Every finding on record at Pacific Coast Post Acute

Based on interview and record review the facility failed to ensure one of three residents (Resident 1) met the care and services according to professional healthcare standards of practice when:1. An assessment to determine the continued need for Eliquis (Apixaban, a medication that is used to prevent blood clots) for Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not conducted following the discontinuance related to nosebleed on 10/31/24 was not done. Eliquis not given since 10/31/24 through 7/13/26;2. Resident 1 did not have a follow-up appointment with Cardiology (a medical specialty focused on diagnosing, treating and preventing health diseases) after 1/6/25;3. Resident 1 missed seven doses of Eliquis and six doses of Plavix (Clopidogrel, antiplatelet medication to prevent harmful blood clots) for multiple days.These failures put Resident 1 at risk for stroke (lack of blood flow to a part of the brain), and blood clots that could jeopardize Resident 1's health and well-being.Findings:1. Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE].Review of Resident 1's History and Physical (H&P), dated 1/23/23, indicated Assessment: underwent interventional radiology assisted stenting of aneurysmal left popliteal artery (image-guided technique to place a tiny metal and fabric tube inside a dangerous, bulging weak spot in the main blood vessel behind the knee, fixing a problem without open surgery). Chronically occluded left anterior tibial and posterior tibial arteries (the two main blood vessels running down the left lower leg were completely blocked by long-standing plaque buildup restricting blood flow) and on Eliquis. Paroxysmal atrial fibrillation [an irregular and often very rapid heart rhythm that can lead to blood clots in the heart]: Rate controlled, patient not on medication for rate control. Patient maintained on Eliquis, patient followed by cardiology as an outpatient.Review of Resident 1's Order Summary Report, dated 1/20/23, indicated an order of Apixaban [Eliquis] oral tablet 2.5 mg (milligram, unit of measurement) Give 1 tablet by mouth two times a day for Atrial Fibrillation.Review of Resident 1's Cardiology visit report, dated 3/20/23, indicated Plan:.I will continue Eliquis 2.5 mg twice daily for secondary stroke (when a person who already survived one stroke has another one later in life) prevention.He takes Plavix (Clopidogrel, antiplatelet [a medication that makes blood cells called platelets less sticky] medication to prevent harmful blood clots) 75 mg daily on top of Eliquis 2.5 mg twice daily without bleeding. I will continue current management.Review of Resident 1's Health Status Note, dated 11/6/23, indicated MD [Medical Doctor] reviewed resident's medication and ordered to d/c [discontinue] Eliquis d/t [due to] nose bleeding.Review of Resident 1's Report of Consultation, dated 5/7/24, indicated Please ensure patient is taking Eliquis 2.5 mg twice a day as well as Plavix 75 mg daily.Review of Resident 1's physician's order, dated 5/7/24, indicated Eliquis 2.5 mg tablet. Give 1 tablet by mouth two times a day.Review of Resident 1's physician's order, dated 10/31/24, indicated Eliquis discontinued 10/31/24 1730; reason for discontinue: dc [discontinue], nose bleeding.Review of Resident 1's Cardiology visit report, dated 1/6/25, indicated Plan: Paroxysmal atrial fibrillation: No palpitations [feeling the heartbeat when usually cannot]. He is in normal rhythm today. I will continue current management and monitor his heart rhythm and symptoms.I will continue Eliquis 2.5 mg twice daily for secondary stroke prevention.He takes Plavix 75 mg daily on top of Eliquis 2.5 mg twice daily. He denies claudication. I will continue current management. Follow up in about 6 months (around 7/6/25).During a concurrent interview and record review with the Nursing Supervisor (NS), on 7/31/26 at 2:28 p.m., the NS confirmed that Resident 1's Eliquis was ordered on admission on [DATE] and was discontinued on 11/6/23 due to nose bleeding. The Eliquis was re-ordered on 5/7/24 after the cardiology visit. Eliquis then discontinued on 10/31/24 due to nosebleed.During a telephone interview with the Primary Care Physician (PCP), on 8/3/26 at 1:11 p.m., the PCP stated he did not know that a cardiologist was following Resident 1. The PCP also stated that he would follow the recommendation of the cardiologist to restart the Eliquis. The PCP further stated that he would rely on the cardiologist.During a concurrent telephone interview and record review with the NS, on 8/6/26 at 10:51 a.m., Resident 1's cardiology visit report on 1/6/25, indicated .I will continue Eliquis 2.5 mg twice daily for secondary stroke prevention.Review of Resident 1's Physician Progress Notes, dated 12/1/25, indicated Plan: Continue Eliquis.During a telephone interview with the NS, on 8/7/26 at 11:04 a.m., the NS stated the medical record of Resident 1 was sifted through [searched] and there was no order placed to continue Eliquis.During a concurrent interview and record review with the Pharmacy Consultant (PC), on 8/7/26 at 1 p.m., the PC stated he looked at the entire medical record of Resident 1 during monthly review. The PC stated he knew that Eliquis was discontinued on 10/31/24 and was not restarted. The PC further stated that he was aware that the Eliquis was for Resident 1's atrial fibrillation.During a concurrent interview and record review with the PC, on 8/7/26 at 2:01 p.m., the PC stated he has no recommendation to restart the Eliquis. The PC also stated Resident 1 would be at risk for stroke while not on Eliquis.Review of Resident 1's Health Status Note, dated 7/14/26, indicated Resident 1 was transferred to an acute care facility (ACF).Review of Resident 1's ACF's Hospitalist (a doctor who only works inside a hospital) H&P, dated 7/14/26, indicated Paroxysmal atrial fibrillation history-will plan to resume DOAC [direct oral anticoagulant, oral medications used to prevent and treat blood clots] once confirmed.Review of Resident 1's ACF Hospitalist progress note, dated 7/15/26, indicated Assessment & Plan: Fortunately patient is conversant and appears to be coughing less. He developed atrial fibrillation with controlled rate unfortunately also concurrently developed hypotension [low blood pressure] that is thought to be secondary to worsening pneumonia [infection of the lungs] and concurrent sepsis [body's extreme and potentially dangerous response to infection] . Consult cardiology recommended IV [Intravenous, within a vein] heparin [anticoagulant medication] drip [continuous delivery of the medication]; IV amiodarone [a medication that prevents and treats an irregular heartbeat] . Will need to confirm DOAC. Has not been on Eliquis since 2024, unclear why discontinuedReview of Resident 1's ACF's Cardiologist Progress Note, dated 7/17/26, indicated His prior cardiologist was [name of provider] who last saw him in January 2025, who started him on Eliquis 2.5 mg BID [twice a day], and BB [beta blocker, a type of heart medication] for rate control. Prior stroke likely related to paroxysmal AF [atrial fibrillation]. Eliquis was not being given at his care facility. Initially presented to ACF in NSR [normal sinus rhythm, normal heartbeat] but developed atrial fibrillation with a controlled ventricular response [heart rate that stays under 100 beats per minute at rest]. For some reason he has not been taking Eliquis 2.5 mg twice daily at his care facility. He developed atrial fibrillation the day after admission.continue Amiodarone 200 mg every day. Continue Eliquis 2.5 mg BID. If he remains in AF, we are not concerned and will treat for rate management.Review of Resident1's ACF's Hospitalist Discharge summary, dated [DATE], indicated Paroxysmal atrial fibrillation, rate controlled at this point. Continue Eliquis.Review of the facility's policy and procedure (P&P), titled Anticoagulation - Clinical Protocol, undated, indicated As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of deep vein thrombosis (DVT, a blood clot inside a blood vessel), or heart valve replacement, atrial fibrillation or those who have had recent joint replacement surgery. The staff and physician will identify situations where an individual is not anticoagulated but where anticoagulation may be indicated; for example, new onset deep vein thrombosis (DVT), or new or previously unrecognized carotid artery stenosis (narrowing of the main blood pipes) or atrial fibrillation.Review of the facility's undated (P&P), titled Medication Regimen Review, indicated a licensed Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The purpose of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities, for example, the use of medication.According to the National Institutes of Health's (NIH) National Library of Medicine 2025 Guidelines for direct oral anticoagulants: a practical guidance on the prescription, laboratory testing, peri-operative [around the time of surgery] and bleeding management, dated 5/31/25, indicated DOACs [direct oral anticoagulants] are indicated for the prevention of stroke and systemic embolism [a piece of a blood clot that breaks loose from one part of the body and travels through the blood vessels that get stuck cutting off blood flow] in patients with atrial fibrillation (AF), chronic stable atherosclerotic disease, the treatment of new deep vein thrombosis and pulmonary embolism [blood clot in the lungs], and secondary prevention of VTE [venous thromboembolism], as well as the prevention of venous thrombosis in hip and knee arthroplasty [stopping new blood clots from forming or keeping existing small clots from growing larger after surgery].Anticoagulation can be resumed 1-6 weeks after major bleeding, depending on individual bleeding and thrombosis risk.According to the Journal of the American College of Cardiology's (JACC) 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee, dated 7/14/20, indicated Irrespective of severity, local measures should be employed where possible to control any bleeding. For patients with a nonmajor bleed, the writing committee does not support routine reversal of the OAC [oral anticoagulant], although it is often advisable to temporarily discontinue OAC therapy until the patient is clinically stable and hemostasis [the body's process of stopping bleeding after an injury] has been achieved. Determining whether the OAC should be temporarily held in a patient with a nonmajor bleed depends upon individual patient characteristics, the nature of the bleed, and the intensity of anticoagulation; should follow discussion with the patient and/or family as part of shared decision making.If it is determined that the patient does not require hospitalization, a procedure, or a transfusion [a medical procedure where fresh blood is slowly put into a person's body through a tube in the vein] , and hemostasis has been achieved, the writing committee supports continuing the OAC. If these patients are on