Every finding on record at Petaluma Post-Acute Rehabilitation

Based on observation, interview and record review, the facility failed to ensure two of two residents (Resident 36 and Resident 92) had access to devices needed for sensory impairment when,1. Resident 36 reported broken glasses, needed for distance, on admission, and the glasses remained unaddressed a month later. And,2. Resident 92 reported needing hearing aids to hear people clearly, on admission, and Social Services did not respond to his request.This failure affected both residents' ability to actively engage in their care, their overall functionality, and their sense of well-being. Findings:1. A review of Resident 36's clinical record indicated she was admitted in 11/2025, with a diagnosis of a fracture of her left patella and a large contusion over her left eye after a fall. A review of Resident 36's inventory of personal effects, dated 11/18/25, indicated she reported that glasses were broken. A review of Resident 36's MDS (MDS-A resident assessment tool), dated 11/22/25, indicated no cognitive impairment and that vision was adequate (meaning she could read fine print). A review of Social Services initial assessment, dated 11/25/25, indicated she did not require a vision referral. A review of Resident 36's Care Plan indicated the Activities Assistant identified a vision deficit and need for glasses, on 11/28/25. A care plan further indicated Resident 36 was a high falls risk. During a concurrent interview and observation on 12/16/25 at 9:30 a.m., with Resident 36 in her room, her glasses were visualized, and the right lens was completely shattered. Resident 36 stated she had told staff but could not remember who, and needed glasses for distance, watching TV, driving, and having her glasses would help with physical therapy and walking. Resident 36 stated, I really don't want to fall again. During an interview on 12/18/25 at 2:41 p.m., with the Social Services Director (SSD), the SSD stated the broken glasses were reported on admission, but she did not think it was urgent. The SSD further stated she understood how it would affect Resident 36's functionality and could cause her anxiety about falling again as well as her readiness for discharge. 2. A review of Resident 92's clinical record indicated he was admitted in 12/2025, with a diagnosis of surgical aftercare following surgery on the digestive system. A review of Nursing Progress Notes, dated 12/10/25 at 03:29 p.m., indicated Resident 92 reported he lost his hearing aids during his transfer from the hospital. The note further indicated the nurse would endorse this with Social Services. A review of an MDS, dated [DATE], indicated Resident 92 had minimal cognitive impairment, and he had moderate difficulty hearing (meaning speaker had to increase volume and speak distinctly). A review of Resident 92's initial Social Services assessment, dated 12/15/25, indicated Resident 92 did not need a hearing amplifier or a hearing referral. During an interview on 12/15/25 at 12:38 p.m., with Resident 92 in his room, Resident 92 reported he did not have his hearing aids and needed them; he reported it to someone but not sure who. Resident 92 stated he could hear if it was up close, but it made communication difficult and he must ask people to repeat themselves frequently. During an interview on 12/18/25 at 10:56 a.m., with the SSD, the SSD stated she could not find a note about Resident 92's hearing aids and there may have been some confusion. During a subsequent interview at 11:26 a.m., the SSD stated nothing had been done about the missing hearing aids. At 2:49 p.m., the SSD stated residents and staff reported concerns verbally to herself and to her partner but there could be a better way to record or document these concerns, so they do not get missed or delayed. During an interview on 12/19/25 at 9:22 a.m. with the Director of Nursing (DON), DON stated nursing or SSD should do a sensory assessment for quality of life and if a resident brings the need to our attention her expectation would be to get started on it right away. A review of a facility policy titled, Sensory Impairments-Clinical Protocol, revised 3/2021, indicated staff would identify individuals with sensory impairment. identify the cause.order appropriate consultations when necessary.

Based on observation, interview and record review, the facility failed to ensure safe medication labeling and storage practices were followed when,1. A loose Lantus Solostar Insulin Pen (A disposable prefilled injection device for long-acting insulin administration for diabetic residents) was found in the medication refrigerator with no label, no resident name, no instructions, no open date. And,2. Medication tablets and pills intended for wasting, were collected and filled in an unlabeled urine specimen cup that was stored inside a medication cart.These failures had the potential to contribute to unsafe medication use and administration and medication diversion.Findings: 1. During a concurrent observation and interview on 12/17/25 at 1:05 p.m., in the main medication room with the Nurse Manager (NM), a loose unlabeled Lantus Solostar Insulin Pen was found in the medication refrigerator. The NM stated he did not know why it was not labeled or which resident it was for. The NM further stated, if the medication was not labeled it could be used for the wrong resident. During an interview on 12/19/25 at 9:22 a.m., with the Director of Nursing (DON), the DON stated all medications should be labeled with the resident name, date of birth , directions, expiration date and open date. The DON further stated this did not meet her expectations, and the medication would be unusable as they did not know who it belonged to. A review of a facility policy titled, Medication ordering and receiving from Pharmacy, dated 04/2014, indicated each prescription label should include resident name, specific directions for use, medication name, medication strength, prescribers name, date dispensed, quantity of medication, expiration date, name address and telephone number of the pharmacy, and prescription number. 2. During an observation on 12/17/25 at 8:53 a.m., of a medication administration in Hall C with Medication Cart C, Licensed Nurse 2 (LN2) spilled a med cup with two medications inside and proceeded to waste the two medications into a urine specimen cup filled with loose meds and stored in the medication cart drawer. During an interview on 12/17/25 at 9:05 a.m., with LN 2, LN 2 stated the urine cup was for non-controlled medications intended for destruction and acknowledged the cup was full. LN 2 further stated it was emptied at some point, but she was unsure of when and by whom. During a concurrent observation and interview on 12/17/25 at 10:45 a.m., in Hall C, Medication Cart C was surveyed with LN 2. The urine cup full of loose medications to be destroyed was still in cart. LN 2 stated she was not sure if this followed facility policy, but to destroy medications she would take them to the main medication room, crush them, and put them in the incinerator bin, if it was a controlled medication, do the same process with another nurse to witness and co-sign. LN 2 stated, having loose medications in carts presented a risk of potential access by residents and other facility staff. During a concurrent observation and interview on 12/17/25 at 11:10 a.m., in Hall D with Medication Cart D and Licensed Nurse 3 (LN 3), no urine specimen cup with loose medications was seen. LN 3 stated she would destroy medications as soon as possible and that it was not policy to keep a urine cup full of meds in the cart. During an interview on 12/17/25 at 11:42 a.m., with Licensed Nurse 1(LN1), LN 1 stated to destroy non-controlled medication she would take it to the med room and dispose of it in the incinerator bin, and that she did not think it was policy to keep loose medications in a urine cup in the med cart. LN 1 further stated the policy was to not have any loose medications in the carts. During an interview on 12/17/25 at 1:05 p.m., with the Nurse Manager (NM), the NM stated all non-controlled meds should be destroyed by end of shift, and if there is a urine cup holding loose medications in the cart, it should not be full and should have been emptied. During an interview on 12/19/25 at 9:22 a.m., with the DON, the DON stated she did not feel it was best practice to keep a urine specimen cup full of loose medications to be wasted in the cart. This Surveyor requested a more specific policy for medication wasting during administration. The DON could not provide such a policy. A review of facility policy titled, Disposal of Medications and Medication Related Supplies, revised 10/2025, indicated that non-controlled medications shall be disposed in the proper waste container in the medication room.

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed for two of two Residents (Resident 62 and Resident 64), when Licensed Nurse 1(LN 1) did not disinfect the blood pressure cuff between use on these residents.This failure had the potential to spread infection between residents.Findings:During an observation on 12/17/25 at 8:09 a.m., in Hall A, LN1 checked the blood pressure of Resident 64 and did not disinfect the blood pressure cuff afterwards.During an observation on 12/17/25 at 8:26 a.m., in Hall A, LN1 proceeded to check the blood pressure of Resident 62 and did not disinfect the blood pressure cuff prior to using.During an interview on 12/17/25 at 8:43 a.m., with LN 1, LN1 stated she should have cleaned the blood pressure cuff between residents to stop the spread of germs from resident to resident.During an interview on 12/17/25 at 1:36 p.m., with the Infection Preventionist (IP), the IP stated all vitals equipment should be cleaned at the start of the shift and between residents always, all multi-use equipment should follow this standard to protect residents against infection.During an interview on 12/19/25 at 9:22 a.m., with the Director of Nursing (DON), the DON stated it was her expectation that all reusable equipment be cleaned between residents, and all staff should follow the infection control program.A review of a facility policy titled, Cleaning and Disinfecting Non-Critical Resident Care Items, revised 6/2021, indicated non-critical reusable items are disinfected between residents and as needed.

