Every finding on record at Orchards Skilled Nursing

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled resident (Resident 2) remained free from accident hazards. * Resident 2's bilateral floor mats were not in place as ordered. This failure had the potential to put the resident at risk for further injury in the event of a possible fall.Findings: Review of the facility's P&P titled Falls Intervention Policy and Procedure revised 1/29/26, showed the residents' care plans will address interventions based on the resident's fall risk and other input as appropriate. On 7/14/26 at 0916 hours, Resident 2 was observed in bed with Sitter 1 at his bedside. Resident 2's floor mats were observed propped up against the wall, not on the floor next to his bed. Sitter 1 stated Resident 2 was confused and unable to answer questions appropriately. Sitter 1 verified the floor mats were already propped up against the wall when they arrived and were only used at night-time. Medical record review for Resident 2 was initiated on 7/14/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 6/23/26, for bilateral floor mats at bedside while in bed every shift, to mitigate the risk of injury related to a fall. Review of Resident 2's H&P examination dated 6/24/26, showed the resident had a spinal fracture resulted from a fall. Review of Resident 2's Care Plan Report (undated) showed a focus for Resident 2 being at risk for falls or injury related to a history of falls. Interventions included bilateral floormats at bedside while the resident was in bed and a caregiver for cuing and redirection. On 7/14/26 at 0927 hours, an observation and concurrent interview was conducted with RN 1. RN 1 stated Resident 2 ambulates without direction, and family provides the sitter for safety. RN 1 verified the bilateral floor mats were propped against the wall and should be placed on the floor next to each side of the bed. RN 1 stated floor mats are to be in place at all times, while the resident was in the bed.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical processes was followed. * The facility failed to ensure Resident 5 received a multivitamin with minerals medication as ordered by the physician. * The facility failed to ensure the incoming and outgoing licensed nurses signed the reconciled controlled medications sheet at shift change for Medication Cart A. * Resident 20's lidocaine 5% topical patch was removed as ordered by the physician. These failures had the potential to result in inaccurate controlled medication reconciliation and a delay in identifying potential drug diversion; and the potential to develop adverse outcomes to the residents due to not following medication orders. Findings: 1. Review of the facility's Medication Administration P&P revised March 2021 showed to reorder medications at least three days before the supply is exhausted. Medical record review for Resident 5 was initiated on 7/14/26. Resident 5 was readmitted to the facility on [DATE]. Review for Resident 5's Order Summary Report showed a physician's order dated 3/3/26, for liquid multivitamin with mineral, administer 15 ml via GT daily. On 7/15/26 at 0838 hours, a medication administration observation for Resident 5 was conducted with LVN 2. During the observation, LVN 2 was unable to locate multivitamin with mineral in the medication cart and therefore, did not administer it to the resident as ordered. LVN 2 stated she would look in the stock room for multivitamin with mineral supply. On 7/15/26 at 1015 hours, LVN 2 stated there was no multivitamin with mineral in stock at the facility. 2. Review of the facility's P&P titled Controlled Drugs revised October 2018 showed controlled drugs have a potential for abuse, and may also lead to physical or psychological dependence. Controlled medications are subject to special handling, which includes storage under separate lock from non-controlled drugs, use of a count sheet for accounting usage, and routine auditing. Controlled medications shall be audited at shift change and a record of the audit shall be kept. On 7/15/26 at 1208 hours, an inspection of Medication Cart A was conducted with LVN 2. Review of the narcotic/controlled medication reconciliation count sheet titled Narcotic Book #3, showed signatures for incoming and outgoing licensed nurses for each shift change. Signatures to show a controlled medication audits were conducted at shift change were observed to be incomplete on the following dates:- On 5/12/26 at 2300 hours, the outgoing licensed nurses' signature was missing;- On 6/1/26 at 2300 hours, the outgoing licensed nurses' signature was missing; and- On 7/8/26 at 2300 hours, the outgoing licensed nurses' signature was missing.LVN 2 verified the missing signatures. 3. Medical record review for Resident 20 was initiated on 7/14/26. Resident 20 was admitted to the facility on [DATE]. Review for Resident 20's Order Summary Report showed a physician's order dated 9/3/25, to apply a lidocaine (a fast-acting local anesthetic) external patch 5% to the resident's left shoulder daily for pain, and to remove the patch as scheduled. Review of Resident 20's MAR for July 2026 showed the lidocaine patch was scheduled to be applied at 0900 hours, and removed at 2059 hours. On 7/15/26 at 0826 hours, a medication administration observation for Resident 20 was conducted with LVN 1. When LVN 1 exposed Resident 20's shoulder to apply the lidocaine external 5% patch, a patch was already observed on the resident's shoulder. LVN 1 removed the old patch and applied the new patch. LVN 1 verified she removed the old lidocaine patch, and the patch should have been removed the night before at 2059 hours.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to one of five final sampled residents (Resident 13) reviewed for unnecessary medications. * The facility failed to hold Resident 13's BP medication per the physician's ordered parameters. This failure had the potential for the resident to develop significant adverse and side effects from the medication.Findings: Review of the facility's Medication Administration P&P revised March 2021 showed the prescriber's orders will be used to verify the medication and dosage. Medical record review for Resident 13 was initiated on 7/14/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a clinician's order dated 6/23/26, for lisinopril (medication to treat high blood pressure) 30 mg daily by mouth for hypertension, and to hold the medication for a SBP less than 130 mmHg. Review of Resident 13's MAR for June 2026 showed the lisinopril medication was administered to the resident when it should have been held for a SBP below 130 mmHg, on the following dates:- On 6/24/26 at 0900 hours for a BP of 128/80 mmHg;- On 6/25/26 at 0900 hours for a BP of 124/80 mmHg;- On 6/27/26 at 0900 hours for a BP of 124/26 mmHg;- On 6/28/26 at 0900 hours for a BP of 128/57 mmHg; and- On 6/30/26 at 0900 hours for a BP of 120/68 mmHg. Review of Resident 13's MAR for July 2026 showed the lisinopril medication was administered to the resident when it should have been held for a SBP below 130 mmHg, on the following dates:- On 7/1/26 at 0900 hours for a BP of 118/67 mmHg;- On 7/3/26 at 0900 hours for a BP of 129/69 mmHg;- On 7/4/26 at 0900 hours for a BP of 122/76 mmHg;- On 7/5/26 at 0900 hours for a BP of 120/64 mmHg;- On 7/8/26 at 0900 hours for a BP of 122/60 mmHg;- On 7/9/26 at 0900 hours for a BP of 123/73 mmHg;- On 7/10/26 at 0900 hours for a BP of 120/65 mmHg;- On 7/11/26 at 0900 hours for a BP of 124/67 mmHg; and- On 7/12/26 at 0900 hours for a BP of 120/82 mmHg. On 7/15/26 at 1144 hours, an interview and concurrent medical record review for Resident 13 was conducted with LVN 1. When asked how the hold parameters for the BP medications are determined, LVN 1 stated the facility's hold parameters for the BP medications were to hold the medication for a SBP less than 110 mmHg. LVN 1 reviewed Resident 1's MAR for June and July 2026, and verified the above doses were administered. LVN 1 then reviewed the physician's order, and verified the above medication doses should have been held per the physician's ordered hold parameters.

