dated 12/24/19, attended by LVN 1 and the DSS showed both staff met to address Resident 79's weight loss. However, there was no documentation why the RD's recommendations were not carried out. There were no new interventions added to address the resident's severe weight loss. Further review of the Nutritional Progress Note showed an entry by the RD dated 12/26/19. The RD documented her previous recommendations to increase the Prostat and HPN were not ordered and repeated the same recommendations. The RD documented there was no improvement in Resident 79's intake. However, the note failed to show the RD observed Resident 79 for meals nor contacted the family for the resident's dietary preferences. Review of the medical record failed to show the RD's repeated recommendations were acted upon, nor documentation to show Resident 79's physician was informed of the above RD recommendations. Further review of the Nutritional Progress Note showed an entry by the RD dated 1/2/20. The RD documented her previous recommendations for supplements were never carried out and Resident 79 remained at high nutritional risk and weight loss. The RD documented the recommendations to add the protein and calorie supplements were for the resident's benefit. Review of the medical record showed the above RD recommendations were not carried out until 1/7/20. Review of the laboratory results dated [DATE], showed Resident 79's [MEDICATION NAME] level was at 2.6 g/dL (normal range: 3.5 - 5.7 g/dL; low [MEDICATION NAME] levels can also be seen in malnutrition and conditions where the body did not properly absorb and digest protein). Review of the laboratory results dated [DATE], showed Resident 79's pre-[MEDICATION NAME] level was 9 mg/dL (normal range: 17 - 34 mg/dL; an indicator of protein status, can be a sign of malnutrition). Review of the Weekly Pressure Injury/Ulcer Progress Reports showed Resident 79 developed an unstageable pressure ulcer to the sacrococcyx area (tailbone) on 12/5/19. The wound had progressed to a Stage 4 pressure ulcer by 12/12/19, and was increasing in size. Review of the RD's Nutritional Progress Notes dated 12/8, 12/26/19, and 1/2/20, failed to show documentation Resident 79's laboratory values and pressure ulcer were addressed by the RD in reference to her continued weight loss and poor meal intakes. On 1/9/20 at 0850 hours, an interview and concurrent medical record review was conducted with the RD. LVN 1, who introduced herself as the facility's Weight Variance Coordinator, joined the interview. The RD stated she assessed Resident 79 for severe unplanned weight loss on 12/8/19. The RD verified her recommendations were not acted upon in a timely manner and she had to make repeated recommendations. Her recommendations to increase the Prostat and HPN were not carried out until 1/7/20, a month after she had recommended them. The RD stated the recommendations were beneficial for Resident 79 because it could have addressed Resident 79's protein and caloric requirements. LVN 1 verified there was no documentation to show why the RD's repeated recommendations were not addressed in a timely manner. LVN 1 stated the RD's recommendations should be carried out within 72 hours. On 1/10/20 at 0726 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 79 needed assistance with meals and her appetite varied for breakfast and lunch. CNA 3 stated Resident 79 liked to drink the shake (HPN). CNA 3 stated Resident 79 used to only get the shake for lunch, now that she had it for breakfast, she would mix the shake with the cream of wheat and Resident 79 would eat it. CNA 3 stated the shake was not included in her documentation of meal intake because there was no area to document it. The area on the ADL flowsheet to document the nourishment referred to the snack (ice cream) which Resident 79 received at 1400 hours every day. On 1/10/20 at 1123 hours, a follow-up interview was conducted with the RD. The RD verified she had not addressed Resident 79's pressure ulcer in her assessments; however, had the facility carried out her recommendations in a timely manner, the RD stated that could have helped prevent the development and worsening of Resident 79's pressure ulcer. The RD reviewed her notes and verified she also failed to address Resident 79's abnormal laboratory values, specifically the pre-[MEDICATION NAME] level which was low. The RD stated she was not informed Resident 79 had a facility-acquired Stage 4 pressure ulcer. Cross reference to F686. On 1/14/20 at 0733 hours, a telephone interview was conducted with Resident 79's family member. The family member stated she was aware of Resident 79's weight loss and the family tried their best to come so they could assist in feeding Resident 79. The family member stated Resident 79 needed a lot of cuing and time when eating, and she felt the facility staff did not have the time and patience to feed her. 2. Review of the facility's P&P titled Nutritional Assessment revised 2/1/14, showed the purpose of nutritional assessments is to ensure the residents are properly assessed for dietary needs. According to the P&P, the RD will complete the Nutritional Assessment within 14 days of admission. Medical record review for Resident 599 was initiated on 1/8/20. Resident 599 was admitted to the facility on [DATE]. Review of Resident 599's Individual Resident Weight History showed the following weight entries: - 12/23/19, the resident weighed 120.6 pounds - 12/29/19, the resident weighed 114 pounds - 1/5/20, the resident weighed 110 pounds Review of Resident 599's Nutritional assessment dated [DATE], showed Resident 599's first nutritional assessment was completed 15 days after admission. The assessment showed Resident 599 was 62 inches in height with a usual body weight of 120 +/- one to five pounds. Resident 599's current body weight was 114 pounds (Resident 599's weight on 1/5/20, was recorded on the Individual Resident Weight History as 110 pounds). The assessment showed Resident 599 experienced the weight loss and showed the RD's recommendation to add Prostat two times a day and snacks three times a day to the resident's diet. Review of Resident 599's Nutritional assessment dated [DATE], showed a re-recommendation for Prostat twice a day and snacks three times a day. Review of the medical record on 1/10/20 at 0900 hours, failed to show the above RD's recommendations were acted upon. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated she expected her recommendations to be completed within 72 hours. The RD stated since she was only at the facility two days a week, she checked the residents' medical records to see if the recommendations were implemented. The RD stated if the recommendation was not carried out, she re-recommended or verbalized her recommendation to a charge nurse. The RD stated the time frame she had to complete her first nutritional assessment on a resident was 14 days. The RD verified her nutritional assessment on Resident 599 was late and was completed after 15 days. The RD verified she was at the facility on 12/31/19, during the 14 days the resident was at the facility. The RD verified she did not attend the weight-variance committee meeting on 12/31/19, addressing Resident 599's significant weight loss. The RD verified the medical record failed to show her recommendations for Prostat and snacks. 3. Review of the facility's P&P titled Quarterly Nutritional Evaluation and Progress Notes revised 6/1/18, showed the purpose of quarterly nutritional evaluations is to ensure residents are properly evaluated for dietary needs on an ongoing basis. According to the facility's P&P, if a resident is receiving enteral (GT) feeding, the RD will complete a quarterly evaluation. Medical record review for Resident 11 was initiated on 1/8/20. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's Physician order [REDACTED]. An additional physician's orders [REDACTED].>On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD stated tube feeding assessments should be completed on a quarterly basis. The RD verified Resident 11's last Quarterly Nutritional Assessment was completed on 2/26/19, and the last Nutrition Progress Note was completed on 6/6/19. The RD stated she made herself a calendar to help keep track of the quarterly assessments. The RD stated she did not have a facility document showing her by when the assessments should be completed. 4. Medical record review for Resident 68 was initiated on 1/8/20. Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's Physician order [REDACTED]. Review of Resident 68's Nutritional assessment dated [DATE], showed the resident's last nutritional assessment was completed on this date. On 1/10/20 at 0942 hours, an interview and concurrent medical record review was conducted with the RD. The RD verified Resident 68's last Nutritional Assessment was completed on 7/18/19.