Every finding on record at Rancho Bellagio Post Acute

Based on interview and record review, the facility failed to ensure a resident was informed and allowed to exercise the right to choose and attending physician for four of four residents reviewed for physician choice (Residents 1, 2, 3, and 4). This failure resulted in Residents 1, 2, 3, and 4 not being afforded the opportunity to retain a personal physician or select an attending physician of their choice upon admission. Findings: A review of Resident 1's admission record indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis which included chronic osteomyelitis, left thigh (long term bone infection in the left upper leg) and osteonecrosis, left femur (part of the large bone in the left upper leg had died because it does not get enough blood). Resident 1's History and Physical, dated [DATE], indicated, .Alert, oriented, x3. On [DATE], at 10:20 a.m., an interview was conducted with Resident 1 inside her room. Resident 1 stated that upon admission she was assigned to a facility physician and was not asked whether she wished to retain her own physician or select a physician of her choice. A review of Resident 2's admission records indicated Resident 2 was admitted to the facility on [DATE], with diagnosis which included encounter for orthopedic aftercare (follow-up care with bone and joint specialist) following surgical amputation (part of the limb has been surgically removed). Resident 2's History and Physical dated [DATE], indicated, .Alert, oriented, able to follow commands, good safety awareness . On [DATE], at 2:35 p.m., an interview was conducted with Resident 2. Resident 2 stated her physician was assigned to her by a facility staff, and she did not have a choice which physician would see her. A review of Resident 3's admission records indicated that Resident 3 was admitted to the facility on [DATE], with diagnosis which included fracture of unspecified part of neck of right femur (a break in the upper part of the right thigh bone, close to the hip joint). Resident 3's History and Physical dated [DATE], indicated, .has the capacity to understand and make decisions . On [DATE], at 2:00 p.m., an interview was conducted with Resident 3. Resident 3 stated that she did not have a choice regarding who her attending physician would be and that a physician was assigned to her upon admission by a facility staff. A review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE], with diagnosis which included difficulty in walking and major depressive disorder (a serious form of depression that affects mood, sleep, appetite, energy, and interest in activities). Resident 4's History and Physical, dated [DATE], indicated, .Cognitive status within normal limits .Alert, oriented, x4. On [DATE], at 2:30 p.m., an interview was conducted with Resident 4. Resident 4 stated the facility did not ask her if she wanted to choose her own physician or if she had any preference for an attending physician. On [DATE], at 10:12 a.m., an interview was conducted with the Admissions Marketer (AM). The AM stated that attending physicians were assigned to residents from a panel of approved physicians and assignments were rotated among the physicians on the list. The AM stated residents were not asked whether they had preferred physician or wished to retain their personal physician upon admission. The AM further stated that during his five years working in admissions, residents had always been assigned to a physician upon admission and could request a different physician from the facility's approved physician panel after admission. On [DATE], at 5:05 p.m., an interview was conducted with the Admissions Director (AD). The AD stated she reviewed the admission packet, resident rights, consents, and facility policies with residents during the admission process. The AD stated the attending physician's name was already listed in the admission packet before admission and residents were admitted with the assigned physician. the AD stated residents were not offered a choice of attending physician upon admission and were not asked whether they wished to retain their personal physician. The AD further stated that if a resident was dissatisfied with the assigned physician after admission, the resident could request a different physician from the facility's approved physician list. On [DATE], at 5:18 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that upon admission, residents were already assigned an attending physician and staff informed residents who their assigned physician would be. The DON stated residents were not asked whether they had a preferred physician because the facility assigned physicians from a list of physicians affiliated with the facility. The DON stated that if a resident later requested a different physician, the resident could select another physician from the facility's approved physician list. The DON acknowledged that Residents 1 and the other three residents were not asked whether they preferred a particular physician prior to assignment. The facility's policy titled, Resident Rights, dated February 2021, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the rights to.choose an attending physician and participate in decision-making regarding his or her care.

Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required minimum of actual total Certified Nurse Assistant (CNA) Direct Care Hours Per Patient Day (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for the months of October 2025, November 2025, December 2025, and January 2026.The failure to maintain the required minimum CNA DHPPD hours had the potential to place residents at risk for unmet needs, compromised safety, and decreased quality of care. Findings:On January 28, 2026, at 1:40 p.m., the facility staffing records were reviewed. The review indicated the facility's CNA staffing levels were below the minimum required DHPPD of 2.4 hours on the following dates:-October 1, 2025, through October 31, 2025-November 1, 2025, through November 30, 2025-December 1, 2025, through December 20, 2025-December 22, 2025, through December 30, 2025-January 1, 2026, through January 19, 2026-January 21, 2026-January 23, 2026, through January 25, 2026-January 27, 2026On January 28, 2026, at 1:40 p.m., a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) report was conducted with the Director of Staff Development (DSD). The DSD stated the facility's CNA DHPPD hours were below 2.4 hours for the entire months of October 2025 and November 2025. The DSD further stated the CNA DHPPD hours were below 2.4 hours for 30 of 31 days reviewed in December 2025 and 24 of 27 days reviewed in January 2026. The DSD stated the CNA DHPPD hours should be maintained at 2.4 hours to ensure safe and quality resident care. On January 29, 2026, at 11:40 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated staff resignations, position changes, reductions in hours, and call-off contributed to the facility's inability to meet the required CNA DHPPD hours. The DON further stated CNA DHPPD hours should be maintained at 2.4 hours to ensure residents' needs were met and quality care was provided. A review of the facility's policy and procedure titled, Staffing, dated October 2017, indicated, .facility provides sufficient numbers of staff.to provide care and services for all residents.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 22) reviewed received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. For Resident 22, nursing staff did not follow the physician's insulin (medication to treat diabetes) sliding scale order (a chart with insulin doses to maintain blood sugar levels) to notify the physician when the blood sugar (BS) result was above 350. This failure had the potential to compromise Resident 22's health and well-being. Findings: A review of Resident 22's admission Record, dated January 28, 2026, indicated Resident 22 was admitted to the facility on [DATE], with diagnoses including diabetes. A review of Resident 22's Care Plan Report, dated May 8, 2025, indicated, Focus.Diabetes.Interventions.Administer medication as ordered.Blood glucose (sugar) checks as ordered. Report to physician if blood glucose is outside of set parameters. A review of Resident 22's blood sugar records dated December 3, 2025, at 21:08 (9:08 p.m.) indicated her BS was 438 mg (milligram, unit of measurement) /dl (deciliter, unit of measurement). A review of Resident 22's medical record indicated a provider's order dated May 5, 2025, for Insulin Lispro (medication for diabetes) Injection Solution 100 units/ml (milliliters, unit of measurement), Inject as per sliding scale if (BS):70 - 150 (mg/dl) = 0 No Correction; 151 - 200 (mg/dl) = 4 units; 201 - 250 (mg/dl) = 6 units; 251 - 300 (mg/dl) = 8 units; 301 - 350 (mg/dl) = 10 units; > (greater than) 350 = 12 units and Call and Notify MD (medical doctor),subcutaneously (SC, under the skin) three times a day for Diabetes Mellitus, Hold if BS < (less than) 70. A review of Resident 22's Medication Administration Record (MAR) dated December 2025 indicated nursing staff documented Insulin Lispro Injection Solution insulin sliding scale was not administered to Resident 22 on December 3, 2025, at 21:08 (9:08 p.m.) when her BS was 438 mg/dl. A review of Resident 22's electronic MAR (eMAR) Medication Administration Note dated December 3, 2025, at 21:08 (9:08 p.m.) indicated there was no evidence of nursing documentation that the doctor was notified when Resident 22's blood sugar level was above 350, as prescribed on the provider's order for Insulin Lispro sliding scale dated May 5, 2025. During a concurrent interview and record review on January 28, 2026, at 10:36 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 22's physician's order dated May 5, 2025, and MAR dated December 2025 were reviewed. LVN 2 stated when Resident 22's BS was 438 mg/dl on December 3, 2025, at 21:08 (9:08 p.m.) he would have followed the physician's order, administered 12 units of insulin lispro and called the physician. Additionally, LVN 2 stated he would have documented in the nursing MAR note that the physician was notified and any additional instructions from the physician. LVN 2 stated he was unable to locate documentation in Resident 22's medical record that nursing staff notified the physician when her BS was 438 mg/dl on December 3, 2025, at 21:08 (9:08 p.m.). During a concurrent interview and record review on January 28, 2026, at 11:00 a.m., with the Director of Nursing (DON), Resident 22's physician's order dated May 5, 2025, MAR dated December 2025 and eMAR Medication Administration Note dated December 3, 2025, were reviewed. The DON stated when Resident 22's BS was 438 mg/dl, the nurse should have administered 12 units of insulin lispro and notified the physician as ordered. Additionally, the DON stated the nurse should have documented in the resident's medical record that the physician was notified. The DON acknowledged there was no evidence in Resident 22's medical record of documentation by nursing staff that the doctor was notified when BS was 438 mg/dl on December 3, 2025, at 21:08 (9:08 p.m.). The DON stated the expectation was for nursing staff to follow the physician's order and document in the resident's medical record. During a review of the facility's policy and procedure (P&P), titled Administering Medications, revised April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders .

Based on interview, and record review, the facility failed to promptly notify the physician for a change in condition, for two of eight residents reviewed for changes in condition (Resident 8 and 110) when: 1. For Resident 8, licensed nurses did not notify the physician of multiple refusals of prescribed insulin [chemical in the body that helps move sugar from the blood into the body's cells]. 2. For Resident 110, licensed nurses did not notify the physician of the repeated episodes of blood pressure readings less than 100/60 mm Hg (millimeters per mercury - unit of measurement). These failures placed the residents at increased risk to their health and well-being due to the lack of physician oversight necessary to evaluate and address changes in their medical conditions. Findings: 1.On January 25, 2026, at 12:06 p.m., an interview was conducted with Resident 8 in his room. Resident 8 stated he had insulin ordered but had been refusing it because he believed he did not need it. On January 26, 2026, Resident 8's admission record was reviewed. The resident was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage caused by high blood sugar). A review of Resident 8's Minimum Data Set (MDS – an assessment tool) dated December 28, 2025, indicated a Brief Interview for Mental Status (a tool to assess cognitive function) score of 12 (moderate cognitive impairment) A review of Resident 8's record, titled, Order Summary Report, dated January 28, 2026, indicated, .Humalog Solution 100 unit/ml (unit of measurement) Insulin Lispro [fast-acting insulin medication used to lower blood sugar quickly] Inject as per sliding scale. A review of Resident 8's Diabetic Administration Record for December 2025, indicated multiple consecutive refusals of prescribed insulin as follows: -December 17, 18, and 19, 2025, during the 9 p.m. dose -December 23, 24, 25, and 26, 2025, during the 9 p.m. dose. Further review of Resident 8's Diabetic Administration Record for January 2026, indicated additional consecutive insulin refusals, including: -January 5, 6, 7, and 8, 2026, during the 4:40 p.m. dose -January 9,10, 11, and 12, 2026, during the 6:30 a.m. dose -January 15,16, 17, 18, and 19, 2026, during the 6:30 a.m. dose -January 24, 25, 26, and 27, 2026, during the 6:30 a.m. and 11:30 a.m. doses A review of Resident 8's record indicated there was no documentation licensed nurses notified the physician of the consecutive insulin refusals during December 2025 or January 2026. On January 29, 2026, at 10:13 a.m., an interview with the Licensed Vocational Nurse (LVN) 3 was conducted. LVN 3 stated, if a resident refused a medication multiple times, he would notify the physician and complete a change in condition assessment. On January 29, 2026, at 10:23 a.m., a concurrent interview and record review with the RN Supervisor (RNS) was conducted. The RNS stated the physician should have been notified of the repeated refusals. On January 29, 2026, at 1:56 p.m., an interview was conducted with the DON. The DON stated, when medications were refused three consecutive times, the physician should be notified, and documentation should be made in the progress notes for resident safety. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated May 2017, indicated, .facility shall promptly notify.Attending Physician.of changes in the resident's medical.condition and/or status.refusal of treatment or medications two (2) or more consecutive times . 2. A review of Resident 110's admission Record dated January 29, 2026, indicated an admission date of December 30, 2025, with a diagnosis which included heart failure. A review of Resident 110's Minimum Data Set (an assessment tool) dated January 5, 2026, indicated a Brief Interview for Mental Status (a tool to assess cognitive function) score of 11 (moderate cognitive impairment). A review of Resident 110's Care Plan revised January 9, 2026, indicated, .Focus.ADL/Mobility.actual.at risk for ADL (activities of daily living) /mobility decline.related to.12/30/254 dx (diagnosis) [NAME] Syndrome (hypersensitivity reaction) .Interventions.Monitor vital signs and report abnormal findings to physician. A review of blood pressure records indicated Resident 110 had repeated blood pressure readings of less than 100/60 mm Hg (millimeters mercury- unit of measurement): -January 3, 2026, at 1:30 a.m.: 93/73 -January 4, 2026, at 9:26 a.m.: 68/49 -January 4, 2026, at 9:27 a.m.: 68/49 -January 4, 2026, at 1:57 p.m.: 96/52 -January 5, 2026, at 8:47 a.m.: 87/66 -January 5, 2026, at 8:48 a.m.: 87/66 -January 5, 2026, at 9:20 a.m.: 87/66 -January 5, 2026, at 1:01 p.m.: 98/68 -January 6, 2026, at 4:58 a.m.: 97/77; and -January 6, 2026, at 8:51 a.m.: 98/70 On January 29, 2026, at 9:29 a.m., an interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated if the resident had three consistent low blood pressure readings, it should be reported to the physician as a change in condition. LVN 1 stated there was no documentation indicating the physician was notified regarding Resident 110's low blood pressure readings. On January 29, 2026, at 10:56 a.m., an interview and record review was conducted with the Director of Nursing (DON). The DON stated there was no documented evidence the physician was notified of Resident 110's low blood pressure readings from January 3, 2026, to January 6, 2026. The facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .Hypotension. blood pressure less than 100/60 mm/Hg.should be reported to the physician.

Based on interview and record review, the facility failed to develop a comprehensive care plan to address a resident's repeated refusal of prescribed insulin (a chemical in the body which helps more sugar from the blood into the body's cells) for one of ten residents for care planning (Resident 8). This failure placed Resident 8 at risk for uncontrolled blood glucose levels and potential diabetic complications.Findings:On January 25, 2026, at 12:06 p.m., an interview was conducted with Resident 8 in his room. Resident 8 stated that he had insulin ordered but refuses to take it because he believed he did not need it. On January 26, 2026, Resident 8's admission record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (high blood sugar) with diabetic Neuropathy (nerve damage caused by high blood sugar). A review of Resident 8's record, titled, Order Summary Report, dated January 28, 2026, indicated, .Humalog Solution 100 unit/ml (unit of measurement) Insulin Lispro [fast acting insulin medicine used to lower blood sugar quickly] Inject as pre sliding scale. A review of Resident 8's Diabetic Administration Record indicated the resident initially refused the prescribed insulin on December 16, 2025. Further review indicated the resident refused insulin a total of 23 times during December 2025. A review of the Resident 8's comprehensive care plan dated December 15, 2025, indicated, .Psychosocial- Refusal of care: Resident refuses care and services within their rights as manifested by non-compliance/ refusal of treatments.refusal to have BS check and insulin date-initiated January 16, 2026. Further review of Resident 8's comprehensive care plan indicated no care plan was initiated on or after December 16, 2025, when the resident first refused insulin, to address the repeated refusal of prescribed insulin. There was no documentation of identified problem statements, measurable goals, interventions, or monitoring related to insulin refusal between December 16, 2025, and January16, 2026. On January 29, 2026, at 1:56 p.m., a concurrent interview and record review of Resident 8's care plan were conducted with the DON. The DON stated the resident's care plan should have been initiated on December 16, 2025, when the resident first refused insulin and not on January 16, 2026. The DON further stated, it was important to have continuation of care, so staff were aware of the plan and to prevent potential complications from occurring. The facility policy and procedure, titled, Care Plan Comprehensive Person Centered dated December 2016, indicated, .includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.incorporate identified problem areas.incorporate risk factors associated with identified problems.

Based on interview and record review the facility failed to ensure that upon written request, medical records were released within two working days, for one of two sampled residents (Resident 5). This failure had the potential to impact continuity of care, appeals, or legal matters. Findings: On November 20, 2025, at 11:30 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On November 20, 2025, Resident 5's record was reviewed. Resident 5 was admitted on [DATE], and discharged [DATE], with diagnoses that included aftercare following surgical amputation (a medically approved removal of a part of the body). A review of the facility document titled, Released Records Log indicated that on May 14, 2025, the following records were to be released for Resident 5, .5/14 nursing notes.not picked up. There were no additional notations made on this log related to the records request for Resident 5's medical records being provided to or picked up by a representative party of Resident 5 until November 20, 2025. A review of the facility document titled Authorization form for the Release of Health Information dated May 14, 2025, indicated a request for medical records for Resident 5. The form indicated Resident 5 requested copies of nursing progress notes dated May 14, 2025, for personal use, and indicated that the records would be picked up at the facility. Resident 5's signature and the date May 14, 2025, were documented on the form. A review of the untitled electronic response from the facility legal analyst dated May 15, 2025, indicated .according to PCC (the online medical record) the resident only has a BIMS (Brief Interview for Mental Status) of 4 (0-7 signifies severe cognitive impairment) The wife, (name of wife), will need to sign the request form in order for records to be released.There was no documentation indicating that the resident's representative was notified that a signature was required to process the record's request. On November 20, 2025, at 12:01 p.m., an interview was conducted with the Medial Records Director (MRD). The MRD stated that once a request had been received, the facility had two days to process the request and have the records sent. The MRD continued, that once a request was received it would be forwarded to the legal for approval. The MRD stated once the legal team approved the request, the records would be prepared and sent. The MRD stated, the original request was forwarded to the legal department on May 15, 2025, but she did not follow up with Resident 5's wife when she did not arrive to pick up the records. The MRD acknowledged that she should have followed up within two days and did not do so. The MRD stated that the resident's wife contacted the facility on November 20, 2025, requesting all records, which were being processed and expected to be available on November 21, 2025. On 11/20/2025 at 4:50 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated when a records request is submitted, the MRD verifies the information, forwards the request to the legal department for authorization, and the records should be released within two business days following approval. The DON further stated, the records requested in May 2025, should have been provided to the requesting party within two business days of the request. A review of the facility policy titled, Release of Information dated April 1, 2020, indicated, .all information contained in the resident's medical record may only be released by written consent of the resident or his/her legal representative.the resident may initiate a request to release such information in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request form the resident or representative.long term care facilities to provide a copy of their records within two working days (when requested by the resident).Specifically, CMS is modifying the timeframe requirement to allow LTC facilities ten working days to provide a resident's record rather than two working days.

Based on interviews and record reviews, the facility failed to ensure STAT, (done without delay) chest radiology and laboratory orders were done as ordered by the physician for one of eight residents reviewed for quality of care (Resident 1), in a universe of 91 residents. This failure had the potential to result in delayed diagnosis and treatment. Findings:On December 3, 2025, at 1:07 p.m., an unannounced visit to the facility on two complaints and a Facility Reported Incident were initiated.A review of Resident 1's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of immunodeficiency, (failure of the immune system to protect the body from infection), anemia, (blood has a lower-than-normal amount of red blood cells), type 2 diabetes, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), primary hypertension, (high blood pressure with no single, identifiable cause), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hyperlipidemia, (high cholesterol), benign prostatic hypertrophy (BPH - enlargement of the prostate gland), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), chiefly affecting middle-aged and elderly people), posttraumatic stress disorder, (PTSD - is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), gastroesophageal reflux disease (GERD- occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach), atherosclerotic heart disease (develops when a sticky substance called plaque builds up inside the arteries), dysphagia (difficulty swallowing), malignant neoplasm (cancerous tumor) of left lung, pleural effusion (an abnormal collection of fluid between the thin layers of tissue lining the lung and the wall of the chest cavity), stroke (damage to tissues in the brain due to a loss of oxygen to the area), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and severe protein-calorie malnutrition (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients).A review of Resident 1's History and Physical dated August 1, 2025, indicated resident had the capacity to understand and make decisions.A review of Resident 1's Progress Notes dated August 31, 2025, at 11:01 p.m., indicated Resident reported that his (sic) having a (sic) Shortness of Breath. (sic) And family requested to have labs and Chest STAT XRAY informed MD [medical doctor] MD wants resident to be sent out. RN [Registered Nurse] informed Family is at his bedside and family refused to be sent out and instead family wants resident to have labs first and have STAT Chest X ray as per Family(sic) resident just came here 2 days ago and hospital is too much (sic) At this time family wants its (sic) to have LABS here first and STAT XRAY before deciding to be sent out again. MD aware and to carry out all the labs and X-ray as requested.A review of Resident 1's Radiology Order dated August 31, 2025, at 8:53 p.m., indicated .Priority: STAT.Exam - XRAY CHEST 3 VIEW.Symptom - SHORTNESS OF BREATH. A review of Resident 1's Order Requisition dated September 1, 2025, at 12:44 a.m., indicated .Service Required: Laboratory.Test CBC [complete blood count] w Diff, Platelets Comprehensive Metabolic Panel.There was no documented evidence Resident 1's orders for STAT X-ray and labs were done as ordered by the physician.On December 11, 2025, at 1:10 p.m., an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated that STAT radiology and laboratory orders should be completed within the first couple of hours, while routine orders are to be completed the following day. Upon review of Resident 1's Progress Notes, dated August 31, 2025, at 11:01 p.m., the DON confirmed that the laboratory tests and chest X-ray should have been completed as ordered by the physician, and it was not done. A review of Resident 1's Progress Notes dated September 1, 2025, at 7:55 p.m., indicated .Resident noted desaturated, [a drop in blood oxygen levels below normal 95-100%], o2 sat [oxygen saturation], 89% on nasal canula, wife at bed side stated to monitor to see if he gets better, a while after resident became alter metal (sic) status, afebrile, no facial expression of pain, wife remains at bed side, [name of physician] was notifiedwith (sic) new order to transfer to ER [emergency room] of further evaluation. 911 was call (sic) and took over on arrival, resident was transfer to [name of hospital] ED [emergency department].A review of the facility's policy and procedure titled Request for Diagnostic Services revised April 2007, indicated .3. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. 4. Emergency requests must be labeled stat to assure that prompt action is taken.