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 facility failed to ensure the kitchen utensils had smooth cleanable surface and in good condition. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Resident Diet Information dated 4/14/25, showed 38 of 40 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed the dishes, trays and utensils shall be routinely checked for stains or spots. Chipped or cracked dishes, trays shall be discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/14/25 at 0804 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the RD and Chef de Cuisine. The following was observed and verified by the RD and Chef de Cuisine: - Three white basting brush used for butter spread were discolored, had frayed bristles and worn out. - Four rubber spatulas with red handles used for mixing food were stained, discolored, and worn out. - One white plastic spatula was chipped, cracked at the edges, old and worn out. - One stainless steel spatula with black handle was peeling and partially melted. - One clear plastic spatula was old and worn out. - Two stainless steel ice cream scoop was discolored, old and worn out. - One stainless steel spatula with white handle was deformed at the edges and handle was discolored and worn out. - Two slotted stainless steel serving spoon with black handle was peeling, discolored, and partially melted. - Two scoops with black handle used for food portioning was peeling, old and worn out. - One scoop with cream handle used for food portioning was discolored, peeling, old and worn out. The RD and Chef de Cuisine acknowledged the above findings and stated the worn out and old utensils should have been replaced and discarded for infection control purposes. 2. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed the cutting boards need to be washed and sanitized between each use. Replace cutting boards once lined with knife marks and they are un-sanitizable. Color-coded cutting boards are desirable designating boards for raw products versus cooked products. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 4/14/25 at 0804 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the RD and Chef de Cuisine. The white and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The RD and Chef de Cuisine verified the findings and stated the cutting boards should have been replaced for infection control purposes.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure a copy of the advance directive was maintained in the medical record for one of three final sampled residents (Resident 5) reviewed for advance directives. This failure had the potential for Resident 5's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directive reviewed 1/2/25, showed prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence of any written Advance Directives. Further review of the P&P showed information about whether or not the resident has executed an advance directive shall be display prominently in the medical record. Medical record review for Resident 5 was initiated on 4/14/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE], and 1/16/25. Review of Resident 5's POLST dated 1/16/25, showed Resident 5's advance directive was not available. Review of Resident 5's H&P examination dated 1/17/25, showed Resident 5 had fluctuating capacity and could make needs known. Review of Resident 5's Interdisciplinary Care Conference notes dated 1/21/25, showed Resident 5's Family Member 1 stated the resident had an advance directive and would bring in a copy of the advance directive. Review of Resident 5's medical record failed to show a copy of the advance directive was maintained in Resident 5's medical record. On 4/15/25 at 1024 hours, an interview and concurrent medical record review for Resident 5 was conducted with the SSD. The SSD verified there was no copy of Resident 5's advance directive in the medical record, nor was it uploaded in Resident 5's EMR. The SSD stated Resident 5 had an advance directive and should have followed up and obtained a copy of the resident's advance directive. The SSD further stated a copy of the advance directive should have been maintained in Resident 5's medical record and should have been readily retrievable by the facility staff. On 4/16/25 at 0853 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one nonsampled resident (Resident 41). * The facility failed to ensure a physician's order was obtained, a care plan was formulated, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of a heart monitoring machine for Resident 41. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being. Findings: Review of the facility's P&P titled General Equipment Use Guidelines dated 3/4/25, showed the residents admitted with equipment to follow the manufacturer guidelines for use and management. On 4/14/25 at 0913 hours, an observation and concurrent interview was conducted with Resident 41 in her room. Resident 41 was observed with a machine on top of her bed plugged in to the electrical wall outlet and with a pillowcase on top. Resident 41 stated she had a heart condition and needed a machine to monitor her heart which automatically transmitted the data to the contracted company. Resident 41 stated she would lay down on top of the machine placed on her bed, turned on the machine, and the machine monitored her heart. Medical record review for Resident 41 was initiated on 4/15/25. Resident 41 was admitted to the facility on [DATE], with a clinical diagnosis of heart failure. Review of Resident 41 's Order Summary Report dated 4/15/25, Admission Evaluation dated 3/26/25, and Care Plan Report failed to show a documented evidence a physician's order was obtained for the use, care and maintenance of the heart monitor machine, a care plan was formulated, and the presence of Resident 41 's heart monitor machine was documented when the resident was admitted to the facility. On 4/15/25 at 0914 hours, a follow-up interview was conducted with Resident 41. Resident 41 stated she brought her heart monitor machine from home to monitor her heart and was using it every day. Resident 41 was asked if the facility staff assisted her on taking care and checking the functionality of the machine. Resident 41 stated no. On 4/15/25 at 1436 hours, an interview and concurrent medical record review for Resident 41 was conducted with LVN 3. LVN 3 was asked about Resident 41 's condition. LVN 3 verified Resident 41 had a heart problem and was receiving medication. LVN 3 was asked about Resident 41's heart monitor machine at bedside. LVN 3 acknowledged and verified she was not aware about Resident 41 's heart monitor machine at bedside. LVN 3 verified there was no physician's order, no care plan, and no documentation of the heart monitor machine were documented. LVN 3 acknowledged there should have been a physician's order obtained, care plan formulated, and documentation of the heart monitor machine. On 4/ 16/25 at 1122 hours, an interview and concurrent medical record review for Resident 41 was conducted with the DON. The DON was asked about the facility's process of the residents' own machine brought from home. The DON stated per facility's P&P, they would follow the recommendation from the manufacturer's guidelines in care and management of the machine. The DON was asked what should have been documented about the resident's machine use. The DON stated there should have been a physician's order, a formulated care plan, and an assessment for the functionality of the machine use of the resident. The DON was informed of Resident 41 's heart monitor machine at the resident's bedside with no physician's order, care plan, and assessment for the functionality of the machine documented. The DON verified the findings and stated there should have been a physician's order obtained, a care plan formulated, and an assessment for the functionality of the machine documented when Resident 41 was admitted to the facility.