The facility failed to ensure the Ombudsman (A government official who advocates for residents directly with the facility to resolve concerns and complaints) was notified, when one Resident (Sampled Resident #83) was transferred to the hospital.This failure had the potential to deny protection to Resident #83 from being inappropriately transferred or discharged and to have access to an advocate who could inform them of their options and rights. Findings:During a concurrent interview with the Nurse Manager (NM) on 12/17/2025 at 11:47 AM, the NM stated, when a resident was going to be transferred the expectation for nurses was to call the physician, notify family, get paperwork ready and to complete a hand-off report to the accepting facility. The NM did not state the expectation was to also notify the facility Ombudsman.During an interview and concurrent record review with the Director of Nursing (DON) at 11:47 AM, she stated Resident #83 was sent to the hospital for shortness of breath on 10/20/2025. She stated Resident #83 was admitted to the hospital, and the physician and Resident #83's husband were notified. She stated she could not find documentation the Ombudsman was notified of the transfer. The DON stated the, Ombudsman was not notified.During an interview and concurrent record review with Social Services (SS) on 12/17/25 at 11:55 AM, she stated a Notice Of Transfer document was completed in the electronic medical record and was automatically emailed to the Ombudsman. She stated the facility Policy & Procedure supported this practice. She attempted to find a copy of the notification to the Ombudsman in the medical record and then in a binder where she kept copies of all the notifications. She stated the notification to the Ombudsman was not done and indicated, We missed it. SS stated they did not complete the notice to the Ombudsman for this discharge and transfer for Resident #83. She stated it was, Supposed to be done, and it was not done, and they did not follow the facility Policy & Procedure.During an interview on 12/17/2025 at 12:40 PM, with the Director of Nursing (DON) and Administrator (ADM), they stated they tried to locate the notice to the Ombudsman for Resident #83's transfer to the hospital. The Administrator stated, anytime a resident left the facility, The Ombudsman SHALL be notified. She stated the Ombudsman was not notified for Resident #83 and it was supposed to have been completed.The Policy and Procedure for Transfer Notification to the Ombudsman was requested and not received by the end of Survey.

Based on interviews and record reviews, the facility failed to implement an effective discharge planning process for one resident (Resident 1) of three sampled residents when Resident 1 and his family member were not trained on how to administer Resident 1's enteral nutrition formula (liquid nutrition) using Resident 1's gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and Resident 1's feeding pump (used to deliver the enteral nutrition) had not been delivered to Resident 1's residence upon his discharge. These failures resulted in Resident 1 not having received any nutrition for over 30 hours after his discharge from the facility, his transfer to the Emergency Department (ED) to be evaluated because of the potentially negative effect to his health and well-being, and his readmission to the facility on e day after discharge. Findings: A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with diagnoses which included pneumonitis (the inflammation of lung tissue) due to the inhalation of food and vomit, severe protein-calorie malnutrition, dysphagia (difficulty swallowing food or liquid by mouth), and dyskinesia of the esophagus (when the muscular tube that carries food from the throat to the stomach moves abnormally). A review of Resident 1's transfer/discharge note dated 2/27/24 at 12:24 p.m., indicated, Patient [Resident 1] discharged to home at [11:45 a.m.] per MD [physician] orders .Demonstration on G-tube care provided . During an interview on 3/12/25 at 12:50 p.m., Licensed Nurse A (LN A) stated she was the nurse assigned to Resident 1 on 2/27/25. LN A stated she provided Resident 1 and his family with the enteral feeding formula, tubing, and syringes. The LN A confirmed Resident 1 was not provided with a feeding pump upon discharge because it was her understanding the social services department had arranged for the feeding pump to be delivered to Resident 1's house. The LN A stated she provided Resident 1's family member with discharge instructions which included the medication list. A review of Resident 1's Discharge Instruction , dated 2/24/25 at 3:55 p.m., indicated the following: -discharge date : 2/27/25. -Discharge To: Home. -Diet: NPO (Nothing by mouth). -G-Tube Feeding: Isosource 1.5 at 65 ml (milliliters)/ hr per hour). - Resident 1's Cognition (ability to think and understand) /Psychosocial (the relationship between a person's social factors and behavior) Status: Alert, Confused and times, and Cooperative. -Resident 1's Rehab/Discharge Potential: Motivated to Self-Care and Follows Instructions. -Activities of Daily Living (basic tasks people perform to maintain their daily life and well-being): Resident 1 was dependent on others to eat. -Resident 1 was scheduled to receive services at home for physical, occupational, and speech therapy and nursing services for the administration of his medications and management of his G-tube feedings. -Medical Equipment Arrangements were made to be delivered. -Medication Education was provided by the facility's nurse. -Special Trainings/Instructions specifically for the Tube Feeding/Administration was not indicated as completed by any licensed staff at the facility prior to or upon Resident 1's discharge. During an interview on 3/13/25 at 1:25 p.m., Resident 1's family member stated when Resident 1 was discharged on [DATE], he was under the impression the facility would order the tube feeding formula and feeding pump for Resident 1's use at home. The family member denied having been trained before on how to start the tube feeding using the feeding pump prior to or upon Resident 1's discharge on 2/27/25. The family member stated the home health nurse came to Resident 1's home 2/28/25 at approximately 11:30 a.m. At the time, Resident 1 had not received any nutrition for approximately 24 hours. The family member stated the home health nurse called the facility to inquire about the tube feeding formula and the feeding pump. Then the home health nurse advised the family member to take his Resident 1 to the hospital if the facility was not readmitting him. A review of Resident 1's hospital emergency provider note dated 2/28/25 at 2:35 p.m., indicated, .The patient has not been fed since yesterday at 10am .The patient was discharged from post-acute care yesterday .Weight .90 lb [pounds] Height .5' [feet] 8 [inches] .This is a .male who presents to the ED for feeding. The patient does not know how to do this at home and so was brought in for some education and some sustenance .The post-acute care facility will take this patient back and so he will be discharged to their care today. A review of Resident 1's care plan focused on his discharge home initiated on 1/28/25 indicated, The resident's goal is to return home .Goal .The resident will demonstrate correct administration of medications/treatments through the next review date .[Interventions for staff to implement to assist Resident 1 to achieve his goal of returning home included] Evaluate/record the resident's abilities and strengths, with resident's family and IDT [Interdisciplinary Team, a group of professionals from different disciplines who work together collaboratively to achieve a common goal]. Address gaps by referral to appropriate home health disciplines, assessment and education of additional caregivers with resources provided, facilitation of DME [Durable Medical Equipment, such as a feeding pump]. During an interview on 3/14/25 at 10:20 a.m., Management Staff C denied she had verified Resident 1's enteral feeding formula and feeding pump were to be delivered to the facility or Resident 1's home prior to Resident 1's discharge. Management Staff C acknowledged she had only provided Resident 1 with the name of the medical supply company, the name of the home health company, and their phone numbers. During an interview on 3/14/25 at 11:05 a.m., Management Staff D acknowledged it was her responsibility to order DME for residents but at times would share the load. For Resident 1's discharge, Management Staff C ordered the feeding pump for Resident 1. Management Staff D stated she found out after Resident 1's discharge the medical supply company scheduled to deliver Resident 1's tube feeding supplies did not deliver to resident homes. A review of Resident 1's facility document titled History and Physical dated 2/28/25, indicated, Readmission due to nutrition supply delay. A review of the facility's policy and procedure (P&P) titled Social Services dated 3/2022, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial . well-being . The Director of Social Services is a qualified social worker and is responsible for . Submitting nursing, therapy, and DME orders upon discharge to appropriate agencies. A review of the facility's P&P titled Discharge Summary and Plan dated 10/2022, indicated, When a resident's discharged is anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment . The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include .What factors may make the resident vulnerable to preventable readmissions.

Based on observation, interview, record review, facility policy review, the facility failed to complete an assessment to determine if a resident was able to self-administer their medication(s) for 1 (Resident #52) of 18 sampled residents. Findings included: A facility policy titled, Self-Administration of Medications, revised 12/2022, indicated, 1. As part of their overall evaluation, the staff will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff will perform a more specific skill assessment, including (but not limited to) the residents a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. An Admission Record revealed the facility admitted Resident # 52 on 11/13/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of intracapsular fracture of the right femur. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #52's care plan included a focus area initiated 11/13/2024, that indicated the resident had alteration in comfort due to pain. Interventions directed staff to administer prescribed pain medication. Resident #52's Admission / Readmission Screen and Baseline Care Plan, dated 11/13/2024, indicated the resident did not request to self-administer medication(s). Resident #52's Medication Review Report, for the timeframe 12/13/2024 - 01/13/2025, revealed an order dated 12/12/2024, for Biofreeze professional external gel 5%, apply to neck topically every six hours as needed for pain management. During a concurrent observation and interview on 12/16/2024 at 2:06 PM, Resident #52 removed Biofreeze (a pain relief gel) from their bedside table and stated they spoke with someone who agreed to allow them to keep the medication at their bedside. Resident #52 stated the medication was used for their neck pain. During an interview on 12/18/2024 at 8:04 AM, Registered Nurse (RN) #2 acknowledged Resident #52 kept Biofreeze medication at their bedside. RN #2 stated she did not know if a self-administration of medication assessment had been completed. During an interview on 12/18/2024 at 1:37 PM, the Director of Nursing (DON) stated she was not aware Resident #52 had medication at their bedside. The DON stated Resident #52 had not been assessed to keep the Biofreeze at their bedside. According to the DON, the nurse should not have given the medication to the resident to keep at their bedside as the interdisciplinary team had not met to discuss if the resident was safe and able to self-administer the medication.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore a gown and gloves when they provided incontinence care to 2 (Resident #34 and Resident #66) of 18 sampled residents. Findings included: A facility policy titled Enhanced Barrier Precautions, effective 08/06/2024, revealed, Enhanced Barrier Precautions (EBP) - used in conjunction with the standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs [multidrug-resistant organisms] to staff hands and clothing to reduce transmission. The policy specified, 4. Facility staff shall perform hand hygiene and in cases when standard precautions may not be sufficient, will don gown and gloves before performing high-contact resident care activities. The list below is not all-inclusive, and activities requiring EBP are on a case by case basis as determined by the facility * Device care or use: PICC/MID [peripherally inserted central catheter/midline] line, urinary catheter, feeding tube, tracheostomy/ventilator * Wound care on chronic wounds requiring a dressing * Bathing/showering * Dressing and/or Transferring where contact with bodily fluids is likely * Providing hygiene where standard precautions may not be sufficient * Changing soiled linens * Changing briefs or assisting with toileting. 1. An Admission Record revealed the facility admitted Resident #66 on 11/07/2024.According to the Admission Record, the resident had a medical history that included a diagnosis of retention of urine. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2024, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #66 was dependent on staff for lower and upper body dressing. The MDS indicated the resident was dependent on staff for toileting hygiene and had an indwelling catheter. Resident #66's care plan included a focus area initiated 12/02/2024, that indicated the resident had an activity of daily living self-care performance deficient related to impaired mobility, weakness, deconditioned, and multiple medical problems. During an observation on 12/17/2024 at 2:01 PM, Certified Nurse Aide (CNA) #3 and CNA #4 assisted Resident #66 with repositioning. CNA #3 and CNA #4 wore gloves and no gowns. CNA #3 handed CNA #4 the resident's urinary catheter bag and assisted the resident to turn in bed. CNA #3 was also noted to hold the resident's urinary catheter bag and adjusted the resident's catheter tubing. During an interview on 12/17/2024 at 2:02 PM, CNA #3 stated she did not wear a gown because she did not empty the resident's urinary catheter bag. According to CNA #3, she only needed to wear a gown when she emptied the resident's urinary catheter bag. During an interview on 12/17/2024 at 2:13 PM, CNA #4 stated she did not wear a gown when she assisted CNA #3 to reposition Resident #66. Per CNA #4, she only needed to wear a gown when she emptied the resident's urinary catheter bag. During an interview on 12/18/2024 at 8:20 AM, the Infection Preventionist stated staff should use personal protective equipment for high contact activities for residents on enhanced barrier precautions. 51749 2. An Admission Record revealed the facility admitted Resident #34 on 02/25/2019. According to the Admission Record, the resident had a medical history that included diagnoses of chronic kidney disease and retention of urine. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene, was frequently incontinent of bowel, and had an indwelling catheter. Resident #34's care plan included a focus area initiated 11/14/2024, that indicated the resident was at high risk for developing complications to include a urinary tract infection due to the presence of a catheter related to obstructive uropathy. During an observation on 12/17/2024 at 2:22 PM, Certified Nurse Aide #5 did not wear a gown when she provided incontinence care to Resident #34. During an interview on 12/18/2024 at 8:20 AM, the Infection Preventionist stated staff should use personal protective equipment for high contact activities for residents on enhanced barrier precautions.