Based on interviews and record reviews, the facility failed to ensure resident right to choose attending physician for two of eight sampled residents (Residents 1 and 6) in a universe of 91 residents.This failure had the potential to harm the resident's autonomy, continuity of care, which could potentially lead to unmet needs for residents in the facility. Findings:On December 3, 2025, at 1:07 p.m., an unannounced visit to the facility was initiated to investigate a resident's right issue. 1) A review of Resident 1's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of immunodeficiency (failure of the immune system to protect the body from infection), anemia (blood has a lower-than-normal amount of red blood cells), type 2 diabetes (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), primary hypertension (high blood pressure with no single, identifiable cause), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hyperlipidemia (high cholesterol), (BPH - enlargement of the prostate gland), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement chiefly affecting middle-aged and elderly people), posttraumatic stress disorder (PTSD - is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), gastroesophageal reflux disease (GERD- occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach), atherosclerotic heart disease (develops when a sticky substance called plaque builds up inside the arteries), dysphagia (difficulty swallowing), malignant neoplasm (cancerous tumor) of left lung, pleural effusion (an abnormal collection of fluid between the thin layers of tissue lining the lung and the wall of the chest cavity), stroke (damage to tissues in the brain due to a loss of oxygen to the area), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and severe protein-calorie malnutrition, (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients) under Physician B's care.A review of Resident 1's History and Physical dated August 1, 2025, indicated resident had the capacity to understand and make decisions.On December 3, 2025, at 253 p.m., an interview was conducted with the facility's Director of Business Development, (DOBD). The DOBD stated when a hospital sends the facility a referral for admission of a resident, if clinically appropriate, they have five physicians on the facility panel and would alternate between the seven physicians to assign the resident. The DOBD stated that if a physician were to attend to a resident in the facility, the physician would need to have credentials, license, a login for medical records, and be on the facility panel. The DOBD stated that Physician A was not on the panel. The DOBD was unaware that Resident 1's family had requested Physician A as the attending physician.On December 3, 2025, at 3:07 p.m., an interview was conducted with the facility's Medical Records Director, (MRD). The MRD stated that when the medical records department received a request to add a physician to the facility panel, the MRD would request a license number, credentials, and sets up in the electronic medical records (EMR). The MRD stated that the information would be sent to corporate for approval. The MRD stated that once an email is received from corporate the MRD would request a current email, job role, license number to the requesting physician, which the MRD would send a pin to the requester to set up external user access. The MRD stated that Physician A was last validated on August 22, 2022. The MRD stated that if the physician was not active, the facility administrator would need to inform medical records of the request. The MRD stated that if a physician was no longer on the panel of active physicians, the facility administrator would need to inform the Medical Records Department, in order to reactivate the physicians' credentials to sign into the electronic medical record remotely. The MRD confirmed that Physician A was no longer active and did not currently have access to the electronic medical records. On December 3, 2025, at 3:15 p.m., an interview was conducted with the Registered Nurse, (RN). The RN stated that if a resident requested a physician that was not on the panel, the RN would direct the resident to social services department. The RN stated that she was unaware that Resident 1 had requested for Physician A to provide care while at the facility. On December 3, 2025, at 3:23 p.m., an interview was conducted with the Social Services Director, (SSD). The SSD stated if a resident wanted to change physicians, the SSD would meet with the resident and find out which physician from the panel the resident wanted to provide care from, and have the resident write a written statement requesting the change. The SSD stated that if the resident wanted an outside physician, the physician would need to agree to take on the resident's care and would need to have credentials and would inform the medical records department to follow through. The SSD stated he was not aware that Resident 1 had requested a change in physicians.On December 3, 2025, at 3:30 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that it would be up to the facility administrator to bring on a new physician to provide care to residents at the facility. The DON stated that if a resident requested an outside physician the resident or family would need to provide a written request to social services. On December 3, 2025, at 3:39 p.m., a telephone interview was conducted with the facility Administrator, (Admin). The Admin stated that Physician A was credentialled and provided access to the electronic medical records back in August of 2022. The Admin stated that he started at the facility in May of 2023. The Admin stated that if they no longer wanted the physician on the panel the facility would send a termination letter to the physician. The Admin was not aware that a termination letter was sent to Physician A. The Admin stated that physician credentials never expire. The Admin stated that a physician's credentials never expire. The Admin further stated that residents are not followed by hospital physicians and the resident can only choose from the list of physicians on the facility's panel. On December 4, 2025, at 11:53 a.m., a telephone interview was conducted with Physician A. Physician A stated that Resident 1 was his patient for 27 years. Physician A stated that he was on the facility's panel of physicians in August of 2022. Physician A stated that he had been credentialed at the facility and was not aware that his credentials had expired and denied that he had received a termination letter.On December 8, 2025, at 2:13 p.m., an interview and record review was conducted with the MRD. The MRD stated that the facility's Medical Professional Report dated December 2025, indicated seven physicians with active accounts. The MRD confirmed that Physician A was not one of the seven physicians that had an active account. The MRD stated that if a physician with an inactive account wanted to have their account reactivated, the facility administrator would have to notify medical records. The MRD stated the Administrator had not requested reactivation of Physician A. On December 8, 2025, at 2:30 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that if Resident 1 wanted a physician that did not have privileges at the facility, he would schedule an appointment for the resident to see in the physician's office. The LVN was unaware that Resident 1's family had requested Physician A to oversee Resident 1's care. On December 17, 2025, at 3:22 p.m., a telephone interview was conducted with Resident 1's family member, (FM). The FM stated they requested to have Physician A to be the attending physician upon admission to the facility. The FM stated the facility's business office informed them that they had to use a physician from the facility's panel and did not provide instructions on how to submit a request for an outside physician (Physician A). The FM further stated they were not involved in selecting Physician B. 2) A review of Resident 6's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of muscle weakness, GERD, chronic kidney disease, primary hypertension, diabetes mellitus type 2, BPH, hyperlipidemia, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body) following a stroke, and atherosclerotic heart disease, under the care of Physician C. A review of Resident 6's History and Physical dated November 20, 2025, indicated resident judgement and insight were intact.On December 3, 2025, at 253 p.m., an interview was conducted with the facility's Director of Business Development, (DOBD). The DOBD stated when the facility receives a hospital referral for admission, if clinically appropriate, the facility assigns an attending physician by alternating among seven physicians on the facility's panel. On December 3, 2025, at 3:15 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated that if a resident requested a physician who was not on the panel, the RN would direct the resident to Social Services Department.On December 3, 2025, at 3:23 p.m., an interview was conducted with the Social Services Director, (SSD). The SSD stated if a resident wanted to change physicians, the SSD would meet with the resident and find out which physician from the panel the resident wanted to provide care from, and have the resident write a written statement requesting the change. The SSD stated that if the resident wanted an outside physician, the physician would need to agree to take on the resident's care and would need to have credentials and would inform the medical records department to follow through. The SSD stated he was not aware that Resident 1 had requested a change in physicians.On December 3, 2025, at 3:30 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that it would be up to the facility administrator to bring on a new physician to provide care to residents at the facility. The DON stated that if a resident requested an outside physician the resident or family would need to provide a written request to social services.On December 8, 2025, at 1:14 p.m., an interview was conducted with Resident 6. Resident 6 stated that he had been admitted from the hospital for physical therapy on November 20, 2025. Resident 6 stated that he was not involved in choosing an attending physician at the facility. Resident 6 stated that he was unaware that he could choose a physician to provide care while in the facility. Resident 6 stated that he was not involved in choosing Physician C as his attending physician. On December 8, 2025, at 2:30 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The LVN stated that if a resident requested to have an attending physician that was not on the panel, they would schedule an appointment for the resident to see that physician in the office. A review of the facility's policy and procedure titled Resident Rights revised February 2021, indicated .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.s. choose an attending physician and participate in decision-making regarding his or her care.

