Every finding on record at Sierra View Homes

Based on interview record review, the facility failed to have a qualified, full-time certified dietary manager (CDM) for oversight of the Food and Nutrition Services.This failure had the potential of compromising the safety and nutritional status of residents through potential transmission of foodborne illnesses (illness that comes from eating contaminated food) and decreased quality of food for 52 of 52 residents who received food from the kitchen and could negatively affect the resident's quality of life and health.Findings:During an interview on 2/5/26 at 3:40 p.m. with Dietary Supervisor (DS) 1, DS 1 stated the CDM was on leave until 4/25. DS 1 stated the Registered Dietician (RD) came to the facility for eight hours a week. DS 1 stated, We [ DS 1 and DS 2] are covering for her [CDM]. DS 1 stated DS 2 was going to school to obtain his CDM certification.During an observation and interview on 2/9/25 at 10:59 a.m. with DS 2, DS 2 stated he was covering the CDM position. DS 2 stated he was responsible for in-services for the kitchen staff. DS 2 stated he was responsible for making sure the dietary staff were trained and competent in performing their job. DS 2 stated residents could have gotten sick and could have gotten cross-contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and food borne illnesses without proper training. During a record review of the facility's CDM leave document untitled, dated 12/12/25, the document indicated the CDM should have returned from leave on 1/5/26.During a record review of the facility's CDM leave document untitled, dated 1/5/26, the document indicated the CDM should have returned from leave on 4/7/26.During a record review of the DS 2's Certification, undated, the Certification indicated DS 2 had one certificate for Food Protection Manager Certification. No CDM certificate was provided.During a record review of DS 1's Certification, undated, the Certification indicated DS 1 was certified for California food handler and food protection manager. No CDM certification was provided.During an interview on 2/9/25 at 3:17 p.m. with the RD, the RD stated she came in one time a week on average for eight hours. The RD stated she was available on the phone. The RD stated DS 2 was covering for the CDM. The RD stated she spoke with DS 2 about residents' therapeutic diet (a specialized, medically prescribed meal plan that modifies a regular diet by adjusting nutrients, calories, or texture to treat or manage specific diseases, conditions, or intolerances) and looked at his quarterly (three months) notes. The RD stated DS 2 was providing the kitchen staff in-services. The RD stated it was important that the CDM had adequate training and certification to ensure ongoing training was done to prevent potential for cross-contamination and foodborne illness.During an interview on 2/11/26 at 12:15 p.m. with the Administrator (ADM), the ADM stated the facility had a full-time CDM and the CDM was out on leave since 12/25. The CDM stated DS 2 was filling the CDM role until the CDM return date of 4/26. The ADM stated the RD was in the facility for eight hours a week and available on call when needed. The ADM stated the RD was supposed to supervise the kitchen staff. The ADM stated DS 2 was getting his education and would be done with school by 4/26. The ADM stated DS 2 could have contacted the RD when needed. The ADM stated it was important to have a CDM on site to ensure things were checked, accomplished and followed through. The ADM stated residents could have gotten sick when there was no one supervising the kitchen staff.During a review of the facility's job description titled Food & Nutritional Manager, undated, the job description indicated, Maintain employee competency of all kitchen staff .Qualifications: 1. Be a certified dietary Manager having met eligibility requirements for food, and passed a nationally recognized credentialing examination, Maintain a current Certified Dietary Manager Certificate. During a review of the California Code, Health and Safety Code - HSC S 1265.4, the HSC indicated, A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b). to supervise dietetic service operations.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed for 52 of 52 residents when:1. Two bags of cabbage with a used by dated 2/2/26, a bag of celery with a used by date of 1/30/26 and a bag of daikon with a used by date of 2/2/26 were stored on the shelves next to other produce in the walk-in refrigerator.2. Two cartons of apple cobbler with a received date of 7/22/25 with no used by date were on the top self in a freezer.3. Two packs of unlabeled cooked chicken with no pulled-out date and used by date were on a tray next to the deli ham in refrigerator 3.4. Black and pink substances inside and white substances were found outside the ice machine.5. One staff member stored their lunch bag inside the resident refrigerator.These failures had the potential risk of cross contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) from improperly stored and labeled food and could cause foodborne illness ( illness that comes from eating contaminated food) to 55 of 55 residents.6. The Resident's food refrigerator at the west wing nursing station was not within the recommended temperature.This failure placed residents at risk of consuming food which was not within the recommended temperatures which could lead to gastrointestinal illness (illness that affects the digestive system [GI tact] which runs from mouth to anus) and serious health conditions. Findings: 1. During a concurrent observation and interview on 2/4/26 at 1:46 p.m. with Dietary Supervisor (DS) 1, in the walk in produce refrigerator Two bags of cabbage with a used by dated 2/2/26, a bag of celery with a used by date of 1/30/26 and a bag of daikon with a used by date of 2/2/26 were stored on the shelves next to other produce in the walk-in refrigerator. DS 1 stated the items should have been tossed by the used by dates. During an interview on 2/9/26 at10:14 a.m. with Dietary Aide (DA) 2, DA 2 stated, I take care of stocking and delivery. DA 2 stated It is everyone's job to look through the refrigerator and freezer to check expired items. DA 2 stated expired items were no longer edible and were a safety hazard. DA 2 stated items past the used by dates could have caused residents to have foodborne illness. DA 2 stated storing items past the used by date could have caused cross-contamination with other products. During an interview on 2/9/26 at10:28 a.m. with DS 2, DS 2 stated the two bags of cabbage, a bag of celery and daikon should have been caught and discarded on their used by date. DS 2 stated the kitchen staff were responsible for ensuring it was thrown away at the time of their used by date. DS 2 stated the items could have been served to residents. DS 2 stated residents could have gotten foodborne illness. DS 2 stated residents could have gotten sick and hospitalized when consuming items past their used by date. During an interview on 2/9/26 at 3:27 p.m. with the Registered Dietician (RD), the RD stated the items should have been discarded by the used by date. The RD stated residents could have gotten foodborne illness from consuming food past their used by date. The RD stated used by items could have caused cross-contamination when stored with other items. The RD stated residents could have nausea, vomiting and diarrhea which could have led to hospitalization. The RD stated all kitchen staff were responsible for ensuring everything was discarded by the used by date. The RD stated the kitchen staff should have been checking it daily. The RD stated she and DS 2 were responsible for checking on the kitchen staff. During a review of the facility's policy and procedure (P&P) titled, Storage, rotation and discard of food and beverage items from dietary department to skilled nursing unit, dated 8/10/16, the P&P indicated, All food and beverage brought into the facility for resident consumption be labeled and dated for monitoring of food safety.Food or beverages past the manufacture expiration date will be discard immediately by designated facility staff. 2. During a concurrent observation and interview on 2/4/26 at 2:05 p.m. with DS 1, two cartons of apple cobbler pie with a received dated 7/22/25 with no used by date were on the top self in freezer 4. DS 1 stated the apple cobbler pies was past the expiration date and should have been thrown away. During an interview on 2/9/26 at 10:41 a.m. with DS 2, DS 2 stated Our staff should have caught it [items past their used by date]. DS 2 stated DA 2 should have gone through the freezer during inventory and tossed it. DS 2 stated residents could have gotten sick from foodborne illness when they consumed food past the used by date. DS 2 stated residents could have diarrhea, vomiting and other issues which could have led to hospitalization after consuming food past the used by date. During an interview on 2/9/26 at 3:53 p.m. with the RD, the RD stated items should have been tossed by the used by date. The RD stated residents who consumed items past the used by date had the potential for foodborne illness. The RD stated residents with foodborne illness could have been hospitalized . The RD stated residents could have diarrhea, nausea and vomiting and other stomach issues from consuming food past the used by date. The RD stated the certified dietary manager, DS 1 and DS 2 should have been responsible for ensuring all kitchen staff were responsible in discarding items past the used by date and it should have been done daily. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection control, dated 2023, the P&P indicated, 10. Refer to the suggested Freezer Storage guidelines for recommended storage time of food items.Baked Goods.Fruit pies, baked or unbaked.3 months. 3. During a concurrent observation and interview on 2/4/26 at 2:20 p.m. with DS 1, in refrigerator 3, two packs of unlabeled cooked chicken with no pulled-out date and used by date were on a tray next to the deli ham. DS 1 stated the bags were cooked chicken meat and should have been labeled with a pulled-out date and a used by date. During an interview on 2/9/26 at 10:54 a.m. with DS 2, DS 2 stated the two packs of cooked chicken should have been labeled with a pulled-out date and used by date. DS 2 stated it was important to ensure things were labeled for timeline and food safety. DS 2 stated resident could have gotten diarrhea, nausea and vomiting from consuming food past the used by date. DS 2 stated resident could have foodborne illness. DS 2 stated residents could have been hospitalized from foodborne illness. During an interview on 2/9/25 at 3:59 with the RD, the RD stated the cook chicken should have been labeled with a pulled-out date and used by date. The RD stated residents could have food born illness from consuming items past the used by date. The RD stated it was important for items to be labeled to ensure it was safe to consume. The RD stated there was potential for items to be served past the used by date. The RD stated residents could have diarrhea, vomiting and diarrhea from consuming food. The RD stated the facility did not follow their policy and procedure. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, 11.All meat.placed in the refrigerator for thawing must be labeled.with pull by date and used by date. 4. During an observation and interview on 2/5/26 at 10:10 a.m. with the Maintenance Supervisor/Operational Manager (MNT), the ice machine had black and pink substances inside and white substances was found outside. The MNT stated the ice machine should not have black and pink substances inside and white substances outside. The MNT stated it was unacceptable to have black and pink substances inside the ice and white substances outside the ice. The MNT stated MAINT 1 was responsible for cleaning the ice machine monthly. During an interview on 2/9/26 at 4:23 p.m. with the RD, the RD stated the ice machine should have been cleaned properly to prevent cross-contamination. The RD stated not cleaning the ice machine could have caused pathogens (mold, virus and bacteria) to grow. The RD stated, It is important to make sure they are removing pathogen and bacterial from the ice. The RD stated, Resident could have gotten foodborne illness and gotten nausea, vomiting, diarrhea and other gastrointestinal (GI- conditions affecting the digestive tract, including the stomach, intestines, liver, and gallbladder, ranging from mild discomfort to chronic diseases) issues and could have cause hospitalization. During an interview on 2/10/26 at 11:40 a.m. with the MNT, the MNT stated MAINT 1 should have followed the manufacturer's guidelines for cleaning the ice machine. The MNT stated MAINT 1 was responsible for cleaning the ice machine. The MNT stated not cleaning the ice machine could have caused cross-contamination of ice. The MNT stated everyone who consumed ice from the ice machine could have gotten foodborne illness. The MNT stated cross-contaminated ice could have put everyone at risk for being hospitalized . The MNT stated it was not acceptable for the ice machine to have black particles and pink substances inside the ice machine and it should have been cleaned thoroughly. During an interview and record review on 2/11/26 at 12:36 p.m. with the Administrator (ADM), the ADM was shown photos of the black and pink substance inside the ice-machine. The ADM stated the maintenance staff should have cleaned and sanitized the ice-machine. The ADM stated the ice machine should be cleaned and sanitized to prevent ice from being cross-contaminated. The ADM stated there could have been potential chance of sickness from cross-contamination and hospitalization of residents from consuming ice from the ice-machine. During a review of the facility's P&P titled, The importance on Maintaining a Ice Machine, dated, the P&P indicated, Maintaining commercial ice machines in California is crucial for compliance with strict state health codes.to prevent bacterial/mold, growth.California health and Safety Codes regulate ice as foodborne illness. 5. During a concurrent observation and interview on 2/5/26 at 2:25 p.m. in the east dining room with DS 2, one staff member's lunch was stored in the resident refrigerator. DS 2 stated staff member's lunch should not be stored in the residents' refrigerator, and it could have caused cross-contamination into the residents' food. DS 2 stated residents' food could be cross-contaminated when it was stored with food items that came from unknown places. DS 2 stated residents could have gotten foodborne illness if they consumed cross-contaminated food. DS 2 stated residents could have eaten food that was not ordered for their therapeutic diet (specialized, medically prescribed meal plan that modifies a regular diet by adjusting nutrients, calories, or texture to treat or manage specific diseases, conditions, or intolerances) causing harm such as choking or other health related issues. DS 2 stated dietary staff were responsible for ensuring the residents' refrigerator was cleaned. During an interview on 2/5/26 at 2:31 p.m. with Certified Nurse Assistant (CNA) 6, CNA 6 stated, It was my lunch bag. It was in the east dining room refrigerator. CNA 6 stated her lunch bag should have been in the break room. CNA 6 stated, I was working alone and I put it in there and I should have not put it in there. CNA 6 stated, The refrigerator is strictly for resident, and the residents could have gotten a hold of it. CNA 6 stated residents could have gotten harmed when consuming food from the lunch bag. CNA 6 stated residents could have choked on the food and the items in the lunch bag and the food could have been against their diet. CNA 6 stated she was trained to not put her lunch in the resident refrigerator last year. During an interview on 2/9/26 at 4:20 p.m. with the RD, the RD stated it was not okay to store employee lunch in the resident refrigerator. The RD stated it could have caused cross-contamination and was not sanitary. The RD stated residents could have foodborne illness and infections. The RD stated residents could have choking hazards, foodborne illness and food allergies to the items in the lunch bag. The RD stated residents were at risk for GI upset, vomiting, diarrhea, hospitalization, and death. During an interview on 2/11/26 at 12:45 p.m. with the ADM, the ADM stated staff should not be storing food in the resident refrigerator The ADM stated there could be cross-contamination from the employee lunch bag. The ADM stated staff did not follow our policy and procedure. During a review of the facility's policy and procedures (P&P) titled, Resident Refrigerator and Outside food Storage, updated 2/11/26, the P&P indicated, It is the policy of the facility to maintain resident refrigerators in a manner that ensures food safety, infection control, and regulatory compliance. To reduce the risk of foodborne illness, only approved food items from authorized sources may be stored in resident refrigerators.Staff are strictly prohibited from storing personal food or beverages in resident refrigerators. 6. During a concurrent observation, interview, and record review on 2/6/26 at 11:03 a.m. in the west wing nursing station, with Licensed Vocational Nurse (LVN) 4, a black refrigerator had food stored in it and the refrigerator temperature was 32 degrees Fahrenheit ( degrees F- a scale for measuring temperature). There was a temperature guide displayed on the side of the refrigerator. The temperature guide was reviewed with LVN 4. The temperature guide indicated . At 32 degrees F and below, the food in your refrigerator will start to freeze. Keep your refrigerator temperature above 32 degrees F to avoid this, and if you want anything frozen, put it in the freezer which should be kept below 0 degrees F. During a concurrent interview and record review on 2/6/26 at 11:10 a.m. with LVN 4, the facility's Temperature Log, dated November 2025, December 2025, January 2026 was reviewed. The temperature log indicated in the month of January 2026, the log was not completed 14 out of 31 times on the morning (AM) shift and the temperature was at 32 degrees F and below 11 times out of 17 recorded entries on the AM shift, the log was not completed 9 out of 31 times on the afternoon (PM) shift and the temperature was at 32 degrees F and below 10 times out of 22 recorded entry on the PM shift, and the log was not completed 1 out of 31 times on the night (NOC) shift and the temperature was at 32 degrees F and below 26 times out of 30 recorded entries on the NOC shift. The temperature log indicated in the month of December 2025, the log was not completed 7 out of 31 times on the AM shift and the temperature was at 32 degrees F and below 18 times out of 24 recorded entries on the AM shift, the log was not completed 5 out of 31 times on the PM shift and the temperature was at 32 degrees F and below 19 time out of 26 recorded entries on the PM shift, and the log was not completed 2 out of 31 times on the NOC shift and the temperature was at 32 degrees F and below 26 times out of 29 recorded entries on the NOC shift. The temperature log indicated in the month of November 2025, the log was not completed 7 out of 31 times on the AM shift and the temperature was at 32 degrees F and below 17 times out of 24 recorded entries on the AM shift, the log was not completed 1 out of 30 times on the PM shift and the temperature was at 32 degrees F and below 18 time out of 29 recorded entries on the PM shift, and the log was completed on the NOC shift and the temperature was at 32 degrees F and below 22 times out of 30 recorded entries on the NOC shift. LVN 4 stated the refrigerator was used to store residents' food and snacks. LVN 4 stated temperatures should be checked every day. LVN 4 stated checking the refrigerator was important to ensure the temperature of the refrigerator was in the ideal range. LVN 4 stated not checking the refrigerator temperature could lead to the refrigerator getting too hot or too cold and that could lead to spoiling of food. LVN 4 stated if food was not stored properly, residents could get sick. LVN 4 stated the temperature logs should have been completed. During an observation on 2/9/26 at 4:18 p.m. at the west wing nursing station refrigerator, the refrigerator temperature was 24 degrees F. During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), the pictures of the thermometer (an instrument used to measure how hot or cold something is[temperature]) in the west wing nursing station refrigerator and the temperature logs for the refrigerator, undated were reviewed. The DSD stated and validated the temperature of the refrigerator was 24 degrees F which indicated freezing zone. The DSD stated the food should be discarded. The DSD stated the refrigerator should be adjusted and corrected. The DSD stated this was important because it could cause damage to the residents and there could be adverse outcomes. The DSD stated the refrigerator log blanks should have been filled in. The DSD stated this was important because food could be harmful if not stored at the right temperature. During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), the pictures of the thermometer in the west wing nursing station refrigerator and the temperature logs for the refrigerator, undated were reviewed. The DON stated the refrigerator food guide indicated food was freezing at 24 degrees F. The DON stated the expectation from the facility staff was that the refrigerator should have been at the appropriate temperature of 35 degrees F- 40 degrees F. The DON stated this was important to make sure there was no bacteria or frozen foods. The DON stated the failure could result in food spoilage, bacterial growth or compromised food safety. The DON stated the log was incomplete. The DON stated the facility policy states the night shift should monitor the temperatures. The DON stated it was important to maintain proper temperature of the refrigerators, otherwise there could be spoiled items or frozen items. During a review of facility's document titled, The right temperature for your refrigerator and freezer, dated 6/26/25, the document indicated, Refrigerator temperature guide- Above 40 degrees - Any temperature above 40 degrees F may allow bacteria to multiply rapidly. At 40 degrees , the U.S. Food and Drug Administration says the recommended temperature is below 40 degrees F. Between 35 degrees and 38 degrees - the ideal refrigerator temperature is between 35 degrees F and 38 degrees F, below the safety threshold outlined by the FDA and above freezing. It's not uncommon for refrigerators to be a few degrees off the mark you set, so err on the side of too cold to avoid food spoiling more quickly or potential food safety issues. At 32 degrees - At 32 degrees F and below, the food in your refrigerator will start to freeze. Keep your refrigerator temperature above 32 degrees F to avoid this, and if you want anything frozen, put it in the freezer which should be kept below 0 degrees F. During a review of the facility's P&P titled, Refrigerator temperatures, dated 9/29/2009, the P&P indicated, . Purpose: to ensure that the temperatures of the refrigerator in the skilled nursing department are maintained between 36- 41 degrees at all times. Policy: the night shift chart nurse will check and document the temperature of the refrigerator located in the medication room and at the nurses station on a nightly basis to ensure temperatures are between 36-41 degrees at all times. If there is a malfunction and the temperature rises above 41 degrees for more than 1/2 hour, medications will be assessed and destroyed and replaced as needed.

Based on observation, interviews, and record review the facility failed to ensure Dietary Aide (DA) 1, DA 2 and Maintenance (MAINT) 1 were trained to carry out the functions of the food and nutrition services safely and effectively for 52 of 52 residents when:1.DA 1 did not demonstrate and DA 2 did not verbalize the proper use of a test strip (paper that measures the concentration of quaternary ammonium compounds [chemicals that kills germs on surfaces] for the sanitizing bucket (a container used to store and mix a chemical solution that reduces germs on surfaces).This failure had the potential for improper disinfection of surfaces increasing the risk of cross-contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of foodborne illnesses (a condition where a person becomes sick after consuming contaminated food or beverages. It is caused by the ingestion of harmful microorganisms, such as bacteria, viruses, parasites, or toxins), to all residents.2. MAINT 1 did not verbalize the proper cleaning procedure for the ice machine according to the manufacturer's guideline.This failure had the potential for cross- contaminated ice to be served to residents, thereby increasing the risk of foodborne illness and hospitalization of all the residents in the facility.Findings:1. During a concurrent observation and interview on 2/5/26 at 9:37 a.m. in the kitchen, DA 1 placed a test strip into a red sanitizing bucket. DA1 took out the test strip and compared the color of the strip to the bottle and DA 1 stated it was at 200 parts per million (ppm - a unit of measurement used to describe the concentration of a substance in a mixture). DA 1 stated 200 ppm was good. DA 1 stated she was responsible for preparing the sanitizing bucket. DA 1 stated, I put the test strip in the red bucket until it changes color. DA 1 stated, I put the test strip in the bucket for 1-2 seconds. DA 1 stated she had an in-service last week on sanitizing. DA 1 stated it was important to properly test the sanitizing solution to ensure the solution was within range. DA 1 stated the solution in the bucket was used to clean the germs on the kitchen surface. DA 1 stated residents could have gotten sick from cross-contamination and infections.During an interview on 2/9/26 at 10:14 a.m. with DA 2, DA 2 stated he was responsible for testing the sanitizing solution. DA 2 stated he rinsed the sanitizing bucket, obtained the sanitation solution from the dispensary and checked the solution with the test strip. DA 2 stated, I usually put in the strip, and it turns out right away. DA 2 stated the strip will turn to a different color instantly and he would have compared it to the bottle. DA 2 stated the ranges for the test should have been at 200 ppm. DA 2 stated inaccurate testing of the sanitizing solution could cause pathogens to grow. DA 2 stated not having the sanitizing solution in the appropriate ranges could have caused cross-contamination when surfaces were not cleaned properly. DA 2 stated, We touched base on it last week. DA 2 stated residents could have been hospitalized and died from food borne illness and cross-contamination.During an observation and interview on 2/9/25 at 10:59 a.m. with Dietary Supervisor (DS) 2, DS 2 stated he was unsure how long the strip should be in the sanitizing solution. DS 2 went to look at the policy and procedure binder. DS 2 stated DA 1 and DA 2 should have left the test strip in the solution for 10 seconds to ensure the strip was in the solution for accurate reading. DS 2 stated DA 1 and DA 2 were not competent in their training and needed more training. DS 2 stated he was responsible for making sure the dietary staff were trained and competent in performing their jobs. DS 2 stated residents could have gotten sick and could have gotten cross-contamination and food borne illness from not having kitchen surface cleaned and sanitized.During an interview on 2/9/26 at 4:15 p.m. with the Registered Dietician (RD), the RD stated DA 1 and DA 2 should have followed the instructions per manufacture or policy guidelines. The RD stated DA 1 and DA 2 were not competent in the sanitization process when they were not able to demonstrate and verbalize the correct timing. The RD stated DA 1 and DA 2 should have proper training so the facility policy could be followed. The RD stated when DA 1 and DA 2 did not test the sanitizing solution correctly, this could have caused items to not be sanitized and put residents at risk for cross-contamination from food borne illnesses. The RD stated residents could have nausea, vomiting, diarrhea and other stomach issues and could have required hospitalization. The RD stated the certified dietary supervisor, and dietary supervisor were responsible for staff training. The RD stated the certified dietary supervisor ? was responsible for ensuring the policy was being followed.During a review of the manufacture's instructions titled, [Manufacture's name] QT-40 Instructions, undated, the Manufacture's Instruction indicated, Dip paper in quat solution. for 10 seconds.During a review of the facility's policy and procedure (P&P) titled, Sanitizing equipment and surfaces with Quaternary Ammonium (QUAT) Sanitizer, dated 2023, the P&P indicated, Test the sanitizer solution by placing a sanitizing test strip in the solution. Allow the test strips to sit in the solution for 10 seconds.2 . During an observation and interview on 2/5/26 at 10:10 a.m. with the Maintenance Supervisor/Operational Manager (MNT), the ice machine had black and pink substance found inside and a white substance was found outside. The MNT stated the ice machine should not have black and pink substances inside and white substances outside. The MNT stated it was unacceptable to have black and pink substances inside the ice machine and dust outside on the ice. The MNT stated MAINT 1 was responsible for cleaning the ice machine monthly. During an interview on 2/5/26 at 10:26 a.m. with MAINT 1, MAINT 1 stated, I cleaned the ice machine monthly or every three weeks. MAINT 1 stated, I get the descaler [a cleaning solution used to removed lime scale and mineral deposit] chemical and put 1 tablespoon into the tray [area where cleaning solution goes for cleaning] and let it run through the cycle. MAINT 1 stated he took ice machine components apart and sprayed the front and the probe with a descaling solution mixed with two bottle caps [cap from the bottle of the descaling solution] of descaler mixed with 10 ounces (unit of measurement) of hot water. MAINT 1 stated he soaked the ice machine components for one minute and washed it off using a solution made with two caps full of sanitizing solution mixed with water. MAINT 1 stated he mixed two bottle caps of sanitizing solution with eight ounces of hot water and used the solution to clean the inside and outside of the ice machine. MAINT stated he was trained to clean the ice machine by an employee who was no longer working at the facility.During an interview on 2/9/26 at 4:23 p.m. with the RD, the RD stated, The person who is servicing [ice-machine] should be competent in knowing what they are doing. The RD state, The ice machine should be cleaned according to the manufacturer's guideline, The RD stated the ice machine should have been cleaned properly to prevent cross-contamination. The RD stated not cleaning the ice machine by manufacturer's guidelines could have caused pathogens (mold, virus and bacteria) to grow. The RD stated, It is important to make sure they are removing pathogen and bacterial from the ice. The RD stated, Resident could have gotten foodborne illness and gotten nausea, vomiting, diarrhea and other gastrointestinal (GI) issues and could have cause hospitalization. The RD stated she was not sure who trained and supervised MAINT 1.During an interview on 2/10/26 at 11:40 a.m. with the MNT, the MNT stated MAINT 1 was trained by an employee that was no longer with the facility. The MNT stated MAINT 1 should have followed the manufacturer's guidelines for cleaning the ice machine. The MNT stated MAINT 1 was not competent and needed to be retrained. The MNT stated MAINT 1 was responsible for cleaning the ice machine. The MNT stated not cleaning the ice machine according to the manufacturer's guidelines could have caused cross-contamination to the ice. The MNT stated everyone who consumed ice from the ice machine could have gotten foodborne illness. The MS stated cross-contaminated ice could have put everyone at risk for being hospitalized . The MNT stated it was not acceptable for the ice machine to have black particles, pink substance inside the ice machine and it should have been cleaned thoroughly. During an interview and record review on 2/11/26 at 12:36 p.m. with the Administrator (ADM) the ADM was shown photos of the black and pink substance inside the ice-machine. The ADM stated maintenance staff should have cleaned and sanitized the ice-machine. The ADM stated the ice machine should be cleaned and sanitized to prevent ice from being cross-contaminated. The ADM stated there could have been potential chance of sickness from cross-contamination and hospitalization from the ice-machine. The ADM stated MAINT 1 needed more training on cleaning the ice-machine and following the manufacturer's guidelines.During a review of the facility's In-Service titled, The Importance on Maintaining the Ice Machine, dated 7/31/25, the in-service indicated, It's important we follow the guideline of the manufacture step by step on sanitizing and cleaning. During a review of the facility's manufacturer's operation instruction titled, No title undated, the manufacturer's operation instruction indicated, .mix a solution of cleaner warm luke warm water depending upon the amount of mineral buildup.use ratio in the table below to mix enough solution to thoroughly clean all parts.cleaner.1 [gallon-units of measurement] 16 ounces (oz-unit of measurement) cleaner.use 1/2 of the cleaner/water mixture to clean all components.soak part for 5 minutes (15-20 minutes for heavily scaled parts). While components are soaking, use half descaler and water solution to clean all food zone surfaces of the ice machine and bin.Mix a solution of sanitizer with warm water. Solution type: sanitizer. Water: 3 gal (gallon-unit of measurement) Mixed with: 2 oz (60 ml (milliliter- a unit used to measure capacity) .