Based upon observation, interview and record review the facility failed to provide individualized activities for three of 17 sampled residents (Resident 43, 58, and 64). This deficient practice had the potential to affect the quality of life of residents by placing them at risk of sensory deprivation and decreased cognitive functioning. Findings: 1. During a review of Resident 43's, Admission Record, dated 2/10/22, indicated she had been admitted to the facility on [DATE] following a hip replacement surgery (surgery to implant an artificial hip joint), muscle weakness and low blood pressure when standing or sitting. A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/31/22, indicated the resident exhibited no cognitive deficits. During a concurrent observation an interview on 3/7/22, at 3:28 p.m., Resident 43 stated that no one had come to her bedside to offer books or or provide other activities to complete at the bedside. Resident 43 was asked if she attended activities that were schedule at the facility, she stated, No, I do not know anything about activities, what would that be? Resident 43's attention was directed to a calendar indicating March, posted on the resident's wall. The calendar indicated activites scheduled each day of the month, at various times. Resident 43 stated she could not read the activity calendar from her bed because it was too small to read. Resident 43 was asked if she might enjoy listening to New [NAME] music. The resident answered affirmatively and wanted to know when that had been scheduled. When Resident 43 was informed the activity had already taken place, the resident exhibited an expression of disappointment. During a review of Resident 43's, Plan of Care, dated 2/23/22, indicated staff would provide one-to-one visits for social interactions and to provide accommodations, such as discussing about Daily News/World News for leisure activities. During a review of Resident 43's, Activity Assessment Form, dated 2/23/22 indicated the resident liked to listen to music, keep up with the news and do things with people as very important. During a review of Resident 43's, Activity Attendance Record, for the month of March 2022 indicated the resident had not attended any activities outside of her room but was provided three in-room visits (3/1/22, 3/8/22 and 3/10/22) where conversation had taken place. A request had been made for, Activity Attendance Record for the month of February and the facility could not produce documentation. 2. During a review of Resident 58's, Admission Record, dated 2/8/22, indicated Resident 58 had been admitted to the facility on [DATE] with a history of Diabetes (a group of diseases that result in too much sugar in the blood), [CONDITION(S)] (a group of lung disease that block air flow and make it difficult to breathe) and high blood pressure. A review of Minimum Data Set (MDS), a standardized cognitive assessment dated [DATE], indicated she had minimal cognitive deficits. During an interview, on 3/8/22 at 10:04 a.m., Resident 58 stated no one had offered her engagement with activities while she was in bed. Resident 58 was asked if she was aware of the activity calendar for March 2022 posted on the wall in her room, and the resident stated, No. Resident 58 stated she was unable to view the calendar because of the effect diabetes had on her eyes. Resident 58 stated she was bored and thought it was very boring here. During a review of Resident 58's, Plan of Care, dated 2/9/22 indicated the staff would provide one to one visit for social interaction and to provide accommodations such as outdoor leisure time activities. During a review of Resident 58's, Activity Assessment Record, dated 2/9/22, indicated listening to music, being with groups of people and doing her favorite activities were somewhat important. Resident 58 indicated the only activity as very important was going outside and getting fresh air. During a review of Resident 58's, Activity Attendance Record, dated the month of February 2022 indicated she had not attended any activities outside of her room and she had seven room visits (2/9/22, 2/10/22, 2/11/22, 2/15/22, 2/21/22, 2/24/22 and 2/28/22), during which conversation and social interaction had taken place. 3. During a review of Resident 64's, Admission Record, the record indicated Resident 64 was admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. A review of Minimum Data Set (MDS), a standardize cognitive assessment dated [DATE], indicated she had moderate cognitive deficits. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During a review of Resident 64's, Plan of Care dated 2/17/22 indicated she liked to listen to music and for staff to be aware of resident's preferences and to provide care in a timely manner. During a review of Resident 64's, Activity Assessment Form dated 2/17/22, indicated her family provided the answers to the form. Listening to music was indicated to be somewhat important to Resident 64 per her family. During an observation on 3/9/22 at 9:57 a.m., in the hallway outside of room [ROOM NUMBER], MTG E was observed going into room [ROOM NUMBER] with no supplies and stayed in the room for a few minutes and then exited the room to go into another resident room. During an interview on 3/9/22 at 4:29 p.m., with MTG E, she stated she had no other staff to carry out activities as she was the sole employee for the Activity Department. MTG E stated she did not have a list of residents that require one to one time in their rooms. MTG E stated she would visit each resident every morning to do a check in on how everyone was feeling. MTG E stated she did not like bringing a cart to check-in on residents and if a resident requested materials like coloring pages, she could then go back to the activity room and bring a binder full of various coloring pages. MTG E stated she did not think it was a problem to conduct daily visits then head back to her activity room which was located at the end of a resident hallway to provide supplies and then start activities per the March calendar by 10:30 a.m., Monday through Friday. MTG E stated she did not work on the weekends. MTG stated there were 80 residents in the building and she would visit each resident from one minute to 15 minutes if they wanted to speak with her. MTG E stated she arrived at the facility at usually 8:00 a.m. to start visiting residents. MTG E could not explain when she had time to document if residents were attending activities or how often room visits were conducted. MTG E stated for Resident 64 as an example, she would provide the room visit documentation for the month of February. MTG E could not produce documentation regarding room visits for February 2022. MTG E stated she had March 2022 documentation and by observing the document, Resident 64 had two room visits (3/2/22 and 3/7/22 where sensory touch stimulation had been done. MTG E stated that meant she had stroked Resident's hands or face. During a review of the facility's policy and procedure (P&P) titled, Activity Programs, dated 2022, the P&P indicated, Activities are scheduled 7 (seven) days a week .All activities are documented in the medical record .b. Are offered at hours convenient to the residents, including evenings, holiday and weekends: .

Based on observation, interview and record review, the facility failed to ensure residents could receive visitors outside of regular working hours for one (Resident 64) of 17 sampled residents. This failure did not ensure Resident 64's rights, and had the potential to negatively affect residents' psychosocial outcomes due to restricted visitation of families and friends who may want to visit and cheer-up residents in the morning or evening, outside of business hours. Findings: A review of Resident 64's Admission Record indicated she was admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up, become alert and respond to requests for interview. During an interview on 3/9/22 at 1:43 p.m., with Resident 64's Responsible Party (RP), the RP stated she could come and visit Resident 64 from 1 p.m. to 5 p.m. and that those were the facility's visiting hours, posted on the door coming into the facility. Resident 64's RP stated she would not ask to visit outside of these posted visiting hours since those were the rules, and she would follow the rules. During an interview on 3/10/22 at 3:11 p.m., with Director of Staff Development (DSD), the DSD stated as part of her role as infection preventionist she did not participate in determining visiting hours. During an interview on 3/10/22 at 3:26 p.m., with Direct of Nursing Services (DON), the DON stated she had participated in determining visiting hours and the recommended visiting hours were from 1 p.m. to 5 p.m. The DON stated the time frame had been determined to not conflict with resident care. During an interview on 3/10/22 at 3:36 p.m., with the Administrator (Admin), the Admin stated the posting on the door for visiting hours were from 1 p.m. to 5 p.m. but visitors could arrive at the facility outside of those hours and still be allowed to visit. Admin stated she would not know if visitors wanted to come to the facility outside of the posted hours unless someone approached her to request a different visiting time. During a review of the facility's policy and procedure (P&P) titled, General Visitation Policy: dated 2/21/22, the P&P indicated, Our recommended visitation hours are 1p.m.-5p.m. in order to not interfere with resident ADL (activity of daily living) care and scheduled meals.