Based on observation and interview, the facility failed to ensure resident 's call light was within reach, for one of three sampled residents out (Resident 1). This failure could have resulted in Resident 1 not receiving nursing assistance when needed. Findings: On April 14, 2025, at 750 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, the residents use their call lights to request help from nursing staff. CNA 1 stated, the call light should always be within reach of the resident. On April 16, at 1105 a.m., a concurrent observation and interview of Resident 1 were conducted. Resident 1 was heard calling out from the room for staff assistance. Resident 1 was then observed in his room sitting in a reclining chair, with his legs and feet up, the chair was horizontal to the foot of his bed. Resident 1 ' s call light was at the head of the bed, out of reach from resident. Resident 1 stated, I ' ve been here too long, I want to go to bed. On April 16, 2025, at 11:18 a.m., a concurrent observation of Resident 1 and interview with CNA 2 was conducted. CNA 2 stated, the call lights should always be within reach of the resident so they can call for assistance. CNA 2 observed Resident 1 in his room, reclining in the chair, and stated, Oh (Resident 1 ' s) back, he was just in the dining room somebody must have put him in his room I think from activities (department). CNA 2 verified (Resident 1 ' s) call light was not within reach, and resident had no way to call for staff ' s assistance. Resident 1 stated, I want to go to bed. On April 16, 2025, at 1132 a.m., an interview was conducted with the Activity Assistant (AA), who stated, after activities group, she returned Resident 1 to his bedroom and placed him at the foot of the bed in his reclining chair. The AA stated, when she returned Resident 1 to his bedroom, she hit the call light to inform the nursing staff resident was back to his room from activities. The AA stated, she returned to the activities department without waiting for nursing staff to answer resident ' s call light, to hand off resident 's care. The AA stated, I had to get back to the activity room to monitor the residents. The AA could not explain the process of the call lights and residents ' use for assistance. On April 16, 2025, at 11:42 a.m., an interview was conducted with the Activities Director (AD), who stated, when activity staff return a resident back to their unit, they are to take the resident directly to the nursing station and hand off care to nursing staff via communication. If a resident is returned to their room, care must be handed off to a member of nursing staff, prior to leaving the resident in their bedroom. The AD verified, Resident 1 should not have been left in his room by AA, without communicating to staff resident had returned to his bedroom. The AD further stated, Resident 1 's call light should have been within resident 's reach. On April 22, 2025, at 4:26 p.m., an interview conducted with the Director of Nursing (DON), who stated, call lights should always be within the residents reach. DON further stated, activity staff should communicate to nursing staff resident has been returned to the unit/bedroom, and the call light should be left within resident 's reach. A review of Resident 1's Admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal level of blood sugar) and hemiplegia (a condition characterized by paralysis of one side of the body) and hemiparesis (a condition characterized by weakness or partial loss of strength on one side of the body). A review of Resident 1's care plan dated January 30, 2025, indicated, .ADL (activities of daily living)/Mobility .at risk for ADL/Mobility decline and requires assistance related to bed-bound status .Interventions .Encourage to use call light for assistance . A facility Policy & Procedure, titled, Call Lights, revised, October 2010, indicated, . Purpose: . is to respond to the resident ' s requests and needs. General Guidelines: . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to one of six sampled residents (Resident 1), who was diagnosed with dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and had history of elopement (incident when a resident leaves the facility without authorization). In addition, the facility failed to frequently monitor the whereabouts of Resident 1 in accordance with the care plan. Resident 1 exited the facility on December 20, 2024, via the BC wing (name of a facility wing) automatic sliding door. It was observed that the sliding door led directly to the facility's parking lot, which led to a two-way street. This failure exposed the resident to immediate danger, accidents, serious harm, or death. Resident 1 returned to the facility on [DATE] (18 days after the resident eloped). On January 24, 2025, at 12:23 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD), were provided a copy of the CMS Immediate Jeopardy (IJ) template and notified them an immediate jeopardy (IJ) existed on December 20, 2024, related to Title 42 Code of Federal Regulation 483.25- Accidents (F 689). On January 24, 2025, at 1:32 p.m., the facility provided the corrective action plan dated January 15, 2025. On January 24, 2025, at 4:03 p.m., the surveyor validated that the facility removed the IJ (the facility has taken the necessary corrective actions to address and resolve the seriousness and urgent risk) before the survey entrance on December 24, 2024. IJ at F 689, severity J, cited as Past non-compliance (at some point, the facility did not meet the established rules). Findings: A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE], with diagnoses of dementia, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and psychoactive substance abuse (a strong desire or sense of compulsion to take a drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). A review of Resident 1's History and Physical, dated November 7, 2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Elopement and Wandering (the behavior of moving about without clear purpose) Risk Observation/Assessment, dated November 6, 2024, indicated, Instructions: Evaluate/Assess the resident status in the seven clinical areas listed below. If the total score is 10 or greater, the resident would be considered At Risk for Wandering or Elopement. Interventions implemented as determined by the facility IDT .A. MOBILITY STATUS . 4. Does the resident ambulate (move from one place to another) independently with or without the use of assistive devices (tools or equipment to help resident perform task that might be difficult) . B. COGNITIVE STATUS .2. Is the resident disoriented or has periods of confusion and/or impaired attention span but does not wander . C. DISEASE DIAGNOSIS .Does the resident have a diagnosis that may impact cognition? (i.e. Alzheimer's disease [a progressive, neurodegenerative disorder that affects memory, thinking, and behavior], Anxiety Disorder [a mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life] . 4. Two or more present .E. MEDICATION (Does the resident take medications that could increase restlessness or agitation . 4. Takes two or more medications . I. INTERVENTIONS . 1. Has the care plan been initiated/updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement a. Yes . A review of Resident 1's eINTERACT Change in Condition Evaluation, dated November 12, 2024, at 6:24 p.m., indicated .Resident wanders around. Found resident outside facility along (name of the street - which was 2.2 miles from the facility) . A review of Resident 1's eINTERACT Change in Condition Evaluation, dated December 20, 2024, at 6 p.m., indicated, .charge nurse reported to RN [Registered Nurse], patient was not located in her room around 1700 (5p.m.), patient was last seen at 16:00 (4 p.m.) in-patients (sic) room. All nursing staff looked all around facility and could not find the patient. police dept (department) was notified at 17:45 (5:45 p.m.). Md (Medical Doctor), notified. No family or emergency contact phone number is listed on patient face sheet. A review of Resident 1 ' s Care Plan indicated the following: - On November 12, 2024, .Resident wanders around .Goal .Resident will stay in the facility until they find placement .Interventions .Did frequent visual check to resident. Placing resident close to nursing station .resident was placed to another room and station for closer monitoring and doors with alarms . - On November 27, 2024, .Elopement: Resident is at risk for elopement/exit seeking/wandering related to dementia or other cognitive impairment (decline or difficulty in mental abilities such as memory, thinking or decision making) .Goal .will not wander out of facility .Interventions .monitor whereabouts frequently . A review of the video surveillance footage of the whereabouts of Resident 1 with time stamped images with date and time indicated the following: .12-20-2024 .2:57 p.m. Resident 1 was standing in Hallway B lobby, in front of the nursing station located in the BC wing of the facility, with automatic doors open. .12-20-2024 .2:58 p.m. Resident 1 was walking out of the facility BC wing automatic sliding door. .12-20-2024 .3:02 p.m. Resident 1 was walking into the facility with BC wing automatic sliding door open and sitting in the front lobby with belonging bag in hand watching television. .12-20-2024 .3:08 p.m. Resident 1 was walking out of the facility BC wing automatic sliding door and did not re-enter the facility. Further review of the video surveillance footage dated December 20, 2024, from 2:57 to 3:08 p.m. did not show presence of facility staff to supervise the resident nor to redirect the resident away from the BC wing automatic sliding door. A review of Resident 1 ' s progress notes dated December 20, 2024, at 5:57 p.m., .CNA (Certified Nursing Assistant) alerted charge nurse of patient not being in room at 5:00 p.m. Patient was last seen at 3:45 p.m. in patients (sic) room, CNA stated she saw the patient at the beginning of her shift before she started doing patient care and after she was done with patient care went to go check on patient and noticed she was not in her room .We notified police at 5:45 p.m. Further review of Resident 1's progress notes dated November 16, 2024, to December 20, 2024, indicated there was no documented evidence that the facility frequently monitored Resident 1's whereabouts. On January 23, 2025, at 12:52 p.m., during an interview with CNA 1, CNA 1 stated on December 20, 2024, Resident 1 was assigned to her for the 7 a.m. to 3 p.m. shift. CNA 1 stated on December 20, 2024, prior to leaving for the day at 3 p.m., she had seen Resident 1 in her room. CNA 1 stated she was unaware Resident 1 had eloped from the facility on November 12, 2024, and would have considered the resident as high risk for elopement. CNA 1 stated residents at risk for elopement would require checking on the resident at least every two hours. CNA 1 stated that during her shift on December 20, 2024, BC wing automatic sliding door was opened and was being used by visitors to enter and exit the facility. On January 23, 2025, at 1:11 p.m., during an interview with Licensed Vocational Nurse (LVN 1), LVN 1 stated that he was working on December 20, 2024, 7 a.m. to 3 p.m., shift. LVN 1 stated that he had seen Resident 1, who was from Hallway A, sitting in a chair adjacent from Nursing station B, by the BC wing automatic sliding door before 3 p.m. LVN 1 stated that when residents have a history of elopement they should be placed on 1:1 (one staff to one resident) for 72 hours, they should be checked at least hourly, and the residents ' location should be known at all times. LVN 1 stated he was unaware that Resident 1 had a history of elopement and was unsure if the staff in Hallway A knew Resident 1 was by the BC wing automatic sliding door. On January 23, 2025, at 1:24 p.m., during an interview with CNA 2, CNA 2 stated if a resident is at risk for elopement, the staff should check on the resident every hour and the facility staff should know where the residents are at all times. CNA 2 stated that the BC wing automatic sliding door was open before, (prior to the elopement incident of Resident 1), but this door is now locked. On January 23, 2025, at 1:30 p.m., during a concurrent observation and interview, Resident 3 was sitting in a chair next to the BC wing automatic sliding door. Resident 3 stated that on December 20, 2024, he was sitting here in this location (near the BC wing with automatic sliding door) with Resident 1. Resident 3 stated that Resident 1 walked out the automatic door a little after 3 p.m. Resident 3 stated that there were staff at the nursing station across from the BC wing automatic sliding door. On January 23, 2025, at 4:21 p.m., during an interview with the Registered Nurse Supervisor (RN), the RN stated she was working on December 20, 2024, 3 p.m. to 11 p.m. shift. The RN stated Resident 1 was not able to be located on December 20, 2024. The RN stated they searched the premises, reported the elopement to the Director of Nursing, and the police department. On January 24, 2025, at 10:40 a.m., during an interview with LVN 2, LVN 2 stated that she was working on December 20, 2024, from 7 a.m. to 11 p.m. LVN 2 stated that she had given Resident 1 her medications between 12:30 p.m. and 1 p.m., prior to attending the staff meeting, which ended at approximately 3 p.m. LVN 2 stated at approximately 5 p.m., CNA 3 reported to her that she could not locate Resident 1. LVN 2 stated that she was aware that Resident 1 was a risk for elopement, however, she did not report this information to CNA 3 as she (CNA 3) had cared for Resident 1 before. LVN 2 stated they should have been checking on Resident 1 every two hours. LVN 2 stated that they should have been aware that Resident 1 was off the unit. On January 24, 2025, at 2:49 p.m., a telephone interview was conducted with CNA 3. CNA 3 stated she was working on December 20, 2024, 3 p.m. to 11 p.m., and was assigned to care for Resident 1. CNA 3 stated that when she came on to her shift, she went room to room to check on her assigned residents but did not see Resident 1. CNA 3 stated did not know that Resident 1 was a high risk for elopement, as she never received that information. A review of the facility's policy and procedure titled Wandering and Elopements revised March 2019, indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . A review of the facility's Corrective Action Plan dated January 15, 2025, included the following: Immediate Actions: Facility followed the policy and procedure in searching for the resident missing upon knowledge of resident not being in the facility on December 20, 2024. Staff searched inside the facility while other staff searched around the vicinity. The facility notified the police department as well calling (emergency room s) ER around the area and called the homeless shelter where she was at prior, to see if she checked in there. Staff continued driving round the area to search for the resident on December 20, 2024. The facility created a plan to close BC wing sliding door between 8:30 am to 5 pm and have a designated staff to monitor the door between 6:00 am to 8:30 am. Signage was also placed of the time the sliding door will be closed and when it will be available for entrance and exit. In-services were given by the RN supervisor and the Director of Staff Development on December 21, 2024, to staff regarding the facility policy and protocol on elopement and wandering of the residents, as well as, providing staff an update on the plan discussed by IDT. Identification of others: The DON reviewed all current residents who were at high risk for elopement on December 21, 2024. The facility identified 1 resident. This resident was placed on l: l sitter immediately. Facility identified all residents who are considered high risk for elopement and necessary interventions were placed such as (I: I Sitter. activity monitoring Q hour, [every hour], Q 2 [every two] hours). The Emergency IDT [Interdisciplinary Team] meeting with all the department managers was held on December 21, 2024, to discuss a plan to prevent resident elopement. On December 21, 2024, the facility created an elopement risk binder with the face sheet and photos of residents who are high risk for elopement and this binder is kept in nursing station and in the front lobby with the receptionist, for the staff to be aware of the residents at risk for elopement. Binders are updated by the DON and updated as needed. On admission a wandering evaluation will be conducted and when resident scores I0 and above or noted to have high risk of wandering, staff will initiate preventative measures and ensure proper documentation and notify DON accordingly. The maintenance supervisor or designee will check all the emergency doors, making sure the alarm is placed and working daily. Any findings will be corrected immediately. On December 21, 2024, facility Administrator contacted wander guard vendor for installation quotes and installing schedule. Estimated installation schedule is anticipated to be completed by January 31, 2025. The maintenance supervisor will conduct random checks on different shifts to monitor the alarms of the emergency door and report the response time of the staff when the alarm goes off biweekly x 3 months. Findings will be reported during the QA Meeting to monitor trends and compliance. The DON will report on monthly QA those residents at risk for elopement or any resident identify score of 10 or above on elopement assessment and discuss effectiveness of measure provided and monitor for trends. Completion date: January 13, 2025.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation for one of six residents reviewed, (Resident 1), as the resident's record indicated Resident 1 was last seen at 3:45 p.m. on December 20, 2024, while the video surveillance showed Resident 1 left the facility at 3:08 p.m. on December 20, 2024. This failure resulted in an inaccurate account of Resident 1's whereabouts and potentially impacting the accuracy of their care documentation. Findings: On January 23, 2025, at 10:45 a.m., an unannounced visit to the facility on a facility reported incident was initiated. A review of Resident 1's medical records indicated she was admitted on [DATE], with diagnoses of dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), paranoid schizophrenia, (a mental illness that is characterized by disturbances in thought), psychoactive substance abuse. (a strong desire or sense of compulsion to take a drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Resident 1 eloped from the facility on December 20, 2024. A review of Resident 1's History and Physical dated November 7, 2024, indicated she did not have the capacity to understand and make decisions. A review of the video surveillance footage of the whereabouts of Resident 1 with time stamped images with date and time indicated the following: .12-20-2024 .3:08 p.m. Resident 1 was walking out of the facility through BC wing automatic sliding door and did not re-enter the facility. A review of Resident 1's Nurse's Note dated December 20, 2024, at 5:57 p.m., indicated, .CNA alerted charge nurse of patient (Resident 1) not being in room at 1700. Patient (Resident 1) was last seen at 15:45 (3:45 p.m.) in patients room. The CNA stated she saw the patient at the beginning of her shift before she started doing patient care and after she was done with patient care went to go check on patient and noticed she was not in her room . A review of Resident 1's eINTERACT Change in Condition Evaluation dated December 20, 2024, at 6 p.m., indicated, .charge nurse reported to RN, patient (Resident 1) was not located in her room around at 1700 (5 p.m.), patient (Resident 1) was last seen at 16:00 (4 p.m.) in-patients room. All nursing staff looked all around facility and could not find the patient. police dept was notified at 17:45. (5:45 p.m.) md notified. No family or emergency contact phone number is listed on patient face sheet . On January 23, 2024, at 1:30 p.m., an interview was conducted with Resident 3. Resident 3 was sitting in a chair next to the automatic door in Hallway B. Resident 3 stated that on December 20, 2024, he was sitting here in this location with Resident 1. Resident 3 stated that Resident 1 walked out the automatic door a little after 3 p.m. and headed to the right. Resident 3 stated that there were staff at the nursing station across from the BC wing automatic sliding door. On January 24, 2024, at 10:40 a.m., an interview was conducted with LVN 2. LVN 2 stated that she was working on December 20, 2024, from 7 a.m. to 11 p.m. LVN2 stated that she had given Resident 1 her medications between 12:30 p.m. and 1 p.m. LVN2 stated she went to a staff meeting at 2:30 p.m. and saw Resident 1 in her room. LVN 2 stated the meeting ended approximately 3 p.m. LVN 2 stated that approximately 5 p.m. CNA 3 reported to her that she could not locate Resident 1. LVN 2 stated that CNA 3 had reported that she last saw Resident 1 in her room or nursing station between 3:45 p.m. and 4 p.m. On January 24, 2024, at 2:49 p.m., a telephone interview was conducted with CNA 3. CNA 3 stated she was working on December 20, 2024, 3 p.m. to 11 p.m., and was assigned to care for Resident 1. CNA 3 stated that when she came on to her shift, she goes room to room to check on her assigned residents. CNA 3 stated that she did not see Resident 1 on her first rounds. CNA 3 stated that after she provided care to a resident, she searched the facility for Resident 1. CNA 3 stated that she informed LVN 2 that she was unable to locate Resident 1 after she searched for her. CNA 3 stated that she was unsure that Resident 1 was a high risk for elopement as she never received that information. A review of the facility policy and procedure titled Charting and Documentation revised July 2017, indicated .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters were overflowing, the lids could not be closed, and the surrounding area was littered with debris. This failure had the potential to attract pests and cause infection control issues. Findings: On December 8, 2024, at 8:15 a.m., during an observation of the dumpster storage area outside of the facility near the corner entrance, three out of three dumpsters were overflowing with garbage and cardboard boxes. The dumpster lids were not closed, and debris was scattered around the dumpsters. On December 8, 2024, at 10:17 a.m., during a concurrent observation and interview with the Dietary Supervisor (DSS), in front of the dumpsters, the DSS stated the dumpsters should be closed and not overflowing with garbage or boxes. The DSS further stated there should not be any debris surroundnig the dumpster area to prevent pest infestations, which could lead to infection control issues. On December 8, 2024, at 10:22 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MTD), in front of the dumpsters, the MTD stated all dumpsters should be closed and not overflowing to prevent rodent infestation which could result in infection control problems. The MTD further stated, the dumpsters should be inspected daily to ensure no garbage is left around the outside perimeter of the dumpsters. On December 8, 2024, at 3:13 p.m., during an interview with the Registered Dietitian (RD), the RD stated the dumpsters should not be overflowing and should always remain closed to avoid attracting flies, insects, rodents, and other pests. The RD stated, there should not be no garbage in the surrounding area. The RD further stated, not adhering to the policy could result in pest infestation and infection control issues. A review of the facility policy and procedure titled Miscellaneous Areas: Garbage and Trash Procedure, dated 2023, indicated, .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed .The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean .

Based on interview and record review, the facility failed to provide Advance Directive (AD-a written instruction related to the provision of health care when the resident is no longer able to make decisions) education, materials, and follow-up for three of five residents reviewed for AD (Residents 19, 35, and 69) and/or their resident representatives (RP). This failure had the potential for Residents 19, 35, and 69's medical preferences not being honored during critical healthcare decisions. Findings: 1. Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with a diagnoses which included cerebral infarction (lack of oxygen to the brain). A review of Resident 35's history and physical dated November 4, 2024, indicated Resident 35 had the capacity to understand and make decisions. Resident 35 is self-responsible. A review of Resident 35's, Advance Directive Acknowledgement, dated November 3, 2024, indicated, Resident 35 was not screened or provided AD education. A review of Resident 35's, IDT (Interdiciplinary Team) Conference Summary, dated November 5, 2024, indicated Resident 35 was not screened or provided AD education. Further review of Resident 25's records, indicated there was no documented evidence education and information was provided to Resident 35 in the medical record. On December 10, 2024, at 11:43 a.m., during a concurrent interview and review of Resident 35's medical record with the Social Service Director (SSD), he stated Resident 35 was not screened, provided education, and reviewed for an AD. The SSD further stated there was a potential for resident preferences to not be honored if they are not screened for an AD. 2. Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses that included traumatic subdural hemorrhage with loss of consciousness (bleeding from the brain). A review of Resident 69's Minimum Data Set (MDS- an assessment tool), dated November 23, 2024, indicated, Resident 69 had a Brief Interview of Mental Status (used to assess cognitive status in elderly) score 8 (moderate cognitive impairment). A review of Resident 69's, Advance Directive Acknowledgement, dated November 3, 2024, indicated, Resident 69 was not screened or provided AD education. A review of Resident 69's, IDT Conference Summary, dated November 12, 2024, indicated Resident 69 was not screened or provided AD education. Further review of Resident 69's medical records indicated no documented evidence that education and information were provided to Resident 69. On December 10, 2024, at 11:43 a.m. during a concurrent interview and review of Resident 69's medical record with the Social Service Director (SSD), he stated Resident 69 was not screened, provided education, and reviewed for an AD during the IDT meeting. The SSD further stated he should have discussed the AD with the resident and or the resident representative. 47202 3. Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE]. A review of Resident 19's History and Physical dated November 8, 2024, indicated Resident 19 has fluctuating capacity to understand and make decisions. A review of Resident 19's Advance Directive Acknowledgement Form, undated, indicated Resident 19 was not screened or provided AD education. A review of Resident 19's Social History Assessment, dated November 18, 2024, indicated, .Self-responsible .Advance Directive .None of the above . A review of Resident 19's IDT Conference Summary, dated November 11, 2024, indicated the formulation of AD was not discussed with Resident 19 or the RP. Further review of Resident 19's medical record indicated no documented evidence Resident 19 was screened and the resident or the RP was provided education and information about AD. On December 10, 2024, at 11:42 a.m., during a concurrent interview and review of Resident 19's medical record with the SSD, he stated if a resident did not have an AD, he would offer resources and education to the resident or RP. The SSD further stated it was important for residents to be educated and have the opportunity to formulate an AD in the event the resident were unable to make decisions in the future. The SSD stated Resident 19 had no AD and he did not provide resources and education. The SSD further stated he should have provided AD resources and education to Resident 19 or the RP. A review of the facility policy and procedure titled, Advance Directives, dated 2021, indicated, .Prior to, upon, or immediately after admission, the social service director or designee inquires of the resident .about the existence of any written advance directive .If a resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .Information about whether or not the resident has executed and advance directive is displaced prominently in the medical records.