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for three of eight sampled residents (Resident 9, Resident 11, and Resident 49) when:1. Resident 9 was on Droplet Precautions (infection control measures designed to prevent the spread of germs (viruses/bacteria) transmitted through large respiratory droplets created by coughing, sneezing, or talking that usually travel short distances (less than 6 feet) and facility staff did not put on appropriate Personal Protective Equipment (PPE- wearable gear and clothing designed to protect individuals from workplace injuries, illnesses, and infections) when entering Resident 9's room.2. A urinal (a portable, handheld, or bedside container used by patients to receive urine) was seen on Resident 11's dresser close to Resident 11's water pitcher.3. Resident 49's nasal cannula (a lightweight, flexible device used to deliver supplemental oxygen or increased airflow to a person's respiratory system) tube was found on the floor.These failures placed residents, staff, and visitors at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings: 1. During an observation on 2/4/2026 at 3:35 p.m. during the initial tour outside Resident 9's room, there was a droplet precaution sign with instructions outside the room door and Resident 9 was in the room, observed to be dressed and lying in bed with his eyes closed. The droplet precaution signage indicated . clean hands including entering . make sure their eyes, nose and mouth are fully covered before room entry . remove face protection before room exit. During a review of Resident 9's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 9 was admitted to the facility from an assisted living /board and care/group home on [DATE] with diagnoses which include . Acute and chronic respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epileptic seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that disrupts normal function), bipolar disorder (chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from high-energy manic episodes to low-energy depressive episodes), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) . During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/8/26, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS score indicated Resident 9 had severe cognitive impairment. During an observation on 2/4/26 at 3:38 p.m., Certified Nursing Assistant (CNA) 1 and CNA 4, entered Resident 9's room with a surgical mask but no goggles. During an interview on 2/4/26 at 3:39 p.m. with CNA 4, CNA 4 stated, Droplet precautions required masks, goggles, gloves, and gowns. CNA 4 stated before facility staff went into Resident 9's room, facility staff should sanitize and put on PPE. CNA 4 stated this was important, so facility staff did not get sick or bring it out and get everybody else sick. CNA 4 stated, If everybody got sick, there could be an outbreak. During an observation on 2/4/26 at 3:57 p.m. Registered Nurse (RN) 1 entered Resident 9's room with a mask but no goggles. During an observation on 2/4/26 at 4:05 p.m., the Social Services Director (SSD) and Maintenance Supervisor (MNT), entered Resident 9's room with a mask but no goggles. During an interview on 2/4/26 at 4:42 p.m. with CNA 1, CNA 1 stated droplet precaution meant gown, mask, gloves and goggles should be worn. CNA 1 stated she did not use her goggles. CNA 1 stated she should have been using the goggles as it was important for her safety. CNA stated failure to use goggles could potentially lead to a spread around of the infection During an interview on 2/9/26 at 3:57 p.m. with the Infection Preventionist (IP), the IP stated the expectation from facility staff was that anyone going into Resident 9's room should wear a mask and goggles. The IP stated when providing close care, the expectation from facility staff was that anyone going into the room should have a mask, gloves, goggles, and gown. The IP stated the CNAs, the RN, the SSD, and the MNT did not use their goggles, and they did not follow the droplet precaution policy. The IP stated it was important to follow the policy to protect themselves and others. The IP stated this could lead to the spread of infection or whatever illness Resident 9 had. During an interview on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), the DSD stated the expectation from facility staff regarding droplet precautions was to put on the mask and goggles outside the room. The DSD stated if there was close contact, gloves and gown should also be worn. The DSD stated this was important to protect the facility staff from getting droplets into their eyes, ears, nose, or mouth and to protect them from getting sick. The DSD stated the potential outcome could be the facility staff got sick and spread the infection. During an interview on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the expectation from facility staff was to follow protocol and wear the proper PPE for the proper precaution. The DON stated this was important so that the facility staff did not continue to cross contaminate or spread the infection. The DON stated the potential outcome was that facility staff would risk spreading the infection. During a review of the facility's document titled, Job Description, Infection Preventionist IP Nurse, dated 12/29/2025, the document indicated, . Responsible for the facility infection prevention and control program (IPCP), which is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (infectious illnesses caused by bacteria, viruses, parasites, or fungi, spreading directly or indirectly between people, animals, or contaminated environments ) and infection. Oversights of the IPCP which includes . Ensure that local state federal and [OSHA- Occupational Safety and Health Administration] standard and transmission based precautions are to be followed to prevent spread of infection: when and how infections should be used for resident; including the type and duration of the isolation . Assess the need for, develop, and present IPCP in service education for individual departments . During a review of the facility's policy and procedure (P&P) titled, Infection prevention and control program, dated 10/30/2024, the P&P indicated, . Policy: An infection prevention and control program (IPCP) is to be established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases an infection. The IPCP is coordinated and overseen by an infection prevention specialist (infection preventionist) . a. policies and procedures are cornerstone of the IPCP. b. policy and procedures reflect the current infection prevention and control standards of practice. Important facets of infection prevention include . Educating staff and ensuring that they adhere to proper techniques and procedures. 2. During an observation on 2/4/2026 at 3:35 p.m. in Resident 11's room, Resident 11 was observed dressed, lying in bed, and unable to respond appropriately to questions asked. A urinal was noted to be on Resident 11's dresser close to Resident 11's water pitcher. During a review of Resident 11's AR, dated 2/11/26, the AR indicated Resident 11 was admitted to the facility from acute care hospital on 6/22/25 with diagnoses which include . essential hypertension (high blood pressure that has no single, identifiable medical cause), gastroesophageal reflux disease (condition where stomach acid frequently flows back into the tube connecting the mouth and stomach [esophagus]), varicose veins (swollen, twisted, and enlarged veins that usually appear blue or dark purple just under the skin's surface, most commonly in the legs) of unspecified lower extremity with ulcer of unspecified sites, alcoholic cirrhosis of liver with ascites (a severe, advanced stage of liver disease caused by long-term alcohol abuse), venous insufficiency (condition where leg vein valves are damaged or weakened, preventing blood from flowing efficiently back to the heart), anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life) . During a review of Resident 11's MDS, dated [DATE], the MDS section C indicated Resident 11 had a BIMS score of 07, which indicated Resident 11 had severe cognitive impairment. During a review of Resident 11's MDS assessment section GG Functional Abilities, dated 12/22/25, the MDS indicated Resident 11's functional abilities were coded between 01, 02, and 88. Resident 11 was code 01 (dependent: helper does all the effort; resident does none of the effort to complete self-care) for shower/bath self. Resident 11 was code 02 (substantial/ maximal assistance: helper does more than half the effort) for oral hygiene, toilet hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, lying-to-sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 11 was code 88 (not attempted due to medical condition or safety concerns) for sit to stand. The functional abilities code indicated Resident 11 needed substantial/ maximal assistance in 10 abilities, was dependent on facility staff in 1 ability and 1 ability was not attempted due to Resident 11's medical condition or safety concerns. During a review of Resident 11's MDS assessment, dated 12/22/25, the MDS section H indicated Resident 11's Bladder and Bowel function included Resident 11 was occasionally (less than 7 episodes of incontinence) for urinary continence (the inability to control when you urinate or have a bowel movement). Resident 11 was frequently incontinent (2 or more episodes of continence bowel movement) for bowel continence. During a concurrent observation and interview on 2/4/26 at 3:38 p.m. with CNA 4, Resident 11's urinal was seen on the dresser close to the water pitcher. CNA 4 stated Resident 11 could get up and go to the bathroom but if Resident 11 did not want to get up, he could use the urinal. CNA 4 stated the urinal should not be on the dresser. CNA 4 stated the urinal should be by the bedside so Resident 11 could reach it. CNA 4 stated this was important because if the urinal was full, it could spill and there could be cross contamination with the water. CNA 4 stated Resident 11 could also fall trying to reach the urinal. During a concurrent observation and interview on 2/4/26 at 3:57 p.m. with RN 1, Resident 11's urinal was seen on the dresser. RN 1 stated and validated the urinal was on the dresser. RN 1 stated the urinal should be within Resident 11's reach. RN 1 stated if Resident 11 was unable to reach the urinal it could spill. RN 1 stated the urinal should be placed lower. RN 1 stated this was important so that Resident 11 could use the urinal to urinate. RN 1 stated if the urinal content spilled, it could be a mess and there could cause cross contamination. RN 1 stated the potential outcome could be unsanitary conditions. During a concurrent interview and record review on 2/9/26 at 3:57 p.m. with the IP, pictures of Resident 11's urinal close to the water pitcher were reviewed. The IP stated the facility staff were not supposed to put the urinal on the dresser. The IP stated the urinal should be in the bathroom or at the foot side of the bed and if Resident 11 wanted to use it, he could use it independently. The IP stated this was important because it could lead to cross contamination. The IP stated the urinal was dirty and the facility staff put other things on the resident's dresser. The IP stated the urinal could also fall and urine could spill everywhere. The IP stated since it was body fluid, the facility staff would not know what was in it and that could lead to infection or harm to the skin. During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, pictures of Resident 11's urinal close to the water pitcher were reviewed. The DSD stated the expectation from the facility staff was that the urinal should be separated from the water because it was an infection control issue. During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, pictures of Resident 11's urinal close to the water pitcher were reviewed. The DON stated the expectation from facility staff was that the urinal should be dumped and cleaned and put in the drawer. The DON stated this was important to prevent infection and contamination. The DON stated the potential outcome could be the urine could spill and fall on Resident 11. During a review of the facility's document titled, Job Description, Certified Nurse Assistant (CNA), dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A certified nurse assistant is responsible for the direct care of the group of residents assigned, and provides the activities of daily living care, including ADL documentation, and psychosocial services [support actions that address the mental, emotional, social, and spiritual needs of individuals, particularly when facing illness, crisis, or disability].2. To assist also the vice presidents with physical needs such as . Feeding, oral hygiene, .or any other physical need. 8. To encourage the resident to function at his/ her maximum level of ability at all times. During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated, . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call.5. Organize and direct total nursing service on their respective shift. During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts. During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated, . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident. During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated, . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care . During a review of the facility's P&P titled, Resident Rights, revision dated 7/9/2025, the P&P indicated, . Policy: The facility shall uphold and protect the rights of all residents without discrimination, consistent with federal and state regulations. Resident Rights Include but Are Not Limited To: I. Dignity and Respect. Be treated with dignity, respect and consideration. During a review of the facility's P&P titled, Respect and Dignity, dated 8/4/2016, the P&P indicated, Respect and dignity: the state of quality of being worthy of honor and respect. The sense of importance and value. [named company] Intentions are to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and/ or enhancement of his or her quality of life, recognizing each president's individuality. protect and promote the rights of all residents. Providing care that supports self- respect of the resident. 3. During an observation on 2/4/26 at 3:47 p.m. in Resident 49's room, a nasal cannula tube was found on the floor. During a concurrent observation and interview on 2/4/26 at 4:10 p.m. with CNA 5, CNA 5 confirmed the nasal cannula was on the floor. CNA 5 stated, It should have been wrapped around the oxygen concentrator on the handle, so it won't be on the floor. CNA 5 stated the nasal cannula tube should not have been on the floor. CNA 5 stated Resident 49 could have had cross-contamination if the nasal cannula was used after it was found on the floor and was dirty. CNA 5 stated Resident 49 could have gotten a respiratory infection. CNA 5 stated, I should have thrown it away and notified the nurse. CNA 5 stated she started working two to three months ago and did not remember having an in-service on the nasal cannula storage. During a review of Resident 49's AR, dated 2/11/26, the AR indicated Resident 49 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease ( a disease characterized by a progressive decline in mental abilities), Hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and pulmonary edema (condition characterized by excess fluid accumulation in the lung's air sacs (alveoli), severely impairing breathing and oxygen exchange). During a review of Resident 49's MDS, dated [DATE], the MDS section C indicated Resident 49 had a BIMS score of 00, which indicated Resident 49 was cognitively impaired. During a review of Resident 49's Order Summary (OS-a legally required, dated, and signed document containing specific directives for a patient's medical treatment, including medication, dosages, tests, and care instructions), dated 4/18/25, the OS indicated, Oxygen at 2 [ liters (L)- a metric unit of capacity] per nasal cannula [as needed (prn)] [shortness of breath (sob)]. During an interview on 2/9/26 at 5:04 p.m. with the IP, the IP stated the nasal cannula tube should always be stored in a bag when not in use. The IP stated it was all staff member's responsibility to make sure the nasal cannula was not on the floor. The IP stated the residents were at risk for cross-contamination of their nasal cannulas when the nasal cannula was on the floor. The IP stated residents could have used the nasal cannula tubing that was once on the floor and could have a respiratory infection. The IP stated residents who were dependent on oxygen could have worsening health from a respiratory infection. The IP stated she was not sure when the last in-service was done about nasal cannulas storage or infection prevention. During an interview on 2/11/26 at 12:59 p.m. with the DON, the DON stated the nasal cannula tubes should be stored in bags when not used. The DON stated it should not be wrapped around the concentrator or on the floor. The DON stated it was important to store items properly to prevent cross-contamination. The DON stated residents were at risk for a respiratory infection from cross-contamination. The DON stated all staff were responsible for ensuring nasal cannulas w stored properly when residents were not using it. During a review of the facility's Inservice Meeting Minutes titled, Oxygen is a Medicine and Poses risks for Infection and safety, undated, the in-service indicated, .All healthcare provider.tubing is kept in the bags provided on the concentrators and not dropped or left on the floor when not in use. During a review of the professional reference titled, Tips for Meeting Respiratory and Tracheostomy Requirements in Skilled Nursing Facilities, undated, retrieved from, https://www.ahcancal.org/Quality/Clinical-Practice/Documents/Tips%20for%20Respiratory%20Requirement, the reference indicated, . follow the facility's policy on proper storage of respiratory equipment [e.g., masks, tubing, continuous positive airway pressure, oxygen tanks] . if Manufacturer's Instructions for Use (MIFU) states specific frequency to change, ensure the equipment [e.g., oxygen cannula/tubing] is consistently labeled [date/initials], and the resident's treatment records include orders or documentation for regular cannula changes. Any lapses can increase the risk of infection and indicate a failure to follow facility policy and physician orders . bagging or covering equipment when not in use . respiratory equipment must remain clean, do not allow equipment to touch the floor, bedside table, trash bin, etc.

Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for eight of 16 sampled residents (Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38), when Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38's copy of the Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete.This failure had the potential for Resident 9, Resident 11, Resident 36, Resident 39, Resident 55, Resident 6, Resident 7, and Resident 38's decisions regarding lifesaving treatment options and end of life wishes to not be honored.Findings 1. During a concurrent observation and interview on [DATE] at 2:56 p.m. in Resident 36's room, Resident 36 was observed dressed and lying in bed. Resident 36 stated she had been in the facility since [DATE]. During a review of Resident 36's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 36 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which include . Chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), atherosclerotic heart disease of native coronary artery ( condition where plaque (fat, cholesterol, and other substances) builds up inside the original, un-grafted arteries supplying blood to the heart), gastroesophageal reflux disease (GERD- condition where stomach acid frequently flows back into the tube connecting the mouth and stomach [esophagus]), essential hypertension (high blood pressure that has no single, identifiable medical cause), personal history of other mental and behavioral disorders, . During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 36 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS scores indicated Resident 36 was moderately impaired. During an observation on [DATE] at 3:35 p.m. in Resident 9's room, Resident 9 was observed dressed and lying in bed with his/her eyes closed. During a review of Resident 9's AR, dated [DATE], the AR indicated Resident 9 was admitted to the facility from an assisted living /board and care/group home on [DATE] with diagnoses which include . Acute and chronic respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epileptic seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that disrupts normal function), bipolar disorder (chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from high-energy manic episodes to low-energy depressive episodes), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), . During a review of Resident 9's MDS, dated [DATE], the MDS section C indicated Resident 9 had a BIMS score of 03, which indicated Resident 9 had severe cognitive impairment. During an observation on [DATE] at 3:35 p.m. in Resident 11's room, Resident 11 was observed dressed, lying in bed, and was unable to respond appropriately to questions asked. During a review of Resident 11's AR, dated [DATE], the AR indicated Resident 11 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which include . essential hypertension, gastroesophageal reflux disease, varicose veins (swollen, twisted, and enlarged veins that usually appear blue or dark purple just under the skin's surface, most commonly in the legs) of unspecified lower extremity with ulcer (an open, painful sore on the skin that occurs when surface tissue breaks down) of unspecified sites, alcoholic cirrhosis of liver with ascites (a severe, advanced stage of liver disease caused by long-term alcohol abuse), venous insufficiency (condition where leg vein valves are damaged or weakened, preventing blood from flowing efficiently back to the heart), anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life), . During a review of Resident 11's MDS, dated [DATE], the MDS section C indicated Resident 11 had a BIMS score of 07, which indicated Resident 11 had severe cognitive impairment. During an observation on [DATE] at 3:35 p.m. in Resident 55's room, Resident 55 was observed dressed and sitting in bed. During a review of Resident 55's AR, dated [DATE], the AR indicated Resident 55 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which include . Senile degeneration of brain (the progressive, irreversible breakdown and death of brain cells [neurons] and their connections), hypothyroidism (condition where the butterfly-shaped thyroid gland in the neck does not produce enough thyroid hormones), type 2 diabetes mellitus (when the blood sugar levels in the body are too high), major depressive disorder (a serious, common medical illness characterized by persistent, intense feelings of sadness, low mood, or loss of interest in activities), anxiety disorder, essential hypertension, acute respiratory failure with hypoxia, . During a review of Resident 55's MDS, dated [DATE], the MDS section C indicated Resident 55 had a BIMS score of 00, which indicated Resident 55 had severe cognitive impairment. During an observation on [DATE] at 12:16 p.m., Resident 39 was seen in the hallway in front of her room and sitting in her wheelchair. During a review of Resident 39's AR, dated [DATE], the AR indicated Resident 39 was admitted to the facility from acute care hospital on [DATE] with diagnoses which include . Hyperlipidemia (abnormally high levels of fats [lipids] in the blood), essential hypertension, neuromuscular scoliosis (a sideway curvature of the spine caused by underlying nerve or muscle disorders), multiple sclerosis (a chronic disease where the immune system mistakenly attacks the protective coating [myelin] surrounding nerve fibers in the brain and spinal cord), . During a review of Resident 39's MDS, dated [DATE], the MDS section C indicated Resident 39 had a BIMS score of 09, which indicated Resident 39 was moderately impaired. During a concurrent interview and record review on [DATE] at 3:03 p.m. with Registered Nurse (RN) 1, POLST forms for Residents 9, 11, 36, 39 and 55 were reviewed. The POLST indicated the second page which included, Patient's information (name, date of birth and gender), Supervising Physician's name, Preparer's name/title and phone number were incomplete for Residents 9, 11, 36, 39 and 55. RN 1 stated the POLST was important because it informed medical professionals of the residents' wishes and allowed their legal decision-maker to determine whether they wished to be resuscitated. RN 1 stated the potential outcome of an incomplete POLST included confusion regarding the residents' wishes and a resident who did not wish to be resuscitated could most likely be resuscitated as a result. During a concurrent interview and record review on [DATE] at 4:08 p.m. with the Medical Records Custodian (MR), POLST forms for Residents 9, 11, 36, 39 and 55 were reviewed. The POLST indicated the second page which included, Patient's information (name, date of birth and gender), Supervising Physician's name, Preparer's name/title and phone number were incomplete for Residents 9, 11, 36, 39 and 55. The MR stated the purpose of the POLST was to ensure that it was present in the residents' medical record and signed by the physician. The MR stated it was her responsibility to ensure the POLST was signed by the responsible party and physician, however, she typically only reviewed the front of the POLST form. The MR stated regarding the back of the POLST form, she was unaware that it was required to be completed. The MR stated when a resident was transferred out, a copy of the POLST was sent with them however she was unaware that the back portion of the form should also be completed before the resident was sent out. The MR stated proper completion of the POLST was important to protect the facility and to ensure that the residents' information was legally protected and transmitted appropriately. The MR stated the potential outcome of improper completion included the possibility of a family member filing a complaint that the information was sent out without the appropriate signatures or was handled improperly. During an interview on [DATE] at 3:15 p.m. with the Director of Nursing (DON), the DON stated the purpose of the POLST was to ensure the residents' wishes were properly communicated when transferring information from one facility to another. The DON stated this was to ensure the residents received care in accordance with their documented wishes. The DON stated the potential outcome of failing to follow the POLST could result in the facility staff providing either too much or too little care as the residents' wishes would not be properly followed. During a concurrent observation and interview on [DATE] at 3:16 p.m. in Resident 6's room, Resident 6 was observed dressed and sitting in a wheelchair next to her bed. Resident 6 stated she had been at the facility for a couple of months for getting sick. During a review of Resident 6's AR, dated [DATE], the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), type 2 Diabetes Mellitus, sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), atrial fibrillation (an irregular heartbeat), weakness, and anxiety disorder. During a review of Resident 6's MDS, dated [DATE], the MDS section C indicated Resident 6 had a BIMS score of 13, which indicated Resident 6 was cognitively intact. During a review of Resident 6's Order Summary Report (OSR), dated [DATE], the OSR indicated, .DNR (Do Not Resuscitate) [DNR - do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) if breathing stops or the heart stops beating]. During a review of Resident 6's Care Plan (CP), (undated), the CP indicated, .resident code status is DNR.date initiated: [DATE].resident's Advanced Directives [a legal document indicating resident preference on end-of-life treatment decisions] Wishes will be known.date initiated [DATE].staff will follow resident POLST form.date initiated: [DATE]. During a concurrent interview and record review on [DATE] at 11:47 a.m. with LVN 3, Resident 6's POLST, undated, was reviewed. The POLST indicated no date was entered when the form was prepared, no patient date of birth was entered, section D Information and Signatures, which indicated who the form was discussed with, Patient, or Legally Recognized Decisionmaker was not completed. LVN 3 stated Resident 6's POLST was not dated, and section D was not complete. LVN 3 stated Resident 6's POLST should have been dated. LVN 3 stated section D indicated who the POLST was discussed with for completion of Resident 6's POLST. LVN 3 stated the POLST form informed caregivers of what care to give during a resident's end of life or during an emergency. LVN 3 stated all sections of the POLST should have been completed. During a concurrent observation and interview on [DATE] at 3:29 p.m. in Resident 7's room, Resident 7 was observed dressed and lying in bed. Resident 7 stated she had been at the facility for three years due to pneumonia. During a review of Resident 7's AR, dated [DATE], the AR indicated Resident 7 was admitted on [DATE] from an acute care hospital with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pneumonia, anxiety disorder, major depressive disorder single episode, depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life) and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 7's MDS, dated [DATE], the MDS section C indicated Resident 7 had a BIMS score of six, which indicated Resident 7 was severely cognitively impaired. During a concurrent interview and record review on [DATE] at 11:54 a.m. with LVN 3, Resident 7's POLST, dated [DATE] was reviewed. The POLST indicated, Patient date of birth was not completed, no date of birth listed, and the back side of the POLST, which indicated who completed the POLST and additional contact information was not completed. LVN 3 stated the Resident's date of birth should have been entered to verify it was the right resident and the back side of the POLST was important to be completed so staff would know the contact information of the resident's next of kin. LVN 3 stated the back side of Resident 7's POLST should have been completed. During a concurrent observation and interview on [DATE] at 2:58 p.m. in Resident 38's room, Resident 38 was observed dressed, lying in bed with her husband sitting next to bedside table. Resident 38 stated she had been at the facility since [DATE] due to her kidney's shut down. Resident 38 stated she has had six dialysis treatments and just returned from a treatment. During a review of Resident 38's AR, dated [DATE], the AR indicated Resident 38 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of acute pulmonary edema (a buildup of fluid in the lungs), acute respiratory failure, acute kidney failure, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and depression. During a review of Resident 38's MDS, dated [DATE], the MDS section C indicated Resident 38 had a BIMS score of 14, which indicated Resident 38 was cognitively intact. During a review of Resident 38's OSR, dated [DATE], the OSR indicated, .CPR (cardiopulmonary Resuscitation) SELECTIVE TREATMENT. During a concurrent interview and record review on [DATE] at 4:20 p.m. with the Infection Preventionist (IP), Resident 38's POLST, dated [DATE] was reviewed. The POLST indicated section C Artificially Administered Nutrition was not filled in. The IP stated section C should have been completed as it indicated if Resident 38 would receive artificial nutrition and what type of feeding. The IP stated a POLST was important since it stated the way the resident was to be treated at the resident's end-of-life and if the resident was a Full Code or DNR. The IP stated if the POLST was not complete, staff would not have known what to do and how to treat the residents during their end-of-life or during an emergency. During a concurrent interview and record review on [DATE] at 12:00 p.m. with LVN 3, Resident 38's POLST, dated [DATE] was reviewed. The POLST indicated section C Artificially Administered Nutrition was not filled in. LVN 3 stated section C Artificially Administered Nutrition was not completed. LVN 3 stated section C of Resident 38's POLST should have been completed, since it informed staff if Resident 38 wanted tube feeding in case she was not able to eat. LVN 3 stated if Resident 38's POLST was not complete, Resident 38 could have received treatment she did not ask for or wanted during her end-of-life care. During an interview on [DATE] at 2:45 p.m. with the Social Services Director (SSD), the SSD stated Admissions will start filling out the POLST form with the residents and the SSD will follow up on obtaining signatures and direct the forms to the physician. The SSD stated the nurses made sure the POLST was complete. The SSD stated the POLST was important in case there was an emergency with the residents and they needed to be sent out, the POLST form went with the resident. The SSD stated the POLST informed staff if a full code or no code was to be implemented for the residents. The SSD stated it was important to know the residents' wishes. During an interview on [DATE] at 3:53 p.m. with the MR, the MR stated if there was a planned admission, the POLST was generated out of the Administration Office. The MR stated if she saw the physician, she asked him to sign the POLST. The MR stated she asked the nurses to complete the POLST forms if they were not completed. The MR stated she made sure the completion of the POLSTs were done. The MR stated the POLST was important since it indicated if the residents would have full CPR during an emergency. During an interview on [DATE] at 4:29 p.m. with the DON, the DON stated the POLST was the advanced directive for the residents. The DON stated the POLST indicated the medical wishes for the residents' end-of-life care. The DON stated the POLST was communication between facilities to honor the residents' wishes. The DON stated all sections of the POLST should have been completed. The DON stated if the POLST was not complete, there was the potential to affect the end-of-life wishes of the residents or the resident's Responsible Party (RP). During a review of the facility's job description document titled, Medical Records Director, dated [DATE], the document indicated, .Duties and Responsibilities: 1. This position reports to the Director of Nursing and is accountable for maintenance and updating patient records in compliance with state and federal regulations. During a review of the professional reference titled, Physician Orders for Life-Sustaining Treatment Forms & Instructions (POLST), dated 2026, retrieved from, https://www.[NAME]-[NAME].org/programs/support-services/services/healthcare-ethics/polst.html, the professional reference indicated, .the Physician Orders for Life Sustaining Treatment (POLST) is a physician's order that outlines a plan for end of life care reflecting both a patient's preferences and a physician's judgment based on a medical evaluation.the POLST form is completed by a patient 's physician [or by someone who has undergone special training about POLST and who works with the patient's physician] in conjunction with thorough conversation with the patient regarding the patient 's current and future health conditions and treatment preferences. Both the physician and patient must sign the POLST. If the patient lacks capacity to make medical decisions, the patient 's legally recognized decision-maker can participate in both completing and signing the POLST form .

Based on observation, interview, and record review, the facility failed to ensure the residents' water pitcher was within reach for five of eight sampled residents (Resident 9, 11, 13, 39 and 55), when the water pitcher was observed to be placed on the residents' dressers and were not accessible to the residents.This failure had the potential to violate Residents 9, 11, 13, 39, and 55's right to respect and dignity by neglecting their basic need for hydration, and undermining their autonomy and their right to person centered dignified care.Findings:During a concurrent observation and interview on 2/4/2026 at 3:35 p.m. in Resident 9's room, Resident 9 was observed dressed and lying in bed with his eyes closed. Resident 9's water pitcher was observed to be on his dresser and was not within Resident 9's reach.During a review of Resident 9's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 9 was admitted to the facility from an assisted living /board and care/group home on [DATE] with diagnoses which include . Acute and chronic respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epileptic seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that disrupts normal function), bipolar disorder (chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from high-energy manic episodes to low-energy depressive episodes), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) .During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/8/26, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS score indicated Resident 9 had severe cognitive impairment.During an observation on 2/4/2026 at 3:35 p.m. in Resident 11's room, Resident 11 was observed dressed, lying in bed, and unable to respond appropriately to questions asked. Resident 11's water pitcher was observed to be placed on his dresser and was not within Resident 11's reach.During a review of Resident 11's AR, dated 2/11/26, the AR indicated Resident 11 was admitted to the facility from an acute care hospital on 6/22/25 with diagnoses which include . essential hypertension (high blood pressure that has no single, identifiable medical cause), gastroesophageal reflux disease (condition where stomach acid frequently flows back into the tube connecting the mouth and stomach [esophagus]), varicose veins (swollen, twisted, and enlarged veins that usually appear blue or dark purple just under the skin's surface, most commonly in the legs) of unspecified lower extremity with ulcer of unspecified sites, alcoholic cirrhosis of liver with ascites (a severe, advanced stage of liver disease caused by long-term alcohol abuse), venous insufficiency (condition where leg vein valves are damaged or weakened, preventing blood from flowing efficiently back to the heart), anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life) .During a review of Resident 11's MDS, dated [DATE], the MDS section C indicated Resident 11 had a BIMS score of 07, which indicated Resident 11 had severe cognitive impairment.During an observation on 2/4/2026 at 2:38 p.m., Resident 13 was sitting in her wheelchair in her room. Resident 13's water pitcher was observed to be placed on her dresser and was not within Resident 13's reach.During a review of Resident 13's AR, dated 2/11/26, the AR indicated Resident 13 was admitted to the facility from an acute care hospital on 2/28/25 with diagnoses which include . pneumonia (an infection that inflames the air sacs [alveoli] in one or both lungs, causing them to fill with fluid or pus), anemia (blood condition characterized by a shortage of healthy red blood cells, which reduces the blood's ability to carry oxygen to organs and tissues), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple daily tasks), hyperlipidemia, heart failure (condition where the heart muscle is too weak or stiff to pump blood efficiently, failing to meet the body's oxygen needs), essential hypertension, Presence of cardiac pacemaker (a small, battery-operated, implantable device that acts as a backup to the heart's natural electrical system), depression (a serious, common medical illness characterized by persistent, intense feelings of sadness, low mood, or loss of interest in activities), hypokalemia (abnormally low levels of potassium in the blood, that affects the function of nerves and muscles, particularly the heart) .During a review of Resident 13's MDS, dated [DATE], the MDS section C indicated Resident 13 had a BIMS score of 06, which indicated Resident 13 had severe cognitive impairment.During an observation on 2/4/2026 at 2:31 p.m., Resident 39 was not in her room, Resident 39's water pitcher was observed to be placed on her dresser and was not within Resident 39's reach.During a review of Resident 39's AR, dated 2/11/26, the AR indicated Resident 39 was admitted to the facility from an acute care hospital on 8/28/25 with diagnoses which include . Hyperlipidemia (abnormally high levels of fats [lipids] in the blood), essential hypertension, neuromuscular scoliosis (a sideway curvature of the spine caused by underlying nerve or muscle disorders), multiple sclerosis (a chronic disease where the immune system mistakenly attacks the protective coating [myelin] surrounding nerve fibers in the brain and spinal cord), edema (swelling caused by an abnormal buildup of excess fluid trapped in the body's tissues) .During a review of Resident 39's MDS, dated [DATE], the MDS section C indicated Resident 39 had a BIMS score of 09, which indicated Resident 39 was moderately impaired.During an observation on 2/4/2026 at 3:35 p.m. in Resident 55's room, Resident 55 was observed dressed and sitting in bed. Resident 55's water pitcher was observed to be placed on his dresser and was not within Resident 55's reach.During a review of Resident 55's AR, dated 2/11/26, the AR indicated Resident 55 was admitted to the facility from an acute care hospital on 4/18/25 with diagnoses which include .type 2 diabetes mellitus (when the blood sugar levels in the body are too high), major depressive disorder (a serious, common medical illness characterized by persistent, intense feelings of sadness, low mood, or loss of interest in activities), anxiety disorder, essential hypertension, acute respiratory failure with hypoxia .During a review of Resident 55's MDS, dated [DATE], the MDS section C indicated Resident 55 had a BIMS score of 00, which indicated Resident 55 had severe cognitive impairment.During a concurrent observation and interview on 2/4/26 at 3:38 p.m. with Certified Nursing Assistant (CNA) 4, in Resident 9, Resident 11 and Resident 55's room, the water pitchers were noted to be on the residents' dressers. CNA 4 stated the water pitchers should not have been placed on the residents' dressers. CNA 4 stated the water pitchers should be placed on the bedside table or nightstand, within the residents' reach so that the residents could access them easily without having to get up. CNA 4 stated the potential outcome of the water pitchers being placed out of reach included the risk of the residents attempting to get up unassisted and falling.During a concurrent observation and interview on 2/4/26 at 3:57 p.m. with Registered Nurse (RN) 1 in Resident 9, Resident 11 and Resident 55's room, the water pitchers were noted to be on the residents' dressers. RN 1 stated it was the responsibility of the CNA to place water pitchers in the residents' rooms. RN 1 stated as long as the water pitcher was near the residents' bedside it was acceptable. RN 1 stated residents on the [NAME] wing of the facility consisted of a combination of hospice (compassionate care for individuals with a terminal illness (typically less than six months to live) that focuses on comfort, dignity, and quality of life rather than curing the disease ), long term care and rehabilitation residents. RN 1 stated rehabilitation residents are short stay residents recovering from physical injuries such as broken or fractured legs with the goal of being discharged to their homes. RN 1 stated long term care residents were more stable individuals who resided at the facility due to their families being unable to care for them and who presented with multiple comorbidities such as Alzheimer's disease, hypertension, and diabetes that were progressively worsening, leaving them unable to perform some of their activities of daily living (ADL- fundamental, routine self-care tasks essential for independent living, health, and safety, typically including bathing, dressing, eating, transferring (mobility), toileting, and continence ) independently. RN 1 stated as long as the water pitcher was in the room and on the residents' bedside it was acceptable. RN 1 stated he would not want the water pitcher to be placed somewhere that was not within the residents' reach.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), pictures of water pitchers placed on residents' dressers were reviewed. The DSD stated water pitchers should not have been placed on the dressers and should instead be placed on the bedside table where they were accessible to the residents. The DSD stated this was important in order to encourage adequate hydration. The DSD stated the potential outcome of the water pitcher being out of the residents' reach included the risk of dehydration.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), pictures of water pitchers placed on residents' dressers were reviewed. The DON stated the water pitchers should not have been placed on the residents' dressers and should instead be on the bedside table where residents could reach them. The DON stated the residents required a greater level of assistance. The DON stated and acknowledged that the facility staff could do better in ensuring residents' needs were met. The DON stated this was important so residents were able to access their water independently and remain adequately hydrated. The DON stated the potential outcome of the water pitchers being out of the residents' reach included the risk of dehydration and illness.During a review of the facility's document titled, Job Description, Certified Nurse Assistant (CNA), dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A certified nurse assistant is responsible for the direct care of the group of residents assigned, and provides the activities of daily living care, including ADL documentation, and psychosocial services (support actions that address the mental, emotional, social, and spiritual needs of individuals, particularly when facing illness, crisis, or disability).2. To assist also the vice presidents with physical needs such as . Feeding, oral hygiene, .or any other physical need. 8. To encourage the resident to function at his/ her maximum level of ability at all times.During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated, . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call.5. Organize and direct total nursing service on their respective shift.During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts.During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated, . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident.During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated, . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care .During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revision dated 7/9/2025, the P&P indicated, . Policy: The facility shall uphold and protect the rights of all residents without discrimination, consistent with federal and state regulations. Resident Rights Include but Are Not Limited To: I. Dignity and Respect. Be treated with dignity, respect and consideration.During a review of the facility's P&P titled, Respect and Dignity, dated 8/4/2016, the P&P indicated, Respect and dignity: the state of quality of being worthy of honor and respect. The sense of importance and value. [named company] Intentions are to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and/ or enhancement of his or her quality of life, recognizing each president's individuality. protect and promote the rights of all residents. Providing care that supports self- respect of the resident.During a professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC12300510/ and https://doi.org/10.3390/nu17142256 titled, Hydration Strategies in Older Adults, dated 2025, the professional reference review indicated, . Hydration also plays a key role in physical performance and muscle function. Even minimal fluid loss can negatively impact cognitive performance, emphasizing the need for adequate hydration. Ensuring adequate fluid intake can prevent cognitive decline. While being aware that cognitively impaired individuals may have unique hydration needs, addressing these needs through targeted hydration strategies can enhance cognitive performance and overall wellbeing. Older adults with cognitive impairments, such as dementia, are particularly vulnerable to dehydration. Dehydration is a prevalent yet preventable condition, particularly among older adults, that poses significant health risks if left unaddressed. Healthcare professionals should encourage regular fluid intake in older adults to support optimal physiological functioning (he normal, healthy, and routine physical and chemical processes that occur within an organism's cells, tissues, and organ systems to sustain life ). Education should emphasize starting the day with water and maintaining hydration throughout. To promote adequate hydration, consistent fluid intake should be encouraged, including offering water with meals, between meals, and during medication administration.