Based on observation, interview and record review, the facility failed to follow the Infection Control Policy for 2 of 17 residents (Residents 14 and 33) when: 1. The Infection Preventionist (IP) did not perform hand hygiene between concluding a wound care and treatment for one resident (Resident 14) and touching doorknobs inside the resident's room. In 7/2021, Resident 14's wound became colonized with an infection caused [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)], a strain of bacteria resistant to certain antibiotics and spread by contact with infected people, surfaces, or things that carry the bacteria); 2. Resident 33 exhibited potential symptoms of C. Diff. (a healthcare-associated infection causing loose stools) but the facility delayed implementation of its infection surveillance policy. These failures delayed monitoring and treatment for Resident 33's infection, and had the potential to spread [CONDITION(S)] and C. Diff infections among residents in the facility. Findings: 1) During an observation on 03/09/22 10:00 a.m., in Resident 14's room, the IP prepared sterile liquid to wash and clean the wound/pressure ulcer in right hip and applied wound gel then covered the wound with sterile bandage. IP removed the dirty gloves and placed them inside the dirty plastic bag and sealed the bag with her bare hands. IP handed the dirty plastic bag to Certified Nursing Assistant to put in garbage. IP opened the resident's bathroom door using her bare hands, but the bathroom was occupied by a resident. IP then opened the other exit door with her bare hands. During an interview on 3/9/22 at 10:15 a.m., with IP stated the hand sanitizers were located outside resident's rooms in the hallway. During an interview on 03/10/22 09:27 a.m., with IP stated, Resident 14 was colonized ([CONDITION(S)] was present but not causing illness) with [CONDITION(S)]. IP stated Resident 14's condition only required standard precautions (e.g., universal precautions used fo avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields). IP stated she did not clean the doorknobs after she touched it with her dirty hands. IP stated the Primary Medical Doctor (PMD) did not order isolation precaution for Resident 14. During an interview on 3/10/22 at 9:29 a.m., the Director of Nursing (DON) stated IP's dirty hands touched dirty doorknobs, what's the difference, both were dirty? During an interview on 03/10/22, at 10:13 a.m., the Director of Staff Development (DSD) stated staff must use contact precaution when faced with the potential exposure of body fluids, to prevent the spread of an infection to other resident, staff, and visitors. The DSD stated, all surfaces needed to be clean and disinfect with bleach. During a telephone interview on 03/11/22, at 09:44 a.m., the Primary Medical Doctor (PMD) for Resident 14 stated the resident's wound was colonized with [CONDITION(S)]. A review of medical records for Resident 14 titled Nursing Care plan dated 1/13/22, indicated the wound was reinfected with green purulent drainage. A review of the facility Policy & Procedure (P&P) titled Handwashing/Hand hygiene dated 1/2019 revealed, The facility considers hand hygiene the primary means to prevent the spread of infections., #2 All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #3 Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. #7j After handling used bandages, contaminated equipment, etc. #7 m. after removing gloves. #8 Hand hygiene is the final step after removing and disposing of personal protective equipment. A review of facility (P&P) titled Isolation-categories of Transmission-based Precautions dated 12/2020, indicated: It is the intent of this facility that all resident blood body fluids, excretions and secretions other than sweat will be considered potentially infectious so standard precautions will be used for all residents. Contact Precautions 1) Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms (germs) that can be transmitted by direct contact with the resident. 4) Staff . will wear gloves (clean, non-sterile) when entering the room. When caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed, and hand hygiene performed before leaving the room. 2. During a review of Resident 33's Discharge Summary, dated 12/18/21, this document indicated Resident 33 was admitted to a hospital from 11/16/21 to 11/21/21, for epididymitis/orchitis (inflammation and infection of the scrotum and testicles). Resident 33 was started on antibiotics in the hospital and continued taking them at the skilled nursing facility until the end date of 12/1/21. During a review of Resident 33's Bowel Elimination task report for 12/2021 documented Resident 33 was having large loose/diarrhea stools. On 12/1/21 and 12/3/21 Resident 33 had 1 normal and 1 large loose stool. On 12/4/21 Resident 33 had 2 large loose stools. On 12/8/21 Resident 33 had 1 large loose stool. On 12/9/21 Resident 33 had 1 normal stool and 1 large loose stool. On 12/10/21 Resident 33 had 2 large loose stools and 1 large putty like stool. On 12/11/21 Resident 33 had 1 normal stool and 2 loose stools. On 12/12/21 Resident 33 had 2 large loose stools. During a review of Resident 33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The last dose was for 12/1/21 and this was documented as given. Resident 33 was on Senna ( a [MEDICATION(S)] to prevent constipation,) 1 tablet to be given twice a day (morning and evening,) and to be held if resident had loose stools. Resident 33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Senna was not given on 12/11/21. On 12/12/13 the morning dose was given, and the evening dose was not given. Resident 33 was also on [MEDICATION(S)] (a [MEDICATION(S)] used to treat occasional constipation) ordered to be given once a day and held if resident had diarrhea. This medication was given to Resident 33 on 12/1/21 to 12/10/2 and not given 12/11/21, then given 12/12/21 and 12/13/21 in the morning. During a review of Resident 33's Progress Notes, on 12/10/21 at 1:15 p.m., Staff L documented Resident 33 had a bout of diarrhea before lunch, and staff would continue to monitor. During a review of Resident 33's Progress Notes, on 12/12/21 at 7:53 p.m., Staff M documented that the physician was notified that Resident 33 had a change of condition, related to a fever of 101.3 degrees Fahrenheit. the physician recommended to obtain urine and blood work done if the fever recurred. During a review of Resident 33's Progress Notes, on 12/13/21 at 2:30 p.m., Staff N documented that on the way to a physician's appointment Resident 33 vomited. The physician advised the transport team to send Resident 33 to the Emergency Department. During an interview on 3/11/21 at 10:30 a.m., DON stated that it was known that Resident 33 had some diarrhea, and they held his laxatives. DON stated Resident 33 normally had one large normal stool every day. DON stated that the bout of diarrhea that she knew of did not appear to be a stool that would have been infected with Clostridioides difficile. DON stated they did not investigate further, did not start an infection surveillance check list, and did not notify the physician. During an interview and concurrent record review on 3/11/21 at 10:30 a.m., DON stated facility staff had documented Resident 33's infection on the Infection Prevention and Control Surveillance Log for 12/2021. Review of the Infection Prevention and Control Surveillance Log indicated the facility documented on 12/19/21 that Resident 33 had C. Diff. due to antibiotic use. The Log indicated the onset date as 12/19/21. The Log indicated no record of infection surveillance of Resident 33 during the first two weeks of December 2021, the time when the resident had loose bowel movements and immediately after the resident completing concurrent courses of antibiotics. During a review of Resident 33's Discharge Summary dated 12/18/21 indicated Resident 33 presents back to the ED for further evaluation of fevers, nausea, abdominal pain and diarrhea. Resident 33 was found to have C Diff Positive which is Clostridioides difficile. Illness from Clostridioides difficile typically occurs after one's use of antibiotic medications. The germ most commonly affects older adults in hospitals or in long-term care facilities. The most common signs and symptoms of mild-to-moderate C. difficile infection are watery diarrhea three or more times a day for more than one day, and mild abdominal cramping and tenderness. Signs and symptoms of severe infection include: Watery diarrhea as often as 10 to 15 times a day abdominal cramping and pain which may be severe, fever and nausea. This information is from the CDC webpage: CDC Healthcare-associated Infections (HAI) Diseases and Organisms. The facilities policy Surveillance for Infections, dated 2/2022, instructed the IP or DON will conduct ongoing surveillance for Healthcare-Associated Infections and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precaution . Infections that should be included were pneumonia, urinary tract infections and Clostridioides difficile.