Based on observation, interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures and appetizing taste according to residents' preferences for 14 of 96 sampled residents (Residents 14, 15, 19, 29, 36, 41, 43, 51, 65, 69, 73, 77, 182, and 282). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Findings: On December 8, 2024, at 8:47 a.m., during an interview with Resident 73, she stated, the served food does not taste very good, not good quality. On December 8, 2024, at 9:30 a.m., during an interview with Resident 282, he stated, food tasted bad and is cold for breakfast, lunch and dinner every day. On December 8, 2024, at 9:55 a.m., during an interview with Resident 182, he stated, food tasted bland. On December 8, 2024, at 9:55 a.m., during an interview with Resident 14, she stated, the served food taste bad. On December 8, 2024, at 10:12 a.m., during an interview with Resident 41, she stated, the served food not appetizing, sometimes tasted salty and sometimes tasted bland. On December 8, 2024, at 10:20 a.m., during an interview with Resident 65, he 65 stated, served food is cold and they don't serve what's listed on the menu. On December 8, 2024, at 11:17 a.m., during an interview with Resident 36, he stated, the food is unbearable and is cold. On December 8, 2024, at 11:18 a.m., during an interview with Resident 15, she stated, food tasted, bland, cold and sometimes tasted salty. On December 8, 2024, at 12:16 p.m., during an interview with Resident 19, he stated, food is served cold on 3 meals mostly on breakfast. On December 8, 2024, at 12:54 p.m., during an interview with Resident 43, she stated, food is too salty, not cooked well, sausage has pink and turkey is dry and hard. On December 8, 2024, at 12:58 p.m., during an interview with Resident 69, he stated, food is cold especially during dinner. On December 9, 2024, at 11:00 a.m., Residents 51 and Resident 77 stated, cold food service. On December 9, 2024, at 11:00 a.m., Resident 29 stated, food is cold. On December 9, 2024, at 1:54 p.m., a concurrent observation of test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) for regular diet and pureed diet and interview with the Registered Dietitian (RD) were conducted. The RD acknowledged she could not taste garlic or parmesan cheese on the served Garlic Parmesan Cheese Spinach. The RD stated served spinach (regular and pureed) required more seasoning. The RD stated cooks should follow recipes when preparing meals to ensure the food is appealing and palatable (refers to the taste and/or flavor of the food). She further stated serving unseasoned foods could result in residents not wanting to eat, which could lead to malnutrition (a condition when the body doesn't get the right amount of nutrients). A review of the facility policy and procedure titled, Meal Service, dated 2023, indicated, .Meals that meet the nutritional needs of the residents will be served in an accurate and efficient manner, and served at the appropriate temperatures .Temperature of the food when the resident receives it is based on palatability .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food and Nutrition Service employees did not follow the facility cleaning procedure to clean food preparation surfaces and stationary equipment. 2. Four out of four green storage shelves in the walk-in refrigerator had buildup; 3. Dust was hanging on walk-in refrigerator's fan covers; and 4. One wet plastic container was stacked with other dried plastic containers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 95 out of 95 residents who received food prepared in the kitchen. 1. During a review of the facility provided procedure title, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING SINKS (HANDWASHING, FOOD PREPARATION, ETC.), the procedure indicated, CLEANING PROCEDURE: 1. Remove any large debris and wash surface with a warm detergent solution . 2. Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. 3. Spray with a sanitizer . On December 8, 2024, at 10:29 a.m., an interview was conducted with the Dietary Supervisor (DSS). The DSS stated Food and Nutrition service employees only used sanitizer to clean used prep table surfaces and stationary equipment. On December 8, 2024, at 10:47 a.m., an interview was conducted with [NAME] (Ck) 2. Ck 2 stated he only used sanitizer to clean used prep table surface and stationary equipment. On December 8, 2024, at 10:56 a.m., an interview was conducted with Ck 4. Ck 4 stated she used detergent to wash the stationary equipment and then sanitized it with sanitizer. Ck 4 stated, for used Prep table surface, she only used sanitizer to sanitize. On December 9, 2024, at 8:30 a.m., an observation was conducted with [NAME] (Ck) 1. Ck 1 cleaned stationary mixer base with sanitizer after preparing pudding. On December 9, 2024, at 11:44 a.m., a concurrent observation and interview were conducted with Ck 3. Ck 3 cleaned stationary blender base with sanitizer after preparing mechanical soft meat. Ck 3 confirmed she cleaned the blender base twice with sanitizer. On December 11, 2024, at 3:45 p.m., a phone interview was conducted with the RD. The RD stated Food and Nutrition service employees should follow the facility cleaning procedure to wash, rinse, and sanitize used stationary equipment and food preparation surface. The RD further stated if the cleaning procedure was not followed, used equipment and food preparation surface would not be properly cleaned, which could result in cross-contamination and lead to food borne illness in the residents. 2. On December 8, 2024, at 10:29 a.m., a concurrent observation and interview were conducted with the DSS in the walk-in refrigerator. Four out of four green storage shelves were observed to have whitish, grayish, blackish particles, and grime buildup. Milk, egg, and produce were observed stored on the green storage shelves. The DSS verified the buildup and stated, Food and Nutrition Service employees had missed cleaning the green storage shelves. The DSS stated unsanitary storage shelves could potentially cause cross-contamination when Food and Nutrition Service employees touched the unsanitary shelves while removing food items from the refrigerator. On December 8, 2024, at 3:46 p.m., an interview was conducted with the RD. The RD stated storage shelves in walk-in refrigerator should be kept clean. The RD stated the potential concern for unsanitary storage shelves in walk-in refrigerator was cross-contamination and mold growth. During a review of the facility's Policy and Procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, .11. All .shelves . shall be kept clean . 3. On December 8, 2024, at 11:37 a.m., a concurrent observation and interview with the DSS were conducted, in the walk-in refrigerator. The DSS confirmed black debris was dust hanging on the refrigerator's fan covers. On December 8, 2024, at 3:46 p.m., an interview was conducted with the RD. The RD stated the walk-in refrigerator's fan covers should not have dust. The RD explained dust could potentially fall into food items stored in the refrigerator. During a review of the facility's Policy and Procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean . 4. On December 8, 2024, at 12:06 p.m., a concurrent observation and interview with the DSS were conducted in the coffee room. A wet clear plastic container was stacked together with four dried plastic containers on the rack. The DSS stated the wet clear plastic container should not have been stacked with the dried plastic containers. On December 8, 2024, at 3:46 p.m., a concurrent observation and interview with the RD. The RD stated wet container should be air dried before being stacked and stored with other dried containers on the rack. The RD explained that the moisture from the wet container could create an environment for bacteria to grow, which could lead to cross-contamination and food borne illness. During a review of the facility's Policy and Procedure (P&P) titled, DISHWASHING, dated 2023, the P&P indicated, .PROCEDURE: .5. Dishes are to be air dried in racks before stacking and storing .