Based on observation, interview, and record review the facility failed to meet professional standards of practice for five of ten sampled residents (Resident 8, Resident 13, Resident 29, Resident 39 and Resident 47) when:1. Resident 39's physician orders for Oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy was incomplete on 9/23/25.This failure had the potential for Resident 39 to be administered incorrect O2 treatment.2. Resident 39's O2 tank was found empty on 2/5/26, and Resident 39 did not receive O2 therapy as ordered by the physician on 2/5/26.This failure placed Resident 39 at risk for experiencing shortness of breath (SOB) and respiratory distress (difficulty breathing).3. Resident 13 and Resident 47's medication from 2/1/26, 2/2/26, and 2/5/26 were not administered according to physician's orders and were still in the medication cart on 2/6/26.This failure had the potential to negatively impact Resident 13 and Resident 47's health and overall well-being, resulting in a decline in their medical condition, ineffective symptom management, and the risk of serious or life-threatening complication due to missed medication doses.4. Resident 8 and Resident 29 did not get timely response from the physicians for significant weight loss faxed on 2/5/26 and 2/10/26.This failure resulted in Resident 8 and Resident 29's significant weight loss to not be addressed in an appropriate time and had the potential for poor wound healing, functional decline and unavoidable weight loss.Findings: 1. During an observation on 2/5/2026 at 12:16 p.m., Resident 39 was seen in the hallway in front of her room, sitting in her wheelchair with nasal cannula (NC or N/C- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nostrils, and an O2 tank attached to her wheelchair. During a review of Resident 39's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information),, dated 2/11/26, the AR indicated Resident 39 was admitted to the facility from acute care hospital on 8/28/25 with diagnoses which included . Hyperlipidemia [abnormally high levels of fats [lipids] in the blood], essential hypertension (high blood pressure that has no single, identifiable medical cause), neuromuscular scoliosis [a sideway curvature of the spine caused by underlying nerve or muscle disorders], multiple sclerosis [a chronic disease where the immune system mistakenly attacks the protective coating (myelin) surrounding nerve fibers in the brain and spinal cord], edema [swelling caused by an abnormal buildup of excess fluid trapped in the body's tissues] . During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/24/25, the MDS section C indicated Resident 39 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 09 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS score indicated Resident 39 was moderately impaired. During a review of Resident 39's MDS assessment section O Special treatments, Procedures, and Programs, dated 11/24/25, the MDS indicated Resident 39 was on oxygen therapy. During a record review of Resident 39's O2 orders, dated 9/23/25 were reviewed, the O2 orders indicated, Oxygen at 4 liters per minute (L/min- a unit of measurement for the flow rate of oxygen) per via N/C-every shift for to help maintain normal oxygen levels. The O2 order did not indicate whether it should be continuous or as needed (PRN). During a concurrent interview and record review on 2/9/26 at 3:03 p.m. with Registered Nurse (RN) 1, Resident 39's O2 orders, dated 9/23/25 was reviewed. RN 1 stated the O2 order indicated 4 L/min via NC was started on 9/23/25. RN 1 stated the O2 order was incomplete because it did not specify whether the oxygen was to be administered continuously or PRN. RN 1 stated that since it was not listed as a PRN order, it was interpreted by the licensed nurses (LN)s to be a routine continuous order. RN 1 stated if Resident 39 was on continuous O2, the expectation was for LNs to monitor Resident 39's O2 levels and ensure O2 saturation (measures the percentage of an iron-rich protein found inside red blood cells [hemoglobin] that is carrying oxygen compared to the amount that is not) remained above 90 percent (%-a way of expressing a number as a fraction of 100, representing a part of a whole). During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), Resident 39's O2 orders, was reviewed. The DSD stated the O2 orders should clearly specify whether it was a PRN or continuous order, as without that clarification, LNs would not be able to determine whether they were properly following the physician's orders. During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), Resident 39's O2 orders, were reviewed. The DON stated and validated that Resident 39's O2 order was incomplete, as it did not specify whether O2 was to be administered continuously or PRN, and the O2 order did not indicate the required oxygen saturation level Resident 39 needed to maintain. The DON stated the O2 order information was important so that LNs could properly follow the physician's direction and provide care in accordance with the ordered treatment. The DON stated the potential outcome of an incomplete order included the risk of errors, including the administration of incorrect treatment. 2. During an observation on 2/5/2026 at 12:16 p.m., Resident 39 was seen in the hallway in front of her room, sitting in her wheelchair with a NC in her nostrils, and an O2 tank attached to her wheelchair. The O2 tank was noted to be empty and set at 4L/min. During a concurrent observation and interview on 2/5/26 at 12:19 p.m. with Certified Nursing Assistant (CNA) 3 in the west wing hallway, Resident 39's O2 tank was observed to be empty and set at 4L/min. CNA 3 stated and validated that the O2 tank was empty and set at 4L/min. CNA 3 stated she would immediately notify the LN to assess the situation. During a concurrent observation and interview on 2/5/26 at 12:21 p.m. with the Infection preventionist (IP), the IP stated she had just taken over resident care and the medication cart in the west wing from the outgoing LN. The IP stated and confirmed that the O2 tank was empty and had been set at 4 L/min. The IP stated she would replace the O2 tank immediately. During a concurrent interview and record review on 2/9/26 at 3:03 p.m. with RN 1, a picture of Resident 39's O2 tank behind Resident 39's wheelchair was reviewed. RN 1 stated the O2 tank was set at 4 L/min despite being empty. RN 1 stated the expectation when a resident was on O2, LNs should routinely check the O2 tank level to ensure there was an adequate supply of O2 available. RN 1 stated the O2 tank should not have been empty because Resident 39 required O2, had low O2 saturation without it, and exhibited significant difficulty breathing. RN 1 stated the potential outcome of an empty O2 tank included hypoxia (condition where the body's tissues and organs do not receive enough oxygen to function properly) which could lead to further complications. During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, a picture of Resident 39's O2 tank behind Resident 39's wheelchair was reviewed. The DSD stated and validated Resident 39's O2 tank was set at 4 L/min despite being empty. The DSD stated that the expectation was the LNs monitored the O2 tank to ensure accurate and continuous administration of O2. The DSD stated failure to do so placed the overall well-being of Resident 39 in jeopardy. During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, a picture of Resident 39's O2 tank behind Resident 39's wheelchair was reviewed. The DON stated and validated that Resident 39's O2 Tank was set at 4 L/min and was empty. The DON stated the expectation was LNs routinely checked the O2 tanks to ensure that residents always had an adequate supply of O2. The DON stated in Resident 39's case the physician's O2 order was not followed. The DON stated the potential outcome of an empty O2 tank included hypoxia and low oxygen saturation which could lead to increased illness and a wide range of additional complications. During a review of the facility's policy and procedures (P&P) titled, Health Information Management Guideline- Section Record Systems- Guideline for Quality Documentation, undated, the P&P indicated, . G. Physician Orders .6. Drug orders that include: .b. quantity and duration of therapy. C. dosage. D. time of administration. During a review of the facility's (P&P) titled, Oxygen Administration, dated 11/13/2009, the P&P indicated, .Responsibility: Licensed Nurse. Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. procedure . 1. check physician order for later flow and method of administration. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patient's hypoxia and ultimate outcome . During a professional reference review retrieved from https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications titled, Recommendations to Enhance Accuracy of Administration of Medications, dated 3/30/23, the professional reference review from the National Coordinating Council for Medication Error Reporting and Prevention indicated, . any order that in incomplete, illegible, or poses any concern should be clarified before preparation and administration.the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason. 3. During a concurrent observation and interview on 2/6/2026 at 3:05 p.m. in the west wing hallway with Licensed Vocational Nurse (LVN) 4, unopened prepacked medications were found in the medication cart. LVN 4 stated and validated the unopened prepacked medications belonged to Resident 13 with package date 02/05/26- 8:00 a.m. included Potassium Chloride ER [Extended Release-designed to release active ingredients slowly into the bloodstream over an extended period, providing a steady, consistent dose rather than an immediate spike and drop] 20[mEQ-(milliequivalent) is a unit of measurement in medicine that defines the chemical combining power or electrical activity of potassium ions in a solution]- [quantity (Qty)] 1., Lisinopril [used to treat high blood pressure (hypertension), heart failure, and to improve survival after a heart attack] 40 [Milligram -mg-a metric unit of mass equal to one-thousandth of a gram, used for medicine dosages ]- Qty 1., Metoprolol Succinate ER [a medication used once daily to manage hypertension, and heart failure] 50mg- Qty 1., Sertraline HCl [medication that increases serotonin levels in the central nervous system to treat mental health disorder] 50mg- Qty 1., and Memantine [medication used to treat and improve cognitive function and daily functioning] 10mg- Qty 1. and the unopened prepacked medications belonging to Resident 47 with package dates 02/01/26- 8:00 a.m. included Sertraline HCl 25mg- Qty 1., and 02/02/26- 8:00 a.m. included Sertraline HCl 25mg- Qty 1. LVN 4 stated the process for medication administration required LNs to pull up the medications and administer them to the residents. LVN 4 stated that if a resident was unavailable at the time of administration, the medication should be destroyed or placed in the destruction box and should not remain in the medication cart. LVN 4 stated the presence of medications in the medication cart that should not be there, creates the possibility of those medications being accidentally administered to the incorrect resident or the resident to receive multiple doses. LVN 4 stated the potential outcome of this practice included the risk of a resident being accidentally double dosed. During a review of Resident 13's AR, dated 2/11/26, the AR indicated Resident 13 was admitted to the facility from an acute care hospital on 2/28/25 with diagnoses which included . pneumonia [an infection that inflames the air sacs [alveoli] in one or both lungs, causing them to fill with fluid or pus], anemia [blood condition characterized by a shortage of healthy red blood cells, which reduces the blood's ability to carry oxygen to organs and tissues], Alzheimer's disease [a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple daily tasks], hyperlipidemia [an excess of lipids or fats in your blood], heart failure [condition where the heart muscle is too weak or stiff to pump blood efficiently, failing to meet the body's oxygen needs], essential hypertension [high blood pressure that has no single, identifiable medical cause], presence of cardiac pacemaker [a small, battery-operated, implantable device that acts as a backup to the heart's natural electrical system], depression [a serious, common medical illness characterized by persistent, intense feelings of sadness, low mood, or loss of interest in activities], hypokalemia [abnormally low levels of potassium in the blood, that affects the function of nerves and muscles, particularly the heart] . During a review of Resident 13's MDS, dated [DATE], the MDS section C indicated Resident 13 had a BIMS score of 06, which indicated Resident 13 had severe cognitive impairment. During a review of Resident 13's Order Summary Report (OSR), the OSR indicated Resident 13 had physician orders for Potassium Chloride ER Oral Tablet Extended Release 20meq (Potassium Chloride)-Give 1 tablet by mouth one time a day related to heart failure. with start date 3/26/25, Lisinopril Oral Tablet 40mg (Lisinopril)- Give 1 tablet by mouth one time a day related to essential (primary) hypertension . with start date 3/27/25, Metoprolol Succinate ER oral tablet extended release 24 hour 50mg (metoprolol succinate)- Give 1 tablet by mouth one time a day related to essential(primary) hypertension . with start date 3/27/25, Sertraline HCl Oral Tablet 50mg (Sertraline HCl)- Give 1 tablet by mouth one time a day related to depression. with start date 3/26/25, Memantine HCl Oral Tablet 5mg (Memantine HCl)- Give 1 tablet by mouth at bedtime related to Alzheimer's disease,. for 1 week then give 2 tablet by mouth two times a day related to Alzheimer's disease.with start date 4/18/25. During a review of Resident 47's AR, dated 2/11/26, the AR indicated Resident 47 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which included . hypokalemia, pneumonia, essential primary hypertension, depression . During a review of Resident 47's MDS, dated [DATE], the MDS section C indicated Resident 47 had a BIMS score of 11, which indicated Resident 47 was moderately impaired. During a review of Resident 47's OSR, the OSR indicated Resident 47 had physician orders for Sertraline HCl Oral Tablet 25mg (Sertraline HCl)- Give 1 tablet by mouth one time a day for depression with start date 1/29/26. During a concurrent interview and record review on 2/10/26 at 2:35 p.m. with the IP, Resident 13 and Resident 47's OSR and Medication Administration Record (MAR) were reviewed. The IP stated and validated Resident 13 had active physician orders for Potassium Chloride ER 20meq, Lisinopril 40mg, Metoprolol Succinate ER 50mg, Sertraline HCl 50mg, and Memantine 10mg. The IP stated the MAR reflected the medications were checked off as administered on 2/5/26. The IP stated the medication should not have been in the medication cart and she was unable to determine what medications were actually given to Resident 13. The IP stated the expectation from the LNs was that medications were administered as scheduled. The IP stated it was important because Resident 13 required the medications which included blood pressure medications, and antidepressants (prescription medications designed to treat and relieve symptoms such as low mood, hopelessness, and fatigue) and that the medications must be administered timely and as prescribed. The IP stated the potential outcome of medications not being administered as scheduled included complications arising from missed doses, including elevated blood pressure. The IP stated and validated Resident 47 had active physician orders for Sertraline HCL 25mg. The IP stated Resident 47 did not receive the medications dated 2/1/26 and 2/2/26 found in the medication cart, despite the MAR reflecting the medications had been checked off as administered on both days. The IP stated the physician orders required Resident 47 to take the medications as prescribed and the LNs did not follow the physician's orders. The IP stated it was important that the LNs followed the physician's orders because Sertraline was an antidepressant that must be taken consistently in order to be effective. The IP stated the potential outcome of medications not administered to Resident 47 included adverse effects of Resident 47's behavior including lack of motivation, sadness, and mood disturbances. The IP stated the prescribed medications were not administered and could cause Resident 47 to not receive the intended therapeutic benefits of the medication. During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, a picture of Resident 13 and Resident 47's unpacked medications were reviewed. The DSD stated the expectation from LNs was that all medications were to be administered to residents on the day they are due. The DSD stated it was important medications were administered as ordered because failure to administer medications as scheduled could result in adverse consequences for Resident 13 and Resident 47. The DSD stated the potential outcome of improper medication administration included the risk of overdose if medications were administered at the wrong time or conversely, the residents would not receive an adequate amount of medication to achieve the intended therapeutic effect. During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, a picture of Resident 13 and Resident 47's unpacked medications were reviewed. The DON stated and validated the unpacked medications were not administered to Resident 13 on 2/5/26 and to Resident 47 on 2/1/26 and 2/2/26. The DON stated it was important to follow the physician's orders to ensure the overall wellbeing of the residents. The DON stated the potential outcome of medications not being administered as ordered included illness, depression, hypertension, stroke (medical emergency that happens when something prevents your brain from getting enough blood flow), and conditions that could ultimately lead to death, as well as adverse effects on the residents' mental health and coping abilities. During a review of the facility's P&P titled, Medication and Treatment Administration, dated 10/30/2003, the P&P indicated, Policy: The complete nursing function of administering drugs entails preparing the individual dose from a dispensed, prepacked container, charting the time, dose of medication and actually administering the dose. The licensed nurse is responsible for selecting the correct dose from supply, knowing how to administer such medication, verifying the identity of the medication, verifying the identity of the resident, monitoring the resident's response to the medication and/ or detecting a possible adverse reaction to the medication or treatment administered. Licensed nurses will administer only medications that they have personally prepared. During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated, . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. 3 .gives or supervises giving of all prescribed treatments. 4. notes and transcribe physicians' orders with their appropriate flow through.Knowledge and abilities. 3. Give medication as prescribed with good basic knowledge of side effects of these.5. Organize and direct total nursing service on their respective shift. During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts. 3 .gives medication as prescribed .6. Gives and supervises giving of all prescribed treatments. 7. notes and transcribe physicians' orders with their appropriate flow through.Knowledge and abilities. Give medication as prescribed with good basic knowledge of side effects of these. During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated, . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident. During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated, . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care . During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ titled, Nursing Rights of Medication Administration, dated 9/4/23, the professional reference review indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Medical errors are a reality . Examples of human error are lack of medical knowledge, lack of attention to detail or care, failing to verify information in an effort to save time, disorganization of workplace or supplies, and miscommunication among healthcare professionals or with a patient.Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient's personal safety, they can also be extremely costly for hospitals. 4. During a review of Resident 8's AR dated 2/11/26, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of difficulty walking, chronic atrial fibrillation (heart arrhythmia characterized by rapid, disorganized, and irregular electrical impulses in the heart's upper chambers (atria), constipation and hypertension (high blood pressure). During a review of the Resident 8's fax form Untitled, dated 2/5/26, the fax form indicated,.Registered Dietician [RD] Weekly Review with Recommendations.Significant weight loss [times (x)] 1 month.Recommendation: Recommended increase whole milk to 4 [ounces (oz)] three times a day (TID)] with meals to 8 oz with meals.2. Add weekly weights. No fax was returned and followed up within 24 hours. During a review of the Resident 8's fax form Untitled, dated 2/10//26, the fax form indicated,.Dietician Weekly Review with Recommendations.Significant weight loss x 1 month.Recommendation: Recommended increase whole milk to 4 oz. TID with meals to 8 oz with meals.2. Add weekly weights. A second fax was submitted to the physician to notify of the recommendations five days after the first fax. During a review of Resident 29's AR, dated 2/11/26, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD -irreversible kidney failure) and legal blindness. During a review of Resident 29's [Facility Name] Progress Note (PN), dated 2/4/26, the PN indicated, RD Weight Review. [resident (res)] with significant yet noteworthy [weight (wt.)] loss since admission. Discussed in [interdisciplinary Team (IDT)- meeting is a structured, regular gathering of health professionals—typically nurses and RD-who collaborate to create, review, and update comprehensive care plans for residents], res has not been eating [due to (d/t)] disliking minced and moist and d/t blindness and does not know what she is eating staff has obtained waiver from family stating res may eat regular.RD recommendations: 1. Remove [Consistent Carbohydrate (CC) or Renal/Consistent Carbohydrate (RCS) (type of diet order)].2. Continue to monitor weekly weights. During a review of the Resident 29's fax form Untitled, dated 2/5/26, the fax form indicated,.Dietician Weekly Review with Recommendations.1 Recommend remove CC/RCS, Renal and cardiac restrictions of diet d/t poor intake. 2. Continue to monitor weekly weights.3. Upgrade textures to regular once wavier has been received. No fax was returned and followed within 24 hours. During a review of the Resident 29's fax form Untitled, dated 2/10/26, the fax form indicated,.Dietician Weekly Review with Recommendations.1 Recommend remove CC/RCS, Renal and cardiac restrictions of diet d/t poor intake. 2. Continue to monitor weekly weights.3. Upgrade textures to regular once wavier has been received. A second fax was submitted to the physician to notify of the recommendations five days after the first fax.During a concurrent observation and interview on 2/6/26 at 3:19 p.m. in Resident 29 's room, Resident 29 was in the wheelchair sitting with Family Member (FM) 2 getting ready for lunch. FM 2 stated he was concerned about Resident 29's meal intake. FM 2 stated Resident 29 was blind and should have some finger food. FM 2 stated she struggled to eat and lost weight. During a concurrent interview and record review on 2/11/26 at 9:09 a.m. with LVN 2, Resident 29's fax form, dated 2/5/26 was reviewed. LVN 2 stated nurses should have faxed the RD recommendations to the physician after receiving it. LVN 2 stated she faxed Resident 8 and Resident 29's RD recommendations on 2/5/26 and had not received any reply from the physician. LVN 2 stated, We fax the order and we need to follow up. LVN 2 stated sometimes the fax took three to four days for the physician to reply. LVN 2 stated the RD recommendations included monitoring weight loss weekly, and this was needed to keep track and prevent further weight loss. LVN 2 stated the licensed nurses need to keep the physician informed of the RD recommendation to prevent further weight loss. LVN 2 stated residents with weight loss could have poor wound healing and decrease in functional status contributing to hospitalization and unavoidable weight loss. During an interview on 2/11/26 at 10:49 a.m. with the RD, the RD stated the nurse should have faxed the weight loss recommendations to the physician. The RD stated the recommendations should have reached the physician and the orders carried out within 24 hours. The RD stated that the weight loss recommendations was discussed with the residents and family members and were agreeable with the new recommendations. The RD stated family members expected the RD recommendations to be changed the same day. The RD stated the family could have lost trust in the medical staff when the recommendations took a long time to be carried out. The RD stated not following up with the recommendations and getting the order in a timely manner could have contributed to further weight loss. The RD stated residents with weight loss could have poor wound healing and functional decline such as muscle weakness. The RD stated residents with further weight loss could have led to hospitalization from poor wound healing. The RD stated the facility should have followed up with the physician to ensure the response was timely. During an interview on 2/11/2026 at 1:07 p.m. with the DON, the DON stated we should receive a new physician order within a day. The DON stated, Sometimes he [physicians] is good at responding and we wait till Wednesday to notify the physician in person. The DON stated the facility discussed the weight loss recommendations with family members. The DON stated, We are at the mercy of the physician. The DON stated, When the [RD] recommendations were not addressed residents could continue to have weight loss and they could get sicker. The DON stated, Their [residents] wound would not heal. The DON stated residents could have declined in functional status and put residents at risk for hospitalization. During an interview on 2/11/2026 at 1:00 p.m. with the Medical Director (MD-licensed physician responsible for leading clinical services, setting medical policies, and ensuring high-quality care in nursing homes), the MD stat[TRUNCATED]

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2), received a Level II Pre-admission Screening and Resident Review (PASRR - an evaluation for individuals suspected of having a Serious Mental Illness [SMI] or Intellectual/Developmental Disability [I/DD]/Related Condition [RC]- to determine if they needed specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when, Resident 2, who had a diagnosis of schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly) and had a PASRR Level I screening indicating Resident 2 had no diagnosis of schizophrenia which resulted in a negative Level I result for SMI.This failure resulted in Resident 2 not receiving the required PASRR level II screening which had the potential to result in missed identification of specialized services needed and placed Resident 2 at risk for delayed treatments.Findings:During a concurrent observation and interview on 2/4/26 at 2:20 p.m. in Resident 2's room, Resident 2 was observed dressed, lying in bed with his lower legs elevated. Resident 2 stated he had been at the facility for nine years because it was a retirement home and he was a retired man.During a review of Resident 2's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/1/26, the AR indicated Resident 2 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of schizophrenia, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (when the blood sugar levels in the body are too high), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/15/24, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was cognitively intact.During a review of Resident 2's MDS, dated 4/15/24, the MDS section GG indicated Resident 2 needed partial to moderate assistance with his Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's MDS, dated 4/15/24, the MDS section I indicated Resident 2 had diagnoses of Alzheimer's disease, depression, and schizophrenia.During a review of Resident 2's MDS, dated 4/15/24, the MDS section N indicated Resident 2 was taking antipsychotic (a medication that affects brain activities associated with mental processes and behavior used to treat a collection of symptoms that affect your ability to tell what's real and what is not) and antianxiety high-risk drug class medications.During a review of Resident 2's physician orders titled, Medication Review Report, dated 2/11/26, the Medication Review Report indicated, .(brand name antipsychotic medication) oral tablet 5 milligrams [mg -unit of measurement] [olanzapine -an antipsychotic medication used to treat schizophrenia] give 0.5 tablet by mouth in the evening for schizophrenia related to paranoid schizophrenia . order status . active . order date 10/23/24.start date.10/23/24.During a review of Resident 2's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 12/09/21, the PASRR indicated .does the individual have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder? . No.the individual has been prescribed psychotropic [a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior] medications for mental illness.No.During a concurrent interview and record review on 2/9/26 at 5:00 p.m. with the Director of Staff Development (DSD), Resident 2's PASRR, dated 12/09/2021 was reviewed. The PASRR indicated Resident 2 did not have a diagnosis of schizophrenia and did not take psychotropic medications for mental illness. The DSD stated Resident 2 had a diagnosis of schizophrenia and question 10, which indicated if a resident had a diagnosis of schizophrenia, should have been marked Yes. The DSD stated marking yes for question 10 would have triggered a Level II PASRR screening. The DSD stated the PASRR screening evaluated if a resident was receiving accurate care for mental conditions that might have required additional care that the facility was not able to provide. The DSD stated if a Level II screening was triggered, the facility expected the Department of Healthcare Services (DHCS) to contact the facility and request documentation to see if additional care was needed. The DSD stated the Level II screening was able to determine if the resident was able to be in the facility. The DSD stated if the resident triggered a Level II evaluation that was not completed, there was a risk of possible injury to other residents as well as to themselves due to the lack of adequate care.During an interview on 2/10/26 at 4:29 p.m. with the Director of Nursing (DON), the DON stated staff should have been checking if the resident had a completed PASRR before being admitted to the facility from the hospital. The DON stated the facility made sure if a level II screening was needed. The DON stated her expectations were that the residents had a Level I screening and if needed, a Level II screening completed. The DON stated if a resident had some mental illness or mental diagnosis, the PASRR was needed to verify the facility was able to provide the type of care the resident needed. The DON stated if a Level II PASRR screening was not done, the resident might not have had adequate care for their diagnosis.During a review of the facility's policy and procedure (P&P) titled, PASRR Policy and Procedure, dated 4/4/23, the P&P indicated, .a level I Screening is used to identify if an individual has, or is suspected of having, a PASRR condition, i.e., SMI, ID/DD, or RC. If the Level 1 Screening in either scenario is positive for an individual as having, or is suspected of having a PASRR condition, then a Level 2 Evaluation will be performed, and a Determination made.During a review of the professional reference titled, Preadmission Screening and Resident Review, dated 2026, retrieved from, https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx, indicated, .the California Department of Health Care Services (DHCS), PASRR Section is responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require .nursing facility services, considering the least restrictive setting .specialized services .During a review of the professional reference titled, Preadmission Screening and Resident Review, (undated), retrieved from, https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review, indicated, . Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care .evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) .offered all applicants the most appropriate setting for their needs [in the community, a nursing facility, or acute care settings] .provide all applicants the services they need in those settings .PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care .

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a tailored document summarizing a person's health conditions, care needs, medications, and goals to ensure consistent care and improve quality of life) was developed and implemented for one of five sampled residents (Resident 49), when Resident 49 had an oxygen (a prescribed treatment that provides supplemental oxygen to individuals with low blood oxygen levels) order that started on 4/18/25.This failure had the potential for Resident 49's oxygen needs not be monitored, revised, and met which could cause increase in shortness of breath.Findings:During an observation on 2/4/26 at 3:47 p.m. in Resident 49's room, an oxygen concentrator was next to the bed with the oxygen tubing wrapped on the side rail and nasal cannula (a lightweight, flexible medical device used to deliver supplemental oxygen or increased airflow directly into a patient's nostrils via two small prongs) on the floor.During a concurrent interview and record review on 2/9/26 at 4:47 p.m. with the Infection Preventionist (IP), the IP stated Resident 49 was admitted on [DATE]. The IP stated Resident 49's oxygen was at two liters per minute (LPM-a unit of volumetric flow rate that measures the volume of liquid or gas passing through a point in one minute) as needed which started on 4/18/25. The IP stated Resident 49's nursing note indicated her oxygen saturation was in the 80's on 1/31/26. The IP stated Resident 49 did not have a care plan. The IP stated Resident 49 should have an initial care plan on 4/18/25 when the oxygen order was ordered by the physician. The IP stated the care plan should be revised every three months to meet the needs of Resident 49. The IP stated on 1/31/26 Resident 49's had a change in condition and the care plan for the oxygen should have been revised. The IP stated there should have been a revision to the care plan for Resident 49's low oxygen saturation. The IP stated it was important to develop an initial care plan so nurses would know how to provide care for residents and for communication. The IP stated each resident's needs were dependent on the care plan. The IP stated we should have monitored the residents according to the care plan. The IP stated we provide care for the residents according to the care plan. The IP stated nurses should close out the care plan when the issues or needs of the residents were resolved. The IP stated nurses should be revising and updating ongoing care plans. The IP stated revisions and updates were not done for Resident 49's oxygen needs.During an interview on 2/11/26 at 1:02 p.m. with the Director of Nursing (DON) the DON stated the care plan should have been done with all orders. The DON stated nurses should have created the care plan immediately or by end of the day. The DON stated we want to follow the care plan to provide correct care for the residents. The DON stated, We want it to be a comprehensive. The DON stated resident's needs could not be met without a care plan. The DON stated there could be cracks with the care of the residents without a care plan. The DON stated staff would not be providing correct care for the residents. The DON stated all nurses were responsible for the care plan. During a review of Resident 49's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 49 was admitted to the facility 11/17/20 with diagnoses of Alzheimer's Disease ( a disease characterized by a progressive decline in mental abilities), Hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and pulmonary edema (condition characterized by excess fluid accumulation in the lung's air sacs, severely impair breathing and oxygen exchange).During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 2/12/26, the MDS section C indicated Resident 49 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 00 (a score of 00-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 49 was cognitively impaired.During a review of the facility's policy and procedure (P&P) title, Resident Care Plans, dated 11/20/2017, the P&P indicated, .Individualized care of each resident care plan flow from unique list of diagnosis and specific needs. the care plans allow for continuity of care and ongoing communication in the residents' care.the care plans expanded as the resident's needs are identified.the care identified the concerns, the goal and interventions.Care plans are reviewed weekly and upon and condition on changes or order changes, the care plan is updated.updating consists of revision date and the information updated.

Based on observation, interview, and record review, the facility failed to follow the policy and procedure (P&P) to ensure the care plans (CP) were reviewed and revised for one of eight sampled residents (Resident 39) when:The CP for Resident 39 was not reviewed and revised after Resident 39 had a change in physician's order for oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy from 2 liters per minute (L/min- a unit of measurement for the flow rate of oxygen) to 4L/min on 9/23/25.Findings:During a concurrent observation and interview on 2/5/2026 at 12:16 p.m., Resident 39 was seen in the hallway in front of her room and sitting in her wheelchair with a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nostrils, and an O2 tank attached to her wheelchair. The O2 tank was set to 4L/min.During a review of Resident 39's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 39 was admitted to the facility from acute care hospital on 8/28/25 with diagnoses which include . Hyperlipidemia [abnormally high levels of fats (lipids) in the blood], essential hypertension (high blood pressure that has no single, identifiable medical cause) , neuromuscular scoliosis [a sideway curvature of the spine caused by underlying nerve or muscle disorders], multiple sclerosis [a chronic disease where the immune system mistakenly attacks the protective coating (myelin) surrounding nerve fibers in the brain and spinal cord], edema [swelling caused by an abnormal buildup of excess fluid trapped in the body's tissues] .During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/24/25, the MDS section C indicated Resident 39 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 09 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS score indicated Resident 39 was moderately impaired.During a review of Resident 39's MDS assessment section O Special treatments, Procedures, and Programs, dated 11/24/25, the MDS indicated Resident 39 was on oxygen therapy while as a resident.During a record review of Resident 39's medical record, dated 2/5/26 at 11:32 a.m., Resident 39's physician's O2 orders, dated 8/28/25 and 9/23/25 and Resident 39's O2 CP, dated 9/5/25 were reviewed. The O2 order indicated Resident 39 had an initial physician order for O2 at 2L/min per via NC dated 8/28/25 at 11:50 p.m., the 2L/min via NC O2 order was discontinued on 9/23/25 at 9:09 p.m. with reason being, need to increase oxygen to maintain normal levels. The O2 order on 9/23/25 indicated, Oxygen at 4 L/min per via N/C-every shift for to help maintain normal oxygen levels. The CP indicated Resident 39 had interventions that included O2 as ordered PRN 2L via N/C-check O2 saturation as of 2/5/26.During a concurrent interview and record review on 2/10/26 at 2:35 p.m. with the Infection preventionist (IP), Resident 39's O2 orders, dated 9/23/25 and CP, dated 9/5/25 were reviewed. The IP stated the O2 order was updated to 4 L/min on 9/23/25 after the previous O2 order for O2 at 2 L/min via nasal cannula was discontinued on 9/23/25, having been in effect since 8/28/25. The IP stated the CP indicated Resident 39 was using oxygen therapy related to shortness of breath, with the intervention documenting O2 as ordered 2L/min via NC as needed (PRN). The IP stated the CP was not updated to reflect the new order of 4 L/min. The IP stated there was no revised care plan in place for the 4L/min O2 order. The IP stated when a new order was received it was the responsibility of all licensed nurses (LN) to initiate and update the CP immediately. The IP stated the expectation when a change in residents' condition occurred would be that LNs should address the problem and initiate a care plan update without delay. The IP stated it was important in order to ensure that proper care was provided to Resident 39, interventions were implemented and LNs were able to monitor whether those interventions were effective. The IP stated the potential outcome of a CP that was not updated included LNs being unable to determine whether the current interventions were working.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), Resident 39's O2 orders, dated 9/23/25 and CP, dated 9/5/25 were reviewed. The DON stated the CP reflected an O2 order of 2L/min which was no longer consistent with the current physician's order. The DON stated the expectation from LNs was that the CP accurately reflects the current plan of care for Resident 39 and the CP should have been updated to reflect the new order. The DON stated it was important so that all LNs were aware of the exact and current plan of care for Resident 39. The DON stated the potential outcome of the CP not being updated included the risk of a medication error.During a review of the facility's policy and procedure (P&P) titled, Resident Care Plan, dated 11/20/2017, the P&P indicated, . It is the policy of [named company] to provide direction for individualized care of each resident. Care plans flow from unique list of diagnosis and specific needs. The care plans allow for continuity of care and ongoing open communication in the residents' care. Procedure: Resident care plans initiated upon admission of the resident. The care plans expanded as the resident's needs are identified. The care plan identifies the concern, the goal and interventions. b. Care plans are reviewed weekly with the weekly progress note and quarterly during the IDT team meetings. c. Upon any condition changes or order changes, the care plan is updated. d. Updating consists of the revision date and the information updated.During a review of the facility's P&P titled, Care Plan Revision, dated 9/4/2016, the P&P indicated, . In revising of a care plan, staff identify which areas in the president's plan of care require updating to reflect the current situation . The ultimate goal of the care plan is to provide the plan of care for the resident in question . can plans need to be revised when orders have changed. Care plans need to be revised when they no longer are appropriate for the resident. Care plans need to be revised to reflect on the current status of the resident. The nursing care plan can be computerized or in written form and is a representation of clinical judgment. The nursing care plans contain diagnosis, treatments, and reflective practice for the individual resident.During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call.Knowledge and abilities. 5. Organize and direct total nursing service on their respective shift.6. Recognize changes in the condition of each resident and take necessary action.During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts. 10 . Recognize the significant changes in the condition of each resident . follow through with the appropriate action. Document change or condition or residence chart.During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident.During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care .During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on interview and record review, the facility failed to ensure services were provided to restore or improve normal bladder function and bowel function to the extent possible for one of eight sampled residents (Resident 6), when Resident 6's bowel and bladder training (a behavioral technique used to help individuals regain control over their bladder and bowel function) for incontinence (lack of voluntary control over urination or defecation) was not implemented.This failure had the potential to place Resident 6 at risk for urinary tract infections (UTI -infection of any part of the urinary system), pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and not maintaining or improving Resident 6's Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). Findings:During a concurrent observation and interview on 02/04/2026 at 3:16 p.m. in Resident 6's room, Resident 6 was observed dressed and sitting in a wheelchair next to her bed. Resident 6 stated she had been at the facility for a couple of months for getting sick. Resident 6 stated she wore a brief and had no bowel or bladder training. Resident 6 stated recently her bum hole was very irritated.During a review of Resident 6's AR, dated 2/10/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), atrial fibrillation (an irregular heartbeat), UTI, weakness, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/26/26, the MDS section C indicated Resident 6 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 6 was cognitively intact.During a review of Resident 6's MDS, dated 1/26/26, the MDS section GG indicated, .toileting hygiene. 04 - Supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.toilet transfer.04 - Supervision or touching assistance.During a review of Resident 6's MDS, dated 1/26/26, the MDS section H - Bladder and Bowel indicated, .has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility .No.urinary continence.always incontinent.bowel continence.always incontinent.During a review of Resident 6's Bowel and Bladder Program Screener (B&B Screener), dated 1/29/26, the B&B Screener indicated, .voids appropriately without incontinence? .not always, but at least daily.incontinent of stool.1-3[times per week].mentally aware of need to toilet.usually aware of need to toilet.Score 13.Candidate for Schedule toileting [timed voiding].During an interview on 2/9/26 at 12:40 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated if a resident was on a B&B training program, the CNAs would have encouraged the residents to use the bathroom, push fluids, encourage food, check the residents every one to two hours for bowel movement (BM), and will check the residents every two hours to see if they needed to use the bathroom. CNA 1 stated the Director of Staff Development (DSD) did the training for B&B training. CNA 1 stated staff would be notified of residents on a B&B training program during report from the previous shift and the nurse will inform CNAs of residents on a B&B training program. CNA 1 stated there were no residents on a B&B training program.During a concurrent interview and record review on 2/9/26 at 4:15 p.m. with the Infection Preventionist (IP), Resident 6's B&B Screener, dated 1/29/26 was reviewed. The B&B screener indicated, .scheduling toilet program recommended. The IP stated Resident 6 was not on a B&B training program and staff had two weeks from the B&B assessment to decide what to do with the resident. The IP stated she was not sure who did the B&B screening, but whoever completed the screening needed to communicate the results to the Interdisciplinary Team (IDT) or the DSD for B&B training. The IP stated B&B training was important as it helped Resident 6 to become more dignified and able to manage less incontinent episodes. The IP stated there was a risk for Resident 6 to obtain skin breakdown, rashes, skin disorders, and discomfort from incontinence. The IP stated Resident 6 should have had a B&B training program initiated.During a concurrent interview and record review on 2/9/26 at 5:00 p.m. with the DSD, Resident 6's B&B Screener, dated 1/29/26 was reviewed. The B&B Screener indicated, .candidate for schedule toileting [timed voiding].score 13. The DSD stated Resident 6 should have had a B&B training program initiated. The DSD stated she gave B&B training during the facility's annual in-services to staff. The DSD stated staff were to toilette B&B training residents at least every two hours when the residents were awake and during rounds at night. The DSD stated CNAs assisted with checking and changing the residents on B&B training. The DSD stated she needed notification from the IDT or from the person who completed the B&B assessment if a resident needed B&B training so she would be able to initiate a care plan and train staff on implementation and documentation of B&B training.During an interview 2/9/26 at 5:15 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 6 was not on a toileting program. LVN 1 stated Resident 6 called the CNA when she needed to use the bathroom to assist Resident 6 to the wheelchair and the bathroom.During a review of the facility's policy and procedure (P&P) titled, Policy and procedure for Bowel and Bladder Management and Training, dated 11/4/2013, the P&P indicated, .training the bladder to empty when full and lesson the symptoms of an overactive bladder [a condition that causes more frequent and urgent urination] or stress incontinence [when stress or pressure on the bladder causes urine to leak] is the ultimate goal for our residents.if the resident could benefit from bowel and bladder re-training and is a good candidate. Staff will document as required.upon determination that a resident can benefit from the bowel and bladder re-training program, the resident is evaluated for one week if positive results are seen with the resident, the evaluation continues for an additional 2 weeks minimal or as long as required for the individual.assessment of the residents' schedule.train staff to utilize the residents' schedule every two hours. Toileting/offering toileting/checking for need of toileting.staff to assist with toileting as needed.call light kept within reach at all times, and answered promptly.During a review of the facility's P&P titled, The Nursing Process (Nursing Assessments), dated 12/20/17, the P&P indicated, .the assessment: a way of collecting and analyzing data about the resident. The initial step in delivering nursing care.the assessment will also include ADL function.which can affect the care provided.both the residents status and the effectiveness of the nursing care plans require frequent evaluation and updating to reflect the current level of care.

Based on observation, interview, and record review, the facility failed to meet state/federal laws and professional standards of practice for labeling and storage of drugs and biologicals (medical products or agricultural agents derived from living organisms such as humans, animals, or microorganisms) for two of eight sampled residents (Resident 11 and Resident 47) when:1. Resident 11's controlled medication (medications that are highly regulated by the government because of the significant risk of abuse and dependence they pose) record sheet did not indicate the Administration Instructions (specific directions, including dosage form, route (e.g., by mouth), and frequency (e.g., 1-tab daily) for use of the medications.This failure placed Resident 11 at risk of being administered the wrong dosage of the medication at the wrong time and the route. 2. Resident 47 was administered a controlled medication on 1/3/26 and the Controlled Drug Record (CDR) was not signed by the licensed nurse (LN) according to the facility's policy and procedure (P&P) titled, Controlled Drug Accountability.This failure placed Resident 47 at risk for not receiving her medication which could cause adverse effects (unexpected, harmful, or undesirable reaction resulting from a medication, medical treatment, or procedure, ranging from mild to severe or life-threatening). 3. The facility's medication refrigerator containing residents' medications was not monitored to be within the recommended temperature and the Temperature Log (TL) for medication was not completed accurately according to the facility's P&P titled, Refrigerator Temperatures. This failure had the potential for ineffective medications to be administered to residents.4. Medications were destroyed and the Medication Disposition Log (MDL) was not accurately completed by two required witnesses as indicated on the MDL. This failure had the potential for medications to be diverted (illegal transfer or use of prescription medication).5. Loose medications were found in the west wing medication cart, and the medications were not disposed according to the facility's P&P titled, Discarded Medication.This failure had the potential to be a safety hazard to residents if administered.Findings:1. During an observation on 2/4/2026 at 3:35 p.m. in Resident 11's room, Resident 11 was observed dressed, lying in bed, and unable to respond appropriately to questions asked.During a review of Resident 11's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 11 was admitted to the facility from an acute care hospital on 6/22/25 with diagnoses which include . essential hypertension [high blood pressure that has no single, identifiable medical cause], gastroesophageal reflux disease [condition where stomach acid frequently flows back into the tube connecting the mouth and stomach [esophagus]], varicose veins [swollen, twisted, and enlarged veins that usually appear blue or dark purple just under the skin's surface, most commonly in the legs] of unspecified lower extremity with ulcer of unspecified sites, alcoholic cirrhosis of liver with ascites [a severe, advanced stage of liver disease caused by long-term alcohol abuse], venous insufficiency [condition where leg vein valves are damaged or weakened, preventing blood from flowing efficiently back to the heart), anxiety disorder [mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life] .During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/22/25, the MDS section C indicated Resident 11 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 07 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS score indicated Resident 11 had severe cognitive impairment.During a review of Resident 11's Order Summary report (OSR), the OSR indicated Resident 11 had physician orders for Lorazepam (a Schedule IV controlled medication used for short-term treatment of anxiety disorders (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early, despite having the opportunity to rest , acute seizures (a sudden, temporary burst of abnormal electrical activity in the brain) Oral Tablet 0.5mg (Milligram- a metric unit of mass equal to one-thousandth of a gram, used for medicine dosages)- Give 1 tablet by mouth at bedtime to assist with anxiety and or sleep, with a start date of 10/31/25.During a concurrent interview and record review on 2/6/26 at 3:05 p.m. in the west wing nursing station, with Licensed Vocational Nurse (LVN) 4, Resident 11's medication packet, dated 12/12/25 and medication record sheet, undated were reviewed. The medication packet indicated administration instructions, but the medication record sheet did not have the administration instructions. LVN 4 stated the controlled medication labeling was incomplete, noting that lorazepam 0.5 mg was documented without direction or instructions. LVN 4 stated proper labeling was relevant to ensure the right dosage was given to the right patient, at the right time, with the right medication. LVN 4 stated what was missing from the label included when the medication was due, how frequently it should be administered, and the dosage was not clearly written. LVN 4 stated that the importance of accurate labeling was to prevent giving the wrong medication to the wrong patient, or the wrong dosage to the right patient. LVN 4 stated the potential outcome of such an error could result in the wrong patient experiencing an allergic reaction (a set of symptoms that happen after you touch, inhale or eat something) or death, while the intended patient does not receive their medication resulting in a double loss.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), the pictures of Resident 11's medication packet, dated 12/12/25 and medication record sheet, undated were reviewed. The DSD stated the medication was not properly documented with indication, noting that the label was handwritten rather than generated from the pharmacy, and therefore lacked the required pharmacy sticker. The DSD stated the indications on the medication record sheet were missing, which was important as proper documentation serves as a way to double check what was being administered and confirms the correct timing of the medication.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), the pictures of Resident 11's medication packet, dated 12/12/25 and medication record sheet, undated were reviewed. The DON stated Resident 11's medications were not properly documented with indications noting that the handwriting was sloppy and illegible and did not constitute a complete order. The DON stated that the implication of such incomplete documentation was a medication error. The DON stated the importance of complete documentation was to prevent medication errors as the label failed to include the time, route, indication, and frequency, making it easy for mistakes to occur. The DON stated that the potential outcome of this deficiency was a medication error.During a review of the facility's P&P titled, Safe administration assistance, dated 5/14/2021, the P&P indicated, . Procedure. General and specific procedures on administration of medication: right person, right medication, right date, right time, right route, and right dose, expiration date. If there is a discrepancy, the medication will not be administered until the physician verifies appropriate instruction .During a review of the facility's &P titled, Medication and treatment administration, dated 5/14/2021, the P&P indicated, . Policy: The complete nursing function of administering drugs entails preparing the individual dose from a dispensed, prepared container, charting the time, dose of medication and actually administering the dose. The licensed nurse is responsible for selecting the correct drug from supply, and knowing how to administer such medication, verifying the identity of the medication, verifying the identity of the resident. In administering medication, medication sheets are used as a check against physicians' orders .2. During a review of Resident 47's AR, dated 2/11/26, the AR indicated Resident 47 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which included . hypokalemia [condition characterized by abnormally low levels of potassium in the blood], pneumonia [an infection that inflames the air sacs (alveoli) in one or both lungs, causing them to fill with fluid or pus], essential primary hypertension [a condition where the force of blood pushing against your artery walls is consistently too high], depression [a common, serious mood disorder characterized by a persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities] .During a review of Resident 47's MDS, dated [DATE], the MDS section C indicated Resident 47 had a BIMS score of 11, which indicated Resident 47 was moderately impaired.During a review of Resident 47's OSR, the OSR indicated Resident 47 had physician orders for Lorazepam Oral tablet 0.5mg- Give 0.5 tablet by mouth at bedtime for anxiety/phobias (feeling of worry or fear about future events) with a start date of 12/14/25.During a review of Resident 47's Medication Administration Record (MAR), the MAR indicated Lorazepam Oral tablet 0.5mg- Give 0.5 tablet by mouth at bedtime for anxiety/phobias and was checked off as administered to Resident 47 on 1/3/26.During a review of Resident 47's CDR,, the CDR indicated the Lorazepam Oral tablet 0.5mg- Give 0.5 tablet by mouth at bedtime for anxiety/phobias and was not signed off by the LN on 1/3/26 at 8:00 p.m.During a concurrent interview and record review on 2/6/26 at 11:03 a.m. in the west wing nursing station, with LVN 4, Resident 47's CDR, dated 1/3/26, and Resident 47's MAR, dated 1/3/26 were reviewed. were reviewed. The CDR indicated there was a blank space that required a LN's signature. The MAR indicated the medication Lorazepam 0.5mg was administered to Resident 47 on 1/3/26. LVN 4 stated the controlled medication was administered and there was one missing signature on the CDR on 1/3/26 for Resident 47. LVN 4 stated the process for Controlled Drug Accountability required that at shift change, oncoming and outgoing LNs performed a medication count to ensure accuracy, both nurses signed to verify that the count was completed and accurate and when controlled medications were given, the LN must sign to confirm administration. LVN 4 stated this was important because these are controlled substances and if the count was off there could be suspicion of diversion and it was essential to ensure residents were receiving the medications they were ordered to take. LVN 4 stated the potential outcome was if a pain medication was missed, the resident could be in pain and if lorazepam was missed, then the resident could become restless.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, the pictures of Resident 47's CDR, dated 1/3/26 and MAR, dated 1/3/26 were reviewed. The DSD stated the situation was a controlled medication concern, noting that nurses were required to count the medication, verify the account and sign the record sheet when the medication was administered to residents. The DSD stated this was important because if the count was not accurate or the record sheet was not signed, there was no way to account for what happened to the medication. The DSD stated the potential outcome was that Resident 47 may not receive the medication she was supposed to get, which could leave her experiencing anxiety.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, the pictures of Resident 47's dated 1/3/26 and MAR, dated 1/3/26 were reviewed. The DON stated a controlled medication concern was identified for Resident 47, noting that a signature for lorazepam administration was missing. The DON stated the process of controlled drug accountability required the LNs to sign for any medications administered to the residents. The DON stated this was important to keep the medication count accurate and to ensure residents received their medication as scheduled. The DON stated the potential outcome of this practice was that the count could be off and the residents could experience anxiety as a result of not receiving their medication.During a review of the facility's P&P titled, Controlled Drug Record, dated 5/14/2021, the P&P indicated, Policy- It shall be the policy of [named company] skilled unit to be accountable for controlled medication and antibiotic medications each shift Accounting process for controlled drugs: when controlled drugs are delivered a controlled / antibiotic drug log record is made for each drug usually the pharmacy will provide these, but if not, the nurse is to make one. Procedure for providing controlled medication: the number of pills is listed on the record, and each time a medication is given, it is signed for by the licensed nurse. The nurse is to pour the pill, sign the pill out of the controlled/ antibiotic drug log record, give the medication to the resident and then document and sign the medication record.3. During a concurrent observation, interview, and record review on 2/6/26 at 11:03 a.m. in the west wing nursing station, with LVN 4, a medication refrigerator had medications stored in it and the refrigerator temperature was 34 Fahrenheit ( F- a scale for measuring temperature). There was a temperature guide displayed on the side of the west wing refrigerator at the nursing station. The facility's temperature guide was reviewed with LVN 4. The temperature guide indicated . At 40 F- The Us Food and Drug Administration (FDA) says the recommended refrigerator temperature is below 40 F. Between 35 F and 38 F- The ideal refrigerator temperature is between 35 F and 38 F, below the safety threshold outlined by the FDA and above freezing. LVN 4 stated and validated the refrigerator temperature was at 34 F.During a concurrent interview and record review on 2/6/26 at 11:10 a.m. with LVN 4, the facility's TL, dated November 2025, December 2025, and January 2026 were reviewed. The TL indicated in the month of January 2026, the log was not completed 14 out of 31 times on the morning (AM) shift and the temperature was at 36 F and below 16 times out of 17 recorded entries on the AM shift, the log was not completed 10 out of 31 times on the afternoon (PM) shift and the temperature was at 36 F and below 20 times out of 21 recorded entry on the PM shift, and the log was not completed 1 out of 31 times on the night (NOC) shift and the temperature was at 36 F and below 25 times out of 30 recorded entries on the NOC shift. The TL indicated in the month of December 2025, the log was not completed 7 out of 31 times on the AM shift and the temperature was at 36 F and below 24 times out of 24 recorded entries on the AM shift, the log was not completed 5 out of 31 times on the PM shift and the temperature was at 36 F and below 25 time out of 26 recorded entries on the PM shift, and the log was not completed 2 out of 31 times on the NOC shift and the temperature was at 36 F and below 29 times out of 29 recorded entries on the NOC shift. The TL indicated in the month of November 2025, the log was not completed 10 out of 31 times on the AM shift and the temperature was at 36 F and below 21 times out of 21 recorded entries on the AM shift, the log was not completed 2 out of 30 times on the PM shift and the temperature was at 36 F and below 28 time out of 28 recorded entries on the PM shift, and the log was completed on the NOC shift and the temperature was at 36 F and below 30 times out of 30 recorded entries on the NOC shift. LVN 4 stated temperatures should be checked every day. LVN 4 stated checking the refrigerator was important to ensure the temperature of the refrigerator was in the ideal range as failure to check could lead to medication damage. LVN 4 stated the potential outcome of improper storage of medication was that residents could get sick, the chemical composition of medications could change, and residents may not receive the intended effects from their medications. LVN 4 stated there was missing documentation on the temperature logs. LVN 4 stated the expectation was that the temperature log should have been completed.During an observation on 2/9/26 at 3:18 p.m. in the medication room, the medication refrigerator temperature was 26 F. The refrigerator was observed to contain various residents medications, some of which were Insulins (vital hormone produced by the pancreas that acts as a key, allowing sugar (glucose) from food to enter cells to be used for energy e.g insulin glargine), a box of influenza vaccine (a safe, yearly injection that helps the immune system fight the flu virus), lorazepam oral concentrate 30 mL (milliliter- unit of measure), a box of 5TU/ 0.1 mL tuberculin (sterile liquid used in a skin test to see if a person has been infected with tuberculosis) vial. The insulin glargine indicated, .store unused insulin glargine in a refrigerator 36 F-46 F .Do not freeze. Discard insulin glargine if it has been frozen, the Influenza vaccine indicated store between . (36 F-46 F). Do not freeze. The Lorazepam indicated, .store at cold temperature. Refrigerate . (36 F-46 F). The tuberculin indicated .store between . 36 F-46 F. Do not freeze.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, the pictures of the thermometer (an instrument used to measure how hot or cold something is[temperature]) in the medication room refrigerator and the temperature logs for the refrigerator, undated were reviewed. The DSD stated the policy required temperature checks once a day, with the facility standard being twice a day, and that the blanks in the logs should have been filled in. The DSD stated this was important because if medications were not stored at the correct temperature, they could be harmful. The DSD stated the potential outcome was an adverse consequence resulting from administering medications that were not stored at the proper temperature. The DSD stated and validated the temperature of the refrigerator was 26 F which fell within the freezing zone as indicated by the reviewed guide. The DSD stated upon reviewing the manufacturer's guide, Tuberculin should be stored between 36 - 46 F and should not be frozen, lorazepam should be stored between 36 - 46 F and influenza vaccine should be stopped between 36 - 46 F and should not be frozen. The DSD stated the expectation was that the refrigerator should be monitored twice a day, and if found out of range, medications should be discarded, the refrigerators should be repaired, and the temperatures should be confirmed to be within the correct range before replacing with new medications. The DSD stated that this was important because improper storage could cause harm to residents and the potential outcome was an adverse health consequence.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, the pictures of the thermometer in the medication room refrigerator and the temperature logs for the refrigerator, undated were reviewed. The DON stated the log was found to be incomplete, and the policy required the night shift nurse to monitor the temperatures. The DON stated this was important to maintain the proper temperature of the refrigerators and that the potential outcome of noncompliance included spoiled or frozen items. The DON stated upon reviewing the medication refrigerator temperature it was found to be too low at 25 F and that the expectation was that the refrigerator should have been maintained between 36 - 46 F. The DON stated this was important to keep medications accurate and safe, and the potential outcome of improper temperature included illness and adverse effects from medication use.During a review of facility's document titled, The right temperature for your refrigerator and freezer, dated 6/26/25, the document indicated, Refrigerator temperature guide- Above 40 - Any temperature above 40 F may allow bacteria to multiply rapidly. At 40 , the U.S. Food and Drug Administration says the recommended temperature is below 40 F. Between 35 and 38 - the ideal refrigerator temperature is between 35 F and 38 F, below the safety threshold outlined by the FDA and above freezing. It's not uncommon for refrigerators to be a few degrees off the mark you set, so err on the side of too cold to avoid food spoiling more quickly or potential food safety issues. At 32 - At 32 F and below, the food in your refrigerator will start to freeze. Keep your refrigerator temperature above 32 F to avoid this, and if you want anything frozen, put it in the freezer which should be kept below 0 F.During a review of the facility's P&P titled, Refrigerator temperatures, dated 9/29/2009, the P&P indicated, . Purpose: to ensure that the temperatures of the refrigerator in the skilled nursing department are maintained between 36- 41 at all times. Policy: the night shift chart nurse will check and document the temperature of the refrigerator located in the medication room and at the nurses station on a nightly basis to ensure temperatures are between 36-41 degrees at all times. If there is a malfunction and the temperature rises above 41 for more than 1/2 hour, medications will be assessed and destroyed and replaced as needed.During a review of the facility's P&P titled, Storage of medication and treatment supplies, dated 5/14/2021, the P&P indicated, . Policy: [Named company] Policy for medication and treatment supplies storage is to maintain medication and supplies in adequate storage areas in accordance to health and safety regulations. Storage of unused medications and/ or treatment supplies shall be . adequate temperature, adequate humidity 4. During a concurrent interview and record review on 2/6/26 at 11:10 a.m. with LVN 4, the facility's MDL, dated October 2025, November 2025, and December 2025 were reviewed. The MDL indicated in the month of October 2025, the log was not signed by a second witness 33 out of 49 times which involved 41 out of 58 medications destroyed not signed by a second witness. The MDL indicated in the month of November 2025, the log was not signed by a second witness 132 out of 135 times and was not signed by two witnesses 1 out of 1 time which involved 277 out of 285 medications destroyed not signed by a second witness and 1 out of 1 medication destroyed not signed by two witnesses. The MDL indicated in the month of December 2025, the log was not signed by a second witness 24 out of 40 times which involved 30 out of 47 medications destroyed not signed by a second witness. LVN 4 stated the MDL required both a nurse and a witness to sign when medications were destroyed, however multiple witness signatures were found to be missing. LVN 4 stated the process for medication destruction was required whenever LNs had time or at least once a week, one of the LNs would retrieve the medication destruction bin, destroy the medications, document and sign, then a second nurse will verify that the medications have been destroyed and signed the document as a witness, with both nurses ensuring the medications were placed in the incineration box (is an enclosed, furnace-like container designed to safely burn waste materials at very high temperatures). LVN 4 stated the process was followed part of the time and was not followed part of the time. LVN 4 stated it was important to ensure that medications were destroyed as they are supposed to be, and that the potential outcome of noncompliance was that the medications could be diverted.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, the pictures of the MDL were reviewed. The DSD stated when medications were discontinued, they are to be discarded with a witness by another LN during incineration, and the details of the discarded medications were to be entered and signed by both LNs. The DSD stated this was important as it served as verification that the destruction was actually completed and that no one was taking the medications for personal use. The DSD stated the potential outcome of noncompliance was that individuals could be taking the medications home or sell them.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, the pictures of the MDL were reviewed. The DON stated the expectation was that two LNs should be present for discarding and documenting when medications are destroyed. The DON stated this was important because it was the proper way to ensure medications were safely destroyed. The DON stated the potential outcome of noncompliance was medications could get into the wrong hands.During a review of the facility's P&P titled, Disposal of Medications, dated 5/14/2021, the P&P indicated, . Policy: Discontinued medications and/ or medications left in the nursing care center after a residence discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition Procedures the director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations in the handling of medications .5. During a concurrent observation and interview on 2/6/2026 at 3:05 p.m. in the west wing hallway with LVN 4, three loose medications were found in different places in the medication cart. LVN 4 was unable to identify the medications. LVN 4 stated the process required the medication cart to be checked at all times to ensure there were no loose medications present. LVN 4 stated this was important because medications left lying around could be dangerous.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the DSD, the pictures of the loose medications found in the medication cart were reviewed. The DSD stated the loose medications found in the medication cart may indicate that residents were not receiving their medications. The DSD stated the expectation was that any medication not given should be documented as not administered and if the medication needed to be discarded, it should go through the proper disposal process with a witness present. The DSD stated this was important because if residents do not receive their medications, it could cause health problems.During a concurrent interview and record review on 2/10/26 at 2:35 p.m. with the Infection Preventionist (IP), the pictures of the loose medications found in the medication cart were reviewed. The IP stated the expectation was that the medication should have been removed from the medication cart, the pharmacy should have been contacted, and the replacement medication should have been ordered. The IP stated this was important because residents may not receive the medications prescribed to them. The IP stated the potential outcome was that if the resident missed the medication, the intended effects of the medication would not be active in the resident.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the DON, the pictures of the loose medications found in the medication cart were reviewed. The DON stated the loose medications found in the medication cart were not disposed of properly. The DON stated this was important because administering those medications could result in a medication error, and proper disposal was necessary to prevent that from occurring.During a review of the facility's P&P titled, Discarded Medication, revision dated 5/14/2021, the P&P indicated, . Policy: As medications are being passed, there are times that medications need to be discarded due to resident refusal or dropped pills for example. Loose medications are a safety hazard for residents. The facility has a responsibility to maintain a safe environment for residents. Through this process the facility will maintain the safety of the residents. Procedure: A labeled container will be kept in the Med cart for the purpose of collecting discarded medications, excluding narcotic medications. As incidents happen of pills that are not administered to the resident for various reasons, the pills will be placed in the labeled container for later removal to the grey discard box in the Med room. Every Monday night, the night shift nurse is responsible to place the container in the grey discard box in the Med room. If the container becomes too full during the week, the nurse that notes it being too full is responsible to deposit the medications in the designated grey box in the Med room for the DON to appropriately discard.During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated, . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. 3 .gives or supervises giving of all prescribed treatments. 4. notes and transcribe physicians' orders with their appropriate flow through.Knowledge and abilities. 3. Give medication as prescribed with good basic knowledge of side effects of these.5. Organize and direct total nursing service on their respective shift.During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts. 3 .gives medication as prescribed .6. Gives and supervises giving of all prescribed treatments. 7. notes and transcribe physicians' orders with their appropriate flow through.Knowledge and abilities. Give medication as prescribed with good basic knowledge of side effects of these.During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated, . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident.During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated, . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care .

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were in place for unnecessary medications for two of eight sampled residents (Resident 2, and Resident 7), when:1. Pharmacy recommendations to include resident specific symptoms and/or behaviors which should indicate the reason these residents were being treated with the prescribed antipsychotic (a medication that affects brain activities associated with mental processes and behavior used to treat a collection of symptoms that affect your ability to tell what's real and what is not) and psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications were not listed in Resident 2 and Resident 7's physician's orders for the medications.This failure had the potential for Resident 2 and Resident 7 to be prescribed unnecessary medications due to no monitoring of the resident specific symptoms and/or behaviors they were being prescribed antipsychotic and psychotropic medications for.2. Resident 2 and Resident 7 did not have specific non-pharmacological interventions (any intervention intended to improve the health or the well-being of individuals that do not involve the use of any drugs or medicine) documented prior to the use of psychotropic medications.This failure had the potential for Resident 2 and Resident 7 to be prescribed unnecessary medications due to not having appropriate non-pharmacological interventions implemented prior to administering psychotropic and antipsychotic medications.Findings:1. During a concurrent observation and interview on 2/4/26 at 2:20 p.m. in Resident 2's room, Resident 2 was observed dressed, lying in bed with his lower legs elevated. Resident 2 stated he had been at the facility for nine years because it was a retirement home and he was a retired man.During a review of Resident 2's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/1/26, the AR indicated Resident 2 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (when the blood sugar levels in the body are too high), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/15/24, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was cognitively intact.During a concurrent interview and record review on 2/9/26 at 4:30 p.m. with the Infection Preventionist (IP), Resident 2's physician orders titled, Medication Review Report, dated 2/11/26 was reviewed. The Medication Review Report indicated, .(brand name antipsychotic medication) oral tablet 5 [milligrams (mg )-unit of measurement] [olanzapine - an antipsychotic medication used to treat schizophrenia] give 0.5 tablet by mouth in the evening for schizophrenia related to paranoid schizophrenia . order status . active . order date 10/23/24.start date.10/23/24. The IP stated the physician order for Resident 2's antipsychotic medication should have had more specific indications for use.During a review of Resident 2's Consultant Pharmacist's (PC) MRR Review Report (MRR), dated Jan. 2026, the MRR indicated, .[brand name medication] 5 mg 0.5 tablet [orally] [at bedtime] for schizophrenia related to paranoid schizophrenia . change order to [brand name medication] 5 mg 0.5 tablet [orally] [at bedtime] for paranoid schizophrenia [manifested by (m/b)] one of the following . hallucinations [a sight, sound, smell, taste, or touch that a person believes to be real but is not real] . combativeness [an eagerness to fight or argue]. delusions [a mental condition with false beliefs or judgment about external reality]. irritability with aggression. The recommendation had fax written in red with no documentation of the physician's response or change in the order.During an interview on 2/10/26 at 4:29 p.m. with the Director of Nursing (DON), the DON stated new physician orders were audited by the Medical Records (MR) department and the MR followed up with the physician for any clarification or issues with the orders. The DON stated the nurses were responsible for verifying the order was complete. The DON stated when nurses documented the resident's weekly progress notes, the nurses should have been checking the resident's care plans and physician orders. The DON stated if there was no clear order, staff could have been giving unnecessary medications.During a concurrent observation and interview on 2/4/26 at 3:29 p.m. in Resident 7's room, Resident 7 was observed dressed and lying in bed. Resident 7 stated she had been at the facility for three years due to pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid).During a review of Resident 7's AR, dated 2/10/26, the AR indicated Resident 7 was admitted on [DATE] from an acute care hospital with diagnoses of COPD, pneumonia, anxiety disorder, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities) single episode, depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life) and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).During a review of Resident 7's MDS, dated 1/11/26, the MDS section C indicated Resident 7 had a BIMS score of six, which indicated Resident 7 was severely cognitively impaired.During a concurrent interview and record review on 2/9/26 at 4:30 p.m. with the IP, Resident 7's Order Summary Report (OSR), dated 2/10/26 was reviewed. The OSR indicated, .aripiprazole [an antipsychotic medication used to manage and treat schizophrenia and major depressive disorder] tablet 10mg give 1 tablet by mouth one time a day related to major depressive disorder, single episode, unspecified.order status active . order date 01/07/2026.start date 01/08/2026.mirtazapine [a drug used to treat depression] tablet 7.5 mg give 1 tablet by mouth at bed time related to depression, unspecified.sertraline hydrochloride [HCI][a medication used to treat depression and anxiety] tablet 100 mg give 1 tablet by mouth one time a day for depression. The IP stated the order for Resident 7's antidepressant medications should have had more specific indications for use and supplemental documentation to see how the medication was working.During a concurrent interview and record review on 2/10/26 at 4:29 p.m. with the Director of Nursing (DON), Resident 7's OSR, dated 2/10/26 was reviewed. The OSR indicated, .aripiprazole tablet 10mg give 1 tablet by mouth one time a day related to major depressive disorder, single episode, unspecified.order status active . order date 01/07/2026.start date 01/08/2026.mirtazapine tablet 7.5 mg give 1 tablet by mouth at bed time related to depression, unspecified.sertraline HCI tablet 100 mg give 1 tablet by mouth one time a day for depression. The DON stated there were no manifestations listed for Resident 7's orders for antidepressants (medications used to treat depression). The DON stated the nurses were responsible for verifying the physician orders were complete. The DON stated when nurses documented the resident's weekly progress notes, the nurses should have been checking the resident's care plans and physician orders. The DON stated if there was no clear order, staff could have been giving unnecessary medications.During a review of Resident 7's Care Plan Report (CP), the CP indicated, .[Resident name] uses antidepressant medication related to [r/t] depression . date initiated: 04/06/2024. revision on: 01/13/2026. administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q [every] Shift.date initiated: 04/06/2024. No monitoring for target behaviors was listed on Resident 7's CP.During a review of Resident 7's Consultant Pharmacist's (PC) MRR Review Report (MRR), dated Jan. 2026, the MRR indicated, .[brand name medication] 10 mg PO [orally] daily for major depressive disorder, single episode, unspecified.mirtazapine 7.5 mg PO [at bedtime (QHS)] for depression, unspecified. sertraline 100 mg PO daily for depression . change order for [brand name medication] 10 mg 0.5 PO daily for major depressive disorder m/b one of the following lack of motivation.crying.self-isolation.feelings of helplessness.change the order for sertraline to sertraline 100 mg daily for major depressive disorder m/b one of the following .lack of motivation.crying.self-isolation.feelings of helplessness.change the order for mirtazapine to mirtazapine 7.5 mg PO QHS for major depressive disorder m/b poor appetite (eating less than 50% of meals). The recommendation had fax written in red with no documentation of the physician's response or change in the orders.During a review of the Consultant Pharmacist's Medication Regimen Review Report (MRR), titled Psychotropic Medication Orders, dated Jan. 2026, the Report indicated, .CMS requires target symptoms/behaviors for psychotropic medications. These symptoms/behaviors must be RESIDENT SPECIFIC and include what exact behavior is being treated. They should be observable, measurable, functionally relevant and trackable over time.During an interview on 2/11/26 at 9:58 a.m. with the PC, the PC stated once recommendations were made during the monthly MRR, she followed up the following month to see if any response was received or changes made by the physician. The PC stated there were no residents with issues on her recommendations.During a concurrent interview and record review on 2/11/26 at 12:13 p.m. with the DON, the PC MRR binder, dated Jan. 2026 was reviewed. The MRR indicated Pharmacist recommendations and Fax written in red by facility staff had no notation of MD response. The DON stated she started the process for communication with the physician and noted in red fax and will send a fax to the physician with the PC's recommendations. The DON stated the physician response time depended on the physicians. The DON stated her expectation was to have a physician response as soon as possible or by the end of the week.During an interview on 2/11/26 at 1:25 p.m. with the Medical Director (MD), the MD stated the diagnoses symptoms are what the medications were prescribed for. The MD stated she did not write the symptoms in her orders, that she never had, and it was not required. The MD stated she did not check the transcribed orders, she trusted staff to write the orders appropriately. The MD stated her response to faxes was several days. For emergencies staff could have called her as she was available for a quicker response 24/7 (24-hours per day/seven days a week).During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Policy and Procedure, dated 1/18/24, the P&P indicated, .the purpose of the Psychotropic Medication Policy and Procedure is to develop a facility system to ensure a resident is not given a psychotropic medication unless a comprehensive assessment which identifies clear indications and parameters for use.During a review of the facility's P&P titled, Psychotherapeutic Medication Review, dated 11/28/2012, indicated, .the targeted behavior will be clearly and specifically identified and monitored every shift.2. During a concurrent interview and record review on 2/9/26 at 4:30 p.m. with the IP, Resident 7's MAR, dated 2/11/26 was reviewed. The MAR indicated, .non-pharmacological interventions for agitation, depression, lack of motivation, sadness/crying resident will be offered the following interventions: orientation and/or redirection.provided quiet, calm environment, music program, 1 on 1 attention, offered daily activities, offered daily [Rehabilitative Nursing Assistant (RNA)]/exercise routine every shift for depression.start date. 01/16/2026. The days of the week and monitoring times of .day.evening.night. had a check mark with initials of the nurse who performed the charting. There was no indication which intervention(s) were attempted. The IP stated the non-pharmacological interventions should have had numbers next to each intervention to help indicate which intervention was implemented, just a check off does not specify what interventions were implemented. The IP stated non-pharmacological interventions helped staff to know which interventions to adjust and helped create a resident-specific care plan for the residents.During an interview on 2/10/26 at 4:36 p.m. with the DON, the DON stated only documenting a check mark on Resident 2 and Resident 7's MAR did not specify which intervention was implemented. The DON stated if there was no clear physician's order for monitoring the effectiveness of non-pharmacological interventions, there was a risk of giving unnecessary medications to the residents.During a review of the facility's P&P titled, Psychotropic Medication Policy and Procedure, dated 1/18/24, the P&P indicated, .the purpose of the Psychotropic Medication Policy and Procedure is to develop a facility system to ensure a resident is not given a psychotropic medication unless a comprehensive assessment which identifies clear indications and parameters for use.non-pharmacological interventions care plans and individualized plans of care will be utilized. Non-pharmacological interventions are utilized to decrease or discontinue psychotropic medications and limit PRN [as needed] use.During a review of the facility document titled, Health Information Management Guidelines, undated, the document indicated, .each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are defined as those given in excessive doses, for excessive periods of time without adequate monitoring, or in the absence of a diagnoses or reason supporting the necessity of the drug.documentation in the clinical record must justify the use of psychoactive drugs [a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior] by showing evidence that the resident has a specific condition, with specific behaviors listed.all interventions used to control the behavior prior to medicating.