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 14 final sampled residents (Resident 2). * The facility failed to administer the oxygen therapy treatment as ordered by the physician for Resident 2. This failure had the potential for the resident to not receive oxygen as ordered and adequate respiratory care. Findings: Review of the facility's P&P titled Oxygen Management revised 10/28/19, showed oxygen therapy is administered to the resident only upon the written order of a licensed physician or in the event of an emergency until a physician order can be received. The licensed nurse is to check for physician's order for oxygen and liters/minute to be administered. On 4/14/25 at 0949 hours, during the initial tour observation, Resident 2 was observed lying in bed with oxygen via nasal cannula which was attached to the oxygen machine concentrator with setting noted at 1 liter per minute. During the observation, the oxygen tubing was labeled and dated; however, the nasal cannula was not placed on the resident's nares. Medical record review for Resident 2 was initiated on 4/14/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 2/8/25, showed Resident 2 had no capacity to make health care/ medical decisions; however, the resident could make simple needs known. Review of Resident 2's Order Summary Report dated 4/14/25, showed a physician's order dated 2/7/25, for oxygen at 2 liters per minute via nasal cannula every shift to keep oxygen saturation level greater than 92%. Review of Resident 2's care plan report dated 2/10/25, showed a care plan problem for altered respiratory status and the intervention included to administer oxygen at 2 liters per minute via nasal cannula. On 4/14/25 at 0949 hours, an observation and concurrent interview for Resident 2 was conducted with IP 2. IP 2 verified the oxygen setting was at 1 liter per minute and the nasal cannula was not on the resident's nares. IP 2 acknowledged the findings and placed the nasal cannula to Resident 2's nares. On 4/14/25 at 1049 hours, an interview for Resident 2 was conducted the IP 2 who stated the oxygen concentrator was replaced due to malfunction issue, and the dial to set the amount of oxygen administration was not working. On 4/17/25 at 1010 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings and stated the physician's order for the oxygen administration for Resident 2 should have been followed. On 4/17/25 at 1251 hours, an interview was conducted with the DON. The DON was informed and acknowledged all of the above findings. The DON stated the physician's order for the oxygen administration for Resident 2 should have been followed.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses followed their P&P for medication administration for three of 14 final sampled residents (Residents 9, 10, and 36). * The facility failed to ensure the physician was notified when the medication, Biotene (medication spray to relieve dry mouth, tongue, and throat) was not available for Resident 9 and missed three doses on 4/5/25, and two doses on 4/6/25. The facility failed to ensure Resident 36's IV medication Ertapenem (antibiotic administered intravenously to treat serious infections) was administered on 3/12, 3/18, 3/19, and 4/16/25. * The facility failed to ensure the physician's orders for the route of medication administration for Resident 10 were accurate. The medication route was ordered to be oral instead of via the GT. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Ordering and Receiving Medications from Pharmacy - Promptness of Availability of New Orders, page 14, showed all new drug orders other than those specified here- in, should be available the day ordered by the physician unless the drug would not normally be started until the next day. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Charting Doses Administered - General Principles, page 33, showed medications charted as unavailable should notify pharmacy, central supply as soon as possible, and/or get orders from MD to hold medication, or start when available. On 4/14/25 at 0845 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 9. Resident 9 stated she had chemotherapy for cancer and was stopped when she fell twice at home. Medical record review for Resident 9 was initiated on 4/16/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MOS dated 3/30/25, showed a BIMS score of 15, which meant Resident 9 was cognitively intact. Review of Resident 9's Order Summary Report dated 4/15/25, showed a physician's order dated 4/5/25, for Biotene dry mouth moisturizing mouth/throat solution one spray by mouth three times a day for dry mouth. Review of Resident 9's April 2025 MAR showed documentation of code 9 (chart code meaning: other/ see progress notes) on the following: - dated 4/5/25 at 0900, 1300, and 1700 hours; and - dated 4/6/25 at 0900 and 1300 hours. Review of Resident 9's progress note dated 4/5/25, showed Resident 9 complained of dry mouth, physician was made aware and ordered Biotene medication three times a day for dry mouth. The progress notes on 4/5/25 at 1214 hours and 4/6/25 at 0918 hours, showed waiting on the order and pending delivery, respectively. There were progress notes documented for the entries on 4/5/25 at 1300 hours and 1700 hours. In addition, there was no progress note documented for 4/6/25 at 1300 hours to explain the MAR documentation coded as 9. On 4/16/25 at 0920 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 9 verbalized that she was uncomfortable of her dry mouth and requested to have the Biotene medication. LVN 1 stated if the medication was not available, she will notify the physician. On 4/16/25 at 0928 hours, an interview and concurrent medical record and facility record review for Resident 9 was conducted with LVN 2. LVN 2 stated, usually if a medication was not delivered at night, she will call the pharmacy and ask when the medication will be delivered and will call the physician if the medication will not be available indefinitely. Reviewed with LVN 2 the facility's P&P on Charting Doses Administered on medications charted as unavailable showed, should notify the pharmacy or central supply ASAP, and/or get orders from the MD to hold the medications, or start when available. LVN 2 stated, But like this order of Biotene, it would not be necessary, to notify the resident's physician. On 4/16/25 at 1200 hours, an interview and concurrent medical record and facility document review for Resident 9 was conducted with the DON. The DON verified the documented entries in MAR for the Biotene medication dated 4/5 and 4/6/ 25, as not administered pending delivery and should have informed the physician as outlined in the facility's Medication P&P. 2. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Charting Doses Administered- General Principles page 33 and Charting Routine Medication Administration page 34, showed: - each dose administered to a Resident 5hall be properly recorded in the resident's medical record; - the initials of the nurse must be recorded on the front of the MAR in the proper column for the correct date and time of administration for each routine medication given. Review of Resident 36's medical record was initiated on 4/14/25. Resident 36 was admitted to the facility on [DATE]. Review of Resident 36's diagnoses showed Resident 36 had UTI as the admitting diagnosis and ESBL Resistance. Review of Resident 36's Order Summary Report dated 4/15/25, showed a physician's order dated 4/13/25, for Ertapenem (an antibiotic medication to treat infections) Sodium Solution reconstituted 1 gram intravenously every 24 hours for UTI, ESBL for 24 days. Review of Resident 36's MAR for March and April 2025 showed undocumented Ertapenem IV administration as follows: - dated 3/12, 3/18, 3/19, and 4/16/25. On 4/17/25 at 0906 hours, an interview and concurrent medical record review for Resident 36 was conducted with RN 1. RN 1 verified there was no documentation to show Resident 36 received the Ertapenem medication as ordered by the physician for 3/12, 3/18. 3/19, and 4/16/25, a total of four doses. RN 1 further stated, Let me check it out. On 4/17/25 at 0919 hours, an interview and concurrent medical record review for Resident 36 was conducted with the DON. The DON verified the missing MAR documentations for the Ertapenem medication on 3/12, 3/18, 3/19, and 4/16/25. The DON stated, It is not signed. The DON further stated what was not documented was not done or not administered and will speak to the licensed nurses. The DON also stated the licensed nurses had to document right after administering the medications. 