Based on observation, interview, and record review, the facility failed to ensure the lunch menu on December 9, 2024, met residents' needs when: 1. Dietary Aide (DA 1) served pudding instead of mandarin oranges for five of five residents (Residents 19, 41, 134, 190 and 332) on a renal diet (a restricted diet that can help slow kidney damage). 2. [NAME] (CK 1) served pureed spinach instead of green beans for one of one resident (Resident 332) on a renal pureed diet (smooth, lump-free foods that require no chewing). 3. DA 1 used a #8 scoop size to serve dessert for regular diets. 4. CK 1 did not follow the recipe when preparing garlic parmesan spinach. These failures had the potential for residents to miss out on therapeutic and nutritional benefits, correct serving portion, and/or palatability (acceptable taste). Findings: 1. A review of the facility's Winter menu for Week 2, dated December 9, 2024, indicated: -Southern beef patties with cream gravy, Mashed Potatoes (renal diet: wheat pasta) Garlic Parmesan Spinach (renal diet: green beans) Dessert: Ambrosia pudding (1/3 (one-third) cup (unit of measurement), pudding with coconut for regular diets No pudding for renal diets, instead 1/2 (one-half) cup mandarin oranges with coconut. A review of the physician diet orders for Residents 19, 41, 134, 190 and 332 indicated Residents 19, 41, 134, 190, and 332 were on renal diet. On December 9, 2024, at 11:30 a.m., during a concurrent observation and interview of the lunch tray line service (the serving of food onto plates) in the kitchen, DA 1 was observed preparing and scooping pudding into individual cups. DA 1 stated all residents would receive pudding for dessert. On December 9, 2024, at 12:45 p.m., during an observation of the tray line in the kitchen, the meal trays for Residents 19 and 41 contained pudding. On December 9, 2024, at 12:55 p.m., during an observation of the meal service carts, the meal trays for Residents 134 and 190 included pudding. On December 9, 2024, at 1:20 p.m., during a concurrent observation, interview, and review of the spreadsheet menu with the Dietary Supervisor (DSS) in the kitchen, the DSS stated Resident 332's lunch meal tray included pudding. The DSS stated the resident was on a renal diet and should not have been served pudding. The DSS further stated Residents 19, 41, 134 and 190 were also on renal diets and should not have received pudding with their lunch meal trays. She further stated DA 1 should have followed the menu to avoid potential strain on residents with compromised kidney function. On December 9, 2024, at 1:54 p.m., during an interview with the Registered Dietitian (RD), the RD stated dietary staff should have followed the cook's spreadsheet and prepare the meals according to the menu and physician orders to meet residents' nutritional needs. The RD further stated Residents 19, 41, 134, 190 and 332 should not have received pudding because the high phosphorus (a mineral that help keep bones and muscles healthy) content could be harmful to residents with kidney disease. A review of the facility policy and procedure titled Menu Planning, Section 3, dated 2023, indicated, .Menus and cook's spreadsheets are to be dated and posted in the kitchen .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician orders and followed .The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . A review of the facility policy and procedure titled Renal Diet 40-60-80 Gram Protein, Low Potassium, Low Salt Menu, dated 2023, indicated, .This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidneys . 2. Resident 332's record were reviewed. Resident 332 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (when the kidneys stop working) and on hemodialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body). A review of Resident 332's physician's diet order, dated December 9, 2024, indicated, .Controlled Carbohydrate diet, Renal diet, and pureed texture . A review of Resident 332's Care Plans included a care plan with a .Focus .nutritional risk: Resident is at risk for nutritional imbalance related to dialysis, therapeutic diet .Interventions .Provide diet, supplements .as ordered . A review of the facility's Winter menu for week 2, dated December 9, 2024, indicated, .renal diet to be served seasoned green beans with margarine . The facility's Winter menu for Week 2 (Monday) was reviewed. The menu indicated renal diet to be served seasoned green beans with margarine. On December 9, 2024, at 11:39 a.m., during a concurrent observation and interview, CK 1 placed spinach and green beans into serving pans. CK 1 stated, spinach would be served to residents on regular diets and green beans to residents on renal diets. On December 9, 2024, at 1:20 p.m., during a concurrent interview and observation of the lunch tray line in the kitchen, CK 1 prepared pureed spinach on Resident 332's meal tray. CK 1 stated she forgot to substitute green beans for Resident 332, who was on a renal diet. CK 1 stated she did not check the meal card or followed the menu. CK 1 further stated, she should have prepared green beans as spinach was high in potassium (a mineral that help the body function) which may not be safe for residents with kidney disease. On December 9, 2024, at 1:20 p.m., during a concurrent observation and interview with the DSS in the kitchen, the DSS verified Resident 332's meal tray included spinach. The DSS stated, Resident 332 was on a renal diet and should not have been served spinach because of the high potassium content, which could further damage the resident's kidneys. On December 9, 2024, at 1:54 p.m., during an interview with the RD, the RD stated CK 1 should have followed the cook's spreadsheet and recipes, preparing meals according to the menu to meet Resident 332 nutritional needs according to physician orders. The RD further stated Resident 332 should not have been served spinach because high levels of potassium could accumulate in the body and further damage the kidneys. A a review of the facility policy and procedure titled Menu Planning, Section 3, dated 2023, indicated, .Menus and cook's spreadsheets are to be dated and posted in the kitchen .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician orders and followed .The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . A review of the facility policy and procedure titled Renal Diet 40-60-80 Gram Protein, Low Potassium, Low Salt Menu, dated 2023, indicated, .Description .This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidneys . A review of the facility policy and procedure titled Therapeutic Diets, dated October 2017, indicated, .Policy Interpretation and Implementation .A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . 3. On December 9, 2024, at 11:30 a.m., during a concurrent observation and interview with DA 1 in the kitchen, DA 1 used a #8 gray colored scoop to serve pudding and stated it was the correct scoop. During a review of the Winter Menus Spreadsheet, the menu indicated the Ambrosia pudding for regular diet portions was to use the #12 scoop size, equivalent to 1/3 (one-third) cup (unit of measure) or 5 tablespoons (unit of measure). On December 9, 2024, at 4:33 p.m., during a concurrent observation, interview, and review of the menu spreadsheet with the DSS, the DSS stated, DA 1 had used a #8 scoop and should have used a #12 scoop to serve the pudding. The DSS further stated a #8 scoop was almost doubled the portions of the pudding and could result residents to receive too many calories and affect their health. On December 12, 2024, at 3:25 p.m., a telephone phone interview was conducted with the RD. The RD stated the dietary staff should have used the correct serving scoop when preparing pudding. She stated using the wrong scoop could result in residents receiving incorrect calorie amounts and could affect their health. The RD further stated all dietary staff were expected to follow the menu, recipes and serving portions accurately. A review of the facility policy and procedure titled Portion Control, dated 2023, indicated, .To provide specific portion control information .To be sure portions served equal portion sizes listed on the menu, the portion control equipment must be used .Scoop numbers and amounts are listed within the Healthcare Menus Direct, LLC. Recipe books . 4. On December 9, 2024, at 11:39 a.m., during a concurrent interview and observation with CK 1, CK 1 prepared the garlic parmesan spinach. CK 1 stated she had steamed seven large bags of spinach to make about 100 servings. The recipe sheet titled, Recipe: Garlic Parmesan Spinach, was reviewed. The recipe for the garlic parmesan spinach indicated the addition of 11/2 (one and one-half) cup margarine, 12 chopped cloves, 1 tablespoon of salt, and 3 cups of Parmesan cheese to boiled or steamed spinach and may substitute 1/8 teaspoon garlic powder for 1 clove garlic. On December 9, 2024, at 11:45 a.m., during a concurrent interview and observation with CK 1 in the kitchen, CK 1 added an unmeasured amount of butter to the spinach. CK 3 stated the recipe called for one stick of butter and parmesan cheese to be sprinkled on top of the spinach when plating. CK 1 stated she should have followed the recipe as listed to ensure the flavor of the spinach would be palatable and the residents would be served good quality food. On December 9, 2024, at 1:20 p.m., during a concurrent observation and interview with the DSS in the kitchen, the DSS stated CK 1 had not used all the ingredients in the recipe for the garlic parmesan spinach. The DSS stated it was important to follow the recipe because it was designed to meet the nutritional needs and flavor for each serving of food. The DSS further stated, not following the recipe could result in the food being under-flavored and the residents may not want to eat it, which could lead to weight loss. On December 9, 2024, at 1:54 p.m., a test tray sample was conducted with the RD in the DSD's office. The RD stated she did not taste salt or garlic in the spinach. She stated cooks should follow recipes when preparing meals to ensure the food were appealing and the residents met the nutritional value of the meals. The RD further stated not following the recipe could result in residents not wanting to eat the food which could lead to low calorie intake or malnutrition (a condition when the body doesn't get the right amount of nutrients). A review of the facility policy and procedure titled Food Preparation, dated 2023, indicated, .Food shall be prepared by methods that conserve nutritive value, flavor .The facility will use approve recipes, standardized to meet the resident census .Recipes are specific as to portion, yield, method of preparation, quantities of ingredients, and time and temperature guidelines .

Based on observation, interview, and record review, the facility failed to implement proper infection control measures when Certified Nurse Assistant (CNA) 1 did not perform hand hygiene and wear personal protective equipment (PPE - equipment use to protect against infection or illness) upon entering the room and while providing care to Resident 283, who was positive for Clostridium Difficile infection (C. diff - a bacteria that cause diarrhea and is spread through contact with contaminated surfaces or people). This failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents, potentially leading to illness. Findings: On December 10, 2024, at 8:25 a.m., during a concurrent observation and interview in the hallway outside Resident 283's room, a contact precaution (a set of precautions to prevent the spread of germs that are transmitted through direct or indirect contact) sign was observed on the wall. CNA 1 entered and exited the room, provided care to Resident 283, and did not perform hand hygiene or don (put on) PPE. CNA 1 stated Resident 283 was on contact precautions for C. diff. CNA 1 stated, facility staff and visitors must wash hands, wear a gown and gloves before room entry and upon room exit. CNA 1 further stated she entered and exited Resident 283's room, provided care and she did not wash her hands and wear PPE. CNA 1 stated she should have washed her hands and worn gloves and a gown (PPE) to prevent the spread of pathogens and infection to facility resaidents. On December 10, 2024, Resident 283's record was reviewed. Resident 283 was admitted to the facility on [DATE], with diagnosis which included Enterocolitis (inflammation of intestines) due to Cdiff. A review of Resident 283's Minimum Data Set (MDS - an assessment tool), dated September 12, 2024, indicated Resident 283 had a Brief Interview for Mental Status (use to assess cognition) score of 3 (severe cognitive impairment). A review of Resident 283's Lab Results, dated December 7, 2024, indicated, .Critical result .December 8, 2024 .Cdiff: Positive . A review of Resident 283's Care Plan, dated December 8, 2024, indicated, .Stool culture positive for c-diff .Interventions: isolation with contact precautions . A review of the facility document titled, Contact Precaution Sinage, undated, indicated, .Everyone Must: Clean their hands, including before entering and when leaving the room .Providers and Staff must also: Put on gloves before room entry .Put on gown before room entry . On December 11, 2024, at 9:05 a.m., during an interview with the Infection Preventionist (IP), he stated it was the facility practice for staff to perform hand hygiene upon entering and exiting a resident's room and to wear personal protective equipment when caring for residents on contact preacutions. The IP stated, all staff were expected to follow the facility infection control practices to prevent cross contamination and infection to facility residents. A review of the facility Policy and Procedure titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, dated September 2022, indicated, .Contact Precautions .Staff and visitors wear gloves when entering the room .Wear disposable gown upon entering the room . A review of the facility Policy and Procedure titled, Handwashing/Hand Hygiene, dated 2021, indicated, .This facility considers hand hygiene as the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to to help prevent the spread of infection to .residents .

Based on observation, interview, and record review, the facility failed to ensure the medication error rates were not five percent or greater when: 1. Resident 21's lidocaine (local anesthetic to relieve pain) patch was applied to the wrong body location; and 2. Resident 137's Metformin (medication to treat high blood sugar) and Carvedilol (heart medicine) were administered without food. These failures had the potential for Residents 21 and 137 to not adequately received the therapeutic effect of the medications. Findings: 1. On December 10, 2024, at 8:39 a.m., during medication administration observation inside Resident 21's room with Licensed Vocational Nurse (LVN) 3, LVN 3 applied Lidocaine Patch 5% (percent - unit of measurement) on Resident 21's back near the right shoulder blade. A review of Resident 21's Physician's Orders, dated August 18, 2024. indicated, .Lidocaine Patch 5% apply to each knee topically one time a day for pain management . On December 10, 2024, at 12:27 p.m., during a concurrent interview and review of Resident 21's Physician's Orders, with LVN 3, he stated he had applied the lidocaine patch to Resident 21's back. LVN 3 further stated he did not follow the physician's order. LVN 3 stated if the resident was complaining of pain in a different site, he should have called the physician to change the area of application. A review of the facility policy and procedure titled, .SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, dated October 2012, indicated, .Apply topical treatment as per physician's order . 2. On December 10, 2024, at 9:30 a.m., during medication administration observation with LVN 1 inside Resident 137's room, LVN 1 administered Carvedilol and Metformin to Resident 137 without food. A review of Resident 137's Physician's Orders, indicated the following: - On November 20, 2024, indicated, .Carvedilol tablet 25 mg (milligram - unit of measurement) .Give 1 tablet by mouth two times a day .Give with food/meal . - On November 27, 2024, indicated .Metformin .oral tablet 1000 mg .Give 1 tablet by mouth two times a day .Give with food/meal . On December 10, 2024, at 3 p.m., during a concurrent interview and review of Resident 137's Physician's Orders, with LVN 1, she stated she did not administer food when she gave Carvedilol and Metformin to Resident 137. LVN 1 further stated she should have administered the medications with food as indicated by the physician's order. The facility's undated policy titled, .SPECIFIC MEDICATION ADMINISTRATION PROCEDURES .ORAL MEDICATION ADMINISTRATION, dated October 2012, indicated .To administer oral medication in a safe, accurate and effective manner .if needed for medication .administered in food .