Based on observation, interview, and record review, the facility failed to ensure the residents' call light was within reach for three of eight sampled residents (Resident 9, 11, and 55), when:1. Resident 9's call light was on the floor and not within his reach.2. Resident 11 and Resident 55's call lights were on their dressers and not within their reach. These failures had the potential to cause harm to Resident 9, Resident 11, and Resident 55 when these residents were not able to call for assistance with the use of their call lights in the event of an emergency.Findings:1. During an observation on 2/4/2026 at 3:35 p.m. in Resident 9's room, Resident 9 was observed dressed and lying in bed with eyes closed. Resident 9's call light was observed to be on the floor at the head of the bed and was not within Resident 9's reach.During a review of Resident 9's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/11/26, the AR indicated Resident 9 was admitted to the facility from an assisted living /board and care/group home on [DATE] with diagnoses which include . Acute and chronic respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epileptic seizures (a sudden, temporary surge of uncontrolled electrical activity in the brain that disrupts normal function), bipolar disorder (chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from high-energy manic episodes to low-energy depressive episodes), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), .During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/8/26, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS scores indicated Resident 9 had severe cognitive impairment.During a review of Resident 9's MDS assessment section GG Functional Abilities, dated 2/8/26, the MDS indicated Resident 9's functional abilities were coded 02. Resident 9 was code 02 (substantial/ maximal assistance: helper does more than half the effort) for toilet hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying-to-sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. The functional abilities code indicated Resident 9 needed substantial/ maximal assistance in 13 abilities.2. During an observation on 2/4/2026 at 3:35 p.m. in Resident 11's room, Resident 11 was observed dressed, lying in bed, and unable to respond appropriately to questions asked. Resident 11's call light was observed to be placed on his dresser and was not within Resident 11's reach.During a review of Resident 11's AR, dated 2/11/26, the AR indicated Resident 11 was admitted to the facility from an acute care hospital on 6/22/25 with diagnoses which include . essential hypertension (high blood pressure that has no single, identifiable medical cause), gastroesophageal reflux disease (condition where stomach acid frequently flows back into the tube connecting the mouth and stomach [esophagus]), varicose veins (swollen, twisted, and enlarged veins that usually appear blue or dark purple just under the skin's surface, most commonly in the legs) of unspecified lower extremity with ulcer (an open, painful sore on the skin that occurs when surface tissue breaks down) of unspecified sites, alcoholic cirrhosis of liver with ascites (a severe, advanced stage of liver disease caused by long-term alcohol abuse), venous insufficiency (condition where leg vein valves are damaged or weakened, preventing blood from flowing efficiently back to the heart), anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life), .During a review of Resident 11's MDS, dated [DATE], the MDS section C indicated Resident 11 had a BIMS score of 07, which indicated Resident 11 had severe cognitive impairment.During a review of Resident 11's MDS assessment section GG Functional Abilities, dated 12/22/25, the MDS indicated Resident 11's functional abilities were coded between 01, 02 and 88. Resident 11 was code 01 (dependent: helper does all the effort; resident does none of the effort to complete self-care) for shower/bath self. Resident 11 was code 02 (substantial/ maximal assistance: helper does more than half the effort) for oral hygiene, toilet hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, lying-to-sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 11 was code 88 (not attempted due to medical condition or safety concerns) for sit to stand. The functional abilities code indicated Resident 11 needed substantial/ maximal assistance in 10 abilities, was dependent on facility staff in 1 ability and 1 ability was not attempted due to Resident 11's medical condition or safety concerns.During a review of Resident 11's MDS, assessment, dated 12/22/25, the MDS section H indicated Resident 11's Bladder and Bowel function included Resident 11 was occasionally (less than 7 episodes of incontinence) incontinent (meaning the inability to control when you urinate or have a bowel movement) for urinary continence. Resident 11 was frequently incontinent (2 or more episodes of continence bowel movement) for bowel continence.During an observation on 2/4/2026 at 3:35 p.m. in Resident 55's room, Resident 55 was observed dressed and sitting in bed. Resident 55's call-light was observed to be placed on his dresser and was not within Resident 55's reach. During a review of Resident 55's AR, dated 2/11/26, the AR indicated Resident 55 was admitted to the facility from an acute care hospital on 4/18/25 with diagnoses which include . Senile degeneration of brain (the progressive, irreversible breakdown and death of brain cells [neurons] and their connections), hypothyroidism (condition where the butterfly-shaped thyroid gland in the neck does not produce enough thyroid hormones), type 2 diabetes mellitus (when the blood sugar levels in the body are too high), major depressive disorder (a serious, common medical illness characterized by persistent, intense feelings of sadness, low mood, or loss of interest in activities), anxiety disorder, essential hypertension, acute respiratory failure with hypoxia (condition where body tissues and cells do not receive enough oxygen to function properly ), .During a review of Resident 55's MDS, dated [DATE], the MDS section C indicated Resident 55 had a BIMS score of 00, which indicated Resident 55 had severe cognitive impairment.During a review of Resident 55's MDS assessment section GG Functional Abilities, dated 1/1/26, the MDS indicated Resident 55's functional abilities were coded between 02 and 03. Resident 55 was code 01 (partial/moderate assistance: helper does less than half the effort) for upper body dressing, lower body dressing and tub/shower transfer. Resident 55 was code 02 (substantial/ maximal assistance: helper does more than half the effort) for toilet hygiene, shower/bathe self, putting on/taking off footwear, and personal hygiene. The functional abilities code indicated Resident 55 needed partial/moderate assistance in 3 abilities, and substantial/ maximal assistance in 4 abilities.During a concurrent observation and interview on 2/4/26 at 3:38 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 checked for Resident 9, Resident 11 and Resident 55's call light. CNA 4 found Resident 9's call light on the floor. CNA 4 found Resident 11 and Resident 55's call lights on their respective dressers. CNA 4 stated Resident 11's call light was found hanging over the dresser instead of being placed within the resident's reach. CNA 4 stated the call light should be positioned next to Resident 11 at all times so he could use it when needed. CNA 4 stated it was important in the event Resident 11 needed to use the restroom and required assistance or experienced a fall. CNA 4 stated without proper placement, Resident 11 could experience an emergency and be unable to call for help. CNA 4 stated Resident 9's Call light was found on the floor behind Resident 9's bed. CNA 4 stated the reason for its placement there was unknown. CNA 4 stated Resident 9 was alert, incontinent, and required assistance with transferring and personal care. CNA 4 stated without access to the call light, Resident 9 would be unable to call for help, thus preventing facility staff from responding to Resident 9's needs in a timely manner. CNA 4 stated Resident 55's call light was found on his dresser rather than within reach. CNA 4 stated the reason for its placement on the dresser was unknown. CNA 4 stated Resident 55 was ambulatory and able to use the bathroom independently, however the call light should have remained within reach at all times in the event of an emergency or if assistance was needed. CNA 4 stated without proper placement of the call light, Resident 55 could attempt to get out of bed unassisted and fall, remained soiled for an extended period of time, or developed pressure sores or skin rashes as a result of delayed care.During a concurrent interview and record review on 2/4/26 at 3:57 p.m. with Registered Nurse (RN) 1, pictures of call lights in Resident 9, Resident 11, and Resident 55's room were reviewed. RN 1 stated and validated that the call light for Resident 11 was found on the dresser, the call light for Resident 9 was found on the floor, and the call light for Resident 55 was found on the dresser. RN 1 stated facility staff needed to be more diligent regarding the placement of call lights, and that call lights should always be kept at the bedside within the residents' reach. RN 1 stated it was important so that facility staff could respond promptly if a resident needed assistance, whether for something as simple as pain management or a more serious emergency. RN 1 stated that the potential outcome of improper call light placement could be fatal, as residents would be unable to reach facility staff when they needed help.During a concurrent interview and record review on 2/9/26 at 4:29 p.m. with the Director of Staff Development (DSD), pictures of call lights in Resident 9, Resident 11, and Resident 55's room were reviewed. The DSD stated call lights should always be within reach of the residents while in bed. The DSD stated it was important in order to prevent falls and to ensure that residents were able to get assistance promptly when needed. The DSD stated the potential outcome of improper call light placement included injuries or other emergencies going unattended.During a concurrent interview and record review on 2/10/26 at 3:15 p.m. with the Director of Nursing (DON), pictures of call lights in Resident 9, Resident 11, and Resident 55's room were reviewed. The DON stated call lights should always be within reach of the residents so that they were able to use them as needed. The DON stated it was important for the overall safety of the residents. The DON stated the potential outcome of improper call light placement included injuries.During a review of the facility's document titled, Job Description, Certified Nurse Assistant (CNA), dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A certified nurse assistant is responsible for the direct care of the group of residents assigned, and provides the activities of daily living care (ADL), including (ADL) documentation, and psychosocial services [relating to the interrelation of social factors and individual thought and behavior].2. To assist also the vice presidents with physical needs such as . Feeding, oral hygiene, .or any other physical need. 8. To encourage the resident to function at his/ her maximum level of ability at all times.During a review of the facility's document titled, Job Description, Registered Nurse, dated 7/12/2023, the document indicated, . Duties and Responsibilities: 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call.5. Organize and direct total nursing service on their respective shift.During a review of the facility's document titled, Job Description, Day Charge Nurse, Afternoon Charge Nurse, Night Charge Nurse, dated 7/12/2016, the document indicated, . Duties and Responsibilities: 1. A licensed professional nurse is responsible for the direct and indirect care of the residents. 2.is responsible for the nursing and nursing home . Provide such service under the direct supervision of the medical doctor and administrator on call. Take and give reports at the beginning and end of shifts.During a review of the facility's document titled, Job Description, Director of Staff Development and Education, dated 7/30/2022, the document indicated, . Duties and Responsibilities: Responsible for the planning, implementation, direction, and evaluation of all facility educational programs . 3 ongoing in-service education. The DSD works in direct conjunction with the director of nursing and all other department heads and is responsible for the education of all facility employees.15. train staff for proper competency or special needs resident.During a review of the facility's document titled, Job Description, Director of Nursing, dated 12/29/2025, the document indicated, . Duties and Responsibilities: 1. Reviews and establishes nursing policies practices and procedures. 2. interprets and administers general policies of [named company]. 3. supervises planning, organization and coordination and directing all nursing services. 4. responsible for effective patient care .During a review of the facility's policy and procedure (P&P) titled, Physical Environment Call Bell System, dated 8/8/2022, indicated, Policy Statement- [named company] maintains adequately equipped communication system to allow residents to call for staff assistance. Requirements: Call light is a remote residents use to call for assistance. Procedure: .Call system available at every resident bedside, restroom, shower area. Call light remotes within resident reach at all times, when in bed.During a review of the facility's P&P titled, Resident Rights, revision dated 7/9/2025, the P&P indicated, . Policy: The facility shall uphold and protect the rights of all residents without discrimination, consistent with federal and state regulations. Resident Rights Include but Are Not Limited To: I. Dignity and Respect. Be treated with dignity, respect and consideration.During a review of National Library of Medicine.org, Professional Reference titled, Use of Notification and Communication Technology (Call Light Systems) in Nursing Homes: Observational Study, dated 3/27/20, (found at https://pmc.ncbi.nlm.nih.gov/articles/PMC7148550/ ) the reference indicated, .Among the technologies used in nursing homes is the call light system, which plays a key role in communication. The call light system is critical for interactions between the nursing home staff and their residents. Research conducted in other health care settings has reported that nurse call systems significantly influence overall resident satisfaction in the delivery of their health care by creating a communication link between residents and nursing home staff. Nurse call light systems also help to ensure the safety of patients. a lifeline for patients because it is linked with patients' needs and alerts the staff to the situations in which patients may ask for help. Malfunctions of the nurse call light system can cause negative medical outcomes, . a relationship exists between the time it takes to respond to a call light system and adverse events such as falls. Certified nurse assistants (CNAs) contribute to more than 80% of direct care to residents. they must also respond to different types of alarms such as bed exit, chair exit, and clip alarms, as they are ultimately responsible in cases of adverse events.

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASRR) when 2 (Resident #19 and Resident #39) of 2 sampled residents reviewed for PASRR were diagnosed with a new serious mental illness. Findings included: A facility policy titled, PASRR Policy and Procedure, dated 04/04/2023, revealed, The PASRR consists of a Level I Screening, a Level 2 evaluation (if needed), and a determination, The PASRR is divided into two components, the Preadmission Screening (PAS) and the resident review (RR). The PAS process is completed by the hospital prior to an individual discharging to a skilled nursing facility (SNF). A SNF can also complete the PAS process, but only when the individual is being admitted directly from the community. The RR process is completed for current SNF residents, readmissions, or inter-facility transfers when there is a significant change in the individual's physical or mental condition. In the case of an RR, the NF [nursing facility] initiates the process by submitting a Level I Screening as an RR in the PASRR system. The policy specified, 3. The MDS coordinator shall complete the RR after 30 days from admission, and when there is a significant change in the resident's physical or mental condition. 1. An Admission Record revealed the facility admitted Resident #19 on 03/17/2022. According to the Admission Record, the resident received diagnoses of bipolar disorder and anxiety disorder on 03/12/2024. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #19 had active diagnoses to include anxiety disorder and bipolar disorder. Resident #19's Care Plan Report included a focus area revised 04/05/2025, that indicated the resident used anti-anxiety medication related to a diagnosis of anxiety disorder. Resident #19's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASRR evaluation when the resident received a new mental illness diagnosis. The Admissions Coordinator (AC) was interviewed on 04/09/2025 at 11:08 AM. The AC stated if a resident received a new mental illness diagnosis after admission, the MDS Coordinator was responsible for updated the PASRR. The AC stated that without the psychiatric diagnoses included, the state agency would not have requested a level II PASRR, but not having a level II PASRR had not affected Resident #19's care. The MDS Coordinator was interviewed on 04/09/2025 at 1:25 PM and stated she was unaware Resident #19 required a level II PASRR. The Executive Director was interviewed on 04/10/2025 at 9:05 AM and stated she expected staff to revise and resubmit the PASRR to the state agency. 2. An Admission Record revealed the facility admitted Resident #39 on 07/03/2023. According to the Admission Record, the resident received diagnoses of psychosis, anxiety disorder, and dementia with agitation on 11/08/2023. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/2024, revealed Resident #39 had active diagnoses to include non-Alzheimer's dementia, anxiety disorder, and psychotic disorder. Resident #39's Care Plan Report included a focus area revised 07/10/2024, that indicated the resident used anti-anxiety medications related to a diagnosis of anxiety disorder. Resident #39's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a level II PASRR evaluation when the resident received a new mental illness diagnosis. The MDS Coordinator was interviewed on 04/09/2025 at 1:25 PM and stated she was unaware Resident #39 required a level II PASRR. The Executive Director was interviewed on 04/10/2025 at 9:05 AM and stated she expected staff to revise and resubmit the PASRR to the state agency.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan that addressed hospice care for 1 (Resident #38) of 1 sampled resident reviewed for hospice and end of life. Findings included: A facility policy titled, Comprehensive Individualized Resident Care Plan (Activities) Isolation, dated 01/01/2024, indicated Comprehensive Individualized resident care plans provide a past and current history to current issues, illnesses, medication use, and another other factors. An Admission Record revealed the facility admitted Resident #38 on 09/22/2023. According to the Admission Record, the resident had a medical history that included an anxiety disorder and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2025, indicated Resident #38 had a Staff Assessment for Mental Status (SAMS) that revealed the resident had modified independence in cognitive skills for daily decision making. The MDS indicated that the resident received hospice care. Resident #38's Care Plan Report with an admitted [DATE], revealed no evidence to indicate a care plan that addressed hospice services. Resident #38's Order Summary Report with orders active as of 04/09/2025, revealed an order dated 09/22/2023, that directed admitted to hospice, no hospitalization , routine laboratory tests or x-rays without prior authorization. The MDS Coordinator was interviewed on 04/09/2025 at 1:01 PM. The MDS Coordinator stated she typically included hospice on a resident's care plan but did not add the residents' code status to the care plan since the code status was included in the physician's orders. The MDS Coordinator stated it was important to add hospice to the care plan so facility staff would be able to identify the reason the resident was admitted to hospice and to alert staff that another team would be working with a resident. The MDS Coordinator confirmed that Resident #38 received hospice services and that she did not include hospice services on Resident #38's care plan with information about what would be provided by the hospice agency. On 04/09/2025 at 3:10 PM, the MDS Coordinator stated she amended Resident #38's care plan to include hospice and the services provided. The MDS Coordinator stated she had been unaware she omitted hospice on the resident's care plan until the omission was brought to her attention. The Director of Nursing (DON) was interviewed on 04/09/2025 at 3:20 PM and stated it was important to include hospice on the resident's care plan so facility staff would know who provided what type of care. The DON stated she expected the care plan to include the reason the resident admitted to hospice and any specific requests Resident #38 and/or their family might have. The Executive Director was interviewed on 04/10/2025 at 8:57 AM and stated she expected hospice care to be identified on Resident #38's care plan.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 2 (Resident #19 and Resident #38) of 14 sampled residents. Findings included: A facility policy titled, Minimum Data Set, dated dated [DATE], revealed, To provide an accurate assessment of all residents through clinical competence, observational, interviewing, and critical thinking skills, combined together to develop individualized plan of care for each individual. 1. An Admission Record revealed the facility admitted Resident #19 on 03/17/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. A significant change in status MDS, with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #19 was rarely/never understood. The MDS Coordinator was interviewed on 04/09/2025 at 1:25 PM. The MDS Coordinator stated that it was important for the MDS to be accurate because the MDS reflected the resident's condition. The MDS Coordinator reviewed the MDS for Resident #19 and stated she had made an error when she coded the resident was rarely/never understood. The MDS Coordinator reported on 04/09/2025 at 3:10 PM that she amended Resident #19's MDS to correct the resident's cognitive ability and that she had been unaware the MDS was inaccurate until the inaccuracy was brought to her attention. The Director of Nursing (DON) was interviewed on 04/09/2025 at 3:20 PM and stated she expected the MDS to be accurate. The DON stated if the resident's cognitive status was not correct, the MDS was inaccurate. The Executive Director (ED) was interviewed on 04/10/2025 at 9:05 AM. The ED stated there needed to be communication between the staff to ensure the MDS was accurate. 2. An Admission Record revealed the facility admitted Resident #38 on 09/22/2023. According to the Admission Record, the resident had a medical history that included an anxiety disorder and major depressive disorder. A quarterly MDS, with an Assessment Reference Date (ARD) of 02/16/2025, indicated Resident #38 had a Staff Assessment for Mental Status (SAMS) that revealed the resident had modified independence in cognitive skills for daily decision making. The MDS indicated the resident did not have an active diagnosis of anxiety disorder or depression. The MDS Coordinator was interviewed on 04/09/2025 at 1:01 PM. The MDS Coordinator stated she amended Resident #38's MDS to include their diagnoses of depression and anxiety. The Director of Nursing was interviewed on 04/09/2025 at 3:20 PM and stated she expected depression and anxiety to be included on the MDS for Resident #38 under the MDS section that included active diagnoses. The Executive Director (ED) was interviewed on 04/10/2025 at 8:57 AM. The ED stated she expected the MDS to be accurate and to include all diagnoses that were pertinent to Resident #38's care. She stated she expected Resident #38's depression and anxiety to be captured on the MDS.

Based on interview and record review, the facility failed to offer 53 of 54 residents the Covid 19 (a disease caused by a virus named SARS-CoV-2) vaccine (an injection that teaches the immune system how to recognize and fight off specific diease or virus) when it became available to them and did not educate residents, or their designated responsible parties (a person, not the resident, who are responsible for that residents care), on the risks and benefits of Covid-19 vaccination (injection into the body to produce protection from a specific disease). This failure resulted in the Covid-19 vaccine not being available to residents and had the potential to put the residents safety at-risk. Findings: During a review of the facility's Residents Covid Vaccination Status- Resident Directory (RCVS), dated 12/11/23, the RCVS indicated 53 out of 54 Residents were unvaccinated in regard to Covid-19. During a review of the facility's [Pharmacy Store]- Screening Questionnaire and Consent (permission from resident) Form (SQ), not dated, the SQ indicated it was received by Infection Preventionist Late September - Early October . During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 26's MDS assessment indicated Resident 26's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 26 was cognitively intact. During an interview on 12/15/23 at 2 p.m., with Resident 26, Resident 26 stated he was not educated or offered the most recent Covid vaccine. During an interview on 12/15/23 at 2:26 p.m., with the Infection Preventionist (IP), the IP stated the most current version of the Covid-19 vaccine was available to the facility at the beginning of September, or early October 2023. The IP stated she went to the local [Pharmacy Store], they provided her with consent forms and told her they would provide the vaccine to any resident that wanted it. The IP stated she did not educate or offer the vaccine to residents, or their responsible parties, after the vaccine was available to the facility. The IP stated she was busy and never got around to doing it. The IP stated she did not follow the facility's policy and procedure Coronavirus Disease (Covid-19) - Vaccination of Residents. During an interview on 12/15/23 at 4:04 p.m., with the Administrator (ADM), the ADM stated there was not any documentation about the facility offering or educating residents on the availability of the current Covid-19 vaccine. The ADM stated she knew the IP went to [Pharmacy Store] in early October and they could provide the vaccine to the residents that consented to it. During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (Covid-19) - Vaccination of Residents, dated 12/1/23, the P&P indicated, Implementation . [skilled nursing facility] want to ensure the safety of the residents .by encouraging residents to get the most up to day Covid-19 vaccines . All residents must be educated about the most up to date Covid-19 vaccines and offered the opportunity to be taken out of the facility to receive the vaccine .

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Two of three sampled Certified Nursing Assistants (CNAs) placed clean linen on top of the personal protective equipment (PPE-equipment worn to minimize exposure to illnesses) cart in the hallway while donning (putting on) their PPE. These failures had the potential to cause an outbreak of the COVID-19 virus (a serious contagious respiratory [Lung] infection transmitted from person to person) outbreak (a sudden rise in the number of cases of a disease) throughout the facility. 2. One of three sampled CNAs exited a room marked red zone (rooms with residents testing positive for COVID-19) with PPE on and walked down the hallway. These failures had the potential to spread the COVID-19 virus throughout the hallway. 3. One of three sampled CNAs exited a red zone room and placed her face shield contaminated side down on top of the PPE cart. These failures had the potential to contaminate the top of the PPE cart and spread the COVID-19 virus. 4. One of two facility entrance doors did not have signage instructing visitors and staff to self-screen for COVID-19 symptoms prior to entering the facility according to policy and procedures. These failures had the potential to cause an outbreak of the COVID-19 virus for the facility residents and staff. 5. The facility did not have an annual review, or committee, as stated in the policy and procedure for Legionella (a bacteria that can cause pneumonia [a potentially fatal infection of one or both lungs that could cause breathing difficulties) since 2016. This failure had the potential for the facility to have outdated information in regard to Legionella and possibly expose residents to communicable disease Legionellosis (Legionnaires Disease is pneumonia caused by legionella bacteria that is spread through the air). This disease could cause serious harm, or death in residents through mist from places such as air and heating units. 6. One of one Certified Nursing Assistant (CNA) 11 did not follow the facility policy and procedure when she went into resident Covid-19 positive rooms (Resident 5, Resident 352, Resident 28) with a portable blood pressure machine to take their vital signs (essential body function including heartbeat, breathing rate, temperature and blood pressure) rather than using a dedicated sphygmomanometer (commonly referred to as a blood pressure cuff, an instrument used to measure a person's blood pressure) for each isolation room. This failure had the potential to spread the Covid-19 infection and put rooms 301, 302, 303, 304, 305 and 307 safety at-risk. 7. The facility did not follow the manufacturer guidelines for the use of germicidal disposable wipes for three of three residents (Resident 5, Resident 352, Resident 28) when Certified Nursing Assistant (CNA 11) did not properly disinfect a multi-use item (portable blood pressure cuff) after use. This failure had the potential to result in the spread of Covid-19 infection and put resident safety at-risk for residents in rooms 301, 303, 305 who were not covid positive. 8. One of one resident (Resident 32) who was on transmission-based precautions (measures to prevent spread of infections) was found in the hallway coughing and without a mask, was accompanied by Certified Nursing Assistant (CNA) 7 to the dining room. This failure had the potential to result in infection or bacterial growth for one of one resident (Resident 2), when: 9. Licensed Vocational Nurse (LVN 1) did not clean glucometer (device used for measuring glucose in the blood) after use for Resident 2 per facility policy and manufacturer guidelines (written recommendations by manufacturer for use of product). This failure had the potential to result in the spread infections and bacteria to other residents and staff in the facility. Findings: 1. During a concurrent observation and interview on 12/11/23 at 11:45 a.m. with CNA 4, in front of room [ROOM NUMBER], room [ROOM NUMBER] was marked with a sign which indicated the room was a red zone. CNA 4 placed a pile of clean linen on top of the PPE cart. CNA 4 stated the red zone sign indicated the residents in the room were positive for COVID-19. CNA 4 wore an N95 mask (designed to protect wearer from contaminated airborne particles), donned a gown, gloves and face shield to enter room [ROOM NUMBER]. CNA 4 stated she should not have placed clean linen on top of the PPE cart because it could contaminate the linen and spread COVID-19 to the residents. During an observation on 12/11/23 at 12:16 p.m. CNA 5 was observed at the PPE cart next to room [ROOM NUMBER]. CNA 5 placed a pile of clean linen on top of the PPE cart and donned PPE. CNA 5 picked up the clean linen pile and entered room [ROOM NUMBER] which was marked red zone. During an interview on 12/11/23 at 2:25 p.m. with CNA 5, CNA 5 stated he had placed the linen on top of the PPE cart to don his PPE. CNA 5 stated clean linen should not be placed directly on the PPE cart because it was not sanitary. CNA 5 stated residents could become ill from contaminated linens. During an interview on 12/12/23 at 11:20 a.m. with the Director of Staff Development (DSD), the DSD stated she was also an Infection Preventionist (healthcare personnel who specializes in infection prevention and control). The DSD stated the expectation was for staff to place a protective barrier on top of the PPE cart and don PPE. The DSD stated the clean linen should not be placed on the PPE cart without a barrier because the top of the cart carries germs which could be taken into the resident rooms causing illness and spreading COVID-19. During an interview on 12/12/23 at 4:37 p.m. with the Director of Nursing (DON), the DON stated, It was not a good idea to place clean linen on top of the PPE cart due to infection control. During a review of the facility's document titled, Coronavirus Disease (COVID-19) Mitigation Plan Addendum to the [Facility name] Policy and Procedure Mitigation Plan, updated on 12/1/2023, was reviewed. The mitigation plan indicated, . Staff have been trained on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care . During a review of professional reference from https://www.cdc.gov/hai/prevent/resource-limited/laundry.html titled Healthcare-Associated Infections (HAIs), dated 5/4/2023, was reviewed. The professional reference indicated, . Linen and laundry management Best Practices . Best practices for management of clean linen . Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items . Transport clean linens to patient care areas on designated carts or within designated containers . 2. During a concurrent observation and interview on 12/11/23 at 12:26 p.m. with CNA 6, CNA 6 walked out of room [ROOM NUMBER] marked red zone wearing a gown, gloves, goggles and an N95 mask. CNA 6 walked down the hallway to place a dining tray onto the cart. CNA 6 removed the gown in the middle of the hallway and walked into the shower room wearing the gloves. CNA 6 stated she placed the soiled gown in the shower room receptacle. CNA 6 stated she exited room [ROOM NUMBER] with her PPE still on. CNA 6 stated the residents in room [ROOM NUMBER] had COVID-19 and she should not have left the room with the PPE on. CNA 6 stated the PPE was contaminated with COVID-19 and she could have spread it in the hallway. CNA 6 stated she should have taken the PPE off in the room to place them in biohazard (substance dangerous to humans) containers. CNA 6 stated if she spread COVID it could cause the residents to become very sick. During an interview on 12/12/23 at 11:20 a.m. with the DSD, the DSD stated the expectation was for staff to remove gown and gloves prior to exiting the COVID-19 isolation rooms. The DSD stated the hallway could become contaminated from the PPE and spread COVID-19. During a review of the facility's document titled, Coronavirus Disease (COVID-19) Mitigation Plan Addendum to the [Facility name] Policy and Procedure Mitigation Plan, updated on 12/1/2023, was reviewed. The mitigation plan indicated, . Staff have been trained on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care . Trash bags or bins are positioned as near as possible to the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room . During a concurrent interview and record review on 12/12/23 at 3:35 p.m. with the IP, the facility's policy and procedure (P&P) titled, Isolation, dated 5/14/21 was reviewed. The P&P indicated, . An ISOLATION sign should be placed on the outside door . Removing an Isolation Gown . Slip out of gown and . Discard it carefully in the soiled linen hamper in the resident's room . During a concurrent interview and record review on 12/12/23 at 4:37 p.m. with the Director of Nursing (DON), the facility's P&P titled, Isolation, dated 5/12/21 was reviewed. The DON stated the P&P indicated PPE should have been removed inside the residents' room. The DON stated if PPE was not removed in the residents' room, it could contaminate the hallway and cause infection control issues. 3. During a concurrent observation and interview on 12/11/23 at 11:45 a.m. with CNA 4, CNA 4 exited room [ROOM NUMBER], marked red zone wearing a face shield. CNA 4 took off the face shield and laid it contaminated side down on top of the PPE cart. CNA 4 wiped both sides of the shield with a cleaning wipe and put it immediately into a brown paper bag. CNA 4 stated should not have placed her face shield on top of the PPE cart because it was contaminated from the red zone room. CNA 4 stated it infected the top of the PPE cart and could spread COVID-19. CNA 4 stated she should have let the face shield dry before putting into the paper bag. During an interview on 12/12/23 at 11:20 a.m. with the DSD, the DSD stated the expectation for reusing the face shields was for the staff to use a barrier on top of the PPE cart and not place a contaminated face shield directly on the cart. The DSD stated the PPE cart would become contaminated and could spread COVID-19. The DSD stated a wet face shield should not be placed in a bag because it would not be sanitized. During an interview on 12/12/23 at 4:37 p.m. with the Director of Nursing (DON), the DON stated the PPE cart would be contaminated from the face shield and could cause infections to spread. 4. During an observation on 12/11/23 at 3:14 p.m. of the facility's north entrance, there was no signage indicating what signs or symptoms staff and visitors should self-screen for prior to entering the facility. During an interview and record review on 12/12/23 at 2:02 p.m. with the IP, a photo taken on 12/11/23 of the north entrance doors was reviewed. The IP stated the facility's process for self-screening was posting signs on the entrances which indicated symptoms to screen for prior to entering the facility. The IP reviewed the photo and stated there was no self-screening sign on the doors in the photo. The IP stated the north entrance should have a self-screening sign on the doors. The IP stated screening was important to stop anyone with symptoms from entering the facility. During an interview on 12/12/23 at 3:35 p.m. with the IP, the IP stated the facility's COVID-19 policy and procedure was the Mitigation Plan. During a review of the facility's document titled, Coronavirus Disease (COVID-19) Mitigation Plan Addendum to the [Facility name] Policy and Procedure Mitigation Plan, updated on 12/1/2023, was reviewed. The mitigation plan indicated, . [Facility name] has a self-Screening plan where Posters are Posted at the Front Main entrance and the North Entrance instructing Everyone to self-evaluate for any respiratory Signs or Symptoms and to stay out if any are present . 47888 5. During an interview on 12/14/23 at 11 a.m., with Maintenance Supervisor (MS), the MS stated he was responsible for Legionella oversight at the facility. The MS stated he has been in his position for 2 years and had never been part of an annual review or committee in regard to Legionella. The MS stated the last committee meeting for Legionella was in 2016 per the form [Facility name] Water Management Program to Reduce Legionella. During an interview on 12/14/23 at 1:40 p.m., with the Administrator (ADM), the ADM stated the facility hadn't documented any meetings, or reviews, in regard to legionella. The ADM stated the facility would committee in the future. During an interview on 12/14/23 at 1:56 p.m., with the Infection Preventionist (IP), the IP stated that she had never been part of a committee for legionella. The IP stated the facility did not follow the policy and procedure, Reducing Risk of Legionella. During an interview on 12/14/23 at 1:58 p.m., with the Director of Staff Development (DSD), the DSD stated she had never been part of a committee for legionella. The DSD stated that an annual review would be helpful to see if the legionella program was working properly and assess for potential improvements needed. The DSD stated the last annual review for legionella was in 2016. During a review of the facility's Legionella committee meeting minutes titled, [Facility name] Water Management Program to Reduce Legionella (WMP), dated 12/7/16, the WMP indicated, Objective: To prevent the occurrence of Legionnaire's Disease in [Facility name], we will establish a water management program . Agenda: .External (outside) factors that can promote Legionella growth . Internal Factors . Steps of Water Management . Meeting on 12/7/16 . During a review of the facility's communicable disease information titled, Title 17, California Code of Regulations (CCR) 2500, 2593, 2641.5-2643.20 and 2800-2812 Reportable Diseases and Conditions, no date, the CCR indicated, .Reportable Communicable Diseases . Disease Name . Legionellosis . During a review of the facility's policy and procedure (P&P) titled, Reducing Risk of Legionella, dated 9/28/18, the P&P indicated, Legionella bacteria are naturally present in the environment and if water conditions are favorable to the bacteria i.e. (for example) warm, nutritious and stagnant, they will proliferate (grow). Disturbance of this 'contaminated' water can cause tiny droplets to become airborne which, if inhaled, can cause a potentially fatal type of pneumonia called Legionnaires disease. Those people especially at risk are the old or those who are ill as their immune system is less able to fight the disease .Procedure: A committee has been established to oversee water quality related to prevention of Legionella. It consists of: The administrator . Infection Preventionist . Maintenance Supervisor . A facility risk assessment will be conducted and reviewed annually to identify possible risks where Legionella may be found . 6. During a review of Resident 352's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included Unspecified Dementia (a progressive disease with memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Disease involves parts of the brain that control thought, memory and language) and a subsequent diagnosis of Covid-19 (infectious disease). Resident 5 and Resident 28 Face Sheet's were requested but were not received. During a concurrent observation and interview on 12/14/23 at 3:40 p.m., with CNA 11 in the East Hallway, CNA 11 took a portable blood pressure machine (PBPM) with a thermometer and blood pressure cuff into a Covid-19 positive room [ROOM NUMBER]. CNA 11 stated she took the PBPM to get vital signs from all of the rooms she was responsible for. CNA 11 stated she was responsible for four Covid-19 positive rooms and one non-covid room. CNA 11 stated she took the same PBPM to both the Covid and non-covid rooms. During an interview on 12/14/23 at 3:55 p.m., with the Infection Preventionist (IP), the IP stated CNA 11 should not take the PBPM from a Covid-19 positive room to a non-covid room. The IP stated cross-contamination (process by which bacteria is transferred from one substance or object to another, with harmful effect) could occur between residents. The IP stated this practice could spread disease and put resident safety at-risk. During an interview on 12/15/23 at 8:36 a.m., with the Director of Nursing (DON), the DON stated the PBPM should not be going into Covid-19 positive rooms. The DON stated each Covid-19 room should have had its own manual blood pressure instrument and thermometer to take resident vital signs. The DON stated the PBPM going into Covid-19 positive rooms could spread infection and was a risk to resident safety. The DON stated the policy and procedure Isolation was not followed. During an interview on 12/15/23 at 10:08 a.m., with the Director of Staff Development (DSD), the DSD stated the PBPM going into Covid-19 positive rooms could spread infection. The DSD stated this was a resident safety issue. During an interview on 12/15/23 at 11:50 p.m., with the IP, the IP stated the policy and procedure Isolation was not followed. The IP stated the thermometer and PBPM should not have gone into Covid-19 positive rooms. During a review of the facility's Daily Work Schedule (DWS), dated 12/14/23, the DWS indicated, .room [ROOM NUMBER]-A Resident 5, room [ROOM NUMBER]-B Resident 352, room [ROOM NUMBER]-C Resident 28 . During a review of the facility's policy and procedure (P&P) titled, Isolation, dated 5/14/21, the P&P indicated, Isolation .Taking Temperature and Blood Pressure . 1. Leave thermometer and sphygmomanometer (instrument used to measure a person's blood pressure) in the isolation room until the resident is discharged or removed from isolation . 7. During a review of Resident 352's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included Unspecified Dementia (a progressive disease with memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Disease involves parts of the brain that control thought, memory and language) and a subsequent diagnosis of Covid-19 (infectious disease). Resident 5 and Resident 28 Face Sheet's were requested but were not received. During a concurrent observation and interview on 12/14/23 at 3:40 p.m., with CNA 11 in the East Hallway, CNA 11 took a portable blood pressure machine (PBPM) from Covid-19 positive room [ROOM NUMBER] to Covid-19 positive room [ROOM NUMBER]. CNA 11 wiped the PBPM with a germicidal disposable wipe in-between rooms and let it dry for 45 seconds before she went into the next room. CNA 11 stated that after she used the germicidal wipes, she would let it dry for about a minute before going into the next room. During an interview on 12/14/23 at 3:55 p.m., with the Infection Preventionist (IP), the IP stated disease could be spread if the PBPM was not cleaned properly. The IP stated cross-contamination (process by which bacteria is transferred from one substance or object to another, with harmful effect) could occur between residents. The IP stated resident safety could be put at-risk. During an interview on 12/15/23 at 8:36 a.m., with the Director of Nursing (DON), the DON stated the PBPM should not be going into Covid-19 positive rooms. The DON stated the germicidal disposable wipes should be wet for 2 minutes until dry. The DON stated the bottle was clearly labeled with a disinfect time of 2 minutes. The DON stated that if instructions on the bottle were not followed that contamination could occur, infection could spread and resident safety could be put at-risk. During an interview on 12/15/23 at 10:08 a.m., with the Director of Staff Development (DSD), the DSD stated if the PBPM was not cleaned properly that this was a resident safety issue. During a review of the manufacturer guideline titled, General Guidelines For Use- [Brand Name] Germicidal Disposable Wipe, the manufacturer guideline indicated, .Disinfects in 2 minutes . 4. Allow treated surface to remain wet for two (2) minutes. Let air dry . 48713 8. During an observation on 12/11/23 at 11:30 a.m. on the [NAME] Hallway, Resident 32 was observed in her wheelchair exiting a room with transmission-based precautions, coughing, and was not wearing a mask. Resident 32 was observed to be taken into the dining room by CNA During a review of Resident 32's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 11/3/23, the MDS indicated Resident 32 had a BIMS (Brief Interview for Mental Status) score of 99 (resident was unable to complete Brief Interview for Mental Status). During an interview on 12/11/23 at 1:54 p.m. with LVN 3, LVN 3 stated Resident 32 was on transmission-based precautions due to cohorting (sharing a room) with a resident with COVID-19 (a contagious respiratory disease that has caused millions of deaths around the world as well as lasting health problems in those that have survived the disease). LVN 3 identified CNA 7 and stated CNA 7 took Resident 32 into the dining room. LVN 3 stated, the CNAs are supposed to distance the resident from each other, and it was expected that the Residents are offered to wear a mask. LVN 3 stated she would not expect to see Resident 32 sitting in the dining room because there was a potential for spreading COVID-19 to other people or residents. During an interview on 12/11/23 at 2:12 p.m. with CNA 7, CNA 7 stated Resident 32 was on transmission-based precautions, and it was expected that if a resident exited their room, CNAs would notify the LVN in charge. CNA 7 stated they did not expect to see Resident 32 in the dining room because it was open to all residents and if there were other residents in the dining room, there was a potential to spread COVID-19. During an interview on 12/11/23 at 3:41 p.m. with Infection Preventionist (IP), IP stated the expectation was for Resident 32 to remain in room and treated as a Resident on transmission-based precautions for a period of 10 days. IP stated she was unaware that Resident 32 was out of the room. During an interview on 12/12/23 at 1:42 p.m. with the Director of Nurses (DON), the DON stated it was the expectation for everyone inside the facility to have been masked and for residents to be kept in their rooms. The DON stated CNA 7 should have put a mask on Resident 32 if exiting Resident 32's room was needed. The DON stated CNA 7 should not have made the clinical decision to remove Resident 32 out of their room and should have informed the Licensed Nurse (LN). DON stated Resident 32 being out of her room without a mask had the potential for exposure to everyone in the facility, including visitors. During a review of Resident 32's, Plan of Care (POC), dated 12/11/23, the POC indicated, . COVID-19 infection . isolated in red zone with staff to care for res . During a review of facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) Mitigation Plan Addendum to [facility name] Policy and Procedure Mitigation Plan, dated 12/1/23, the P&P indicated, . If dedicated COVID-19 positive area is unavailable, the resident will remain in current room and it will become a Covid Positive room. Since the roommates of the confirmed Covid positive resident were significantly exposed they will remain isolated in the room as well . 9. During a concurrent observation and interview on 12/12/23 at 11:01 a.m. with LVN 1, LVN 1 was observed exiting resident 2's room following blood glucose check (test that measures glucose in the blood). LVN 1 was observed removing contaminated gloves, proceeded to don new pair of gloves without completing hand hygiene, used a [brand name] (disposable disinfecting wipe) located on the medication cart to clean Resident 2's glucometer. LVN 1 was observed wiping the top of the glucometer and wrapped it in the disinfecting wipe. LVN 1 stated the glucometer will sit wrapped in the disinfecting wipe for 2-3 minutes and stated 3 minutes was better. During a review of Resident 2's Record of Admission ([NAME]) [a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information], indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Type 2 diabetes mellitus (body blood sugar levels are higher than normal and doesn't produce adequate amount of insulin). During a review of the manufacturer's General Guidelines for use Super Sani-cloth germicidal disposable wipe, dated 2021, the manufacturer's guidelines indicated, .If present, use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry . During an interview on 12/12/23 at 3:33 p.m. with LVN 1, LVN 1 stated after the glucometer was used the process was for the Licensed Nurse (LN) to clean the top of the glucometer, around and underneath using a [brand name] disinfecting wipe that was folded over after every wipe, the glucometer would then be wrapped with a clean [brand name] disinfecting wipe for two to three minutes. LVN 1 stated it was important to effectively clean the glucometer to prevent infection. LVN 1 stated if glucometer is not cleaned properly there was a potential for infection to Resident 2 due to possible bacterial growth. LVN 1 stated it was expected the LN followed the manufacturer guidelines for contact time (the amount of time a disinfectant need to sit on a surface, without being wiped away or disturbed, to effectively kill germs) and allow surface to remain wet for 2 minutes and let it dry. LVN 1 stated following the guidelines for cleaning removed bacteria from the clean surface. During an interview on 12/15/23 at 2:49 PM with IP, IP stated it was important that staff understand the contact time when cleaning glucometers, so they know how long it would take for them to kill the germs on surfaces. IP stated she did not recall the last time LN were educated on the process of cleaning a glucometer. IP stated if staff was using the incorrect contact time or not allowing the glucometer to dry the surface will not be clean and free of germs. During a review of the facility's policy and procedure titled, Cleaning and Disinfecting Glucose Meter, dated 1/18/20, indicated, . Nurse to wear gloves . use Sani-cloth wipes . rub the entire outside of the meter using a circular wiping motion, with moderate pressure on the front, back, left side and right, top to bottom of the meter . let meter dry thoroughly before use or storage .

Based on interview and record review, the facility failed to develop a comprehensive resident - centered care plans for 12 of 37 sampled residents (Residents 7, 17, 24, 26, 28, 31, 33, 34, 35, 37, 42 and 43) when Social Service Director (SSD) and Activity Director (AD) did not develop activity care plans for Residents 7, 17, 24, 26, 28, 31, 33, 34, 35 37, 42 and 43 since they were admitted to the facility. These failures resulted in Residents 7, 17, 24, 26, 28, 31, 33, 34, 35, 37, 42 and 43 not having activities they could engage in, which could lead to boredom, loss of interest, inactivity, depression, feelings of isolation, decreased socialization opportunities with others, and loss of control over their lives while residing at the facility. Findings: During a review of Resident 7's Record of Admission ([NAME], (a document with patient information, past medical history, allergies, insurance status or other pertinent information) dated 12/13/23, the [NAME] indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (high levels of fat particles in the blood) and osteoporosis (a disease in which bones become fragile and more likely to break (fracture). During a review of Resident 17's [NAME] dated 12/13/23, the [NAME] indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and diabetes (high level of sugar in the blood). During a review of Resident 24 's [NAME] dated 12/13/23, the [NAME] indicated Resident 24 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), osteoarthritis (wear and tear of the joints which causes joint pain and stiffness) and dementia. During a review of Resident 26's [NAME] dated 12/13/23, the [NAME] indicated, Resident 26 was admitted to the facility on [DATE], with diagnoses which included, diabetes, anxiety (feelings of worry and fear about things that are about to happen, or which could happen in the future) and muscle weakness During a review of Resident 28's [NAME] dated 12/13/23, the [NAME] indicated Resident 28 was admitted to the facility on [DATE], with diagnoses which included, hypertension, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and osteoporosis. During a review of Resident 31's [NAME] dated 12/13/23, the [NAME] indicated Resident 31 was admitted to the facility on [DATE], with diagnoses which included, atrial fibrillation (irregular and often very rapid heart rhythm), diabetes and hyperlipidemia (excessive fats in the blood). During a review of Resident 33's [NAME] dated 12/13/23, the [NAME] indicated Resident 33 was admitted to the facility on [DATE], with diagnoses which included, Alzheimer's disease, hypertension and diabetes. During a review of Resident 34's [NAME] dated 12/13/23, the [NAME] indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included, end stage renal disease (kidneys cease functioning on a permanent basis), diabetes and glaucoma (group of eye diseases that can cause vision loss and blindness). During a review of Resident 35's [NAME] dated 12/13/23, the [NAME] indicated, Resident 35 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (progressive disorder of the nervous system that gets worse over time and causes tremor, stiffness in the limbs or the trunk of the body and impaired balance). During a review of Resident 37's [NAME] dated, 12/13/23, the [NAME] indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included, hypertension, spinal stenosis (narrowing of the spinal canal in the lower part of the back) and Alzheimer's disease. During a review of Resident 42's [NAME] dated, 12/13/23, the [NAME] indicated Resident 42 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (disrupted blood flow to the brain), diabetes, osteoarthritis, and muscle weakness. During a review of Resident 43's [NAME] dated 12/13/23, the [NAME] indicated, Resident 43 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis, hypertension and glaucoma. During a concurrent interview and record review on 12/13/23 at 1:37 p.m. with SSD and AD, The SSD stated the AD reports to her. The AD stated she did not do care plans in the computer and does it on paper. The SSD and AD reviewed care plans for Residents 7, 17, 24, 26, 28, 31, 33, 34, 35, 37, 42 and 43's and stated, We did not find activity care plans for all 12 residents on paper and electronic. The SSD reviewed facility policy titled, Resident Care Plan, undated and stated they did not follow their own care plan policy and procedure. During an interview on 12/15/23 at 4:45 p.m. with the Director of Nursing (DON), the DON stated care plans provides individualized care for residents and staff to follow the plan of care. The DON stated the AD was responsible in making sure the comprehensive care plans were completed in a timely manner. The DON stated the AD knew how to do care plans and was responsible in initiating the activity care plan for each residents. The DON stated if the AD did not know how to do care plans she could have let her know and DON could have shown AD how to do care plans. During a review of facility's policy and procedure (P&P) titled, Resident Care Plan, undated, the P&P indicated, . The Resident Care Plan form generall has three (3) major columns: Problem/Need, Goal, and Approaches . The problem/need that is to be addressed should be entered in a concise, specific, understandable manner . During a review of facility's policy and procedure titled, Policy and Procedure for Care Plans, dated 5/14/21, the P&P indicated, . a comprehensive plan of care developed for every resident within the first 30 days following admission, as the intake process and needs assessment continues .

Based on observation, interview and record review, the facility failed to provide comprehensive assessments and monitoring of pressure ulcers (PU) (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) consistent with professional standards of practice for four of five sampled residents (Residents 1, 2, 3, and 4) when wound sizes were not assessed, measured, and documented as indicated in the facility ' s policy and procedure. These failures resulted in Resident 1 ' s sustaining a deep tissue pressure injury (DTPI) (persistent non-blanchable deep red, maroon, or purple discoloration) on her coccyx (lower back) on [DATE] and had no skin assessments completed prior. Resident 2 ' s right hip pressure ulcer progressed from a stage 2 (tender, painful injury to partial thickness of the skin caused by pressure) to a stage 4 (deep wound reaching the muscles, ligaments, and bone) pressure wound from [DATE] to [DATE], and Residents 3, and 4 had the potential for worsening pressure injuries when they did not receive the wound care assessment and monitoring needed to promote healing and prevent worsening of wounds. Findings: During a review of Resident 1 ' s Face Sheet, (FS, document with resident information) dated [DATE], the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of surgical repair of a fracture to the right hip, atrial fibrillation (abnormally fast heart rhythm), and hypertension (abnormally high blood pressure affecting the blood vessels in the body), and repeated falls. During a review of Resident 2 ' s Face Sheet dated [DATE], the FS indicated, Resident 2 was admitted to the facility on [DATE]. The FS indicated, Resident 2 had diagnoses of chronic heart failure (condition where the heart is unable to pump enough blood to supply the body ' s organs with oxygen), type II diabetes mellitus (chronic condition where the body is not able to produce/use the hormone insulin to metabolize glucose), degenerative disease of the nervous system (characterized by problems controlling movements of the body and loss of sensation). During a review of Resident 3 ' s Face Sheet dated [DATE], the FS indicated, Resident 3 was admitted to the facility on [DATE]. The FS indicated, Resident 3 had diagnoses of heart failure, atrial fibrillation, and type II diabetes mellitus. During a review of Resident 4 ' s Face Sheet, dated [DATE], the FS indicated, Resident 3 was admitted to the facility on [DATE]. The FS indicated, Resident 4 had diagnoses of left hip fracture, heart failure, atrial fibrillation, hypertension, and type II diabetes mellitus. During a concurrent interview and record review, on [DATE], at 1:15 p.m., with the Registered Nurse/Director of Staff Development (RN/DSD), Resident 1 ' s physician ' s orders, dated [DATE] and admission records, dated [DATE] were reviewed. RN/DSD stated, she was familiar with Resident 1. The RN/DSD stated, Resident 1 had a deep tissue pressure injury on her coccyx (lower back) area. The RN/DSD stated, Resident 1 was admitted to the facility on [DATE]. The RN/DSD stated Resident 1 was on hospice care and had stopped eating and drinking and had died on [DATE]. The RN/DSD stated, Resident 1 ' s DTPI was acquired in the facility because it was not on the MDS admission skin assessment dated [DATE]. The RN/DSD was unable to find Resident 1 ' s start date of the DTPI or a measurement of the wound due to lack of documentation of the pressure injuries in the nursing notes. The RN/DSD stated, she did not know when the wound was found. The RN/DSD reviewed the physician ' s orders for Residents 2, 3 and 4 dated [DATE]. The RN/DSD confirmed Residents 2, 3, and 4 had pressure injuries. The RN/DSD had difficulty using the electronic health record system and was unable to find daily skin assessments for these residents. The RN/DSD stated, the Director of Nurses (DON) was responsible for PU assessments and planning of care for PU, but the DON was unavailable to be interviewed so she was in charge of retrieving the requested records. The RN/DSD stated, she was unable to locate the wound care documents and would need help from the DON to locate information on the wounds for Residents 1, 2, 3 and 4. The RN/DSD stated, the assessment of PU should include routine measurement, color, and drainage. The RN/DSD stated, the resident ' s PU should have been measured by the nursing staff to monitor the PU. During a concurrent observation and interview, on [DATE] at 1:32 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 4 ' s room at the facility, Resident 4 was in her bed with her feet elevated on a pillow. Resident 4 had PU on both heels of her feet that were dry with dark colored scabs. Resident 4 ' s heel wounds had an ointment on them. LVN 1 stated, Resident 4 had an unstageable DTPI on both heels of her feet. LVN 1 stated, Resident 4 ' s wound on the right heel was 6.0 centimeters (cm-measurement) by 6.0 cm and the left heel wound was at 10 cm by 9 cm on [DATE] per documentation of the wound doctor at a previous visit to the facility. LVN 1 stated the wounds had not been remeasured since the PU on both heels began [DATE], 25 days ago. LVN 1 stated the wounds had started as blisters and then opened. LVN 1 stated, she had not measured the wounds since the wounds began treatment on [DATE]. LVN 1 stated, PU should have been measured to monitor for worsening. LVN 1 stated, wound measurement was part of the assessment and should have been done. LVN 1 stated, she had not looked at the facility ' s policy and procedure on wounds in a long time and was not told to do wound measurements by the DON. LVN 1 stated, she thought wound measurements should have been done daily. During a concurrent observation, interview, and record review, on [DATE] at 1:48 p.m., with LVN 1, in Resident 3 ' s room, Resident 3 was lying in her hospital bed on her right side watching television. Resident 3 ' s wound was observed at coccyx area approximately the size of a nickel and the wound was covered in white powder. Resident 3 stated, Leave me alone. LVN 1 stated, the treatment for Resident 3 ' s stage 2 PU was to clean it with normal saline solution and cover with nystatin powder (medication used to treat infections) three times a day. LVN 1 reviewed the nursing notes from [DATE] to [DATE] and was unable to find a wound measurement for Resident 3 ' s PU due to lack of documentation in the nursing notes. LVN 1 stated, the original wound size was 1 cm by 1 cm on admission [DATE]. LVN 1 stated, she looked at the wound every shift but had not measured the wound since Resident 3 ' s admission. LVN 1 stated, she should have measured Resident 3 ' s PU wound but had not. During a concurrent observation and interview, on [DATE] at 2:10 p.m., with the RN/DSD in Resident 2 ' s room, Resident 2 was in his hospital bed asleep, lying on his left side. The RN/DSD stated, Resident 2 had a stage 4 PU on his right hip area. The RN/DSD stated, she did not know when Resident 2 had developed the PU. The RN/DSD stated, she was unable to find an assessment or nursing note with the size of the wound on the facility ' s electronic charting system. The RN/DSD stated, . I would need to talk to the DON about Resident 2 ' s PU. The RN/DSD stated, she was unable to access the EMR for the residents with PU and the DON was unavailable at this time. The RN/DSD stated, the DON was responsible for residents with PU. The RN/DSD stated the nursing assessments with wound sizes should have been available to all nursing staff. During a concurrent interview and record review, on [DATE] at 2:12 p.m., with RN 1, RN 1 reviewed the nursing notes dated ,d+[DATE] to [DATE], the physician ' s orders (PO) dated [DATE], and the undated nursing care plan for Resident 2. RN 1 stated she had been assigned to care for Resident 1. RN 1 stated, Resident 2 had a stage 4 (Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) PU with tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) on the right hip. RN 1 reviewed Resident 2 ' s wound care specialist notes dated [DATE] and stated the most recent wound measurement was dated [DATE] and indicated the size was 1.2 cm by 2.5 cm by 1.2 cm deep with tunneling. RN 1 stated, she thought Resident 2 ' s PU began ,d+[DATE] but was unable to find nursing notes or physician ' s notes on Resident 2 ' s wound. RN 1 stated, Resident 2 started a wound care specialist on [DATE] and was diagnosed with stage 4 PU. RN 1 stated the licensed nurses should have been documenting wound length, width, depth, color, drainage, odor, and how the resident tolerated the treatment every time they did a treatment but had not. RN 1 validated there was no tracking and monitoring of the wound measurement since admission of Resident 2. During a concurrent interview and record review, on [DATE] at 2:42 p.m., with the Social Services Director (SSD), the SSD stated, she was unable to find documentation of when Resident 2 acquired the PU in the nursing notes dated [DATE] to [DATE]. The SSD stated the nursing care plan for Resident 2 ' s PU should have had the start date of the PU but did not. The SSD stated, she was unable to find the start date of Resident 2 ' s PU on the MDS. The SSD stated, the DON was responsible for assessment and care for PU. The SSD stated, she expected the nurses would have documented start date and size of PU for Residents 1, 2, 3, and 4 but had not. During a concurrent interview and record review, on [DATE] at 2:55 p.m., with the Registered Nurse/Medical Data Set (RN/MDS), the RN/MDS reviewed the nursing notes, physician ' s notes, nursing care plans, MDS skin assessments for Residents 1, 2, 3, and 4 ' s PU. The RN/MDS stated, she was unable to find any physician ' s notes for Resident 2 for ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] on his PU. The RN/MDS stated she was responsible for documenting admission assessments and change in condition assessments on the MDS. The RN/MDS stated, she found a nursing note dated [DATE] which indicated a change in condition for Resident 2 ' s PU but the note did not indicate a wound size measurement. The RN/MDS stated the DON was responsible for residents PU and I would need to talk to her about documentation because she was unable to find the requested documentation. The RN/MDS stated, she only found an order dated [DATE] for antibiotics for cellulitis (signs of inflammation (redness, edema, pain, increased exudate, and surface warmth) on Resident 2 ' s right hip. The RN/MDS stated, she was unable to find nursing assessments for Residents 1, 2, 3, and 4 ' s PU but she thought the DON had them in a separate location and I would need to speak to her. The RN/MDS stated, the DON was unavailable. The RN/MDS stated she thought all nursing staff should have access to the resident ' s wound care information. The Braden scale, nursing notes, detailed wound assessments for Residents 1, 2, 3, and 4 were requested but not provided by the RN/MDS. The RN/MDS stated the licensed nurses should be documenting on PU assessments daily but had not. During a concurrent telephone interview, and record review, on [DATE] at 1 p.m., with the DON, the DON reviewed the documentation for wounds for Residents 1, 2, 3, and 4. The DON had not provided a Braden Scale (tool used to assess skin and predict pressure ulcers) assessment for Resident 1 which had been requested from the RN/DSD and again from the DON by email on [DATE]. The DON stated, the nursing staff reported to her Resident 1 had a 10 cm by 4.5 cm DTPI on [DATE] per the nursing notes. The wound specialist notes dated [DATE] indicated Resident 1 ' s wound was an unstageable deep tissue injury that was 7 centimeters by 7 centimeters by unmeasurable depth. The DON stated the last measurement for Resident 1 ' s PU was [DATE] and she died on [DATE]. The DON stated, Resident 1 was admitted with the redness to her back on [DATE] but there was no documentation in the MDS assessment. The DON stated it took a while for the area to open. The DON stated, Resident 2 ' s PU started on [DATE] and it was stage 2 when he was hospitalized on [DATE]. The DON stated, Resident 2 ' s PU was a stage 4 when he returned from the hospital on [DATE]. The DON stated, she was unable to find any documentation for Resident 2 for a description or size of the PU in the nursing notes from [DATE] to [DATE]. The DON stated Resident 3 was admitted with a 1 cm by 1 cm PU on her coccyx area. The DON stated, the licensed nurses had not documented assessment of size and description of P U in the nursing notes. The DON provided the assessments, nursing notes, physician ' s notes, and wound care documentation for Residents 1, 2, 3, and 4. The DON confirmed the documents did not have routine measurements of wound size and descriptions of the PU. The DON stated, the facility needed to change the way they document wound care to include assessment with description and size of the wounds. The DON stated, she was unable to find any physician ' s notes which indicated whether the wounds were avoidable (resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident ' s clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate) or unavoidable (resident developed a pressure ulcer/injury even though the facility had done everything required). The DON stated, she was responsible for assessment and care planning for PUs. The DON stated, the facility had not been documenting the assessment, wound description, or measurements of PU wounds. The DON stated, the facility needed to change the way documentation wound care. The DON stated, If it wasn ' t documented, it wasn ' t done. During a review of Resident 1 ' s Physician ' s Orders (PO) dated [DATE], the PO indicated Resident 1 had an order started on [DATE] for DTI (deep tissue injury). The order indicated, .Monitor DTI to coccyx measuring 4.5 cm x 4.0 cm . The PO indicated another order was initiated on [DATE] for the DTI. The order indicated, .Irrigate unstageable DTI of distal sacrum (lower back) and use 0.25% Dakin ' s (antiseptic solution) moistened gauze for wet to dry [every shift] . A Braden skin assessment for Resident 1 was requested on [DATE] from the RN/DSD but was not provided by time of exit. During a review of Resident 2 ' s PO dated [DATE] through [DATE], the PO indicated Resident 2 started an order on [DATE] for unstageable DTI. The order indicated, Unstageable DTI to right hip cleanse with NS (normal saline), pat dry. Use 0.25 % Dakin ' s for wet to dry dressing, cover with gauze island border [three times a day] for 30 days . A Braden skin assessment from [DATE] to [DATE], before Resident 2 was hospitalized , was requested from the RN/DSD but was not provided. During a review of Resident 3 ' s Face Sheet dated [DATE], the FS indicated Resident 3 was admitted to the facility on [DATE]. The FS indicated Resident 3 had diagnoses of heart failure, atrial fibrillation and type II diabetes mellitus. During a review of Resident 3 ' s PO dated [DATE], the PO indicated Resident 3 started an order on [DATE] which indicated, .Off load pressure to sacrum, split measuring 2.5 cm .Nystatin powder to coccyx daily . A Braden skin assessment prior to ,d+[DATE] was requested on [DATE] for Resident 3 from the RN/DSD but was not provided. During a review of Resident 4 ' s PO dated [DATE], the PO indicated Resident 4 started an order on [DATE] which indicated, .Measure open area left heel AM .Measure open area [right] heel AM . Another order dated [DATE] indicated, Skin prep to dark scabs [left heel] QD (daily) until resolved AM . Skin prep to dark scabs [right heel] QD until resolved AM .Offload bilateral heels at all times .Apply collagen open areas surrounding dark dry scab to bilateral heels QD until healed AM . During a review of the facility ' s policy and procedure titled, Pressure Ulcers Prevention and Management Skin Integrity dated [DATE], the policy indicated, .To maintain the integrity of residents skin .To minimize the risks and prevent the occurrence of skin breakdown .Skin assessment includes: head to toe evaluation, including bony prominences, skin folds and creases .To promote prompt plan of care for any skin concerns .The use of the Braden Scale/Braden Score on admission, quarterly and PRN (as needed) .Daily inspections .Identified skin concerns(decubitus) assessed, measured, staged. Documentation includes description of tissue involved .Communication with nursing staff on progress of wound .Wound Physician weekly and PRN . During a review of the professional reference retrieved from http://www.ncbh.nlm.nih.gov/books/NBK532897/ . titled, Wound Pressure Injury Management dated [DATE], the professional reference indicated, .Pressure injuries are defined as the breakdown of skin integrity due to pressure. This can occur when a bony prominence is under persistent contact with an external surface. The most common site for pressure injuries is the sacrum. Other common sites include the heels . Explain the importance of improving care coordination among interprofessional team members to ensure proper pressure injury prevention protocols are in place and enhance surveillance in order to optimize outcomes for patients with pressure wounds .Elderly and bed-bound individuals are more prone to developing pressure (decubitus) ulcers. The hip and buttock region accounts for approximately two-thirds all pressure ulcers .The Braden scale is a widely used screening too to determines the patients who are at risk .Daily skin check-up is required, especially for patients who are at a high risk for skin breakdown .If patients develop skin breakdown due to moisture, the nurse is at fault for not properly delegating and overseeing the nursing assistants .Initiating weekly rounds is a great way to assess the wound and skin integrity. Working as a team, the wound care doctor, nurse, and nursing assistant should fully assess all patients admitted to the floor. Bedsores are evaluated and proper care determined according to need .Complications of pressure injuries still occur and can be life-threatening. All stages of pressure ulcers are prone to complications, especially stage III and stage IV .Pressure ulcers are very difficult to treat, it is crucial that the nurses and clinicians work together as an interprofessional team to provide the very best care including treatment, monitoring, and follow up care .