3. Review of the facility's P&P titled Medication Administration dated 10/2018 showed the complete act of medication administration included the licensed nurse to verify the medication to the prescriber's orders. Prior to the medication administration, the licensed nurse must compare the resident's MAR to the medication label. On 4/17/25 at 0808 hours, a medication administration observation for Resident 10 was conducted with LVN 2. LVN 2 was observed administering all the medications ordered by the physician for 0900 hours via the GT to Resident 10. Medical record review for Resident 10 was initiated on 4/15/25. Resident 10 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 4/4/25, showed Resident 10 had an enteral feeding tube and had a medical diagnosis of dysphagia. Review of Resident 10's Nutritional Evaluation V6 dated 4/4/25, showed Resident 10 should have the NPO diet due to the resident's swallowing problems. Review of Resident 1 O's Order Summary Report, showed the following physician's orders: - dated 4/2/25, to administer 650 mg of Tylenol (pain medication) by mouth every four hours as needed for general pain. - dated 4/2/25, to administer 30 ml of milk of magnesia (laxative medication) by mouth as needed for bowel management daily if no bowel movement in three days. - dated 4/5/25, to administer 30 ml of pro-stat (supplement) oral liquid by mouth one time a day for skin healing. Review of Resident 10's MAR for April 2025 showed Resident 10 was administered the Pro-Stat protein supplement from 4/6 to 4/17/25 at 0900 hours, and signed for by the licensed nurses as administered via the oral route. On 4/17/25 at 0829 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 2. LVN 2 reviewed Resident 10's medical record and verified the above findings. LVN 2 stated Resident 10 had a GT, and all of Resident 1 O's medications should be administered via GT. LVN 2 further stated the ordered route for the above medications should be changed to accurately reflect the care the resident was receiving, which was to receive the medications via GT. On 4/17/25 at 0832 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 1. RN 1 reviewed Resident 10's medical record and verified the above findings. On 4/17/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings for Resident 10.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. A plan to maximize recruitment and retention of direct care staff; and 3. A contingency plan for staffing needs. These failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, showed CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included a plan to maximize the recruitment and retention of the direct care staff member, and a contingency plan for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited, to the availability of direct care nurse staffing or other resources needed for resident care. Review of the Facility's assessment dated [DATE], failed to show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. On 4/16/25 at 1454 hours, an interview and concurrent review of the Facility Assessment was conducted with Administrator. The Administrator verified there were no direct care staff, direct care representatives, residents, residents' representatives, and residents' family members actively involved in developing the Facility Assessment. The Administrator further verified there were no plan to maximize the recruitment and retention of the direct care staff or include a contingency plan for the staffing needs. The Administrator verified the Facility assessment dated [DATE], and acknowledged the Facility Assessment was not updated based on the latest update from CMS

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled resident (Resident 2) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 2 with the contracted hospice. The hospice calendar did not show complete SN and HA visits were provided as per the physician's orders. Furthermore, the facility failed to ensure staff awareness of the facility's hospice designee/coordinator. These failures posed the risk of Resident 2 not receiving the necessary hospice care and services. Findings: Review of the facility's P&P titled Palliative/End of Life Care Protocol revised 3/24/21, showed the community and hospice will identify the specific services that will be provided by each entity and this information will be communicated with the resident and family, and in the plan of care. Review of the Nursing Facility Services Agreement between the facility and Hospice Provider A with the effective date of 4/21/23, showed the following: - Inpatient Clinical Record. Facility shall maintain an inpatient clinical record for each Hospice Patient that includes a record of all Inpatient Services furnished and events regarding care that occurred at Facility. A copy of the inpatient clinical record shall be available to Hospice at the time of discharge. Review of the facility's documents showed the hospice coordinator/designee was the SSD. Medical record review for Resident 2 was initiated on 4/14/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 2/8/25, showed Resident 2 had no capacity to make health care/medical decisions; however, the resident could make simple needs known. Review of Resident 2's Order Summary Report dated 4/14/25, showed a physician's order dated 3/19/25, to admit to Hospice Provider A on routine level of care for primary hospice diagnosis of Alzheimer's disease. Review of Resident 2's care plan report dated 4/1/25, showed the interventions included Hospice Provider A staff discipline visit frequencies as follows: SN visits one time a week and three times a week as needed for symptom management and HA visits two times a week for personal care/AOL care support. On 4/17/25 at 1010 hours, an interview was conducted with LVN 1. LVN 1 was asked regarding the SN and HA visit frequency. LVN 1 stated the SN came once a week and as needed but unsure how often the HA came to the facility and visited Resident 2. LVN 1 verified the hospice calendars for March and April 2025 were not completely marked and did not show the days of SN and HA visits. LVN 1 stated the hospice calendar should have been marked accurately to know when the hospice team would see Resident 2. Furthermore, LVN 1 was asked who the facility's hospice designee/coordinator was, and responded that it was the DON. On 4/17/25 at 1251 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the facility's hospice designee/coordinator was the SSD.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. In addition, the facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection meet the McGeer's criteria for true infection. These failures posed the risk for not identifying resident infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other resident in the facility. Findings: Review of the facility's P&P titled Surveillance of Infections Protocol revised 9/24/24, showed the facility will track and trend for potential/actual infections and will monitor and take measures to prevent or minimize a potential outbreak. The Infection Control Surveillance Log is maintained by IP. The IP/DON/Designee will review the log and will trend all validated infections using the McGeer's criteria monthly. The Infection Control Committee will monitor and report to the QAPI Committee at least quarterly. 1. Review of the facility's monthly Infection Prevention and Control Surveillance Log showed inaccurate documentation for January and February 2025: For January 2025, the total number of residents who were screened as HAI were 13 and CAls were 13. In addition, the total number of the residents who did not met the criteria for true infection were 10. However, the Infection Control Monthly Summary for January 2025 showed the total number of the residents who were assessed as HAis were nine and GAis were six. The total number of the resident who did not met the criteria for true infection was five. The data from the surveillance log did not match to the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for January 2025. For February 2025, the total number of the residents on the surveillance log who were screened as HAi's were nine and GAis were 15. In addition, the total number of the residents who did not met the criteria for true infection were 14. However, the Infection Control Monthly Summary for February 2025 showed the total number of the residents who were assessed as HAis and GAis had no data reported. The total number of the residents who did not met the criteria for true infection was five. The data from the surveillance log did not match with the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for February 2025. 