concomitant antiplatelet agents [taking two or more clot-preventing medicines at the same time], the risk versus benefit of stopping these drugs should be weighed, although it may be reasonable to continue both.2. Review of Resident 1's Health Status Note, dated 7/5/24, indicated Follow up on 1/6/25 at 10:30 with [name of specialist provider] was scheduled.Review of Resident 1's Health Status Note, dated 7/14/25, indicated .Transportation brought resident to cardiology clinic and was told that appointment was rescheduled to 8/11/25 at 2:30 p.m.Review of Resident 1's Health Status Note, dated 8/13/25, indicated Pt [patient] will have appt [appointment] on 10/9/25 with cardiologist.During a concurrent telephone interview and record review of Resident 1's medical record, with the NS on 8/5/26 at 3:02 p.m., the NS confirmed Resident 1 was not on Eliquis when PCP took over the care of Resident 1 on 11/3/25.During a concurrent telephone interview and record review of Resident 1's medical record, with the NS, on 8/5/26 at 3:41 p.m., the NS stated there was no documentation that Resident 1 attended the cardiology appointment on 10/9/25.During a telephone interview with the NS on 8/6/26 at 3:56 p.m., the NS stated the appointment scheduler resigned in 3/2026. Unable to be interviewed.During a telephone interview with the NS, on 8/7/26 at 11:04 a.m., the NS stated she was unable to find the reason why the cardiology appointment on 10/9/25 did not happen.During a telephone interview with the NS, on 8/10/26 at 2:20 p.m., the NS stated that Resident 1's name was not in the binder for appointments. The NS stated that it meant there was no scheduled appointments.Review of the appointment scheduler job description indicated, The Appointment Scheduler is responsible for coordinating and scheduling resident medical appointments, diagnostic procedures, consultations, and other healthcare-related services for residents of the skilled nursing facility. This position works closely with nursing, providers, residents, families, transportation services, and external healthcare organizations to ensure appointments are scheduled accurately, communicated timely, and coordinated with the resident's care needs. The Appointment Scheduler supports continuity of care by maintaining accurate appointment information, coordinating transportation and required documentation, communicating schedule changes, and ensuring appropriate follow-up information is received and routed to the appropriate clinical team.3. Review of Resident 1's Order Summary Report, dated 1/20/23, indicated an order for Apixaban oral tablet 2.5 mg. Give 1 tablet by mouth two times a day for Atrial Fibrillation.During a concurrent telephone interview and record review of Resident 1's Medication Administration Record (MAR, a record of prescribed medications) with the NS, on 8/7/26 at 10:53 a.m., the NS confirmed that Eliquis were not given on the following:1/20/23 PM dose, indicated in the medication administration note on order;1/28/23 AM and PM dose, indicated in the medication administration note awaiting delivery;2/6/23 PM dose, indicated in the medication administration note on order;9/8/23 AM dose, indicated blank in the MAR;5/7/24 PM dose, indicated in the medication administration note on order; and5/8/24 AM dose, indicated in the medication administration note on order.During a telephone interview and record review of Resident 1's medication administration note with the NS, on 8/7/26 at 10:57 a.m., the NS stated that she was unable to find any documentation on why the MAR on 9/8/23 was blank.During a telephone interview with the NS on 8/11/26 at 8:38 a.m., the NS stated that the nurses should call the pharmacy and asked the reason why the medication was not available and to let the physician know.Review of facility's P&P, titled Pharmacy Services - Role of the Provider Pharmacy, undated, indicated .Provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week.Supply the facility with approved medications, biologicals [drugs made from living cells or part of living things], and supplies, as well as any compounded medications [custom-made drugs] or investigational drugs that are needed.Deliver medications to the facility, and help the facility ensure that all deliveries are correct and proper documentation related to delivery is provided.Review of the facility's P&P, titled Administering Medications, undated, indicated 4. Medications are administered in accordance with prescriber orders, including any required time frame.Review of the facility's P&P, titled Anticoagulation - Clinical Protocol, undated, indicated As part of the initial assessment, the physician and staff will identify individuals who are currentlyanticoagulated; for example, those with a recent history of deep vein thrombosis (DVT), or heart valve replacement, atrial fibrillation.Review of the facility's P&P, titled Pharmacy Services Overview, undated, indicated The facility shall accurately and safely provide or obtain pharmaceutical [pharmacy] services, including the provision of routine and emergency medications and biologicals . Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner and emergency medications and biologicals, and the services of a licensed consultant pharmacist.Review of the facility's P&P, titled Medication Regimen Review, undated, indicated The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities, for example, the use of medication.

Based on interview and record review, the facility failed to inform the Responsible Party (RP) of one of three residents (Resident 1) when a new medication was initiated. This failure had the potential for the RP to not be updated with the current treatment of Resident 1.Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE].Review of Resident 1's History and Physical (H&P) assessment, dated 1/23/23, indicated a diagnosis of essential (primary) hypertension (high blood pressure that does not have a known cause) controlled on current medication regimen Losartan (medication used to treat high blood pressure).Review of Resident 1's Order Summary Report, dated 2/28/23, indicated an order for Metoprolol Succinate (a medication used to treat high blood pressure) tablet extended release 25 milligrams (mg, unit of measurement) give 1 tablet by mouth one time a day for HTN (hypertension, high blood pressure). Hold if SBP (systolic blood pressure, the top number in a blood pressure reading) if less than 110 mmHg (millimeters of mercury, unit of measurement) was initiated on 2/17/23.Review of Resident 1's Health Status Note, dated 2/17/23, indicated .Reported regarding BP [blood pressure] readings, MD [medical doctor] reviewed.Informed of new order and agreed.During a concurrent interview and record review with the Nursing Supervisor (NS), on 7/31/26 at 2:28 p.m., the NS stated Metoprolol was initiated on 2/17/23. The NS also stated that the health status note on 2/17/23 did not indicate who was informed.During a telephone interview with the Director of Staff Development (DSD), on 8/3/26 at 11:01 a.m., the DSD confirmed the health status note, dated 2/17/23, did not indicate that the RP was notified when Metoprolol was started.During a telephone interview with the Director of Nursing (DON), on 8/11/26 at 10:57 a.m., the DON stated the RP will be notified when they get a new order for a new medication.Review of the facility's policy and procedures (P&P), titled Resident Representative, undated, indicated 3. The term resident representative is defined as: a. an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident, manage financial matters; or receive notifications.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from significant medication error, when the physician's order for Plavix (Clopidogrel Bisulfate, antiplatelet medication to prevent harmful blood clot) was not followed when Plavix was not given for four consecutive days in July 2026.This failure resulted in Resident 1 not receiving the medication which had the potential to increase the risk for developing blood clots and stroke (lack of blood flow to a part of the brain).Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE].Review of Resident 1's History and Physical (H&P) assessment, dated 1/23/23, indicated a diagnoses including chronic total occlusion of artery of the extremities (blockage of the blood vessels affecting blood flow), peripheral vascular disease (a slow and progressive circulation disorder).Review of Resident 1's Order Summary Report, dated 1/20/23, indicated an order for Clopidogrel Bisulfate (Plavix) oral tablet 75 mg (milligrams, unit of measurement) give 1 tablet by mouth one time a day for peripheral vascular disease.During a concurrent telephone interview and record review with the Nursing Supervisor (NS), on 8/6/26 at 11:06 a.m., the NS confirmed Plavix was not given on the following:7/1/26 the medication administration note indicated waiting for refill;7/2/26 the medication administration note indicated waiting for refill;7/3/26 the medication administration note indicated being processed; and7/4/26 the medication administration note indicated on order.During a telephone interview and record review with the NS on 8/7/26 at 10:51 a.m., the NS confirmed that Resident 1 missed four doses of the medication.During a telephone interview with the NS on 8/11/26 at 8:38 a.m., the NS stated that the nurses should call the pharmacy and asked the reason why the medication was not available and to let the physician know.Review of facility's P&P, titled Pharmacy Services - Role of the Provider Pharmacy, undated, indicated .Provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week.Supply the facility with approved medications, biologicals, and supplies, as well as any compounded medications or investigational drugs that are needed.Deliver medications to the facility, and help the facility ensure that all deliveries are correct and proper documentation related to delivery is provided.Review of the facility's P&P, titled Administering Medications, undated, indicated 4. Medications are administered in accordance with prescriber orders, including any required time frame.Review of the facility's P&P, titled Pharmacy Services Overview, undated, indicated The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner and emergency medications and biologicals, and the services of a licensed consultant pharmacist.According to the National Institutes of Health's (NIH) National Library of Medicine 2025 Guidelines for direct oral anticoagulants: a practical guidance on the prescription, laboratory testing, peri-operative and bleeding management, dated 5/31/25, indicated DOACs [direct oral anticoagulants] are indicated for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF), chronic stable atherosclerotic disease, the treatment of new deep vein thrombosis and pulmonary embolism, and secondary prevention of VTE [venous thromboembolism], as well as the prevention of venous thrombosis in hip and knee arthroplasty.