Based on observation, interview and record review the facility failed to care plan (care plans provide communication among nurses, their residents and other healthcare providers to achieve health care outcomes) its continued use of a position change alarm (an audible alarm that alerts staff the resident is getting up, and that should be used only when medically necessary and with intermittent reevaluation for continued use) for for 1 of 17 sampled residents (Resident 28). Resident 28 was known to remove the clip connected to the alarm. The failure to care plan resulted in the position change alarm constantly in use, and had the potential to diminish Resident 28's psychosocial well-being. Findings: During an observation on 3/7/22 at 11:10 a.m., Resident 28 was sleeping in her bed. A position change alarm device was visible at the head of her bed. During an observation and concurrent interview on 3/8/22 at 10:25 a.m., Resident 28 was resting in bed. Staff L stated Resident 28 prefers to get up after lunch. We get her up into a wheelchair and she moves herself around the facility. Staff L stated we use the position change alarm every time Resident 28 is in her wheelchair and added, Resident 28 can remove the clip and string attached to the position change alarm. During an observation and concurrent interview on 3/10/22 at 10:25 a.m., Resident 28 was in her wheelchair at the doorway to her room and the position change alarm was in place. Staff L stated we always use the alarm, and the use of the alarm should be a part of the care plan. During an observation and concurrent interview on 3/11/22 at 9:20 a.m., Resident 28 was seen in the hall, a few doors from her bedroom. Staff N stated we use the position change alarm while Resident 28 is in bed and when she is in the wheelchair. Staff N stated we use the alarm because she is a fall risk and an elopement risk. Staff N stated, Resident 28 can propel herself all around the facility and likes to go to the doors to look outside. Staff N stated Resident 28 knows how to remove the clip and string attached to the alarm and will hide the clip. Staff N stated Everyone (staff) is to lookout for her and to respond when the alarm sounds. During a record review of Resident 28's Medication Review Report (recap of Physician orders) March 2022, revealed that a position change alarm was not ordered by an MD. During a record review of Resident 28's care plan, (printed 3/11/22) The care plan included a focus for Risk for Wandering or Elopement. The interventions listed were offering to walk with Resident 28, redirecting her when seen going toward door, offering structured activities, food, conversations, television and reading materials and providing her with a consistent routine. During a record review of Resident 28's care plan, (printed 3/11/22) The care plan included a focus for Risk of Falls. The interventions listed were anticipate and meet Resident 28's needs, make sure call light is within reach and respond promptly, ensure Resident 28 has appropriate footwear and provide Resident 28 a safe environment such as clean, clutter free floors, good lighting and a working call light. The facilities policy Care Planning Interdisciplinary Team, dated 1/2022, indicated Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on interview and record review the facility failed to revise a care plan with updated interventions for one (Resident 64) of 17 sampled residents, when facility staff reviewed the nutritional care plan but did not document new interventions to manage resident 64's continued weight loss. This failure resulted in Resident 64 suffering significant weight loss within one month. Findings: During a review of Resident 64's, Admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated 2/15/22, the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55 milliliters (ml) an hour (hr.) for 20 hours and to stop the feeding from 10:00 a.m. until 2:00 p.m., so Resident 64 could participate in therapy. Additional water had been added to meet 100% of her estimated nutritional needs. During a review of Resident 64's, Nursing Progress Notes dated 2/17/22, indicated the tube feeding hourly rate was going at a rate of 45 ml/hr. on 2/17/22, Dietary Progress Note, indicated the rate for the tube feeding was changed to 55 ml/hr per the doctor's order. Resident 64's weight was measured and indicated to be 94 lbs. During a review of Resident 64's, Dietary Progress Notes, dated 2/25/22 indicated Resident 64's weight had been measured at 90.8 lbs. The rate of tube feeding was recommended to be increased to 65 ml/hr. due to weight loss and additional water was added to meet nutritional needs. Blood sugar ranged from 117 to 390 with an average of 230 indicted in the dietary note. During a review of Resident 64's, Dietary Progress Notes dated 3/4/22 indicated Resident 64's weight had been measured at 89.4 lbs. Blood sugar levels were indicated to range from 90 to 389 with an average of 242. The dietary noted indicated Resident 64 had an unintended weight loss of 4.6 lbs. or 4.9% of total body weight. Dietary noted indicated Resident 64 remained on appropriate tube feed formula and she was meeting 100% or greater of her estimated needs. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During an interview on 3/10/22 at 3: 55 p.m. with RD J, she stated Resident 64 had high blood sugar levels and with those levels being so high, she would be unable to absorb the tube feeding formula and gain weight without additional insulin to lower the blood sugar levels and bring that sugar or energy back into the cells. RD J stated that more insulin would help Resident 64's body absorb the formula better and might allow her to gain weight. RD J stated she thought she should have followed up with the doctor regarding the consistently high blood sugar levels. RD J stated she had not spoken with the nursing staff to ask if Resident 64 had been getting all the formula being prescribed and if there were any challenges like the therapy schedule which might have interfered with her getting all the formula prescribed. RD J stated Resident 64's was considered significant and of concern since it had been going downward and not stabilizing or remaining the same. During a review of Resident 64's, Plan of Care dated 2/16/22 indicated Resident 64 would achieve a goal of tolerating her tube feedings. On 2/18/22, Resident 64's, Plan of Care had been updated on 3/4/22 to achieve a goal of maintaining her weight plus or minus four pounds with a set point of 89 pounds, indicating she had continued to lose weight since 2/17/22 (Admission weight was 94 pounds). Resident 64's, Plan of Care was reviewed for updated interventions to stabilize or encourage weight gain but no updated interventions beyond 2/18/22 were observed. During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team dated, 2022, the P&P indicated, 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team .5. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face to face, teleconferences, written communications, etc.) is a the discretion of the Care Planning Committee.

Based on interview and record review, the facility failed to adopt a discharge care plan that identified nutritional needs for one (Resident 64) of 17 sampled residents, when the facility's discharge plan for Resident 64 did not address weight loss and how to stabilize or gain weight. This failure had the potential to cause Resident 64 further weight loss and fatigue. Findings: During a review of Resident 64's, Nursing Progress Notes, dated 11/11/21, indicated Resident 64 had been admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 64's, Nursing Progress Notes, dated 11/16/21, indicated Resident 64 had discontinued [CONDITION(S)]. During a review of Resident 64's, Dietary Progress Notes, dated 11/19/21, indicated Resident 64 had lost 5.2 pounds, or 4.3% of her total body weight, and weighed 121 pounds. The Dietary Progress note indicated Resident 64 had been eating approximately 41% of her meals. Resident 64's diet preferences had been changed to add sherbet for a snack and continue to monitor weights and follow-up. The Dietary Progress Note indicated Resident 64 had her own supply of a protein supplement drink. During a review of Resident 64's, Dietary Progress Notes, dated 11/26/21 indicated Resident 64 had lot a total weight of 5.6 pounds or 4.8% of her body weight within one week and her weight was measured at 110.8 pounds. Resident 64 had been consuming approximately 54% of her meals, plus the snack and protein supplemental drink, no new recommendations were included in the plan of care. The goal weight had been adjusted to stay within plus or minus four pounds of 110 pounds. During a review of Resident 64's, Dietary Progress Notes, dated 12/7/21, indicated Resident 64 had lost 13.6 pounds since admission (11/9/21) or 11% of her total body weight and had a body weight measured at 108 pounds. The goal weight had been adjusted to stay within plus or minus four pounds of 110-pound body weight. The Dietary Progress Note indicated Resident 64 had met the goal weight range. The note indicated a recommended change to discontinue regular sherbet and add sugar free sherbet to her diet. During an interview on 3/10/22, at 3:55 p.m., Registered Dietician J (RD J) stated Resident 64 was admitted to the facility on [CONDITION(S)], due to a condition that caused fluid build-up. RD J stated that fluid build-up caused a resident to gain weight, not lose weight. RD J stated she did not contact the [CONDITION(S)] center to learn Resident 64's dry weight (the resident's weight without the excess fluid that builds up between [CONDITION(S)] treatments). RD J stated Resident 64 indicated her desired weight was around 110 pounds, and the Resident 64's initial weight loss had been acceptable. RD J stated Resident 64 stopped [CONDITION(S)] while receiving care at the facility. RD J verbalized agreement that when a resident usually would gain weight rather than lose weight after stopping [CONDITION(S)]. RD J did not know the reason why Resident 64 continued to lose weight through her stay at the facility stay. RD J did not know why Resident 64's discharge plan did not include recommendations to ensure weight stability or to increase weight from 98.2 pounds, at discharge. When asked how Resident 64's protein shakes were calculated into the resident's dietary plan, RD J was unable to vocalize a process. RD J stated staff did not measure each drink container to determine how much was consumed each day. RD J stated Resident 64 lost a total of 13 pounds of body weight during the facility stay, and RD J considered a significant weight loss and concerning. RD J stated she provided no recommendations for managing Resident 64's weight loss. During a review of Resident 64's, Nursing Progress Note, dated 12/13/21 indicated she would be discharged on [DATE] to home with follow up appointments, equipment needs addressed and referrals for Home Health services made. During a review of Resident 64's, Plan of Care, dated 11/11/21 had a discharge plan to follow up with kidney specialist, outlined medical devices she used but did not indicate any dietary changes to stabilize or gain weight. During a review of Resident 64's, Discharge Order, dated 12/13/21 or Resident 64's, Discharge Instructions dated 12/9/21 did not indicate a plan for Resident 64's weight loss or recommendations to stabilize or gain weight for Resident 64. Resident 64's Discharge Instructions indicated she had a documented weight of 98.2 pounds measured on 12/10/21. During a review of the facility's policy and procedure titled, RD (Registered Dietician) FOR HEALTHCARE, INC WEIGHT CHANGE PROTOCOL, dated 2018, the P&P indicated, Identify reasons for the weight loss, .Consider possible health effects from the weight change .Suggest interventions to correct the identified problem, diet supplementation, appetite stimulation .The evaluation process is done again if there is another significant weight change .The following criteria defined significant .Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 5% weight loss in one month .

