Every finding on record at Regents Point - Windcrest

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, clean surfaces. * The facility failed to ensure the heavy-duty blenders used for puree preparation were air dried prior to storage. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the hair and/or beard restraint was worn appropriately by the dietary staff. These failures had the potential to cause cross contamination and foodborne illness to the 43 of 44 residents consuming the food prepared in the kitchen.Findings: Review of the facility's List of Residents and Diets for Crosscheck dated 6/7/26, showed 43 of 44 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Cutting Boards revised date January 2024 showed cutting boards are cleaned and sanitized between each use or at least every four hours during continuous use. Replace all cutting boards with grooves and pits 1/8-inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 6/7/26 at 0910 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining. Two green and two red and white cutting boards were observed fuzzy, heavily marred and had deep grooves. The Director of Dining verified the findings and stated cutting boards should have been replaced when they were heavily scratched and too dirty to clean. 2. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Storage of Pots, Dishes, Flatware, Utensils revised date January 2023 showed pots, dishes and flatware are stored in such a way as to prevent contamination by splash, dust, pests or other means. Air dry all food contact surfaces, including pots, dishes, flatware and utensils before storage, or store in a self-draining position. Do not stack or store when wet. Store all pots, glasses and cups in an inverted position on a clean storage surface. Invert the top plate, bowl or dish of any stacks of dishes. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 6/7/26 at 0910 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining. Two heavy duty blenders used for puree preparation stored on the countertop shelf were observed to be still wet with visible water inside. The Director of Dining verified the findings and stated the blenders should have been air dried to prevent bacteria growth. 3. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Cleaning of Food and Nonfood Contact Surfaces revised date January 2025 showed nonfood contact surfaces of equipment, such as handles on reach-in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. It is not necessary to sanitize nonfood-contact surfaces; however, in-use wiping cloths must be kept in sanitizing solution between uses regardless of their intended use. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 6/7/26 at 0910 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining. The kitchen hood over the stove had black, dirty, grease residue. The Director of Dining acknowledged the findings and stated the dishwasher cleaned the hood once a week and the hood was also cleaned by an outside company every three months. The sticker on the hood showed it was last serviced on 5/5/26. In addition, the Director of Dining stated the kitchen hood should not be greasy because it was a fire hazard. 4. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Cleaning of Food and Nonfood Contact Surfaces revised date January 2025 showed food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable. Discard any food contact surfaces with chips, nicks or broken pieces, such as fryer baskets or skimmers that have damaged, loose or broken wires, strainers, pans, skillets and knives which cannot be cleaned properly. Further review of facility's P&P titled Sanitation and Infection Prevention/ Control: Damaged China and Glassware Surveillance revised date January 2024 showed cups, saucers, plates, dishes, glasses and trays are under surveillance constantly and damaged items are immediately taken out of service. Remain alert for cracked, chipped, deglazed or damaged dishes, glassware and trays. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 6/7/26 at 0910 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining. The following was observed: - two rubber spatulas with red handles had chipped and cracked edges;- two stainless steel scoops with green handles were partially melted;- one stainless steel scoop with blue handle was partially melted; and- one stainless steel scoop with gray handle was partially melted. The Director of Dining verified the findings and stated all worn out kitchen utensils and equipment should have been discarded and replaced. 5. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Cleaning of Food and Nonfood Contact Surfaces revised date January 2025 showed to prevent cross-contamination, kitchenware and food-contact surfaces equipment shall be washed, rinsed and sanitized after each use and following any interruption of operations during which time contamination may have occurred. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 6/7/26 at 0910 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining. The following was observed: - one stainless steel spatula with purple handle was dirty and had dry, crusted residue and fuzzy films;- one stainless steel spatula was dirty and had dry, crusted residue and watermarks;- two clear plastic containers used for utensils storage were dirty and had dry crumbs and residue inside;- one stainless steel serving scoop with cream handle was dirty and had dry, crusted residue;- one stainless steel serving scoop with green handle was dirty and had dry, crusted residue;- two stainless steel serving scoops with black handles were dirty and had dry, crusted residue;- one stainless steel serving spoon was dirty and had dry, crusted residue;- one stainless steel spatula with wooden handle was dirty and had dry, crusted residue;- one scoop for food portioning with red handle had watermarks;- one scoop for food portioning with white handle had watermarks and dry, crusted residue;- two scoops for food portioning with yellow handles were dirty and had dry, crusted residue;- two scoops for food portioning with blue handles were dirty and had dry, crusted residue;- two scoops for food portioning with red handles were dirty and had dry, crusted residue; and- one scoop for food portioning with cream handle was dirty and had dry, crusted residue. The Director of Dining verified the findings and stated all dirty kitchen utensils and equipment should have been rewashed for infection control purposes. 6. Review of the facility's untitled and undated P&P showed according to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/ or beard restraint) to prevent hair from contacting food. According to the Food Code, food service staff must wear hairnets when cooking, preparing or assembling food, such as stirring pots or assembling the ingredients of a salad. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils. During the lunch meal tray line observation on 6/8/26 at 1211 hours, the [NAME] was serving lunch with facial hair not covered with a hair restraint. The Director of Dining verified the findings and stated hair restraints should have been worn to prevent hair from getting into the food. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the residents received adequate fall prevention interventions identified for three of three residents reviewed for falls (Residents 9, 40, and 52). * Resident 9 had unwitnessed fall incidents on 2/24, 3/13, and 3/17/26. Resident 9's post-fall neurological assessments were incomplete and inaccurate, and the facility failed to document a COC form. In addition, the facility failed to ensure Resident 9 was provided appropriate care after his fall incident on 2/24/26. * The facility failed to implement the floor mattress as ordered by the physician as a fall risk precaution for Resident 40. * The facility failed to conduct a post fall assessments when Resident 52 had a fall on 12/1/25. The facility failed to complete a COC assessment when Resident 52 had a fall on 8/31/25. In addition, the facility failed to complete an actual fall care plan when Resident 52 had a fall on 8/31 and 12/1/25. These failures had the potential to negatively impact the residents' well-being.Findings: 1. Review of the facility's P&P titled Resident Examination and assessment dated [DATE] showed the purpose of the procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Review of the facility's P&P titled Fall and Managing Fall Risk dated March 2018 showed the staff will identify interventions related to the residents' specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. Review of facility's P&P titled Change in Resident's Condition or Status dated February 2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the nurse will notify the resident's attending physician or physician on call when there has been changes in the resident's medical or mental condition. These events can include an accident, discovery of injuries of an unknown source, and a need to transfer the resident to a hospital or treatment center. The nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. Review of the facility's P&P titled Neurocheck revised 10/2024 showed the facility will assess a resident who had sustained a suspected head injury either by fall or other trauma for 72 hours. The assessment will be documented on the neuro-checklist, and all areas will be completed by the licensed nurses and documented as follows: 15 minutes x 4, 30 minutes x 2, 1 hour x 6, 4 hours x 4, and 8 hours x 6. Medical record review for Resident 52 was initiated on 6/9/26. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's medical record showed the resident had a fall on 8/31/25; however, the medical record failed to show a COC Assessment and Actual Fall Care Plan were completed. Further reeview of Resident 52's medical record showed the resident had another fall on 12/1/25; however, the medical record failed to show a Post Fall Assessment and Actual Fall Care Plan were completed. On 6/8/26 at 1531 hours, an interview and concurrent medical record review for Resident 52 was conducted with the DSD. The DSD stated a Post Fall Assessment, COC, and an Actual Fall Care Plan were initiated every time a resident had a fall. The DSD verified Resident 52 did not have a COC Assessment and Actual Fall Care Plan completed post fall on 8/31/25, and did not have a Post Fall Risk Assessment and Actual Fall Care Plan completed post fall on 12/1/25. The DSD further stated the IDT reviewed the incident of fall with no specific person in charge. Additionally, the DSD stated, We have to do a Fall Risk Assessment, COC Assessment, and Actual Fall Care plan after every fall occurred to make sure we have everything covered, so that we will be able to determine if the previous interventions are working and what additional interventions are to be implemented. On 06/10/26 at 0823 hours, an interview and concurrent medical record review for Resident 52 was conducted with the DON. The DON stated the post fall documentations were to be completed as followed: COC Assessment, Post Fall Assessment, and an Actual Fall Care Plan. The DON verified Resident 52's medical record failed to show the following: - COC Assessment for the fall on 8/31/25. fall and DON stated, - Post -Fall Risk and COC Assessments for the fall on 12/1/25. - Actual Fall Care Plan for the falls dated 8/31/25, and 12/1/25, The DON stated the COC assessment had to be done even if there was a progress notes and there should be a short-term Actual Care Plan for the falls. The DON further stated the licensed nurses maybe just forgot to do the Fall Risk and COC assessments. On 6/10/26 at 1637 hours, an interview was conducted with the Administrator, DON, and Executive Director. The Administrator, DON and Executive Director were notified and acknowledged the above findings 2. Medical record review for Resident 9 was initiated on 6/7/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 5/6/26. showed Resident 9 had a diagnosis of dementia. Resident 9 had impaired judgement and was confused. a. Review of Resident 9's Progress Notes dated 2/24/26 at 2230 hours, showed Resident 9 had an unwitnessed fall incident and was found by a CNA on the floor by his bed at 2200 hours. Resident 9 was bleeding from his nose and continued to bleed from his nose until after the second neurological assessment was completed. Resident 9 was transferred back into bed, and the physician was notified and made aware that Resident 9 was not on blood thinner medication. Review of Resident 9's February 2026 MAR showed one Brillinta (antiplatelet medication) 90 mg tablet for CVA prophylaxis was administered on 2/24/26 at 0900 and 1700 hours. Review of Resident 9's Neurocheck – V1 dated 2/24/26, showed a missing entry for section 19 – 8 hour evaluation #3. Further review of Resident 9's medical record failed to show a COC form was completed for his fall incident. b. Review of Resident 9's Post Fall Evaluation dated 3/13/26, showed Resident 9 had an unwitnessed fall and was found in his room lying on the floor mat. Resident 9 had a small laceration to his left eyebrow. The physician and resident representative were notified. Resident 9 was transferred to an acute care hospital for further evaluation. Review of Resident 9's Neurocheck – V1 dated 3/13/26, showed Sections 3 to 22 were missing entries and the document was in progress. Further review of Resident 9's medical record failed to show a COC form was completed for his fall incident. c. Review of Resident 9's Post Fall Evaluation dated 3/17/26 at 1915 hours, showed Resident 9 had an unwitnessed fall and was found next to his bed. Resident 9 had an abrasion and swelling to the left side of his forehead. The physician and resident representative were notified. Resident 9 was transferred to an acute care hospital for further evaluation. Review of Resident 9's Neurocheck – V1 dated 3/17/26 showed sections 2 to 12, 16,1 7, and 19 had the same documentation of vital signs obtained at 3/18/26 0037 hours. Review of Resident 9's Progress Notes dated 3/17/26 at 2233 hours, showed Resident 9 was transferred to an acute care hospital at 2210 hours. Review of Resident 9's Progress Notes dated 3/18/26 at 0340 hours, showed Resident 9 returned to the facility at 0315 hours. Further review of Resident 9's medical record failed to show a COC form was completed for his fall incident. On 6/10/26 at 1136 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 3. LVN 3 stated when a resident had an unwitnessed fall, the process included to notify the physician and resident representative, complete a COC form and a neurological assessment for 72 hours. LVN 3 stated the purpose of a neurological assessment was to closely monitor the resident for any changes. LVN 3 further stated that when residents had an unwitnessed fall and were on blood thinner medications, the licensed staff members were expected to call 911 to send the resident to an acute care hospital for evaluation. LVN 3 reviewed Resident 9's medical record and verified the above findings. LVN 3 stated the physician should have been made aware of Resident 9's blood thinner medication after his fall incident on 2/24/26. On 6/10/26 at 1457 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON stated a COC form should be completed and neurological assessment should be accurately and fully completed. The DON further stated if a resident had an unwitnessed fall and was taking blood thinners, the physician should be notified. The DON verified the above findings. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and the Executive Director. The DON, Administrator, and the Executive Director were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Managing Falls and Fall Risk revised date 3/2018 showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Further review of the facility's P&P titled Use of Bedside Floor Mats for Fall Prevention revised 1/19/25, showed the facility implements the use of bedside floor mats as an individualized fall prevention intervention for residents identified at risk for injury from bed-related falls. The purpose is to reduce the risk and severity of injury from falls occurring at the bedside while ensuring safe environmental conditions for residents, staff and visitors. On 6/7/26 at 1055 hours, during the initial tour of the facility, Resident 40 was observed lying in bed, one floor mattress in place. In addition, the other floor mattress leaned against the oxygen concentrator in the room. Medical record review for Resident 40 was initiated on 6/7/26. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's H&P examination dated 1/9/25, showed Resident 40 had a diagnosis of Alzheimer's disease and was alert. Review of Resident 40's Order Summary Report dated 6/2026 showed a physician's order dated 5/21/26, for bilateral floor mattress at bedside every shift. Review of the Annual MDS assessment dated [DATE], showed Resident 40 had short-term and long-term memory problems. Review of Resident 40's Fall Risk assessment dated [DATE], showed a score of 15, a score of 10 or greater was considered high risk. On 6/10/26 at 1328 hours, an interview concurrandent medical record review for Resident 40 was conducted with RN 1. RN 1 was informed of the above observation with a photograph of the floor mattress leaning against an oxygen concentrator taken on 6/7/26 at 1059 hours. RN 1 verified the above findings and stated the bilateral floor mattress should be in place for fall precautions and to prevent injuries. On 6/10/26 at 1646 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations, the facility failed to ensure a staff member was onsite who could provide respiratory services to the residents, in accordance with the residents' plan of care. * For the past year, during the night shift on Fridays and Saturdays, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. This failure had the potential to result in negative health outcomes for the residents. Review of California Code of Regulations, title 16, section 1399.365, showed the respiratory care services LVNs may perform in the long-term care setting. Respiratory services LVNs may not perform include the initial setup, change out, or replacement of a breathing circuit or adjustment of oxygen liter flow or oxygen concentration.Review of the facility's Community assessment dated 5/2026 showed the facility had sufficient and competent staff to care for the residents with diseases and conditions of the respiratory system, which included the residents with diagnoses of COPD, pneumonia, asthma, and chronic lung disease. The facility provides comprehensive basic services, including full cooperation with the residents' physicians and skilled nursing care. Treatments provided by the facility include oxygen therapy.Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the oxygen therapy is administered by way of an oxygen mask, nasal cannula, or nasal catheter. The P&P showed to verify there is a physician's order for oxygen therapy, and to review the physician's orders or facility protocol for oxygen administration. The P&P showed to review the resident's care plan to assess any special needs of the resident.On 6/8/26 at 0935 hours, an interview was conducted with the DSD. The DSD stated the facility's staffing schedule consisted of three shifts, the morning shift (0700 - 1500 hours), evening shift (1500 - 2300 hours), and the night shift (2300 -0700 hours). The DSD was asked for the previous year, if the facility scheduled an RN on every shift. The DSD stated an RN was assigned to work all shifts, except for Fridays and Saturdays on the night shift.A list of residents with active orders for oxygen therapy was requested from the facility. Review of the list dated 6/9/26, showed six of the 44 residents who resided at the facility had active orders for supplemental oxygen continuously and/or as needed. Residents 3 and 13 were included on the list and had orders for supplemental oxygen.1. Medical record review for Resident 3 was initiated on 6/7/26. Resident 3 was admitted to the facility on [DATE].Review of Resident 3's Order Summary Report showed an order dated 10/15/25, for oxygen to be administered at a rate of 2 to 5 liters per minute as needed, to maintain an oxygen saturation greater than ninety-two percent.Review of Resident 3's Care Plan Report showed a care plan focus titled Altered Respiratory Status / Difficulty Breathing related to heart failure, revised 4/26/26. The care plan interventions included administering oxygen as ordered.On 6/9/26 at 0824 hours, an observation of Resident 3 was conducted. Resident 3 was observed sleeping in her bed. Resident 3 was observed receiving continuous supplemental oxygen at a rate of 2 liters per minute, via nasal cannula.Review of Resident 3's Vitals Summary dated 6/2026 showed the LVN adjusted Resident 3's oxygen liter flow. On 6/7/26 at 0248 hours, Resident 3's oxygen saturation was measured at 97 percent while having received supplemental oxygen via nasal cannula. Then, on 6/7/26 at 0627 hours, Resident 3's supplemental oxygen was removed by the LVN, and Resident 3's oxygen saturation was measured at 97 percent on room air.On 6/9/26 at 0902 hours, an interview, Community Assessment review, facility staffing schedule review, and concurrent medical record review, was conducted with the DON. The DON verified the facility's Community assessment dated 5/2026 showed the facility had sufficient and competent staff, to care for the residents with diseases and conditions of the respiratory system and treatments provided by the facility include oxygen therapy. The DON was asked which respiratory services LVNs could provide to the residents. The DON stated the LVNs could provide basic respiratory tasks and services and administer oxygen in emergent situations. The DON stated the LVN basic respiratory tasks and services did not include the adjustment or titration of oxygen liter flow or oxygen concentration, in non-emergent situations. The DON verified Resident 3's Vitals Summary dated 6/2026 showed the LVN assigned to the night shift adjusted Resident 3's oxygen liter flow on 6/7/26 at 0627 hours, when the LVN removed Resident 3's supplemental oxygen and Resident 3 was placed on room air. The DON reviewed the June 2026 facility staffing schedule and verified a RN was not scheduled to work on the morning of 6/7/26, when the LVN adjusted Resident 3's oxygen liter flow.The DON stated for the last year the facility did not have a RN assigned to work the night shift on Fridays and Saturdays. The DON stated only LVNs were assigned to work the night shift on Fridays and Saturdays. The DON verified on the night shift on Fridays and Saturdays, the facility did have a nurse on site who could provide respiratory services to the residents with oxygen titration orders.2. Medical record review for Resident 13 was initiated on 6/7/26. Resident 13 was admitted to the facility on [DATE].Review of Resident 13's H&P dated 5/22/26, showed Resident 13 had a diagnosis of pulmonary hypertension.Review of Resident 13's Order Summary Report showed an order dated 5/23/26, for oxygen to be administered at a rate of 2 to 5 liters per minute as needed via nasal cannula, to maintain an oxygen saturation greater than 92 percent. Review of Resident 13's Care Plan Report showed a care plan focus titled Oxygen Therapy related to respiratory illness, initiated 5/27/26. Care plan interventions included administering oxygen at a rate of 2 to 5 liters per minute via nasal cannula, to maintain an oxygen saturation greater than 92 percent.On 6/9/26 at 0800 hours, an observation was conducted of Resident 13. Resident 13 was observed lying in bed. An oxygen concentrator was observed adjacent to Resident 13's bed. Resident 13's family member (Family Member 1) was observed at the bedside. Family Member 1 stated Resident 13 received oxygen therapy intermittently as needed.Review of Resident 13's Vitals Summary showed Resident 13 intermittently received supplemental oxygen therapy between 5/21/26 and 6/9/26.On 6/9/26 at 0902 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 13's Vitals Summary showed Resident 13 intermittently received supplemental oxygen therapy throughout the months of May and June 2026. The DON was asked if the facility was able to provide respiratory services to Resident 13, in accordance with Resident 13's physicians' order to administer oxygen at a rate of 2 to 5 liters per minute via nasal cannula, to maintain Resident 13's oxygen saturation greater than 92 percent. The DON stated on Fridays and Saturdays during the night shift, the facility did have a nurse on site who could titrate Resident 13's oxygen in accordance with the physician's order.

Based on observation, interview, and facility document review, the facility failed to ensure the following: * Federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). * The Director of Dining was competent in managing the day-to-day functions of the food and nutrition department. These failures to employ staff with the federal and state mandated qualifications to manage the food and nutrition department, the competencies to effectively and competently run the day to day operations of the food and nutrition department, and to effectively implement departmental processes in accordance with standards of practice, had the potential to jeopardize the health and well-being of the 43 residents who received food prepared in the kitchen. Findings: Review of the facility's List of Residents and Diets for Crosscheck dated 6/7/26, showed 43 of 44 residents consumed food prepared in the kitchen. 1. According to the Health and Safety Code 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. Review of the facility's document titled Job Description - Dining Services Director signed on 6/1/26, showed the Dining Services Director must meet a minimum one of the following qualifications: Education: a. BA degree in Hotel Management/ Restaurant Management preferred or equivalent experience; b. Two to three years in related experience and/ or training; or equivalent combination of education and experience. Knowledge of food service operations and a variety of styles of services. Certificates, Licenses, Registrations: CDM or DSS preferred. On 6/7/26 at 0910 hours, the initial tour observation of the kitchen and interview was conducted with the Director of Dining. The Director of Dining stated she had been working in the facility for one year and overseen the kitchen. On 6/8/26 at 0940 hours, an interview was conducted with the Director of Dining and requested her credentials. The Director of Dining provided the ServSafe certification. When asked the Director of Dining for other credentials she stated she had the facility's RD's credentials. On 6/10/26 at 1442 hours, an interview was conducted with the DSD. The DSD verified and stated there were no certification or credentials for CDM/ DSS in the Director of Dining's employee file. On 6/10/26 at 1526 hours, an interview was conducted with the Administrator. When asked the Administrator what is the required qualification for the facility's DSS/ CDM, the Administrator stated she was not sure of the regulations and requirements. The Administrator verified and stated the Director of Dining does not have HSC qualifications and the RD works remotely. 2. Review of the facility's document titled Job Description - Dining Services Director signed on 6/1/26, showed the Dining Services Director is responsible for managing all food and beverage operations and for delivering an excellent guest experience. The incumbent will forecast, plan, manage and oversee staff for the Community's dining room, bistro and bar. Operates dining services within the established budget guidelines. The Director of Dining essential functions includes the following: responsible for team members scheduling, training and development; oversees the scheduling of all dining service personnel to maintain compliance with budgetary guidelines; hires, trains, evaluates team members in accordance with company policies; provides ongoing education of foods and ingredients to all staff; conducts pre-shift meetings and hands on training; demonstrates knowledge and teaching of food handling and storage procedures with regards to public health standards; establishes and ensures adherence to all product: quality, consistency, presentation, portioning, garnishment and utilization goals; develops well balanced menus in collaboration with Executive Chef and Dietitian; demonstrates the proper operation of all equipment to staff per proper procedures and testing equipment to ensure accuracy of temperature gauges, heating or cooling elements; ensures a clean, sanitary, safe and organized operation, adhering to all health and safety regulations; responsible for purchasing all food and non-food items as required by weekly menus as well as emergency supplies; acts as the community's representative for any health department or other required inspections, assuring compliance and follow up on any deficiencies; maintains all logs per policies and procedures; ensures all dining service employees adhere to the grooming and uniform policies; strives to maintain a safe working environment through the prevention of accidents, the preservation/ maintenance of all kitchen equipment, and the achievement of safe working practices; adheres to all company policies and procedures. During the annual recertification survey from 6/7/26 to 6/10/26, multiple issues were found in the kitchen, including kitchen utensils and equipment were not clean or stored in a sanitary manner, hair restraints were not worn, food service equipment was not air dried, and multiple cutting boards were heavily marred and had deep groves. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings. Cross reference to F812.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 13 final sampled residents (Residents 3, 11, and 13) reviewed for oxygen therapy. * The facility failed to ensure signage for oxygen use was placed in Resident 3 and Resident 13's door. * The facility failed to ensure the physician's order for the PRN oxygen therapy for Resident 11 was transcribed to the facility's order from the hospice. In addition, the facility failed to ensure Resident 11's oxygen signage was posted on the door. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions.Findings: 1. Review of the facility's P&P titled Oxygen Administration revised date 10/2010 showed to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. Place an Oxygen in Use sign on the outside of the room entrance door. On 6/7/26 at 1112 hours, during the initial tour of the facility, Resident 11 was observed lying in bed and had an oxygen concentrator in his room; however, there was no oxygen signage posted on the door. On 6/9/26 at 1105 hours, during an observation, Resident 11 was observed lying in bed and had an oxygen concentrator in his room; however, there was no oxygen signage posted on the door. Medical record review for Resident 11 was initiated on 6/7/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 7/31/25, showed Resident 11 had no capacity to exercise rights and signed necessary documents. Review of Resident 11's Order Summary Report for 6/2026 failed to show a physician's order for the PRN oxygen therapy. The form titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report date was unclear, showed a physician's order for the oxygen gas for inhalation at two liters as needed for SOB/ comfort. On 6/10/26 at 1307 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no PRN oxygen order for the facility; however, the form titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report date was unclear, showed a physician's order for oxygen gas for inhalation at two liters as needed for SOB/ comfort. Furthermore, there was no oxygen signage on the resident's door and RN 1 stated the oxygen order from the hospice provider should have been carried over to the facility's order and there should have been a signage for oxygen use. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings. 2. On 6/7/26 at 1044 hours, during the initial tour of the facility, Resident 3 was observed lying in bed with the oxygen on via nasal cannula, which was attached to the oxygen concentrator machine and set at two and half liters per minute. In addition, during the observation, the oxygen tubing was labeled and dated; however, there was no oxygen signage posted on the door. On 6/9/26 at 1055 hours, during an observation, Resident 3 was observed lying in bed with the oxygen on via nasal cannula, which was attached to the oxygen concentrator machine and set at two liters per minute however, there was no oxygen signage posted on the door. Medical record review for Resident 3 was initiated on 6/7/26. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 3's care plan dated 10/5/25, showed the resident had COPD and an intervention dated 10/5/25, was to administer oxygen at two liters per minute. Review of Resident 3's Order Summary Report for 6/2026 showed a physician's order dated 10/15/25, for oxygen at two to five liters per minute to keep oxygen saturation above 92% every shift. On 6/10/26 at 1205 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings and stated there should have been a signage for oxygen use. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings. 3. On 6/7/26 at 1108 hours, during the initial tour of the facility, Resident 13 had an oxygen concentrator in her room. In addition, during the observation, the oxygen tubing was labeled and dated; however, there was no oxygen signage posted on the door. On 6/9/26 at 1140 hours, an observation and concurrent interview was conducted with Resident 13. Resident 13 stated she used oxygen at night, and the nasal cannula was changed weekly. Medical record review for Resident 13 was initiated on 6/7/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report for 6/2026 showed a physician's order dated 5/23/26, for intermittent PRN oxygen at two to five liters per minute via nasal cannula to maintain oxygen saturation above 92% as needed. Review of Resident 13's care plan dated 5/27/26, showed the resident had oxygen therapy related to respiratory illness and an intervention dated 5/27/26, was to administer oxygen at two to five liters per minute via nasal cannula to maintain oxygen saturation above 92%. On 6/9/26 at 1552 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings and stated there should have been a signage for the oxygen use. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 36) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 36's lorazepam (antianxiety medication) medication was administered according to the physician's orders. This failure had the potential risk for the resident to experience adverse effects associated with the psychotropic medication.Findings: Review of the facility's P&P titled Medication Management revised 1/2026 showed each resident's drug regimen is reviewed to ensure it was free from unnecessary drugs. PRN (as needed) orders for the psychotropic medications were only used when the medication was necessary, with limited PRN use. The clinical record must reflect an adequate indication for use of the psychotropic medication. Medical record review for Resident 36 was initiated on 6/7/26. Resident 36 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 36's H&P examination dated 5/21/26, showed Resident 36 had no capacity to make medical decisions. Review of Resident 36's Order Summary Report showed the following physician's orders:- dated 5/21/26, to monitor for anxiety manifested by the inability to relax every shift, and- dated 6/9/26, to administer one lorazepam 0.5 mg tablet by mouth every eight hours as needed for anxiety manifested by the inability to relax for 14 days. Review of Resident 36's MAR for 5/2026 and 6/2026 showed the following dates and times the lorazepam medication was administered, however zero episodes of anxiety were observed and documented during the shift: - dated 5/27/26 at 0256 hours, - dated 5/30/26 at 1905 hours,- dated 5/31/26 at 1854 hours, - dated 6/2/26 at 1358 hours, and - dated 6/9/26 at 0750 hours. On 6/10/26 at 1407 hours, an interview and concurrent medical record review for Resident 36 was conducted with the DSD. The DSD stated Resident 36 had a PRN order for the lorazepam medication for the anxiety manifested by restlessness. The DSD further stated the lorazepam medication should not be administered if Resident 36 was not exhibiting the behavioral episodes. The DSD reviewed Resident 36's medical record and verified the above findings. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and Executive Director. The DON, Administrator, and Executive Director were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents and/ or responsible party as well as the Ombudsman about the transfer, discharge, and bed-hold information upon the residents transfer to an acute care hospital for three of five residents reviewed for acute care hospital transfer (Residents 5, 9, and 52). * The facility failed to ensure the Ombudsman was notified of Resident 5's acute care hospital transfer on 9/5/25, and 5/13/26. In addition, the facility failed to ensure Resident 5's responsible party received a written bed-hold notice for Resident 5's 5/13/26, acute care hospital transfer. * The facility failed to ensure the Ombudsman was notified of Resident 9's acute care hospital transfer on 3/13/26, and 3/17/26. * The facility failed to ensure Resident 52's responsible party received written notification of the transfer/discharge policy information and bed hold during the acute care hospital transfer. In addition, the facility failed to ensure the Ombudsman was notified of Resident 52's transfer/discharge and bed hold policy information during the acute care hospital transfer. These failures had the potential to the residents from receiving the accurate information necessary to make informed decisions regarding bed holds and their return to the facility. Findings: Review of the facility's P&P titled Bed-Holds and Returns revised 10/2022 showed the residents and/or representatives were informed in writing of the facility and state bed-hold policies. The written bed-hold notices provided to the residents/representatives explain in detail the duration of the state bed-hold policy, the reserve bed payment policy, the facility policy regarding bed-hold periods, the facility per-diem rate required to hold a bed, and the facility's return policy. Residents are provided written notices about these policies at least twice: a. notice 1 – in advance of any transfer; and b. notice 2 – at the time of transfer, or if the transfer was an emergency, within 24 hours. Review of the facility's P&P titled Transfer or Discharge, Facility Initiated dated 10/2022 showed: 2. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis under 483.15(c)(1)(i)(A) -(F) b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the residents' rights to appeal the transfer or discharge to the state, including: (1) the name, address, email and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e. The Notice of Facility Bed-Hold and policies; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative(s). 1. Medical record review for Resident 9 was initiated on 6/7/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 5/6/26, showed Resident 9 had a diagnosis of dementia. Resident 9 had impaired judgement and was confused. a. Review of Resident 9's Post Fall Evaluation dated 3/13/26, showed Resident 9 had an unwitnessed fall and was found in his room lying on the floor mat. Resident 9 had a small laceration to his left eyebrow. The physician and resident's responsible party were notified. Resident 9 was transferred to an acute care hospital for further evaluation. Review of Resident 9's Notice of Transfer/ discharge date d 3/13/26, showed the section indicating a copy was provided to the State LTC Ombudsman Office was not checked off and no date was documented. b. Review of Resident 9's Post Fall Evaluation dated 3/17/26 at 1915 hours, showed Resident 9 had an unwitnessed fall and was found next to his bed. Resident 9 had an abrasion and swelling to the left side of his forehead. The physician and resident's responsible party were notified. Resident 9 was transferred to an acute care hospital for further evaluation. Further review of Resident 9's medical record did not show a Notice of Transfer/ Discharge was completed and a copy was provided to the State LTC Ombudsman Office. On 6/10/26 at 1015 hours, an interview and concurrent medical record review for Resident 9 was conducted with the Social Services Designee. The Social Services Designee stated the Notice of Transfer/Discharge form should be completed by the licensed nursing staff or the social services department and a copy would be provided to the resident or resident's responsible party and ombudsman. On 6/10/26 at 1219 hours, a follow-up interview was conducted with the Social Services Designee. The Social Services Designee verified they did not have documentation the facility provided a copy of the Notice of Transfer/Discharge forms to the Ombudsman. On 6/10/26 at 1332 hours, a request was sent to Ombudsman 2 to verify whether the Notices of Transfer/Discharge for Resident 9's 3/13/26 and 3/17/26, acute care hospital transfers had been received. Ombudsman 2 stated she had not received any Notice of Transfer/Discharge for Resident 9. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and the Executive Director. The DON, Administrator, and the Executive Director were informed and acknowledged the above findings. 2. Medical record review for Resident 5 was initiated on 6/7/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 1/18/25, showed Resident 5 had no capacity to make medical decisions. a. Review of Resident 5's Progress Note dated 9/5/25 at 1412 hours, showed Resident 5 was waiting for a transportation to be transported to an acute care hospital due to her clogged G-Tube. Review of Resident 5's Notice of Transfer/ discharge date d 9/5/25, showed the section indicating a copy was provided to the State LTC Ombudsman Office was not checked off and no date was documented. b. Review of Resident 5's Progress Note dated 5/13/26 at 2014 hours, showed Resident 5 was transferred to an acute care hospital due to the dislodged G-Tube. Review of Resident 5's Notice of Transfer/ discharge date d 5/13/26, showed the section indicating a copy was provided to the State LTC Ombudsman Office was not checked off and no date was documented. Review of Resident 5's medical record failed to show a bed-hold notice was documented and completed for Resident 5's acute care hospital transfer. On 6/10/26 at 1015 hours, an interview and concurrent medical record review for Resident 5 was conducted with the Social Services Designee. The Social Services Designee stated the Notice of Transfer/Discharge form should be completed by the licensed nursing staff or the social services department and a copy would be provided to the resident or resident's responsible party and Ombudsman. On 6/10/26 at 1136 hours, an interview was conducted with LVN 3. LVN 3 stated the bed hold notices were provided to the resident or resident's responsible party every time the resident was transferred out of the facility. On 6/10/26 at 1206 hours, an interview and concurrent medical record review for Resident 5 was conducted with LVN 1. LVN 1 verified Resident 5 did not have a bed hold notice for the transfer on 5/13/26. On 6/10/26 at 1219 hours, a follow-up interview was conducted with the Social Services Designee. The Social Services Designee verified they did not have documentation the facility provided a copy of the Notice of Transfer/Discharge forms to the Ombudsman. On 6/10/26 at 1332 hours, a request was sent to Ombudsman 2 to verify whether the Notices of Transfer/Discharge for Resident 5's 9/5/25 and 5/13/26, acute care hospital transfers had been received. Ombudsman 2 stated she had not received any Notice of Transfer/Discharge for Resident 5. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and the Executive Director. The DON, Administrator, and the Executive Director were informed and acknowledged the above findings. 3. Review of Resident 52's medical records was initiated on 6/8/26. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 3/10/26, showed diagnoses of dementia without behaviors, stable, and did not show Resident 52's capacity to make decisions. Review of Resident 52's progress note dated 3/13/26, showed Resident 52 was receiving IV fluids, refused all the medications and meals, transferred to the acute acre hospital due to poor oral intake for evaluation and insertion of gastrostomy tube (G-Tube). Review of Order Summary Report dated 6/9/26, showed an order dated 3/13/26, to transfer Resident 52 to the acute care hospital due to poor oral intake for G-Tube insertion. Review of the Transfer/ Discharge Notification dated 3/13/26, showed Resident 52's RP (Responsible Party) was notified on 3/13/26. The Transfer/ Discharge Notice showed the acute care hospital where Resident 52 was discharging to was blank, and the section indicating a copy was provided to the State LTC Ombudsman Office was not checked off and no date was documented. On 6/10/26 at 0900 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated, If the family is here, we give the Transfer/ Discharge Notification to them, if not, we call the family and give the Transfer/ Discharge Notification with the transfer documents to the paramedics. When asked with whom the paramedics give the residents transfer documents to, the DON responded, to the hospital nurses, I guess it does not go to the resident's family. The DON was further asked if Resident 52's family member was provided with the Transfer/ Discharge and Bed Hold Notification in writing, the DON replied I don't think so. The DON acknowledged the Transfer/ Discharge and Bed Hold Notifications were not provided to the resident's family member or resident's responsible party in writing. On 6/10/26 at 0925 hours, an interview and concurrent medical record review were conducted with the Social Service Designee. The Social Service Designee stated the nurses will speak to the resident's family regarding the transfer and bed hold, and nurses will send the Transfer/ Discharge Notice to the Ombudsman. The Social Service Designee further stated if she was present on the day a resident was discharged , she sends the form to the Ombudsman and files it in a binder with the fax confirmation. When asked if the nurses file their fax confirmation from the Ombudsman, the Social Service Designee stated, I have to check with them where they kept the form on their end. The Social Service Designee further stated Resident 52's Bed hold Notice were with the Case Manager who recently resigned, and the facility could not find it. On 6/10/26 at 1332 hours, a request was sent to Ombudsman 2 if Notice of Transfer/ Discharge and Bed hold Notice were received on Resident 52 on 3/13/26, acute care hospital transfer. Ombudsman 2 stated she did not receive any Notice of Transfer/ Discharge and Bed hold Notice for Resident 52. On 6/10/26 at 1350 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated, if the resident to be transferred to the hospital is alert or if the family is present, the Notice of Transfer/ Discharge and Bed hold Notice is provided, if not, we call the resident's family notifying them of the transfer, reason of transfer and bed hold policy, then the Notice of Transfer/ Discharge and Bed hold Notice is sent with the paramedics and the copy is kept in the chart, I have not sent notices to the Ombudsman. On 06/10/2026 at 1637 hours, an interview with the Administrator, DON, and Executive Director was conducted. The Administrator, DON and Executive Director were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for one of 13 final sampled resident (Residents 6). * The facility failed to develop a care plan to address Resident 6's dementia diagnosis and the use of alternate pressure relieving mattress for skin management. This failure posed the risk for the resident not receiving the necessary care and services to improve or maintain their highest level of care.Findings: Review of the facility's P&P titled Care Planning dated 11/28/16, showed care planning for individual residents is a critical job function for licensed nurses in the Health Center, not only on admission, but when new orders are received, new conditions arise, unexpected events occur, and when residents are transferred back to the Center. The care planning is to be individualized, resident-centered, and involve the resident and his or her family and legal representative. Licensed nurses shall develop and maintain an individualized care plan for each resident that includes the instructions needed to provide effective and person-centered care and that align with professional standards of quality care. 1. Medical record review for Resident 6 was initiated on 6/7/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's admission MDS assessment dated [DATE], showed Resident 6 had a BIMS score of 13 (13-15 suggests intact cognition). Review of Resident 6's H&P examination dated 5/25/26, showed Resident 6 had a diagnosis of dementia and had no capacity to exercise rights and sign necessary documents. Review of Residents 6's Order Summary Report for June 2026 showed a physician's order dated 5/11/26, for pressure relieving mattress every shift for skin maintenance and comfort. Review of Resident 6's plan of care failed to show a care plan problem and interventions was developed to address Resident 6's dementia diagnosis and the use of a pressure relieving mattress. On 6/10/26 at 1037 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified there was no care plan formulated for Resident 6 's dementia diagnosis and the use of pressure relieving mattress. RN 1 stated there should have been a care plan for the use of the pressure relieving mattress to show the residents' problem, goals, and interventions. In addition, RN 1 stated the plan of care dictates the care of the residents. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pressure injury care and services for one of two sampled residents (Resident 11) reviewed for pressure injuries. * The facility failed to ensure Resident 11's pressure relieving mattress setting was consistent with the resident's weight and comfort. This failure had the potential for the resident to not benefit from the therapy provided by the pressure relieving mattress.Findings: Review of the facility's P&P titled Support Surface Guidelines revised date 9/2013 showed the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Review of Drive Med-Aire Reference Guide (undated) showed once the resident is in bed: alternating pressure mode is the automatic primary therapy offered for the resident once in the bed and resident weight settings are intended to be used as a guide. Initial setting should be chosen based on the resident's weight, comfort and tolerance, but can be adjusted anytime based on resident's comfort level. On 6/7/26 at 1112 hours, during the initial tour of the facility, Resident 11 was observed positioned on his back and lying on a pressure relieving mattress - Drive Normal Pressure with the comfort pressure level set at firm and 320-pound weight. On 6/9/26 at 1105 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed positioned on his back and lying on a pressure relieving mattress - Drive Normal Pressure with the comfort pressure level set at firm and 320-pound weight. When Resident 11 was asked how his pressure relieving mattress was, Resident 11 stated the pressure relieving mattress was uncomfortable and had too many bumps. Medical record review for Resident 11 was initiated on 6/7/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 7/31/25, showed Resident 11 had no capacity to exercise rights and signed necessary documents. Review of Resident 11's Quarterly MDS assessment dated [DATE], showed Resident 11 had a BIMS score of 8 (8-12 suggests moderate cognitive impairment). Review of Resident 11's Order Summary Report for June 2026 showed a physician's order dated 9/2/25, for pressure relieving mattress every shift for skin management and comfort. Review of Resident 11's weight records showed Resident 11 weighed 107.7 pounds on 6/4/26, and 108 pounds on 5/8/26. Review of Resident 11's Care Plan Report initiated on 8/11/25, showed the resident was at risk or potential for pressure injury development. The interventions included to have a pressure relieving mattress, which was added on 11/14/26. On 6/10/26 at 1307 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings and stated the pressure relieving mattress setting should have been based on the resident's weight and comfort. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for the use of the indwelling urinary catheter to one of five sampled residents (Resident 6) reviewed for indwelling urinary catheter use. * Resident 6 had a physician's order for indwelling urinary catheter; however, the physician's order did not include the diagnosis or clinical indication to justify the need for the continued use of the indwelling urinary catheter. This failure had the potential for Resident 6 to continue using an indwelling urinary catheter without a medically necessary reason.Findings: Review of the facility's P&P titled Indwelling (Foley Catheter) Insertion, Male Resident dated August 2022 showed to verify there is a physician's order for this procedure. It also showed the catheter size is specified in the order. Medical record review for Resident 6 was initiated on 6/9/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 4/17/26, showed Resident 6 had no capacity to exercise rights and sign the necessary documents. Review of Resident 6's MDS assessment dated [DATE], showed Resident 6 had a BIMS score of 12 (moderate cognitive impairment). Review of Resident 6's Order Summary Report dated 6/9/26, showed a physician's order dated 5/3/26, for Urinary Catheter size 18 Fr 10 cc bulb as needed for occlusion or leakage as needed. The physician's order failed to include Resident 6's diagnosis and indication for the use of the indwelling urinary catheter. On 6/9/26 at 1105 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DSD. The DSD verified there was no diagnosis and indication for the continued use of the indwelling urinary catheter. On 6/10/23 at 0823 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON verified the findings. On 06/10/2026 1637 hours, an interview was conducted with the Administrator, DON, and Executive Director. The Administrator, DON, and Executive Director were informed and acknowledged the above findings.

Based on interview, medical record review, and P&P review, the facility failed to ensure the medical record was complete and accurately maintained, for two of 13 final sampled residents (Residents 3 and 56).*The facility failed to ensure Resident 3's Arbitration Agreement contained the date signatures were obtained for the facility representative and Resident 3's representative.*The facility failed to ensure Resident 3's POLST contained the physician's name and phone number. *Resident 56's POLST failed to show if the resident had formulated an advance directive.These failures had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: 1. a. Medical record review for Resident 3 was initiated on 6/7/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. On 6/10/26 at 1630 hours, an interview and concurrent medical record review was conducted with the Administrator. Review of Resident 3's Arbitration Agreement showed a facility representative signature and a signature obtained on behalf of Resident 3, however, the section containing the date was blank. The Administrator verified the findings and stated Resident 3's Arbitration Agreement should contain the date the signatures were obtained. b. Review of facility's P&P titled Charting and Documentation date revised 7/2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of Resident 3's POLST dated 10/5/25, showed Section D Information and Signatures for the physician's name and phone number was left blank. On 6/10/26 at 1205 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings and stated the POLST was incompletely filled out and should have been filled out completely. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 56 was initiated on 6/7/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's POLST dated 6/6/26, Section D (Information and Signatures) showed that the advance directive field was left blank. However, the Advanced Healthcare Directive Acknowledgment form dated 6/6/26, showed Resident 56 did have an advance directive. On 6/9/26 at 1451 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings and stated the POLST was incompletely filled out and should have been filled out completely. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 13 final sampled residents (Resident 11). * The facility failed to ensure the hospice visit calendar, hospice skilled nurse visit notes, and physician's certification for hospice benefits were available and included in Resident 11's medical records. This failure posed the risk of delay in communication between the hospice provider and facility which may affect resident care. Findings: Review of the facility's P&P titled Hospice Program date revised 7/2017 showed the hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. Our facility has designated the Desk nurses and Social Services Team to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following: collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family; ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians; obtaining the following information from the hospice: the most recent hospice plan of care specific to each resident; hospice election form; physician certification and recertification of the terminal illness specific to each resident, etc. Review of the facility's Hospice Agreement with Hospice A (undated) showed hospice shall make available to the facility the residents' hospice records and other relevant residents' information as necessary for the facility to provide services under this agreement. Medical record review for Resident 11 was initiated on 6/7/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 7/31/25, showed Resident 11 had no capacity to exercise rights and signed necessary documents. Review of Resident 11's Order Summary Report showed a physician's order dated 7/31/25, to admit to the facility with Hospice A with a diagnosis of ASCVD. Review of the Quarterly MDS assessment dated [DATE], showed Resident 11 had a BIMS of 8 (moderate cognitive impairment). Review of Resident 11's care plan for hospice care revised 2/8/26, showed the resident was under care the of hospice services. Interventions included coordinating care with hospice. Review of Resident 11's hospice binder and medical records failed to show a calendar for June 2026 to show the schedule for when the hospice staff visited, any skilled nurse hospice progress notes for May 2026 and June 2026 and the physician's certification for the resident's hospice benefits. On 6/9/26 at 1523 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 1. RN 1 verified the above findings and stated the hospice binder was kept at the nurses' station. RN 1 further stated the hospice documents should have been in the binder or in Resident 11's medical records for communication purposes. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control program to prevent the development and transmission of infections. * RN 1 failed to wear required personal protective equipment (PPE) while providing central line care for Resident 24, who was on enhanced barrier precautions (EBP). In addition, RN 1 failed to perform hand hygiene during the medication administration. * LVN 1 failed to perform hand hygiene during the medication administration for Residents 6 and 34. * LVN 2 failed to perform hand hygiene during the medication administration for Resident 5. * The facility failed to ensure clean linens and towels were stored in a manner that protected them from potential contamination in the laundry storage area. These failures had the potential to contribute to the spread of infection within the facility. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised 10/2023 showed hand hygiene is considered the primary means to prevent the spread of healthcare-associated infections. The indications for hand hygiene included before applying non-sterile gloves and immediately after glove removal. Review of the facility's P&P titled Enhanced Barrier Precautions revised 12/2024 showed the EBP referred to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. The EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. Examples of high-contact resident care activities requiring the use of gown and gloves include dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, wound care, and device care or use such as central line, urinary catheter, feeding tube, and tracheostomy. 1. On 6/8/26 at 0922 hours, a medication administration observation for Resident 24 was conducted with RN 1. An EBP signage was observed outside of Resident 24's room. RN 1 wore a surgical mask, performed hand hygiene, and donned gloves prior to entering Resident 24's room. RN 1 failed to wear an isolation gown before providing central line medication administration. RN 1 assessed Resident 24's right upper arm PICC dressing, cleaned the hub with an alcohol wipe, and flushed the PICC line with normal saline. RN 1 removed her gloves, performed hand hygiene, then donned new gloves. RN 1 prepared Resident 24's intravenous ceftriaxone (antimicrobial) 2 grams in 50 ml medication at bedside. RN 1 then connected the IV tubing to Resident 24's PICC line, however the IV medication was not flowing properly. RN 1 checked the IV tubing clamps, disconnected the IV tubing from Resident 24's PICC line, and flushed the PICC line with normal saline. RN 1 removed her gloves, then donned new gloves. RN 1 was not observed performing hand hygiene between glove use. RN 1 then reconnected Resident 24's PICC line to the IV tubing. On 6/8/26 at 0948 hours, an observation and concurrent interview was conducted with RN 1. RN 1 stated Resident 24 had EBP precautions because she had a PICC line. RN 1 stated she usually wore only a mask during central line care for Resident 24. RN 1 reviewed the EBP signage outside of Resident 24's room door and verified she should have worn an isolation gown. RN 1 verified she did not perform hand hygiene in between glove use. On 6/10/26 at 1407 hours, an interview was conducted with the DSD. The DSD stated hand hygiene should be performed before, in between, and after glove use. In addition, the DSD stated facility staff members were expected to wear gowns and gloves when providing central line care for EBP residents. 2. a. On 6/9/26 at 0822 hours, a medication administration observation for Resident 34 was conducted with LVN 1. LVN 1 obtained Resident 34's blood pressure, exited Resident 34's room, and donned gloves to sanitize the blood pressure cuff and medication tray. After discarding the gloves, LVN 1 proceeded to prepare Resident 34's medications without performing hand hygiene. LVN 1 entered Resident 34's room, provided Resident 34 her oral medications, donned gloves, and asked Resident 34 if she wanted to use her inhaler medication. When Resident 34 declined, LVN 1 removed their gloves without performing hand hygiene and exited the room. b. On 6/9/26 at 0834 hours, a medication observation for Resident 6 was conducted with LVN 1. LVN 1 prepared Resident 6's medications for administration. LVN 1 performed hand hygiene prior to entering Resident 6's room, then provided Resident 6 her oral medications. LVN 1 applied a lidocaine (pain reliever) patch to Resident 6's left shoulder, then donned gloves and administered Resident 6's eye drop medication to both eyes. LVN 1 then removed her gloves and performed hand hygiene. On 6/9/26 at 0855 hours, an interview was conducted with LVN 1. LVN 1 stated hand hygiene should be performed prior to putting on new gloves. LVN 1 verified the above findings. 3. On 6/9/26 at 1414 hours, a medication administration observation for Resident 5 was conducted with LVN 2. LVN 2 was observed wearing gloves and sanitizing a stethoscope with a sanitation wipe. After discarding the gloves, LVN 2 started to prepare Resident 5's medication without performing hand hygiene. LVN 2 proceeded to administer Resident 5's medication. On 6/9/26 at 1425 hours, an interview was conducted with LVN 2. LVN 2 verified the above findings. On 6/10/26 at 1407 hours, an interview was conducted with the DSD. The DSD stated hand hygiene should be performed before, in between, and after glove use. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and Executive Director. The DON, Administrator, and Executive Director were informed and acknowledged the above findings. 4. On 6/9/26 at 1018 hours, a linen storage room inspection was conducted with Housekeeping 1. The linen room contained bagged clean linens, towels, and under pads stored on the shelves. File binders and a bottle of hand sanitizer were placed at the end of a shelf in direct contact with open bags of clean towels and linens, creating a potential for contamination. Housekeeping 1 initially stated these items were placed there purposely, but later stated and acknowledged clean linens and towels should not contact unclean things. Housekeeping 1 verified the above findings. On 6/9/26 at 1105 hours, an interview was conducted with the DSD. The DSD was informed and acknowledged the above findings. The DSD stated the binders and sanitizer should be stored away from the clean linen to prevent contamination.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide appropriate care for the peripheral and central line access devices consistent with professional standards of practice for two of two residents reviewed for parenteral IV fluids (Resident 56 and nonsampled Resident 24). * RN 1 failed to assess Resident 24's PICC line for patency by aspirating for blood return prior to administering intravenous medication. * The facility failed to ensure the peripheral IV line dressing for Resident 56 was labeled and dated. These failures had the potential to delay identification of a central line associated complication. Findings: Review of the facility's P&P titled Peripheral and Midline IV Dressing Changes date revised 3/2022 showed the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Place new dressing over insertion site. Under steps in the procedure showed to label dressing with the date and time of dressing change and initials. Under documentation showed the following should be documented in the resident's medical record: a. date, time, type of dressing and reason for dressing change; b. any complications/ intervention related to insertion site or surrounding area; c. resident's response to procedure. Review of the facility P&P titled Maintaining Patency of Peripheral and Central Vascular Access Devices revised 10/2024 showed vascular access devices are aspirated for a blood return and flushed prior to each infusion to assess catheter function and prevent complications. 1. During the initial tour of the facility, Resident 56 was observed lying on her left side in bed with a peripheral IV line to the right forearm. The transparent dressing was observed to be unlabeled and undated. Medical record review for Resident 56 was initiated on 6/7/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's admission H&P examination dated 6/7/26, showed Resident 56 had a medical history of dementia, nod and smile but unclear whether Resident 56 understood and primarily speaks Farsi. Review of Resident 56's MAR for 6/2026 showed a physician's order dated 6/7/26, for Azithromycin (antibiotic) Intravenous Solution Reconstituted 500 mg use one dose intravenously one time a day for Aspiration Pneumonia for one day at 0900 hours. Review of Resident 56's care plan date initiated 6/7/26, showed the resident had a peripheral IV catheter due to a diagnosis of Aspiration Pneumonia requiring IV antibiotic therapy. Under interventions showed to assess the IV site every shift and as needed: palpate gently and note any pain, redness, swelling or drainage over or around the insertion site. Further review of the medical record for Resident 56 failed to show a documented evidence for the assessment of the peripheral IV line and no documentation as when the peripheral IV line was inserted upon admission. On 6/9/26 at 1451 hours, an interview and concurrent medical record review for Resident 56 was conducted with RN 1. RN 1 was informed of the above findings with a photograph of the right forearm peripheral IV line taken on 6/7/26 at 1106 hours. RN 1 verified the findings and stated the IV line was change every seven days and as needed when infiltrated and dislodged. The dressing should have been labeled and dated. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings. 2. On 6/8/26 at 0922 hours, a medication administration observation for Resident 24 was conducted with RN 1. Resident 24 was observed with a PICC line inserted to their right upper arm area. RN 1 assessed Resident 24's PICC dressing, cleaned the hub with an alcohol wipe, and flushed the PICC line with normal saline. RN 1 prepared Resident 24's intravenous ceftriaxone (antibiotic) 2 grams in 50 milliliters medication by bedside. RN 1 connected the IV tubing to Resident 24's PICC line, however the IV medication was not flowing properly. RN 1 checked the IV tubing clamps, disconnected the IV tubing from Resident 24's PICC line, and flushed the PICC line with normal saline. RN 1 did not aspirate for a blood return prior to medication administration. On 6/8/26 at 0948 hours, an interview was conducted with RN 1. RN 1 stated that prior to accessing a resident's PICC line, the licensed nurse should assess for swelling, redness, pain, and flush the line with normal saline. RN 1 further stated licensed nurses did not have to aspirate for a blood return prior to using a resident's PICC line. On 6/10/26 at 1457 hours, an interview was conducted with the DON. The DON stated the licensed nurses should check for blood return prior to the medication administration via PICC line to assess for patency. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and Executive Director. The DON, Administrator, and Executive Director were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage.* The facility failed to ensure expired medication was removed from Medication Cart A. This failure had the potential to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Medication Administration revised 1/2023 showed Medications are administered as prescribed in accordance with manufacturers' specifications and good nursing principles and practices. Drugs dispensed in the manufacturer's original container will be labeled with manufacturer's expiration date; there will be no expired medications administered to a resident. On 6/9/26 at 0822 hours, a medication administration observation for Resident 34 was conducted with LVN 1. LVN 1 was preparing Resident 34's medications at Medication Cart A. An observation of Resident 34's opened inhaler of levalbuterol 450 mcgs per actuation had an expiration date of 2/28/26. On 6/9/26 at 0855 hours, an interview was conducted with LVN 1. LVN 1 verified the above findings and removed the inhaler from Medication Cart A. On 6/10/26 at 1650 hours, an interview was conducted with the DON, Administrator, and Executive Director. The DON, Administrator, and Executive Director were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests or rodents that can carry diseases.Findings: Review of the facility's P&P titled Sanitation and Infection Prevention/ Control: Solid Waste Disposal revised date 1/2025 showed food waste and rubbish in the Food and Nutrition Services Department will be disposed of in an approved manner to prevent contamination of food, clean dishes, or clean working areas. Garbage containers are clean, lined and covered at all times. Keep lids closed on all outside trash receptacles. According to the 2022 FDA (Food and Drug Administration) Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 6/7/26 at 0753 hours, an observation was conducted of the facility's one of one outside garbage dumpster. The garbage dumpster was observed with one of the lids opened. On 6/9/26 at 0920 hours, an interview was conducted with the Director of Dining and Maintenance Tech. The Director of Dining and Maintenance Tech were informed of the above observation with a photograph of the garbage dumpster taken on 6/7/26 at 0753 hours. The Director of Dining verified the above findings and stated the dumpster lids should be fully closed for sanitation and pest control purposes. On 6/10/26 at 1646 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in appetizing temperatures: * The temperature was not maintained at the acceptable range for cold beverages. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen. Findings: Review of the facility's Diet Type Report dated 5/12/25, showed 45 of 45 residents consumed the food prepared in the kitchen. Review of the facility's P&P titled Cold Holding and Storage revised date 12/1/22, showed cold TCS (Time/Temperature Control for Safety) food must be held at proper temperatures to prevent harmful bacterial growth and/ or toxin production that can occur if it remains in the temperature danger zone too long. Cold TCS foods must be maintained at 41 degrees Fahrenheit or below during holding, display, service, and transport. On 5/13/25 at 1140 hours, a tray line observation and concurrent interview was conducted with the CDM. The CDM checked and verified the following temperatures: - cranberry juice - 42.6 degrees Fahrenheit; - another cranberry juice - 43.8 degrees Fahrenheit; - orange juice - 42.8 degrees Fahrenheit; and - mixed cranberry and orange juice - 43.6 degrees Fahrenheit. The CDM verified the temperature of the cranberry juice, orange juice, and mixed cranberry juice were not holding the cold beverage temperature. The CDM stated the holding temperatures for the cold beverages should be 41 degrees Fahrenheit and below. The CDM acknowledged the beverage temperatures varying from 42.6 to 43.8 degrees Fahrenheit were above the recommended temperatures for cold food. The pitcher of beverages was placed in bucket of ice to keep beverages cold prior to serving the residents' lunch.