2. Review of the facility document titled Surveillance Data Collection Form for Residents 47, 98,445, and 447 showed the following information: For Resident 47, the Surveillance Data Collection Form dated 1/15/25, showed Resident 47 was administered with Flagyl (antibiotic) 500 mg every 12 hours for three days and cefuroxime (antibiotic) 250 mg by mouth every 12 hours for three days for pneumonia. The McGeer's criteria were met; however, the Surveillance Data Collection Form failed to show if Resident 47 had HAI or CAI. For Resident 98, the Surveillance Data Collection Form dated 2/3/25, showed Resident 98 was administered with cefuroxime (antibiotic) 500 mg by mouth every 12 hours for two days for UTI. The McGeer's criteria were not met; however, the Surveillance Data Collection Form failed to show if Resident 98 had HAI or CAI. For Resident 445, the Surveillance Data Collection Form dated 2/6/25, showed Resident 445 was administered with Flagyl (antibiotic) 500 mg every 12 hours for three days and Macrobid (antibiotic) 100 mg by mouth twice a day for seven days for UTI. The McGeer's criteria were met; however, the Surveillance Data Collection Form failed to show if Resident 445 had HAI or CAI. For Resident 447, the Surveillance Data Collection Form dated 1/29/25, showed Resident 447 was administered with Fluconazole (antibiotic) 100 mg tablet once a day for five days for UTI. The McGeer's criteria were met however, the Surveillance Data Collection Form failed to show if Resident 447 had HAI or CAI. On 4/17/25 at 0841 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she used the McGeer's criteria to determine for a true infection for the residents. The IP stated the infection control summary was reported to the QAPI and used to determine the trend of the infection rate in the facility. The IP was informed of the reported numbers for the HAI and CAI on each month from the surveillance log not matching with the total numbers on the infection control monthly summary report for January and February 2025. The IP verified the numbers were inaccurate. The IP stated the numbers of the infection should have matched to the monthly summary report to ensure an accurate information about the infection control of the facility. The IP was asked to review the Surveillance Data Collection Form for Residents 47, 98, 445, and 447. The IP verified and acknowledged the forms were incomplete. On 4/17 /25 at 1253 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' medical records were safeguarded to protect the confidential health information of the residents in the facility. This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users. Findings: Review of the facility's P&P titled Privacy, Electronic Data Security dated 11/2017 showed the protection of all the resident's data is the responsibility of the facility and shall be protected from accidental or malicious destruction, disclosure, or modification. The facility's workstation security must place the display screens and keyboards devices in a way access is limited/restricted and not in public view. Log-off when leaving the terminal. On 4/14/25 at 1211 hours, during the initial tour of the facility, Nurses' Station A was observed with a laptop on top of the medication cart turned on with the residents' information available to be viewed and read. The medication cart was placed in the hallway unattended and there was no licensed nurse present near the medication cart. The other facility staff, residents, and residents' visitors were observed passing by the medication cart in the hallway with the computer screen left turned on, opened, and unattended. On 4/14/25 at 1219 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 was observed attending to the medication cart located in Nurses' Station A and noticed the laptop on top of the medication cart was opened. LVN 5 stated, Why was the computer opened and who opened it? LVN 5 verified the laptop was opened and stated the computer screen should have been closed for privacy. LVN 5 acknowledged she should have been very careful not to leave the medication cart computer screen open for privacy issue. On 4/16/25 at 1129 hours, an interview and concurrent facility P&P review was conducted with the DON. The DON was informed of the observation of the electronic medical record on the medication cart left opened and unattended. The DON verified and acknowledged the above findings

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 14 final sampled residents (Resident 7) was accurate. * The facility failed to ensure Resident 7's information on the POLST form related to the Advanced Directive was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate. Findings: Review of facility's P&P titled Record Content dated 11/2017, showed the complete entries must be accurate. Medical record review for Resident 7 was initiated on 4/15/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's POLST dated 9/12/24, showed under Section D -Information and Signatures, the box for the Advance Directive not available was checked. On 4/15/25 at 1001 hours, an interview and concurrent medical record review for Resident 7 was conducted with the SSD. The SSD stated Resident 7 had an Advance Directive which was uploaded in the resident's EMR on 9/17/24. The SSD stated Resident 7's POLST Section D was inaccurate, and the box for Advance Directive was available and reviewed should have been checked and dated to reflect the accuracy of Resident 7's current medical record. The SSD verified the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the meat thawing process was followed. * The facility failed to ensure the expired food was discarded. * Time/Temperature Control for Safety (TCS) foods (food that required time and temperature controls to limit the growth of illness causing bacteria) were not monitored to ensure the proper cool down process was followed. * Two of two ice machines were not clean. * The facility failed to ensure hair and beard restraints were worn by dietary personnel inside the main kitchen. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure a storage container was free of a scoop. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the drying rack was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated [DATE], showed 40 of 40 residents residing in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section ,d+[DATE].13, Thawing, showed freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/ or produce toxins. Review of the facility's P&P titled Meat Cookery and Storage revised [DATE], showed the meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees Fahrenheit (F) or less. Date meat when pulled for defrosting. Review of facility's P&P titled Food Storage revised [DATE], showed all products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. Any expired or outdated food products should be discarded. Date meat when taken out of freezer. Follow meat pull schedule when available in menu program. On [DATE] at 0830 hours, during the initial tour of the kitchen, an observation of the walk-in refrigerator and concurrent interview was conducted with the FNSD. The following items were observed: - 51 lbs of chicken breasts with no use by date or freezer pull date; - 40 lbs of chicken thighs with a received date of [DATE], but with no use by date or freezer pull date; - 12 lbs. of turkey breasts with a received date of [DATE], but with no use by date or freezer pull date; - two 12 lbs. of sealed packs of beef tenderloin with a received date of [DATE], but with no use by date or freezer pull date; and - two boxes of 10 lbs of cod fish with no use by date or freezer pull date. All food items were completely thawed. The FNSD stated the food from the freezer in the process of thawing should be labeled with the received date, use by date, and freezer pull date. The FNSD verified the above findings. 2. According to U.S. Food and Drug Administration, the fresh poultry (chicken and turkey whole and parts) should be kept in the refrigeration for one to two days. These short but safe time limits will help keep refrigerated food to 40 degrees F from spoiling or becoming dangerous. Review of the facility's P&P titled Food Storage revised [DATE], showed all products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. Any expired or outdated food products should be discarded. Review of the facility's P&P titled Meat Cookery and Storage revised [DATE], showed the meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees F or less. Date meat when pulled for defrosting. On [DATE] at 0830 hours, during the initial tour of the kitchen, an observation of the walk-in refrigerator was conducted. 51 lbs of completely thawed chicken breasts with no received date, no use by date, and no freezer pull date was observed. 