Based on observation, interview and record review the facility failed maintain acceptable nutrition for one (Resident 64) of 17 sampled residents. This resulted in Resident 64 suffering a significant weight loss within one month of admission, which effected her overall health and well-being. Findings: During a review of Resident 64's, Admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated [DATE], the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55 milliliters (ml) an hour (hr.) for 20 hours and to stop the feeding from 10:00 a.m. until 2:00 p.m., so Resident 64 could participate in therapy. Additional water had been added to meet 100% of her estimated nutritional needs. During a review of Resident 64's, Nursing Progress Notes dated [DATE], indicated the tube feeding hourly rate was going at a rate of 45 ml/hr. on [DATE], Dietary Progress Note, indicated the rate for the tube feeding was changed to 55 ml/hr per the doctor's order. Resident 64's weight was measured and indicated to be 94 lbs. During a review of Resident 64's, Nursing Progress Notes dated [DATE], indicated Resident had a change in condition by appearing less responsive, very sleep and had a blood sugar level of 577 (per MedicineNet/WebMD, normal blood sugar for an adult with diabetes should be less than 180). The medical doctor was notified, and insulin (a hormone that controls the amount of sugar in the bloodstream and helps the body store glucose (simple sugar) in the liver, fat and muscles) medication had been prescribed. During a review of Resident 64's, Dietary Progress Notes, dated [DATE] indicated Resident 64's weight had been measured at 90.8 lbs. The rate of tube feeding was recommended to be increased to 65 ml/hr. due to weight loss and additional water was added to meet nutritional needs. Blood sugar ranged from 117 to 390 with an average of 230 indicted in the dietary note. During a review of Resident 64's, Dietary Progress Notes dated [DATE] indicated Resident 64's weight had been measured at 89.4 lbs. Blood sugar levels were indicated to range from 90 to 389 with an average of 242. The dietary noted indicated Resident 64 had an unintended weight loss of 4.6 lbs. or 4.9% of total body weight. Dietary noted indicated Resident 64 remained on appropriate tube feed formula and she was meeting 100% or greater of her estimated needs. During an observation on [DATE] at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up and respond. During a concurrent interview and observation on [DATE] at 2:32 p.m., with Licensed Staff O at Resident 64's bedside, she stated the tube feeding at the bedside was turned off and disconnected so Resident 64 could attend physical therapy. Licensed Staff O stated she had previously requested from the Rehabilitative Therapy Department to work with her during 10:00 a.m. and 2:00 p.m. while the feeding was scheduled to be turned off. Licensed Staff O then left the room to demonstrate physical therapy was working with Resident 64 in the hallway just outside of her room. Licensed Staff O stated Resident 64 was tolerating her tube feedings as nursing would check if the formula was not being absorbed by the stomach. At 2:45 p.m., Resident 64 was working with physical therapy and the tube feeding continued to be turned off. During an interview on [DATE] at 3: 55 p.m. with RD J, she stated she was aware of Resident 64's wieght loss and stated each time she was weighed there were new calculations regarinding required nutritional needs. RD J stated she was aware the current tube feeding regime had not been assisting Resident 64 in stablizing if not gaining weight but stated the calculation were based on evidence based practice for dieticians. RD J stated, Resident 64 had high blood sugar levels and with those levels being so high, she would be unable to absorb the tube feeding formula and gain weight without additional insulin to lower the blood sugar levels. RD J stated that more insulin would help Resident 64's body absorb the formula better and might allow her to gain weight. RD J stated she thought she should have followed up with the doctor regarding the consistently high blood sugar levels. RD J stated she had not spoken with the nursing staff to ask if Resident 64 had been getting all the formula being prescribed and if there were any challenges like the therapy schedule which might have interfered with her getting all the formula prescribed. RD J stated Resident 64's was considered significant and of concern since it had been going downward and not stabilizing or remaining the same. During a concurrent interview and observation with Licensed Staff P, on [DATE] at 9:32 a.m. at Resident 64's bedside, she stated there was approximated 300 milliliters of formula left in the tube feeding bag and the tube feeding would be stopped at 10:00 a.m., per the doctor's order. Licensed Staff P stated the tube feeding bag might be used for the tube feeding when it would be started back up at 2:00 p.m., since the bag would not have expired. Licensed Staff P stated for charting purposes she would document when she turned off the feeding and when it was turned back on, and on a separate piece of paper she would document the water given to Resident 64 and how many millileters of the feeding was infused during the shift. Licensed Staff P demonstrated where then tube feeding milliliter numbers were documented. A review of Resident 64's, Intake and Output Record indicated for the month of March, the following days did not indicate 24-hour totals were calculated, [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 11:43 with DON, she stated there is no weight loss committee, but the Department managers discussed what was going on with residents daily. DON stated she was not aware that physical therapy was working with Resident 64 outside of the times set aside for therapy (10:00 a.m. to 2:00 p.m.). During a review of the facility's policy and procedure titled, RD (Registered Dietician) FOR HEALTHCARE, INC WEIGHT CHANGE PROTOCOL, dated 2018, the P&P indicated, Identify reasons for the weight loss, .Consider possible health effects from the weight change .Suggest interventions to correct the identified problem, diet supplementation, appetite stimulation .The evaluation process is done again if there is another significant weight change .The following criteria defined significant .Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights. 5% weight loss in one month .

Based on observation, interview and record review, the facility failed to provide necessary behavioral health care and services for 1 out of 17 residents (Resident 50), when facility staff failed to facilitate the resident's referral for psychological services and evaluation. This failure resulted on Resident 50 showing increased anxious behavior and receiving a new medication to address her anxiety, and did not ensure services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, Findings: During an observation, interview and record review with Resident 50 on 3/7/22 at 3:00 p.m., Resident 50 was crying. Resident 50 stated she's sad and anxious but refused to discuss the matters further. Review of admission Minimum Data Set (an assessment tool) dated, 2/09/22, the facility admitted Resident 50 on 2/07/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review with Staff H on 3/09/22 11:11 a.m., Staff H verified Resident 50 had a Physician standing order for Psychologist Referral. The order, dated 2/7/22, indicated the facility would contact a psychologist (a professional who practices psychology and studies normal and abnormal mental states, emotional and social processes and behavior). Staff H stated the facility's process required Social Services to review the order and secure the referral with a psychologist. Staff H stated Resident 50 was started on a medication as needed (PRN) on 3/06/22 for anxiety. Staff H stated Resident 50 had not received any medication for anxiety until 3/05/22. During concurrent interview and record review with Management (Mgt) B on 3/09/22 at 11:27 a.m., Mgt B stated she made the referral with Psychologist K on 2/11/22. Mgt B stated Resident 50 had not been evaluated by Psychologist K. Mgt B stated she thought there was a barrier with Resident 50's insurance or payment source, which resulted in no evaluation. Mgt B stated she contacted Resident 50's insurance company on 2/14/22, and learned Psychologist K was listed on the insurace company's approved clinician list. Mgt B confirmed she had no documentation indicating she notified Psychologist K of the insurance's approval for Resident 50's services. During an interview and concurrent record review with Staff H on 3/09/22 at 3:47 p.m. Staff H stated Resident 50 received a medication on 3/5/22 for expressing feeling down due to resident 50 not having a husband, episodes of crying, and wanting to go home. Staff H confirmed Resident 50 having episodes of crying on 3/01/22 and 3/02/22. Upon review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview with DON on 3/10/22 at 10:38 a.m., DON confirmed Resident 50 had not been seen by Psychologist K. DON stated Resident 50 needed to be seen by Psychologist K because her mood changes so fast. DON stated there was a small risk of Resident 50's anxiety increasing if she was not seen by Psychologist K. The facility's Policy and Procedure titled Referrals, Social Services indicated Social Services shall coordinate resident referrals with outside agencies.

Based on observation, interview, and record review, the facility failed to ensure the drug regimen for one of 17 residents (Resident 33) was free from unnecessary drugs, when facility staff administered laxitive medication to Resident 33 when the resident had loose bowel movements, contrary to physician order. This failure resulted in Resident 33 receiving medication that was not clinically indicated, which had the potential to cause unnecessary discomfort and stress to the gastrointestinal (GI) tract, and delay diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review of Resident 33's Discharge Summary, dated 12/18/21, this document indicated Resident 33 was in the hospital 11/16/21 to 11/21/21 for epididymitis/orchitis (inflammation and infection of the scrotum and testicles). The summary indicated Resident 33 was started on antibiotics in the hospital and continued taking them at the facility, until the end date of 12/1/21. During a review of Resident 33's Bowel Elimination task report for 12/2021 documented Resident 33 was having large loose/diarrhea stools. On 12/1/21 and 12/3/21 Resident 33 had 1 normal and 1 large loose stool. On 12/4/21 Resident 33 had 2 large loose stools. On 12/8/21 Resident 33 had 1 large loose stool. On 12/9/21 Resident 33 had 1 normal stool and 1 large loose stool. On 12 /10/21 Resident 33 had 2 large loose stools and 1 large putty like stool. On 12/11/21 Resident 33 had 1 normal stool and 2 loose stools. On 12/12/21 Resident 33 had 2 large loose stools. During a review of Resident 33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The last dose of antibiotics was scheduled for 12/1/21 and administered. In addition to antibiotics, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ., not administer) the Senna if Resident 33 had loose stools. Resident 33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Senna was not administered on 12/11/21. On 12/12/13, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to Senna, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Similarly to Senna, [MEDICATION(S)] was administered to Resident 33 from 12/1/21 to 12/10/21, held on 12/11/21, but administered on 12/12/21 and 12/13/21. During a review of Resident 33's Progress Notes, on 12/10/21 at 1:15 p.m., Staff L documented Resident 33 had a bout of diarrhea before lunch, and staff would continue to monitor. During a review of Resident 33's Progress Notes, on 12/12/21 at 7:53 p.m., Staff M documented that the physician was notified that Resident 33 had a change of condition, a fever of 101.3 degrees Fahrenheit. Recommendations by the physician were to get urine and blood work done if fever recurs. During an interview on 3/11/21 at 10:30 a.m., DON stated that it was known that Resident 33 had some diarrhea, and they held his laxatives. DON stated Resident 33 normally had one large normal stool every day. DON stated that the bout of diarrhea that she knew of did not appear to be a stool infected with Clostridioides difficile (C. Diff., a germ that causes severe diarrhea and inflammation of the colon, presents in most cases when an individual is taking antibiotics). DON stated they did not investigate further, did not start an infection surveillance check list, and did not notify the physician. During an interview and concurrent record review on 3/11/21 at 10:30 a.m., DON stated they had documented Resident 33's infection on the Infection Prevention and Control Surveillance Log . Review of the Infection Prevention and Control Surveillance Log for 12/2021 showed that Resident 33 was on the log for C Diff. due to antibiotic use, and listed the onset date as 12/19/21. During a review of Resident 33's Discharge Summary, dated 12/18/21, the record indicated Resident 33 visited an [Emergency Department] for further evaluation of fevers, nausea, abdominal pain and diarrhea. Resident 33 was found to have C Diff Positive. Illness from Clostridioides difficile typically occurs after use of antibiotic medications. It most commonly affects older adults in hospitals or in long-term care facilities. The most common signs and symptoms of mild to moderate C. difficile infection are watery diarrhea three or more times a day for more than one day and mild abdominal cramping and tenderness. Signs and symptoms of severe infection include: Watery diarrhea as often as 10 to 15 times a day abdominal cramping and pain which may be severe, fever and nausea. This information is from the CDC webpage: CDC Healthcare-associated Infections (HAI) Diseases and Organisms. The facilities policy Surveillance for Infections, dated 2/2022, instructed the IP or DON will conduct ongoing surveillance for Healthcare-Associated Infections and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precaution . Infections that should be included were pneumonia, urinary tract infections and Clostridioides difficile.