Based on observation, interview and record review, the facility failed to administer [MEDICATION(S)] fluids ([MEDICATION(S)] fluids administered by injection through the tissue and circulatory system) in accordance with professional standards of practice for one of 15 sampled residents (Resident 32), when Resident 32 was admitted to the facility on [DATE] with a peripherally inserted central catheter (PICC, tube that is inserted into a vein in the upper arm to the heart) for the purposes of administering intravenous (IV - through the vein) antibiotics. The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Four of four Registered Nurses (RN) were not trained and did not follow the standards of practice in the care of the PICC line nor the administration of the IV antibiotics. These failures had the potential to cause Resident 32 to experience adverse outcomes such as life threatening blood infection and [CONDITION(S)] (skin infection that happens when bacteria spread through the skin to the deepest tissue)due to nursing staff not having the knowledge, training, and competency to safely care for Resident 32's PICC line and administer her IV antibiotics. Because of the serious potential harm to Resident 32 who received IV antibiotic therapy through a PICC line from Nursing staff who did not follow the professional standards of practice, nor have the training or competencies to perform PICC line care and medication administration per PICC line, an Immediate Jeopardy (IJ) situation (a situation that involves immediate action to remove the threat of harm or potential harm) was called on 4/15/21 at 4:43 p.m., under Code of Federal Regulations (CFR) 483.25 [MEDICATION(S)] Fluids (F694) with the facility Administrator (ADM), Director of Nurses (DON), the Infection Preventionist (IP - are professionals who make sure healthcare workers and residents are doing all the things they should to prevent infections), and Director of Staff Development (DSD). IJ template was provided to the ADM. The facility submitted an acceptable IJ Plan of Removal (POR) Version 3) on 4/19/21 at 6:50 a.m. The IJ POR included but was not limited to the following: 1) The IP , DSD, and DON were immediately trained by a primary Care Physician (PCP) on standards of care for PICC, 2) Policies and Procedures (P&P) based on current standards of practice for the care of residents with central lines were revised and updated, in serviced, and implemented, 3) Physician orders for medication administration, use of IV pump as ordered, and frequency and care of residents with central lines were followed, 4) Trained and competent RNs were assigned to care for the resident with central line each shift, 5) Licensed Vocational Nurses (LVN) were immediately reassigned to care for residents without central lines, and, 6) A process was developed to ensure that (future) resident needs are identified prior to admission and could be met by qualified and competent staff. The components of the IJ POR were validated onsite to be fully implemented through observations, interviews, and record review. The IJ was removed on 4/20/21 at 1:37 p.m. with the ADM, DON, IP and DSD. Findings: During a review of Resident 32's Record of Admission (document with resident demographic and medical diagnosis) undated, and the Minimum Data Set (MDS- a resident assessment tool used to identify a resident's cognitive and physical functional level) assessment dated [DATE], indicated Resident 32 was a [AGE] year old female who was admitted to the facility on [DATE] from a general acute care hospital (GACH) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 32's MDS - Brief Interview for Mental Status (BIMS) score was 13, which indicated Resident 32 had intact memory and judgement and had no cognitive deficits. During a review of Resident 32's Discharge Documentation dated 3/19/21 at 3:36 p.m., from the GACH, indicated . In summary this is a patient admitted for progressive neck pain found to have imaging evidence of [CONDITION(S)] and discitis (inflammation of spinal disc, rubbery pads between the vertebrae, the specialized bones that make up the spinal columns). Neurosurgery was consulted who recommended medical management. IR (Interventional Radiology - minimally-invasive image-guided procedures to diagnose and treat diseases) was consulted twice for bone biopsy (The removal of a sample of bone marrow and a small amount of bone through a large needle) but deemed too high risk to proceed. ID (Infectious Disease) was consulted for empiric (experience-based therapy) and recommended the therapy stated above x (every) 8 weeks. There was concern that this could be due to underlying malignancy .Patient discharged to SNF (Skilled Nursing Facility) with weekly labs . Neurosurgery recommended a hard collar (device used to limit neck movement and promote healing) when OOB (out of bed); patient to continue collar until cleared by neurosurgery. Lack of improvement in [CONDITION(S)] markers (causes for swelling) and symptoms may suggest abx (antibiotic) failure vs (versus) alternative dx (diagnosis) such as malignancy. During a review of Resident 32's Physician's Telephone Order (PTO) dated 3/19/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date on 3/29/21 .RN only to provide PICC line site care . [The PICC line care PTO did not indicate the directions for dressing changes and site care]. During a review of Resident 32's PTO dated 3/28/21 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = {equals} 50 milliliters (unit of measurement) daily until 5/19/21 for cervical spine abscess (pocket of pus in the neck and spinal tissues). During a review of Resident 32's Physician's Order (PO) dated 3/30/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview, on 4/14/21 at 10 a.m., with Resident 32, in her room, Resident 32 was alert, oriented, and responded when greeted, Resident 32 had a PICC line located on her right upper arm. Resident 32's PICC line port (entrance point to PICC line tube) did not have a port protector cap (an alcohol-filled cap to prevent infection). A green elastic pressure dressing (typically used after blood had been drawn from a vein) was in place on Resident's 32's right upper arm. When asked who changed the PICC line dressing, Resident 32 stated, The DON, IP, and DSD usually change the [PICC] dressing every Monday . but they changed the dressing last Wednesday (4/7/21). Resident 32 stated, I am just here for the IV antibiotic treatment. I do not want my PICC line to get infected. During an interview on 4/14/21 at 10:06 a.m., with the MDS Coordinator (a Registered Nurse responsible for the resident MDS assessments), the MDS Coordinator stated, the PICC line entry port should have a protector cap to prevent cross-contamination (the process by which bacteria and other micorogranisms are tranfered from one substance to another). The MDS Coordinator stated, We don't have the protector cap in stock and have to order them from the pharmacy. During a concurrent record review and interview regarding the lack of port protector cap on Resident 32's PICC entry port, on 4/14/21 at 11:57 a.m. with the IP, the P&P titled Guidelines for Preventing Intravenous Catheter-Related Infections, dated August 2014, indicated General Guidelines .Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy including .indications for IV catheter use .proper procedures for the insertion and maintenance of IV catheters . appropriate infection control measures to prevent IV catheter-related infections. The IP stated he had no comment as to why there was no protector cap on Resident 32's PICC entry port. During an interview regarding Resident 32's PICC line care, on 4/14/21 at 4:01 p.m. with IP, the IP stated . The PICC line did not have a protector cap at the port entry . I did not put port protector caps because we don't have them nor use them. The IP stated Resident 32's PICC dressing change as ordered to be done on Mondays (4/5/21 and 4/12/21) were not done because the pharmacy had not delivered sterile gloves in his size (extra-large). The IP stated Resident 32's PICC line dressing was only changed on 4/7/21 by the DSD under his guidance. The IP stated he had not informed Resident 32's PCP that the PICC line dressing had not been changed. The IP stated, I was not aware I needed to notify the PCP. The IP stated he had not put the PICC Line dressing change on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The IP stated he documented the PICC line dressing change in the nursing notes. The IP was unable to provide a PICC Line dressing change nursing note since Resident 32's admission on 3/19/21. The IP stated he did not measure the PICC line during dressing changes [to check for migration/movement]. The IP stated he used a black permanent marker on the skin near the PICC line insertion site to measure the catheter line. The IP stated the pen did not need to be sterile. The IP stated he had always done it that way. When asked what standard of practice the IP followed for PICC Line dressing changes, the IP stated he followed the instructions on the dressing packaging. A review of the PICC line dressing package provided by the IP indicated, Latex Free Dressing Change Kit. The IP validated the Dressing kit did not have instructions for changing a PICC line dressing. During an interview on 4/14/21 at 4:30 p.m., with the ADM, the ADM stated the DON decided to accept Resident 32 with a PICC line because she (DON) thought she could provide the PICC line care by herself. During a concurrent observation and interview on 04/14/21 at 5:01 p.m., with the DON and the IP outside of Resident 32's room, Resident 32 was seated at the edge of the bed with the green pressure dressing still covering the PICC line on Resident 32's right arm. When asked about the choice of dressing used, the IP entered Resident 32's room and prepared to don gloves. When asked what he intended to do, he stated in a loud tone of voice, What do you want me to do? If you want me to take off the pressure dressing, I will! The IP was requested to provide the standard of practice for IV PICC line care. After the IP exited the room, the DON entered the room and removed the pressure dressing from Resident 32's right upper arm. After the DON had the left the room, Resident 32 stated that her right arm hurt. Upon examination of Resident 32's right upper arm, two non-blanching, (when the redden skin is pressed it does not lose the red pigmentation) red lines were present. A crinkled off-white paper taped over the [transparent dressing] was dated 4/7/21. The [MEDICATION(S)] edges was lifted and loose and did not cover the entire PICC line site. The standard of practice for IV PICC line care was not provided as requested. During an observation and interview on 04/15/21 at 6:51 a.m. with the IP in Resident 32's room, the IP informed Resident 32 that he would be administering the IV antibiotics today. Resident 32 stated, The DON always hangs my morning medicine, she is the only one that has ever done it since I have been here. The IP donned non-sterile gloves and opened the brown plastic bag which had a pharmacy label (PL) dated 4/12/21 indicating the Physician's IV antibiotic order for Resident 32. The PL indicated, .Assemble [drug name] to NACL (a solution that contains 1:1 ration of sodium and chloride, as directed and immediately infuse 100 ml 2 (GM - unit of measure), over one hour IV via IV pump daily until 5/19/2021 * Infuse contents entire bag . The IP took out a vial of [MEDICATION(S)] (brand name for [MEDICATION(S)]) 2 grams for IV use Single-dose. The IP mixed the [MEDICATION(S)] powder with the 50 ml bag of saline and prepared for infusion. The IP connected the tubing to the injection port but did not use the IV tubing regulator to ensure the right drops per minute was administered. Instead, the IP took his cell phone out of his pocket and counted the number of drops infusing per minute by using his cell phone as a timer. The IP stated, It should be 50 drops per minute . I was never trained on how to use this tubing. During calculation of rate per minute; for 50 ml to infuse in one hour, the drops to infuse would be 8.3 drops per minute. During a concurrent interview and record review, on 4/19/21, at 11:24 a.m., with the Director of Nurses (DON), Resident 32's Physician's Orders (PO's) dated 3/19/21, indicated the PICC Line dressing was to be changed weekly. The PO did not indicate type of dressing for the PICC Line or instructions on the procedure to change the dressing. The DON stated she needed to clarify the PO for the PICC Line dressing change. During an interview on 4/20/21 at 9:25 a.m., with the IP, the IP stated the facility had about eight (8) PICC Lines in four (4) years. The IP stated, .We [RN's] are rusty . The IP stated the RN's should have had training on PICC Line medication and care before admission of residents who needed this therapy. During an interview and record review, on 4/20/21 at 11:23 a.m., with the Director of Staff Development (DSD), the DSD confirmed the Licensed Nurse Competencies (Core abilities required for nursing procedures) training were not done in 2019, 2020, or 2021 for the three RN's employed at the facility (DSD, DON and MDS/RN). The DSD confirmed there were no Licensed Nurse Competencies done at orientation for the IP, who began about three month ago. The DSD stated RN competencies were supposed to be done at orientation and annually. The DSD stated she was responsible for RN competencies. The DSD stated she did not know who was responsible for the DON competencies. The DSD stated she thought the Administrator (ADM) would do the training for the DON, because she was the DON's boss. During an interview on 4/20/21 at 11:28 a.m., with the DON and the ADM, the DON, .We should assess the residents prior to admission to ensure we can provide care for them . I admit we are lacking on education . we do not get residents with PICC line all the time. The DON stated skills competencies for licensed nurses should be done annually. During an interview on 4/20/21 at 11:52 a.m., with the ADM, the ADM stated the DSD was responsible for ensuring the nursing competencies were done. The ADM stated the DSD was responsible for the DON's competency training. The ADM stated the facility did not have a way to track the nursing competencies. During a concurrent interview, and record review on 4/21/21 at 9:00 a.m., with the DON, the Licensed Nurse Competencies for 2019, 2020, and 2021 were reviewed for the four RN's currently employed at the facility. The DON confirmed there was no record of Licensed Nurse Competencies for the DON for 2019, 2020, or 2021. The DON confirmed there was no record of Licensed Nurse Competencies for the Minimum Data Set Coordinator (MDSC) (MDS) (a standardized assessment and care planning tool), for 2020 or 2021. The DON confirmed there were no Licensed Nurse Competencies for the Director of Staff Development (DSD) for 2019, 2020, or 2021. The DON confirmed the IP was hired about three months ago and had no Licensed Nurse Competencies on file. The DON stated the Licensed Nurse Competencies were supposed to be done annually, but were not. The DON stated the Licensed Nurse Competencies were the responsibility of the DSD. The DON stated she would have to help the DSD get coordinated with a tracking plan for the nursing competencies. The DON stated the Licensed Nurse Competencies were important to ensure the nurses were competent in patient care. During a review of the facility policy and procedure titled, Nursing Services-Building Competency ongoing Training and In-Services dated 2/20/20, indicated, .The purpose of this policy is to define and set up expectations regarding a system to enhance the competency skills of the nursing department .This process includes verification of education and competence Upon hire and then ongoing basis to substantiate evidence of proficiency and skill for the quality of resident care .Including but not limited to ongoing evaluation of competency, and education .[Name of facility] will follow clinical skills of competency and will have at a minimum annual performance reviews . During a review of the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf, dated October 2017, indicated, 1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site 2. If the patient is diaphoretic (sweating heavily) or if the site is bleeding or oozing, use a gauze dressing until this is resolved. 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. 4. Do not use topical antibiotic ointment or creams on insertion sites, except for [CONDITION(S)] catheters, because of their potential to promote fungal infections and antimicrobial resistance. 5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). 6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. 7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. 8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed 14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. 15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. During a review of the Journal of Infusion Nursing The Official Publication of the Infusion Nurses Society Infusion Therapy Standards of Practice, dated January/February 2016, indicated, . Standard 1.1 The Infusion Therapy Standards of Practice is applicable to any patient care setting in which vascular access devices (VADs) [a sterile tube that provides access to your veins for the delivery of intravenous (in the vein) medication such as a PICC (Peripherally inserted central catheter- external device placed in upper arm) line] are placed and/or managed and where infusion therapies are administered. 1.2 Infusion therapy is provided in accordance with laws, rules and regulations . federal and state regulatory and accrediting bodies . 1.3 Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders . 3. SCOPE OF PRACTICE .Practice Criteria . D. Nursing Personnel . 5. Registered Nurse (RN) a. Complete an organized educational program on infusion therapy due to the lack and/or inconsistency of infusion therapy in basic nursing criteria . b. Do not accept assignments and tasks when one . is inadequately prepared to perform the assignment or task . d. Delegate tasks, activities, and components of care after determination of competency to perform the specific task . f. Use critical thinking and nursing judgement to apply the Five Rights of Delegation . 4. INFUSION TEAM . A. Assign vascular access device (VAD) . management and surveillance only to individuals and or teams with infusion therapy education, training, and validated competency . 5. COMPETENCY ASSESSMENT AND VALIDATION Standard . 5.2 The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration . 5.3 Competency assessment and validation is performed initially and on an ongoing basis. 5.4 Competency validation is documented in accordance with organizational policy . C. Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform the assigned job. 1. Validate initial competency before providing patient care . when the scope of practice changes, and with the introduction of new procedures, equipment, or technology. 2. Validate continuing competency on an ongoing periodic basis . 10. DOCUMENTATION IN THE MEDICAL RECORD Standard 10.1 Clinicians document their initial and ongoing assessments . 10.2 Documentation contains accurate, complete, chronological, and objective information in the patient's medical record regarding the patient's infusion therapy and vascular access with the clinician's name, licensure or credential to practice, date, and time. 10.3 Documentation is legible, timely, accessible to authorized personnel, and efficiently retrievable. 10.4 Documentation reflects the continuity, quality, and safety of care . Practice Criteria A. Documentation includes . 1. Patient . responses to therapy, interventions, and education. 2. Specific site preparation, infection prevention, and safety precautions taken, using a standardized tool for documenting . 3. The type, length, and gauge/size of the vascular access device (VAD) inserted . date and time inserted . 6. peripherally inserted central catheters (PICCs): a. External catheter length and length of catheter inserted. b. Arm circumference: before insertion of a PICC and when clinically indicated to assess the presence of [CONDITION(S)] [swelling] and possible deep vein [CONDITION(S)] [DVT-blood clot] . 7. Condition of site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort or any pain with each regular assessment of the access site, and patient report of changes related to the VAD or access site. 9. condition of the . access site prior to and after infusion therapy. 10. Results of VAD functionality assessment including patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of a blood return upon aspiration. 41. VASCULAR ACCESS DEVICE (VAD) ASSESSMENT, CARE AND DRESSING CHANGES . H. Perform dressing changes . 1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressing at least every 2 days . 4. Change the dressing . if dressing becomes loose/dislodges . During a review of the APIC POSITION PAPER: SAFE INJECTION, INFUSION, AND MEDICATION VIAL PRACTICES IN HEALTH CARE (2016) dated January 2016, indicated, Disinfect catheter hubs, needleless connectors, and injection ports before accessing. Use either an antiseptic containing port protector cap37-41 or vigorously apply mechanical friction with [MEDICATION(S)]/alcohol,42-43 sterile 70% [MEDICATION(S)] alcohol,44-47 or other approved disinfectant swab. Change disinfecting port protectors as directed per manufacturer's recommendations. Follow institutional policy when using the wiping method to disinfect catheter hubs, needleless connectors, and injection ports. Published studies, guidelines and organizations vary (from 3 to 15 seconds) on the amount of time to disinfect when using the wiping method.22,42,48-53 Some of these studies were product and /or device specific therefore results may not be able to be extrapolated to other types of devices. Allow adequate dry time (unless directed otherwise by manufacturer's instructions) before entry . During a review of the Peripherally Inserted Central line Catheter(PICC) Dressing Change undated , indicated, .A transparent dressing on a Peripherally Inserted Central Catheter (PICC) is changed every 7-10 days and/or if it is damp, visibly soiled, loosened or if redness/drainage is noted at the site. The preferred dressing to use on a PICC site is the [MEDICATION(S)] CHG (Trademark) dressing, unless a skin reaction to the dressing occurs. To determine appropriate dressing and exit site care to use if skin reaction occurs, refer to Management of Dressing Related [CONDITION(S)] algorithm. The use of a securement device is recommended to ensure secure stabilization of a PICC. The [MEDICATION(S)] (Trademark) CHG dressing is considered a securement device. If not using the [MEDICATION(S)] (Trademark) CHG dressing, a [MEDICATION(S)] (Trademark) device must be used to secure the catheter. If a gauze dressing is used or if gauze is placed under a transparent dressing and obscures the exit site, the dressing must be changed every 48-72 hours, or more often if it becomes damp/soiled/loose. Aseptic technique is an essential component of all central vascular catheter access procedures to reduce the risk of catheter related blood stream infection. PICC exit sites are visually examined when changing the dressing and by palpation through an intact dressing every shift. For outpatients, sites are examined at each visit. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing is to be removed to allow thorough examination of the site. [MEDICATION(S)] CHG (Trademark) dressings are not appropriate for use in patients younger than 2 months of age. For changing the dressing on a cuffed PICC, follow procedure for dressing change of cuffed central venous catheter.

Based on interview and record review, the facility failed to ensure [MEDICAL TREATMENT] (is a process by which dissolved substances are removed from a patient's body by diffusion (movement or spread) from one fluid compartment (space) to another across a semipermeable membrane (a layer that only certain molecules (smallest particle of a substance) can pass through) services were provided consistent with professional standards of practice for two of three sampled residents (Resident 1 and Resident 2) when licensed nurses performed Peritoneal [MEDICAL TREATMENT] (PD- is a treatment for [REDACTED]. Health care providers call this lining the peritoneum (is a tissue that lines the abdominal wall and covers most of the organ in the abdomen) on Resident 1 and Resident 2 without written orders from a Nephrologist (NT-physician specializing in the treatment kidney diseases), performed PD without having been trained by [MEDICAL TREATMENT] nurses from a certified [MEDICAL TREATMENT] center (DC), failed to perform adequate pre and post PD assessments, and the facility did not have approved specific PD policies and procedures based upon current standards of practice. These failures resulted in the potential harm of not adequately dialyzing Residents 1 and Resident 2 and could have led to adverse outcomes such as electrolyte (is a substance that plays a vital role in maintaining homeostasis (is any self-regulating process by which an organism tends to maintain stability while adjusting to conditions that are best for its survival)in the body) imbalance, blood pressure instability, and possibly death. On 11/5/20, after Licensed Vocational Nurse (LVN) 1 had disconnected Resident 1 from the PD machine, Resident 1experienced syncopal ([MEDICAL CONDITION]) episode, became unresponsive, and had a low blood pressure (BP) of 88/40 mmHg ((millimeters of mercury- a unit of measurement) the normal range of systolic BP (the pressure of the blood is exerting against the artery walls when the heart beats) is 120 and the normal range for diastolic BP (how much pressure the blood is exerting against the artery walls while the heart is resting between beats) is 80). Resident 1 was transferred to the hospital and subsequently admitted for further treatment. Because of the serious potential harm to Residents 1 and Resident 2 the serious potential harm for any resident requiring PD due to not having trained and competent nurses and no policies and procedures to provide PD, an Immediate Jeopardy situation was called on 11/9/20 at 6:39 p.m., under Code of Federal Regulations (CFR) 483.25 (F698-[MEDICAL TREATMENT]) with the facility Administrator (ADM) and Director of Nursing (DON). The facility submitted an acceptable IJ Plan of Removal (POR) on 11/10/20 at 5:15 p.m. The IJ POR included not accepting/admitting any PD residents, instructing nurses and staff that the facility will not accept residents on PD, and notification of physicians and medical director to not admit residents requiring PD. No residents with PD were being cared for in the facility at the time of the IJ. The components of the IJ Removal Plan were validated onsite to be fully implemented through observations, interviews, and record review. The IJ situation was removed on 11/10/20 at 5:45 p.m. with the ADM and the DON. Findings: 1. During a review of Resident 1's Record of Admission (ROA) dated 10/28/20, the ROA indicated Resident 1was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].{poisonous substances} for people whose kidneys can no longer perform these functions naturally). During an interview on 11/6/20 at 9:49 a.m., Licensed Vocational Nurse (LVN 1) stated she had performed PD treatment for [REDACTED]. LVN 1 stated, she had no training or in-service on PD treatment besides watching a YouTube on-line video and training from school years ago. LVN stated, on 11/5/20, LVN 2 guided her on how to disconnect Resident 1 from the PD machine. LVN 1 stated she did not review the manufacturer guidelines for the PD machine and relied on LVN 2's guidance. LVN 1 stated Resident 1 became unresponsive and pale after disconnecting Resident 1 from the PD machine on 11/5/20, and had to do a sternum rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert). LVN 1 stated Resident 1 opened her eyes slowly and nodded that she was ok. LVN 1 stated Resident 1's blood pressure was 88/40 mmHg. LVN 1 stated, I called the doctor after she (Resident 1) told me she did not feel well. During an interview on 11/6/20 at 11:29 a.m., the Registered Nurse /Minimum Data Set (is a process that entails a comprehensive standardized assessment of a resident's functional capabilities and health needs) Coordinator (RN/MDSC) stated, she did not receive training or in-service on how to perform PD treatment at the facility. RN/MDSC stated she educated herself by reviewing a binder on PD instructions at the nurses' station, reading articles, and watching YouTube. RN/MDSC stated she was available to the licensed staff if they had questions and assisted them when the Resident 1's PD machine alarm would go off. RN/MDSC stated there was an instance where she had to call the PD machine company on how to troubleshoot when the alarm would go off on Resident 1's PD machine. During a telephone interview on 11/6/20 at 1:10 p.m., LVN 2 stated she had not been trained on PD from a [MEDICAL TREATMENT] facility and had educated herself by watching a video she had googled. LVN 2 stated Resident 1 guided and instructed her through the process on how to work the PD machine. LVN 2 stated Resident 1 was particular on how she wanted to disconnect the PD machine. LVN 2 stated she was not sure whether Resident 1 had a bruit (audible sounds resembling heart murmurs heard through a stethoscope) and a thrill (a vibration or buzz that can be felt) as indicated in Resident 1's care plan. LVN 2 stated, She (Resident 1) didn't tell me she had a bruit and thrill. LVN 2 stated she did not know patients on PD did not have a shunt that required assessment of bruit and thrill. During a concurrent interview and record review on 11/6/20 at 2:22 p.m., with LVN 1, Resident 1's Care Plan dated 10/27/20 was reviewed. The care plan indicated, .At risk for complications of [MEDICAL CONDITION]/[MEDICAL CONDITION] (end stage kidney disease) requiring [MEDICAL TREATMENT] treatment .Monitor access site for bruit and thrill .Notify Medical Doctor (MD) immediately of absent bruit and/or thrill, with follow up as indicated .Do not take blood pressure on arm with shunt/fistula (is a connection that's made between an artery and a vein for [MEDICAL TREATMENT] access) not indicated . LVN 1 stated, .I will listen for a bruit and a thrill on the resident's abdomen since that was where the [MEDICAL TREATMENT] catheter was inserted. LVN 1 stated there were residents at the facility who had a bruit and thrill on the arm but Resident 1's [MEDICAL TREATMENT] tube was on her abdomen so she would listen for a bruit and thrill on her abdomen. During an interview on 11/6/20 at 2:30 p.m., the DON stated licensed nurses were not trained by certified DC staff on how to perform PD on Resident 1. DON stated there were no lesson plans or in-service on how to perform PD for the LNs. DON stated she had printed the instruction manual for the PD machine and had a stand up meeting. DON stated, They are all nurses . they know how to connect the (PD) tube . the same way as connecting a tube feeding (tube inserted into the stomach for nourishment for a person who is unable to swallow). During a concurrent interview and record review on 11/6/20 at 2:58 p.m., with Registered Nurse (RN), the Physician order [REDACTED].Peritoneal [MEDICAL TREATMENT] TX (treatment) to be done QHS (at bedtime) . RN reviewed the PO and treatment record and stated this was the only order prescribed for PD. RN stated the order was not specific and did not contain the number of cycles (frequency of treatment), volume of fluid (amount of liters used), duration, and concentration of the [MEDICATION NAME] (solution of pure water, electrolytes and salts which pulls toxins from the blood). RN stated the order only indicated to do the [MEDICAL TREATMENT] at night and nurses had no way to perform the five rights (right patient, medication, route, dose and time). RN stated Resident 1 brought her own equipment for PD treatment. RN stated she had provided Resident 1 with PD treatments on 10/29/20 and 10/31/20 and her training came from LVN 4. RN stated she was not trained on how to perform PD treatment from a certified DC. During a concurrent interview and record review on 11/6/20 at 4:03 p.m., with DON, Resident 1's Care Plan dated 10/27/20 was reviewed. DON stated Resident 1's care plan was not resident focused. DON stated Resident 1 did not have a shunt to check bruit and thrill. During a concurrent interview and record review of Resident 1's Physician order [REDACTED]. DON stated Resident 1's PO only indicated to do the treatment at night. DON stated she did not know how many bags of [MEDICATION NAME] ran at night and stated, You (referring to the surveyor) will have to ask the nurses. DON stated Resident 1 had brought the [MEDICATION NAME] from home. DON stated the number of exchanges, volume of fluid, duration, concentration of fluid, and the use of automated machine was not included in the order. When DON was asked to provide the orders from the NT, DON stated she did not have the orders from the NT. The PD machine brochure was reviewed with DON. The brochure did not include instructions on how to use and trouble shoot the PD machine. DON stated this is what (manufacturer's guideline for use) we have. During a telephone interview on 11/9/20 at 9:34 a.m., with the NT, the NT stated she did not agree to, nor approved Resident 1's admission to the SNF. NT stated Resident 1 had [MEDICAL CONDITION] and needed [MEDICAL TREATMENT] (is a process of purifying the blood of a person whose kidneys are not working normally) if Resident 1 wanted to move to a SNF. NT stated she had communicated with the DC's social worker (SW) and advised the SW not to send Resident 1 to a SNF because PD could not be performed at the SNF. During a telephone interview on 11/9/20 at 1:01 p.m., with Family (FM), FM stated Resident 1 had received PD treatment for [AGE] years. FM stated Resident 1's health had declined in the past year, and experienced low blood pressure and dehydration (harmful reduction in the amount of water in the body). FM stated, when Resident 1 was admitted to the Skilled Nursing Facility (SNF), the DC notified (FM) that they would discontinue Residents 1's care from the DC due to not having a contract with the SNF. During an interview on 11/9/20 at 3:43 p.m., with the DON, DON stated, Resident 1's admission to the facility was jointly decided by the DON and the ADM. DON stated Primary Care Physician (PCP) had experience with PD as a medical intern (student or trainee). DON stated PCP had accepted to follow Resident 1 and wrote the order for PD. DON stated, I did not follow up with the NT . that is the PCP's responsibility to follow up. DON stated she was not aware the NT did not approve for Resident 1 to receive PD at the facility until 11/5/20. The DON stated the facility followed Resident 1's PCP orders. DON stated the PCP's orders, administering medications, assisting with activity of daily living was the plan of care for Resident 1. DON stated there were no documentation to indicate the time Resident 1's PD treatment started and/or ended. DON stated the training and qualification for nurses to perform PD was watching YouTube specific to the [MEDICAL TREATMENT] machine and using the (name of professional reference) instructions. During an interview on 11/9/20 at 3:45 p.m., with the ADM, the ADM stated the facility was not certified to perform PD and did not have a contract with (name of [MEDICAL TREATMENT] center). During an interview on 11/9/20 at 5:11 p.m., with Resident 1's the PCP and DON, the PCP stated she was the admitting physician for Resident 1. The PCP stated she was not a NT. The PCP stated she wrote the order for Resident 1's PD treatment by following the NT's order to perform PD daily at night. The PCP stated she did not remember who the NT was and where the {original/written} order was located. The PCP stated she assumed the facility's licensed nurses were trained on handling PD complications. The PCP stated the licensed nurses had to run the PD machine and watch/assess for any signs of complications. The PCP stated the NT should have orders labs for Resident 1. The DON stated Resident 1's weights were not checked before and after treatment. During an interview on 11/9/20 at 5:58 p.m., with ADM, the ADM was asked to provide record of Resident 1's NT's orders for PD treatment. ADM provided (name of hospital) H&P dated 1/14/20, but did not provide the NT's orders for Resident 1's PD treatment. During a concurrent interview and record review on 11/9/20 at 6:00 p.m., with PCP, Resident 1's (name of hospital) H&P dated 1/14/20 did not have PD treatment orders. PCP stated she had no communication with the NT and did not know that the NT was not in agreement for Resident 1 to receive PD treatment at the SNF. During a telephone interview on 11/10/20, at 12:03 p.m., LVN 3 stated she had provided PD treatments for Resident 1on 11/3/20 and 11/4/20. LVN 3 stated she had no training or in service on how to perform PD treatments. LVN 3 stated she watched YouTube and read a pamphlet on how to perform PD treatments. During an interview on 11/10/20 at 1:00 p.m., with the DON, the DON stated Resident 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. DON stated licensed nurses did not receive PD training from a DC and that Resident 2's family showed them the technique to work Resident 2's machine. DON stated, They (licensed nurses) all know how to wash hands and hook up tube. During a concurrent telephone interview on 11/10/20 at 3:14 p.m., with LVN 3, LVN 3 stated she was the admitting nurse for Resident 1. LVN 3 stated she had called the DC (could not recall the date) and was informed they were not going to send a nurse to the SNF to do Resident 1's PD treatments because they (DC) did not have a contract with the facility. LVN 3 stated, (Resident 1's FM) told me, she will try to have Resident 1 go to another DC. LVN 3 stated Resident 1's FM brought the equipment (PD machine) to the facility for PD treatment. LVN 3 stated Resident 1's Home treatment Record (HTR) dated 10/2017 indicated, .Total UF ((ultrafiltration) removal of fluid) .Average dwell time (a prescribed period of time [MEDICATION NAME] stays in abdomen) .1.53 .1.19 .1:55 .Effluent (liquid waste) Clear or Cloudy . LVN 3 stated Resident 1 had brought the HTR with her and the nurses used this form to document and track the PD treatments. LVN 3 stated she did not know what the average dwell time was and did not know what the documented numbers represented. LVN 3 stated Resident 1 did not have order in place for Lab (to check blood results) to assess the effectiveness of the PD treatment. LVN 3 stated Resident 1's weight was not measured on 11/3/20-11/5/20; and post [MEDICAL TREATMENT] weights were not performed. LVN 3 stated the nurses' documentation were [MEDICAL TREATMENT] as ordered, dressing in place, and PD treatment went well. LVN 3 stated the color of drainage fluid was not documented in the HTR or nurses notes. During a concurrent interview and record review on 11/10/20 at 4:10 p.m., with DON, Resident 1's HTR was reviewed. DON stated the nurses used the HTR to track the PD treatments. DON stated the HTR was incomplete and the nurses were not assessing the color of drainage as indicated on the form. During a review of the facility document for Resident 1 titled, Interdisciplinary Progress Notes (name of entity) (IPN) dated 11/5/20 indicated .Approximately 0940 while disconnecting her (Resident 1) from peritoneal [MEDICAL TREATMENT], she became unresponsive. Raised her feet up and give her sternum rub, she slowly began to open her eyes and verbally responsive. B/P (blood pressure) was 88/40 pulse 81 .she is alert but looks weak. Called Primary Care Physician (PCP) to inform her and got order to send her out to hospital . During a review of Resident 1's Hospital's History and Physical (H&P) dated 11/5/20, the H&P indicated, .was sent from SNF for syncopal episode. Today before PD, did not get [MEDICATION NAME] (medication used to increase blood pressure) .Patient was passed out for short period of time and woke up by herself after few minutes .Patient was seen by Nephrologist .who recommended against peritoneal [MEDICAL TREATMENT] at SNF . Recently, Patient decided to move to SNF on PD despite recommendations against it. I clearly stated that PD is not an option at SNF that she must switch to [MEDICAL TREATMENT] . Explained earlier if she (Resident 1) is moving to SNF . However, she (Resident 1) moved to a SNF facility where she reportedly continues to get PD exchange in a condition where standard of care to do PD have not been inspected or established .She (Resident 1) was sent to emergency room (ER) for [MEDICAL CONDITION] (low blood pressure) .admit patient to discuss goal of care or to switch to [MEDICAL TREATMENT] (procedure where a [MEDICAL TREATMENT] machine and a special filter called an artificial kidney, or a dialyzer, is used to clean the blood of a person whose kidneys are not working normally) . During a review of the facility document for Resident 1 titled, Interdisciplinary Progress Notes (name of entity) documented by LVN 2 dated 10/27/20 indicated, .(Resident 1 walked this writer on how to work her (Resident 1) peritoneal [MEDICAL TREATMENT] machine . 2. During a concurrent interview and record review on 11/10/20 at 1:15 p.m., with DON, Resident 2's Care Plan was reviewed dated 4/16/20 indicated, .At risk for complications of [MEDICAL CONDITION]/[MEDICAL CONDITION] requiring [MEDICAL TREATMENT] treatment .Monitor access site for bruit and thrill . Notify MD immediately of absent bruit and/or thrill .Do not take blood pressure on arm with shunt/fistula right arm ., DON stated Resident 2 did not have a shunt to check for bruit and thrill. DON stated the care plan was not accurate and did not reflect Resident 2's current status which was PD and not [MEDICAL TREATMENT]. During a concurrent interview and record review on 11/10/20 at 1:18 p.m., with DON, Resident 2's Physician order [REDACTED]. DON stated Resident 2's PCP's order for PD every night was not specific and did not contain the number of cycles, volume of fluid, duration, and concentration. During a telephone interview on 11/10/20 at 1:54 p.m., LVN 4 stated she had provided PD treatments for Resident 2 on 10/29/20 and 10/31/20. LVN 4 stated she did not have PD training. LVN 4 stated she read a book and pamphlet on how to perform PD treatment. LVN 4 stated when the PD machine alarm went off, Resident 1 would tell her how to troubleshoot. LVN 4 stated when the PD treatment went well, she did not need to document her assessments. LVN 4 stated she should have documented her assessments because if it was not documented it was not done. LVN 4 stated Resident 1 did not have specific orders on what [MEDICATION NAME] to use. LVN 4 stated she did not verify how many bags of [MEDICATION NAME] and the concentration of the fluid used for treatment because it was the admission nurse's responsibility. LVN 4 stated she was unaware of the HTR and was not told to fill out that form. LVN 4 stated the meaning of dwell time was maybe 6 to 8 hours when waste was draining into the toilet. LVN 4 stated she did not know what total UF meant and was unfamiliar with the term. During an interview on 11/10/20 at 2:39 p.m., DON stated the facility did not have a contract with (name of [MEDICAL TREATMENT] center) for Resident 2. During a concurrent interview and record review on 11/10/20 at 3:36 p.m., with Registered Nurse/Infection Preventionist (RN/IP), Resident 2's IPN dated 4/20/20 indicated, .call placed to .(name of [MEDICAL TREATMENT] center) .to inquire .rx (prescription) for [MEDICAL TREATMENT] treatment . She stated that the [MEDICAL TREATMENT] time is 9 hour and total volume is 8,000 ml (milliliter-unit of measure) . [MEDICATION NAME] is 2,000 . RN/IP stated she had called the DC to verify if the prescription was correct. RN/IP stated the PO was not specific and did not include the volume of the [MEDICATION NAME]. RN/IP stated Resident 1's discharge orders from acute hospital indicated the name of peritoneal [MEDICAL TREATMENT] solution and dose of 6000 ml (unit of measurement). RN/IP stated they followed the transfer orders dated 4/11/20 from the acute hospital and it would have been the PCP's responsibility to verify the orders with the NT. RN/IP stated, since the PO did not include specific orders she was unable to validate the [MEDICATION NAME] dose Resident 2 received. During an interview on 11/10/20, at 5:00 p.m., with ADM and DON, a portion of the SOM (State Operations Manual) for responsibilities for the provision of [MEDICAL TREATMENT] care/services was reviewed. The DON stated, All of that did not happen and there was no collaboration with the [MEDICAL TREATMENT] center. DON stated the facility policy titled Peritoneal [MEDICAL TREATMENT] did not include all the minimum requirements as specified in the federal regulations. During a professional reference review retrieved from https://[MEDICAL TREATMENT].com/117.32/laboratory-test-and-expected-values-[MEDICAL TREATMENT] on 11/24/20, titled, Important Laboratory Test and Expected Values for People on [MEDICAL TREATMENT] undated indicated, . Your physician will order laboratory test on your blood in order monitor your health and the effectiveness of your treatment plan . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/ 996/ on 11/23/20, titled, Peritoneal [MEDICAL TREATMENT] in the nursing home dated 2010 indicated, . With appropriate training of the NH ( Nursing Home) nursing staff, peritoneal [MEDICAL TREATMENT] could be performed successfully in these nursing homes. Successful peritoneal [MEDICAL TREATMENT] in a nursing home requires a close collaboration between the nursing home staff and PD [MEDICAL TREATMENT] unit . During a professional reference review retrieved from https://journals.sagepub.com/doi/pdf/10.3747/pdi.2013XXX on 11/24/2020, titled, Peritoneal [MEDICAL TREATMENT] for Acute Kidney Injury dated 2014 indicated, . A volume of [MEDICATION NAME] is prescribed as well as the therapy time and fill volume. The advantage of this system is that it can be set up by a trained staff member once per day to reduce the risk of complications .A further disadvantage of cyclers is that if there is no support after hours for inexperienced nurses using the cyclers, there is the risk of the machines being turned off during the night to avoid alarms . During a review of an online article from Mayo Clinic (www.mayoclinic.org) dated 2020, the article indicated, Infections of the abdominal lining (peritonitis) is a common complication of peritoneal [MEDICAL TREATMENT]. An infection can also develop at the site where the catheter is inserted to carry the cleansing fluid ([MEDICATION NAME]) into and out of a person's abdomen. The risk of infection is greater if the person doing the [MEDICAL TREATMENT] isn't adequately trained. Weight gain: The [MEDICATION NAME] contains sugar ([MEDICATION NAME]). Absorbing some of the [MEDICATION NAME] might cause a person to take in hundreds of extra calories daily, leading to weight gain. The extra calories can also cause high blood sugar, especially if the person has diabetes. Inadequate [MEDICAL TREATMENT]: Peritoneal [MEDICAL TREATMENT] can become ineffective after several years. A person may need to switch to [MEDICAL TREATMENT].

Based on observation, interview, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of a [MEDICAL CONDITION] (COVID-19- a contagious serious respiratory infection transmitted from person to person) outbreak for 28 of 57 sampled Residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 22, 23, 24, 25, 26, 27 and 28) when: 1. Dedicated and trained staff were not trained to conduct active COVID-19 screening of Health Care Personnel (HCP) and instead HCP screened themselves for symptoms of COVID-19, prior to the start of all three shifts (morning, evening and night) and potentially placed 57 of 57 residents at risk from symptomatic COVID-19 staff. 2. The Director of Staff Development/Infection Preventionist (DSD/IP) did not provide education to HCP on the most current signs and symptoms of COVID-19 infection. Staff did not know what steps to follow when symptoms developed during their shift. Three of three Certified Nursing Assistants (CNA 12, CNA 13, and CNA 3) provided resident care while experiencing symptoms of COVID-19 (loss of taste, loss of smell and headache) on 6/25/2020 subsequently exposing Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 16, 17, 18, 19, 20, 21 22, 23, 24, 25, 26, 27 and 28 to COVID-19 infection. 3. The DSD/IP did not implement a facility wide infection control (IC) program to prevent, identify, investigate and control communicable diseases and infections among residents and staff. The DSD/IP failed to conduct education and training of staff to correct and improve IC practices such as the screening process and current signs and symptoms (s/s) of COVID-19 in the facility which subsequently lead to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15's COVID-19 infection and to the exposure of Residents 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28. 4. CNA 1 took a dedicated thermometer used for the screening of HCP to measure a resident's temperature inside the bedroom without disinfecting the thermometer prior to and after the thermometer's use. Because of the failures to maintain essential and effective IC activities to reduce the spread of a COVID-19 outbreak, and the potential serious harm to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 and 28, related to employees working with symptoms associated with COVID-19 and eventually laboratory tested as COVID-19 positive, an Immediate Jeopardy situation (IJ) was called on 7/3/2020 at 7:05 p.m., under Code of Federal Regulations (CFR) 483.80 (F880-Infection Prevention and Control) with the facility Administrator (ADM) and Director of Nursing (DON). The facility submitted a Plan of Removal to address the IJ situation, which included having a designated trained screener for each shift to actively screen all HCP prior to the start of each shift; in-service training was provided to all staff on the signs and symptoms (s/s) of COVID 19 when to report and to whom to report; with a plan to provide in-services on an ongoing basis on s/s of COVID-19; a full time IP to implement monitoring and surveillance to track COVID-19 and staff compliance to infection control practices. The Plan of Removal was accepted on 7/5/2020 at 4:33 p.m. While onsite, the surveyors verified and confirmed the interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on 7/7/2020 at 2 p.m., with the ADM and DON. The severity of the violation remains at a scope and severity of an 'L'. Findings: 1. During an observation on 7/3/2020 with the ADM, at 7:23 a.m., at the south entrance of the facility, a screening station was located on the right side of the hallway. There was no staff available to screen employees or visitors who entered the facility. The ADM called staff to the facility entrance to screen the two nurse evaluators. The DON approached the unattended entrance screening station, and stated her hands were soiled with residue from a broken fish tank and was unable to complete the COVID-19 screening. The DON called on an available staff member to conduct the screening of the two nurse evaluators. During a concurrent observation and interview on 7/3/2020, at 7:27 a.m., with Certified Nursing Assistant (CNA 1) at the screening station, CNA 1 stopped the distribution of meal trays from nearby resident rooms. CNA 1 approached the screening station, and proceeded to conduct the screening of the two nurse evaluators. CNA 1 measured the tympanic (ear) temperature and asked the screening questions from a written questionnaire. CNA 1 documented the information collected on the screening data form. CNA 1 stated the screening station was not staffed routinely. CNA 1 stated if staff needed to be screened the staff would call out for an available staff member to stop what they were doing and request they come and perform the temperature screen. CNA 1 completed the COVID-19 screen on the two evaluator nurses proceeded to the south hallway to continue picking up trays from Resident rooms. During a review of the undated and untitled screening data form used to collect the screening information, the questionnaire contained seven columns. The first column indicated the date the screening was conducted, the second column indicated, Employee or HCP's Name or ESSENTIAL VISITOR. The third column indicated, Department. The fourth column indicated, TEMP LESS THAN 100.4? The fifth column indicated, DO YOU HAVE A COUGH, SORE THROAT OR SHORTNESS OF BREATH? the sixth column indicated, In the last 14 days have you been in contact with symptoms of COVID-19 or tested positive? (IF YES, ask for a nurse before entry). The seventh column indicated, Wash your hands or do hand hygiene! During an interview on 7/3/2020 at 7:35 a.m., with the DON, the DON stated Residents 1, 2, 3, 4, 5 and 6 were positive for COVID-19. During a review of Resident 1's laboratory COVID-19 result dated 7/2/2020, indicated Resident 1 tested positive for COVID 19 on 7/2/2020. During a review of Resident 2's laboratory COVID-19 result dated 6/28/2020, indicated Resident 2 tested positive for COVID 19 on 6/28/2020. During a review of Resident 3's laboratory COVID-19 result dated 7/2/2020, indicated Resident 3 tested positive for COVID 19 on 7/2/2020. During a review of Resident 4's laboratory COVID-19 result dated 6/27/2020, indicated Resident 4 tested positive for COVID 19 on 6/27/2020. During a review of Resident 5's laboratory COVID-19 result dated 6/27/2020, indicated Resident 5 tested positive for COVID 19 on 6/27/2020. During a review of Resident 6's laboratory COVID-19 result dated 7/2/2020, indicated Resident 6 tested positive for COVID 19 on 7/2/2020. During an interview on 7/3/2020, at 7:55 a.m., with CNA 1, CNA 1 stated the facility did not have dedicated staff to screen the staff or visitors entering the facility. CNA 1 stated when she entered the facility and a staff member was not available to conduct the screen she would proceed to screen herself. CNA 1 stated she completed the screening questionnaire, took her own temperature and documented the results on the screening log. CNA 1 stated she had been performing her own screening for two months. During an interview on 7/3/2020, at 8:05 a.m., with CNA 2, CNA 2 stated, she started her shift the morning of 7/3/2020 at 6 a.m. CNA 2 stated there was no staff assigned to conduct and complete the screening at the beginning of her shift. CNA 2 stated, I have been doing my own screening since June. CNA 2 stated she did not receive training on the screening process or the steps that needed to be completed prior to entering the facility. During an interview on 7/3/2020, at 8:06 a.m., with CNA 9, CNA 9 stated there was no dedicated or designated staff to conduct the screening of COVID-19 s/s prior to the start of each shift. CNA 9 stated she and another CNA checked their temperatures prior to the start of the shift on 7/3/2020. CNA 9 stated the DSD previously told her it was ok for them to conduct their own screening of COVID-19 symptoms. During an interview on 7/3/2020, at 8:15 a.m., with CNA 10, CNA 10 stated after clocking in that morning (7/3/2020) she took her own temperature and answered the screening questionnaire by herself because no one was at the screening station. During an interview on 7/3/2020, at 10:05 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she started her shift that morning (7/3/2020) at 6 a.m. LVN 1 stated there was no dedicated or designated staff to conduct the screening of COVID-19 s/s prior to the start of each shift. LVN 1 stated she had been performing her own COVID-19 screen each time she arrived for work for the past three months. LVN 1 stated she had not observed staff at the screening station conducting active COVID-19 screening. LVN 1 stated she did not feel comfortable screening herself, but had not addressed her concern with anyone in the facility administrative or nursing staff. During an interview on 7/3/2020, at 10:25 a.m., with Housekeeping Supervisor (HS), the HS stated there was no dedicated or designated staff to conduct the COVID -19 screening. The HS stated she screened herself in the morning, prior to the start of her shift on 7/3/2020. The HS stated, I do my own screening most of the days (and have done so) for the last three months. During an interview on 7/3/2020, at 10:29 a.m., with LVN 5, LVN 5 stated there was no dedicated or designated staff to conduct the COVID -19 screening that morning on 7/3/2020. During an interview on 7/3/2020, at 12:05 p.m., with CNA 11, CNA 11 stated, she screened herself prior to the start of her shift and had been performing her COVID-19 self-screening independently for the past month. CNA 11 stated she was concerned staff were screening themselves independently without oversite and could erroneously document the self-screening. During an interview on 7/3/2020, at 1:20 p.m., with DSD/IP, the DSD/IP stated the facility was required to conduct active screening of all HCP and visitors who entered the facility. The DSD/IP stated the facility staff needed to have one person screen the other. The DSD/IP stated she did not have enough staff to assign as designated screeners. The DSD/IP stated local public health workers visited the facility on 7/2/2020 and instructed her to have dedicated staff for the completion of screening HCP and visitors. The DSD/IP stated she had not yet implemented the instructions. DSD/IP stated the residents in the facility were at risk to contract COVID-19 if active screening of staff was not conducted. DSD/IP stated, The point of entry is a vulnerable area for infectious diseases to come into the facility unchecked, and placed staff and residents at risk. The DSD/IP was asked about the systems the facility implemented for infection control and did not answer. During an observation on 7/3/2020, at 2:23 p.m., at the screening station, CNA 8 was standing at the screening station using an ear thermometer and took his own temperature. CNA 8 documented the results on the screening data form. During an interview on 7/3/2020, at 4:12 p.m., with CNA 8, CNA 8 stated he had been screening himself for the past three months. CNA 8 stated the screening area did not have a designated staff to conduct the screening. During an interview on 7/4/2020, at 10:45 a.m., with the DON, the DON stated the COVID-19 unit had one point of entry and exit. The DON stated a screening station was in place for the staff to use. During an observation on 7/4/2020, at 10:50 a.m., in the COVID-19 unit, a screening area for staff and visitors was not set up at the side entrance of the facility. During an interview on 7/4/2020, at 11:01 a.m., with LVN 3, LVN 3 stated, clear directions were not provided on the screening process for all staff entering the COVID-19 unit. LVN 3 stated another nurse took her temperature early in the morning on 7/4/2020 although the questionnaire for COVID-19 screening was not completed. LVN 3 stated she was not actively screened since 6/28/2020, when she was initially assigned to the COVID-19 unit. LVN 3 stated active screening should have been completed and documented upon entering the facility. LVN 3 stated there were two additional COVID positive residents identified on the evening of 7/3/2020 and stated Resident 8 and Resident 9 were moved into the COVID-19 unit. During a review of Resident 8's COVID-19 laboratory report dated 7/3/2020, indicated Resident 8 was positive for COVID 19 on 7/3/2020. During a review of Resident 9's COVID-19 laboratory result dated 7/3/2020, indicated Resident 9 tested positive for COVID 19 on 7/3/2020. During an interview on 7/4/2020, at 11:30 a.m., with CNA 5, CNA 5 stated she was assigned to work in the COVID -19 unit since 6/28/2020. CNA 5 stated the COVID-19 unit had a separate entrance. CNA 5 stated she was not screened prior to entering the COVID-19 unit since 6/28/2020. CNA 5 stated, We just check our temperatures throughout the shift but do not document our temperatures. During an interview on 7/6/2020, at 11:15 a.m., with the ADM, the ADM stated there were seven additional residents identified positive for COVID-19 on 7/6/2020. The ADM stated the positive COVID-19 results were on Resident 7, 10, 11, 12, 13, 14 and 15 which brought the total to 15 positive cases in the residents of the facility. During a review of Resident 7's COVID-19 laboratory report dated 7/5/2020, indicated Resident 7 was positive for COVID 19 on 7/5/2020. During a review of Resident 10's COVID-19 laboratory report dated 7/5/2020, indicated Resident 10 was positive for COVID 19 on 7/5/2020. During a review of Resident 11's COVID-19 laboratory result dated 7/5/2020, indicated Resident 11 tested positive for COVID 19 on 7/5/2020. During a review of Resident 12's COVID-19 laboratory result dated 7/5/2020, indicated Resident 12 tested positive for COVID 19 on 7/5/2020. During a review of Resident 13's COVID-19 laboratory result dated 7/5/2020, indicated Resident 13 tested positive for COVID 19 on 7/5/2020. During a review of Resident 14's COVID-19 laboratory report dated 7/5/2020, indicated Resident 14 was positive for COVID 19 on 7/5/2020. During a review of Resident 15's COVID-19 laboratory result dated 7/5/2020, indicated Resident 15 tested positive for COVID 19 on 7/5/2020. During a review of the facility's policy and procedure titled, (Employee/Visitor Screening during COVID-19), dated 3/20/2020, indicated Policy: .To protect residents from harmful pathogens .identifying persons with symptoms before they enter the facility . Procedure: .all who enter the facility are screened before entering .individuals are screened .before being allowed to enter the facility . During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 7/17/2020, titled, Preparing for COVID-19 in Nursing Homes dated 6/25/2020 indicated, Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19.Actively take their temperature* and document absence of symptoms consistent with COVID-19. Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace.*Fever is either measured temperature (greater than) 100.0 (degrees) F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed (weak immune system), or taking certain medications (e.g., NSAIDs) . 2 a. During an interview on 7/3/2020, at 8:05 a.m., with CNA 2, CNA 2 stated CNA 2 stated she believed a temperature of 101 degree Fahrenheit or higher needed to be reported to the DON. CNA 2 stated the DSD/IP told her (an employee) with a temperature of 101 degree Fahrenheit or above needed to be reported to a nurse. CNA 2 stated that the most current s/s of COVID-19 were not provided. During an interview on 7/3/2020, at 8:15 a.m., with CNA 10, CNA 10 stated having a temperature greater than 99 degrees F was unacceptable and would need to alert a nurse. CNA 10 stated if during her shift she felt s/s of COVID-19, she would alert the nurse in charge. CNA 10 was asked to verbalize reportable s/s of COVID-19. CNA 10 stated she would report cough, fever and shortness of breath; and was unaware of the additional symptoms. During a telephone interview on 7/3/2020, at 9:57 a.m., with CNA 12, CNA 12 stated she worked on 6/25/2020 during the PM shift from 2:15 p.m., to 10:45 p.m. CNA 12 stated she completed the COVID-19 HCP screening process independently that day (6/25/2020) because there was no staff available to conduct active screening. CNA 12 stated the main reportable s/s of COVID-19 were high fever and SOB. CNA 12 stated on 6/25/2020 during her lunch break she experienced the loss of taste and smell. CNA 12 stated she did not know the loss of taste and smell were s/s of COVID-19, and continued to provide resident care after her lunch break. CNA 12 stated she did not receive an updated in service to let her know the loss of taste and smell were s/s of COVID-19. CNA 12 stated she tested positive for COVID-19 on 6/27/2020. During a concurrent interview and record review on 7/3/2020, at 5:12 p.m., with Medical Records (MR), MR reviewed CNA 12's written Work Schedule for 6/24/2020 and 6/25/2020. MR stated CNA 12 worked on 6/24/2020 during the PM shift (2:15 p.m. to 10:45) and provided care to Residents 1, 3, 6, 7, 9, 13, 14. MR stated on 6/25/2020, CNA 12 provided care to Residents 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28. During a concurrent interview and record review on 7/3/2020, at 5:40 p.m., with the DON, the DON reviewed the facility's CNA electronic assignment titled, Point of Care History Report and stated CNA 12 was also assigned to Residents 2 and 4 on 6/24/2020, one day prior to exhibiting symptoms of COVID-19. During a review of the facility document titled, Payroll report with specific Dates dated 6/25-6/26 indicated, CNA 12 worked on 6/25/2020 from 2:19 p.m., through 10:34 p.m. During a review of the facility document titled, REPORT OF POSITIVES AT (Skilled Nursing Facility) undated indicated, CNA 12 tested positive for COVID-19 on 6/28/2020. 2 b. During a telephone interview on 7/3/2020, at 3:41 p.m., with CNA 13, CNA 13 stated she worked on 6/25/2020 during the PM shift from 2:15 p.m., to 10:45 p.m. CNA 13 stated she completed the COVID-19 self-screening symptom questionnaire for the past month prior to the start of her shift. CNA 13 stated on 6/25/2020 during her lunch break she experienced the loss of taste and smell. CNA 13 stated she was not in-serviced for all the s/s of COVID-19 and was unaware the loss of taste and smell were s/s of COVID-19. CNA 13 stated she was experiencing symptoms of the common cold. CNA 13 stated the only symptoms she was aware of for COVID-19 were high fever, cough and sore throat. CNA 13 stated, she continued to provide Resident care unaware she was experiencing s/s during her lunch break. CNA 13 stated she tested positive for COVID-19 on 6/27/2020. During a concurrent interview and record review on 7/3/2020, at 5:13 p.m., with Medical Records (MR), MR reviewed CNA 13's Work Schedule for 6/25/2020. MR stated CNA 13 worked on 6/25/2020 PM shift (2:15 p.m. to 10:45) and provided care to Residents 11, 12 and 15. During a review of the facility document titled, Payroll report with specific Dates dated 6/25-6/26 indicated, CNA 13 worked on 6/25/2020 from 2:22 p.m. through 10:46 p.m. During a review of the facility document titled, REPORT OF POSITIVES AT (Skilled Nursing Facility) undated indicated, CNA 13 tested positive for COVID-19 on 6/27/2020. 2 c. During a telephone interview on 7/3/2020, at 4:55 p.m., with CNA 3, CNA 3 stated, the last day she worked at the facility was on 6/25/2020 on the PM shift. CNA 3 stated she started her shift at 2:15 p.m., and ended it at 10:45 p.m. CNA 3 stated she had a headache during the shift and did not think anything of it. CNA 3 stated she continued to provide resident care unaware the headache was a symptom of COVID-19 and worked throughout her shift. CNA 3 stated she tested positive for COVID-19 on 6/28/2020. During a concurrent interview and record review on 7/3/2020, at 5:13 p.m., with Medical Records (MR), MR reviewed CNA 3's Work Schedule from 6/24/2020 and 6/25/2020. MR stated CNA 3 worked on 6/24/2020 during the PM shift (2:15 p.m. to 10:45) and provided care to Residents 11, 12 and 15. MR stated CNA 3 worked with CNA 12 on 6/25/2020 during the PM shift and helped care for Residents 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28. During a review of the facility document titled, Payroll report with specific Dates dated 6/25-6/26, indicated, CNA 3 worked on 6/25/2020 from 2:19 p.m., to 10:35 p.m. During a review of the facility policy and procedure titled Coronavirus Preparation Response, and Mitigation dated 5/27/2020, indicated, Policy: .It is our policy that we will make efforts to protect our residents in our facility from these diseases . Healthcare Personnel training a. Staff will be trained to recognize signs and symptoms of COVID-19. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 7/17/2020, titled, Symptoms of Coronavirus dated 6/25/2020 indicated, Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. 3. During an interview on 7/3/2020, at 1:20 p.m., with the DSD/IP, IP stated, she did not have documentation and did not have lesson plans on COVID-19 for staff training. The DSD/IP stated she did not provide in-service training for the screening process. The DSD/IP did not answer when asked if the facility IC committee completed a risk assessment in relation to infection control and COVID-19. The DSD/IP was asked to share the systems the facility had in place to track and conduct surveillance., the DSD/IP stated she did not have time to complete the logs and spreadsheets (a system of identifying all residents and staff on one monitoring tool called a line-list, (The line list serves as surveillance tool to track and monitor the clinical and COVID-19 status of each resident and staff member)) asked of her. During a professional reference review retrieved from https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf on 7/20/2020, titled, Long-Term Care (LTC) Respiratory Surveillance Line List dated 3/12/2019 indicated, The Respiratory Surveillance Line List provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak at a nursing home or other LTC facility. Using this tool will provide facilities with a line listing of all individuals monitored for or meeting the case definition for the outbreak illness . Information gathered on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases, and assist with implementation of infection control measures by identifying units where cases are occurring . During an interview on 7/3/2020, at 5:47 p.m., with the DSD/IP, the DSD/IP stated she was overburdened with duties of which involved staff development and did not have sufficient time to complete IC duties. The DSD/IP stated she did not have documentation that she had updated anything. The DSD/IP stated the ADM was aware she was overloaded with the duties of DSD and IP. The DSD/IP stated she was informed the ADM and DON that she was busy completing DSD duties and was not fulfilling IP duties. The DSD/IP could not recall the date she communicated to the ADM and DON that her DSD duties were affecting the IP duties. The DSD/IP stated she did not provide the staff up to date in-service education about the most current s/s of COVID-19. The DSD/IP stated the facility staff did not know what s/s needed to be reported other than cough, fever and SOB. The DSD/IP stated the infection surveillance was not updated and she did not have an effective tracking system to record outbreaks. The DSD/IP stated she did not have the time she needed to complete all of her tasks. The DSD/IP stated the last in-service education she provided to all of the facility staff was in March 2020 when the pandemic was initially declared. The DSD/IP stated she did not provide any additional in-service education on infection control since March 2020. The DSD/IP stated she was unaware who oversaw her work and felt the administrative staff should have known that she was overloaded with duties in the IP and DSD department. During a concurrent interview and record review on 7/3/2020, at 6:15 p.m., with DSD/IP, the DSD/IP reviewed the in-service binder and stated the last in-service conducted was on 3/17/2020. The DSD/IP stated there were no additional in-services related to infection control in the in-service education binder. During an interview on 7/3/2020, at 6:14 p.m., with DON, the DON stated the facility had no issues in the infection control department. The DON stated the DSD/IP was able to perform her duties and was not having a difficult time conducting and performing her duties. The DON stated that she was running a good facility and her facility was not the only facility experiencing an outbreak of COVID-19. The DON was unable to describe and explain the level of oversite she offered the DSD/IP. The DON stated there were times when nurses who were not IC certified and nurses who were not DSD certified had come to help the DSD/IP. The DON stated they did not feel it was necessary to have a dedicated staff assigned to conduct screening of HCP and visitors. The DON stated she felt the staff could perform their own screening. During a review of the facility's policy and procedure titled, (Director of Staff Development Job Description), (undated), indicated, .trains, develops plans, directs, and coordinates programs to enhance the knowledge skills of the staff .will review and evaluate training and apprenticeship programs for compliance with government standards .Essential functions . Establish/implement training program .train staff for best practices .compliance with state and federal requirements .Coordinate, develop and implement employee education .Ensure education policy procedures meet regulation standard .Organize facility wide in-service .will be responsible for functions of the employee training and education. During a review of the facility's policy and procedure titled, (Infection Prevention IP Nurse Job Description) (undated), indicated, .specializes in preventing the spread of infectious agents, such as viruses and bacteria . training on how to prevent contamination .organize infection prevention in-services . 4. During an observation on 7/3/2020, at 9:11 a.m., CNA 1 picked up the tympanic thermometer from the screening station located at the entrance of the facility. CNA 1 took the thermometer into a resident's room and measured the temperature of the resident inside the room without disinfecting the thermometer. CNA 1 exited the room and placed the thermometer back onto the screening table without disinfecting the thermometer. During an interview on 7/3/2020, at 9:17 a.m., with CNA 1, CNA 1 stated she did not have a thermometer nearby so she decided to use the screening thermometer. CNA 1 stated she should have disinfected the thermometer after use to prevent cross contamination but did not do so. During an interview on 7/3/2020, at 5:57 p.m., IP stated, any device including thermometer should have been disinfected after use to prevent the transmission of infections. During a review of the facility policy and procedure titled Disinfecting Shared Equipment dated 3/2020, indicated, Pathogens can be transmitted through the use of equipment that is shared between residents and/or employees. It is important for the protection of residents and staff that this route of transmission be prevented . When equipment such as thermometers and blood pressure cuffs are used, they must be cleaned and then disinfected with a disinfectant that will effectively kill pathogens that may be transmitted between people. This will be done by the staff member that is utilizing it before using it on the next person .