Based on interview and record review the facility failed to ensure follow-up of surgeon and oncology (study of cancer) referrals dated 12/17/24 and 1/31/25 for one of three sample residents (Resident 1). This failure resulted in a delay in evaluation and treatment for Resident 1.Findings:Review of Resident 1's clinical records indicated Resident 1 with diagnoses including malignant neoplasm (cancerous tumor) of unspecified site of left female breast and secondary, unspecified malignant neoplasm of axilla (underarm) and upper limb (jointed, muscle) lymph nodes (small, bean-shaped structures that act as filters for your immune system), and dementia (decline in mental abilities severe enough to interfere with daily life).Review of Resident 1's Pathology (study and diagnosis of disease) Report dated 12/13/24, indicated Resident 1 was diagnosed with invasive ductal carcinoma of the left breast (type of breast cancer that spread beyond the milk ducts into surrounding breast tissue) and metastatic adenocarcinoma (advanced form of cancer) involving the left axillary lymph node.Review of Resident 1's Health Status Note, dated 12/17/24, indicated the physician reviewed the pathology report and ordered referrals to a general surgeon and oncologist (doctor who has special training in diagnosing and treating cancer). Review of Resident 1's Order Listing Report dated 1/31/25 indicated the physician ordered a Referral to Oncology for left breast metastatic cancer.Review of Resident 1's Oncology Consultation Report dated 10/13/25 indicated the oncologist reviewed Resident 1's pathology results from 12/13/24, which indicated invasive ductal carcinoma of the left breast and metastatic adenocarcinoma involving the left axillary lymph node. The oncology report indicated No further workup or referrals. The report indicated the oncologist did not know why Resident 1 had not been referred for further evaluation or treatment. The report also indicated there were no records of complete staging for the breast cancer. The oncologist ordered Letrozole (used to treat breast cancer), PET (Positron Emission tomography, a medical imaging test that shows how the tissues and organs are functioning at a cellular level), CT (Computed Tomography, imaging test that combines x-rays and computer technology) scan, referral to surgeon and follow-up in 4 to 6 weeks.During a concurrent interview and record review with the Director of Nursing (DON) on 6/3/26 at 4:20 p.m., the DON stated the facility was unable to locate the scheduler's appointment calendar and was unable to locate documentation indicating the December 17, 2024 oncology and surgeon referrals were scheduled or completed. The DON also stated there was no documentation indicating Resident 1 refused the referrals. The DON stated resident refusals and family notifications would normally be documented in the Health Status Note. During a follow-up phone interview and record review with the DON on 6/4/26 at 1:52 p.m., the DON provided Resident 1's physician order dated 1/31/25 for an oncology referral related to metastatic left breast cancer. The DON stated there was no documentation showing the referral was scheduled, completed, or refused by Resident 1. The DON also confirmed the facility was unable to locate the physician orders related to the 12/17/24 oncology and surgeon referrals. Review of the facility's undated policy titled Medication and Treatment Orders indicated Orders for medications and treatments will be consistent with principles of safe and effective order writing.Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on interview and record review, the facility failed to ensure adequate supervision and implement fall prevention interventions for one of three sampled residents (Resident 1) when Resident 1 had repeated attempts to stand on 1/17/26 and staff did not provide extra activity to keep Resident 1 occupied during attempts of standing up unassisted. This failure resulted in Resident 1 sustaining a 5-centimeter (cm, unit of measurement) x 2 cm head laceration (wound on the skin, typically caused by blunt trauma) that required hospitalization and 13 staples (specialized metal or plastic used in medical procedure to close deep wound).Findings:Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental health condition that is marked by hallucinations [something that does not exist in reality] and delusions [not based on reality], and mood disorder symptoms, bipolar disorder (mental health condition that causes extreme mood swings) vascular dementia (changes to memory, thinking, behavior resulting from conditions that affect the blood vessels in the brain, muscle weakness, and repeated falls.Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool), Section C, dated 1/12/26, indicated Resident 1 had impaired short-term and long-term memory and was coded as severely impaired for daily decision making. Resident 1 was unable to recall items under memory/recall ability.Review of Resident 1's MDS, Section GG (function and mobility assessment), dated 1/12/26, indicated Resident 1 was coded as dependent for sit-to-stand and transfers, toileting, and requiring staff to provide full assistance for mobility.Review of Resident 1's Fall risk Observation/assessment dated [DATE] indicated Resident 1 had a high fall risk score of 20 (high risk). The assessment form indicated multiple risk factors including impaired vision, unsteady gait, impaired mobility, and multiple underlying health conditions.Review of Resident 1's Comprehensive Fall Risk Care plan initiated 4/19/23 indicated Resident 1 was at risk for falls related to impaired cognition, wandering (moving from place to place), psychoactive (affecting the mind or mood or other mental processes) medication use, and gait/balance problems. Interventions included monitoring the resident's whereabouts, assisting with toileting, ensuring a safe environment, and providing activities to keep the resident occupied to reduce the risk of standing without assistance.Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) dated 1/17/26 indicated Resident 1 was found on the floor in room A by the door on 1/17/26, approximately 2100 with a laceration to the back of the head measuring approximately 3 cm. The SBAR indicated Resident 1 had been sitting in the hallway for approximately two hours prior to the fall, and staff were assisting another resident at the time of the incident. The SBAR further indicated the aide was approximately 5 feet away from her when Resident 1 was found on the floor.Review of Resident 1's Progress notes (Health Status Note) dated 1/17/26 indicated Resident 1 was sitting in a hallway chair for approximately two hours prior to the fall and had been attempting to stand up and walk prior to the fall. At approximately 2100, staff heard a loud sound and found Resident 1 on the floor in room A next to the doorway with a laceration to the back of the head and significant bleeding. Emergency medical services were contacted, and Resident 1 was transferred to the hospital.Review of Resident 1's Hospital Discharge summary dated [DATE] indicated Resident 1 was hospitalized following a fall and sustained a head laceration. The discharge summary also indicated Resident 1 required close supervision as evidenced by recent fall while unsupervised.Review of Resident 1's Comprehensive Skin Evaluation/assessment dated [DATE] indicated Resident 1 had a laceration to the back of the head measuring 5 cm x 2 cm and 13 staples at laceration site.Review of Resident 1's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) note dated 2/5/26, late entry for 1/20/26 indicated Resident 1 had a history of impulsive behaviors, including sudden standing and rapid ambulation (ability to walk), requiring supervision. The IDT note indicated interventions included continued supervision by nursing and activity staff. The IDT note indicated that at the time of the fall on 1/17/26, approximately 9:00 p.m., another resident required assistance, which caused the CNA A to turn away, and a loud sound was heard shortly after.Review of Resident 1's clinical record indicated the following:2/14/25 - witnessed fall with no injury3/5/25 - unwitnessed fall with left brow swelling3/6/25 - witnessed fall with no injury5/14/25 - witnessed fall with left knee discoloration5/25/25 - unwitnessed fall with right wrist swelling6/4/25 - witnessed fall with right forearm discoloration6/23/25 - unwitnessed fall with no injury8/8/25 - witnessed fall with no injury8/30/25 - assisted to the floor with no injuryReview of Resident 1's Rehab-Status Post Fall Screen document dated 8/12/25 indicated Resident 1 was at a high risk for falls due to cognitive deficit and impulsivity in movement (acting on urges without thinking) patterns. The document recommended continued 24/7 (twenty-four hours a day, seven days a week) supervision.During a phone interview on 3/13/26 at 9:10 a.m., Certified Nursing Assistant A (CNA A) stated that she was the only CNA supervising approximately 15 residents in the hallway on 1/17/26 at approximately 2100, while two other CNAs were assisting residents in their rooms. CNA A stated Resident 1 had been attempting to stand multiple times, and CNA A reminded Resident 1 to sit back down. CNA A stated she turned to assist another resident and did not see Resident 1 get up, then heard a loud sound and found Resident 1 on the floor.During a phone interview on 3/13/26 at 2:16 p.m., Licensed Vocational Nurse B (LVN B) stated Resident 1 was a high fall risk and had a history of attempting to stand and ambulate without assistance. LVN B stated that when Resident 1 attempted to stand, staff would provide snacks and redirect Resident 1 to sit back in the chair; however, at the time of the fall, CNA A was assisting another resident. During a phone interview with the Director of Nursing (DON) on 4/3/26 at 10:31 a.m., the DON stated Resident 1 was very impulsive and a high risk for falls. The DON stated Resident 1 was not left unattended; however, CNA A missed it when CNA A turned away to assist another resident. The DON stated staff needed to be quick when responding to Resident 1's attempts to stand.During a follow up interview with the DON on 4/14/26 at 12:58 p.m., DON stated Resident 1 required one-to-one supervision, especially after dinner, due to impulsive behavior and attempts to stand. The DON stated that providing activities to keep Resident 1 occupied was an intervention to prevent falls. The DON further stated there were no activities provided at the time of the fall.Review of the undated facility's policy Falls - Clinical Protocol indicated .staff will try various relevant interventions, based on assessment of the nature or category, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance).

Based on interview and record review, the facility failed to ensure the result of the investigation of an alleged resident-to-resident altercation that occurred 2/2/26 was reported to the State Survey Agency (SSA) within the required timeframe for two of three sampled residents (Residents 2 and 3). This failure had the potential to delay the State Survey Agency's review of the investigation results. Findings:Review of Resident 2's clinical records indicated resident with diagnoses including vascular dementia (decline in thinking, memory, and reasoning caused by reduced blood flow to the brain) major depressive disorder (mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and a loss of interest in activities).Review of Resident 2's Health Status Note dated 2/2/26 indicated staff heard Resident 2 yell out from his room. The Certified Nursing Assistant (CNA) immediately responded and saw Resident 3 standing next to Resident 2's bed, holding Resident 2's chest with one hand and hitting Resident 2 in the face. The CNA intervened and separated the residents.Review of Resident 3's clinical records indicated resident with diagnoses including cerebral infarction (stroke), dementia, anxiety disorder (mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life), and major depressive disorder.Review of Resident 3's Health Status Note dated 2/2/26 indicated the CNA observed Resident 3 standing next to his roommate's bed, holding his roommate's chest, and hitting him in the face.On 4/16/26, further review of the facility's documents received there was no 5-day investigation report on file submitted within the required timeframe.During an interview with the Administrator (ADM) on 4/16/26 at 2:18 p.m., the ADM stated the 5-day investigation report was completed but was not emailed or faxed to the Department. The ADM stated he was not sure why it was not sent and stated the facility usually emails investigation reports within five days.Review of the undated facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating indicated All reports of resident abuse.are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) who received dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment received care in accordance with professional standards of practice when:1. Staff did not follow fluid restriction order; and2. Staff did not notify the physician about the resident's excessive fluid intake.These failures had the potential to compromise the resident's health and well-being.Findings:A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and dependence on dialysis.A review of Resident 1' s physician's order, dated 12/19/25, indicated, fluid restriction (limiting liquids) 1000 cubic centimeters (cc, a unit of measurement) per day, Dietary provides: B (breakfast) 240 cc, L (lunch) 120 cc, D (dinner) 240 cc, Total 600 cc, Nursing provides: NOC (night) 100 cc, DAY 180 cc, EVE (evening) 120 cc, Total 400 cc.A review of Resident 1's daily intake record on 12/2025 MAR indicated, 1260 cc on 12/20/25; 1160 cc on 12/25/25;1240 cc on 12/26/25; 1110 cc on 12/27/25; 1460 cc on 12/28/25; 1240 cc on 12/29/25; 1250 cc on 12/30/25; 1100 cc on 1/1/26; 1740 cc on 1/2/26; 1310 cc on 1/6/26; 1400 cc on 1/7/26; 1160 cc on 1/14/26; 1290 cc on 1/20/26.A review of Resident 1's medical record indicated there was no documentation indicating the facility notified the physician about the resident's excessive fluid intake.During an observation and interview with Resident 1 on 1/21/26 at 12 p.m., he was sitting in his wheelchair in the hallway in front of his room. Resident 1 stated he was on fluid restriction and not getting any food and/or drink from outside. Resident 1 further stated he did not have any problem getting any drinks from the facility staff.During an interview with Licensed Vocational Nurse (LVN) A on 1/21/26 at 12:08 p.m., she stated Resident 1 was on fluid restriction but usually consume more than ordered for Day shift because of additional 240 cc of hot chocolate in the morning. LVN A acknowledged Resident 1's fluid restriction order should be followed, and the physician should be notified about the resident's excessive fluid intake.During an interview and record review with the Director of Staff Development (DSD) on 1/21/26 at 2 p.m., she confirmed the above record review. The DSD stated staff should follow the fluid restriction order and the physician should have been notified about the resident's excessive fluid intake.During a review of the facility's policy and procedure (P&P) titled Encouraging and Restricting fluids, dated 2001, the P&P indicated, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. Notify the supervisor if the resident refuses the procedure.During a review of the facility's P&P titled Change in a Resident's Condition or Status, dated 2001, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.During a review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident with, dated 2001, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

Based on interview and record review, the facility failed to complete the discharge planning for one of three sampled residents (Resident 1) when there was no final discharge date and no documented place of discharge for Resident 1.These failures resulted in incomplete discharge planning and had the potential for Resident 1's needs to be unmet after leaving the facility on 6/7/25.Findings:Review of Resident 1's face sheet (a document that gives a resident's information) indicated, Resident 1 was admitted [DATE] with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position.)Review of Resident 1's Social History assessment dated [DATE] indicated resident was homeless prior to hospitalization and had resided at a shelter.Review of Resident 1's Discharge Care Plan (initiated 3/6/25, revised 6/11/25) indicated goals for discharge to an appropriate placement that would meet individualized needs and a safe move to the community. Interventions included: Assess resident/family preference regarding discharge resources and coordinates DME (durable medical equipment), pharmacy, home health, and/or in-home support services.Review of Resident 1's Social Service Note dated 5/21/25 (late entry, created 6/21/25) indicated the SSD informed the resident and son of a 5/30/25 discharge date . The document did not show that the date was updated.Review of Resident 1's Social Service Note dated 5/28/25 (late entry, created 6/21/25) indicated the son requested an extension, which was approved by the IDT (Interdisciplinary Team, consists of professionals from different disciplines who collaborate to provide comprehensive and coordinated care to patients), but there was no specific date when Resident 1 will be discharged .Review of Resident 1's Social Service Note dated 6/4/25 (late entry, created 6/21/25) indicated the son asked about discharge. The SSD explained therapy days had ended but did not confirm a discharge date .Review of Resident 1's Health Status Note dated 6/7/25 (late entry, created 6/13/25) indicated: Resident discharged today.bags packed.received two small bags of medications.Resident was picked up by son at 1200.Review of Resident 1's Social Service Note dated 6/7/25 (late entry, created 6/21/25) indicated the discharge as unplanned.During an interview with the Social Service Director (SSD) on 6/11/25 at 10:30 a.m., the SSD stated that Resident 1 was not scheduled for discharge on [DATE]. The SSD stated she was not aware Resident 1 was leaving that day and she had no social services note for that day because the IDT had not finalized the discharge date .During an interview with the Director of Nursing (DON) on 6/11/25 at 1:30 p.m., the DON stated that discharge planning begins on admission and being updated during resident's stay. The DON stated that for homeless residents, the SSD assist in finding a shelter, and once a discharge date was set, the facility obtains a physician's order and needed equipment.During a follow-up phone call with the DON on 6/20/25 at 3:30 p.m., the DON stated Resident 1 wanted to go home on 6/7/25. On 6/23/25, the DON emailed Social Service notes and wrote: The discharge was planned for a future date, however, it turned unplanned on June 7, 2025 when Resident 1 informed the nurse that he will be going home on that day, June 7, 2025 and was picked up by his son. The documents provided by the DON did not show documentation that Resident 1 requested to be discharged on 6/7/25.During an interview with the SSD on 9/11/25 at 3:28 p.m., SSD stated her practice was to document the name of the shelter or destination in the progress notes prior to a resident's discharge. The SSD acknowledged there was no documented place of discharge for Resident 1 on 6/7/25 because the discharge happened on a Saturday when she was not on site. The SSD further stated that Resident 1 was not supposed to be discharged on 6/7/25 and that the discharge happened due to a miscommunication with the resident.Review of the undated facility's policy titled Discharge Summary and Plan indicated When a resident's discharge is anticipated, a discharge summary is created and the discharge plan is finalized to assist the resident with plans for care after discharge.7) A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 8) The final discharge plan of care shows what arrangements have been made for the resident regarding: a.) where the resident will live after leaving the facility.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management; and 2. The facility did not follow the physician's order. These failures had the potential to compromise residents' care and well-being. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidney), fracture of second cervical vertebra (a broken bone of second bone in the neck), and traumatic subdural hemorrhage (a condition where blood collects between the skull and the brain's outer covering caused by head trauma). Review of Resident 1's physician's order, dated 2/16/25, indicated Lantus Subcutaneous solution (an insulin to lower blood sugar) 100 unit/ml inject 20 unit subcutaneously at bedtime for DM II, hold for BG (blood glucose) < 100. Review of Resident 1's February 2025 Medication Administration Record (MAR) indicated blood sugar was checked once a day at bedtime for Lantus administration. The MAR indicated Resident 1's blood sugar (BS) at 9 p.m. was: 99 milligrams per deciliter (mg/dL, a unit of measure) on 2/16/25; 89 mg/dL on 2/17/25; 380 mg/dL on 2/18/25; 346 mg/dL on 2/19/25; 395 mg/dL on 2/20/25; 399 mg/dL on 2/21/25. Review of the facility's Diabetes-Clinical Protocol, dated 2001, indicated, for the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin. During an interview and record review with the director of nursing (DON) on 4/16/25, at 10:10 a.m., she confirmed that Resident1's BS was checked once a day at bedtime and stated it was not consistent with the facility's policy titled Diabetes-Clinical Protocol. During an interview and record review with the director of staff development (DSD) on 4/16/25, at 10:20 a.m., she confirmed that there was no documentation indicating the physician was notified of BS increase to 380 mg/dL on 2/18/25 from 89 mg/dL on 2/17/25. The DSD verified that Resident 1's BS monitoring once a day at bedtime was not consistent with the facility's policy titled Diabetes-Clinical Protocol. The DSD acknowledged the resident's BS monitoring should have been consistent with the facility policy. Review of Resident 1's physician's order, dated 2/16/25, indicated monitor for symptoms of COVID-19 (an infectious disease caused by the coronavirus), every shift for possible COVID exposure, If yes to any symptom, temperature greater than 100.0 F (Fahrenheit, a scale of temperature) and/or oxygen saturation (O2 sat, a measurement of how much oxygen is being carried by the red blood cells in the blood) lower than 94 % RA (room air), notify MD (medical doctor) and initiate einteract COC (a form for change of condition). Review of Resident 1's February 2025 MAR indicated Resident 1's O2 sat was: 90% on 2/16/25 on night shift; 91% on 2/17/25 on night shift; 90% on 2/18/25 on day shift and evening shift; 91% on 2/19/25 on night shift; 93 % on 2/20/25 on night shift; and 91% on 2/21/25 on day shift. Review of Resident 1's progress note, there was no evidence the physician was notified when Resident 1's O2 sat was lower than 94 % on above shifts. Review of Resident 1's Health status note, dated 2/22/25, indicated Resident 1's O2 sat was 78% RA and BG was 588 mg/dL. The note further indicated Resident 1 was hypoxic (low level of oxygen in the body tissues) and hyperglycemic (high blood) and transferred to hospital. During an interview and record review with the DSD on 4/16/25, at 10:30 a.m., she confirmed that there was no documentation indicating the physician was notified when Resident 1's O2 sat was lower than 94% RA. The DSD acknowledged that the physician should have been notified when Resident1's O2 sat was lower than 94% RA as ordered. During a review of the facility's policy and procedure (P&P) titled Diabetes-Clinical Protocol, dated 2001, the P&P indicated, Monitoring and Follow-Up: 3) for the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin. Adjust monitoring frequency depending on glucose control . During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 2001, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the physician of changes in the resident's condition.

Based on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their use by date, expired food, and rotten vegetables were found in the refrigerator, the freezer, and on the shelves in the kitchen; 2. Dietary Aid E (DA E) and the maintenance director (MD) did not wash their hands when entering the kitchen; and 3. Juice temperature was higher than acceptable delivery temperature. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 144 residents receiving food at the facility. Findings: 1. On [DATE], at 9:30 a.m., during an observation of the kitchen's storage shelves, in the freezer, and the refrigerator, with cook D (CK D) and the dietary director (DD), the following were observed: a. Opened three-gallons containers of apple base, iced tea, apple raspberry, thicken water with no open date and no use by date b. One 20-pound box of frozen sugar cookie dough with no use by date and no expiration date c. One box of cherry twin pops with no use by date d. Five pounds of sour cream with an expiration date of [DATE] e. One lime jello container with an expiration date of [DATE] f. A container of rotten chopped salad g. Two cups of lime jello with no cover and undated h. Two bowls of chopped salad with no date i. Five and a half trays of glasses of punch (32 glasses per tray) had no date j. Eleven glasses of milk and seven glasses of juice had no date k. One honey thick water with an expiration date of [DATE] l. One 20-pound case of zucchini with a use by date of [DATE] m. Fifteen tomatoes with no use by date n. Three stacks of celery with a use by date of [DATE] o. Eleven cantaloupes, one watermelon, and four honeydews with a use by date of [DATE] p. Thirty-three rotten iceberg lettuce with a use by date of [DATE] q. Twenty-two oranges with no open date and no use by date r. One 8-pound pork loin with a use by date of [DATE] s. Ten pounds of bacon received on [DATE] t. Three rotten romaine heads with a use by date of [DATE] u. Four heavy creams with an expiration date of [DATE] v. One open and undated half and half creamer w. A container of cherry jello with a use by date of [DATE] x. Five five-pound shredded cheese with no use by date y. Five five-pound cheese with no use by date and no expiration date z. One open liquid egg with no open date and no use by date aa. Ten pounds of breaded pork patties with no use by date bb. Three pounds of cheese ravioli with no open date and no use by date cc. One hundred and thirty dinner rolls with no open date dd. One pumpkin pie with a use by date of [DATE] ee. Fifty cheese and bean burritos with no open date and no use by date ff. Four pounds of corn tortillas with no open date and no used by date gg. Four two-pound broccoli florets with no open date and no use by date hh. Fifteen pounds of diced carrots with no open date and no use by date ii. Eight pizzas with no open date and no use by date jj. Ground chorizo with no open date and no use by date kk. Twelve beef and pepper patties with a use by date of [DATE] ll. Five pounds of ground beef patties with no open date and no use by date mm. Twelve and a half pounds of asparagus with no received date, no open date, and no use by date nn. Opened box of six bags of tortillas (24-count) with no open date oo. Four pounds of chicken breast with rib meat with no open date and no use by date pp. Eight ounces of non-dairy powdered cream received on [DATE] qq. One gallon of lemon juice with an expiration date of [DATE] rr. Four open bags of cereal with no open dates. ss. Two pounds of pecans with an expiration date of [DATE] tt. Two pounds of almonds with an expiration date of [DATE] uu. One fourth pounds of pecans with a use by date of [DATE] vv. One pound of saline crackers with no received date and no use by date ww. One container of bread crumbs with no date. During a concurrent interview with the DD, he stated the bacon should have been used in three days, and they were expired; non-dairy powdered cream was good for one month, and it was expired; the above mentioned food and drink items should have an open date and use by date; expired food and food past their use by date should have been discarded. Review of the facility's 2023 policy, Labeling and Dating of Foods, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to facility needs to be marked with a received date . Newly opened food items will need to be closed and labeled with an open date and use by date . All prepared foods need to be covered, labeled, and dated. Review of the facility's policy, Food Receiving and Storage, dated ,d+[DATE], indicated, . Dry Food Storage: . 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date) . Refrigerated/Frozen Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Review of the facility's policy, Refrigerators and Freezers, dated ,d+[DATE], indicated, . 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. 2. During an observation on [DATE] at 9:40 a.m., dietary aid E (DA E) came in the kitchen, did not wash her hands, and started working. During a concurrent interview with DA E, she stated she should have washed her hands when she entered the kitchen before starting to work. During an observation of the ice machine in the kitchen with the maintenance director (MD) on [DATE] at 3:15 p.m., the MD came in the kitchen, put on beard net, but did not wash his hands. During a concurrent interview with the MD, he acknowledged that he should have washed his hands when he entered the kitchen. During an interview with the director of staff development/infection preventionist (DSD/IP) on [DATE] at 4:35 p.m., she stated when staff goes beyond the red line on the kitchen floor, the staff should have wash their hands. Review of the facility's undated policy, Kitchen - Employee Hygiene and Sanitary Practices, indicated, . 6. Employees must wash their hands: . c. Whenever entering or re-entering the kitchen; . 3. During a test tray observation with the dietary director (DD) on [DATE] at 1:10 p.m., the temperature of the juice in the glass was 66.6 degrees Fahrenheit (F). During a concurrent interview with the DD, he confirmed the temperature of the juice was high at 66.6 degrees, and he would check on the acceptable delivery temperature of the juice. Review of the facility's undated Room Test Tray Evaluation, indicated the acceptable delivery temperature for a cold beverage was 40 degrees F to 55 degrees F.

Based on observation, interview, and record review, the facility failed to provide meals with food items according to preferences for four of 144 residents (34, 36, 58, and 117). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents. Findings: Review of Resident 36's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 58's Admission Record indicated she was admitted to the facility on [DATE]. During a tray line observation with the dietary director (DD) on 2/11/25 at 12:15 p.m., Resident 58's lunch ticket indicated she preferred to have low-fat milk, but whole milk was served for her. During a tray line observation with the dietary director (DD) on 2/11/25 at 12:50 p.m., Resident 36's lunch ticket indicated he preferred to have yogurt, but yogurt was not served for him. During a concurrent interview with the DD, he confirmed that Resident 58's lunch ticket indicated she preferred to have low-fat milk, but whole milk was served for her; and Resident 36's lunch ticket indicated he preferred to have yogurt, but yogurt was not served for him. The DD stated meals should have been served according to the residents' preferences. 36623 During an interview on 2/9/25 at 12:20 p.m. Resident 117 stated she was allergic to melon, but she got served melon. Resident 117 stated she requested fruit and she was served strawberries with cantaloupe. Review of Resident 117's tray card indicated she was allergic to bell pepper, cucumber, melon, and peanuts. The tray card also indicated melon as one of her dislikes. During a resident council meeting on 2/11/25 at 10:30 a.m., Resident 34 stated the facility kitchen does not follow her preferences. Resident 34 stated she does not like honey dew melon and it was listed in her tray card. She stated she still gets honey dew melon on her tray. Review of the facility's 2023 policy, Food Preferences, indicated, Resident's food preferences will be adhered to within reason.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. A nurse did not perform hand hygiene after removing gloves during Resident 61's wound dressing change; 2. The tips of the feeding tubing was left uncovered for two residents (Residents 137 and 128); 3. Oxygen tubing was undated, touching, and lying on the floor for Resident 41, Resident 71, and Resident 134; and 4. Certified nursing assistant H (CNA H) and certified nursing assistant I (CNA I) walked out of Resident 106's room and Resident 107's room with gloves on. These failures had the potential to result in transmission and spread of infection in the facility. Findings: 1. Review of Resident 61's clinical record indicated she was admitted to the facility with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and stage 4 pressure ulcer (pressure-related damage to skin resulting in full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During an observation and concurrent interview on 2/12/25 at 11:28 a.m. with the treatment nurse (TN), she stated Resident 61 had a Stage 4 pressure ulcer and required a dressing change every day. She prepared supplies to perform a dressing change. The TN washed her hands before removing Resident 61's wound dressing, then she removed her gloves, washed her hands, and donned new gloves. After cleansing Resident 61's wound with with normal saline, the TN removed her gloves and put on new gloves without washing her hands or performing hand hygiene. The TN placed a dressing on Resident 61's wound, removed her gloves and put on new gloves without washing her hands or performing hand hygiene. The TN confirmed she did not perform hand hygiene when she changed her gloves. During an interview on 2/12/25 at 12:28 p.m., the Director of Staff Development/Infection Preventionist (DSD/IP) stated the expectation is to perform hand hygiene in between glove changes. Review of the facility's policy, Handwashing/Hand Hygiene, dated 2001 indicated hand hygiene is indicated immediately after glove removal. 2a. Review of Resident 137's clinical record indicated Resident 137 was admitted to the facility with diagnoses including hemiplegia and hemiparesis (complete paralysis, partial paralysis or muscle weakness on one side of the body), dysphagia (difficulty swallowing food or liquids), aphasia (loss of ability to understand or express speech), dysarthria and anarthria (inability to produce clear and understandable speech) and heart failure (inability of the heart to pump enough blood to the rest of the body). During an observation on 2/9/25 at 11:47 a.m. inside Resident 137's room, Resident 137's enteral feeding tube (a medical device that delivers nutrition directly to the stomach or small intestine through a flexible tube) was lying on a towel on top of the bedside table. The tip of the tube was uncapped and not in use. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with Licensed Vocational Nurse C (LVN C) inside Resident 137's room, LVN C stated the tubing should have been capped with a plastic cap for infection control. 2b. Review of Resident 128's clinical record indicated Resident 128 was admitted to the facility with diagnoses including monoplegia (paralysis or weakness) of upper limb, aphasia (slight or serious difficulty with language or speech), dysphagia (difficulty swallowing food or liquids), and gastrostomy tube (GT tube, a surgical opening into the stomach for administration of nutrition and medications). During an observation on 2/9/25 at 12:16 p.m. inside Resident 128's room, Resident 128's enteral feeding tube was hanging from a pole. The tip of the tube was uncapped and not in use. During an interview on 2/12/25 at 11:20 a.m. with the DSD/IP, the DSD/IP stated the end of the feeding tube the licensed nurse should have capped the feeding tube when not connected to the patient for feedings and not left open to air or in contact with surfaces to prevent contamination. During an interview on 2/12/25 at 11:33 a.m. with the Director of Nursing (DON), the DON stated the tubing should have been stored with a cap on when not in use to prevent contamination. Review of the facility's in-service titled, Nurses Meeting, dated October 22-23, 2024, conducted by the DON, indicated material discussed, Tubings - O2, IV, GT; IV and GT- tape the cap to the tubing after use to prevent contamination of the tip. Review of the facility's Policy and Procedure titled, Infection Prevention and Control Program, dated 10/2019, indicated, .11. Prevention of Infection; a. Important facets of infection prevention include: . (3) educating staff and ensuring that they adhere to proper techniques and procedures. Review of the facility's policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, dated 2001, the P&P indicated, Preventing contamination 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems . 37409 3a. Review of Resident 41's Admission Record indicated she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD, caused by inflammation inside the airways that limits airflow into and out of the lungs). Review of Resident 41's physician order, dated 2/2/25, indicated she had an order for oxygen at 2 liters (L, a metric unit of volume) per minute every evening and night shift for shortness of breath (SOB). During an observation and interview with licensed vocational nurse F (LVN F) on 2/9/25 at 2:25 p.m., Resident 41's oxygen tubing was lying on the floor and undated. LVN F stated Resident 41's oxygen tubing should not be on the floor and it should have been stored in a bag with date. 3b. Review of Resident 71's Admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 71's physician order, dated 1/18/25, indicated she had an order for oxygen at 3 L per minute as needed for SOB. During an observation and interview with LVN F on 2/9/25 at 2:22 p.m., Resident 71's oxygen tubing was lying on the floor and undated. LVN F stated Resident 71's oxygen tubing should not be on the floor; it should have been stored in a bag with date. 3c. Review of Resident 134's Admission Record indicated she was admitted to the facility on [DATE] with a diagnosis of COPD. Review of Resident 134's physician order, dated 11/12/24, indicated she had an order for oxygen at 2 L per minute continuously every shift for SOB. During an observation and interview with respiratory therapist G (RT G) on 2/10/25 at 10:25 a.m., Resident 134 was sitting on the wheelchair in her room. Resident 134 was on oxygen, and her oxygen tubing was hanging down and touched the floor. RT G stated Resident 134's oxygen tubing should not touch the floor, and he would fix that. During an interview with the DSD/IP on 2/13/25 at 4:31 p.m., she stated residents' oxygen tubing should not be touching or lying on the floor; it should have been stored in a bag and date. Review of the facility's undated policy, Departmental (Respiratory Therapy) - Prevention of Infection, indicated, . Infection Control Consideration Related to Oxygen Administration: . 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. 4a. During an observation on 2/12/25 at 3:01 p.m. certified nursing assistant H (CNA H) walked out of Resident 106's room with gloves on, walked in the hallway, and CNA H removed the gloves in the hallway. During a concurrent interview with CNA H, she stated she was helping Resident 106 with changing her brief in her room. CNA H stated she should have remove her gloves in Resident 106's room. 4b. During an observation on 2/10/25 at 10:39 a.m., certified nursing assistant I (CNA I) carried a bag of soiled brief and linen out of Resident 107's room with her gloved hands, walked in the hallway, and removed the gloves in the hallway. During a concurrent interview with CNA I, she stated she was helping another CNA to prepare and transfer Resident 107 for shower in her room. CNA I stated she should have remove her gloves in Resident 107's room. During an interview with the DSD/IP on 2/13/25 at 4:31 p.m., she stated staff should have remove gloves in the resident's room before walking out of the room and in the hallway. Review of the facility's policy, Personal Protective Equipment - Gloves, dated 7/2009, indicated . 2. Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed.

Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for one of four sampled residents (Resident 99) when Resident 99's call light button (a cord with a button used by residents to request assistance) was not within reach to use. This failure had the potential to result in the delay of care and treatments for the resident. Findings: Review of Resident 99's clinical record titled, Admission Record, indicated Resident 99 was admitted to the facility with diagnoses including heart failure (the heart is unable to pump enough blood to the rest of the body), gout (painful tenderness and swelling of one or more joints of the body), osteomyelitis (infection of the bone), and muscle weakness. The quarterly Minimum Data Set (MDS, an assessment tool), dated 1/27/25, indicated Resident 99 had impaired functional use of both sides of his lower extremities. The quarterly MDS, dated [DATE], indicated a score of 4 out of 15 on a Brief Interview for Mental Status (BIMS) indicating Resident 99 had severe memory problems. During an observation and concurrent interview on 2/10/25 at 9:20 a.m., Resident 99 was awake and sitting up in bed. Resident 99 stated, I can't find my call button. Certified Nursing Assistant B (CNA B) located the call light button at the head of Resident 99's bed tucked between the bed frame and mattress. Resident 99 tried to reach for the call light button, but he could not reach it. During an interview on 2/10/25 at 9:25 a.m. with CNA B, CNA B stated the call light button should have been within reach for Resident 99. During an interview on 2/11/25 at 10:15 a.m. with the Director of Nursing (DON), the DON stated, The call light button should have been within reach at all times. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, undated, the P&P indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure service provided met professional standards when: 1. Resident 64 received ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron) and calcium-vitamin D (a medication used to prevent or treat low blood calcium levels) at the same time; and 2. A medication was not administered correctly for Resident 98. This failure resulted in Resident 64 and Resident 98 not getting the full dose and desired effect of the prescribed medications. Findings: 1. Review of Resident 64's Admission Record indicated she was admitted to the facility on [DATE] with anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells) diagnosis. Review of Resident 64's clinical record indicated, she had physician orders for ferrous sulfate 325 milligrams (mg, a metric unit of mass) every other day at 9 a.m., starting on 9/13/24, and for calcium-vitamin D 500-200 mg-unit every day at 9 a.m. and 5 p.m., starting on 2/14/24. Thus, since 9/13/24, ferrous sulfate and calcium-vitamin D were given at the same time at 9 a.m. every other day. During an interview with the director of nursing (DON) on 2/13/25 at 4:08 p.m., she reviewed Resident 64's clinical record and confirmed ferrous sulfate and calcium-vitamin D were given to Resident 64 at the same time at 9 a.m. every other day since 9/13/24. The DON stated ferrous sulfate and calcium-vitamin D should not be administered at the same time due to drug-to-drug interaction, and she would change the administration time so that ferrous sulfate and calcium-vitamin D would be given separately to Resident 64. According to Lexicomp (www.[NAME].com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of the DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption was decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexicomp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction. 49345 2. During an observation of medication administration on 2/9/25 at 11:26 a.m. with Licensed Vocational Nurse (LVN) A, LVN A prepared medications for Resident 98 which included Fluticasone (an oral inhalation medication used to prevent difficulty in breathing, chest tightness, wheezing and coughing) 230 mcg (microgram, a unit of measurement)/21 mcg inhaler. Prior to giving the medication, LVN A shook the inhaler and asked Resident 98 to open his mouth. LVN A then placed the mouthpiece into Resident 98's mouth, administered one puff of the medication, and removed the mouthpiece from the patient's mouth. Resident 98 had his mouth slightly open after the first puff. LVN A waited for a few seconds and asked Resident 98 to open his mouth again and administered a second puff to Resident 98. Resident had his mouth slight open after the second puff. During an interview on 2/9/25 at 12:19 p.m. with LVN A, LVN A verified she did not provide instructions to Resident 98 to effectively administer the Fluticasone Inhaler. LVN A stated, They should not hold their breath, they just hold the medication. LVN A also stated, I should have asked him to inhale before giving the medication. During an interview on 2/12/25 at 11:50 a.m. with the DON, the DON stated, For inhaler medication administration, the nurse should have ask the resident to hold his breath for five or more seconds after giving a puff and then exhale after. Then, the resident must be instructed to rinse his mouth with water. A review of Resident 98's medical record indicated a diagnosis including Chronic Obstructive Pulmonary Disease (COPD, a lung disease that makes it difficult to breathe). A review of Resident 98's Active Physician Orders indicated, (Fluticasone-Salmeterol) 2 puffs inhale orally two times a day for COPD (Rinse mouth & spit after use). A review of facility's policy and procedure (P&P) titled, Administering Medications through a Metered Dose Inhaler dated October 2010, the P&P indicated, .14. Administer medication: .d. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. e. Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around the mouthpiece. f. Firmly depress the mouthpiece against the medication canister to administer medication. g. Instruct the resident to inhale deeply and hold for several seconds. h. Remove the mouthpiece from the mouth and instruct the resident to exhale slowly through pursed lips. 15. Repeat inhalation, if ordered. Allow at least one (1) minute between inhalations of the same mediation . 16. Rinse the mouthpiece with warm water to remove medication residue .

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (86) was served with the appropriate diet texture. This failure had the potential to result in choking for the resident. Findings: Review of Resident 86's Admission Record indicated she was admitted to the facility on [DATE] with a dysphagia (difficulty swallowing) diagnosis. During a tray line observation and concurrent record review with the dietary director (DD) on 2/11/25 at 1 p.m., Resident 86's lunch ticket indicated her diet texture was mechanical soft (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing or grinding; it is designed for individuals who have difficulty swallowing or chewing due to condition such as dysphagia) and ground meats. Chopped meats was served for Resident 86's lunch. During a concurrent interview with the DD, he confirmed that Resident 86's diet texture was mechanical soft/ground meats, but chopped meats was served for her. The DD stated mechanical soft texture with ground meats meal should have been served to Resident 86.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when: 1. The facility staff did not develop a care plan for Resident 1's antibiotic (ATB, used to treat bacterial infections) therapy, which was prescribed on 11/3/24 to treat burning urination (a possible sign of infection); and 2. The facility staff did not develop a care plan to address Resident1's change in condition on 11/11/24. These failures placed Resident 1 at risk of not receiving necessary care and services to maintain resident's health, safety and well-being. Findings: 1.Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Review of Resident 1's physician's order dated 11/3/24, indicated to give Cipro (an antibiotic used to treat bacterial infections) 500 milligrams (mg, unit of measurement) 1 tablet by mouth two times a day for 10 days for burning urination. During concurrent interview and record review with the Director of Staff Development (DSD) on 12/9/24, at 1:56 p.m., the DSD confirmed that Resident 1 did not have a care plan to address Resident 1's antibiotic treatment or monitor her response to therapy. The DSD also stated that Resident 1 should have a care plan in place. 2. Review of Resident 1's Health Status note, dated 11/11/24, indicated, Resident 1 had bradycardia (a slow heart rate) HR (heart rate or pulse, number of times the heart beats per minute [bpm]; normal HR is 60-100 bpm) 54, Oxygen Saturation (O2 Sat, the amount of oxygen in the blood; normal oxygen saturation is 95-100%) 90% on room air (RA, normal air we breathe) .Axillary (armpit, body temperature measured in the armpit) 95 degrees Fahrenheit [ F, measurement of temperature]. Resident's skin was dry and cold to touch . Review of Resident 1's Health Status Note, dated 11/14/24, indicated, Resident 1 had increased confusion, general weakness, nonverbal, and not following instructions .Pulse 45 bpm .O2 sat 88 % . Resident 1 was transferred to the hospital for further evaluation due to increased confusion. During an interview with the DSD on 2/4/25, at 12:45 p.m., the DSD reviewed Resident 1's clinical record and confirmed that no care plan was developed to address bradycardia or the change in condition. The DSD acknowledged the facility should have created a care plan because Resident 1's condition had changed. Review of an undated facility's policy, titled, Care Plans, Comprehensive Person-Centered, indicated, A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition .

Based on interview and record review, the facility failed to follow their policy and procedure for one of three residents (Resident 1) when an allegation of abuse was not reported to proper authorities. This failure had the potential for residents being at risk of abuse/harm. Findings: Resident 1 was admitted with diagnoses which included cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks), major depressive disorder, anxiety disorder, and a history of falling. During an interview with the director of nursing (DON) on 10/4/24 @ 1:50 p.m., the DON had been notified of an allegation of abuse against licensed vocational nurse A (LVN A), the DON stated they had not had any problems with LVN A. During an interview with the DON on 11/20/24 at 10:42 a.m., the DON stated the allegation of abuse brought to her attention was not reported to the police. The DON further stated if they were notified by anyone other than California Department of Public Health (CDPH) they would have reported it. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, dated 2001. The P&P indicated, .1. If Resident Abuse, Neglect, Exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

Based on interview and record review, the facility failed to ensure an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf) and POLST (Physician Orders for Life-Sustaining Treatment) had been formulated and completed, for eight of 27 residents (Residents 1, 44, 68, 85, 117, 135, 241, and 242). These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goal and wishes. Findings: During a review of electronic records (record) for residents 1, 44, 68, 85, 117, 135, 241, and 242, advance directive forms were not located. The residents POLST indicated an incomplete section regarding advance directive. During an interview on 5/24/23 at 12:06 p.m., with the social services director (SSD), who stated We understood that if we talked with the Resident, then we just stopped at section D, but if we discussed with the Legally Recognized Decisionmaker, then we would ask about advance directive. During a review of the facility's policy and Procedure (P&P) titled, Advance Directives, revised 09/2022, the P&P indicated, .Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. .If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. .b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. .If the Resident Has an Advance Directive 1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 44733

Based on observation, interview and record review, the facility failed to ensure there was documented evidence that risks and benefits were explained and informed consent was obtained for the use of bed rails (side rails, safety rails and grab/assist bars) for 23 of 27 sampled residents (Residents 292, 67 123, 135, 241, 117, 242, 125, 128, 11, 53, 57, 75, 83, 87, 93, 1, 44, 47, 68, 80, 85 and 86). These failures had the potential to compromise the residents' rights to be fully informed and make decisions regarding their care and treatment. Findings: 1. During an observation on 5/25/23 at 7:32 a.m., Resident 292 was lying in bed and had grab bars (short rails attached to the sides of the bed to help the resident move around in bed) up bilaterally (on both sides). Resident 292's Bed Rail Observation/Assessment, dated 4/12/23 was reviewed. The section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an observation on 5/25/23 at 8:05 a.m., Resident 67 was sitting up in bed and had grab bars up bilaterally. Resident 67's Bed Rail Observation/Assessment, dated 4/19/23 was reviewed. The section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an interview and concurrent record review with the director of staff development (DSD) on 5/25/23 at 8:18 a.m., the DSD confirmed that Residents 292 and 67 had grab bars on their beds bilaterally. The DSD reviewed these residents' medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of grab bars. 32398 2. During a review of residents electronic records (records) the side rail assessments/consents did not contain a signature or check mark on the consents for discussing the risk vs. benefits of having the side rails in the up position. During an interview on 5/24/23 at 11:56 AM with the DON, she stated We do not have residents sign the side rail assessments, because it is not considered a side rail, because they can still get out of bed. Nor do they limit their capability of getting out of bed. They are not full side rails, they are quarter rails. During an observation on 5/25/23 at 9:49 AM, Resident 123 had grab bars. During an observation on 5/25/23 at 9:49 AM, Resident 135 had 1/4 bars. During an observation on 5/25/23 at 9:52 AM, Resident 241 had 1/4 bars. During an observation on 5/25/23 at 9:53 AM, Resident 117 had grab bars. During an observation on 5/25/23 at 9:53 AM, Resident 242 had grab bars. During an observation on 5/25/23 at 9:54 AM, Resident 125 had grab bars. During an observation on 5/25/23 at 9:54 AM, Resident 128 had grab bars. 46552 3.Record review of Residents 11,53, 57, 75, 83, and 87's Bed Rail Observation/Assessment indicated the section of the assessment designated for documenting the risks and benefits were explained, and informed consent was obtained were left blank. During an observation on 5/22/23 at 8:43 a.m., Resident 11 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 9:57 a.m., Resident 53 had 1/4 bed rails up bilaterally. During an observation on 5/23/23 at 9:22 a.m., Resident 57 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 11:01 a.m., Resident 75 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 10:03 a.m., Resident 83 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 9:22 a.m., Resident 87 had 1/4 bed rails up bilaterally. During a concurrent interview and record review with minimum data set coordinator O (MDSC O) on 5/24/23 at 1:10 p.m., she reviewed above resident's medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of bed rails. MDSC O stated facility should have discussed risks and benefits for the use of bed rails and obtained informed consent prior to using bed rails. During an interview with the DON on 5/25/23 at 3:46 p.m., she stated staff should have followed facility's policy and procedure of explaining risks and benefits and obtaining informed consent before using bed rails for residents. 44733 4. A review of Residents 1, 44, 47, 68, 80, 85, and 86's Bed Rail Observation/Assessment indicated the section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an observation on 5/24/23 at 9:38 a.m., Resident 44 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:40 a.m., Resident 85 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:42 a.m., Resident 86 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:45 a.m., Resident 68 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:48 a.m., Resident 1 was lying in bed and had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:53 a.m., Resident 47 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 1:45 p.m., Resident 80 was sitting up in her wheelchair and had grab bars up bilaterally. During a concurrent interview and record review on 5/24/23 at 1:30 p.m., with Minimum Data Set Coordinator O (MDSC O), she reviewed these residents' medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of bed rails. MDSC O stated that the facility should have discussed the risks and benefits of the use of bed rails and obtained informed consent prior to applying the bed rails. The facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/2022, the P&P indicated, For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars. The P&P further indicated, Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food service safety for 133 of 136 residents who received food from the kitchen when: 1. Undated milk was stored in the kitchen refrigerator; 2. Outdated milk was stored in the kitchen refrigerator; and 3. Undated food was stored in the resident food refrigerator. These failures had the potential to cause foodborne illness for 133 residents who received food from the kitchen. Findings: 1. During the initial kitchen tour on 5/22/23 at 8:04 a.m. with the Dietary Supervisor (DS), three 236-millimeter (ml, a type of unit measurement) cartons of milk without a use-by date were stored in the kitchen refrigerator. The DS confirmed the observation and removed the three milk cartons from the refrigerator. The DS stated he did not know its use-by date and/or why it didn't have a use-by date. The DS stated those milks should not be stored in the refrigerator. 2. During the initial kitchen tour on 5/22/23 at 8:06 a.m. with the DS, one 236-ml carton of milk with a use-by date of 5/07/23 was stored in the kitchen refrigerator. The DS confirmed the observation and removed the milk carton from the refrigerator. The DS acknowledged that the milk was outdated and should have been used by 5/07/23. The DS stated the milk should not be stored in the refrigerator. 3. During a refrigerator inspection on 5/23/23 at 4:31 p.m., with the Director of Staff Development/infection preventionist (DSD/IP), station 2's resident food refrigerator had an unlabeled plastic container filled with beans, sauce and two pieces of cheese. The DSD/IP confirmed the observation and removed the plastic container from the resident food refrigerator. The DSD/IP stated that staff should have labeled the plastic and the food container with the resident's name and the date the food was brought into the facility before storing them in the refrigerator. The DSD/IP further stated that perishable food was safe for three days in the refrigerator. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage revised 11/22, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During a review of the facility's P&P tilted, Foods Brought by Family/Visitors revised 3/22, the P&P indicated, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. Containers are labeled with the resident's name, the item, and the date the food was brought into the facility Perishable food is safe in the refrigerator for up to 3 days.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was adequately assessed for proper transfer method to prevent injury. Certified Nursing Assistant (CNA) E failed to transfer Resident 1 safely from the wheelchair to the bed. Resident 1 was identified by the facility to require a two person transfer; however on 6/14/16 at approximately 4 p.m., CNA E attempted to transfer the resident by himself. He placed the wheelchair with Resident 1's weaker side against the bed. During the transfer Resident 1 yelled out in pain. CNA E noticed the prosthetic (artificial) leg did not pivot (turn) during the transfer. An X-ray was obtained on 6/17/17 that showed Resident 1 sustained a hip fracture. The failure of the facility to ensure staff were knowledgeable in proper transfer techniques was the direct cause of Resident 1's right hip fracture. Findings: Clinical record review for Resident 1 was initiated on 6/30/17. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 3/23/17, indicated he had moderate cognitive impairment (usually understands). In addition, Resident 1 was totally dependent for transfers with two staff members and had functional limitations to one arm and leg. Review of Resident 1's care plan with a revised date of 3/29/17, to address his self-care deficits related to his right side edweakness, indicated he was totally dependent on the staff for transfers. Review of Resident 1's Weekly Progress Note dated 5/29/17 showed the resident was legally blind and required extensive assistance with his activities of daily living (ADL) care and total assistance with transfers. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's hospital History and Physical report dated 6/18/17 showed his right knee/hip X-ray results showed he had an acute fracture to his right lower hip bone and a large right knee swelling. A hard cast splint was applied to his right stump (knee). Review of Resident's 1 Investigation Report dated 6/23/17, showed during a transfer from the wheelchair to the bed, Resident 1 felt that his leg hit on the bed frame, causing him pain. An interview with CNA E showed during the transfer, the resident's prosthetic leg did not fully turn with the rest of his body. On 6/30/17 at 10 a.m., an interview was conducted with RN A. He stated Resident 1 was alert, oriented and able to make his needs known. He stated Resident 1 required total assistance from two staff members for transfers since admission. During an interview on 6/30/17 at 10:15 a.m., Resident 1 was interviewed with CNA B as an interpreter. Resident 1 was alert to name and place. He stated he hurt his right leg during a transfer from the wheelchair to the bed. Resident 1 stated CNA E placed the wheelchair on the right side of the bed with his head facing the wall (weaker side against the bed). He stated during the transfer, he was wearing his prosthetic leg and his right leg hit the bed frame. Resident 1 stated he was screaming in pain during the transfer. A concurrent observation of Resident 1's right stump showed a hard cast/splint in place with an ace wrap. He was not able to wear his right prosthetic leg. During an interview on 6/30/17 at 11:15 a.m., Physical Therapists (PT) C and D stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). They stated Resident 1 required a two person maximum assistance for transfers. PT C and D stated they were unaware of the reason Resident 1 was transferred from the bed to his wheelchair with the wheelchair positioned on his right side (weaker). During an interview on 6/30/17 at 11:30 a.m., the director of nurses (DON) stated if a resident has [DIAGNOSES REDACTED], two staff members should transfer the resident with the resident's dominant side closest to the bed/chair. During an interview on 6/30/17 at 11:40 a.m., CNA E stated on 6/14/17 at approximately 4 p.m., he was transferring Resident 1 from the wheelchair to bed. He stated he turned the wheelchair around so the resident was facing the wall and the resident's right side was against the bed. CNA E stated during the transfer the resident's prosthetic leg did not turn with him and the resident yelled out in pain. He stated he did not notify the nurse about Resident 1's pain because the pain subsided when the resident laid down in the bed. When CNA E was asked the reason he positioned Resident 1's weaker side against the bed, he stated because there was no room on the opposite side of the bed. He was unable to answer the reason he was unable to answer. Review of the National Institute for Occupational Safety and Health Website (www.cdc.gov/niosh/docs) documented for safe resident handling from the bed to the chair when the resident has impaired upper extremity strength, use a full-body sling (lift) and two caregivers should be used. If the resident has partial weight-bearing capacity, transfer toward the stronger side.