Based on observation, interview, and record review, the facility failed to dedicate licensed nursing staff to its COVID-19 unit, when it allowed licensed nursing staff to care for both COVID-19 residents and non-COVID-19 residents. This failure allowed potential transmission of COVID-19 within the facility and did not ensure a safe environment for resident care. Findings: During an interview on 7/28/20, between 1:35 p.m. and 2:30 p.m., the Director of Nursing Services (DON) discussed the facility's staffing of licensed nurses for managing COVID-19 in the facility. The DON stated the facility had assigned one licensed nurse to work on the facility's designated COVID-19 unit (Wing C). The DON stated this licensed nurse had also been assigned to work on a non-COVID-19 unit (Wing B) used to house potentially-exposed residents and residents under investigation with sign and symptoms of COVID-19. The DON stated 7/28/20 was the final day a nurse will cross between Wing C and Wing B. The DON stated the licensed nurse was the only clinical staff not dedicated to Wing C, the COVID-19 unit. The DON stated the facility had not experienced a staffing crisis situation during the COVID-19 outbreak. The DON stated the facility has not requested help from public agencies, or private staffing agencies to bolster its staffing roster. During a concurrent observation and interview on 7/28/20, between 2:35 p.m. and 2:45 p.m., Wing B had five residents admitted . Licensed Staff A stated two residents were persons under investigation (PUIs) with symptoms of COVID-19, and three residents were asymptomatic but potentially exposed to COVID-19. Licensed Staff A stated she changed personal protective equipment (PPE), specifically gown and gloves, when transitioning care between a symptomatic resident and an asymptomatic resident. Licensed Staff A stated she was also assigned as the licensed nurse for Wing C (e.g., the facility's COVID-19 unit). Licensed Staff A stated she visited Wing C twice a day, and returned to Wing B after completing her duties. While on the COVID-19 unit, Licensed Staff A stated she administered medication, checked blood sugars, and administered insulin. Licensed Staff A also stated she assisted with any other patient duties. Licensed Staff A stated, at maximum, she spent 5 minutes in each resident's room on each visit to Wing C. Licensed Staff A stated usually I'm just here, on Wing B, but her assignment required that she floated between Wing B and Wing C. During a concurrent observation and interview on 7/28/20, at 2:50 p.m., Wing C had seven residents admitted . Unlicensed Staff B stated she was the certified nurse aide (CNA) assigned to Wing C. Unlicensed Staff B stated she was assigned to all residents on Wing C. Unlicensed Staff B stated no residents on Wing C required more than one person to assist with transfers or repositioning. Unlicensed Staff B stated she contacted the licensed nurse by walkie talkie to request assistance with resident who required two staff to facilitate safe care. Unlicensed Staff B stated the licensed nurse assigned to Wing C was not dedicated to Wing C. The facility policy and procedure titled Management of Residents with Confirmed and Suspected COVID-19 Infection: Cohorting, dated 06/2020, indicated that facility staff who care for residents positive with COVID-19 should not care for residents in other zones, to the extent possible. The CDC guidance, updated 4/30/20, indicated considerations when Responding to Coronavirus (COVID-19) in Nursing Homes. The guidance indicated a facility should, Assign dedicated (healthcare workers) to work only on the COVID-19 care unit. The guidance indicated, All facilities should adhere to current CDC infection prevention and control recommendations .

Based on observation, interview, and record review, the facility failed to implement a system to control transmission of infection within its facility, when it did not establish a process to audit staff compliance with: (1) Personal protective equipment (PPE, clinical equipment that acts as barriers to minimize staff and resident exposure to a variety of hazards) processes; and (2) Hand hygiene (cleaning hands to prevent the spread of germs) processes. These failures did not ensure a safe environment for care and did not facilitate control of COVID-19 transmission among residents and staff. Findings: (1) During an interview on 7/8/20, at 9:50 a.m., Director of Nursing (DON) stated the facility used Wing C as its COVID wing, and the facility had moved exposed residents suspected for COVID-19 to Wing C once the residents became symptomatic or tested positive. During an observation on 7/8/20, during a facility tour between 10:12 a.m. and 11:00 a.m., Unlicensed Staff A donned PPE prior to entering a resident's room on Wing C. Unlicensed Staff A did not perform hand hygiene before donning gloves. Unlicensed Staff A donned personal eyeglasses (which did not protect the side of Unlicensed Staff A's face/eye), instead of goggles or face shield. Unlicensed Staff A entered the room, then performed and completed her task. Upon completion, Unlicensed Staff A doffed her gloves and gown, exited through the room's doorway, and disposed of both items in a trash bin located in the hallway outside the resident's room. Unlicensed Staff A then re-entered the resident's room wearing only an N95 respirator for PPE; no gown or gloves. Unlicensed Staff A walked into the resident's bathroom and closed the door behind her. During an observation on 7/8/20, during a facility tour between 10:12 a.m. and 11:00 a.m., Unlicensed Staff C donned PPE in preparation for entering a resident's room on Wing C. Unlicensed Staff C donned gloves last in the PPE-donning sequence. During an observation on 7/8/20, during a facility tour between 10:12 a.m. and 11:00 a.m., Licensed Staff B donned PPE in preparation for entering a resident room on Wing C. Licensed Staff B donned gloves first in the PPE-donning sequence. During an interview on 7/8/20, at 11:30 a.m., in the presence of the DON, the DSD (Director of Staff Development) stated she was the facility's primary Infection Preventionist (IP). The DSD stated she was accountable for the responsibilities of both jobs, DSD and IP. The DON stated both she the Administrator provided support to the DSD for the facility's IP needs. The DSD stated the facility did not audit healthcare workers on the COVID-19 unit for compliance with appropriate PPE donning and doffing practices. The facility policy and procedure titled Infection Prevention and Control: Novel Coronavirus (COVID-19), dated 6/9/20, indicated the following requirement: Limit only essential personnel to enter the (COVID-19 resident's) room with appropriate (PPE) and respiratory protection. Also, the facility policy and procedure indicated (PPE) includes: . (e)ye protection that covers the front and sides of the face . The facility's competency validation form for Donning and Doffing PPE, dated 9/2016, indicated a sequenced list of steps required by staff when donning and doffing PPE. The form indicated staff must (d)on gloves last when applying PPE for resident care. The form indicated staff must (d)on (g)oggles or (f)ace (s)hield. A review of CDC guidance, titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, indicated a skilled nursing facility should Place signage at the entrance to the COVID-19 care unit that instructs HCP ((healthcare personnel)) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed 7/9/20). A review of CDC guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 7/9/20, indicated Personal eyeglasses and contact lenses are NOT considered adequate eye protection. (Emphasis provided)(https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, accessed 7/14/20). (2) During an interview on 7/9/20, at 9:50 a.m., Director of Nursing (DON) stated the facility used Wing C as its COVID wing, and the facility had moved exposed residents suspected for COVID-19 to Wing C once the residents became symptomatic or positive. During an observation on 7/9/20, during a facility tour between 10:12 a.m. and 11:00 a.m., Unlicensed Staff A donned PPE prior to entering a resident's room on Wing C. Unlicensed Staff A did not perform hand hygiene before donning gloves. Unlicensed Staff A entered the room, then performed and completed her task. During an observation on 7/9/20, during a facility tour between 10:12 a.m. and 11:00 a.m., Unlicensed Staff C donned PPE in preparation for entering a resident's room on Wing C. Unlicensed Staff C donned gloves, but did not perform hand hygiene prior to donning. During a concurrent interview and record review on 7/9/20, at 11:30 a.m., in the presence of the DON, the DSD (Director of Staff Development) stated was the facility's primary Infection Preventionist (IP). The DSD stated she was responsible for training staff and verifying staff competency with hand hygiene. The DSD stated the facility had started auditing staff for compliance with hand hygiene processes. The DSD stated the facility observed staff and used the hand hygiene competency validation to guide the auditing process. On review of the facility's competency validation form for hand hygiene, the DSD stated the form did not indicate a process for auditing hand-hygiene compliance. The DSD stated the facility did not use an audit tool that identified opportunities for hand hygiene, or indicated whether staff performed hand hygiene at each opportunity. The facility policy and procedure titled Infection Prevention and Control: Novel Coronavirus (COVID-19), dated 6/9/20, indicated the facility will re-educate and reinforce strong hand hygiene practices. The facility's competency validation form for Hand Hygiene Competency Validation, dated 9/2016, indicated processes staff must follow to competently perform hand hygiene. The form indicated the process steps when performing hand hygiene with soap & water and hand hygiene with ABHR (alcohol-based hand rub), as well as three general observations. The form did not indicate when staff must perform hand hygiene (e.g., opportunities for hand hygiene), or describe a process for auditing staff compliance with hand hygiene at each opportunity. A review of CDC guidance, titled Hand Hygiene in Healthcare Settings, dated 1/31/20, indicated gloves are not a substitute for hand hygiene, and staff should perform hand hygiene prior to donning gloves, and immediately after removing gloves. (https://www.cdc.gov/handhygiene/providers/index.html, accessed 7/14/20).

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain an environment of respect and highest practicable physical, mental, and psychosocial wellbeing for Resident 1 when Unlicensed Staff C did not communicate to Resident 1 in a respectful manner when caring for him. This failure made Resident 1 feel bad, angry, upset, frustrated, hurt and had the potential for Resident 1 to feel devalued and depressed. Findings: A review of Resident 1's Admission Record and [DIAGNOSES REDACTED]. A review of Resident 1's Quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/4/19, indicated Resident 1 had a BIM (Brief Interview of Mental Status) of 15 (resident's mental understanding was cognitively intact), needed one-person physical assist with bed mobility (how resident moves to and from lying position, turn side to side, and positions body while in bed) and toilet use (how resident uses the toilet room, commode, bedpan, transfers on/off toilet, and cleanses self after elimination), and had fallen one time with no injury since last quarterly assessment. A review of Resident 1's Activities of Daily Living (ADLs: daily self-care activities such as feeding ourselves, bathing, dressing, etc.) care plan, dated 7/8/19, Self Care Performance Deficit care plan, dated 4/12/19, Behavior Problem Verbal Aggression and False Accusations care plan, dated 4/16/19, and Alteration in Mood and Behavior Pattern dated 1/8/19 indicated: 1. Resident 1 had left sided paralysis due to a stroke, 2. required extensive assist with personal hygiene, 3. used a disposable brief, 4. needed assistance to develop more appropriate methods of coping and interaction, 5. caregivers were to provide opportunity for positive interaction and attention, 6. observe for trigger events of the behavior and redirect as needed, and 7. assess resident to process feelings and find positive outcomes. During a concurrent interview with Administrative Staff A and DON (director of nurses) on 9/4/19 at 11:40 a.m., both indicated Unlicensed Staff D informed them on 8/29/19, she had overheard Resident 1 getting upset at Unlicensed Staff C while he was cleaning him in bed after a bowel movement and stated, Stupid, you don't listen. Unlicensed Staff C replied, So are you. Administrative Staff A and DON stated Resident 1 felt bad about the confrontation, but Unlicensed Staff C should not have responded to Resident 1, by stating he was Stupid too. Administrative Staff A and DON stated Unlicensed Staff C was disrespectful to Resident 1. Administrative Staff A and DON stated when interviewing Unlicensed Staff C, he did not feel what he had said to Resident 1 was inappropriate because Resident 1 was being verbally inappropriate to him at the time. During an interview on 9/4/19 at 11:50 a.m., Resident 1 stated Unlicensed Staff C helped him to the commode and back to bed with no problem, but once in bed Unlicensed Staff C was pushing on his hips while turning him from side to side to place a brief on him. Resident 1 stated Unlicensed Staff C was complaining because he did not feel Resident 1 was turning far enough over, so he started to push on his hips, which hurt. Resident 1 stated he did state to Unlicensed Staff C, Quit Stupid Man. Resident 1 stated he had become very frustrated with Unlicensed Staff C not following directions and continuing to push on his hips over the past 2 weeks. He had explained multiple times to Unlicensed Staff C, he had spinal stenosis and pushing on his hips hurt, and he was afraid of falling. Resident 1 stated he felt bad and when Unlicensed Staff C returned to his room, Resident 1 wanted to apologies to Unlicensed Staff C, but Unlicensed Staff C stated to Resident 1, Just because I am black I should not be insulted. I am not in the mood. Resident 1 stated he reported the incident to Administrative Staff A, DON, and Administrative Staff B. During an interview on 9/4/19 at 12:10 p.m., Administrative Staff B stated Resident 1 had left her a voice message on 8/29/19 after his encounter with Unlicensed Staff C. Administrative Staff B stated she went down to talk to Resident 1 within fifteen minutes of him leaving the voice message. Resident 1 did not feel Unlicensed Staff C was abusive, he just did not want to get hurt when being turned and was afraid of falling. Administrative Staff B stated when she interviewed Unlicensed Staff D, she stated she heard Resident 1 state to Unlicensed Staff C, I want to kick you in the balls. Unlicensed Staff C replied, If you think you are man enough. Administrative Staff B stated Unlicensed Staff C should not have tried to challenge Resident 1; he should have walked away and found someone else to help care for Resident 1. Administrative Staff B stated Unlicensed Staff C should have known to walk away from the situation and get a nurse and/or another Certified Nursing Assistant (CNA) to attend to Resident 1. During an interview on 9/9/19 at 12:10 p.m., Unlicensed Staff D stated she was in Resident 1's room assisting another resident with his snack when she overheard the confrontation between Unlicensed Staff C and Resident 1. Unlicensed Staff C was raising his voice at Resident 1, while Resident 1 was telling Unlicensed Staff C to stop pushing him so hard because he felt like he was going to fall out of the bed. Unlicensed Staff C loudly stated to Resident 1, How am I going to change you? Resident 1 stated to Unlicensed Staff C, Stupid Man, and Unlicensed Staff C responded back to Resident 1, So are you. Resident 1 stated to Unlicensed C, I could slap you right now and Unlicensed C replied back to Resident 1, If you are man enough, you should do it. Unlicensed Staff D stated she has taken care of Resident 1 several times and did not have any issues with him. Unlicensed Staff D stated you needed to give direction to Resident 1 when changing his brief because he would doze off to sleep. Unlicensed Staff D stated she thought Unlicensed Staff C was very rude to Resident 1, so she reported the confrontation to Administrative Staff B. Unlicensed Staff D stated Unlicensed Staff C should have asked a nurse and/or another CNA for assistance. He should not have argued with Resident 1. Unlicensed Staff D stated the facility was the residents' home. It was hard enough for the residents; the residents may feel trapped. Unlicensed Staff D stated Resident 1 had told her he felt bad for talking to Unlicensed Staff C like he did, so he reported the incident to Administrative Staff B. The facility policy/procedure titled, Resident Rights Guidelines for All Nursing Procedures, revised 10/10, indicated: 1g. Explain the procedure to the resident. Answer any questions he/she may have and 1h. Ask permission to implement the procedure. If the resident refuses, notify your supervisor. The facility policy/procedure titled, Quality of Life - Dignity, revised 9/09, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation indicated: 1. Resident shall be treated with dignity and respect at all times, 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth ., 7. Staff shall speak respectfully to residents at all times ., 11. Demeaning practices and standards of care that compromise dignity are prohibited.

Based on observation, interview and record review, the facility failed to ensure: 1. One cook was able to describe the cool down process for food, and 2. Spoiled fruits were discarded from the dry storage and tray line of the kitchen. This failure could potentially lead to food borne illness in a vulnerable population. Findings: Food Cool Down Process During an interview on 4/22/19 at 3:36 p.m., Dietary Staff H, who identified herself as a cook, described the cooling process for food. She stated that the process started at 165 degrees Fahrenheit. According to her, in 2 hours the food had to reach 140 degrees Fahrenheit, and in 2 more hours, it had to reach 68 degrees Fahrenheit. Another dietary staff member interrupted the interview, attempting to describe the cool down process herself. She was asked to let Dietary Staff H describe the cool down process. Dietary Staff H stated that she rarely performed the cool down process, as another dietary services staff almost always did it. Spoiled Fruit During a concurrent observation and interview on 4/22/19 at 8:05 a.m., a spoiled banana was observed in the dry storage of the kitchen, labeled with a resident's name, stored with other bananas in good condition. The banana had soft, mushy and brown areas. In addition, the banana was partially cut in half with the skin open, therefore, the pulp of the fruit was exposed to air. A second spoiled banana was observed in a kitchen counter right on top of the tray line, labeled with a resident's name. This banana had soft, mushy and brown areas. The DM (Dietary Manager) stated that the bananas were not supposed to be served like that, and proceeded to throw them away. The facility policy titled, COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS (PHF) also called Time/Temperature Control for Safety (TCS) last revised in (YEAR), indicated, Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety .The method is: THE TWO-STAGE METHOD Cool cooked food from 140° F to 70° F within two hours. Then cool from 70° F to 41° F or less in an additional four hours for a total cooling time of six hours. The facility policy titled, STORING PRODUCE last revised in (YEAR), indicated, Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items .Bananas should be stored at room temperature. When fully ripe, bananas may be stored in the refrigerator for five days, as long as they have no open skin.