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for nine of 13 final sampled residents (Residents 1, 2, 12, 15, 18, 19, 34, 40, and 397) and one nonsampled resident (Resident 16). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety and Bed Rails revised date 8/2022 showed the resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. Bed dimensions are appropriate for the resident's size. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. Review of the facility's Bed System Measurement Device Test Results Worksheet (undated) failed to show Zones 6 and 7 were reflected and recorded on the form and assessed for entrapment. For example: 1. On 5/12/25 at 1036 hours, during the initial tour of the facility, Resident 15 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/13/25 at 0923 hours, Resident 15 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 15 was initiated on 5/12/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 4/11/24, showed Resident 15 had a diagnosis of failure to thrive, T12 compression fracture (a break in the twelfth thoracic vertebra (T12) located in the mid-back), and osteoporosis (a disease that weakens bones, making them more likely to break). Review of Resident 15's Annual MDS assessment dated [DATE], showed a BIMS score of 9 (scores of 8 to 12 suggest moderate cognitive impairment). Review of Bed System Measurement Device Test Results Worksheet dated 5/1/25, failed to show Zones 6 and 7 were reflected and recorded on the form and assessed for the entrapment. Cross reference to F700, example #5. 2. On 5/13/25 at 0926 hours, during an observation, Resident 34 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/14/25 at 1359 hours, Resident 34 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 34 was initiated on 5/12/25. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's Quarterly MDS assessment dated [DATE], showed Resident 34 had severe cognitive impairment. Section GG of the assessment showed Resident 34 had impairment to both the upper and lower extremities. Review of Resident 34's H&P examination dated 4/10/25, showed Resident 34 is high risk for falls and had no capacity to exercise rights and sign necessary documents therefore, family will be informed of medical condition and/ or plan of treatment. Review of Bed System Measurement Device Test Results Worksheet dated 5/1/25, failed to show Zones 6 and 7 were reflected and recorded on the form and assessed for the entrapment. Cross reference to F700, example #6. 3. On 5/13/25 at 0942 hours, during an observation, Resident 40 was awake in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 40 was initiated on 5/13/25. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's H&P examination dated 4/11/25, showed Resident 40 had fluctuating capacity to make decisions. Review of Resident 40's admission MDS assessment dated [DATE], showed a BIMS score of 10 (scores of 8 to 12 suggest moderate cognitive impairment). Review of Bed System Measurement Device Test Results Worksheet dated 5/1/25, failed to show Zones 6 and 7 were reflected and recorded on the form and assessed for the entrapment. Cross reference to F700, example #7. 4. On 5/14/25 at 1127 hours, during a wound care observation, Resident 397 was awake in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 397 was initiated on 5/12/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's H&P examination dated 5/7/25, showed Resident 397 had the capacity to make decisions. Review of Resident 397's admission MDS assessment dated [DATE], showed a BIMS score of 15 (score of 13-15 suggests intact cognition). Review of Bed System Measurement Device Test Results Worksheet dated 5/1/25, failed to show Zones 6 and 7 were reflected and recorded on the form and assessed for the entrapment. On 5/15/25 at 0945 hours, an interview and concurrent record review for Residents 15, 34, 40, and 397, was conducted with the Maintenance Supervisor. The Maintenance Supervisor acknowledged the above findings and stated Zones 6 and 7 were not reflected on the Bed System Measurement Device Test Results Worksheet form; therefore, the entrapment zones were inaccurately assessed. Cross reference to F700, example #8. 5. On 5/12/25 at 0847 hours, during the initial tour, Resident 1 was lying in bed awake, oriented to name and verbally responsive. Resident 1's bed had elevated bilateral side rails. Resident 1 stated she did not use her side rails. Medical record review for Resident 1 was initiated on 5/14/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/15/25, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's cognitive skills for daily decision-making score was 3, indicating severely impaired. On 5/12/25 at 0856 hours, an observation and concurrent interview was conducted with CNA 2. Resident 1 was lying in bed with elevated bilateral upper side rails. CNA 2 stated Resident 1 used the bilateral upper side rails for repositioning while in bed. CNA 2 verified the above findings. Review of Resident 1's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4, however, there was no documented evidence to show the facility assessed for Zones 6 and 7. Review of Resident 1's medical record failed to show for the informed consent and care plan for the use of the bilateral upper side rails. On 5/14/25 at 0909 hours, an interview was conducted with LVN 3. LVN 3 was asked who completed the entrapment assessment. LVN 3 stated she had not heard or seen an entrapment assessment. Cross reference to F700, example #1. 6. On 5/12/25 at 0902 hours, during the initial tour, Resident 2 was lying in bed asleep. Resident 2's bed had elevated bilateral side rails. Medical record review for Resident 2 was initiated on 5/14/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's cognitive skills for daily decision-making score was 3, indicating severely impaired. Review of Resident 2's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4, however, there was no documented evidence to show the facility assessed for Zones 6 and 7. On 5/12/25 at 0905 hours, an observation and concurrent interview was conducted with CNA 2. Resident 1 was observed lying in bed with bilateral upper side rails elevated. CNA 2 stated Resident 2 used the bilateral upper side rails for repositioning while in bed. CNA 2 verified the above findings. On 5/13/25 at 0837 hours, an observation and concurrent interview was conducted with LVN 5. Resident 2 was observed sitting up in bed and eating her breakfast. Resident 2's bed had elevated bilateral upper side rails. LVN 5 verified the above findings. Cross reference to F700, example #2. 7. On 5/14/25 at 0900 hours, an observation and concurrent interview was conducted with Resident 16. Resident 16 was in bed, awake, alert, and verbally responsive. Resident 16's bed had elevated bilateral upper side rails. Resident 16 stated he used the side rails for bed mobility and during transfers. Medical record review for Resident 16 was initiated on 5/14/25. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 9/22/23, showed Resident 16 had the capacity to understand and make decisions. Review of Resident 16's MDS assessment dated [DATE], showed Resident 16's BIMS score was 15, indicating cognitively intact. Review of Resident 16's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4; however, there was no documented evidence to show the facility had assessed for Zones 6 and 7. Cross reference to F700, example #3. 8. On 5/12/25 at 0858 hours, an initial tour observation and concurrent interview was conducted with CNA 2. Resident 19 was lying in bed, awake, alert, and eating her breakfast. Resident 19's bed had the elevated bilateral upper side rails. CNA 2 verified the above findings. CNA 2 stated Resident 16 used the bilateral upper side rails to reposition in bed. Medical record review for Resident 19 was initiated on 5/14/25. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's MDS assessment dated [DATE], showed Resident 19's BIMS score was zero, indicating severe cognitive impairment. Review of Resident 19's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4; however, there was no documented evidence to show the facility assessed for Zones 6 and 7. On 5/15/25 at 1009 hours, an interview, and concurrent facility document review for Residents 1, 2, 12, 16, 18, and 19 was conducted with the Maintenance Supervisor. The Maintenance Supervisor was asked about the facility's process of their bed inspection and entrapment assessment. The Maintenance Supervisor stated any maintenance staff could assess for entrapment using a measuring tape and document on the Bed System Measurement Device Test Results Worksheet. Review of the Bed System Measurement Device Test Results Worksheet for Residents 1, 2, 12, 16, 18, and 19 dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4; however, there was no documented evidence the facility assessed for Zones 6 and 7. The Maintenance Supervisor verified the above findings. Furthermore, the Maintenance Supervisor stated he would rectify and update the Bed System Measurement Device Test Results Worksheet immediately to show Zones 6 and 7. On 5/15/25 at 1505 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings. Cross reference to F700, example #4. 9. On 5/12/25 at 1054 hours and 5/14/25 at 0835 hours, Resident 12 was observed in bed with elevated bilateral upper side rails. Medical record review for Resident 12 was initiated on 5/14/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 9/18/25, showed Resident 12 had no capacity to understand and make decisions. Review of Resident 12's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed the entrapment assessment was completed and passed for Zones 1 to 4; however, there was no documented evidence to show the facility assessed for Zones 6 and 7. Cross reference to F700, example #9. 10. On 5/12/25 at 1045 hours and on 5/14/25 at 0835 hours, Resident 18 was observed in bed with elevated bilateral upper side rails. Medical record review for Resident 18 was initiated on 5/14/25. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 2/8/25, showed Resident 18 did not have the capacity to understand and make decisions. On 5/15/25 at 1050 hours, an interview and concurrent observation was conducted with CNA 6. CNA 6 verified Resident 18 used the side rails for mobility but did not always need them. Review of Resident 18's Bed System Measurement Device Test Results Worksheet dated 5/1/25, showed entrapment assessment was completed and passed for Zones 1 to 4; however, there was no documented evidence to show the facility assessed for Zones 6 and 7. Cross reference to F700, example #10

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blenders used for puree preparation were dried and clean prior to storing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 5/12/25, showed 45 of 45 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control, Area and Equipment Cleaning revised date 1/2025 showed the facility's Maintenance Department is scheduled to clean equipment that requires special training and equipment, such as the ice maker, refrigeration coils and exhaust hood. Review of the facility's P&P titled Equipment Condition and Management dated 10/1/22, showed the equipment must be maintained in a state of good repair and condition, in compliance with applicable local, state, and federal, statutes, regulations, and ordinances. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 5/12/25 at 0836 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Aide. The kitchen hood over the stove had black, dirt residue. The Dietary Aide acknowledged the findings. 2. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control, Cleaning of Food and Nonfood Contact Surfaces revised date 1/2025 showed discard any food contact surfaces with chips, nicks or broken pieces, such as fryer baskets or skimmers that have damaged, loose or broken wires, strainers, pans, skillets, and knives, which cannot be cleaned properly. Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant, nonabsorbent, smooth and easily cleanable, and maintained in good condition. Review of the facility's P&P titled Equipment Condition and Management dated 10/1/22, showed the equipment and utensils must be designed and constructed to be safe and to prevent the migration of harmful substances, colors, odor or tastes to food. Also under normal use conditions, materials that are used in the construction of utensils and food-contact surfaces of equipment must be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Durable, corrosion-resistant, and non-absorbent. Finished to have a smooth, easily cleanable surface. Resistant to pitting, chipping, scratching, scoring, distortion, and decomposition. Free of sharp internal angles, corners, and crevices. Finished to have smooth welds and joints. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of the utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 5/12/25 at 0836 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Aide. The following was observed and verified by the Dietary Aide: - One Ninja blender stored at a countertop shelf was old and worn out and cracked at the base of the blender. The lid was cracked and the rubber portion worn out and discolored. - One stainless steel serving spoon with black handle was partially melted. - One stainless steel spatula with black handle was deformed at the edges and handle partially melted. - One plastic black spoon was partially melted at the edges. - Two rubber spatulas with red handle were chipped/cracked at the edges. - One rubber spatula with brown handle was discolored, chipped/cracked at the edges. - One stainless steel serving scoop with a black handle partially melted. - Two stainless steel slotted serving scoops with black handles were partially melted. - One stainless steel serving spoon with black handle was partially melted. - One stainless steel spatula with brown handle was chipped at the edges and handle was discolored and partially melted. - One stainless steel ice cream scoop old, worn out, and discolored. - One cutting dough with cream handle was discolored and partially melted. 3. Review of the facility's P&P titled Sanitation and Infection Prevention/ Control, Cleaning of Food and Nonfood Contact Surfaces revised date 1/2025 showed the food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable. The food-contact surfaces of all the cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Review of the facility's P&P titled Equipment Condition and Management dated 10/1/22, showed the equipment and utensils must be designed and constructed to be safe and to prevent the migration of harmful substances, colors, odor or tastes to food. Also under normal use conditions, the materials that are used in the construction of the utensils and food-contact surfaces of the equipment must be durable, corrosion-resistant, and non-absorbent. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of the equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 5/12/25 at 0836 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Dietary Aide. The following was observed and verified by the Dietary Aide: - Robot coupe blender at a countertop shelf with blade had dry, orange residue, rubber portion of the lid was dirty and had yellow discoloration. - Four stainless steel serving scoops with green handles were stored in the clear container for clean spoodles and utensils were dirty with dry fuzzy film, watermarks and crusted residue. - Two stainless steel serving scoops with blue handles were stored in the clear container for clean spoodles and the utensils were dirty with dry watermarks and crusted residue. - Two stainless steel serving scoops with cream handles were stored in the clear container for clean spoodles and the utensils were dirty with dry watermarks and crusted residue. - One stainless steel serving scoop with black handle was stored in the clear container for clean spoodles and the utensil was dirty and had dry crusted residue. - Two stainless steel serving spoons with black handles were stored in the clear container for clean spoodles and the utensils were dirty, had dry watermarks and crusted residue. - Two stainless steel serving slotted scoops with black handles were stored in the clear container for clean spoodles and the utensils were dirty, had dry fuzzy film and crusted residue. - One stainless steel slotted serving spoon was stored in the clear container for clean spoodles and the utensil was dirty with crusted residue. - One stainless steel scoop with a blue handle used for food portioning was stored in the clear container for clean spoodles and the utensil was dirty and had crusted residue. - One stainless steel scoop with gray handle used for food portioning was stored in the clear container for clean spoodles and the utensil was dirty and had crusted residue. - One stainless steel serving scoop with black handle was stored in the clear container for clean spoodles and the utensils was dirty and had dry crusted residue. - Two stainless steel slotted serving scoops with black handles were stored in the clear container for clean spoodles and the utensils were dirty and had dry crusted residue. - One stainless steel serving spoon with black handle was stored in the clear container for clean spoodles and the utensil was dirty with dry watermarks. 4. Review of the facility's P&P titled Equipment Condition and Management dated 10/1/22, showed surfaces such as the cutting blocks and boards that are subject to scratching and scoring must be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as the cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 5/12/25 at 0836 hours, an initial tour observation and concurrent interview was conducted with the Dietary Aide. The white, green, and red cutting boards were observed fuzzy, discolored, heavily marred and had deep groves. The Dietary Aide verified the findings, and stated the cutting boards were ordered by the Chef, and was unsure how often. 5. Review of the facility's P&P titled Dish Machine Usage and Testing dated 10/1/22, showed for air dry: place the equipment or utensils onto a clean surface to air dry. Do not dry with a towel or other method. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, the equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, the cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 5/12/25 at 0836 hours, an initial tour observation and concurrent interview was conducted with the Dietary Aide. Two heavy-duty blenders stored at a countertop shelf were still wet with water dripped from the blender lid and visible water inside. The Dietary Aide acknowledged the above findings. The Director of Dining Services was informed and acknowledged all the above findings. The Director of Dining Services stated all the utensils should have been washed properly to prevent bacteria growth and for infection control purposes. The blenders should have been air dried to prevent mold and bacteria growth. The cutting boards should have been replaced for infection control purposes. The hood over the stove should be free from grease or dirt for fire hazard prevention.

5. On 5/12/25 at 1036 hours, during the initial tour of the facility, Resident 15 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/13/25 at 0923 hours, Resident 15 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 15 was initiated on 5/12/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. Review of Resident 15's H&P examination dated 4/11/24, showed Resident 15 had a diagnosis of failure to thrive, T12 compression fracture (a break in the twelfth thoracic vertebra (T12) located in the mid-back), and osteoporosis (a disease that weakens bones, making them more likely to break). Review of Resident 15's Annual MDS assessment dated [DATE], showed a BIMS score of 9 (scores of 8 to 12 suggest moderate cognitive impairment). On 5/14/25 at 1319 hours, an interview and concurrent record review was conducted with RN 3. RN 3 verified the above findings and stated a physician's order should be in place for the used of bilateral half side rails. On 5/15/25 at 0805 hours, an interview and concurrent record review was conducted with RN 1. RN 1 acknowledged the above findings and stated there should be a physician's order, informed consent, entrapment assessment, and bed rail assessment prior to the used of side rails to ensure residents' safety, to prevent injuries and the risk of entrapment. 6. On 5/13/25 at 0926 hours, during an observation, Resident 34 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/14/25 at 1359 hours, Resident 34 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 34 was initiated on 5/12/25. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. Review of Resident 34's H&P examination dated 4/10/25, showed Resident 34 was a high risk for falls and had no capacity to exercise rights and sign necessary documents; therefore, the family would be informed of medical condition and/or plan of treatment. Review of Resident 34's Quarterly MDS assessment dated [DATE], showed Resident 34 had severe cognitive impairment. Section GG of the assessment showed Resident 34 had impairment to both upper and lower extremities. On 5/14/25 at 1333 hours, an interview and concurrent record review was conducted with RN 3. RN 3 verified the above findings and stated a physician's order should be in place for the use of bilateral half side rails. On 5/15/25 at 0805 hours, an interview and concurrent record review was conducted with RN 1. RN 1 acknowledged the above findings and stated there should be a physician's order, informed consent, entrapment assessment, and bed rail assessment prior to the used of side rails to ensure the residents' safety and to prevent injuries and the risk of entrapment. 7. On 5/13/25 at 0942 hours, during an observation, Resident 40 was awake in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 40 was initiated on 5/13/25. Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's medical records failed to show the informed consent for the used of bilateral upper side rails. Review of Resident 40's H&P examination dated 4/11/25, showed Resident 40 had fluctuating capacity to make decisions. Review of Resident 40's admission MDS dated [DATE], showed a BIMS score of 10 (scores of 8 to 12 suggest moderate cognitive impairment). Review of Resident 40's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. On 5/14/25 at 1554 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 verified the above findings and stated there should be a physician's order prior to the used of bilateral half side rails. On 5/15/25 at 0805 hours, an interview and concurrent record review was conducted with RN 1. RN 1 acknowledged the above findings and stated there should be a physician's order, informed consent, entrapment assessment, and bed rail assessment prior to the used of side rails to ensure residents' safety and to prevent injuries and the risk of entrapment. 8. On 5/14/25 at 1127 hours, during a wound care observation, Resident 397 was awake in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 397 was initiated on 5/12/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's H&P examination dated 5/7/25, showed Resident 397 had the capacity to make decisions. Review of Resident 397's admission MDS dated [DATE], showed a BIMS score of 15 (score of 13-15 suggests intact cognition). Review of Resident 397's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. Review of Resident 397's medical record failed to show the informed consent for the used of bilateral upper side rails. On 5/14/25 at 1347 hours, an interview and concurrent record review was conducted with RN 3. RN 3 verified the above findings and stated a physician's order should be in place for the use of bilateral half side rails. On 5/15/25 at 0805 hours, an interview and concurrent record review was conducted with RN 1. RN 1 acknowledged the above findings and stated there should be a physician's order, informed consent, entrapment assessment, bed rail assessment, and care plan prior to the used of side rails to ensure residents' safety, to prevent injuries and the risk of entrapment. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure nine of nine final sampled residents (Residents 1, 2, 12, 15, 18, 19, 34, 40, and 397) and one nonsampled resident (Resident 16) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to obtain a physician's order and informed consent for the use of the bilateral upper side rails for Residents 1, 2, 16, 19, 40, and 397. In addition, the facility failed to ensure the side rails assessment was completed accurately for Resident 1. * The facility failed to ensure the IDT meeting and determination for side rails was complete. Additionally, the facility failed to have the physician's order for side rails, side rail consent, and evaluation for Residents 12 and 18. * The facility failed to obtain a physician's order for the use of the bilateral upper side rails for Residents 15 and 34. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: The FDA issued a Safety Alert titled Entrapment Hazards with Hospital Bed Side Rails (1995), which showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Bed Safety and Bed Rails revised on 8/2022 showed the following: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; - If attempted alternatives do not adequately meet the resident's needs, the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes an evaluation of the alternatives to bed rails which were attempted and how these alternatives failed to meet the resident's needs, resident's risk associated with the use of bed rails, input from the resident and/or representative and consultation with the attending physician; and - Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. 1. On 5/12/25 at 0847 hours, during the initial tour, Resident 1 was observed lying in bed awake, was oriented to name and verbally responsive. Resident 1's bed had elevated bilateral side rails. Resident 1 stated she did not use her side rails. On 5/12/25 at 0856 hours, an observation and concurrent interview was conducted with CNA 2. Resident 1 was lying in bed with elevated bilateral upper side rails. CNA 2 stated Resident 1 used the bilateral upper side rails for repositioning while in bed. CNA 2 verified the above findings. Medical record review for Resident 1 was initiated on 5/14/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/15/25, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's cognitive skills for daily decision-making score was 3, indicating severely impaired. Review of Resident 1's Order Summary Report for 4/2025 failed to show for a physician's order for the bilateral upper side rails. Further review of Resident 1's medical records failed to show for an informed consent for use of bilateral upper side rails. On 5/14/25 at 0909 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 1 currently uses the bilateral upper side rails for turning in bed. LVN 3 was asked about the process prior to applying side rails, the LVN stated there must be a side rail assessment, order, consent and care plan. Furthermore, LVN 3 was asked who completed the entrapment assessment. LVN 3 stated she had not heard or seen an entrapment assessment. On 5/14/25 at 0939 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 1's medical record failed to show the side rails evaluation, entrapment assessments, order, and informed consent. 2. On 5/12/25 at 0902 hours, during the initial tour, Resident 2 was lying in bed asleep. Resident 2's bed had the elevated bilateral side rails. On 5/12/25 at 0905 hours, an observation and concurrent interview was conducted with CNA 2. Resident 1 was lying in bed with bilateral upper side rails elevated. CNA 2 stated Resident 2 used the bilateral upper side rails for repositioning while in bed. CNA 2 verified the above findings. On 5/13/25 at 0837 hours, an observation and concurrent interview was conducted with LVN 4. Resident 2 was sitting up in bed and eating her breakfast. Resident 2's bed had the elevated bilateral upper side rails. LVN 4 verified the above findings. Medical record review for Resident 2 was initiated on 5/14/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's cognitive skills for daily decision-making score was 3, indicating severely impaired. Review of Resident 2's Order Summary Report dated 5/14/25, failed to show the physician's order for the bilateral upper side rails. Reviewed Resident 2's Side Rail Evaluation Quarterly dated 3/28/25, showed the Side Rails/Assist bar were not indicated at this time. Review of Resident 2's medical record failed to show the consent was obtained for the use of bilateral upper side rails. On 5/14/25 at 1028 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2's medical record failed to show there was a physician's order and informed consent from the resident's responsible party for the use of the side rails. 3. Medical record review for Resident 16 was initiated on 5/14/25. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 9/22/23, showed Resident 16 had the capacity to understand and make decisions. Review of Resident 16's MDS assessment dated [DATE], showed Resident 16's BIMS score was 15, indicating cognitively intact. On 5/14/25 at 0900 hours, an observation and concurrent inteview was conducted with Resident 16. Resident 16 was in bed, awake, alert, and verbally responsive. Resident 16's bed had the elevated bilateral upper side rails. Resident 16 stated he used the side rails for bed mobility and during transfers. Review of Resident 16's Order Summary Report dated 5/14/25, failed to show there was a physician's order for the use of the bilateral upper side rails. Further review of Resident 16's medical record failed to show an informed for the use of bilateral upper side rails. On 5/14/25 at 0915 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 reviewed the resident's medical record and verified the findings. LVN 3 stated when the resident had the side rails, they should have a physician's order and an informed consent. 4. On 5/12/25 at 0858 hours, an initial tour observation and concurrent interview was conducted with CNA 2. Resident 19 was lying in bed, awake, alert, and eating her breakfast. Resident 19's bed had the elevated bilateral upper side rails. CNA 2 verified the above findings. CNA 2 stated Resident 19 used the bilateral upper side rails to reposition in bed. Medical record review for Resident 19 was initiated on 5/14/25. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's MDS assessment dated [DATE], showed Resident 19's BIMS score was zero, indicating severe cognitive impairment Reviewed Resident 19's Side Rail Evaluation Quarterly dated 4/23/25, showed the Side Rails/Assist bar were not indicated at this time. Review of Resident 19's Order Summary Report dated 4/2025 failed to show the physician's order to apply the bilateral upper side rails. Review of Resident 19's medical record failed to show an informed consent for the use of bilateral upper side rails. On 5/14/25 at 0939 hours, an interview was conducted with RN 1. RN 1 was asked about the facility's process prior to applying side rails. RN 1 stated the residents must be assessed for the side rails' indication, and they need to obtain physician's order and informed consent from the resident or responsible party. RN 1 stated an entrapment assessment must be included prior to applying the side rails. RN 1 stated the Maintenance Supervisor was responsible for the bed inspection, and the Safety Alarms/Bedrail use/Entrapment Risk Evaluations were completed by the admission nurse and IDT. RN 1 stated the side rails and devices used without appropriate assessments, the order and consent would be considered physical restraint and could cause injury to the residents. On 5/14/25 at 1010 hours, a follow-up interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. On 5/15/25 at 1505 hours, an interview was conducted with the DON and Administrator. The DON was asked for the facility's process prior to side rail use. The DON stated she was responsible for the monthly check of the side rail's assessments and consents completion and accuracy. The DON stated each time a resident needed the side rails, the licensed nurse must assess for appropriateness, obtain the physician's order and consent from the resident or responsible party, develop a care plan, complete the entrapment assessment, and apply the side rails. The DON stated if the side rails were applied to the resident's bed and used by the resident; however, there were no assessments, physician's order, consent, and care plan, then the side rails should not be applied and would be considered a restraint. The DON and Administrator were informed and acknowledged the above findings. 9. On 5/12/25 at 1054 hours and on 5/14/25 at 0835 hours, Resident 12 was observed in bed with elevated bilateral upper side rails. Medical record review for Resident 12 was initiated on 5/14/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Safety Alarms/Bedrail Use/And Entrapment Risk Evaluation dated 9/17/24, showed the IDT Determination for bedrails was left blank. Further review of Resident 12's Entrapment Risk Evaluation showed only one signature from the nursing department for the IDT meeting, resulting in an incomplete IDT meeting Review of Resident 12's Informed Consent for Bedrail Use dated 9/19/24, showed no indications were specified for the use of side rails. Review of Resident 12's medical record did not show the Side Rail Evaluation was completed in conjunction with the 9/19/24 consent. Review of Resident 12's Side Rail Evaluation - Quarterly/Annual dated 3/13/25, showed the side rails/assist bar were not indicated at this time; however the facility entered a new Side Rail Evaluation on 5/14/25, which showed the side rails/assist bar were indicated and served as an enabler to promote independence. Review of Resident 12's Order Summary Report dated 5/14/25, did not show a physician's order for the use of the side rails. Further review of the Order Summary Report showed a new order dated 5/14/25, for side rails, quarter. There was no indication listed for the use of side rails. On 5/14/25 at 1401 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 3. LVN 3 verified the IDT determination for bedrails section was blank. LVN 3 verified the IDT meeting was incomplete because the IDT meeting should consist of members of the care team like the physician and social worker. LVN 3 was unable to locate the physician's order for side rails prior to 5/14/25. LVN 3 verified the physician's order dated 5/14/25, was incomplete because the orders for the side rails need to have an indication. LVN 3 verified the consent dated 9/19/24, was incomplete because there were no indications for side rails listed and stated indications were necessary because the side rails were considered an assistive device, and could be considered a restraint. LVN 3 was unable to locate an assessment associated with the consent dated 9/19/24. LVN 3 verified the side rails should not have been in use for Resident 12 because the evaluation dated 3/13/25, showed side rails were not indicated. 10. On 5/12/25 at 1045 hours and on 5/14/25 at 0835 hours, Resident 18 was observed in bed with elevated bilateral upper side rails. Medical record review for Resident 18 was initiated on 5/14/25. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's Safety Alarms/Bedrail Use/And Entrapment Risk Evaluation dated 2/5/25, showed the sections for the Bedrail Evaluation Summary and IDT Determination for bedrails were left blank. Further review of Resident 18's Entrapment Risk Evaluation showed only one signature from the nursing department for the IDT meeting, resulting in an incomplete IDT meeting Review of Resident 18's Informed Consent for Bedrail Use dated 3/1/25, showed no indications were specified for the use of side rails. Review of Resident 18's Side Rail Evaluation dated 3/27/25, showed the side rails/assist bar were not indicated at this time. Review of Resident 18's Order Summary Report dated 5/14/25, did not show an order for side rails. On 5/14/25 at 1401 hours, an interview and concurrent medical record review for Resident 18 was conducted with LVN 3. LVN 3 verified the bedrail evaluation summary and the IDT Determination were incomplete because there was no documentation. LVN 3 verified the IDT meeting was incomplete because the IDT meeting should consist of members of the care team like the physician and the social worker. LVN 3 was unable to locate a physician's order for side rails prior to 5/14/25. LVN 3 verified the consent dated 3/1/25, was incomplete because there were no indications for the side rails listed and stated the indications were necessary because the side rails were considered an assistive device and could be considered as a restraint. LVN 3 verified the side rails should not have been in use for Resident 18 because the evaluation dated 3/27/25, showed the side rails were not indicated.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 13) maintained acceptable parameters of nutritional status when: 1. The facility failed to implement interventions to maintain Resident 13's nutritional status when Resident 13 experienced the following weight loss: - a significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - a significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - a severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - a severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 2. The facility failed to provide documentation showing the physician was notified of Resident 13's unplanned significant monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22. 3. The facility failed to provide documentation Resident 13's RP was notified of the following changes in condition for Resident 13: - significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 4. The facility failed to revise the resident centered plan of care for Resident 13 for the following changes in condition: - significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. A professional reference review of the National Library of Medicine titled Pressure Ulcer and Nutrition dated 2018 showed, Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930532/#: A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines dated 2011 showed, Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents_/UWL.pdf 1. Review of the facility's P&P titled Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol revised 9/2017 showed in part, the section for Assessment and Recognition 2. The staff and Physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition .4. The staff will report to the Physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. For the section titled Treatment/Management showed 2. The staff and Physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and wishes. For the section titled Monitoring showed 1. The Physician and staff will monitor nutritional status, an individual's response to interventions . Medical record review for Resident 13 was initiated on 1/24/23. Resident 13 was readmitted to the facility on [DATE], with diagnoses which included Muscle Wasting and Atrophy (wasting or thinning of muscle tissue), Muscle Weakness, Peripheral Vascular Disease (circulatory condition which narrowed blood vessels reduce blood flow to the limbs), Dysphagia (difficulty swallowing), and Unspecified Dementia (progressive loss of intellectual functioning). Review of Resident 13's Discharge MDS dated [DATE], showed under Section K, Resident 13 weighed 184 lbs and had not experienced a 5% weight loss or gain in the past month or 10% weight loss or gain in the past six months. Review of Resident 13's History and Physical Examination dated 8/16/22, showed Resident 13 was readmitted from the hospital with urosepsis (infection in the blood caused by infections of the urinary tract), with intravenous (administered into a vein) antibiotics. The Physician noted Resident 13 was stable in the last month with no new event. Review of Resident 13's Physician's Order dated 8/18/22, showed the following orders: - 8/18/22, a mechanical soft ground diet - 8/23/22, four ounces of cranberry juice TID (three times a day) - 8/30/22, four-ounce health shake with meals - 8/31/22, MVI (multi-vitamin) - 10/29/22, Zinc Sulfate (a mineral for wound healing) 220 mg daily - 30 cc prostat (protein supplement). Review of the facility document titled Resident Weight Tracking System Report from 8/14/22 through 1/25/23, showed the following weights and comparisons for Resident 13: * On 8/15/22 = 173.8 lbs, -10.2 lbs, a 5.5% significant weight loss since previous admission [comparison weight on 8/7/22, 184 lbs], * On 9/15/22 = 164.6 lbs, -9.2 lbs, a 5.3% significant weight loss in one month [comparison weight on 8/15/22, 173.8 lbs], * On 12/8/22 = 154.3 lbs, -8.8 lbs, a 5.4% significant weight loss in one month [comparison weight on 11/3/22, 163.1 lbs]; -13.1 lbs, a 7.83% severe weight loss in three months [comparison weight on 9/8/22, 167.4 lbs]; and -19.5 lbs, an 11% severe weight loss since readmission [comparison weight on 8/15/22, 173.8 lbs]. Review of the facility document titled Dietary Assessment completed by the RD on 8/15/22, showed Resident 13 was 68 inches and weighed 173.8 lbs. Resident 13 was confused and had a poor appetite and intake, 25-50% on a regular texture diet. Resident 13 was noted with coughing and choking with meals. Resident 13's skin was intact. The RD noted Resident 13 had weight loss of six lbs in the acute care hospital. The RD recommended to downgrade the diet to mechanical soft with ground meat, offer snacks, and encourage fluid between meals. Resident 13 was at risk for unintended weight loss and dehydration due to poor appetite and intake, infection, HTN (hypertension), dementia and needed assistance with meals. Resident 13 was at risk for pressure ulcer due to limited mobility. The RD documented for MDS triggers, Resident 13 was on IV treatment for infection and hydration. BMI was elevated, but the intake was poor, and no goal was identified for the resident's weight loss at this time. Review of Resident 13's IDT notes written by the RD dated 8/23/22, showed no recent weight, new DTI on heel, and poor intake. The IDT recommended to add cranberry juice with meals for fluid, vitamin C, and calories. Review of Resident 13's IDT notes written by the RD dated 8/30/22, showed current weight was not available, DTI on heel, and poor intake; and recommended to add health shake with meals, evaluate for MVI (multivitamin) supplement. Review of Resident 13's IDT notes written by the RD dated 9/14/22, showed current weight was 167.4 lbs, weight loss of 6.4 lbs in three weeks. The resident's heel was debrided now unstageable. No new recommendations noted. Review of Resident 13's IDT notes written by the RD dated 9/21/22, showed current weight was 164.6 lbs, weight loss of 2 lbs in a week. Intake was variable. No new recommendations were noted. Review of the facility document titled Dietary Assessment completed by the RD on 11/3/22, showed a significant change for Resident 13. Resident 13 was on a mechanical soft ground diet, appetite was poor, and intake was 25-50%. Resident 13 was confused with swallowing difficulty and high risk for pressure ulcer. Resident 13 had a stage 4 pressure ulcer located on the right heel. Lab data dated 10/31/22, showed, BUN (blood urea nitrogen) 11 ok. Current weight was 163 lbs, with weight loss of 19.6 lbs which was 10.7% in three months between admissions. Under the section titled Care Plan showed weight goal of 163 lbs +/- 3% per month x 90 days. Review of Resident 13's MDS dated [DATE], showed under Section A0310, 4. Significant change in condition. The MDS showed a BIMS score of 12 indicating Resident 13 was mostly interviewable but with some confusion. Section K of the MDS indicated Resident 13's weight was 163 lbs, and Resident 13 had experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months and was not on a physician-prescribed weight-loss regimen. Review of Resident 13's IDT notes written by the RD dated 11/8/22, showed current weight was 163.1 lbs, weight loss of 1.3 lbs in a month. The resident's right heel was open and debrided. The document showed a recommendation for magic cup (a fortified ice cream) at lunch. Review of Resident 13's IDT notes written by the RD dated 12/6/22, showed current weight was 157.7 lbs, 3.4 lbs weight loss in a month; (elevated BMI) acceptable weight loss due to overweight. Resident 13 had a pressure ulcer to the right heel and poor intake. The document showed no interventions due to showing positive results from treatment. Review of Resident 13's IDT notes written by the RD dated 12/13/22, showed current weight was 154.3 lbs, a 3.4 lbs weight loss in a week; (elevated BMI) acceptable weight loss due to overweight. Resident 13 had the right heel Stage 4 pressure ulcer and poor intake. The document showed no new interventions, continue current treatment, and to review next week. Review of Resident 13's IDT notes written by the RD dated 12/27/22, showed the current weight was 152.6 lbs, a 2.9 lbs weight loss in a week. The document showed the resident's right heel Stage 4- nursing report improving, and heel protectors were helping. Intake was decreasing. The Social Service staff reported Resident 13 was not as alert as she used to be. The document showed need to encourage better intake, continue current treatment, and review next week. Review of Resident 13's Physician Progress Notes from 8/16/22 to 10/27/22, showed Resident 13 was stable in the last month, no new event noted. The section where to record the resident's body weight was blank. Review of Resident 13's Physician Progress Note dated 11/22/22, showed Resident 13 was stable in the last month, no new event noted. Resident 13's weight was recorded as 161 lbs. There was no documentation of weight loss. Review of Resident 13's Physician Progress Note dated 12/25/22, showed Resident 13 was stable in the last month. Resident 13's weight was recorded as 153 lbs. The progress note further showed, weight loss secondary to? will start on Remeron (an antidepressant used to enhance appetite). On 1/24/23 at 0841 hours, an observation of the breakfast meal and concurrent interview was conducted with Resident 13. Resident 13 stated she did not want to eat any of her breakfast meal and preferred only to drink the four-ounce health shake (a nutritional supplement). On 1/24/23 at 1300 hours, an observation of the lunch meal and concurrent interview was conducted with Resident 13 with CNA 1 present. Resident 13 was propped up in bed with CNA 1 assisting Resident 13 with her lunch meal. Resident 13 stated she did not like any of the food. CNA 1 stated Resident 13 did not eat solid foods and preferred liquids only, specifically health shakes. CNA 1 stated they encouraged Resident 13 to eat but she refused. On 1/25/23 at 0821 hours, an interview was conducted with the DON. The DON stated the protocol when a resident experienced a significant weight loss was to notify the physician and have a meeting with the IDT to discuss the resident's weight loss and implement interventions. On 1/26/23 at 1113 hours, an interview and concurrent medical record review of the initial skin assessment dated [DATE], for Resident 13 was conducted with RN 2. RN 2 stated the initial skin assessment showed Resident 13's skin was intact with a skin tear to the right calf. The skin evaluation form dated 8/21/22, for Resident 13 was reviewed with RN 2. The skin evaluation form showed a DTI which measured 4.0 centimeters (cm) in length and 7.0 cm in width, UTD (undetermined) depth. Resident 13's wound assessment form dated 10/27/22, completed by the Surgical and Wound Care Physician (SWCP) was reviewed with RN 2. The wound assessment form showed Resident 13's right heel had a Stage 4 wound, measuring 4.0 cm in length, 6.0 cm in width and .4 cm in depth. The wound assessment form showed the right heel wound was deteriorating and positive for cellulitis (a common, potentially serious bacterial skin infection). The SWCP recommended Augmentin (an antibiotic) for 10 days. On 1/26/23 at 1159 hours, an interview was conducted with the DON. The DON confirmed weight loss was not indicated in a resident with a Stage 4 wound. On 1/26/23 at 1447 hours, an interview was conducted with CNA 1. CNA 1 was asked how she documented the percentage of the health shake taken for Resident 13. CNA 1 stated the health shake was included in the total meal intake. If Resident 13 drank the health shake and magic cup but not other food, the intake was 25-50%. On 1/26/23 at 1500 hours, a medical record review for Resident 13 and concurrent interview was conducted with the RD. The Dietary Assessment completed by the RD, dated 8/15/22, and the discharge MDS dated [DATE] were reviewed. The RD confirmed she was responsible for Section K of the MDS. The RD stated she did not complete Section K of the discharge MDS dated [DATE], for Resident 13. The RD acknowledged the weight for Resident 13 was 184 lbs on 8/7/22, as per the discharge MDS. The RD confirmed Resident 13 had lost close to ten pounds in the hospital and that the weight loss was significant. The RD stated she could not remember what weight she used to compare Resident 13's admission weight of 173.8 lbs to, but that Resident 13's usual body weight prior to discharge was 180 lbs. The RD confirmed Resident 13 was at risk for unintended weight loss, dehydration, and pressure ulcer development. The RD confirmed Resident 13's skin was intact; intake was poor; the goal for Resident 13 was to keep weight stable at the admission weight of 173.8 lbs; and weight loss was not a goal. The RD confirmed she recommended to downgrade the diet to mechanical soft and offer snacks. The IDT progress notes written by the RD dated 8/23/22 and 8/30/22, were reviewed with the RD. The RD stated Resident 13 was followed by the IDT due to an acquired DTI to the right heel and poor intake. The RD confirmed there was no recent weight noted on the IDT notes dated 8/23/22 or 8/30/22. The RD confirmed cranberry juice was added with meals at the family request and health shakes with meals and MVI (multivitamin) were recommended. The IDT notes written by the RD dated 9/14/22 and 9/21/22, were reviewed with the RD. The RD confirmed Resident 13's weight on 9/8/22 was 167.4 lbs. which was a 6.4 lb. weight loss since admission, a three-week time frame. The RD confirmed Resident 13's weight on 9/15/22, was 164.6 lbs, a 2 lbs weight loss in a week. The resident's right heel was debrided and now unstageable. The RD confirmed Resident 13's intake remained poor. The RD confirmed no interventions were implemented. The IDT progress notes failed to document Resident 13 experienced a significant unplanned weight loss of 9.2 lbs, 5.2% from 8/14/22-9/15/22, a one-month time frame. When asked why no interventions were implemented at this time, the RD stated the weight loss of 6.4 lbs on 9/8/22, was not significant, and Resident 13 was already on health shake with meals. The COC (change of condition) MDS completed by the RD dated 11/4/22, and corresponding Dietary Assessment marked significant change completed by the RD dated 11/3/22, were reviewed with the RD. The RD stated the Dietary Assessment marked significant change was completed for Resident 13 because she had a decline which included weight loss and a Stage 4 wound. The RD confirmed Resident 13 had a poor appetite with meal intake 25-50%. The RD confirmed the current weight was 163 lbs, a significant unplanned weight loss of 19.6 lbs, 10.7% in three months. The RD confirmed the section titled Care Plan showed weight goal of 163 +/- 3% per month x 90 days. The RD confirmed no interventions were recommended. When asked why Resident 13's weight goal had been reduced to 163 lbs, compared to the 173.8 lbs weight goal on 8/15/22, the RD stated she did not want Resident 13 to gain or lose weight. The RD stated Resident 13's average weight had changed and that was how she determined the new goal weight. The RD confirmed the COC MDS showed Resident 13 had experienced a significant unplanned weight loss of 5% or more in the past month or 10% or more in the past six months and was not on a physician-prescribed weight-loss regimen. The IDT notes written by the RD dated 11/8/22, were reviewed with the RD. The RD confirmed Resident 13 weighed 163.1 lbs, a 1.3 lbs weight loss in a month. The resident's heel wound was open and debrided. The IDT agreed to add magic cup (a fortified ice cream) at lunch. The RD was asked how she assessed if the interventions were working. The RD stated Resident 13's intake was poor, so they added the magic cup. The IDT notes written by the RD dated 12/6/22 and 12/13/22, were reviewed with the RD. Although Resident 13 had experienced a significant unplanned weight loss of 8.8 lbs, 5.4% in a month from 11/3/22-12/8/22; a severe weight loss of 13.1 lbs, 7.83% in three months from 9/8/22-12/8/22; and a severe weight loss of 19.5 lbs., 11% since readmission on 8/14/22, the RD confirmed the significant weight losses were not mentioned and that Resident 13's current weight was 157.7 lbs on 12/6/22, a 3.4 lbs weight loss in a month; and 154.3 lbs. on 12/13/22, a 3.4 lbs weight loss in a week. The RD confirmed Resident 13 had poor intake and a Stage 4 wound on the right heel. The RD confirmed she documented the weight loss was acceptable due to an elevated BMI. When asked why the IDT did not recommend an intervention at this point, despite the continued significant unplanned weight loss, the RD stated even though Resident 13 lost weight, the IDT could not figure out what else to do since Resident 13 was already on health shakes with meals and magic cup at lunch. The RD was not sure Resident 13 would eat any more and the wound treatment was improving so the IDT did not recommend any interventions. The RD confirmed it was not appropriate for Resident 13 to lose weight with a Stage 4 wound and added she didn't want Resident 13 to gain any weight. On 1/26/23 at 1604 hours, an interview was conducted with the DON and ADON. The DON stated he returned from leave on 1/9/23, so it was difficult for him to speak about the IDT meetings since he was not present. The DON confirmed if a resident continued to experience unplanned weight loss, the facility must keep trying new interventions. The ADON stated weight loss for Resident 13 was not putting the resident in an unhealthy BMI range. When asked if the ADON was qualified to determine that statement, the ADON agreed the physician should determine if weight loss was indicated for a resident. 2. Review of the facility's P&P titled Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol revised 9/2017 showed the section titled, Assessment and Recognition .4. The staff will report to the Physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Review of the facility document titled Resident Weight Tracking System Report from 8/14/22 through 1/25/23, showed the following weights and comparisons for Resident 13: * On 9/15/22, 164.6 lbs, -9.2 lbs, a 5.3% significant weight loss in one month [comparison weight 8/15/22, 173.8 lbs]. On 1/25/23 at 0821 hours, an interview was conducted with the DON. The DON stated the protocol when a resident experienced a significant weight loss was to notify the physician and have a meeting with the IDT to discuss the resident's weight loss and implement interventions. On 1/25/23 at 1059 hours, an interview and concurrent medical record review of Resident 13's electronic Resident Weight Tracking System Report (RWTSR) was conducted with Desk Nurse 2. Desk Nurse 2 stated the nurses were responsible to notify the physician of significant weight changes. Desk Nurse 2 further stated the RNA obtained the resident weights and the LVN entered the weight in the computer system. The RWTSR calculated significant weight changes, and significant weight loss was coded in red. The physician would be notified of any significant weight changes and the LVN would document this in the resident's electronic record. According to the RWTSR, Resident 13 experienced a significant weight loss on 9/15/22 of 9.2 lbs, 5.3%. Desk Nurse 2 was unable to verify if the physician had been notified of Resident 13's significant weight loss. Cross reference to F580. 3. Review of the facility's P&P titled Weight Assessment and Intervention revised 9/2008 showed care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, dietitian, and the resident or resident's legal surrogate. Review of the facility document titled Resident Weight Tracking System Report from 8/14/22 through 1/25/23, showed the following weights and comparisons for Resident 13: * On 8/15/22, 173.8 lbs, -10.2 lbs., a 5.5% significant weight loss since previous admission [comparison weight on 8/7/22, 184 lbs.], * On 9/15/22, 164.6 lbs, -9.2 lbs., a 5.3% significant weight loss in one month [comparison weight on 8/15/22, 173.8 lbs.], * On 12/8/22, 154.3 lbs., -8.8 lbs., a 5.4% significant weight loss in one month [comparison weight on 11/3/22, 163.1 lbs.]; -13.1 lbs, a 7.83% severe weight loss in three months [comparison weight on 9/8/22, 167.4 lbs.]; and -19.5 lbs, a 14.6% severe weight loss since readmission [comparison weight on 8/15/22, 173.8 lbs.]. On 1/26/23 at 1055 hours, a review of Resident 13's electronic RWTSR and concurrent interview was conducted with DN 3. DN 3 was asked who was notified of resident significant weight changes. DN 3 stated everyone was notified: the physician, family, and RD. DN 3 confirmed Resident 13 experienced a significant weight loss on 9/15/22 of 9.2 lbs, 5.3%; on 12/8/22, a significant weight loss of 8.8 lbs, 5.4% in a month; 13.1 lbs, 7.83% severe weight loss in three months; and 19.5 lbs, 14.6% a severe weight loss since admission on 8/15/22; but was unable to verify if Resident 13's RP was notified. On 1/26/23 at 0917 hours, a telephone interview was conducted with Resident 13's RP. Resident 13's RP confirmed she had not been contacted by the facility regarding Resident 13's significant weight losses. On 1/26/23 at 1159 hours, an interview was conducted with the DON. The DON confirmed the RP should be contacted regarding significant weight changes. Cross reference to F580. 4. Review of the facility's P&P titled Weight Assessment and Intervention, dated 2001 showed, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . Care planning: 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Review of Resident 13's plan of care dated 1/3/23, showed a care plan problem was developed to address Resident 13's nutrition with a goal weight of 153.6 lbs. The care plan failed to address Resident 13's current and continued significant and severe unplanned weight losses. On 1/25/23 at 1059 hours, review of Resident 13's electronic Resident Weight Tracking System Report (RWTSR) and concurrent interview was conducted with Desk Nurse 2. Desk Nurse 2 confirmed Resident 13 had experienced a significant weight loss on 9/15/22 of 9.2 lbs, 5.3%; on 12/8/22 a significant weight loss of 8.8 lbs, 5.4% in a month; 13.1 lbs, 7.83% severe weight loss in three months; and 19.5 lbs, 11% a severe weight loss since admission on 8/15/22. Desk Nurse 2 was asked if the plan of care should reflect these changes in weight. Desk Nurse 2 stated the plan of care should reflect significant weight changes but was not sure if that was the desk nurses' responsibility. Desk Nurse 2 confirmed Resident 13's plan of care did not reflect the significant and severe weight losses. On 1/26/23 at 1500 hours, an interview was conducted with the RD. The RD confirmed she was responsible to update the resident's nutritional plan of care. The RD was asked why Resident 13's plan of care did not reflect the significant and severe weight losses. The RD stated she usually updated the care plan but did not know why she did not update Resident 13's care plan. The RD further stated she did not use the word significant on care plans. When asked why the word significant was not used, she stated she did not know why. The RD confirmed the weight losses for Resident 13 were a problem. The RD confirmed the weight goal documented on the care plan for Resident 13 was now 153.6 lbs which was 20.2 lbs. less than the goal weight established on admission and 30.4 lbs. less than Resident 13's last previous admission weight. The RD stated it was not appropriate for Resident 13 to lose that much weight but that she did not want Resident 13 to gain any weight. Cross reference to F657.

Based on observation, interview, and clinical record review, the facility failed to provide the necessary treatment and services to prevent the development of a pressure sore for one of 12 sampled residents (Resident 5). Resident 5 was admitted to the facility without pressure sores. He developed a Stage I (intact skin with persistent redness) pressure sore to the right heel which deteriorated to an unstageable (full thickness tissue loss obscured by yellow slough dead tissue) pressure sore. Resident 5 resided in the facility approximately 45 days before the pressure sore developed. There was no documented evidence the facility implemented preventative measures/interventions and followed the physician's orders [REDACTED]. Findings: Review of the facility's P&P titled Skin Protocol/Wound Program (undated) showed the facility will identify residents with a potential for skin breakdown and provide appropriate treatment and interventions for residents with impaired skin integrity. On 8/27/14, LVN 2 identified Resident 5 to have an unstageable pressure sore to his right heel. LVN 2 stated Resident 5's pressure sore was being treated by an outpatient wound care clinic weekly. Clinical record review for Resident 5 was initiated on 8/27/14. Resident 5 was admitted to the facility on [DATE], with status [REDACTED]. Review of the physician's Transfer orders from the acute care hospital dated 11/21/13, showed Resident 5 had a right hip surgery on 11/18/13. The resident required assistance with turning side to side every two hours and to provide preventative skin care "lotion to heels twice a day, keep heels off mattress." Review of the Admission Nursing Evaluation form dated 11/21/13, showed Resident 5 was status [REDACTED]. The resident required assistance with bed mobility and transfers. There was no documentation the resident had any rednesses or pressure sores to his heels. Review of MDS (standardized assessment tool) dated 11/28/13, showed Resident 5 was alert and able to make his needs known. He required extensive assistance of two persons for bed mobility, transfers, and toileting. He was non-ambulatory and dependent on staff for bathing. Staff identified Resident 5 to be at risk for developing pressure sores. A care plan problem dated 11/21/13, showed Resident 5 was at risk for skin break down and pressure sore development due to status [REDACTED]. However, review of the care plan approaches failed to show any specific interventions to address relieving/preventing pressure to the resident's heels, which was included in the physician's Transfer order from the acute hospital. On 12/11/13, staff added the resident had decreased sensation to the right lower extremity; however, there were no approaches to address this. On 1/6/14, a low air loss mattress was added to the approaches, and some time after 1/6/14, staff added "off load heels." Review of the Physical Therapy Plan of Care dated 11/22/13, showed Resident 5's bed mobility for rolling side to side was "maximum assistance" with two people. Review of the Physical Therapy Discharge Summary dated 12/20/13, showed Resident 5 was able to safely transition from a supine (lying) position into a sitting position with minimal assistance "with the use of a bed rail, trapeze bar and verbal cues, otherwise he required moderate to maximum assistance." Further review showed Resident 5 could not transition from a sitting position to standing position due to being too weak, and he could only stand with the use of a front-wheel walker for 30 to 60 seconds with maximum assistance of two people. Review of the Nutrition Risk assessment dated [DATE], showed Resident 5 was at risk for unintended weight loss and skin breakdown due to his decreased mobility. Resident 5's weight on admission was 222.3 pounds. Review of the RD's note dated 12/23/13, showed Resident 5's current weight was 208.5 pounds. A care plan problem dated 12/9/13, showed Resident 5 required extensive assistance with ADLs, including bed mobility, transfers, and was non-ambulatory. Review of the laboratory report dated 12/18/13, showed Resident 5's [MEDICATION NAME] level was 3.0 (normal = 3.5 to 5.7), and his total protein level was 5.7 (normal = 6.4 to 8.9). [MEDICATION NAME] and total protein levels are indicators of the amount of protein in the blood and can identify nutritional problems as well as help with tissue growth and healing. Review of the Nutrition Care Progress Notes dated 12/23/13, showed the RD identified Resident 5 was intentionally refusing to eat his lunch in order to lose weight. The RD discussed weight loss concerns with the resident and agreed to change his lunch to small portions. However, there was no documentation to show the RD had reviewed the resident's low [MEDICATION NAME] or protein lab results dated 12/18/13. Review of the Nurse's Notes from 12/17/13 through 1/2/14, showed no documented evidence of any information about the resident's skin or any preventive measures used to off-load the heels to prevent development of pressure sores for Resident 5. Review of the Weekly Summary dated 1/3/14, showed Resident 5's right heel was noted to be red and blanchable. Review of the Skin Integrity Sheet dated 1/4/14, showed Resident 1 was identified to have a Stage I pressure sore to his right heel, measuring 5.5 cm x 9.0 cm. Staff described the area as "skin intact, firm, red, maroon color, resident reports decreased sensation." Staff documented to keep heels floating and provide good skin care. Review of the Nurse's Note dated 1/4/14 at 0832 hours, showed staff documented a new order was obtained for the right heel pressure sore: "Heels kept floating from pressure." A short-term care plan problem dated 1/4/14, for right heel pressure sore showed to off-load the resident's heels. However, review of the care plan approaches failed to show specific pressure-relieved devices to be utilized to relieve pressure from the resident's heels and prevent the Stage I pressure sore on the right heel from deteriorating. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Skin Integrity Sheet dated 1/6/14, showed Resident 1's right heel was documented as "suspected DTI" (deep tissue injury), measuring 6.0 cm x 10.5 cm. Skin was intact and soft, nonblanchable, and gray/brown with maroon color. Surrounding tissue was warm, intact, and blanchable. Staff documented to use "heel protectors, float heels at all times, waiting for APP (low air loss) mattress, wound consult ordered." Not unitl 1/7/14, review of the Nutrition Alert Initial Review and Assessment form showed the RD added Med Pass (nutritional supplement) 30 ml three times a day, vitamin C, and multiple vitamins to promote wound healing. Review of the Nurse's Notes and Weekly Summary forms for Resident 5 from 1/4/14 through 1/9/14, showed no documented evidence staff were floating the resident's heels as ordered to keep pressure off the heels and prevent the right heel pressure sore from deteriorating. Review of the Skin Integrity Sheet dated 1/10/14, showed the right heel had deteriorated to an "unstageable" pressure sore. Staff documented "sharp debridement (removal of dead or infected tissue) done at an outpatient wound care center. Review of the physician's orders [REDACTED]. The Physician's Progress Notes form from the outpatient wound care center showed on 1/10/14, Resident 5 had an unstageable right heel pressure sore, requiring sharp debridement with a large amount of serosanguinous (yellow/red bloody) drainage. It also showed to keep pressure off the heel at all times. Resident 5's right heel pressure sore measured 6 cm x 9 cm, "blister" with 1 cm x 2 cm "open" area with large amount of drainage. The treatment note dated 9/18/14, from the outpatient wound care center showed Resident 5's right heel continued to have sharp debridement done. The wound measured "0.2 cm x 0.15 cm x 0.2 cm width and depth decreasing, red base with scant serous (thin, clear) drainage. To continue treatments one time a week till debrided and closed. PT (patient) will continue to be vigilant in keeping pressure off heel." On 8/28/14 at 1445 hours, Resident 5 was observed in bed with a heel protector (a soft padded heel cushion) applied to his right heel which was resting directly on the mattress. His left heel was resting on the mattress and had no heel protector on. Resident 5 was asked if he was able to reposition himself in bed. He stated he could not turn without the assistance from staff. On 8/29/14 at 0800 hours, an interview was conducted with the RD. The RD was asked if any dietary recommendations were put in place when Resident 5 was identified to have low [MEDICATION NAME] and protein levels. The RD stated he did not look at the [MEDICATION NAME] level, he only looked at the total protein level. The RD further stated he did not remember reviewing the laboratory results dated [DATE]. On 8/29/14 at 0840 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 5 required help with repositioning in bed. CNA 6 stated she would reposition the resident every two hours. When asked where she documented repositioning of the resident, she stated she did not document it. On 8/29/14 at 0915 hours, an interview and concurrent clinical record review was conducted with LVN 2. LVN 2 stated Resident 5 was heavy and had poor motivation. LVN 2 verified Resident 5's plan of care identified his impaired mobility and interventions to assist the resident with repositioning every two hours and conduct weekly skin assessments. LVN 2 confirmed there was no documented intervention to address pressure relief for the resident's heels until after the resident heel pressure sore developed. When asked where staff documented their weekly skin assessments, LVN 2 stated in the licensed nurse Weekly Summary notes. Review of the Weekly Summary notes showed an area where staff were to document resident's "skin conditions," including current skin problems, surgical wounds, pressure relieving devices, turning and repositioning, and nutritional interventions. Review of Resident 5's Weekly Summary forms from 11/27/13 through 1/3/14, found these areas were blank. On 8/29/14 at 1015 hours, an interview was conducted with PT 1. PT 1 verified she evaluated Resident 5. She stated Resident 5 had a problem with strength and was unable to turn in bed without staff assistance.