40 lbs of completely thawed chicken thighs with the received date of [DATE], had no use by date and no freezer pull date observed. On [DATE] at 1015 hours, an observation of the walk-in refrigerator was conducted with the Chef. The 40 lbs of chicken thighs with the received date of [DATE], and with no use by date and no freezer pull date observed on [DATE], were still stored in the walk-in refrigerator. The Chef stated the chicken thighs were never stored in the freezer but put directly in the walk-in refrigerator when received. The Chef further stated normally, the chicken breasts were stored upon receipt in the freezer, then transferred to the refrigerator and thawed. When asked what happened to the undated chicken breasts observed on [DATE], the Chef stated the chicken breasts had been transferred to the cook's preparation refrigerator for dinner service on [DATE]. When asked, the Chef stated he was not sure what the shelf life of the raw chicken was. The Chef checked the posted facility guidelines titled Refrigerated Storage Chart revised [DATE], for the fresh meat, fish, and poultry. The Refrigerated Storage Chart showed unopened fresh chicken was good for two days in the refrigerator. On [DATE] at 1020 hours, the undated chicken breasts observed on [DATE], were observed in the cook's preparation refrigerator, unpacked in a tray, and covered with a plastic wrap. The chicken breasts were labeled with a preparation date of [DATE], and a use by date of [DATE] for dinner. On [DATE] at 1027 hours, an interview was conducted with the FNSD. The FNSD stated she thought the 51 lbs. of thawed chicken breasts and 40 lbs. of thawed chicken thighs had been discarded on [DATE]. The FNSD discarded the chicken breasts prepared in a tray and the 40 lbs. of chicken thighs. 3. According to the USDA Food Code 2022, Section ,d+[DATE].14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less. On [DATE] at 1003 hours, an interview was conducted with Cook 3 and the Chef. Cook 3 stated the chicken would be cooked to use for the chicken salad as a meal alternative. Cook 3 stated they did not have a cool down log to monitor the cool down process. The Chef stated they cooked the chicken in the oven, put the cooked chicken and other salad ingredients in the robot coupe (a device to mince or puree meat) to blend, then stored the chicken salad in the refrigerator. The Chef further stated they did not monitor the temperature of the chicken salad. A clip board with more than 20 blank forms titled Cooling Monitoring Forms were observed posted in the kitchen. 4. According to the USDA Food Code 2022, Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Ice Machine Service revised [DATE], showed the unit is to be cleaned and sanitized per manufactory guidelines as posted on machine on a quarterly basis to ensure that the unit is free of scale and lime buildup. If needed, unit can be cleaned on a more frequent basis. On [DATE] at 0945 hours, an observation of Ice Machine 1 located in the main kitchen and concurrent interview was conducted with the Plants Operation Manager and the Maintenance Technician. Ice Machine 1 was observed with a slimy yellow residue on the ice machine deflector (a device that directs ice from the machine into the ice storage bin) and on the groove in front of deflector when wiped with white paper towel. A yellow-white crusty residue was also observed surrounding the ice chute (area where ice is dispensed into the ice storage bin). The Plants Operation Manager stated the ice machine was cleaned every six months. The Plants Operation Manager stated they would work on cleaning the ice machine. On [DATE] at 1005 hours, an observation of Ice Machine 2 located in the nourishment station and concurrent interview was conducted with the Maintenance Technician. The interior frame of the ice machine door had a clear plastic-like residue. The clear plastic-like residue came off when wiped with a white paper towel. The Maintenance Technician stated the clear plastic-like residue was a silicon sealant. The Maintenance Technician further stated he would close Ice Machine 2 and remove the plastic residue. 5. According to the USDA Food Code 2022, Section ,d+[DATE].11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/Food Handling/ Infection Control revised [DATE], under the Head Covering Worn section, showed the following: - Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. - Head covering must be clean. - Beards, mustaches, or any body hair that maybe exposed must be covered. On [DATE] at 0820 hours, during the initial tour of the kitchen, Cook 1 was observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. On [DATE] at 0955 hours, Cooks 2 and 3 were observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair while pureeing resident's food. On [DATE] at 1150 hours, during the lunch meal tray line service, the Chef, Cooks 1, 2, and 3 were observed with uncovered facial hair. The Chef, Cooks 1, 2, and 3 were observed to wear a baseball cap with exposed hair at the back of their head. On [DATE] at 1003 hours, during an interview in the kitchen, Cook 3 was observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. On [DATE] at 1015 hours, an interview was conducted with the Chef. The Chef was noted to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. The Chef stated he was not aware a hair restraint was required if a baseball cap was worn. The Chef further stated he ordered beard restraints in the past but no longer ordered beard restraints. 6. According to the USDA Food Code 2022, Section ,d+[DATE].12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. According to the USDA Food Code 2022, Section ,d+[DATE].11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. On [DATE] at 0845 hours, during the initial tour of the kitchen and concurrent interview with the FNSD, the following items were observed: - two large and one small frying pans with thick black residue buildup on the cooking surface; - four muffin pans with a crusty thick black residue buildup on interior surface; and - three cutting boards were heavily marred with knife marks. The FNSD verified the above findings and stated they would throw the food equipment. 7. Review of the facility's P&P titled Food Storage under Dry Storage section revised [DATE] showed to remove food stored in bins from their original packaging, label and date all storage containers or bins and keep free of scoops. On [DATE] at 1031 hours, during the pureed meal preparation observation, Cook 2 left the spoon used for scooping the thickener in the container after touching it with gloved hands and touching multiple unclean surfaces. On [DATE] at 1040 hours, an interview was conducted with the Chef. The Chef stated the spoon used for scooping should never be left in the food container. He acknowledged the above findings. 8. Review of the facility's P&P titled Food Storage under Dry Storage section revised [DATE] showed any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated. On [DATE] at 0840 hours, during the initial tour of the kitchen, an observation of the dry storage area was conducted with the FNSD. A chicken base plastic container was observed with the cover not sealed. The FNSD stated the product was open and she tried to close the cover, but it did not seal. The FNSD stated it was not good and she would discard the chicken base. 9. According to the USDA Food Code 2022, Section ,d+[DATE].11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. Review of the facility's P&P titled Dry Storage-Dishes and Utensils revised [DATE], showed the dishes must be stored to promote air drying that is to use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. On [DATE] at 0845 hours, during the initial tour of the kitchen with the FNSD, the robot coupe and blender were observed to be stored with the top on, and the inside of each equipment was still wet. The FNSD verified the findings and stated the equipment were not air dried properly. 10. Review of the facility's P&P titled Food Storage, under the Meat/Poultry and Foods section, revised [DATE], showed the food should be stored in their original containers if designed for freezing. Food to be frozen should be stored in airtight containers or wrapped in heavily-duty aluminum foil or special laminated papers. The P&P also showed to label and date all food items. On [DATE] at 0820 hours, during the initial tour of the kitchen, an observation of the walk-in freezer and concurrent interview was conducted with Cook 1. One box of cookies gourmet sugar was observed with an opened interior plastic bag. The cookies appeared freezer burned (a condition caused by air reaching the surface of the food). The box was not labeled with an open date. Cook 1 stated the cookies were no longer good. 11. According to the USDA Food Code 2022, Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. According to the USDA Food Code 2017, Section ,d+[DATE].13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On [DATE] at 0845 hours, during the initial tour of the kitchen, the drying rack was observed with yellow and black debris. The FNSD verified the findings.

Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Resident 33) was accurately assessed as being capable to self-administer the medications. * Resident 33 had the nasal spray bottle left on his overbed table and self-administered the nasal spray. This failure had the potential for unsafe medication administration. Findings: Review of the facility's P&P titled Self-Administration of Medications dated 10/24/23, showed as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident. On 4/2/24 at 0900 hours, one opened bottle of 30 ml oxymetazoline hydrochloride (afrin) nasal spray was observed on Resident 33's overbed table. Resident 33 stated he had been using the medication one time every day to help relieve his stuffy nose. Medical Record Review for Resident 33 was initiated on 4/2/24. Resident 33 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 33 had BIMS score of 9 (moderately impaired). Review of Resident 33's physician's orders for April 2024 showed no order for nasal spray. Review of Resident 33's Assessments for Self-Administration of Medications dated 3/20/24, showed the question asking if the resident expressed an interest in the self-administration of medication with the answer no. On 4/2/24 at 0925 hours, an interview and concurrent medical record review was conducted LVN 4. LVN 4 stated he was unaware the nasal spray bottle was at the bedside. Resident 33 was not assessed for self-administration of the medication and no care plan was developed for the administration of the nasal spray. LVN 4 stated there was no physician's order for the nasal spray administration. LVN 4 verified the findings.

Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the notification of change for one of one resident reviewed for weight loss (Resident 14). This failure resulted in a delay of Resident 14's significant weight loss being communicated to the resident's physician, responsible party, and RD, which had the potential to negatively impact the resident's well-being. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs. in one month. The P&P also showed the following tasks at the time of identification of weight loss: - A referral is made to dietary. - The physician is notified of the weight loss. - Notification to the resident's family. Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was initially admitted to the facility on [DATE], discharged to the acute care hospital on 3/21/24, and readmitted to the facility on [DATE]. Review of Resident 14's Weight and Vitals Summary dated 4/4/24, showed the following weights: -On 2/23/24, a weight of 142.6 lbs. -On 2/28/24, a weight of 140 lbs. -On 3/7/24, a weight of 140.8 lbs. -On 3/15/24, a weight of 140 lbs. -On 3/26/24, a weight of 0.0 lbs. -On 3/29/24, a weight of 132.4 lbs. (a 5.4% and 7.6 lbs. weight loss from 2/28/24) -On 4/3/24, a weight of 131.6 lbs. (a 6.5% and 9.2 lbs. weight loss from 3/7/24, and a 7.7% and 11 lbs. weight loss from 2/23/24) Review of Resident 14's medical record failed to show the resident's physician, responsible party, and RD were notified of the resident's weight loss. On 4/4/24 at 0929 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 14's weights and verified the resident's weight was triggered for a weight loss of more than 5% on 3/29/24. RN 1 verified Resident 14's medical record failed to show the resident's change of condition for weight loss was reported to the resident's physician, responsible party, and the RD. On 4/4/24 at 1128 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for a significant weight change, the charge nurse or clinical nurse supervisor should notify the physician, RD and resident's responsible party once the weight change was identified. The DON reviewed Resident 14's medical record and verified the resident's weight loss on 3/29/24, was not reported to the resident's physician, responsible party, and RD once it was identified, and should have been.

Based on observation, interview, and facility P&P review, the facility failed to ensure services provided met the professional standards of care for one when LVN 4 failed to properly take a blood pressure for one nonsampled resident (Resident 543). This failure posed the risk for not obtaining accurate blood pressure reading for this resident. Findings: Review of the facility's P&P titled Blood Pressure, Measuring dated 10/2010 showed the purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins, and chambers of the heart. The policy further showed to expose the resident's arm by rolling the sleeve up about five inches above the elbow. When locating the pulsation, place the diaphragm of the stethoscope firmly against the skin, and hold the diaphragm in place with hand. On 4/3/24 at 0813 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 took Resident 543's blood pressure prior to the administration of metoprolol (antihypertensive medication). LVN 4 wrapped the blood pressure cuff on the resident's left upper arm and placed the diaphragm of the stethoscope on the left brachial artery over Resident 543's sweater. On 4/3/24 at 0834 hours, an interview was conducted with LVN 4. LVN 4 verified the resident's sleeve should have been pulled up and the diaphragm of the stethoscope should have been placed on the skin. On 4/3/24 at 1424 hours, an interview was conducted with the DON. The DON verified the blood pressure cuff and diaphragm of the stethoscope were to be placed on the skin when taking a blood pressure.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of one resident reviewed for weight loss (Resident 14). This failure had the potential to result in continued nutritional decline and negative outcomes. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs. in one month. The P&P also showed the following tasks at the time of identification of weight loss: - A referral is made to dietary. - The Nutritional Services Director and/or the Registered Dietician (RD) will complete an assessment Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was initially admitted to the facility on [DATE], discharged to the acute hospital on 3/21/24, and readmitted to the facility on [DATE]. Review of Resident 14's Weight and Vitals Summary dated 4/4/24, showed the following weights: - On 2/23/24, a weight of 142.6 lbs. - On 2/28/24, a weight of 140 lbs. - On 3/7/24, a weight of 140.8 lbs. - On 3/15/24, a weight of 140 lbs. - On 3/26/24, a weight of 0.0 lbs. - On 3/29/24, a weight of 132.4 lbs. (a 5.4% and 7.6 lbs. weight loss from 2/28/24) - On 4/3/24, a weight of 131.6 lbs. (a 6.5% and 9.2 lbs. weight loss from 3/7/24, and a 7.7% and 11 lbs. weight loss from 2/23/24) Review of Resident 14's Nutritional Screen V3.1 - 101 evaluation dated 3/28/24, showed the resident was noted to have decreased PO (oral) intake since readmission; however it was improved on 3/28/24. The plan was to increase the resident's health shakes from twice a day to three times a day. Review of Resident 14's Nutritional Evaluation V6-103 dated 3/29/24, showed the resident's admission weight listed for the previous admission's weight was 140 lbs on 3/15/24. The most recent weight was listed as 0.0 lbs on 3/26/24. The evaluation showed Resident 14's ideal weight range was 139-169 lbs. The summary note showed the resident was now receiving health shakes three times a day to provide an additional 600 calories and 18 grams of protein a day. The note showed there were no recommendations at the time, and to monitor the resident's weights for significant changes. Review of Resident 14's Nutritional Services Note dated 3/29/24, showed the resident returned from a recent hospitalization and the resident's weight was 140 lbs. on 3/15/24. The document showed the resident was at a healthy weight with a target maintenance goal weight of 135-145 lbs. Resident 14's medical record failed to show the nutritional services or RD's intervention after the resident's weight loss was identified. Review of the facility's Report of Dietary Consultant Visit dated 4/3/24, showed a list of the residents that the RD saw and showed the RD calculated the monthly and weekly weight variances. The document failed to show Resident 14 was reviewed by the RD. On 4/4/24 at 0929 hours, an interview and concurrent record review was conducted with RN 1. RN 1 stated the RNA weighed the residents, entered the weight on a paper log, and gave the weight log to the desk nurse who would then enter the weights in the electronic health record. RN 1 stated herself and the RD had a weekly Nutritional At Risk (NAR) meeting every Wednesday and reviewed all the residents triggered with weight changes. RN 1 stated the last NAR was done on 3/27/24, and yesterday's review was rescheduled for today, since the RD was on vacation. RN 1 reviewed Resident 14's weights and verified the electronic health record (EHR) triggered the resident for weight loss. When asked if there was any documentation to show Resident 14's weight loss was reported and addressed, the RN stated no. RN 1 stated they would discuss it at today's NAR meeting. On 4/4/24 at 1128 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the process for the residents readmitted from the acute care hospital was to be weighed on readmission or the day after. The DON verified Resident 14 was readmitted on [DATE], and the first recorded weight was on 3/29/24. The DON stated there was nothing in the resident's record to show they refused their weight being checked. The DON stated significant weight changes should be addressed within that week since the RD made rounds weekly. The DON stated the RD covering for the regular RD's vacation saw the residents yesterday. The DON reviewed the RD's packet given to her by the RD and verified Resident 14 was not seen. The DON reviewed Resident 14's medical record and verified there was nothing to show the resident's weight loss was addressed. On 4/24/24 at 1201 hours, an interview and concurrent medical record review was conducted with RD 1. RD 1 stated they usually were at the facility every Monday and Wednesday, but they were on vacation from 3/30/24-4/3/24, and another RD covered for them. RD 1 stated the covering RD came in on Wednesday, 4/3/24, and RD 1 was planning on coming in on Friday 4/5/24, to see the residents. RD 1 sated their usual process was to come in twice a week, run a weight report with the EHR system to identify residents with weight changes, with a 3 lbs weight change being the standard. RD 1 stated Resident 14's weight loss should have been on the weight report yesterday for the covering RD to know to review the resident.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 26) reviewed for oxygen use was provided with the appropriate respiratory care. The facility failed to ensure Resident 26's oxygen tubing was labeled and not touching the floor. These failures had the potential to affect the respiratory health and well-being of Resident 26. Findings: Review of the facility's P&P titled Oxygen Management revised 5/31/21, showed the oxygen is administered under orders of the attending physician, except in the case of an emergency. The general guidelines concerning oxygen safety during oxygen administration include nasal cannulas, masks and tubing should be changed every seven days, dated, time and initialed. On 4/2/24 at 1023 and 1548 hours, Resident 26 was observed wearing a nasal cannula attached to a portable oxygen tank with a setting of one liter per minute. Part of the oxygen tubing was observed touching the floor. Medical record review for Resident 26 was initiated on 4/2/24. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report dated 4/3/24, showed a physician's order dated 3/27/24, to administer oxygen at one to three liters per minute via nasal cannula every shift to keep the oxygen saturation level greater than 92%. Another physician's order dated 2/20/24, showed to change the oxygen nasal cannula every Sunday night or as needed when in use. On 4/3/24 at 1010 hours, an observation and concurrent interview for Resident 26 with RN 1 was conducted. Resident 26 was observed in the activity room wearing a nasal cannula with the oxygen setting at two liters per minute. RN 1 verified Resident 26 was on oxygen therapy. RN 1 was asked when the oxygen tubing was last changed. RN 1 stated the facility had an order for the oxygen tubing to be changed every Sunday and as needed. RN 1 verified there was no label on the resident's oxygen tubing. Also, the part of the oxygen tubing was observed on the floor. RN 1 stated the oxygen tubing should have been labeled and not touched the floor. On 4/4/24 at 1104 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the above findings and was verified.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 13 final sampled residents (Resident 13). * The facility failed to ensure Resident 13's oxycodone-acetaminophen (narcotic pain medication) was accurately reconciled. The oxycodone-acetaminophen tablets removed as shown on the Controlled Drug Record was not recorded as administered on the electronic MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Controlled Drugs revised 10/2018 showed each dose removed from the supply of controlled drugs shall be signed, dated, and timed out on the proof of count sheet on the line representing that particular dose prior to resident administration. Nurses must sign out, not just initial. Proof of count sheets shall be easily accessible by the medication nurse. Medical record review for Resident 13 was initiated on 4/2/24. Resident 13 was admitted to the facility on [DATE]. Review of the Internal Medicine H&P examination dated 3/1/24, showed Resident 13 had the capacity to understand and make decisions. Review of the Order Summary Report dated 4/3/24, showed a physician's order dated 3/14/24, to administer oxycodone-acetaminophen 10-325 mg one tablet by mouth every four hours as needed for moderate to severe pain. On 4/3/24 at 1119 hours, a controlled medication reconciliation for Resident 13 was conducted with LVN 3. Review of Resident 13's Controlled Drug Record showed oxycodone-acetaminophen was signed out on 3/30/24 at 1322 hours, and 4/1/24 at 1400 hours. Resident 13's medication bubble pack (a package used to dispense medication) for oxycodone-acetaminophen showed 15 tablets remaining, which matched with the number of oxycodone-acetaminophen tablets in the Controlled Drug Record. However, review of Resident 13's electronic MARs for March and April 2024 failed to show documented evidence the oxycodone-acetaminophen was administered to Resident 13 on 3/30/24 at 1322 hours, and 4/1/24 at 1400 hours, as shown in the Controlled Drug Record. LVN 3 verified the above finding. On 4/3/24 at 1411 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding. The DON stated the licensed nurses should sign both the Controlled Drug Record and MAR.