Based on observation, interview, and record review, the facility failed to replace the oxygen humidifier bottle in accordance with the facility policy and procedure for one of one resident reviewed for respiratory (Resident 66). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, cross-contamination, and infection, which would lead to a decline in Resident 66's health condition. Findings: On December 9, 2024, at 10:27 a.m., a concurrent observation and interview were conducted in Resident 66's room with LVN 3. Resident 66 was receiving oxygen via nasal cannuala (NC-plastic tube that allows oxygen to be delivered to the nose from a machine). The nasal cannula was observed to be labeled with a date of 12/7. A humidifier bottle (plastic cannister filled with water to humidify air flow) was less than half filled and labeled with the date 11/24. LVN 3 stated, the nasal cannula and humidifier bottle should be changed every seven days. LVN 3 stated the cannula and humidifier bottle should have been changed together on December 7, 2024 but it did not appear that they were changed at the same time. LVN 3 stated if the nasal cannula and humidifier bottle were not changed according to the facility policy and procedure, there would be a potential for cross-contamination which could lead to a decline in the residents respiratory condition if the cannula and humidifier bottle are not changed according to the facility policy and procedures. On December 12, 2024, at 2:40 p.m. an interview was conducted with the infection preventionist (IP). The IP stated nasal cannulas and humidifier bottles are to be changed every seven days or as needed and if humidifiers are empty, they should be replaced. The IP stated if nasal cannulas and humidifiers should be changed every seven days to prevent the risk of cross-contamination and infection for residents receiving respiratory treatment. On December 12, 2024, Resident 66's record was reviewed. Resident 66 was admitted to the facility on [DATE], with a diagnosis which included immunodeficiency (weak ability to fight infection), and Chronic Obstructive Pulmonary Disease (COPD-lung disease making it difficult to breath). A review of the physicians order dated September 20, 2024, indicated, O2 at 2 L/min (liters per minute) via nasal cannula (a tube used to deliver oxygen through the nose) for as needed for SOB (shortness of breath). A review of the physician's order dated December 6, 2024, indicated, change O2 (oxygen) tubing every shift every Saturday. A review of the Care Plan titled Oxygen: Resident requires the use of oxygen. Indicated, .change humidification and O2 tubing as indicated .follow infection control protocol for universal/standard precautions . A review of the facility policy and procedure titled, Prevention of Infection Respiratory Equipment, Revised November 2011, indicated, .the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff .change pre-filled humidifier when the water level becomes low .change the oxygen tubing every seven (7) days, or as needed .take care not to contaminate internal nebulizer tubes .

Based on interview and record review, the facility failed to ensure the medication Nexium (esomeprazole-is used to treat conditions where there is too much acid in the stomach) was administered according to the physician's order for one of one resident reviewed (Resident 56). This failure had the potential to result in the worsening of gastroesophageal reflux disease (GERD-overaccumulation of stomach acid) for Resident 56. Findings: On December 11, 2024, at 2:48 p.m., during an interview with Resident 56, she stated she had been experiencing a little bit of nausea. Resident 56 stated she takes Nexium before breakfast for GERD but further stated she had not taken her Nexium medication for two days. A review of Resident 56's Admission Record, indicated Resident 56 was admitted to the facility on [DATE], with diagnoses which included gastroparesis (a condition in which the muscles in the stomach does not move food for digestion) and GERD. A review of Resident 56's Physician's Order, dated October 10, 2024, indicated, . Nexium .40 MG (milligram - unit of measurement) Give 1 capsule by mouth in the morning for GERD before breakfast . A review of Resident 56's Care Plan, dated October 11, 2024, indicated .FOCUS .gastrointestinal problem related to GERD .Intervention .Administer medication per physician's order . A review of Resident 56's eMAR (electronic Medication Administration Record) Medication Administration Note, indicated, Resident 56 did not receive Nexium on December 10, 2024 and December 11, 2024. On December 11, 2024, at 2:50 p.m., during a concurrent interview and review of Resident 56's eMAR with LVN 1, LVN 1 stated Resident 56 was not given Nexium on December 10, 2024, and December 11, 2024. LVN 1 stated, Nexium was not available. On December 11, 2024, at 2:55 p.m., during an interview with LVN 2, she stated Nexium had been delivered on December 2, 2024, and Resident 56 should have received the medication on December 10, 2024, and December 11, 2024. LVN 2 further stated Nexium should have been administered as ordered by the physician to prevent the worsening of Resident 56's GERD. A review of the facility policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders .

Based on interview and record review for one of three residents sampled (Resident 1), the facility failed to ensure professional standards of quality of care were met. This failure occurred when Resident 1 had returned to the facility from the general acute care hospital (GACH) where he resumed his previous diet and oral medication regimen, despite GACH discharge documentation that indicated the resident should follow a diet, STRICT NPO (Nothing Per Orem/nothing to be taken by mouth) and No Liquids, STRICT NPO, due to his increased risk for aspiration (inhalation of a foreign material). Findings: On December 30, 2021, an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On December 30, 2021, Resident 1's facility medical record was reviewed. Resident 1 was [AGE] years old and was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1 facility History and Physical, dated August 19, 2021, indicated, This resident: does NOT have the capacity to understand and make decisions. Further review of Resident 1's facility record identified GACH records from the resident's recent admission and discharge. A GACH record for Resident 1 titled, Inpatient Speech Language Pathology Treatment Note, (SLP) dated December 11, 2021, indicated, .STRICT NPO and No liquids, STRICT NPO . The note further indicated, Pt (patient) did not tolerate PO (by mouth) at this time and is a severe aspiration (accidental sucking in of food particles or fluids into the lungs) risk . Review of a facility progress note for Resident 1 titled, Admission Summary (Admit/Re-admit), dated December 12, 2021, at 12:15 a.m., indicated, .MD/NP (medical doctor/nurse practitioner) made aware of patient's admission. Medication reconciliation done, okay to continue discharge medications from the hospital .Diet ordered: fortified diet, pureed texture, thickened liquid . This facility progress note was authored by a registered nurse (RN 1). Further review of Resident 1's facility admission progress note failed to identify documentation that indicated the physician had been informed of the GACH's strict diet recommendations to maintain the resident as NPO on readmission to the facility. Review of Resident 1's facility record titled, Order Summary Report, identified a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's facility record titled, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] Sunday December 12th 0800- (breakfast) 75% of meal consumed. 1300- (1:00 p.m. - lunch) 25% of meal consumed. 1800- (6:00 p.m. - dinner) 50% of meal consumed. Monday December 13th 0800- (breakfast) 50% of meal consumed. 1300- (1:00 p.m. - lunch) 50% of meal consumed. 1800- (6:00 p.m. - dinner) NA (not applicable). Further review of Resident 1's facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet (medication that promotes wakefulness) 50 MG (milligram) Give 1 tablet by mouth one time a day for Sleep apnea (sleep disorder in which breathing repeatedly stops and starts). Resident 1 received the medication at 9:00 a.m. -Vitamin B12 Tablet 500 MCG (microgram) Give 1 Tablet by mouth one time a day for supplement. Resident 1 received the medication at 9:00 a.m. -Snack two times a day. Resident 1 per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure Plus with meals for supplement. Record intake percentage. Resident 1 consumed 100% of his Ensure at 7:30 a.m., 100% at 12:30 pm., and 25% at 5:30 p.m. -2 cal (calorie) Supplement 120cc (cubic centimeter- unit of volume) four times a day for supplement. Record intake percentage. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 5:00 p.m. the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 1's facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Tablet 50 MG Give 1 tablet by mouth one time a day for Sleep apnea. Resident 1 received the medication at 9:00 a.m. -Vitamin B12 Tablet 500 MCG Give 1 Tablet by mouth one time a day for supplement. Resident 1 received the medication at 9:00 a.m. -Snack two times a day. Resident 1 per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure Plus with meals for supplement. Record intake percentage. Resident 1 consumed 25% of his Ensure at 7:30 a.m. A review of a facility progress note for Resident 1 titled, eMar- Medication Administration Note, dated December 12, 2021, at 12:09 p.m., indicated, 2 cal Supplement 120cc four times a day for supplement. Record percentage. resident (sic) unable to tolerate 2 cal. Pt was noted holding 2 cal in mouth with difficulty swallowing. Review of Resident 1's facility document titled, Documentation Survey Report v2 Dec-21, indicated CNA (Certified Nursing Assistant) task entry. The meal percentage amount eaten by Resident 1 on December 12, 2021, at 9:00 a.m. indicated, 1 (1 - 25% - 50%) and 2 (2 - 51% - 75%) at 1:00 p.m. Review of a facility progress note for Resident 1 titled, 72-hour Charting, dated December 12, 2021, at 1:13 p.m., indicated, .Resident was also noted during shift with poor po (by mouth) intake and difficulty swallowing. Resident needed cueing during medication administration to swallow meds. Gargled lung sounds noted upon auscultation (action of listening to sounds from the heart, lungs, or other organs) . A review of a facility progress note for Resident 1 titled, eMar- Medication Administration Note, dated December 12, 2021, at 11:30 p.m., indicated, .Resident was put on npo order. Further review of Resident 1's facility medical record found no documented evidence that the physician had been informed of the resident's GACH diet recommendations to maintain the resident's strict NPO status. The only documentation identified in the record that identified the NPO status was the progress note listed above, which was approximately 12 hours after Resident 1's readmission to the facility. Review a facility progress note for Resident 1 titled, Nurse's Note, dated December 13, 2021, at 12:28 a.m., indicated, upon rounds resident was sob (short of breath) and gurgling .Residnet (sic) was put on npo and hospice around 7:30 p.m . A facility progress note for Resident 1 titled, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Md/Np notified and NPO Until seen by Hospice and ST Eval (speech therapy evaluation). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's facility progress note titled, Discharge Note, dated December 14, 2021, at 10:03 p.m., indicated, Resident discharged via transportation to a facility in (name of city) @ (at) 1930 (7:30 p.m.) Resident left with all belongings . A review of Resident 1's State of California Certification of Vital Record- Certificate of Death, dated January 4, 2022, indicated, Cause of Death: A: [CONDITION(S)] (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), B: Aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, vomit and even small foreign objects. If left untreated, complications can be serious, even fatal.) The date of death was documented as December 15, 2021. The day after Resident 1 had been discharged from the facility. On February 2, 2022, at 5:20 a.m., a phone interview was conducted with RN 1. RN 1 stated that he had not informed the physician of the GACH discharge SLP results and diet recommendations for STRICT NPO and No liquids, STRICT NPO. RN 1 stated that the physician should have been notified. RN 1 stated that he had not read the GACH transfer documentation. He stated that he had only scanned through it for medication verification purposes. RN 1 further explained, Usually if it was a returning resident, the facility staff would resume the previous diet. RN 1 stated that it was not always appropriate to resume the previous diet. RN 1 stated that if the GACH recommendation was not followed, There could be complication such as aspiration, pneumonia, choking, and aspiration risk. RN 1 stated that it was expected to clarify doctor's orders and the recommendations from the GACH. On February 2, 2022, at 11:16 a.m., a phone interview was conducted with the Director of Nursing (DON). The DON stated that the physician depended upon the nursing staff to inform them of GACH recommendations and results. The DON stated that the physician should have been notified of Resident 1's strict NPO diet recommendations. The DON stated, if the recommendations were not followed, it could result in harm to the patient. On February 3, 2022, at 11:45 a.m., an interview was conducted with a Certified Nursing Assistant (CNA 1). CNA 1 confirmed that she had provided care for Resident 1 on December 12, 2021. CNA 1 stated that Resident 1 could not swallow and he seemed like he would aspirate. CNA 1 explained that she had the resident sitting up in bed at 90 degrees and that he was gurgling and coughing while being fed. Review of the Business and Professions Code, Division 2, Chapter 6. Nursing, Article 2. Scope of Regulation, amended 1974, indicated, .(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician .